Psychotic Symptoms in Children and Adolescents

Assessment, Differential Diagnosis, and Treatment

Claudio Cepeda

• Publisher: Routledge
• Year: 2006
• eBook ISBN: 9781135925697
• Topic: Médecine
• Subtopic: Psychiatrie et santé mentale

Psychotic Symptoms in Children and Adolescents demystifies the interviewing diagnostic process of psychosis in children and adolescents and provides a valuable resource for treatment. Psychotic symptoms have traditionally been rationalized and disregarded as products of the child's imagination. There has been a professional reluctance to acknowledge that children could suffer from severe psychotic disorders akin to adult subjects, and that these symptoms merit a comprehensive and systematic evaluation.

This book offers a useful guide to the interviewing process, a review of differential diagnosis, and an overview on psychosocial interventions. It deals also with the use of antipsychotic drugs, beginning with issues related to their use in the field, followed by a review of literature on the subject, atypical side effects, and implementation throughout treatment.

The book fills a vacuum in the field of child and adolescent psychosis, and will have a broad appeal and interest to general psychiatrists, clinical psychologists, to child and adolescent psychiatrists, and many other mental health professionals working with disturbed children and adolescents.

CHAPTER 1

Overview of Psychotic Symptoms in Childhood

This Chapter Will Review The Following Propositions:

• Psychotic symptoms are rather common in clinical practice.
• Psychotic symptoms are common in severe psychiatric disturbances.
• Most of the psychotic features in children and adolescents are associated with affective disorders.
• The great majority of psychotic symptoms of children and adolescents respond to appropriate treatment.
• There are a number of barriers that examiners need to overcome to objectify psychotic disorders.
• Psychotic symptoms in childhood may represent incipient signs of serious psychiatric disorders or may foreshadow serious future psychopathology.
• Oftentimes, psychotic symptoms are not apparent; clinicians need to explore their presence systematically in all patients.
• Serious psychotic disorders may continue into adulthood.
• Psychotic symptoms are seldom trivial. They need close monitoring

THE CONCEPT OF PSYCHOSIS

The concept of psychosis has different levels of explanation. As a symptom, psychosis has traditionally referred to the presence of hallucinations and delusions; as a disorder, and applying the DSM-IV-TR (APA, 2000) definition of mental disorder, the term psychotic disorder refers to a significant clinical behavioral and psychological pattern or syndrome that occurs in an individual and that is associated with distress and disability (impairment in one or more important areas of functioning, or developmental progression), or with a significant increased risk of death (suicide), suffering pain (due to distressing symptoms), disability, or an important loss of freedom due to fear or misinterpretation of reality, secondary to abnormal perception, paranoia, or thought disorder, among others (DSM-IV-TR, 2000, p. xxxi). The Dorland's Illustrated Medical Dictionary (1994) gives a very succinct definition of illness: “a condition marked by pronounced deviation from the normal healthy state.” The subheading of “Mental Illness” refers the reader to the concept of disorder (p. 819), and the term is defined as a “derangement or abnormality of function; a morbid physical or mental state” (p. 492). This short definition of illness agrees with the explanatory definition of disorder obtained from the DSM-IV-TR described above. The concept of psychiatric disorder is customarily used to describe what is informally designated as mental illness.

Psychotic symptoms may emerge in isolation from other disturbances, be coterminous with other disturbances (frequently affective disturbances), or be a substantial component of a major psychotic disorder. Isolated psychotic symptoms, not associated with other psychiatric symptoms, are of no clinical concern because they do not interfere with adaptive functioning. Psychotic symptoms may be secondary to substance abuse or may be associated with other psychiatric disorders, such as mood disorders, anxiety disorders, and others. The DSM-IV-TR established that psychotic symptoms represent an element of severity of the mood or anxiety syndromes, but they become indispensable, prominent, and incapacitating symptoms in patients with severe primary psychotic disorders (so-called “functional” psychotic disorders).

Thought disorder and negative symptoms are also cardinal associated symptoms of severe psychotic disorders (schizophrenic spectrum disorders). Bipolar disorder, in its moderate and severe presentations, may be associated with significant psychotic features. At times, it is dif cult to differentiate one category of disorder from the other. Formerly, there was a rigid separation between the so-called thought disorders (schizophrenic disorders) and the mood disorders (unipolar and bipolar disorders), the belief being that certain forms of thought disorder were exclusive of the schizophrenias. Although, this belief is now considered inaccurate, the distinction between thought disorders and mood disorders is still maintained. However, the boundaries of these disorders are not as distinct and specific as was previously postulated (see chapter 8).

In recent years, a number of accompanying deficits such as disorganized behavior, cognitive deficits, and a variety of neuropsychological deficits have been recognized, and added to the definition of severe psychotic disorders.

In the study of psychosis in childhood and adolescence, the dimension of development needs to be considered. A severe psychosis in childhood causes developmental deviations, impairs the acquisition of adaptive skills, and handicaps the child in a multiplicity of adaptive domains: neuromotor, cognitive, learning, interpersonal, social–adaptive, and subjective functioning.

There is a growing consensus regarding the progression and continuity of the symptomatology (illness/disorder) from childhood to adulthood for a number of psychotic disorders. There is also an increasing recognition that severe, chronic, and progressive psychotic disorders have a neurobiological substrate, and that genetic, neurodevelopmental, neurodegenerative, and neu-rochemical factors, as well as adverse environmental conditions, contribute to the expression (onset and maintenance) of the disorder. Most of these issues will be discussed in chapter 8.

RISKS FACTORS FOR PSYCHOTIC DISORDERS

Multiple risks factors have been considered in the development of psychotic disorders. These include: changes in mental status, such as depression or anxiety; subjective complaints, impaired cognitive, emotional, motor, and automatic functioning; changes in bodily sensations and in external perception; low tolerance for normal stress; drug and alcohol usage; neurocognitive impairment; obstetric complications; and delays in milestones achievement. Possible trait markers include neurological abnormalities and poor premor-bid adjustment (Phillips et al., 2002, p. 261). Patients at risk for psychotic disorders have some positive neurological findings; however, the nature of the neurological abnormalities is unclear. Curiously, patients with larger (though still within the normal range) left hippocampal volumes at intake were more likely to develop a psychotic episode in the subsequent 12-month period. Furthermore, comparison of the MRIs of patients who underwent a psychotic episode with MRIs at intake revealed neurological structural changes in the left insula cortex and in the left posteriomedial temporal structures, including the hippocampus and posterior hippocampus gyrus during the transition to psychosis (Phillips et al., 2002).

PREVALENCE OF PSYCHOTIC SYMPTOMS

Psychotic symptoms are not uncommon experiences in the lives of children; they are not uncommon findings in clinical practice, either. Psychotic features occur more frequently in children than originally thought. Severe psychotic disorders are uncommon in childhood. This proposition is supported by Reimherr and McClellan (2004), who asserted that “Although, psychotic illnesses are relatively rare in youths, especially younger children, these disorders are not uncommon in clinical settings and must be considered in the evaluation of every individual patient” (p. 10). Although psychotic symptoms are rather common in clinical practice, this is not so in regard to the frequency or prevalence of psychotic disorders.

In clinical populations, the prevalence of psychotic symptoms in children and adolescents has been reported as 4 and 8%, respectively. Psychosis becomes more prevalent with increasing age (Birmaher, 2003, p. 257).

In community samples, prevalence of psychosis (psychotic symptoms) in children and adolescents has been estimated to be about 1%. Auditory hallucinations (about 8%) are the most frequent psychotic symptoms. Delusional beliefs in children are less complex than those in adolescents, and their frequency is estimated at about 4% (Ulloa et al., 2000).

In epidemiological studies in adults, 3 to 5% of the subjects report psychotic symptoms before age 21. In a cohort of 2,031 children aged 5 to 21, evaluated at a mood and anxiety disorder clinic, 4.5% of the evaluated children had a definite psychosis (defined as having the presence of a definite hallucination and a definite delusion), and 4.7% had probable psychosis (defined as having the presence of a suspected or likely hallucination, or a suspected or likely delusion). For patients with definite psychotic symptoms, 41% had a major depressive disorder; 24% were diagnosed with bipolar disorder; and 21% were diagnosed as depressive disorder not fulfilling criteria for major depressive disorder. In 14% of the cases, patients received a schizophreniform spectrum disorder diagnosis: four patients had schizophrenia, and nine patients had schizoaffective disorder. Patients with anxiety and disruptive disorders who presented with definite psychotic symptoms always had a comorbid mood disorder (Ulloa et al., 2000, p. 339).

Mood disorders were the most frequent conditions associated with psychosis. These observations are in line with prevalence community studies in general populations; for instance, in a representative sample of 7,076 subjects (aged 18 to 64 years), psychoticlike symptoms were strongly associated with psychotic disorders (van Os, Hanssen, Bijl, & Volleberg, 2001, p. 667).

Among the psychotic symptoms, hallucinations were the most prevalent symptoms in 80% of patients (73.6% endorsed auditory command hallucinations), followed by delusions (22%) and thought disorder (3.3%). Thought disorder was only present (or perhaps only recognized) in adolescents. Hallucinations perceived as coming from outside of the head were more common in adolescents than in children. The frequency of other perceptual disturbances in psychotic children was as follows: 38.5% visual hallucinations, 26.2% olfactory hallucinations, and 9.9% tactile hallucinations. Delusions of reference were the most common type of delusions: delusions that people “could read my mind,” “could know my own thoughts,” or that other people “could hear my thoughts” were less common (Van Os et al., 2001). Usually, these delusional symptoms are rare and only present in severe psychotic disorders, and when present, they are more common in middle to late adolescence and beyond.

REASONS PSYCHOSIS IS UNDERDIAGNOSED IN CHILDREN AND ADOLESCENTS

Clinicians have hesitated to explore perceptual abnormalities or delusional thinking in childhood. Some clinicians feel mystified when they explore psychosis in children. This contributes to the high rate of misdiagnosis and underdiagnosis of psychotic disorders in childhood.

Problems with misdiagnosis probably reflect clinicians' reluctance to consider this diagnosis, a lack of familiarity with clinical presentations of psychosis in childhood, or idiosyncratic practices; it is also true that many cases are difficult to characterize until enough time has passed for the disturbing process to provide a clear pattern of the unfolding illness. The use of standardized diagnostic practices, adherence to diagnostic criteria, and systematic symptom exploration improve accuracy.

Children typically do not share their disordered perceptual experiences or delusional beliefs with parents or other trusted adults. For children, psychotic features belong to the realm of private or secret experiences that are seldom divulged to significant others. Frequently, parents only become aware of the presence of psychotic symptoms when the child starts displaying abnormal behaviors.

Older children and adolescents who develop a psychotic illness of en have some recognition that something is wrong with their thinking, perception, or behavior; they feel frightened due to a feeling of confusion in their sense of reality. Perceptual disturbances and paranoid feelings further limit a patient's willingness to discuss symptoms with caretakers or providers because the individual has a penumbra of awareness of his or her abnormal experiences.

Some parents normalize psychotic experiences or expect that “children will grow out” of them. This idea may be reinforced by professionals; sometimes pediatricians and even mental health professionals support these naïve expectations and give parents false reassurances. Parents are of en told that these unusual experiences are trivial and temporary. Sadly, this contributes to delays in identification and treatment of early presentations of psychotic symptoms. Even psychiatrists may miss the symptoms underlying psychosis as they focus on presenting behavioral manifestations such as aggression or suicide (Semper & McClellan, 2003, p. 682).

As an example of how parents are misguided or falsely reassured, Schaffer and Ross (2002) describe initial experiences of parents of schizophrenic children with professionals:

Once the psychotic symptoms began, the common predominant theme was frustration with the lack of a clear and finite diagnosis at an earlier stage of development. Consistently, they reported telling pediatricians and school psychologists that something was “seriously wrong.” Of those [parents] who recognized psychotic symptoms early, three (out of 17) were explicitly told by a medical professional that “schizophrenia does not exist in children.” Eight families (out of 17) specifically stated that they questioned schizophrenia as a possible cause of the child's symptoms but were told by more than one mental health or medical professional that psychotic symptoms in childhood are not necessarily schizophrenia, and, since the diagnosis could not be made, antipsychotic medications were not indicated. One mother quoted a psychologist as having told her: “Let's make friends with the voices.” This confusion over the meaning of psychotic symptoms was associated with a mean two-year delay in diagnosis, and the trial and failure of alternative treatment plans. Specifically, many trials of mood stabilizers occurred during this period, as did trials of alternative treatments. In all cases, once the diagnosis of schizophrenia was determined and antipsychotic medications were used, a significant change was seen in baseline symptoms. (p. 543)

Psychotic symptoms are baffling for children and parents. Children with psychotic symptoms experience a lack of understanding and support from significant others when they reveal disturbing perceptions or beliefs; as a consequence, they learn to keep abnormal experiences to themselves, increasing, then, their fear and sense of alienation. It is not uncommon to hear from disturbed children that they have suffered from psychotic experiences for a long time, even years, or that the psychotic experiences began in early childhood. It is when the child no longer feels able to control the psychotic influence that the psychosis becomes manifested in unmistakably abnormal or bizarre behaviors.

Some parents become defensive when they become aware that their children are experiencing psychotic symptoms. Others attribute an ominous connotation to psychotic symptoms, not knowing that most of the psychotic symptoms are amenable to appropriate interventions.

Psychotic symptoms in their of spring of en confront parents with their own disturbed sense of reality. Not infrequently, psychotic symptoms in children trigger in the parents painful memories of their own developmental experiences: these symptoms remind parents of their own unusual experiences, of psychotic parents or relatives, or of other disturbing events in their past. It is not unusual, when a child endorses psychotic features, that other family members may endorse psychotic symptoms as well.

Psychotic symptoms should be taken seriously and clinicians need to alert parents to take appropriate steps to prevent the disturbed child from acting out his or her psychotic beliefs. When dealing with psychotic symptoms, the first priority for parents should be to guarantee the safety of the child and that of siblings and caretakers. This is particularly true when the child experiences auditory command hallucinations telling the child to either kill others or to kill himself. A child misguided by distorted beliefs may also pose a serious risk to others when he believes that he needs to defend himself against a falsely perceived persecutor or external danger.

Psychotic symptoms do not occur in isolation; therefore, psychotic symptoms in the context of an otherwise normal mental status examination warrant skepticism (Reimherr & McClelland, 2004, p. 6). Relevant psychotic symptoms impair the child's adaptive capacity in a variety of areas.

TABLE 1.1 Risk factors of psychotic disorders

• Homicidal behavior

• Suicidal behavior

• Terroristic behavior

• Impulsive/self-defeating behaviors

• Alcohol and drug abuse

• Gang participation/antisocial behavior

• Unwanted pregnancies/STDs

• Poor compliance and relapse risk

• School difficulties

• Social and vocational problems

• Self-neglect

• Victimization

RISKS ASSOCIATED WITH PSYCHOTIC SYMPTOMS

Psychotic patients, espec...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Table of Contents
• Preface
• Acknowledgments
• Chapter 1 Overview of Psychotic Symptoms in Childhood
• Chapter 2 Psychiatric Assessment
• Chapter 3 Examination of Other Psychotic Symptoms
• Chapter 4 Examination of Mood and Affect
• Chapter 5 Aids in the Diagnostic Process
• Chapter 6 Differential Diagnosis of Psychotic Disorders: Medical Conditions Associated with Psychosis
• Chapter 7 Differential Diagnosis of Psychotic Disorders: Psychiatric Disorders Associated with Psychosis
• Chapter 8 Etiology and Pathogenesis
• Chapter 9 Psychosocial Interventions for Chronic Psychoses
• Chapter 10 Psychopharmacological Treatment: Considerations in the Clinical Use of Antipsychotic Medications
• Chapter 11 Mood Stabilizing Medications in the Treatment of Psychotic Disorders of Children and Adolescents, Other Treatments, and Alternative Treatments
• Chapter 12 Overview of Atypical Antipsychotics
• Chapter 13 Side Effects of Mood Stabilizers and Atypical Antipsychotics
• Chapter 14 Treatment of Atypical Side Effects
• Appendix A Drug Interactions
• Appendix B Conventional or Classic Antipsychotics
• Notes
• References
• Index