Not sure what to make of this

[DD214_DOC]

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So I'm the only one doing what I do where I'm at, so I don't really have any colleagues to confer with. There are psychologists and SW but I think this is a bit above their level.

Got an adolescent female with prev dx of childhood-onset schizophrenia maybe 2 years or so ago. was hospitalized and started on risperdal which is now 0.5mg bid. pt and mom don't think she's schizo and never was and want to come off the antipsychotic. therapist doesn't think she is or was ever psychotic. therapist says her psychosis was having two, "personalities" where one was all good and one all bad, and the bad would tell her to do bad stuff and vv. I've seen that before and know it isn't really psychosis.

Here's the catch. my first session with her, there's a fam hx + for schizophrenia (by report only). pt endorsed a h/o AH consisting of a running narrative and CAH at times, most recent about 6-8 months ago. also endorsed some paranoid thoughts of being followed or watched, even at school. reports h/o depressed mood and stated that the mood sxs predated the psychotic sxs.

To make it even more complicated, in session she appears as somewhat flat and aloof. there's somethig a bit, "odd" interacting with her. presents similarly to therapist. However, when she leaves the office and reunites with mom her entire affect and demeanor change and she's much more animated and interactive.

Functionally, she's doing great. very good grades, good social life, able to care for herself, etc.

So, I'm not sure what to make of it all. I was pretty confident going in that I would reassure them that schizo wasn't an accurate dx but there are enough red flags in her history that I'm not sure. Her risperdal dose is pretty low for psychosis anyways. I don't think what she reported to the therapist was psychosis, but it sounds like what she reported to me was. I know she and mom really want her to come off meds and this diagnosis to not be accurate, so I'm not sure if she's hesitant in what she reports. A couple big things against that diagnosis is that she's very functional and there aren't any cognitive problems (but it may still be early?) Also, despite being given a dx of a primary thought disorder there was never any medical eval for new-onset psychosis that I can find.

I did not encounter this much during training. The only actual childhood-onset schizo I encountered was in med school, and that guy was 16 and wrote rap songs using only numbers and thought every time an alarm clock went off it meant Jesus was in heaven having sex (and he would then take off his clothes and have sex with the floor). He was also drowning puppies by shoving a garden hose down their throat and turning the water on.

I ended up telling her and mom I don't know yet, need more time and to review hospitalization records. Both were insistent on coming off the risperdal. I told them I'm not sure it's a good idea right now but i would rather we do it together with good oversight than for them to go home and do it themselves without telling me (this is a leftover from the previous provider I inherited them from, and is a completely different topic)

 

[OldPsychDoc]

...
I ended up telling her and mom I don't know yet, need more time and to review hospitalization records. Both were insistent on coming off the risperdal. I told them I'm not sure it's a good idea right now but i would rather we do it together with good oversight than for them to go home and do it themselves without telling me (this is a leftover from the previous provider I inherited them from, and is a completely different topic)

Based on your post, I think you have a good handle on the risks/benefits involved, and how to manage moving forward.

 

[milesed]

I'd be interested in details of the inpt stay, may even call them to see if they remembered her and what their take on her symptoms were at that time. It sounds like she has been truly psychotic in the past. A recent study on short-term vs long-term use of antipsychotics showed very poor outcomes for those adolescents who stopped the meds. First breaks can be much more mild and shorter duration than what you may see with her down the road if sx return. I'd warn them of all of this and if they are set on stopping, do it VERY slowly and continue to monitor her every few weeks for sx returning. Document all of this very carefully. I see this a lot as teens with schizophrenia or bipolar near the age of 18 and want off meds. I explain and carefully document that I have warned them against this and of all of the possible consequences they may face. They are usually back after an arrest, hospitalization, etc.

My experience is that people will do whatever they want and we are essentially just along for the ride. They want our stamp of approval, then want someone to blame when it goes poorly. It happens. We just have to have a safety plan in place to help them pick up the peices and get them back on track.

 

[F0nzie]

Agree with OPD. It sounds like you know what you're doing.

I would cut the Risperdal down to 0.25mg BID and follow up in 2 weeks.

 

[PsyDr]

You might want to consider referring out for testing. Says the guy who tests for a living...

 

[DD214_DOC]

You might want to consider referring out for testing. Says the guy who tests for a living...

Yep, also considering. Not much in the way of resources here, unfortunately. I may go with this depending on what the prior records from the hospitalization show. Thanks for the info!

I've also got this kid who was dx with OCD, eating d/o NOS, and specific phobia to peanuts lulz

 

[Merovinge]

I'm not sure I would reassure them that the patient doesn't have a primary thought disorder. Her symptoms are awfully classic for schizophrenia, although statistically MDD w/ psychosis is much more common at that age (along with medical conditions/drugs/etc), the running commentary, CAH, and paranoia raise a lot of suspicion. I would want to speak to the doc who treated her during the psychotic period, find out if first break medical testing was done, labs/utox, standard stuff.

If she was depressed before, is this being treated now? If she's had a full return to function I think that speaks more to an episodic illness, but as mentioned with kids they can bounce back remarkably from psychosis when treated with antipsychotics. I think Id tackle families opposition to the medication with some medical analogy, like if I get a skin lesion that might be cancer and the pathology comes back indeterminate, its okay to be scared/worried but I'd make sure a doc had close surveillance of it. Worst case scenario is them not coming back to get treatment at all.

Edit: Also only a child fellow, so standard grain of salt applies

 

[nitemagi]

...
Got an adolescent female with prev dx of childhood-onset schizophrenia maybe 2 years or so ago. was hospitalized and started on risperdal which is now 0.5mg bid. pt and mom don't think she's schizo and never was and want to come off the antipsychotic. therapist doesn't think she is or was ever psychotic. therapist says her psychosis was having two, "personalities" where one was all good and one all bad, and the bad would tell her to do bad stuff and vv. I've seen that before and know it isn't really psychosis.

Right.

Here's the catch. my first session with her, there's a fam hx + for schizophrenia (by report only). pt endorsed a h/o AH consisting of a running narrative and CAH at times, most recent about 6-8 months ago. also endorsed some paranoid thoughts of being followed or watched, even at school. reports h/o depressed mood and stated that the mood sxs predated the psychotic sxs.

I'd dig into a bit more of the phenomenology of the CAH. Actually hearing them like sounds, as in with her ears? Or more like thoughts? Also screen for abuse/PTSD (hypervigilance masquerading as paranoia).

To make it even more complicated, in session she appears as somewhat flat and aloof. there's somethig a bit, "odd" interacting with her. presents similarly to therapist. However, when she leaves the office and reunites with mom her entire affect and demeanor change and she's much more animated and interactive.

That sounds like a normal disaffected youth seeing a doctor for the first time with whom she's not comfortable yet.

Functionally, she's doing great. very good grades, good social life, able to care for herself, etc.

So, I'm not sure what to make of it all. I was pretty confident going in that I would reassure them that schizo wasn't an accurate dx but there are enough red flags in her history that I'm not sure. Her risperdal dose is pretty low for psychosis anyways. I don't think what she reported to the therapist was psychosis, but it sounds like what she reported to me was. I know she and mom really want her to come off meds and this diagnosis to not be accurate, so I'm not sure if she's hesitant in what she reports. A couple big things against that diagnosis is that she's very functional and there aren't any cognitive problems (but it may still be early?) Also, despite being given a dx of a primary thought disorder there was never any medical eval for new-onset psychosis that I can find.

I've seen way way way more cases of childhood schizophrenia as a misdiagnosis than anything else -- misattribution of symptoms, anxiety, dissociation, delirium, malingering, etc. Not that it doesn't happen, but I agree -- start the workup over. Don't take schizophrenia off the ddx, but question every bit of data you've gotten so far.

 

[DD214_DOC]

"That sounds like a normal disaffected youth seeing a doctor for the first time with whom she's not comfortable yet."

My only correction is that the pt is the same way wiht her therapist, whom she has known for several months. I'm basically starting over like you said, but when f/u appts are a month or more out it's difficult to get anywhere.

 

[nitemagi]

"That sounds like a normal disaffected youth seeing a doctor for the first time with whom she's not comfortable yet."

My only correction is that the pt is the same way wiht her therapist, whom she has known for several months. I'm basically starting over like you said, but when f/u appts are a month or more out it's difficult to get anywhere.

Fair enough. In my experience that depends a bit on the skill level of the therapist to connect with a kid. Some are really good. Some aren't.

 

[whopper]

Childhood schizophrenia does exist. The problem being that is it extremely rare. The younger the more rare it is. Another problem is that children are poor historians, parents have their own agendas, and it can be hard to read their behavior.

Are you a child psychiatrist? If not and there is a good one in the area consider referring the patient to that doctor.

Approach 1-Be safe, continue the meds.
Approach 2-hedge your bets: Lower the medication very very slowly and if the pt worsens reverse course. I've done this with patients that became psychotic from bath salts or K2 not knowing how long the psychosis would last due to these being newer substances with less data. I'd lower the medication about 1 mg a day per week to month and if the pt noticed worsening we immediately reversed course. Most of them eventually they did not need the medication anymore but their psychosis lasted several months. In a few cases it was likely permanent. After one guy stayed controlled only with meds with him worsening when the med was lowered after two years of being clean from K2 I told him it likely was permanent but we could continue to lower the dosage every few months.

No matter what put the pt on a schizophrenia prevention regimen. 1-No cats 2- Omega-3 rich diet (especially EPA not so much DHA) 3-make sure Vitamin D3 levels are optimal.
http://schizophrenia.com/prev1.htm#

 

[DD214_DOC]

I am a child psych guy. Unfortunately, never saw childhood schizo during training.

 

[MLT2MT2DO]

I am a child psych guy. Unfortunately, never saw childhood schizo during training.

How is this possible?

 

[DD214_DOC]

How is this possible?

Rare diagnosis, very limited inpatient exposure in program; it was heavily outpt focused. Different pt population as well. It's unfortunate.

 

[smalltownpsych]

Childhood schizophrenia does exist. The problem being that is it extremely rare. The younger the more rare it is. Another problem is that children are poor historians, parents have their own agendas, and it can be hard to read their behavior.

Are you a child psychiatrist? If not and there is a good one in the area consider referring the patient to that doctor.

Approach 1-Be safe, continue the meds.
Approach 2-hedge your bets: Lower the medication very very slowly and if the pt worsens reverse course. I've done this with patients that became psychotic from bath salts or K2 not knowing how long the psychosis would last due to these being newer substances with less data. I'd lower the medication about 1 mg a day per week to month and if the pt noticed worsening we immediately reversed course. Most of them eventually they did not need the medication anymore but their psychosis lasted several months. In a few cases it was likely permanent. After one guy stayed controlled only with meds with him worsening when the med was lowered after two years of being clean from K2 I told him it likely was permanent but we could continue to lower the dosage every few months.

No matter what put the pt on a schizophrenia prevention regimen. 1-No cats 2- Omega-3 rich diet (especially EPA not so much DHA) 3-make sure Vitamin D3 levels are optimal.
http://schizophrenia.com/prev1.htm#

From the article it looks like these apply either in utero or first year of life. For a very similar patient of mine who is in early adolescence, would these measures still benefit patient? I guess they couldn't hurt. Also, do you know if early intervention with anti-psychotics is a good thing or not and should they be administered long term in a child? At this point patient is experiencing hallucinations of a person telling her to harm self and is eager for help so it is likely that we will initiate medication, but the side effect profile for antipsychotics can be pretty significant and once on the medications, no one wants to take the risk of decreasing them. I have seen mixed evidence on this so am open to hearing from the board about it.

I just made the referral to a child psychiatrist in the nearest city so we will see what course of treatment she takes, but parents and child definitely trust my judgement and will want to know my opinion. I have really only worked with psychotic adolescents during clinical rotations during my doctoral program so am far from an expert, but in this town we have limited options. I just hope that the psychiatrist doesn't dx ADHD cause then I don't what I will do.

 

[DD214_DOC]

http://www.psychiatrist.com/jcp/article/Pages/2015/aheadofprint/13m08863.aspx

 

[mnc2006]

I get what you are saying! It sounds too simple for a childhood schizo but at the same time enough to be worried about a psychotic element. I will go with whopper's suggestions but avoid any experimenting if there are major life events planned for the near future. May be leave out the trial reduction to the 1 yr mark( from start of tablets). This will probably give u enough time to gather evidence for or against a trial

 

[shan564]

I recently looked into the literature on this topic for one of my patients. It's important to note that a minority of patients might never have another psychotic episode after the first break, and it's not clear if you need to expose those people to the risk of tardive and/or metabolic syndrome.

How long was she psychotic? If it was >6 months, she'll almost certainly become psychotic again. If it was just schizophreniform, Kaplan/Saddock (along with the preponderance of primary literature) report that there's a 20-40% chance that she'll never be psychotic again according to the limited literature available (although there's no data to say what happens to those 20-40%). They go on to recommend a 3-6 month course of antipsychotics for patients who don't go on to meet the 6-month criterion for schizophrenia.

Here's what the APA guidelines say about people with a single episode of non-affective psychosis:
"Unfortunately, there is no reliable indicator to differentiate the minority who will not relapse from the majority who will relapse. Antipsychotics are highly effective in the prevention of relapse in remitted first-episode patients. One-year relapse risk varies from 0% to 46% of patients who are prescribed antipsychotics (210–213). Adherence to maintenance antipsychotic medication likely has an influence on effectiveness and may contribute to varying relapse rates. The most prudent treatment options that clinicians may discuss with remitted first- or multi-episode patients include either 1) indefinite antipsychotic maintenance medication or 2) medication discontinuation (after at least 1 year of symptom remission or optimal response while taking medication) with close follow-up and with a plan to reinstitute antipsychotic treatment on symptom recurrence."

and then a few pages later:

"It is important to discuss with the patient the risks of relapse versus the longterm potential risks of maintenance treatment with the prescribed antipsychotic . If a decision is made to discontinue antipsychotic medication, additional precautions to minimize the risk of a psychotic relapse are warranted."

and then later in that paragraph:

"Indefinite maintenance antipsychotic medication is recommended for patients who have had multiple prior episodes or two episodes within 5 years . "


It sounds like your patient doesn't meet that "multiple prior episodes or two episodes within 5 years," which means that she may not need "indefinite maintenance antipsychotic" according to that Level I recommendation. She seems to fall more into the category of "discuss the risks of relapse vs. the long-term potential risks of maintenance treatment."

It sounds like the patient and mom have the capacity to provide informed consent to accept the risks of relapse, and the patient seems to have appropriate monitoring in place. I'd probably try to carefully taper medications very slowly and have a very low threshold for treating aggressively if she gets psychotic again. I'd probably tell the patient something like "if we stop your medications, there's probably a 70% risk that you'll relapse, it will probably be worse than the first time, and you might require a higher dose of medications next time... but if you're willing to take that risk, we'd have to go very slowly and watch you very closely for any hint of paranoia" (except say that in a more thorough/detailed/sensitive way).
I recently looked into the literature on this topic for one of my patients.

 

[DD214_DOC]

I recently looked into the literature on this topic for one of my patients. It's important to note that a minority of patients might never have another psychotic episode after the first break, and it's not clear if you need to expose those people to the risk of tardive and/or metabolic syndrome.

How long was she psychotic? If it was >6 months, she'll almost certainly become psychotic again. If it was just schizophreniform, Kaplan/Saddock (along with the preponderance of primary literature) report that there's a 20-40% chance that she'll never be psychotic again according to the limited literature available (although there's no data to say what happens to those 20-40%). They go on to recommend a 3-6 month course of antipsychotics for patients who don't go on to meet the 6-month criterion for schizophrenia.

Here's what the APA guidelines say about people with a single episode of non-affective psychosis:
"Unfortunately, there is no reliable indicator to differentiate the minority who will not relapse from the majority who will relapse. Antipsychotics are highly effective in the prevention of relapse in remitted first-episode patients. One-year relapse risk varies from 0% to 46% of patients who are prescribed antipsychotics (210–213). Adherence to maintenance antipsychotic medication likely has an influence on effectiveness and may contribute to varying relapse rates. The most prudent treatment options that clinicians may discuss with remitted first- or multi-episode patients include either 1) indefinite antipsychotic maintenance medication or 2) medication discontinuation (after at least 1 year of symptom remission or optimal response while taking medication) with close follow-up and with a plan to reinstitute antipsychotic treatment on symptom recurrence."

and then a few pages later:

"It is important to discuss with the patient the risks of relapse versus the longterm potential risks of maintenance treatment with the prescribed antipsychotic . If a decision is made to discontinue antipsychotic medication, additional precautions to minimize the risk of a psychotic relapse are warranted."

and then later in that paragraph:

"Indefinite maintenance antipsychotic medication is recommended for patients who have had multiple prior episodes or two episodes within 5 years . "


It sounds like your patient doesn't meet that "multiple prior episodes or two episodes within 5 years," which means that she may not need "indefinite maintenance antipsychotic" according to that Level I recommendation. She seems to fall more into the category of "discuss the risks of relapse vs. the long-term potential risks of maintenance treatment."

It sounds like the patient and mom have the capacity to provide informed consent to accept the risks of relapse, and the patient seems to have appropriate monitoring in place. I'd probably try to carefully taper medications very slowly and have a very low threshold for treating aggressively if she gets psychotic again. I'd probably tell the patient something like "if we stop your medications, there's probably a 70% risk that you'll relapse, it will probably be worse than the first time, and you might require a higher dose of medications next time... but if you're willing to take that risk, we'd have to go very slowly and watch you very closely for any hint of paranoia" (except say that in a more thorough/detailed/sensitive way).
I recently looked into the literature on this topic for one of my patients.

Thanks, very useful. Was this specific to those under 18, adults, or just in general? Unfortunately I don't have time during the day to look stuff up, so I end up doing it at home, although occasionally I also like spending time with my wife...

 

[shan564]

Thanks, very useful. Was this specific to those under 18, adults, or just in general? Unfortunately I don't have time during the day to look stuff up, so I end up doing it at home, although occasionally I also like spending time with my wife...

This was for general patients, not specific to children or adults.

We did recently have an M&M conference about a patient similar to yours. The premise of the conference was that the guy was started on antipsychotics during childhood for something that looked like childhood-onset schizophrenia, but in retrospect, the history was unclear. He stayed on the meds for a couple of decades, until his doctor questioned the diagnosis and decided to taper the drug. After successful taper, he remained stable and asymptomatic for several months, so he was presented as an example of somebody who was exposed to an antipsychotic when he probably didn't need to be. Most of the people at the conference (with experience ranging from junior residents to senior faculty and department chair) agreed that the patient was probably one of the rare cases in which somebody has a single episode and becomes stable without pharmacotherapy afterwards. But then, a couple of months after that conference, he became psychotic again, and his current doctor is having a lot of trouble trying to get him back on antipsychotics.