Psychotic Disorders

Key Features

Essentials of Diagnosis

• Delusional thoughts

• Disorganized speech (rambling or illogical speech patterns)

• Disorganized or bizarre behavior

• Hallucinations (auditory, visual, tactile, olfactory)

• Paranoia, ideas of reference

• Negative symptoms (ie, flat affect, avolition, alogia)

General Considerations

• The incidence of schizophrenia is about 1 per 10,000 per year

• Onset of schizophrenia is typically between the middle to late teenage and early 30s

• Symptoms usually begin after puberty, although a full "psychotic break" may not occur until the young adult years

• Childhood onset (before puberty) of psychotic symptoms due to schizophrenia is uncommon and usually indicates a more severe form of the spectrum of schizophrenic disorders

• Childhood-onset schizophrenia is more likely to be found in boys

• Schizophrenia has a strong genetic component

• Other psychotic disorders that may be encountered in childhood or adolescence include schizoaffective disorder and psychosis not otherwise specified (psychosis NOS)

Clinical Findings

• Children and adolescents display many of the symptoms of adult schizophrenia

• Hallucinations or delusions, bizarre and morbid thought content, and rambling and illogical speech are typical

• Affected individuals tend to withdraw into an internal world of fantasy and may then equate fantasy with external reality

• They generally have difficulty with schoolwork and with family and peer relationships

• Adolescents may have a prodromal period of depression prior to the onset of psychotic symptoms

• Most patients with childhood-onset schizophrenia have had nonspecific psychiatric symptoms or symptoms of delayed development for months or years prior to the onset of their overtly psychotic symptoms

Diagnosis

• Obtaining a family history of mental illness is critical when assessing children and adolescents with psychotic symptoms

• Psychological testing, particularly the use of projective measures, is often helpful in identifying or ruling out psychotic thought processes

• Psychotic symptoms in children younger than age 8 years must be differentiated from manifestations of normal vivid fantasy life or abuse-related symptoms

• Children with psychotic disorders often have learning and attention disabilities in addition to disorganized thoughts, delusions, and hallucinations

• In psychotic adolescents, mania is differentiated by high levels of energy, excitement, and irritability

• Any child or adolescent exhibiting new psychotic symptoms requires a medical evaluation that includes

  • Physical and neurologic examinations (including consideration of magnetic resonance imaging and electroencephalogram)

  • Drug screening

  • Metabolic screening for endocrinopathies

  • Wilson disease

  • Delirium

Treatment

• The treatment of childhood and adolescent schizophrenia focuses on four main areas

  • Decreasing active psychotic symptoms

  • Supporting development of social and cognitive skills

  • Reducing the risk of relapse of psychotic symptoms

  • Providing support and education to parents and family members

• A special school or day treatment environment may be necessary, depending on the child's or adolescent's ability to tolerate the school day and classroom activities

• Support for the family emphasizes the importance of clear, focused communication and an emotionally calm climate in preventing recurrences of ...