Overview
Definition:
First-episode psychosis (FEP) in pediatrics refers to the initial presentation of psychotic symptoms in a child or adolescent
These symptoms can include delusions, hallucinations, disorganized speech, and disorganized or catatonic behavior, significantly impacting functioning
The emergency department (ED) is often the first point of contact for these patients and their families, necessitating a rapid and comprehensive evaluation.
Epidemiology:
While rare, FEP can occur in childhood and adolescence, with incidence increasing in late adolescence and early adulthood
Early onset psychosis (before age 13) is particularly rare
The prevalence of schizophrenia spectrum disorders increases significantly during adolescence
Factors such as family history of psychosis, perinatal complications, and substance use (in adolescents) are risk factors.
Clinical Significance:
Prompt and accurate assessment in the ED is crucial for several reasons: to rule out dangerous medical mimics, to identify immediate safety risks (to self or others), to initiate appropriate treatment, and to establish an early connection to psychiatric care, which is vital for long-term outcomes
Delays in diagnosis and treatment are associated with poorer prognosis.
Clinical Presentation
Symptoms:
Sudden onset or gradual emergence of psychotic symptoms
Hallucinations (auditory most common, but visual, tactile, olfactory also possible)
Delusions (persecutory, grandiose, referential, bizarre)
Disorganized speech (incoherent, tangential, illogical)
Disorganized behavior (agitation, aggression, inappropriate actions)
Negative symptoms (apathy, alogia, avolition) may be present but are often less prominent in the initial ED presentation
Significant decline in academic or social functioning
Social withdrawal
Sleep disturbances
Irritability or mood lability.
Signs:
Disheveled appearance
Poor hygiene
Poor eye contact
Paranoid demeanor
Inappropriate affect
Poorly organized thoughts or speech
Signs of agitation or aggression
Potential for self-harm or harm to others
Vital signs may be normal unless there is concurrent medical illness or agitation.
Diagnostic Criteria:
DSM-5 criteria for psychotic disorders should be considered
While formal diagnosis is complex and often requires longitudinal assessment, the ED evaluation focuses on identifying the presence of psychotic symptoms and ruling out other causes
The primary goal is to determine if the symptoms are consistent with a psychotic episode and if immediate intervention is needed.
Diagnostic Approach
History Taking:
Detailed collateral history from parents/guardians is paramount
Onset, duration, and progression of symptoms
Nature of hallucinations and delusions
Triggers or precipitating events
Any previous psychiatric history or family history of psychiatric illness, especially psychosis
Substance use (including prescribed medications, over-the-counter drugs, and illicit substances)
Recent stressors (trauma, bullying, academic pressure)
Any history of head trauma, seizures, or significant medical illness
Nutritional status and dietary habits
Sleep patterns.
Physical Examination:
Comprehensive physical examination to rule out medical causes
Neurological examination: assess for focal deficits, gait abnormalities, coordination, cranial nerves, and reflexes
Fundoscopy to check for papilledema
Examination of skin for rashes (e.g., neurosyphilis, lupus)
Assess for signs of trauma
Thorough mental status examination: orientation, attention, memory, thought process, thought content, perception, mood, affect, insight, and judgment.
Investigations:
Laboratory tests: Complete blood count (CBC) with differential to check for infection or anemia
Basic metabolic panel (BMP) to assess electrolytes, glucose, and kidney function
Liver function tests (LFTs)
Thyroid function tests (TFTs) to rule out thyroid-related psychosis
Urinalysis to check for infection or drug screen
Toxicology screen (urine and blood) for illicit substances, alcohol, and certain medications
Vitamin B12 and folate levels
Serum ammonia if hepatic encephalopathy is suspected
Consider tests for autoimmune encephalitis (e.g., anti-NMDA receptor antibodies) if clinically indicated
Imaging: Head CT or MRI to rule out structural lesions such as tumors, stroke, trauma, or hydrocephalus
Electroencephalogram (EEG) if seizures are suspected.
Differential Diagnosis:
Medical conditions: Encephalitis (viral, autoimmune), meningitis, CNS infections (e.g., neurosyphilis, Lyme disease), metabolic disorders (hepatic encephalopathy, uremia), endocrine disorders (thyroid storm), intoxications/withdrawal (stimulants, hallucinogens, anticholinergics, cannabis, alcohol), medication side effects (steroids, dopaminergic agents)
Neurological conditions: Brain tumors, epilepsy (especially temporal lobe), stroke, Huntington's disease
Psychiatric conditions: Schizophrenia spectrum disorders, bipolar disorder (manic episode with psychotic features), severe depression with psychotic features, brief psychotic disorder, substance-induced psychotic disorder, trauma-related disorders (e.g., PTSD with dissociative symptoms).
Management
Initial Management:
Ensure patient safety and safety of others
Provide a calm, quiet environment
De-escalation techniques
If agitated or posing a risk, consider physical or chemical restraint according to hospital protocol
Medical stabilization: Address any immediate medical issues identified during the workup (e.g., electrolyte imbalance, hypoglycemia).
Medical Management:
Pharmacological intervention may be necessary for symptom control in the ED, especially for agitation or severe distress
Atypical antipsychotics are generally preferred
For example: Olanzapine (0.1-0.2 mg/kg, max 10-20 mg PO/IM), Risperidone (0.5-1 mg PO/IM), Quetiapine (25-50 mg PO)
Dosing should be cautious in children and adolescents, starting low and titrating slowly
Benzodiazepines may be used for short-term sedation and anxiety relief, but should be used judiciously to avoid masking underlying symptoms or causing excessive sedation
Lorazepam (0.05 mg/kg, max 2 mg PO/IM) is commonly used.
Surgical Management:
Surgical intervention is not typically indicated for the psychiatric symptoms of psychosis itself
However, if the workup reveals a surgically treatable underlying medical condition (e.g., a brain tumor, abscess), prompt surgical management would be initiated for that condition.
Supportive Care:
Continuous observation and monitoring of vital signs and mental status
Reassurance and supportive communication
Ensure adequate hydration and nutrition
Provide for basic needs like hygiene
Involve mental health professionals (psychiatrist, social worker) for comprehensive assessment and planning for disposition and follow-up.
Complications
Early Complications:
Self-harm or suicide
Harm to others due to delusions or command hallucinations
Aggression and violence
Worsening of underlying medical conditions
Medication side effects (e.g., extrapyramidal symptoms, sedation)
Dehydration and malnutrition if not eating/drinking.
Late Complications:
Chronic mental illness
Social isolation and stigma
Academic and vocational impairment
Substance abuse
Co-occurring medical and psychiatric conditions
Relapse of psychosis.
Prevention Strategies:
Early identification and intervention
Comprehensive workup to rule out reversible medical causes
Prompt initiation of appropriate psychiatric treatment
Ongoing psychiatric care and adherence to medication
Psychoeducation for patient and family
Stress management techniques
Substance abuse prevention and treatment.
Prognosis
Factors Affecting Prognosis:
Age of onset (earlier onset generally poorer prognosis)
Degree of prodromal symptoms
Presence and type of hallucinations/delusions
Level of functioning prior to onset
Response to initial treatment
Adherence to treatment
Family history of psychosis
Social support systems
Presence of substance abuse.
Outcomes:
Prognosis varies widely
With early and appropriate intervention, some individuals may achieve remission or significant improvement
However, many experience a chronic course with relapses
Long-term outcomes depend on ongoing treatment, management of co-occurring conditions, and social support.
Follow Up:
Crucial for all patients presenting with FEP
Outpatient psychiatric follow-up with a child and adolescent psychiatrist
Regular monitoring for symptom recurrence, medication efficacy, and side effects
Psychosocial support and rehabilitation services
Family involvement and support
Continued medical monitoring as needed.
Key Points
Exam Focus:
Always rule out medical mimics of psychosis in the ED
Prioritize patient safety and the safety of others
Thorough history, especially collateral from parents, is key
Consider toxicology and substance abuse in adolescents
First-line pharmacological agents are atypical antipsychotics
start low and go slow
Early intervention improves long-term prognosis.
Clinical Pearls:
Don't miss treatable causes like encephalitis, metabolic disorders, or intoxication
Empathy and a non-judgmental approach are vital when interacting with a child/adolescent in psychosis
Develop a clear de-escalation plan
Engage the family as allies in care
Document safety assessments rigorously.
Common Mistakes:
Attributing symptoms solely to a psychiatric cause without a thorough medical workup
Delaying antipsychotic initiation when patient safety is compromised
Inadequate dose or duration of antipsychotic treatment
Failing to involve family/guardians in the assessment and treatment plan
Inadequate follow-up arrangements post-discharge.