Pediatric emergency medicine trisk 1051

Schizophrenia and brief psychotic episodes are relatively rare in pediatric patients; underlying mood, anxiety, or trauma disorders are the most common causes of psychosis in children..

TABLE 126.26

EXOGENOUS SUBSTANCES THAT CAUSE PSYCHOSIS

FOLLOWING INGESTION OF SIGNIFICANT QUANTITY

Alcohol

Barbiturates

Antipsychotics (e.g., phenothiazines)

Amphetamines

Hallucinogens—lysergic acid diethylamide (LSD) peyote, mescaline

Marijuana

Nicotine/vaping

Phencyclidine (PCP)

Quaalude

Anticholinergic compounds

Heavy metals

Cocaine and crack

Corticosteroids

Reserpine

Opiates (e.g., heroin, methadone)

Other Psychiatric Causes Schizophrenia and brief psychotic episodes are relatively rare in pediatric patients; underlying mood, anxiety, or trauma disorders are the most common causes of psychosis in children Patients with depression or mania with psychotic features typically have severe mood symptoms and impairment of functioning When present, psychotic symptoms tend to occur when mood symptoms are at their most severe and are “mood congruent.” Patients suffering from anxiety disorders typically have delusions or hallucinations related to their specific fears Patients with PTSD may also report hallucinatory experiences such as seeing scary people

in the corner of the room or hearing their abuser call out to them Typically, these cases can be distinguished from primary psychotic disorders as the

symptoms are placed within the greater clinical context of the patient’s presentation

TABLE 126.27

ACUTE SCHIZOPHRENIA IN ADOLESCENCE: MOST COMMON FEATURES

Flat affect

(Patient uninvolved and without emotion)

Auditory hallucinations

(Physician: “Have you been hearing voices even when no one is there?”) Thoughts spoken aloud

(Physician: “Can other people read your mind? Can you read their

minds?”)

Delusions of external control

(Physician: “Is anyone trying to kill you?… trying to control your mind or your body?”)

Management

Psychosis due to a Medical Condition Any child with psychosis in which an underlying medical condition is suspected requires medical admission for diagnostic evaluation and treatment Other important management involves controlling the child’s behavior, preventing injury to self/others, and alleviating the child’s fear and anxiety This should be attempted first with supportive statements acknowledging the child’s condition and distress, and using distractions that allow the child to have some control, such as offering choices of food or drink or safe toys As the child is distractible and anxious, instructions may need to be repeated frequently

Brief Psychotic Episode When a brief psychotic episode is suspected, the emergency physician should appreciate that these children may not progress

to have a permanent psychiatric disorder The emergency management is similar to that of other psychotic states, including psychiatric consultation

After acute stabilization, the prognosis of the child depends largely on the restoration or creation of a safe and dependable family support system Referral for outpatient family therapy should be made unless the child requires psychiatric hospitalization for further evaluation or treatment In the absence of adequate family support, some of these children may eventually require foster placement, residential treatment, or other placements

Schizophrenia The management of an acute schizophrenic episode requires psychiatric consultation Patients with suicidal or homicidal ideation require psychiatric hospitalization Psychotic patients from disorganized home environments may also need to be hospitalized for initial treatment In general, the approach to the psychotic patient in the ED depends on the condition of the patient and the anticipated site of the ongoing treatment For agitation and dangerous thoughts or behaviors, approaches include reassurance and a quiet setting, psychotropic medication, and/or physical restraint The patient’s vital signs, general condition, and possible side effects should be monitored frequently If the patient does not respond to medication, inpatient psychiatric hospitalization is necessary If significant improvement occurs, suicidality and homicidality are absent, and side effects

do not occur, the patient can be considered for discharge to outpatient psychiatric treatment with careful follow-up, as long as the parents or caregivers are well organized, appreciate the child’s condition, and feel capable of managing the child at home

The original class of antipsychotic medications, referred to as typical

antipsychotics, exert their influence primarily on dopaminergic neurons The

newer class of antipsychotic medications referred to as atypical

antipsychotics, is now the mainstay of treatment These medications affect

multiple neurotransmitter systems, most frequently dopamine and serotonin

In this class are risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel), ziprasidone (Geodon) Recent additions that are not yet commonly used in pediatric patients include Iloperidone (Fanapt), lurasidone (Latuda), asenapine (Saphris), and paliperidone (Invega) Clinical advantages offered by this new class of medications include clinical effects on the “positive symptoms” of schizophrenia (e.g., an improvement in the ability of the individual to relate

to the environment and to others, not just a positive effect on hallucinations

and delusions) and a decreased likelihood of EPS and long-term tardive dyskinesia

The major acute side effects of typical antipsychotic medications are EPS, including acute dystonic reactions (abnormal muscle tone or posturing), akathisia (motor restlessness), and parkinsonian effects (rigidity, tremor, slowed movement, and loss of balance) Acute dystonic reactions are best treated by PO, intravenous, or IM administration of diphenhydramine (25 to

50 mg) or PO or IM administration of benztropine (1 to 2 mg per day)

SOMATIC SYMPTOM AND RELATED DISORDERS

Goals of Treatment

In the DSM-5, disorders previously classified as “Conversion” or

“Psychosomatic” disorders have been reclassified and renamed The goals of emergency treatment of these disorders are to assess for underlying emergent/common medical etiologies, limit unnecessary medical workup and treatment as much as possible, identify possible contributing stressors, provide the family and patient with empathic, supportive, and therapeutic information about the psychological contributors to the patient’s symptoms, and to provide appropriate referrals and guidance about how families can best support the patient’s return to function

CLINICAL PEARLS AND PITFALLS