Pediatric emergency medicine trisk 4194 4194
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schizophrenia; (ii) brief psychotic episode; and (iii) mood, anxiety, or trauma
disorders. Developmental and cultural factors contribute to the difficulty in
accurately diagnosing psychosis. Hallucinations can be seen in various
normal developmental conditions and cultural and religious beliefs, taken
out of context may be misconstrued as psychotic symptoms. Patients with
new onset or sudden change in psychotic symptoms need careful evaluation
for underlying medical conditions in addition to psychiatry consultation.
Clinical Recognition: Psychosis due to a Medical Condition
Psychosis caused by medical conditions indicates that the underlying
etiology is known, and resolution depends on improvement in the underlying
medical problem. Psychiatrically based psychoses, in contrast, are those in
which specific medical causes have not yet been determined. Differentiating
between medical and psychiatric psychoses can be difficult. Certain features
of the history and physical and mental status examinations are often helpful (
Table 126.23 ). Psychosis caused by medical conditions includes acute or
chronic illnesses, trauma, or intoxications with an exogenous substance (
Tables 126.24 to 126.26 ).
Patients with psychosis due to a medical condition often present in an
agitated, confused state. The patient’s orientation to time and place is often
disturbed; they may be highly distractible, with significant disturbance of
recent memory. Evidence of bizarre and distorted thoughts is apparent, and
disconnected ideas may be juxtaposed. The child may have significant
difficulty controlling behavior and has little regard for personal safety.
Intellectual functioning may also be impaired. Visual and/or tactile
hallucinations may be present. Auditory hallucinations are less common in
medically based psychoses. As a result of impaired reality testing, these
patients are often extremely difficult to control and may strike out at family
or staff when attempts are made to control their behavior.
A thorough history and physical examination is essential looking for
underlying disease. A complete medical history helps determine whether the
psychosis is a concomitant feature of an already existing chronic illness
(e.g., lupus cerebritis), a result of medication or toxin exposure, elevated
intracranial pressure, seizure, trauma, or infections. No specific features of
the mental status examination differentiate the various causes of psychosis.
