A 15-year-old boy presents to the emergency department (ED) with a complaint of altered mental status that began a few days prior (per his mother) and has gotten progressively worse. On arrival, the patient is noted to be awake and oriented to person, place, and time. Bedside blood glucose is 100 mg/dL. His physical examination does not reveal signs of trauma and vital signs are normal. His heart and lung examinations are normal and his Glasgow Coma Score is 14 (E4, V4, M6). His pupils are equal and reactive. No neurologic deficits are noted on examination. He has disorganized speech and states that he is hearing voices. Laboratory testing results, including complete blood count, complete metabolic panel, urine drug screen, and electrocardiogram (ECG) are all within normal limits or negative. Lumbar puncture and computed tomography (CT) of the brain are performed both of which are normal. Given that the patient has no abnormalities on laboratory evaluation and CT shows no signs of intracranial abnormalities that can explain his altered mental status, the patient is diagnosed with new-onset psychosis.
A study published in 2017 performed across five health care systems in patients age 15 to 29 years found an incidence of new-onset psychosis of 86 per 100,000 person-years.1 Risk factors for new-onset psychosis include family history, perturbations of normal brain development (in-utero, perinatally, or postnatally), exposure to drugs such as marijuana, and emergence of subthreshold psychotic symptoms.2 Being on the lookout for comorbid conditions such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder is also important in young patients with schizophrenia, bipolar disorder, and schizoaffective disorder.3
According to Katz et al.,4 psychosis is known as a “severe disturbance in patient's mental functioning, manifested as aberrations in cognition, perception, mood, impulses, and reality testing.” Although psychotic features are rare in children younger than age 12 years,3 attention to detail during the physical examination can help guide management and diagnosis of young patients. Presentation can range from irritation to a true stuporous state.4 Common features of psychosis caused by a primary psychiatric cause, such as schizophrenia, include auditory hallucinations, delusions, and blunted affect. It is important to note that orientation and concentration are preserved in functional psychosis.5
One must acknowledge external influences such as substance abuse in the laboratory testing and management of patients with altered mental status. Comorbid substance abuse makes diagnosis and management challenging. The effects of substance abuse can distort the initial presentation especially if the patient is presenting with altered mental status. Substance abuse can mimic, distort, or exacerbate the psychotic features that are present. Studies show that as many as one-third or more of adolescents with schizophrenia or schizoaffective disorder have problems with substance abuse.3
The differential diagnosis for altered mental status is vast. In a patient presenting with altered mental status, other medical etiologies must be ruled out prior to making a primary psychiatric diagnosis. Vital signs, mental status, eye findings, and neurologic examination are important in the process of narrowing down the differential diagnosis. Paying attention to findings such as fever, tachycardia, skin, and pupillary changes are vital in guidance of diagnosis. Neurological examination should be nonfocal in the evaluation of altered mental status due to psychiatric illness.5
The differential diagnosis for altered mental status includes systemic illness (ie, urosepsis), meningitis, hepatic failure, hypertensive crisis, central nervous system lesions, such as a space occupying mass or intracranial abscess, epilepsy, including post-ictal state, anti–N-methyl-D-aspartate receptor encephalitis, metabolic diseases, thyroiditis or thyroid storm, as well as drug intoxication or withdrawal. Trauma should always be in the differential diagnosis for any patient with an altered level of consciousness. Neurologic diseases like multiple sclerosis or acute demyelinating encephalomalacia are also included in the differential diagnosis. Although rare, psychiatric illnesses like schizoaffective disorder, bipolar disorder, schizophrenia, mood disorders, and conversion disorder must also be considered.6
Psychiatric-based psychosis has three major causes: (1) primary psychotic disorders such as schizophreniform disorder and schizophrenia, (2) brief psychotic episodes, and (3) mood, anxiety, and trauma disorders.4 The most common causes of psychiatric-based psychosis in children are mood, anxiety, and trauma disorders.4 Presentation can vary based on whether the patient has depression with psychotic features or anxiety with delusions or hallucinations related to their fears. Psychotic features can include impairment of thought content, illogical thinking, or loose associations.4 Auditory hallucinations are most common and can include commands for the patient to harm themselves or others around them. These disorders can be distinguished from primary psychotic disorders by recognizing that the symptoms are “placed in a greater clinical context of the patient's presentation.”4
Primary psychotic disorders like schizophrenia are present in 0.5% of the adolescent population and features must be present for more than 6 months.4 The symptoms of schizophrenia impair a patient's overall psychological processes including perception, thinking, and behavior.4 Detailed history often reveals a prodromal phase of unusual behavior, social withdrawal, regression in performance of duties at home or school, and changes in appearance. Brief psychotic episodes, on the other hand, are time limited and usually caused by externally imposed events such as trauma.4 They are differentiated from posttraumatic stress disorder by acuteness of clinical presentation and precipitating events such as abuse, rape, and homelessness.
Conversion disorder is included in the differential diagnosis for altered mental status and should be considered when a patient has inconsistencies throughout their examination, anxiety-driven hyperarousal with obsessive structure, unfocused thought process, and speech full of subclauses making interview difficult to control.7 For example, a patient with conversion disorder may answer one question appropriately and then answer a subsequent question with garbled speech, numbers instead of words, or ignore the question completely. Patients are typically in significant distress and their symptoms are not consciously produced.4 Patients with conversion disorder often have high levels of selective attention, usually directed toward themselves; whereas attention to extraneous stimuli suggest an alternative diagnosis.7
Young people with psychotic illnesses are often misdiagnosed, especially at the initial presentation. This is due to overlapping symptoms at presentation and lack of clinician familiarity with psychotic illnesses in the youth population.3 First and foremost, assessing the primary survey (airway, breathing, and circulation) is most important in any patient with altered mental status. Additional findings such as abnormal vital signs, dyspnea, hypoxia, fever, or acute focal neurologic deficits should guide the clinician to an organic (nonpsychiatric) cause of altered mental status. Speak with the patient to determine the level of altered mental status, assessing for disorientation, hallucinations, and/or abnormal thought content.6 Perform a detailed and complete neurologic examination. Formal diagnosis is usually not made in the ED but by psychiatrists or other mental health personnel using one of many standardized tools that are also used on adults along with local practice patterns.3 The goal of standardized diagnostic tools is to reduce variability among clinicians and improve the accuracy of diagnostic process.
In the office, obtain a bedside serum glucose measurement. Assess and assure patient, family, and staff safety. Consider using emergency medical services for transport if safety is a concern; otherwise the direct caregiver to transport patient to the ED for further evaluation.
In the ED, management priorities include ensuring that the patient has stable vital signs and an intact primary trauma survey, as well as determining if the patient is at risk for hurting self or others. Testing includes detailed history of onset and events leading up to the change in mental status, medication list with recent changes, other medications accessible to the patient in the home, and patient and family psychiatric history. Close attention should be paid to vital signs including oxygen saturation and temperature. Check blood sugar, complete blood count, comprehensive metabolic panel, urine drug screen, and a urine pregnancy test if the patient is of child-bearing age. A lumbar puncture is warranted on a case-by-case basis and if history and physical examination suggest a central nervous system abnormality could be the cause of the patient's change in behavior. CT of the brain should be ordered if there is concern for trauma, decreased consciousness, or focal neurologic deficits. Ensure the patient has a normal ECG. A comprehensive toxicology screen should be obtained but clinicians must be aware that urine drug screens do not detect all causes of altered mental status caused by drug intoxication such as MDMA (3,4-methylenedioxy-methamphetamine), ketamine, or dextromethorphan.5 If the patient has a suspected conversion disorder or another psychosomatic condition, limiting unnecessary testing and identifying possible stressors is key. Expanding the evaluation and treatment is not effective to reassure parents and is counter therapeutic for the patient with conversion disorder.4
An important and essential part of the management in the ED is behavior control and the safety of the patient and staff. A quiet room, child-life consultation, sedative agents, and physical restraints may be necessary.
If your institution has a guideline for care of behavioral and psychiatric patients in place, it can be an excellent tool to help guide further management of these patients. Acute sedative or antipsychotic medications may include a combination of the following standard doses: haloperidol intramuscularly (IM) at 0.15 mg/kg (maximum 5 mg per dose), lorazepam IM or intravenous (IV) at 0.1 mg/kg, and diphenhydramine IM or IV at 1 mg/kg orally (maximum of 50 mg). A combination of one, two, or all three of those medications can be used depending on the level of agitation. Another option for acute sedation is ziprasidone at a dose of 10 mg orally or IM. Antipsychotic medications including quetiapine at a dose of 25 mg orally (12.5 mg if patient is younger than age 10 years) and chloropromazine at a dose of 0.55 mg/kg orally or IM are helpful in the management of psychotic patients either as scheduled doses or administered as needed.
Initiation of typical antipsychotic medications should be at the psychiatrist's discretion. If the patient was previously taking medications that have been stopped for a period of time, resuming these medications should only be done after the patient has been evaluated by psychiatry.
Disposition from the ED is case dependent and is affected by a variety of factors. If your patient presents with altered mentation, it is essential that there is improvement of altered mental status and the patient remains stable after a period of observation. The patient must be evaluated by a psychiatric health professional to help determine if the patient needs in-patient treatment, initiation of new medications, or resumption of current mediations. If the patient is cleared for discharge after evaluation in the ED, prompt and proper follow-up is essential and must be ensured prior to discharge.
Ultimately long-term care is determined by the patient's primary psychiatric team. Long-term care includes not only medication but also psychiatric evaluations. Patients may require in-patient therapy more than once throughout their lives and should have a primary psychiatric team that manages their long-term care. The frequency of psychiatric visits should be determined by the primary psychiatric team. A stable support system is important to ensure medication compliance and the well-being of the patient.
Recovery and Prognosis
After emergency treatment, prognosis depends on restoration or creation of a dependable support system for the patient.4 Inpatient versus outpatient therapy depends on the child and presentation. If the patient is suicidal or homicidal, they require psychiatric hospitalization.
There is little known about prevention of psychiatric disorders. Early recognition and prompt evaluation are paramount. Thorough investigation of medical causes of altered mental status is required before exploring the possibility of a psychiatric etiology. During the diagnostic process, keeping a psychiatric cause in your differential is important but should not be assumed without evaluation and stabilization of the patient. Be sure to involve a mental health professional to aid in the diagnosis and management of these patients.
- Simon GE, Coleman KJ, Yarborough BJ, et al. Incidence and presentation of first-episode psychosis in a population-based sample. Psychiatr Serv. 2017;86(5):456–461. doi:. doi:10.1176/appi.ps.201600257 [CrossRef]
- Heckers S. Who is at risk for a psychotic disorder?Schizophr Bull. 2009;35(5):847–850. doi:. doi:10.1093/schbul/sbp078 [CrossRef]
- Reimherr JP, McClellan JM. Diagnostic challenges in children and adolescents with psychotic disorders. J Clin Psychiatry. 2004;65(suppl 6):5–11.
- Katz ER, Chapman LL, Friedlaender EY, Fein JA, Chun TH. Behavioral and psychiatric emergencies. In: Shaw KN, Bachur RG, eds. Fleischer & Ludwig's Textbook of Pediatric Emergency Medicine. Philadelphia, PA: Wolters Kluwer; 2010:1451–1455.
- Babu KM, Boyer EW. Emergency department evaluation of acute onset psychosis in children. https://www.uptodate.com/contents/emergency-department-evaluation-of-acute-onset-psychosis-in-children?search=evaluation-of-abnormaBabu%20KM,%20Boyer%20EW.%20Emergency%20Department%20Evaluation%20of%20Acute%20Onset%20Psychosis%20in%20Children.l-behavior-in-the-emergency-department&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed April 25, 2019.
- Huff JS. Evaluation of abnormal behavior in the emergency department. https://www.uptodate.com/contents/evaluation-of-abnormal-behavior-in-the-emergency-department. Accessed April 25, 2019.
- Carson A, Hallett M, Stone J. Assessment of patients with functional neurologic disorders. In: Hallett M, Stone J, Carson A, eds. Handbook of Clinical Neurology, Functional Neurologic Disorders. 3rd ed. Cambridge, MA: Elsevier; 2016:169–188. doi:10.1016/B978-0-12-801772-2.00015-1 [CrossRef]