Download PSYCHOSIS IN CHILDHOOD AND ADOLESCENCE

PSYCHOSIS IN
CHILDHOOD AND
ADOLESCENCE
Dr Andrew Court
RCH
“T”
 15
yo living with family, yr 9, presented
with 3-6 month deterioration in
performance/change of
personality(irritable and difficult)/laughing
to self
 Refused to come to clinic
 Hearing voices/believing family involved in
plot/messages from TV
 No family hx/heavy THC use
“D”
 16
yo, yr 11, presenting with “change of
personality”/social withdrawal over 6/12
 Context of family trauma
 On specific questioning- hearing
derogatory voices/others watching her
 Also cutting self regularly/mood
fluctuation/anger outbursts
“N”

18 yo with 6 month baby referred after angry outburst.
Long hx aggression
 Hx of “voices”- since baby/conversations and
comments/2 males”and my thoughts”/only when
bored/able to control them/never bothered by them
 Also “paranoia”(people following-intact reality testing) Nil
else
 No known family hx psychosis
 Long hx physical/sexual abuse
 Drug abuse since 13yo
 No stable relationships
 Long hx impulsivity/aggression and self harm
PSYCHOSIS
 “Distortion
or loss of contact with reality
without clouding of consciousness”
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Hallucinations
Delusions
Thought disorder
Negative symptoms
Disorganisation
DIFFERENTIAL if “ PSYCHOSIS”
 “psychotic
symptoms”
 Schizophrenia
 Schizophreniform
 Schizoaffective
 Mood disorder
 Brief psychotic disorder
 Organic
DIFFERENTIAL of “PSYCHOSIS”
 Pseudohallucinations
 Dissociative
states
 OCD
 Schizotypal
Personality Disorder
 Transient psychotic symptoms with BPD
 Drug intoxication
 Factitious disorder
PSYCHOSIS
INVESTIGATION
 FBE + diff
 U and E’s
 LFT’s
 TFT’s
 RBG
 Urine drug screen
 CT
 + / - EEG
 Other
PSYCHOSIS
ASSESSMENT
 Engagement
 Mental State Assessment
 Risk Assessment
 Physical Investigations
PSYCHOSIS
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ENGAGEMENT
Listen
Acknowledge and respect patient’s point
of view
Appropriate body language if paranoid
Gather information slowly initially
Confidentiality (and its limitations)
Family involvement
PSYCHOSIS
MENTAL STATE ASSESSMENT
 N.B. Will often not volunteer psychotic
symptoms.
 Thought Disorder
“Trouble with thinking
clearly”
 Hallucinations
“Strange experiences
recently, hearing voices
when no one there, people
talking about you”
 Delusions
“unusual events recently
monitored in any way,
strange experiences
watching TV”
PSYCHOSIS
RISK ASSESSMENT
 Ask directly
 Risk if: guarded

depressed

self-destructive commands

drug/alcohol abuse

previously high functioning male in
recovery phase

grandiose delusions
 Check risk to others (paranoia)
“PACE” criteria
 Greater
than one week
 Frequent symptoms
 Assessment of how strongly beliefs are
held
CHILDHOOD SCHIZOPHRENIA
late 19th C “Dementia Praecox”
 Bleuler: 1911 “Schizophrenia”
 Laing: 1960’s “Schizophrenogenic
families”
 DSM II: All psychotic disorders in children
“childhood schizophrenia”- almost any
severe abN of child devt/autism
 Kraepelin:
HALLUCINATIONS IN CHILDREN


?Fantasy vs true hallucination
?age that child can distinguish fantasy from
reality(Despert:3yo/Piaget:6yo)
 Pilowsky(1986): Direct observation (internal
stimuli)/separate interviews of parents and
children/spontaneous reports of children reliable
 More likely “real” if: vivid/acts on hallucination
/ego alien source/no volitional quality
 “parahallucinations” frequent in normal children
(eidetic imagery/imaginary friends/hypnopompic
and hypnogogic hallucinations)
HALLUCINATIONS IN CHILDREN
 Can
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occur in:
Anxiety states
Transient situational
Deprived with PD
SCZ
Organic
DELUSIONS
(1) Belief held with total conviction
(2) Great personal significance
(3) Not amenable to reason or modification
by experience
Less systematised in children
cf Magical thinking but concern if fixed
/pervasive/child acts on them/poor reality testing
THOUGHT DISORDER
 Illogical
thinking
 Loose associations
 Incoherence
 Poverty of speech
(normal < 7 yo)
Differential Dx:
SCZ
Organic
Expressive language disorders

SCHIZOPHRENIA DSM IV
 Psychotic
symptoms(delusions/persistent
hallucinations/thought disorder/
disorganisation/-ve symptoms >1 month)
 Change in functioning
 6 month duration (including prodrome)
 Not Schizoaffective/Mood/Organic
 Not Autism (if autism, h’s and d’s must be
prominent)
SCHIZOPHRENIA-PREVALENCE
AND EPIDEMIOLOGY
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Prevalence 1%
Incidence 0.1%
“Typical” males 15-25/females 20-30
20% < 20yo 5% < 15 yo
Early onset Schizophrenia > 13 yo
Very early onset Schizophrenia < 13 yo
Youngest reported 3 yo/< 6yo vv rare/< 11yo
unusual
 Earlier the onset/larger the abn. of personality
and function
SCHIZOPHRENIA- aetiology
Biology
genetics
birth history
radiology
drugs (inducing/treatment)
Psychological
schizotypal PD
Social
Expressed Emotion
“stress”
SCHIZOPHRENIA- phases
 (1)
PRODROME
 (2)
ACTIVE
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(3) RESIDUAL
SCHIZOPHRENIA- PRODROME
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(1) SUBTHRESHOLD PSYCHOTIC
SYMPTOMS (perceptual abn, changes in
thought patterns, suspiciousness, odd beliefs)
 (2) NON SPECIFIC SYMPTOMS (sleep
changes, anxiety, anger, depression, poor
concentration)
 (3) BEHAVIOURAL CHANGES (social
withdrawal, deterioration in school performance)
“PSYCHOSIS” vs
“SCHIZOPHRENIA”
 EPPIC
model
 Early detection and treatment
 Stress/vulnerability
 “chemical imbalance”
“Typical” antipsychotics
 Haloperidol
 Stelazine
 Chlorpromazine
 Thioridazine
 Pimozide
“Atypical” antipsychotics
 Risperidone
 Olanzapine
 Quetiapine
 Amisulpiride
 Aripiprazole
 Clozapine
PSYCHOSIS
MEDICATION
 Minimise side effects
 Start low dose
 Increase gradually
 Side effect profile
 Compliance issues
PSYCHOSIS
MEDICATION
 Atypicals
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Start
Aripiprazole 5 - 10 mg
Risperidone 2 mg
Olanzapine 10 mg
Quetiapine 300 mg
Amisulpride 20 - 400 mg
for 3/52
then increase to maximum
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Ariprazole 15 mg
Risperidone 4 mg
Olanzapine 20 - 25 mg
Quetiapine 600 - 800 mg
Amisulpride 600 - 800 mg
PSYCHOSIS
MANAGEMENT
 Shift if no change in 8 weeks
 Trial further atypical
 If no improvement think:
 Compliance
 Drug abuse
 Stress
 Clozapine
Risperidone
 Doses
(0.5-4mg) average 2-3mg
 Form- tablets, syrup, quicklets,
depot (risperdal consta)
 Indications Side
effect profile-
Olanzapine
 Dose
 Form-
tablet, wafer, IM
 Indications
 Common
side effects-
Quetiapine
 Dose
 Form
 Indications
 Common
side effects-
Amisulpiride
 Dose
 Form
 Indications
 Common
side effects-
Aripiprazole
 Dose
 Form
 Indications
 Common
side effects-
Clozapine
 Dose
 Form
 Indications
 Common
side effects-
Depots
 Modecate
 Haldol
 Flupenthixol
 Zuclopenthixol
 Risperdal
consta
Risperdal consta
 Dose
 Indications
 Side
effects
Lack of treatment response
 Medication
adherence
 Treatment resistant illness
 Diagnostic uncertainty
 Comorbid illness (e.g., depression)
 Comorbid substance abuse
 Ongoing stress (e.g., high E.E. family)
Medication adherence
 Insight
(psychoeducation)
 Side effects (tailoring to suit patient)
 Engagement/ therapeutic alliance
 Family support/ monitoring
 Dosette box
 Wafer/ liquid/ quicklet
 Depot
PSYCHOSIS
PSYCHOSOCIAL
 Engagement
C B T
 Stress management
 Vocational rehabilitation
 Drug and alcohol
 Family intervention
DIFFERENTIAL DIAGNOSISSchizotypal PD
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Insufficient “doses” of symptoms found in SCZ
Increased risk of SCZ
Absence of clear onset
9 areas
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Ideas of reference
Social anxiety
Odd beliefs and thinking
Unusual perceptual experiences
No friends
Odd speech
Constricted affect
Suspiciousness
Eccentric behaviour
DIFFERENTIAL DIAGNOSISDissociative Hallucinosis
Association with trauma and “borderline” states
Definition
(1) acute onset/brief/may be recurrent and
relapsing but without personality deterioration.
(2) episodes of altered consciousness
(3) anger outbursts
(4) auditory or visual hallucinations/
pseudohallucinations/intrusive mental imagery/
nightmares)