Recognizing and Responding to Psychotic Disorders in Pediatric Primary Care 12/10/2021

Introduction
While typically way beyond the scope of general pediatric practice, the primary care pediatrician can play a critical role in early identification and appropriate referral of patients with psychotic disorders. This is the first of a series of newsletters exploring this important clinical concern.

What is Psychosis?
Psychosis is characterized by impairments in thought, behavior and emotion so severe that the ability to discern reality from non-reality is lost, for a significant a period of time that can range from days to a full lifetime.

The onset of many psychotic disorders peaks between ages 15 to 25, making the pediatric interface with these patients an opportunity to promote early recognition and intervention. Each year, nearly 100,000 adolescents and young adults in the US experience a first-episode psychosis (FEP). The good news is that early interventions to support these individuals are believed to reduce the likelihood of progression to long term illness by roughly 50%.

The underlying etiology and diagnostic profiles of individuals experiencing psychosis can vary considerably as the range of underlying disorders impacting people under the age of 25 or so year is broad and can include schizophrenia, major depressive disorder, delusional disorders, bipolar disorder, PTSD, substance use disorders, neurological and other medical conditions. Co-morbidities amongst these disorders is also not uncommon, potentially complicating diagnostic and treatment efforts, though regardless of the causation, early intervention is critical in reducing both acute and long-term morbidity.

Treatment with psychopharmacologic agents with concurrent attention to physical health and with psychosocial and behavioral health supports of many kinds is the ideal response and these interventions can foster optimal prognostic evolution. Patient safety and long-term functionality during a patient’s lifespan are typical aspirations defining their care and early recognition and intervention are hallmarks of quality care.

Schizophrenia:
The typical profile for a patient who progresses to have schizophrenia, perhaps the most devastating of psychotic illnesses, experiences a prodrome during which an individual may experience changes in thoughts, perceptions, feelings and behaviors but are without symptoms of hallucinations, delusions or overtly disorganized thinking. This in mind, all individuals with evidence of new onset or evolving functional challenges should be assessed for underlying concerns, regardless as to whether they appear to be psychotic.

Pediatricians or family practice practitioners are almost universally an early point of contact for many adolescents and young adults, so that familiarity and comfort in evaluating for, identifying, assessing and ultimately referring patients to mental health specialists for more detailed evaluation and care is a public health function that they can readily provide in their routine practice.

Symptoms and Symptom Presentation

  • Prodromal Symptomatology:
    ··reduced concentration and attention, disorganized thoughts
    ··reduced motivation, changes in energy level, less interest in usual activities
    ··social withdrawal
    ··sleep disturbance
    ··suspiciousness
    ··irritability, anxiety, depressed mood
    ··no longer going to school or work, or performance deteriorating
    ··intense focus on particular ideas, which may seem odd or disturbing to others.
  • Acute Phase Symptomatology:
    ··Delusions: false, fixed beliefs that do not change even if evidence shows the contrary of the belief to be true
    ··Hallucinations: experiences involving perceptions of something in the absence of any external stimulus (auditory hallucinations are most common, although visual, gustatory tactile and olfactory hallucinations can also occur)
    ··Disorganized thinking (speech): jumping from topic to topic, inability to answer questions or answering them in a tangential manner, word salad
    ··Disorganized behavior: abnormal motor behaviors that result in a difficulty performing goal-directed behavior. The most dramatic of the behavioral profiles that can emerge is catatonia which is manifest an overall decreased reactivity to the environment, resulting in an absence of motion, mutism and stupor. It may also include repeated stereotyped movements or echolalia.
    ··Negative symptoms: absence of typical behaviors, including diminished emotional expression, a lack of motivation, poverty of speech, anhedonia and asociality.
  • Chronic Symptomatology: Negative Symptoms
    If not self-remitting, the long term course of patients with a schizophrenic illness is typically manifest by a significant degree of dysfunction and disability as manifest by a persistence and further development of the negative symptoms as identified above. These symptoms and the dysfunction they often cause can be devastating for the individual and the family.
  • Confounding Considerations in Assessing Children:
    Although many children who report psychotic-like symptoms do not go on to develop psychosis in adulthood, these symptoms have been shown to be associated with the presence or the later development of other psychiatric disorders in adulthood. Therefore, it is important to recognize when a child or adolescent describes psychotic-like symptoms that may be distressing to them. Timing is also an important consideration. Hallucinations, for example, are common in children and often do not signify any sort of pathology; however, if hallucinations persist into adolescence, the risk of developing psychosis is 5-6x greater.

Here are some ways that psychotic like symptoms could present in a pediatric visit:
• Feeling “off” or a vague feeling that something is wrong
• A recent drop in grades/work performance
• Increased isolation
• Decreased hygiene or self-care
• Difficulty communicating or confused speech
• New-onset difficulty concentrating
• Trouble separating fantasy from reality
• Cognitive delays not previously in evidence

Future articles in this series will address the elements and processes of assessment appropriate for the pediatric setting and information about referral and intervention services available within San Diego County.

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Thanks to Sheridan Chappelle of the UC San Diego School of Medicine, Class of 2024 under the guidance and supervision of Desiree Shapiro, M.D., Associate Clinical Professor of Psychiatry University of California, San Diego Department of Psychiatry – Division of Child and Adolescent Psychiatry, Medical Director, UC San Diego Child and Adolescent Psychiatry Inclusive Excellence Program

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