Some 'psychiatric' patients have underlying conditions

Don't make assumptions about unusual behavior

An 8-year-old boy came into the ED Northwest Community Hospital in Arlington Heights, IL, swinging his arms at objects that were apparent only to him and saying nonsensical things. At first, nurses suspected a psychiatric disorder, but after determining that the patient had an elevated temperature, a further work-up revealed a diagnosis of encephalitis, says Barbara Weintraub, RN, MSN, MPH, APN, CEN, FAEN, manager of pediatric emergency services.

Without a complete evaluation, it would have been easy to conclude that the boy had a psychiatric disturbance, as his behavior was markedly different than baseline and he had no specific findings on physical examination, says Weintraub. "The finding of an elevated temperature is unlikely in the setting of psychiatric illness and led these care providers to seek a medical cause for his bizarre behavior," she says.

Various ingestions or overdoses, encephalitis, hypoxia, head injury, and diabetic ketoacidosis are all potentially life-threatening conditions which can masquerade as psychiatric conditions in children, says Carol A. Ziolo, RN, LCPC, a clinical educator for Northwest's mental health network. "It is so important to rule out medical conditions before you automatically go to a psychiatric diagnosis," she says.

To avoid missing life-threatening conditions, consider the following:

  • Ask if there has been a sudden change in behavior.
    For instance, a teenager may be disinterested in their usual activities, sleeping more, complaining of headaches, and behaving in a different manner than the parent recognizes as "normal" for their child, says Shawn Kelly, RN, program director of the ED at Columbus (OH) Children's Hospital.
    "In this type of scenario, it is important to consider the possibility of depression versus brain pathology such as a tumor," she says. Even if you suspect depression, probe further to determine if there are other physical signs such as an unsteady gait, weakness in extremities, or an abnormal Glasgow Coma Scale score, says Kelly.
  • Consider new-onset diabetes.
    Hyperglycemia and hypoglycemia can have different presentations in children and in adults, and they could be confused with psychiatric conditions, says Weintraub. All children who are ill or injured, including those presenting with unusual behavior, should have a bedside glucose level checked, she recommends.
    Hyperglycemia frequently presents in children with complaints of abdominal pain and not feeling well, whereas adults more often complain of frequent urination and excess thirst, she says. While hypoglycemia in adults is characterized by altered mental status and diaphoresis, children are rarely diaphoretic and may just seem quieter than usual, says Weintraub.
    "I recall more than a few teenagers being brought to the ED by a parent to rule out drug abuse, only to learn the child had diabetes," says Kelly. If you suspect new-onset diabetes, ask whether the child has been drinking more, is unusually thirsty, or has an increased appetite along with weight loss, she advises.
  • Take psychiatric symptoms seriously.
    The possibility of a brain tumor or diabetes is a significant consideration when a child exhibits behavioral changes, but it is equally important to consider the possibility of suicidal ideation, says Kelly. "This is a growing epidemic that cannot be taken any less seriously than a medical condition that is life-threatening," she emphasizes.
    Ask, "Does your child have a history of any behavioral or psychiatric disorders?" and "Has he/she talked about killing himself, and does he/she have a plan?" says Kelly.
  • Closely assess complaints of abdominal pain.
    Many times, anxiety is the cause of a complaint of stomachache, but you need to be sure there is no gastrointestinal pathology, says Kelly. "Ask questions regarding other physical complaints for this, such as bowel movements, vomiting, level of pain, and location," she says.
  • Perform a thorough history and physical.
    This is your "best tool" in differentiating between medical and psychiatric conditions, says Weintraub. Since children often present with nonspecific signs and symptoms, carefully assess for nasal flaring, unusual odors, neurologic status, and hidden bruising, says Weintraub.
    Ask these questions, recommends Weintraub: How long has the unusual behavior been going on? What was the child doing immediately prior to noticing this? Who was with the child during that time? Is there a family history of similar behavior or incidents? Is anyone else similarly affected? "Assess whether the signs and symptoms that you are seeing match both the caretaker's story as well as the child's developmental level," advises Weintraub.
    When caring for adolescents, recreational drugs may be causing psychotic symptoms, says Ziolo. "Always do a complete history and physical, along with medical tests such as a complete blood count, comprehensive metabolic, urinalysis, urine drug screen, and CT scans, if needed," she says.
  • Document a complete assessment, both physical and psychological.
    Your documentation should show that medical causes of a psychiatric outburst were considered and ruled out, says Gail Schoolden, RN, MS, nurse clinician in the pediatric ED at Johns Hopkins Hospital in Baltimore. "Include their current affect, mood, and whether or not they are cooperating with the exam and care," she says. "Will they look you in the eyes or not?"
    Document answers to questions such as, "Do you want to hurt yourself or anyone else right now?" says Schoolden. "If they say yes, ask about the details and document that information," she says. "It is also vital to document all treatment, medications, and response to any interventions done for the patient."