Giving Bad News: A 13-Year Old With Acute Psychotic Symptoms and Catatonia

CASE: Scott, a 13-year 7-month old white male with no prior psychiatric history, presented to the emergency department after three days of decreased attention span and increased distractibility. An initial examination revealed that he was internally preoccupied (focused on responding to auditory hallucinations), displayed thought blocking (sudden interruption in the flow of his thoughts that prevented him from completing an idea), and he had periodic vague suicidal ideation due to intense guilt. He noted hearing two to three voices accusing him of being rude during an incident with a peer at school. He could not accept reassurance from his mother and grandparents that this incident had not actually occurred. Scott found evidence of his wrongdoing by misinterpreting words on signs and medical equipment that he felt indicated that others also knew of his malicious actions. A recent stressor included the conclusion of his active football season a day prior to the onset of his symptoms. Scott and his family denied a history of prodromal symptoms, mental or medical illnesses, including head injury. After a physical/neurological examination, a negative urine drug screen, and a normal complete blood count and metabolic panel, Scott was transferred to a psychiatric hospital. Scott returned to the emergency department two days later with worsening psychotic symptoms despite a trial of olanzapine. He had deteriorated dramatically from his initial presentation. He was now rigid, unable to speak, move his body, follow directions, eat, drink, or provide any additional history. After being admitted to the pediatrics floor an extensive medical workup was completed that included neurology and infectious disease consults, brain magnetic resonance imaging and angiography studies, a 24-hour electroencephalogram, lumbar puncture, urinalysis, complete blood count, comprehensive metabolic panel, ceruloplasm, anti-nuclear antibody, anti-DNAase, erythrocyte sedimentation rate, heavy metal screen, ammonia, rapid plasma reagin (RPR), and human immunodeficiency virus. All laboratory studies were normal.