Overview
Definition:
Acute psychosis in adolescents refers to the sudden onset of psychotic symptoms, including hallucinations, delusions, disorganized thinking or speech, and grossly disorganized or abnormal motor behavior, in an individual under the age of 18
It represents a significant deviation from the individual's previous level of functioning and often necessitates urgent evaluation and intervention.
Epidemiology:
While less common than in adults, acute psychosis can occur in adolescents
The incidence is estimated to be around 0.1 per 1000 person-years in this age group
Early onset of psychosis (before age 18) is associated with a poorer prognosis and a higher risk of developing chronic psychotic disorders such as schizophrenia.
Clinical Significance:
Prompt and accurate medical workup is crucial in adolescents presenting with acute psychosis
It is vital to rule out underlying medical conditions that can mimic psychiatric symptoms, to identify potential substance use, and to initiate appropriate psychiatric management
Early intervention significantly impacts long-term outcomes and reduces the risk of severe functional impairment and morbidity.
Clinical Presentation
Symptoms:
Sudden onset of hallucinations (auditory, visual, olfactory, tactile, gustatory)
False beliefs that are not amenable to reason (delusions), such as paranoid or grandiose themes
Disorganized speech, including tangentiality, derailment, or incoherence
Bizarre or disorganized behavior, catatonia, or marked psychomotor agitation/retardation
Significant decline in academic performance or social functioning
Withdrawal from social activities
Sleep disturbances
Irritability, aggression, or paranoia
Expressing suicidal or homicidal ideation.
Signs:
Observable signs of distress, agitation, or catatonia
Inappropriate affect or flat affect
Incoherent or illogical speech patterns
Lack of insight into their condition
Evidence of self-neglect or neglect of hygiene
Physical signs related to potential underlying medical conditions (e.g., fever, neurological deficits, rash).
Diagnostic Criteria:
While specific diagnostic criteria for "acute psychosis in adolescents" as a standalone diagnosis are not defined by DSM-5-TR, the presentation is assessed against criteria for psychotic disorders (e.g., Brief Psychotic Disorder, Schizophreniform Disorder, Schizophrenia, Substance/Medication-Induced Psychotic Disorder, Psychotic Disorder Due to Another Medical Condition)
The key is the sudden onset and significant impact on functioning.
Diagnostic Approach
History Taking:
Comprehensive psychiatric history including onset and duration of symptoms
Detailed symptom inventory (hallucinations, delusions, disorganized thought/behavior)
Family history of psychiatric illness, substance abuse, or neurological disorders
History of trauma, abuse, or neglect
Recent stressors
Substance use history (including prescription, over-the-counter, and illicit substances)
Medical history, including prior mental health issues, infections, autoimmune disorders, or neurological conditions
Medications (prescribed and non-prescribed)
Sleep and appetite patterns
Academic and social functioning baseline.
Physical Examination:
Complete physical examination, including vital signs (temperature, pulse, blood pressure, respiratory rate)
Neurological examination to assess for focal deficits, coordination, gait, cranial nerves, and reflexes
Examination for signs of trauma, infection, or systemic illness
Dermatological examination for rashes or signs of drug use.
Investigations:
Laboratory tests: Complete blood count (CBC) with differential to detect infection or anemia
Comprehensive metabolic panel (CMP) to assess electrolytes, glucose, kidney, and liver function
Thyroid function tests (TSH, free T4) to rule out thyroid-related psychosis
Urinalysis for drug screening and infection
Blood alcohol level if intoxication is suspected
Serological tests for syphilis and HIV if indicated
Vitamin B12 and folate levels
Autoimmune markers (e.g., ANA, ESR, CRP) if autoimmune encephalitis is suspected
Lead levels in young children or if exposure is suspected
Imaging: Neuroimaging (MRI brain preferred over CT) to rule out structural lesions, tumors, infections, or evidence of inflammatory processes
Electroencephalogram (EEG) to rule out seizure activity or non-convulsive status epilepticus.
Differential Diagnosis:
Substance-induced psychotic disorder (cannabis, stimulants, hallucinogens, sedatives)
Psychotic disorder due to another medical condition (e.g., autoimmune encephalitis, CNS infections, metabolic derangements, endocrine disorders, neurological conditions like epilepsy or tumors)
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Bipolar disorder with psychotic features
Major depressive disorder with psychotic features
Delusional disorder
Post-traumatic stress disorder (PTSD) with psychotic features
Somatoform disorders with delusions.
Management
Initial Management:
Ensure safety of the patient, staff, and others
Immediate de-escalation techniques
Provide a safe and low-stimulus environment
Assess for suicidal or homicidal ideation and implement safety protocols
Medical stabilization, addressing any physiological abnormalities (e.g., dehydration, electrolyte imbalance, fever).
Medical Management:
Pharmacological treatment typically involves antipsychotic medications
First-generation antipsychotics (e.g., Haloperidol, Chlorpromazine) or second-generation antipsychotics (e.g., Risperidone, Olanzapine, Quetiapine, Aripiprazole) may be used
Dosing should be initiated cautiously and titrated based on response and tolerability
Oral formulations are preferred, but intramuscular injections may be necessary for rapid tranquilization
Aripiprazole and Risperidone are often considered first-line for pediatric psychosis
Benzodiazepines may be used for agitation or anxiety
Long-term management strategy will depend on the underlying diagnosis
Referral to a child and adolescent psychiatrist is essential.
Surgical Management:
Surgical management is not typically indicated for acute psychosis itself
However, if the psychosis is a symptom of an underlying neurosurgical condition (e.g., brain tumor, abscess), surgical intervention would be directed at treating that specific condition.
Supportive Care:
Continuous monitoring of vital signs, behavior, and response to medication
Nutritional support and hydration
Ensuring adequate sleep
Psychoeducation for the patient and family
Establishing a therapeutic alliance
Social support services and family involvement are critical for recovery and reintegration.
Complications
Early Complications:
Self-harm or harm to others
Worsening of psychotic symptoms
Development of catatonia
Medical complications related to underlying conditions or medication side effects (e.g., extrapyramidal symptoms, metabolic syndrome)
Dehydration and malnutrition due to agitation or self-neglect.
Late Complications:
Development of chronic psychotic disorders (e.g., schizophrenia)
Significant academic and social functional impairment
Increased risk of substance abuse
Chronic medical comorbidities
Social isolation and stigma.
Prevention Strategies:
Early identification and intervention
Comprehensive medical and psychiatric workup to rule out organic causes
Prompt initiation of appropriate treatment
Strong family and social support systems
Ongoing monitoring and adherence to treatment
Addressing any co-occurring conditions.
Prognosis
Factors Affecting Prognosis:
Prognosis varies greatly depending on the underlying cause
Acute, transient psychotic episodes (e.g., brief psychotic disorder) have a better prognosis than those evolving into chronic psychotic disorders
Factors associated with a better prognosis include: female gender, abrupt onset, presence of mood symptoms, absence of a family history of schizophrenia, good premorbid functioning, and prompt treatment
Conversely, insidious onset, presence of negative symptoms, poor premorbid functioning, and family history of schizophrenia are associated with a poorer prognosis.
Outcomes:
Outcomes range from complete remission of symptoms to the development of chronic, debilitating psychotic disorders
Adolescents with early onset psychosis who receive timely and comprehensive care have a better chance of achieving functional recovery and a better quality of life
However, many may require long-term psychiatric care and support.
Follow Up:
Regular follow-up with child and adolescent psychiatry is essential to monitor symptom remission, medication adherence, and potential side effects
Continued assessment of functional status (academic, social, occupational) is important
Family support and involvement are crucial for long-term management and relapse prevention.
Key Points
Exam Focus:
Always rule out organic causes of psychosis in adolescents before attributing it solely to a primary psychiatric disorder
Common organic causes include substance intoxication/withdrawal, infections (CNS, systemic), metabolic derangements, autoimmune disorders, and neurological conditions
Second-generation antipsychotics are often preferred due to a better side effect profile
Early intervention is critical for improving long-term outcomes.
Clinical Pearls:
Engage the family early in the assessment and treatment process
Be aware of the unique developmental considerations in adolescents
A comprehensive and systematic approach is paramount
Never underestimate the potential for self-harm or harm to others in an acutely psychotic adolescent.
Common Mistakes:
Failing to perform a thorough medical workup
Prematurely diagnosing a primary psychiatric disorder without ruling out organic causes
Inadequate monitoring of medication side effects
Insufficient engagement of family in the treatment plan
Underestimating the risk of suicidality or aggression.