AOD disorders co-occur frequently with mood and anxiety disorders. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) of 2001-2002 reported that 20 percent of persons affected by an AOD disorder simultaneously suffered from a mood disorder and 18 percent from an anxiety disorder.¹

Both the cause and chronology of a person’s CODs are a topic of controversy within the medical field, as factors that cause a person to form an AOD disorder are also related to the formation of  their mental health disorder. Sterling and colleagues give the example of a person self-medicating a mental health disorder such as depression with alcohol; however, the person’s alcohol dependency would cause them to feel depressed.¹ Because the two are so closely linked, causing professional opinions of cause and chronology to differ, the integration of treatment for both disorders has heeled. Many also believe that once the mental disorder is controlled, AOD use will cease; however, that is not the case, and without treatment for both, chances of relapse are high.

Less studied than co-occurring AOD problems and mental health conditions are co-occurring AOD problems and medical conditions; however, it is well known that persons with AOD disorders are more apt to acquire health problems like hepatitis B and C, HIV disease, hypertension, chronic obstructive pulmonary disorder (COPD), and pain disorders.[4] Therefore, physicians are using the related medical conditions to intervene with a patient’s AOD disorder.[5] However, as with co-occurring AOD disorders and mental health disorders, the causal relationship between co-occurring AOD disorders and medical conditions are controversial. It is clear that the treatments of medical conditions often interfere with the treatment of AOD disorders, as Sterling and colleagues state that conflicting medical appointments and treatment schedules, the effects of certain medical conditions, and certain medications may make it difficult for a patient to continue pursuing treatment of both, often seeing the medical condition as the number one priority and believing that once it is cured, AOD use will decrease.¹

Historically, the treatment of AOD disorders and mental health disorders was provided by one system, usually an asylum or a sanatorium; however, the treatments of the two separated in the late 20th century.¹ For AOD disorders, treatment became more specific as the 12-step and self-help movements took, and some research institutions, such as the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute of Drug Abuse (NIDA) began focusing mainly on AOD use problems.¹ The feeling was that persons suffering from AOD disorders had not previously received correct understanding, diagnosis, and treatment. As AOD disorder treatments further separated from the mental health field, many programs and providers once able to provide treatment for such began to lack the training and resources to continue to do so effectively, often leading to referrals to an institution more suited; however, frequently when a co-occurring disorder is present, it may be ignored or even undiagnosed.¹ In cases of such, often the chance of relapse increases.

Further separating the field of mental health and AOD disorders is their view of medicines. While the mental health field believes medicines are able to help in the treatment of a person, those in the AOD field generally do not agree with their use for those with alcohol dependency, as the 12-step model has proved effective.¹ Therefore, the adaptation of medicines in the field of AOD disorders has been slow. Both fields often fail to screen for co-occurring disorders, suggesting lack of both training and resources.¹

Treatment providers in the mental health, general medicine, and AOD fields generally differ in levels of education and training. General medicine providers are commonly either physicians or advanced-practice nurses, mental health treatment providers commonly hold either masters or doctoral degrees, and those providing addiction treatment range from non-degreed counselors to doctoral degree-holders to medical personnel.¹ Rarely are addiction services overseen by a psychiatrist, who is able to correctly diagnose and treat co-occurring disorders.

Combining treatment for co-occurring AOD disorders and mental health or medical conditions has been a struggle; however, as research emerges stating that correct diagnosis and combined treatment may be more effective in the prevention of relapse, both fields are becoming more open to more detailed screenings and trying new interventions.¹

I hold on to the stereotype.

I hold on to the fairy tale.

I hold on to what was sought to be the norm.

But not every case is the same.

I have tried to find anywhere else to place the blame.

It finds its way back to pin itself on me with a feeling of shame.

I miss my daddy.

I dislike my dad.

I hate my father.

More times than not I wonder why I bother.

You seem to want a part that you don’t tend to play.

You don’t stick to the script.

You are determined to always get your way.

You don’t care who you hurt.

You don’t care who you defend.

Your way or the highway, period, the end.

I just want you to listen.

I just want you to hear me.

I just want you to look at me and see me; who you think I should be.

I want you to love me for more than just blood.

If blood is the reason I must induce this hell, cut me open, bleed me dry, then step back and watch the flood.

You keep making mistakes that you will not own up too.

You’re running out of excuses.

All your truths fall through.

Your facts are not fact.

You’re truths are not true.

The only person you listen to is you.

Is it a symptom of the symptom?

Has the alcohol made you deaf to every voice, but the on in your head?

What the fuck is wrong with you?

What appears in the mirror in front of you?

What happened to you?

I know you think you’re right, but where do you find your validation?

Are you really so self-absorbed that even fact is wrong if it conflicts?

I can see that light will most likely never click.

You hold your pride above your children’s well-being.

You would rather let us die, than be caught in a lie.

Do you ever question yourself?

Is there anywhere you look for advice?

Do you know what it means to think twice?

Do you care?

Or is that too much consideration for you to spare?

I wrote something before that I think might apply to you now. So I need you to listen, though I am not sure you know how. You don’t know what you are talking about. You just drown to my rage.

Reading all those mindless things, can’t you see my world is just a stage? Auditions are my life and death raping is my crime. Tears are my weakness. I keep a monster locked inside. The meds just set the monster free. They turn gold into blue. You tell me you love me. I wish I could believe your statement to be true. Being around you is a waste of time. You don’t really care. You want to pretend as if I am not really there. I hold my hand out for a friend, I look for yours, but you act as if your arm cannot extend. I finally realized that on this my happiness does not depend. This realization does not change the way I feel. I crave this love, affection and attention; like a lion craves his next meal. I’ve done all I can do to stop short of asking the devil to make me a deal. I resent you to no avail; it gets harder and harder to breath.  I can take in air with no hope to exhale. All I want from you is to admit you failed.

Electroconvulsive therapy has been used effectively over the past 70 years, and is known as the most effective form of neuromodulation that exists today. According to Janicak and colleagues, with ECT, electrical currents, strong enough to induce seizure, are delivered to the central nervous system, and over the course of six to 12 sessions, severe depression may be resolved.¹ However, when antidepressants were introduced in the 1950s, the use of ECT declined and still has yet to recover. Additionally, Janicak and colleagues state that several important factors continue to hinder its popularity, as access and expertise are limited in many parts of the country, the patient’s cognition is temporarily negatively affected, relapse rates are high, the cost of the therapy is high, and the public’s perception of the treatment is often negative.¹ In order to improve upon these issues, studies are currently being conducted. For instance, the National Institute of Mental Health has sponsored the Consortium on Research with ECT (CORE) group to research how to effectively maintain the benefits of ECT longer.[2] Also, there are studies being conducted regarding placement of electrodes and wavelength characteristics, looking to increase the benefits and decrease the adverse effects.[3]

In 1997, vagus nerve stimulation was introduced as a treatment for epilepsy; however, in 2005, it became FDA-approved for the treatment of severe, treatment-resistant depression—the first implantable device to gain such approval.¹ The vagus nerve itself regulates a person’s heart rate, intestinal motility, and gastric acid secretion, as information is transmitted to specific brain regions which have serotonergic and noradrenergic nerve distribution.¹ These same neurotransmitters play an active role in major depression. According to Janicak and colleagues, with VNS , a pulse generator is placed subcutaneously in the patient’s chest, on the upper left side. The generator is attached to wires, which are run up through the patient’s neck to the left vagus nerve. Electrical signals are sent from the generator to the nerve via the wires every few seconds, and the strength of the signals are adjusted using a computer. Common side effects are voice alteration, cough, and shortness of breath; however, they may improve when the intensity of the electrical signals is adjusted.¹ In a study conducted to measure the efficiency of VNS in 74 patients with treatment-resistant depression, after three months, 37 percent of patients responded to the treatment, and 17 percent were successfully in remission.⁴ Results grew, and at the one year mark, 53 percent had responded to the treatment and 33 percent were in remission.⁴ However, Janicak and colleagues state that as many insurance companies do not reimburse VNS treatment, it is not a frequently used treatment.¹

More recently, transcranial magnetic stimulation has been FDA-approved for treatment-resistant depression.¹ According to Janicak and colleagues, with TMS, an ferromagnetic coil delivers magnetic pulses caused by electrical charges to the left dorsolateral prefrontal cortex of the brain in fast, repetitive successions.¹ Usually, TMS treatment is conducted on an outpatient basis, and a standard treatment course consists of five sessions per week for four to eight weeks.¹ The largest trial of TMS treatment was conducted by O’Reardon and colleagues, who specifically studied the difference between active TMS treatment and non-active TMS treatment.[4] They found that patients who received active TMS had better treatment responses than those who did not. In fact, remission rates were 14 percent for those receiving active TMS and six percent for those not receiving active TMS. Also, the treatment was well tolerated, and the most common side effects were headache and pain or discomfort at the application site.[5]

Deep brain stimulation is a neurosurgery in which electrical currents are directed at specific locations within the brain.[6] Both reversible and adjustable, a device is inserted subcutaneously into both the left and right upper chest of the patient.¹ Then, electrodes, attached to wires, are run subcutaneously behind the patient’s ears and into burr holes made in the skull, leading to specific locations within the central nervous system.¹ Janicak and colleagues state DBS is approved for the treatment of Parkinson’s disease, depression, and severe obsessive-compulsive disorder (OCD).¹ Adverse effects of the treatment include: seizure, bleeding, infection, device malfunction, memory disruption, cognitive changes, psychiatric symptoms, and intracranial bleeding.¹

According to Janicak and colleagues, cost of treatment must always be included in the patient’s risk-benefit analysis when considering undergoing neuromodulation.¹ As many patients do not have insurance coverage, and many insurance providers do not cover neuromodulation treatment, discussing cost is important.[7] Some device manufacturers will offer programs that aid in cost and coverage obtainment.⁷ However, direct cost is not the only cost the patient should be made aware of, as indirect cost may also significantly impact the patient.¹ For instance, inability to work, caretaker and other assistance, and inpatient versus outpatient procedures all should be discussed with the patient before neuromodulation treatment is begun.¹

Made in illegal laboratories and sold in convenience stores and smoke shops throughout the country, synthetic marijuana poisoning was responsible for 4,500 calls to Poison Control Centers from 2010 to 2011.[1] While the substance produces the euphoric and psychoactive effects similar to marijuana that users desire, it secretly contains various other substances that are much more dangerous. Users who experienced poisoning suffered the following symptoms: restlessness, agitation, catatonia, extreme aggression, diaphoresis, and the inability to speak.¹ While makers of the illegal substance state that its effects are short-lived, health care professionals are becoming increasingly concerned about the long-term effects of synthetic cannabis usage.

Makers of the synthetic drug state that it consists of a mixture of herbs; however, laboratory testing in the United States and Germany have found otherwise.¹ Scientists found large quantities of synthetic tocopherol present, an ingredient not listed on the package.¹ Also, in 2008 German scientists found the plant ingredients to be “unclear” and the source of the synthetic tocopherol to be unknown.¹ In fact, they concluded that the euphoric and psychoactive effects were not a product of their plant ingredients. It is unknown what exactly makes up this synthetic substance, but what is known is that the chemical added to the plants are what produces toxicity in humans.¹

Clozapine, an antipsychotic used to treat schizophrenia, was the first FDA-approved medicine with an anti-suicide indication.¹ It’s approval in 2003 was based upon the International Suicide Prevention Trial which compared clozapine with olanzapine in patients who were at high risk of suicide and diagnosed with schizophrenia and schizoaffective disorder.[4] Results showed that suicidal behavior—including suicide attempts, hospitalizations, and rescue interventions—was significantly lower in patients who were treated with clozapine.¹ However, other evidence states that olanzapine may reduce suicidal ideation if given in combination with a mood-stabilizing medicine for patients with bipolar I disorder mixed episode.[5] Another antipsychotic that may have promise in treating suicide behavior for patients with bipolar depression is quetiapine, when given between 300 and 600 mg per day.[6]

Kay Redfield Jamison, Ph.D. said in 1986 that “one of the most interesting questions in preventative medicine today is the impact of lithium on suicide rates.”[7] While there was no systematic information available at the time as to exactly how the medicine worked on aiding in the prevention of suicide, a decade later it began to appear.[8] A recent analysis of long-term lithium treatment for bipolar disorder and mixed major mood disorders showed an approximate 80 percent reduction in risk of suicide attempts and completed suicides.[9] Also, the lethality of suicide behavior was reduced.¹

Whether or not antidepressants decrease suicidal behavior is questionable. Most data shows that SSRIs are associated with a reduced risk of suicide in adults with depression and an increased risk of suicide in adolescents with depression.[10] However, a recent study found that only 1.6 percent of adolescents who had shown suicidal behavior had taken SSRIs—most adolescents who died by suicide were not taking any antidepressants at the time of their death.[11] Therefore, the topic remains controversial. On the other hand, patients who decide to interrupt or discontinue their treatment without consulting their prescribing doctor, put themselves at risk for suicidal ideation and behavior relapse.¹ While the discontinuation may be due to uncomfortable adverse effects, the risks associated with coming off a medicine may well include increased suicide behavior,[12] especially if the medicines taken have shorter half-lives.[13]

Antiepileptic medicines may possibly be associated with suicidal thoughts and behaviors. However, recent studies have reported inconsistent findings in regards to suicide risk due to taking specific antiepileptic drugs (AEDs). While patients with epilepsy may have a higher risk of suicide, many also have comorbid psychiatric conditions that may also cause the risk to increase.[14] Therefore, it is important for researchers to determine whether or not the suicide risk associated with taking anticonvulsant medicines and benzodiazepines will carry over to other psychiatric patients, as usually these drugs are used to treat a wide variety of psychiatric disorders.[15] While two studies[16]^,[17] have examined the associations between AEDs and suicide risks, both came up with inconclusive results. Other examinations of the AEDs levetiracetam, lamotrigine, and topiramate have shown inconsistent rankings of risk of suicide, but the drugs were found to be among the top three AEDs with the highest observed suicide risks in two of the five analyses.¹ However, levetiracetam was among the top three in all five of the studies.¹

Pompili and Goldblatt state that treatment of the underlying psychiatric illness in the most effective use of medicine in suicidal patients. There are some medicines that may prevent suicidal ideation and behavior; however, there are limited studies that provide sufficient information.¹ While clozapine has shown to be effective at reducing suicide behavior in patients with schizophrenia, olanzapine and quetiapine appear to be promising medicines as well.¹ Lithium is a trusted and effective medicine for decreasing suicidal behavior in patients with bipolar disorder, as it has for years.¹ On the other hand, SSRIs are useful for the treatment of depression and possibly suicidal behavior in adults, yet their use in adolescents is controversial.¹ Also, additional research on any AEDs is needed to gauge their overall safety.¹

Black outs, snorting cocaine off the back of the bar toilet, eating Xanax like skittles was just the end of a new beginning to my life. After a week of having suicidal thoughts, I decided it would be best for me to get some real help. I Google’d long term treatment centers at the bar and I came up with Wellington Retreats number. I called and they accepted me with open arms.

That next Monday I flew to Florida from Texas. I was kindly greeted off the airplane by one of the coordinators, and then driven me to clinical. There I met all the other patients and staff. Everyone welcomed me in with open arms. As days went on, I got into the swing of things and started going to groups. I didn’t know how Wellington Retreat was going to help me but I was open to anything after hitting rock bottom at this point.

The groups are great, every group I was in helped me to become more confident in myself, love myself, not dwell on things and much more. I have become so comfortable here; I shared my whole life story without fear of judgment from anyone. My therapist and the rest of the staff have helped me come along so far from when I came into Wellington Retreat 6 weeks ago.  I have never been happier in my life and I feel I have the strength to stay sober for the rest of my life.

Wellington Retreat saved my life. I’m a happy, sober mother, daughter, granddaughter, sister and wife. Thank you doesn’t begin to describe how much I appreciate what Wellington Retreat has done for me.

Sincerely,

Patient Y

Hey Dr. Moran,

You know living in Dr. Moran’s world wasn’t so bad, still isn’t. LOL. I’m writing you this letter to thank you so much and let you know how much I appreciate everything you have done for me and my family, and for accepting me into your amazing program. Your programs have showed me a new way of life. Also, thank you so much for giving me such an awesome therapist, if it wasn’t for Carolina, I can tell you with no doubt that I wouldn’t be where I am today in Recovery. SHHHHHH, my secret is “you, Dr. Barry, and Carolina, and James, and Donna, and Megan are my favorites!”

SHHH! HAHA, Dr. Barry has given me so much hope and faith in myself; I know I can always talk to him. He had me share in his group so much, I thought my teeth were going to fall out, but it helped me so much, I realized a lot from it. James, he always brings my spirit up, when I’m down, I know I can always count on him to be there for me. When he speaks to me or when I’m in his groups, he just blows me away with words of wisdom; he’s awesome! And Donna; she is like my second mom. I can see how much she cares for other people so much, I respect her a lot. Since the day I met her, I already loved her. She’s given me everything I needed and has always supported me whenever I reached out to her; I know she’ll always be by my side, no matter what. Holding my hand through every mistake I make or struggles I go through, she’ll be there forever.

And for Megan, …WOW…I honestly don’t think I can even manage to put my love and appreciation for her into word form. There is too much of it and it’s so strong. Dr. Moran, Megan is the best, and most thoughtful, caring, supporting, loving, nice, achieving, self-loving, helpful, inspirational, responsible, healthy and most beautiful person inside and out, that I have ever met in my life. I look up to her. She has introduced me to so many people, and I appreciate that so much because I now have a meeting I look forward to every night, and I have a lot of healthy, sober, supporting friends, that look out for me and care for me. I’ve never really had people like that in my life before, so I thank her so much for that. I love Megan so much, and you are blessed to have someone like her working for you because, she is the kind of person that will actually help someone and guide them down the right path, because she definitely did for me.

Last but not least…DR. MORAN (The One and Only)

I FREAKING LOVE YOU!

Yeah Me and You have had our ups and downs, but that is because I wasn’t in a healthy stage of my recovery to understand why you did the things you did, but I realize you did it to help me because you care about me and everyone else. I seriously did think you were out to get me, but that unhealthy thinking towards you is gone, OH WHO AM I KIDDING! I hate you so much for making me so healthy, that my body is sore and my brain is spinning so fast because of everything I’m learning. Even the whole grain food for making me realize I have a problem with my taste buds because I actually thought the food was pretty good.

You will really never understand how much I appreciate you Dr. Moran. You saved my life, you really did and if there is anything I can ever help you with or do for you, don’t think twice about calling me. My family also appreciates you for all the help. Your program works, it really does…That’s if they work it though. Don’t ever think it’s your fault for other people’s mistakes because it’s them who are keeping themselves sick. All you job in the situation is to give them a second chance. You have just given me so much inspiration; you have brought joy to my eyes and happiness to my heart. You will always have a place in my heart; you’re amazing Dr. Moran, keep up the great work!

By the way, the group is doing fantastic. Little mistake here and there with us, but what can I say were addicts, we’ll always be a little crazy at heart. I love seeing everyone when I come to clinical every day, they’re getting so healthy it puts a smile on my face every morning. They support each other so well, call each other out on their mistakes and BS. But they’re also there to help fix the problem. Wellington Retreat is like one big happy family, we all love each other. The staff is great (especially Sara).

HAVE A GOOD DAY!

Sincerely,

Patient Q

The Endocannabinoid System consists of two receptors (CB1 and CB2), two endogenous ligands, and two metabolism enzymes.¹ The System regulates aspects of embryonic development and affects many homeostatic mechanisms. Originally, the CB2 receptor was thought to only regulate immune response; however, many scientists have now linked the CB2 receptor to regulating emotional behavior and cognitive functions.¹ This includes regulating feelings of anxiety and depression. Scientists also believe that altering the receptor’s role will directly relate to a person’s chance of becoming anxious, depressed, or a substance user.¹

The original study was conducted on mice; however, it is now possible that researchers will conduct impulsivity-testing trials on humans using drugs that act upon the CB2 receptor of the brain, being careful not to regulate the CB1 receptor which is already a proven impulsivity manipulator.¹ The study analyzed the action of two cannabinoid drugs that both stimulate and block CB2 in mice.¹ Next, researchers examined whether or not the drugs were capable of regulating impulsive behavior and looked to see what the cerebral modifications with such a behavior change were.¹ It was found that the CB2 receptor activity was regulated and impulsive behavior in the mice was reduced.¹ Currently, the study is still ongoing, and researchers are developing their results more fully before taking the next step.

Patients are commonly transported to emergency departments for presenting signs of agitation, as it can easily escalate to aggression and violent behavior. Therefore, as nonpharmacological interventions for managing crisis situations are used, pharmacological approaches are useful approaches as well.[5] According to Volavka and Citrome, while oral medicines are effective, the rapid onset of short-acting parenteral formulations allow for the full effects of the medicine to be reached quicker.⁵ For example, lorazepam is a useful medicine when the cause of the agitation is unclear or due to alcohol withdrawal. Absorbed intramuscularly, with a half-life of 10 to 20 hours, the usual dosage is 1.5 to 2 mg every one to six hours.[6] However, a benzodiazepine, lorazepam should not be prescribed as a daily medicine as it poses risk for tolerance, dependence, and withdrawal.⁶ Intramuscular haloperidol is used in combination with intramuscular lorazepam, supported by a trial in which intramuscular haloperidol 5 mg, intramuscular lorazepam 2 mg, and a combination was compared in emergency department patients with psychotic disorders, agitation, and aggression.[7]

Interest has been sparked in three intramuscular formulations of the second-generation antipsychotics: aripiprazole, ziprasidone, and olanzapine.[8] Intramuscular aripiprazole was found to reduce agitation in patients diagnosed with schizophrenia and in patients diagnosed with bipolar disorder, manic or mixed,[9] with a recommended dose of 9.75 mg.[10] Intramuscular ziprasidone, was found to be effective when administered to patients with schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, or another psychotic disorder who showed signs of agitation or aggression.[11]^,[12] Volavka and Citrome state that although the product’s label recommends a dosage of 10 or 20 mg, the best dose appears to be 20 mg, as evidenced in two clinical trials.⁵ Intramuscular olanzapine was also found to be effective in treating agitation and aggression in patients with schizophrenia and bipolar disorder, manic or mixed.[13] While the recommended dosage is 10 mg, lower dosages of 2.5 to 5 mg may also be used.[14] However, patients with hypotension, bradycardia, tachycardia, and syncope should use olanzapine,⁵ and olanzapine and benzodiazepines should not be used simultaneously.[15]

According to Volavka and Citrome, most of the information about long-term treatment of aggression in patients with mental illness focuses on patients with schizophrenia.⁵ In fact, antipsychotics are the main long-term pharmacological treatment of aggression in schizophrenia.⁵ Two studies were designed to study aggression in patients with schizophrenia. The first trial, by Volavka and colleagues, compared the medicines clozapine, olanzapine, risperidone, and haloperidol in 157 patients with schizophrenia or schizoaffective disorder.[16] They found that clozapine better reduced hostility compared to risperidone and haloperidol, but not to olanzapine. The second trial, by Krakowski and colleagues, compared clozapine, olanzapine, and risperidone in 110 patients with schizophrenia or schizoaffective disorder.[17] They found that clozapine was more effective than olanzapine, and that olanzapine was more effective than risperidone.

Citrome states that although not FDA-approved, the anticonvulsant valproate is prescribed often in patients with schizophrenia as an adjunctive medicine for impulse control.[18] An analysis demonstrated that valproate was effective during week one of treatment; however, the results were unable to be replicated and empirical data is unavailable.[19] Another anticonvulsant, lamotrigine, was tested in patients with schizophrenia with contradictory results,[20] but some suggest lamotrigine may be used in cases of patients who are clozapine-resistant.[21] The mood-stabilizer lithium has been found to be effective when reducing aggressive behavior in patients with bipolar disorder[22]; however, there is not enough evidence to state the same for patients with schizophrenia.⁵

Overall, as several studies have reviewed the effectiveness of many medicines in the management of agitation and aggression in patients with schizophrenia and other major mood disorders, clozapine was found to be the most effective in reducing violent behavior in patients with schizophrenia. As a close second choice, olanzapine was found to be very effective as well. For patients with bipolar disorder, lithium was an effective choice; but anticonvulsants did not show any promise. In review, Volavka and Citrome state that other antipsychotics did not show any effective qualities in reducing aggressive behavior either.

While there are other reasons children experience hallucinations, psychiatric disorders may be the root cause.  For example, schizophrenia, schizophreniform disorders, and mood disorders with psychotic features all include hallucinations as symptoms.[6] However, there are other psychiatric disorders in which hallucinations are not symptoms of, but can occur as associated symptoms.¹ Examples of such disorders are ADHD, disruptive disorders, anxiety disorders, posttraumatic stress disorder, dissociative disorders, and oppositional defiant disorder.¹ Also, some medicines, such as steroids, anticholinergics, and stimulants, can cause hallucinations to occur, as well as the abuse of illegal substances.¹ Children may also form hallucinations to deal with abuse or in mourning of a deceased parent.[7]

There are also many medical causes for hallucinations, including metabolic disorders, fever, and infections.[8] Also, seizure disorders can cause hallucinations, although rare. Usually the hallucinations associated with seizures are unformed, such as flashing lights or rushing noises, or formed, such as images, spoken words, or music.¹ Migraines, which occur in about five percent of children, often cause visual hallucinations.[9]

Despite the cause of hallucinations, there are treatment options. First and foremost, addressing any underlying medical or psychiatric condition is imperative, including substance abuse.¹ While there is no age at which it is better to begin treatment for children at risk for developing a psychotic disorder, the earlier the symptoms are noted, the better. Although many assessment scales that aid in early identification are not standardized for children, there are some that can still assess a child accurately, including the Scale of Prodromal Symptoms, Structured Interview for Prodromal Symptoms, Comprehensive Assessment of At-Risk Mental States, and the Bonn Scale for the Assessment of Basic Symptoms.¹ Also, a child may be considered to be prodromal if there has been a 30 percent drop in their Global Assessment Functioning score within the past month or if a relative has affective or nonaffective psychotic disorder or schizotypal personality disorder.[10]

While treating a child with antipsychotics should be done cautiously, the use of cognitive-behavioral therapy (CBT) is safe and effective.¹ CBT is known to slow the progression of a child to psychosis, especially in high-risk patients.[11] The focus of the therapy is on the underlying and personalized meaning of the hallucinations, and the child learns to understand what the hallucinations mean, how they began, what they are, and how the child can stop them.[12] Coping strategies, including “normalizing” the hallucinations, are used.[13] The therapist oftentimes explains the common reasons the hallucinations occur, including lack of sleep, isolation, extreme stress, fever, lack of food, and substance abuse.¹ Also, the child learns that the voices are only real if they believe them, learning to cope with the hallucinations by humming, listening to music, reading, exercising, singing, taking medicine, and ignoring them.¹ Through CBT, children are able to control their hallucinations.