Evidence-Based Reviews

Psychosis: 6 steps rule out medical causes in kids

Current Psychiatry. 2006 February;5(2):35-47

References

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Substance abuse

Substance abuse is common among adolescents and adults with psychotic illnesses.⁴ Drug-induced states can cause delusions, hallucinations, paranoia, and disorganized behavior,⁵ which are reported most commonly during intoxication and withdrawal.⁶ Diagnosis is often straightforward because of the temporal association between the substance abuse and onset of psychotic symptoms.

Little evidence supports a causal relationship between drug use and the development of chronic psychotic symptoms, however. Case reports link use of 3,4-methylenedioxymethamphetamine (“Ecstasy”), lysergic acid diethylamide (LSD), and marijuana to chronic schizophrenia-like symptoms.⁷ The strongest evidence links long-term methamphetamine and cocaine use to chronic psychotic symptoms.^8,9

Medications

Side effects of at least 25 drug classes have been reported to mimic psychosis (Table 1),¹⁰ but little is known about the incidence and prevalence of this problem. Case reports and chart reviews provide the only data that associate most medications with psychotic symptoms. These disagree on what defines a “psychotic symptom,” and most fail to rule out delirium as a possible cause.

The relationship between glucocorticosteroids and psychotic symptoms has been studied extensively. A clear link has been found between corticosteroids at dosages >40 mg/d and a markedly elevated risk for transient psychotic symptoms.¹¹

Medical conditions

We identified 27 medical conditions that may cause or worsen clinical symptoms of psychosis (Tables 2 and 3) by searching PubMed, psychiatric journals, and neuropsychiatry and consult-liaison textbooks. We included only conditions:

shown to cause significant morbidity in pediatric populations
shown to have a statistically significant association with psychotic symptoms, or patients’ symptoms consistently resolved when the condition was treated.

Neurologic conditions. Many neurologic conditions had been reported to cause psychotic symptoms,¹² but only four met at least one of our inclusion criteria. Psychotic symptoms are statistically associated with epilepsy,¹³ Huntington’s disease,¹⁴ and Wilson’s disease;¹⁵ psychotic symptoms associated with multiple sclerosis resolve when the underlying medical condition is treated.¹⁶

Endocrine disorders. Behavioral disturbances (including psychosis) may be the earliest manifestation of an endocrine disorder.¹⁷ Cushing’s syndrome,¹⁸ hyperthyroidism,¹⁹ and hypothyroidism²⁰—met our inclusion criteria.

Cushing’s syndrome—caused by long-term systemic glucocorticoids and thyroid disorders—is not uncommon in children and adolescents but rarely presents with psychotic behaviors. For each endocrine disorder we included, however, at least one case report described delayed diagnosis because of prominent psychosis. Treating the endocrinopathies resolved the psychotic symptoms.

Genetic disorders. Genetically determined neurodevelopmental disorders usually present in very young children, but some may appear later. Genetic conditions that co-occur with psychotic symptoms at rates significantly greater than the population prevalence include Prader-Willi syndrome,²¹ metachromatic leukodystrophy,²² Turner’s syndrome,²¹ velocardiofacial syndrome,²³ and Wilson’s disease.¹⁵

Acute intermittent porphyria, GM₂ gangliosidosis (Tay-Sachs disease), and homocystinuria are rare conditions with unknown prevalence in patients with psychotic disorders. Still, they are important to consider when evaluating youths with psychosis because case reports link their treatment with psychotic symptom resolution.^24-26

Infectious disease. An infectious CNS disease does not usually present with psychotic symptoms only. When this does happen, making the correct diagnosis as soon as possible is critical because early treatment is associated with better outcomes.²⁷ Misdiagnosis as a primary psychotic disorder may expose a patient to psychotropics that may adversely affect clinical outcome.

Viruses that affect the CNS (viral encephalopathies) are the infections most likely to cause psychotic symptoms. By decreasing frequency, they are human simian virus, HIV, influenza, measles, Epstein-Barr virus, mumps, and rabies.^27,28 Bacterial infections that cause psychosis include mycoplasma pneumonia,²⁹ syphilis,³⁰ typhoid fever,³¹ and Lyme disease.³²

Brain tumor. Childhood brain tumors often present with behavioral symptoms associated with headache, vomiting, visual changes, and motor and cognitive symptoms. A CNS tumor rarely presents with isolated neuropsychiatric symptoms.³³ A few case reports describe intracranial tumors initially misdiagnosed as primary psychotic illness because of prominent psychotic symptoms.^34,35 In each case, these symptoms resolved with tumor resection.

A temporal relationship does not necessarily equate to a “causal” relationship, however. Tatter et al³⁶ describe a case of “reoccurrence” of manic symptoms initially thought to be caused by an arteriovenous malformation (AVM) 10 years after the AVM was successfully removed. The important point is that, although rarely, pediatric brain tumor can present with prominent psychotic symptoms.

Environmental toxin exposure may cause well-defined psychiatric syndromes,³⁷ although frank psychosis is uncommon at presentation. Most often, environmental toxins produce an encephalopathic process of which psychosis may be one symptom. A few toxic exposures—such as lead,³⁸ carbon monoxide,³⁹ and elemental mercury⁴⁰ —have presented with prominent psychotic symptoms without other encephalopathic symptoms.

Collagen vascular disease is associated with significantly elevated rates of psychiatric illness, especially depression, but only systemic lupus erythematosus (SLE) is known to be associated with prominent psychosis. Case series report delayed SLE diagnosis in patients with this presentation.⁴¹