For most folks the words psychotic and or schizophrenic bring to mind the idea of a floridly disruptive, agitated, and disorganized individual who is experiencing persistent auditory hallucinations, bizarre thinking,  delusional belief system(s), and a break down in their capacity to interact appropriately with others—all core features of a schizophrenic illness.  The more typical course of an evolving schizophrenic disorder, however, is more subtle with gradual onset of the prodromal symptoms of social withdrawal, subtle cognitive declines (decreased concentration, disorganized thinking), and social and functional impairments including irritability, suspiciousness, a decline in functioning.

With recognition of these early signs and symptoms, a primary care provider can contribute to the more formal multidisciplinary diagnostic phase of intervention in three important ways, by.

• Considering the differential diagnoses that may be underlying the youth’s clinical presentation: Is this schizophrenia, or is it a substance-induced psychosis, a psychosis associated with severe depression or mania, an atypical presentation of another psychiatric condition (such as severe PTSD), or a symptom of an identifiable organic (metabolic or neurologic) disorder?
• Conducting a comprehensive physical exam and obtaining relevant laboratory studies, to include CBC, CMP, TSH, electrolytes, ceruloplasmin, ANA, ESR, VDRL, HIV, B12, folate, U/A and urine toxicology—these to rule out organic etiologies and to establish baseline levels to allow for prompt medication treatment when indicated.
• Encouraging the patient and family to seek evaluation and services from child/adolescent psychiatrist or a multidisciplinary behavioral program.

Interviewing the Patient:  Interviewing an individual with suspected psychotic features can at times be challenging, but when feasible, doing so can aid in clarifying a diagnosis and is important in ruling out acute risk considerations and interventions.  Minimally, it is important to explore whether the individual is a potential danger to themselves or others and inquiry as to whether they are having thoughts of hurting themselves or others and/or if they are hearing auditory hallucinations of a derogatory nature or which entail commands to act in a dangerous manner.  Likewise, a history of significant impulsivity or agitation should be noted.  If present, further risk assessment is warranted and may entail referral to an urgent care or other emergency service.

As with any patient experiencing distress or dysfunction, an empathic approach that acknowledges the youth’s distress and communicates your interest in learning more about their condition is most helpful.   Learning about the time of onset of symptoms, their impact, and how the patient is coping are good initial steps. Inquiry as to issues of trauma, abuse, bullying and substance abuse should be made. Exploring for and learning about the presence or absence of overt symptoms of psychosis, such as hallucinations and delusional thinking, can feel awkward but prefacing the content inquiry with a statement to the effect that “Sometimes when people are having difficulties, they may hear or see things differently than usual.  So, I am wondering if you have experienced times when you hear voices or find yourself thinking about things in an unusual way?”

Involving the Family:   Engaging the family is also critical as they can provide important information as to the youth’s developmental history and baseline profile prior to symptom onset; the timeline of symptom progression and impact on functioning; the family history of mental health and substance use problems; and, the presence or absence of major life stressors.

Referral Options:

• If, as discussed above, high risk features are clearly present a referral to a psychiatric emergency setting will be appropriate. If these concerns are less overt, a referral to the Rady’s Behavioral Urgent Care clinic might be considered—a call to the program to discuss the referral concerns would be advisable.  (858) 966-5484
• If there are no imminent risk issues, referral to a child psychiatrist, another qualified behavioral health specialist who works collaboratively with a psychiatrist, or a multidisciplinary clinic program would be appropriate
• SmartCare can be a resource to assist parents in making the recommended connection to care.                                                                     The SmartCare Family Support line is (858) 956-5900.
• Long term treatment resources
  1. Kickstart
• Who they work with: insured and uninsured adolescents and young adults ages 10 to 25
• What they do: 12 to 18 months of interdisciplinary treatment involving multiple therapy modalities, including psychotherapy, group therapy, occupational therapy, education and employment support, peer support, and much more
• When to refer: if there is possible risk of first episode psychosis or psychotic-like symptoms present in your patient, you can refer them to Kickstart for an initial consultation and evaluation. They will determine if your patient is eligible for their services, as well as conduct assessments for psychosis risk. Their focus is on early intervention and prevention of psychosis, so early referral to this program is paramount for a patient to utilize their resources
• How to refer: there is a referral form on the Kickstart website that can be completed by the clinician, patient, and parent, and submitted to Kickstart in-person or via mail or fax. Phone (619) 481-3790    858 966-5484
•     2. CARE Program
• Who they work with: insured adolescents and young adults experiencing psychotic-like symptoms or first episode psychosis
• What they do: clinical services include collaborative care with patients and their families to create a unique treatment plan that best addresses patient needs. This could include medication management, psychotherapy, group therapy, intensive outpatient care, peer support, and inpatient care. Patients ages 12 to 35 can also enroll in research studies conducted at CARE.
• When to refer: if your patient is insured and presents with first episode psychosis or psychosis-related symptoms, they can be referred to CARE for further evaluation and assessment. They will collaborate to determine the level of care necessary and create a treatment plan to address the patient’s needs.
• How to refer: contact CARE as (619) 543-7745 or email: ucsdcareprogram@gmail.com

References

CARE Program | UC San Diego Department of Psychiatry. (n.d.). UC San Diego School of Medicine. Retrieved December 5, 2021, from https://medschool.ucsd.edu:443/som/psychiatry/research/CARE/pages/default.aspx

Hua, L. L. (2021). Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics, 147(6). https://doi.org/10.1542/peds.2021-051486

Kickstart San Diego | Mental Health Prevention and Early Intervention. (n.d.). Kickstart San Diego. Retrieved December 5, 2021, from https://www.kickstartsd.org

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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

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