Early-onset psychosis and mania — formative SAQs

SAQ 1 (10 marks)

A 15-year-old boy is brought to the emergency department after telling his mother that classmates have implanted a chip in his head. He has not slept for four nights, is guarded and frightened, and describes a voice telling him to run. His mother thinks it is "just cannabis and stress." He has smoked high-potency cannabis daily for six months. There is no fever, no fluctuating consciousness, no focal neurology and a normal physical examination, but his marks have fallen and he has lost two friendships over three months. [2] [5]

1. State the immediate priorities in the first hour, including what must be excluded before any psychiatric label is applied. (3) [2]
2. Outline the role of cannabis in this presentation and the evidence supporting your advice. (3) [5] [6]
3. Describe first-line pharmacotherapy and how the TEOSS trial should inform the choice, plus the baseline and follow-up monitoring. (4) [1] [2] [4]

Model answer — SAQ 1

(1) Immediate priorities and organic exclusion (3). Safety first: assess suicide and self-harm risk with plan, intent and means, and apply means-restriction safety planning the same day; assess for acute behavioural disturbance and catatonia. Then exclude organic disease before any psychiatric label — full physical and neurological examination, full blood count, electrolytes, liver and renal function, thyroid function, inflammatory markers and a urine drug screen, with neuroimaging and an electroencephalogram if onset is acute, consciousness fluctuates, or focal neurology is present. A psychotic young person is a medical patient first and a psychiatric patient second; a collateral history from family and school is mandatory because he is an unreliable sole historian. [2]

(2) Cannabis and the evidence (3). Cannabis is a real, modifiable and dose-related risk factor for psychosis, not an aside. Moore's systematic review found cannabis use associated with a clear increase in psychotic outcomes, and Arseneault's longitudinal study showed adolescent cannabis use raised the risk of adult psychosis in a dose-related way, with earlier, more frequent and higher-potency use being worse. In this boy, daily high-potency use may have triggered or worsened the psychotic picture, so ask about potency, frequency and age of first use, counsel reduction, and arrange a period of supported abstinence and reassessment — persistent symptoms after abstinence warrant full assessment and treatment of a primary disorder. [5] [6]

(3) Pharmacotherapy, TEOSS and monitoring (4). After specialist assessment, first-line treatment for early-onset schizophrenia is an antipsychotic. The TEOSS trial compared second-generation drugs (risperidone, olanzapine) with the first-generation molindone and found efficacy was similar across groups with different side-effect burdens — so there is no clear efficacy advantage of second- over first-generation drugs, and the side-effect profile decides the choice. Risperidone or aripiprazole are common first-line options. Because duration of untreated psychosis drives long-term outcome, prompt specialist referral and early treatment are themselves the intervention. Baseline monitoring: weight, body-mass index, waist circumference, blood pressure, fasting glucose and lipids, prolactin and an electrocardiogram; then review at 4–6 weeks, 12 weeks and six-monthly, with extrapyramidal side effects, sedation and suicide risk assessed at every contact. [1] [4]

SAQ 2 (10 marks)

A 14-year-old girl has had seven days of dramatically elevated mood, sleeping two to three hours a night without tiredness, spending large sums online, and talking rapidly about grandiose plans. Her parents describe her as "a completely different child" from her usual self. She has had intermittent cannabis use. She is agitated and expresses fleeting thoughts that people are watching her. [7] [9]

1. Give the diagnosis that best fits and two features that distinguish it from chronic irritability or disruptive mood dysregulation disorder. (3) [7]
2. Outline first-line pharmacotherapy with the trial evidence, naming one agent that should NOT be first-line and why. (4) [9] [10] [8]
3. Describe the metabolic and safety monitoring and the disposition. (3) [7] [9]

Model answer — SAQ 2

(1) Diagnosis and discriminators (3). The best fit is a manic episode, the hallmark of paediatric bipolar I disorder: at least one week of elevated mood with increased activity, markedly reduced sleep without tiredness, and associated symptoms such as grandiosity, pressured speech and risk-taking. Two distinguishing features from chronic irritability or disruptive mood dysregulation disorder are the episodic, distinct-from-baseline quality — her parents describe "a completely different child" — and the markedly reduced need for sleep with boundless energy, neither of which occurs in chronic irritability. Mixed features (agitation alongside elevation) raise the suicide and misdiagnosis risk and must be screened actively. [7]

(2) First-line pharmacotherapy and the negative anchor (4). Second-generation antipsychotics have the strongest randomised-trial evidence for acute paediatric mania. Tohen found olanzapine beat placebo in adolescent bipolar mania, and Haas found risperidone beat placebo in children and adolescents. Aripiprazole (Findling) and quetiapine (DelBello with divalproex) are further supported options. The Geller trial found risperidone, lithium and divalproex each beat placebo, with risperidone most effective but causing the most weight gain, so lithium or divalproex may be added or substituted when severe. The agent that should NOT be first-line is oxcarbazepine: Wagner's trial found it did not separate from placebo in paediatric bipolar disorder. [9] [10] [8]

(3) Monitoring and disposition (3). Capture baseline weight, body-mass index, waist circumference, blood pressure, fasting glucose, lipids, prolactin and an electrocardiogram before starting, then review at 4–6 weeks, 12 weeks and six-monthly; reassess suicide risk at every contact because mixed states carry the highest risk. The girl needs urgent specialist child and adolescent mental-health input, ideally through an early-intervention pathway, with a low-stimulus environment and verbal de-escalation for the acute agitation. Disposition: a written safety plan, means restriction, a named contact, a timed review and an escape route if risk rises, with planning for transition to adult services as adolescence advances. [7] [9]