Psychosis Unit M: Psychosis Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis

Learning Objectives Differentiate among psychosis and other pediatric behavioral health problems with psychotic features List cognitive symptoms of psychosis Describe treatment options and clinical recommendations when selecting and using medications for psychosis New SLIDE Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis

Hidden Slide: Time Table Total Time: 25 minutes Intro, Goals & Objectives: 1’ 4 Slides: 12’ Q&A: 12’ Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis Unit M: Psychosis

What is Psychosis? Severely disrupted thought & behavior resulting in loss of developmentally appropriate reality testing Overt changes in function, w/evidence of disrupted thinking on mental status exam Psychotic symptoms - characteristic of schizophrenia, but do occur in other illnesses, e.g.: mood disorders neurologic conditions acute intoxication New SLIDE Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis

Epidemiology of Psychosis in Children and Adolescents Children < 12 years old Schizophrenia is very, very rare Consider non psychiatric causes, MDD with psychotic features, bipolar disorder, severe PTSD, or other potential ideologies Adolescents 13-17 years old Schizophrenia = 0.3-0.5 percent Same considerations as above Adults > 18 years old Schizophrenia = about 1% Faculty – point out the following resource slides in their books Last updated 9/13/2013 - PSJ Unit M: Psychosis

Medical Causes of Psychosis CNS infections Delirium Neoplasms Endocrine disorders Genetic syndromes (e.g., velocardiofacial [22q11] syndrome) Autoimmune disorders Toxins Faculty – point out the following resource slides in their books Last updated 9/13/2013 - PSJ Unit M: Psychosis

Substances That May Cause Psychosis Dextromethorphan, LSD, hallucinogenic mushrooms (e.g., psilocybin, peyote), MJ, stimulants, inhalants Steroids, anesthetics, anticholinergics, antihistamines, amphetamines Acute psychosis due to intoxication usually remits within days to weeks after substance is D/C’ed Sometimes schizophrenia (and/or unresolved psychosis) first presents after substance ingestion Faculty – point out the following resource slides in their books Last updated 9/13/2013 - PSJ Unit M: Psychosis

Symptoms That May Seem Psychotic in Children Illusions: Sounds and visualizations at night often associated with anxiety “Voices”: Often a single voice telling the child to do something “bad” Imaginary Friends Fantasy: In young, cognitively-delayed or language-delayed child Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis

Core Cognitive Symptoms of Psychosis in Children & Youth Delusions Ideas of reference Belief of be persecuted or controlled Hallucinations Usually auditory, threatening voices giving comments, laughing , humming Visual hallucinations appear more common in children under age 13 Thought Distortions Breaks in the train of thought – so-called “private logic” Incoherent vague thoughts Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis

Asking kids about psychosis Things to say & ask: “Lots of times kids hear or see weird, funny, or even scary things they aren’t sure are real…” “Does your mind ever play tricks like that on you?” “Do you hear voices talking to you when no one is there?” “Does your mind ever feel confused” Youth can often describe relevant aspects of their psychotic symptoms, but some are too disorganized, confused, and/or paranoid to give accurate details or hx Parents, family members, teachers, and treatment providers are important sources of information for identifying changes in behavior, thinking, or function NEW SLIDE Updated 9/9/2013 – RAK Last updated 9/13/2013 - PSJ Unit M: Psychosis

Evaluation of Psychosis Core Symptoms Impairment and Function Drug Toxicology Screen R/O CNS Lesion (MRI) R/O Other Medical Conditions

Psychosis Treatment: Acute Referral for emergency/crisis care, if needed Referral for psychiatric consultation, if possible Use of antipsychotic medication, as needed FDA approved for schizophrenia (ages 13- 17 y.o.) Aripiprazole (Abilify) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) FACULTY: Point out the 2 following Resource Slides in bookj Last updated 9/9/2013 - RAK Further updated 9/13/2013 - PSJ Unit M: Psychosis

Psychosis Treatment: Chronic Patients in your practice Schizophrenia Other disorders with psychotic symptoms Identification and management of adverse effects Coming up next!

Hidden Slide: Faculty Q&A Presenter initiates a 15 minute question and answer session regarding assessment and treatment of psychosis and any previous material Use participant questions collected on white index cards first, then accept other questions. Last updated 9/9/2013 - RAK Unit R: Psychosis Unit M: Psychosis

Q&A Ask The Experts Unit M: Psychosis Last updated 9/9/2013 - RAK Further updated 9/13/2013 - PSJ Unit M: Psychosis

Please fill out Unit M evaluation REMINDER: Please fill out Unit M evaluation Last updated 9/9/2013 - RAK Further updated 9/13/2013 - PSJ Unit M: Psychosis

RESOURCE SLIDE: Psychiatric Disorders other than Schizophrenia that may present with psychotic symptoms Schizoaffective disorder psychotic symptoms plus prominent mood episodes (meeting full criteria for mania or depression) that are present for a substantial duration of the illness Psychotic mood disorders (especially bipolar disorder) Full-blown mania in teenagers often presents with florid psychosis, including hallucinations, delusions, and thought disorder Psychotic depression may present with hallucinations or delusions PTSD and or abused youth are esp. vulnerable to report psychotic-like symptoms - dissociation and/or anxiety, intrusive thoughts/worries, derealization, depersonalization, etc. NEW SLIDE Last updated 9/9/2013 - RAK Further updated 9/13/2013 - PSJ Journal of the American Academy of Child & Adolescent Psychiatry Volume 52, Issue 9 , Pages 976-990, September 2013 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Schizophrenia Unit M: Psychosis

RESOURCE SLIDE: Emergency Medication for Psychosis Olanzapine orally disintegrating Tabs (Zydis) 5-10 mg PO once prn Risperdal M-Tabs 1-2 mg PO once pm Ziprasidone IM 10-20 mg IM once prn NEW SLIDE Last updated 9/9/2013 - RAK Further updated 9/13/2013 - PSJ Unit M: Psychosis