Presentation and Treatment of Acute Psychosis in an Adolescent Girl with Cerebral Palsy

. is a 17-year-old wheelchair-bound girl with a history ofglobal developmental delay, cerebral palsy (CP), and spasticquadriplegia. S. was referred to the pediatric emergency depart-ment with what appeared to be acute new-onset psychotic symp-toms including disorganized speech and behavior, paranoiddelusions, and auditory hallucinations.History of Present IllnessAccording to her mother and aunt, S. started acting abnormallyabout a week and a half prior to her admission. As had been the casefor approximately the past three years, the week prior to her menseswas characterized by S.’s increased mood lability and odd behav-ior, which included inappropriate laughter, tearfulness, and internalpreoccupation. In the past, these episodes had lasted two to threedays, and her outpatient pediatrician had prescribed clonazepam0.125mg as needed when this occurred. The family reported thatthis had not been helpful in the past, and the few doses givencurrently were ineffective as well. Mother reported that S.’ssymptoms worsened, and she became more dysphoric and agitatedand began talking to herself loudly. When mother inquired as towhatwasbotheringher,S.proclaimedthatshehadbeenridiculedatschool by her teacher for her poor singing abilities. When motherasked the teachers what had happened, they had no knowledge ofthe incident,butnotedthat S.hadbeenmore irritablerecently. Overthe next few days, S. became more upset and hyperverbal. Sherefused to eat or drink, refused assistance with brushing her teethand bathing herself, and had an entire night where she did not fallasleep, shouting to herself, seemingly nonsensically. The next day,mother took S. to an emergency department where she was eval-uated, told to discontinue the clonazepam, and sent home. Hersymptomssubsequentlyworsened;shebeganreferringtoherself byadifferentname andrepeatingphrasessuchas‘‘test,testone,two.’’She reportedly became hostile toward her mother, insisting that shewas not her real mother. S. eventually became aggressive, whichwas entirely out of character for her, pulling mother’s hair andswatting at her younger siblings, insisting that her entire family wasnot her real family. Mother took S. to the emergency department ofa different hospital, where S. was evaluated by both the pediatricneurology and pediatric psychiatry consultation services.S. was initially evaluated by a neurologist who noted that she wasawake and alert, but was not oriented to person, place, or time. Shewas reportedly found to have poor attention, was unable to repeatphrases,andwasminimallyableto followcommands.S.appearedtobe responding to internally generated stimuli, saying things such as,‘‘They are talking to my old mother. They are abusing me.’’ Herexam was non-focal and she was afebrile. Preliminary laboratoryevaluation, including blood work and urinalysis, revealed mild de-hydration with elevated bicarbonate and ketones, decreased thyroidstimulating hormone (TSH) and slightly elevated white blood cellcount. The working differential diagnosis was delirium versus acutepsychosis secondary to a primary psychiatric disorder. Continuouselectroencephalogram (EEG) was ordered, and eventually neuroi-maging; records indicated that there was less suspicion of enceph-alitisoraprimaryorganicetiology,astherehadbeenapasthistoryofsimilar, less intense, and less prolonged episodes.S. was interviewed by the psychiatry team in the emergencyroom with her mother initially present, during which she was morecalm and lucid. Additional questioning revealed that S. had ap-parently overheard a conversation in which her mother spoke ofincreasing difﬁculty in caring for S. During the interview, S. re-peatedly pointed to her mother and said she had been abused andwas not her real mother. She reported that her mother was trying topoison her. She denied hearing voices and stated that she wastalking to herself ‘‘to calm myself down.’’S. was admitted to the pediatrics unit where she was rehydratedandcontinuedonherpreviousregimen ofbaclofen5mgthreetimesa day (TID). She was started on quetiapine and lorazepam asneeded by the psychiatry consultation service. Her urine and serumnormalized, and the EEG and magnetic resonance imaging (MRI)were negative for any acute pathology. Additional laboratorystudies including serum ceruloplasmin, B12, antinuclear antibody(ANA), and urine toxicology were normal. There was no lumbarpuncture performed as it was not recommended by neurology.Endocrinology was consulted regarding mild hyperthyroidism,which they felt was unlikely to be contributing signiﬁcantly to heracute presentation. S. remained paranoid and disorganized and wastransferred totheinpatientadolescentpsychiatric unitforcontinuedobservation and treatment.Hospital CourseS. arrived on the unit agitated, shouting, and trying to throwherself out of her wheelchair and bed. She was put on constantobservation for much of her course. She was given quetiapine,initially immediate release, in twice-daily (BID) dosing with which