Childhood Psychoses

Description

The schizophrenia spectrum and other psychotic disorders are primarily characterized by the active (or positive) symptoms of psychosis, specifically delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. Brief psychotic disorder is characterized by the duration of 1 or more of these symptoms for at least 1 day but <1 mo followed by complete resolution. Emergence of symptoms may or may not be preceded by an identifiable stressor ( Table 47.1 ). Although brief, the level of impairment in this disorder may be severe enough that supervision is required to ensure that basic needs are met and the individual is protected from the consequences of poor judgment and cognitive impairment.

If 2 or more psychotic symptoms persist from 1 mo up to 6 mo, the condition is called schizophreniform disorder ( Table 47.2 ). To meet DSM-5 criteria for schizophrenia , 2 or more psychotic symptoms must have been present for a significant time during 1 mo (unless suppressed by treatment), and the level of psychosocial functioning must be markedly below the level achieved before the onset (or there is failure in children to achieve the expected level of functioning). In addition, there must be continuous signs of the disturbance (prodromal, active, or residual symptoms) for at least 6 mo ( Table 47.3 ).

Individuals with schizophrenia can display inappropriate affect, dysphoric mood, disturbed sleep patterns, and lack of interest in eating, or food refusal. Depersonalization, derealization, somatic concerns, and anxiety and phobias are common. Cognitive deficits are observed, including decrements in declarative memory, working memory, language function, and other executive functions, as well as slower processing speed. These individuals may have no insight or awareness of their disorder, which is a predictor of nonadherence to treatment, higher relapse rates, and poorer illness course. Hostility and aggression can be associated with schizophrenia, although spontaneous or random assault is uncommon. Aggression is more frequent for younger males and for individuals with a past history of violence, non-adherence with treatment, substance abuse, and impulsivity.

The essential features of schizophrenia are the same in childhood as in adulthood, but it is more difficult to make the diagnosis. In children, delusions and hallucinations may be less elaborate, visual hallucinations may be more common, and disorganized speech may be better attributed to an autism spectrum or communication disorder. In a review of 35 studies of youth with schizophrenia, the most frequent psychotic symptoms were auditory hallucinations (82%), delusions (78%), thought disorder (66%), disorganized or bizarre behavior (53%), and negative symptoms (50%).

Epidemiology

Brief psychotic disorders have been reported to account for 9% of first-onset psychosis in the United States, with a 2 : 1 ratio in favor of females. The incidence of schizophreniform disorders in the United States appears as much as 5-fold less than that of schizophrenia. The lifetime prevalence of schizophrenia is approximately 0.3–0.7%, although variations are reported by race/ethnicity, across countries, and by geographic origin for immigrants. The male:female ratio is approximately 1.4 : 1. Males generally have worse premorbid adjustment, lower educational achievement, more prominent negative symptoms, and more cognitive impairment than females.

Clinical Course

Brief psychotic disorder most often appears in adolescence or early adulthood, with the average age of onset in the mid-30s, but can occur throughout the life span. A diagnosis of brief psychotic disorder requires full remission within 1 mo of onset and gradual return to premorbid level of function. The age of onset of schizophreniform disorder is similar to that of schizophrenia. Recovery from an episode of the disorder is within 6 mo; however, about two thirds of patients relapse and eventually receive a diagnosis of schizophrenia or schizoaffective disorder. Abrupt onset, confusion, absence of blunted affect, and good premorbid functioning predict a better outcome in schizophreniform disorder.

Schizophrenia typically develops between the late teens and the mid-30s; onset before adolescence is rare. The peak age at onset for the first psychotic episode is in the early to mid-20s for males and in the late 20s for females. The onset may be abrupt or insidious, but the majority of individuals manifest a slow and gradual development of symptoms, with about half of individuals complaining of depressive symptoms. The predictors of course and outcome are largely unexplained. The course appears to be favorable in approximately 20% of cases, and a small number of individuals are reported to recover completely. However, many remain chronically ill, with exacerbations and remissions of active symptoms, whereas others experience progressive deterioration. Most individuals diagnosed with schizophrenia require daily living supports. Positive symptoms tend to diminish over time, and negative symptoms are the most persistent, along with cognitive deficits.

Differential Diagnosis

The differential diagnosis for the psychotic disorders is broad and includes reactions to substances/medications (dextromethorphan, LSD, hallucinogenic mushrooms, psilocybin, peyote, cannabis, stimulants, inhalants; corticosteroids, anesthetics, anticholinergics, antihistamines, amphetamines); medical conditions causing psychotic-like symptoms ( Table 47.4 ); and other psychiatric disorders (depressive, bipolar, obsessive-compulsive, factitious, body dysmorphic, posttraumatic stress, autism spectrum, communication, personality). The differential diagnosis can be difficult because many conditions that can be mistaken for psychosis also increase the risk for it.

Autoimmune encephalitis caused by anti– N -methyl- d -aspartate (NMDA) receptor or other autoantibodies may manifest with psychosis, anxiety, depression, agitation, aggression, delusions, catatonia, visual or auditory hallucinations, disorientation, and paranoia in combination with sleep disturbances, autonomic dysfunction (hypoventilation), dyskinesias, movement disorders, seizures, memory loss, and a depressed level of consciousness ( Fig. 47.1 ). The electroencephalogram (EEG), cerebrospinal fluid (CSF), and MRI are usually, but not always, abnormal. The constellation of psychosis and encephalitic features should suggest the diagnosis, although at presentation, behavioral problems may be the dominant feature (see Chapter 616.4 ).

Determining when identifiable medical conditions are causing delirium with prominent psychotic symptoms may be difficult ( Table 47.5 and Table 47.6 ). In general, delirium due to medical causes is often associated with abnormalities in vital signs and the neurologic examination (including level of consciousness). A positive family or prior personal history of serious psychiatric illness is less likely. When psychotic symptoms are caused by identifiable medical conditions, there are often impairments in attention, orientation, recent memory, and intellectual function. Hallucinations may be caused by medical illness, but are often tactile, visual, or olfactory, whereas auditory hallucinations are more common in primary psychotic disorders. Patients whose hallucinations are caused by medical illness are more likely than patients with primary psychotic disorders to be aware that the hallucinations do not represent reality.

The diagnosis of a psychotic disorder should be made only after other explanations for the observed symptoms have been thoroughly considered. Mistakenly diagnosing psychosis when it is not present can lead to inappropriate use of antipsychotics with all their attendant risks, and mistakenly dismissing psychotic symptoms as nonpsychotic manifestations of, for example, autism or trauma can lead to long delays in treatment of the psychosis. The persistence, frequency, and form of possible psychotic symptoms, as well the degree of accompanying distress and functional regression, need to be considered in determining the likelihood of an underlying psychotic pathophysiology.

Comorbidity

In a review of 35 studies of youth with schizophrenia, rates of comorbidity approximated 34% for posttraumatic stress disorder, 34% for attention-deficit/hyperactivity and/or disruptive behavior disorders, and 32% for substance abuse/dependence.