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Home , Internal monologue, Mental disorder, Prodrome, Thought blocking

Evaluating Suspected

Aditi Sharma, MD Webinar | April 3, 2021

Patrick By the end of this presentation, the learner will be able to:

1. Define “psychosis” 2. Describe three possible causes of psychotic symptoms 3. Provide a differential diagnosis for suspected psychosis 4. Identify common features of prodrome of psychosis • Objectives5. Know when to refer for evaluation for early onset

Arabel Case

• Zoe is a 12-year-old girl referred for an evaluation. She and her family recently moved across the country. Since that time, Zoe has been complaining of and stomachaches and has missed several days of school due to not feeling well.

• Prior to this, Zoe had never been in treatment. She has a normal IQ and no learning problems. Her academic and social functioning are normal. Case continued

• On intake, Zoe endorsed many features of , problems, and hearing voices and her mother also reported concerns about anxiety and sleep problems.

• Her parents were alarmed to learn that Zoe endorsed hearing voices and expressed the that she might have schizophrenia. Poll Question

Q. What percentage of 12-year-olds endorse when surveyed?

A. 17% (Kelleher et al) Are hallucinations the same as psychosis?

• No!

• 17% of kids and 8% of adolescents will answer “yes” when asked if they see or hear things that other people do not see or hear • That does not mean they are psychotic • But they are likely to have some kind of psychiatric disorder

• The most common cause of hallucinatory experiences in kids and adolescents? • Anxiety What is psychosis?

• Loss of touch with reality, or impairment in

• This can look like:

• Hallucinations • • Disorganized thinking • Disorganized behavior and speech Hallucinations - definition

• Sensory experiences that are generated by a person’s rather than something in the environment.

• Common examples include hearing voices or seeing things Delusions - definition

• Fixed false irrational or bizarre beliefs – that lie outside the context of shared cultural and religious beliefs and experiences

• Eg: “Knocking on wood” – not a Disorganized speech and behavior

• You know it when you see it

• Think of this when you are having trouble following what a patient is saying, or getting a history of symptoms Case, revisited

• At the initial interview, Zoe reports that she sees two figures who speak to her. Their names are “Kyle” and “Janie.” She describes them vividly and feels their presence more strongly when she feels anxious and when she goes to school. Case, revisited

On interview, Zoe is well groomed and well spoken. She does not appear internally preoccupied. Her speech and thoughts are organized. Zoe is able to tell the examiner her birthday, the current date, and her new address. She has a euthymic affect when describing her hallucinations. She reports missing her old school and friends and is quite anxious about attending the new school and meeting new people. When the clinician suggests that she cannot miss more school, Zoe starts crying. What features argue for psychosis?

• Hallucinations What features argue against psychosis?

• Good premorbid functioning

• Organized presentation, speech

• Intact -care

• Hallucinatory experiences change based on context

• More common disorder would explain the symptoms Case Wrap Up

Clinical interview and historical features not consistent with a primary psychotic disorder: • Age (onset of true psychosis below age 13 years is rare) • High premorbid and current functioning (no learning disorders, no social problems) • Organized thinking on the mental status exam • Articulate and organized speech and behaviors • Intact self-care (good grooming and hygiene) • Highly organized description of the hallucinations • Report of hallucinations that are situationally specific (e.g., worse with anxiety and when she goes to school) Psychosis is a symptom, not a diagnosis

• Just like pain

• You need to find the cause before you can choose a treatment (or at least have a working hypothesis) Assessment of Suspected Psychosis - Framework

Hallucinations, "delusions," ""

Psychosis Psychosis mimicker

Medical Psychiatric Anxiety

Mood disorder (e.g. bipolar Trauma Behavioral disorder)

Primary psychotic substance disorder (e.g. intoxication schizophrenia)

genetic disorders *This is conceptual and not intended to capture all possible causes of hallucinations / delusions Psychosis mimickers

• Anxiety

• / dialogue

• Depressive ruminations

• Borderline

• Trauma Causes of Psychosis

Medical • Delirium () • Autoimmune disorders (acute) • Genetic disorders (more likely chronic)

Substances • (controversial) • • Hallucinogens • Alcohol withdrawal (hallucinations are a symptom of life-threatening alcohol withdrawal) Causes of psychosis (2)

Psychiatric • Depression (rare) • • Primary psychotic disorder/schizophrenia • Once you know the symptoms are psychiatric in origin

• Your goal should be to identify, is it a primary psychotic disorder, or is the psychosis (or quasi-psychosis) related to another ?

• This matters because it affects treatment

• Eg: You don’t want to treat “hallucinations” related to trauma with if you can help it. What is a primary psychotic disorder?

• Schizophrenia or schizophrenia

• Meaning, the core symptoms are the psychotic symptoms Schizophrenia • A chronic and severe disorder of neurodevelopment • Onset occurs in adolescence or early adulthood • Worldwide prevalence between 0.23-1% • Childhood onset (< age 13) is rare • If you find yourself diagnosing schizophrenia in a patient 13 or younger, ask yourself how compelling the case is • Much more likely to be something else • Three main categories of symptoms: positive, negative, and disorganization Risk Factors for Schizophrenia

• Childhood disruptive behavior disorders

• Academic challenges

• Speech and language disorders

• Social deficits Positive Symptoms

• Hallucinations

• Delusions Negative Symptoms

Problems with thinking and functioning • Lack of motivation • Lack of speech • Flat affect

Difficult to separate from comorbid depression

Don’t respond very well to first-line Disorganization

• Disorganized speech • Loose associations • Tangential speech

• Bizarre behavior

• Poor attention

• Catatonic behavior (general lack of response to one’s environment) Case 2

Dan, a 17-year-old young man with a history of attention- deficit/hyperactivity disorder (ADHD) is brought to the pediatrician by his mother because he has become more withdrawn and isolated over the past 6 months. He rarely engages with friends and seems to go days without speaking to his parents. Dan’s grades have deteriorated, and he is no longer completing homework assignments. His grandmother, visiting from out of state, has noticed that his hair seems greasy and wonders if he has been changing his clothes. Dan seems to be awake late at night and spends a lot of time playing video games on his computer and reading message boards online. Thoughts so far on Dan?

• Speak up or write in the chat Case 2 continued

• On initial interview, Dan speaks quietly and makes little eye contact. He is disheveled and wearing clothes that are quite wrinkled. He answers questions briefly using one- to two-word answers and endorses feeling depressed, with decreased interest in previously enjoyed activities and low energy. • Dan’s pediatrician diagnoses him with depression and prescribes , an medication. The pediatrician asks him to follow up in 6 weeks. Case 2 continued

• At the 6 week follow-up visit, Dan appears more disheveled and is slightly malodorous. He makes little eye contact and seems distracted. He takes a long time to answer questions. Some of the conversation is hard to follow because Dan’s sentences do not always make sense. He does not always seem to register what others say to him. His affect is flat. Dan’s weight is down 4 pounds since the initial visit. His mother shares that at the parent–teacher conference, his teacher commented that when he comes into the classroom, he seems confused and often takes a while to find his seat. Dan has been observed talking and laughing to himself at home and in school. His mother asks if his antidepressant needs to be increased or changed. Case 2 wrap up

• FeaturesFeatures of initialof initial assessment assessment that suggest that evolvingsuggest psychosis. evolving psychosis.• History: marked deterioration in functioning, social relatedness, and self-care •areHistory: all hallmark marked prodromal deterioration symptoms of in psychosis. functioning, social • Observation:relatedness, On MSE,and Dan’sself-care paucity are of all speech hallmark and lack prodromal of engagement is a signsymptoms of developing of psychosis., and also might represent paranoia. • Observation: On MSE, Dan’s paucity of speech and lack of • At theengagement follow-up visit, is a bothsign ofhistory developing and exam thought provide disorder, a clearer and picture also of psychosis.might represent paranoia. • Disorganized thought is demonstrated by Dan’s difficulty finding his seat in • Atclass the and follow on exam-up by visit, his speech both pattern. history and exam provide a clearer• Delayed picture responses ofto questionspsychosis. may reflect thought blocking. • Disorganized thought is demonstrated by Dan’s difficulty • Morefinding overt his signs seat include in class others and seeing on Danexam talking by his to himself,speech weight pattern. loss, and further decline in self-care • Delayed responses to questions may reflect thought blocking. • More overt signs include others seeing Dan talking to himself, weight loss, and further decline in self-care Refer to ! Prodrome

• Functional deterioration that presents before the onset of obvious symptoms • Social withdrawal and isolation • Decreased self-care • Odd or bizarre preoccupations and behaviors • Academic decline Treatment

• Effective treatment is a combination of psychosocial interventions and medications • Psychosocial interventions help with functional deficits • Vocational training • Social skills training • Independent living support • Medications may help reduce core symptoms Assessment of Suspected Psychosis - Framework

Hallucinations, "delusions," "paranoia"

Psychosis Psychosis mimicker

Medical Psychiatric Anxiety Depression

Mood disorder delirium (e.g. bipolar Trauma Behavioral disorder)

Primary psychotic substance disorder (e.g. intoxication schizophrenia)

genetic disorders *This is conceptual and not intended to capture all possible causes of hallucinations / delusions Summary

• True psychosis in children is extremely rare • Diagnosis should be made based on history and observation, and should be re-evaluated regularly • Underlying causes for psychosis should be ruled out before making a diagnosis of a primary psychotic disorder like schizophrenia • Treatment is multimodal • Objectives – did we achieve?

By the end of this presentation, the learner will be able to: 1. Define “psychosis” 2. Describe three possible causes of psychotic symptoms 3. Provide a differential diagnosis for suspected psychosis 4. Identify common features of prodrome of psychosis 5. Know when to refer for evaluation for early onset schizophrenia

Arabel Any Questions?

Olivia