A 19-year-old man is brought to the emergency department by his mother. She says that he has been acting strangely for the past 2 months, spending significantly less time with his friends and more time on the computer. Over the past few nights the mother has observed the patient shouting at the computer screen. She became alarmed when he suddenly disconnected all electronic devices in the house and warned his family that encrypted messages were being sent over the internet to control his brain. The patient's grades at the local community college have recently declined, and he stopped attending classes after he became convinced that other students were laughing at him behind his back. He has no medical history. Psychiatric history is significant for mild anxiety in high school that was never treated. The patient does not use tobacco or alcohol but smokes marijuana daily. He also has used cocaine on several occasions. There is a family history of schizophrenia in a maternal uncle. Vital signs are within normal limits and physical examination shows no abnormalities. The patient is cooperative, guarded, and anxious during the interview. Blood work and a CT scan of his brain are normal. Urine toxicology is positive for tetrahydrocannabinol. The mother asks if her son is going to be okay. After obtaining consent from the patient to speak with his mother, which of the following is the most appropriate response to her at this time?

Question

A 19-year-old man is brought to the emergency department by his mother.  She says that he has been acting strangely for the past 2 months, spending significantly less time with his friends and more time on the computer.  Over the past few nights the mother has observed the patient shouting at the computer screen.  She became alarmed when he suddenly disconnected all electronic devices in the house and warned his family that encrypted messages were being sent over the internet to control his brain.  The patient's grades at the local community college have recently declined, and he stopped attending classes after he became convinced that other students were laughing at him behind his back.  He has no medical history.  Psychiatric history is significant for mild anxiety in high school that was never treated.  The patient does not use tobacco or alcohol but smokes marijuana daily.  He also has used cocaine on several occasions.  There is a family history of schizophrenia in a maternal uncle.  Vital signs are within normal limits and physical examination shows no abnormalities.  The patient is cooperative, guarded, and anxious during the interview.  Blood work and a CT scan of his brain are normal.  Urine toxicology is positive for tetrahydrocannabinol.  The mother asks if her son is going to be okay.  After obtaining consent from the patient to speak with his mother, which of the following is the most appropriate response to her at this time?

Quizplus · Accepted Answer

Explanation: This patient's 2-month history of paranoia, delusions of reference, and social withdrawal is consistent with a diagnosis of schizophreniform disorder. However, the possibility of a substance-induced psychotic disorder must be considered due to his history of daily marijuana and occasional cocaine use. High-potency cannabis has been associated with paranoia, depersonalization, and hallucinations. Some experts suggest that early cannabis use may be a causal factor in developing schizophrenia in those with susceptibility. Cocaine intoxication and withdrawal can also present with acute psychotic symptoms. When encountering a patient with new-onset psychosis in the emergency department, the physician must first rule out medical and substance-induced causes. In this case, the most appropriate response is to acknowledge the seriousness of the patient's psychotic symptoms but avoid making a premature diagnosis as there is a possibility that the symptoms are caused or exacerbated by drug use. (Choice A) Reassurance that the patient's symptoms are entirely substance related is inappropriate. This patient has classic psychotic symptoms that may or may not resolve if he abstains from drugs. (Choice B) Positive psychotic symptoms, such as delusions or hallucinations, are considered good prognostic features and respond well to antipsychotic medication (as compared to negative symptoms, such as social withdrawal and loss of motivation, which respond less well). However, this statement would be premature, as a primary psychotic diagnosis has not yet been made. Other good prognostic features in schizophrenia include acute onset, later age of onset, affective symptoms, good premorbid functioning, and family support. (Choices C and E) This patient's age is typical for the onset of schizophrenia in males, and his family history increases his risk. Early intervention is important for psychotic illness. However, it would be premature and inappropriate to overwhelm the patient and his mother with the diagnosis of a major mental illness before the role of his substance use is clarified. Educational objective: Assessment of new-onset psychosis requires ruling out substance-induced and medical etiologies. If substances are identified as a possible factor, monitoring the patient off the substances is an appropriate initial strategy. Physicians should inform the patient and family of the diagnostic possibilities while avoiding a premature diagnosis or false reassurance. References: The impact of cannabis use on age of onset and clinical characteristics in first-episode psychotic patients: data from the Psychosis Incident Cohort Outcome Study (PICOS). (http://www.ncbi.nlm.nih.gov/pubmed/23290558) Cannabis-induced attenuated psychotic symptoms: implications for prognosis in young people at ultra-high risk for psychosis. (http://www.ncbi.nlm.nih.gov/pubmed/27821204) Alcohol and substance use by patients with psychosis presenting to an emergency department: changing patterns. (http://www.ncbi.nlm.nih.gov/pubmed/21851228)

A 19-Year-Old Man Is Brought to the Emergency Department by His