Psychosis in Children and Adolescents

What is Psychosis?

Psychosis is a broad term encompassing a group of severe mental health disorders which disrupt a person's perception, thoughts, emotions and behaviour through delusions and hallucinations. The most common type is schizophrenia - over a lifetime, about 1 in 100 people will develop schizophrenia, but it is most likely to start between the ages of 15 and 35 years. Presentations in mid-late teens is common but on rare occasions I have encountered younger children with symptoms in keeping with psychosis. 

Causes of early onset psychosis:

Psychosis is more likely to be experienced by individuals who have a genetic predisposition or family history of the condition. However, there will be some people who have underlying biological predisposition without a family history. The hypothesis most favoured is one of gene - environment (e.g. stressful life events, drug use) interaction wherein the latter uncovers the underlying risk manifesting in the illness. 

Types of psychosis in children and adolescents: 

As mentioned schizophrenia is the most common but other forms such as brief psychosis, psychosis in the context of  either depression or mania (bipolar disorder), drug induced or organic i.e. where there is an underlying medical condition are also likely. The latter includes endocrine disorders such as those affecting thyroid, parathyroid, steroidal hormones or porphyria's. Other known medical causes are - autoimmune or infectious encephalitis, epilepsy, Wilson's disease and Huntington's chorea. 

Clinical features: 

Some young people present with acute symptoms out of the blue, others may experience a prodromal phase where the earliest indicators may be mood changes, anxiety, sleep problems, decline in academic performance. There may be attenuated odd beliefs and perceptual abnormalities (hallucinatory experiences) not meeting threshold of a full diagnosis. A family history or presence of certain specific personality traits may lead to such a person being diagnosed as having an "at risk mental state"

The diagnosis is given when a person presents with more obvious signs and symptoms suggestive of the following - delusions, hallucinations, negative symptoms (apathy, a-motivation, self neglect amongst other symptoms), disorganised behaviour or features such as incoherent speech / posturing. The Clinical Criteria are not detailed here but a specialist has to consider whether or not certain thresholds are met to give a diagnosis. 

Assessment:

This includes a detailed history, mental state and physical examination followed by routine blood tests, CT / MRI, EEG are recommended when onset is early. Specialist tests may have to be considered if need be to evaluate if any of the above metabolic / medical causes underly. 

Treatment of Early onset Adolescent Psychosis: 

  • At risk or prodromal stages: It is recommended that close monitoring of mental state, social support, psychological interventions are considered before medication in these cases. 
  • For those with a clear diagnosis for psychosis (not just schizophrenia) medication is the mainstay of the treatment, this leads to use of atypical antipsychotics such as Olanzapine, Risperidone, Aripiprazole. All options need close monitoring for side effects, treatment is initiated and thought of as a trial as for some people the first medication options may either provide sub-optimal benefits or side effects needing to consider alternative approaches. There are no tests to confirm what will work for whom and this is a process learning by trial. 
  • Educating the person affected and carer's about the ailment is vital part of the work. Family therapy is considered in situations where there are "expressed emotions" i.e. over-involvement, criticism, harshness in interactions. 
  • Focus should be on eventual recovery - reintegrating back to education, vocation and society in general.
  • Where medical causes are found, treatment of same is vital, a diagnosis of psychosis may not be given here but treatment of symptoms with anti-psychotics may at times be needed. 

Prognosis: 

About a fifth recover fully, others however may experience chronic or recurring forms of illness. The importance of medication is well established, the longer it takes to start treatment (duration of untreated psychosis) correlates with poor long term outcomes. Medication compliance with treatment for up to 2 years is also likely to lessen chances of relapses.  

© Dr A Joglekar