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Psychosis is a cluster of symptoms used to define specific psychiatric disorders. Psychotic symptoms include hallucinations, delusions, or disorganization of thoughts and behavior. Children, adolescents, and adults can present with these symptoms in the context of depression, bipolar disorder, schizophrenia, substance use/abuse, delirium, and post-traumatic stress disorder (PTSD).

Few studies have examined hallucination and delusion phenomenology in children, thereby making diagnosis and prevalence difficult to assess. Schizophrenia is estimated to impact 1% of the population, with a peak onset in late adolescence.1 Early-onset schizophrenia (EOS), before 18 years of age, is rare and is estimated to occur in less than 4% of all cases of schizophrenia, and has a poor prognosis.2,3 Psychotic symptoms can also be present in other mood disorders in children and adolescents. According to the National Comorbidity Survey Replication-Adolescent Supplement, the lifetime prevalence of mood disorders in adolescents is 14.3%.4 It is estimated that 20% of pediatric patients diagnosed with bipolar type I will have symptoms of psychosis during a mood episode.5 Regardless of the psychiatric diagnosis, hallucinations and delusions are present within the general population and appear to be associated with worse health function, higher incidence of depression, and higher likelihood of diagnosis and treatment for a psychiatric disorder.6


Children with psychosis may present with cognitive abnormalities, emotional difficulties, and changes in social functioning (Table 139-1).3 Studies indicate that premorbid social and emotional function is lower in patients who later on develop schizophrenia or schizoaffective disorder as opposed to mood disorders with psychotic features.7 In children and adolescents there is often a prodromal period during which there is a decline in social, emotional, and academic function that predates the onset of psychosis by a period of weeks to months. Changes in social functioning due to new-onset psychosis may present with disruptive behaviors, social withdrawal, or difficulties with peer relationships.

TABLE 139-1Symptoms Associated with Psychosis

Cognitive manifestations of psychosis include distortions of thoughts to the extent of hallucinations or delusions. Hallucinations are false sensory perceptions in the absence of evidence of stimuli. In children, hallucinations are most frequently auditory in nature.3 David et al. reported the following rates of hallucinations in childhood schizophrenia: auditory (95%), visual (80%), olfactory (30%), and somatosensory/tactile (61%).8

Delusions represent distorted or fixed beliefs held ...

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