Adolescent Psychosis

Essentials

• Psychoses often start in adolescence.
• Particularly people with an immediate family member who has had a psychosis and who themselves have started to show mental symptoms and impaired performance are at risk of psychosis.
• Psychosis is often preceded by long-standing unspecific prodromal symptoms.
• In some cases, psychosis may be of short duration, but it may also be a sign of beginning schizophrenia, psychotic depression or bipolar disorder.
• The so-called positive symptoms of psychosis include hallucinations, delusions, or confused speech and behaviour. Schizophrenia may additionally have negative symptoms, such as isolation or emotional flattening, and cognitive disturbances, impairment of functional capacity, as well as developmental regression.
• Treatment of schizophrenia is of long duration, individual, multiform and multidisciplinary. The therapy includes psychopharmacological medication as well as psychosocial treatment and rehabilitation.

Adolescence and age limits

• Adolescence refers to the period of mental and physical growth from the onset of puberty until early adulthood, between about the ages of 12 and 22.
• Involuntary treatment of minors, i.e. children and adolescents below the age of 18, is regulated by the national legislation (in Finland e.g. by the Mental Health Act and the Child Welfare Act). Depending on the local legislation, the involuntary treatment of minors does not necessary require that the minor is psychotic, but instead a severe mental health disorder may be a criterium.
• As a general principle, if a minor patient is of an age and level of development that allow him/her to decide on the treatment given, he/she should be cared for in mutual agreement with him/her. If a minor patient cannot decide on the treatment given to him/her, he/she is cared for in mutual agreement with his/her guardian or legal representative.
• In practice, if a patient is 12 years old or older, treatment should today normally be given in mutual agreement with the patient, or referral for involuntary inpatient care should be considered, as necessary.

Definition

• Psychosis refers to a mental disorder where the patient's sense of reality is grossly distorted.
• A psychotic patient finds it hard to distinguish between what is real and what not.
• Adolescents may suffer from several types of psychosis, including short-term psychosis, schizophrenia, psychotic depression, bipolar disorder, substance-induced psychosis, and, in adolescents rare, delusional disorder.
• In differential diagnosis, it is important to take into account psychosis caused by somatic disease and by the use of intoxicants or (legal or illegal) drugs, as well as delirium (a state of confusion), which also represents a somatic emergency.

Prevalence

• The prevalence of schizophrenia among adolescents has been estimated to be at least 0.5%.
• In about a half of all patients, schizophrenia begins in adolescence.
• The prevalence of type I bipolar disorder in adolescents is about 0.2-0.6%.
• The onset of type I bipolar disorder occurs by the age of 22 in about half of all patients.
• There are regional differences in the prevalence of psychosis. In Finland, it is highest in the northern and eastern parts of the country.

Assessment of the risk of psychosis

Symptoms

• Positive symptoms
  • Hallucinations (auditory hallucinations particularly in schizophrenia, especially those involving voices that command or criticize, and visual hallucinations particularly in organic psychoses, such as substance-induced psychoses)
  • Delusions (paranoia, delusions of grandeur, delusional jealousy, somatic delusions)
  • Disorganized or incomprehensible speech
  • Highly disorganized or catatonic behaviour, such as immobility, stupor, strange positions and movements
• Negative symptoms
  • Flattened affect
  • Impoverished speech
  • Withdrawal
• In addition, the patient may have anxiety or affective symptoms.
  • Deep hopelessness, inappropriate self-blame, suicide plans and attempts, sometimes also violence or a threat of it.
• Cognitive deficiency symptoms and developmental regression may occur particularly in patients with schizophrenia.

Diagnostic work-up

• When a first psychotic episode is suspected, patients should, after assessment of somatic status, be referred for examination and observation to adolescent or adult psychiatric care, if necessary as an urgent case to an assessment by a multidisciplinary team responsible for patients with acute psychosis or as an emergency case to inpatient care within a hospital ward using an appropriate referral.
• Diagnosis should be based on history, clinical symptoms and their duration, as well as adolescent psychiatric and somatic examinations.
• Patients should be assessed and treated taking into account their incomplete physical and psychosocial development, which may make diagnostics more difficult.
• Comorbidity is common in adolescents. In addition to psychosis, an adolescent may have anxiety, an affective syndrome, a conduct disorder or intoxicant abuse, for example and sometimes also a developmental disability or a neuropsychiatric disorder.
• The use of intoxicants should be investigated.
• Holistic assessment is carried out. In psychotic adolescents, development is often complicated in several areas of life (in relation to themselves or their bodies, home and parents, peers, school/studies, interests and hobbies).
• The basic examinations include individual and family interviews, collection of information also from school and student health care (with the patient's permission), symptom questionnaires, semistructured diagnostic interviews: SCID-I or, for minors, K-SADS-PL.
• Somatic examinations are also needed (general condition, somatic and neurological status, laboratory tests, drug screen; in a first episode of psychosis cranial MRI, other imaging, as necessary, and EEG) and, as required, consultation of appropriate somatic specialists.
• In differential diagnosis consider neurologic and somatic diseases, use of intoxicants, adverse effects of medication, and intoxications.
• Psychosis-like symptoms and confusion may also be caused by systemic infections such as pneumonia, disturbances in the electrolyte and fluid balance, endocrinological conditions such as hypoglycaemia, and disorders of the thyroid and parathyroid glands, as well as Wilson's disease and acute porphyria.
• In addition, examinations should include the following, as considered necessary: psychological (e.g. cognitive performance) and neuropsychological examinations, assessment by a psychotherapist or occupational, music or art therapist as the acute psychosis abates, assessment by a physiotherapist, and evaluation by a social worker (daily compensation and rehabilitation benefits; for minors, contacting child welfare or submitting a child welfare notification should be considered, as necessary).
• See also the articles Schizophrenia Schizophrenia, Bipolar affective disorder Bipolar Disorder, Adolescent depression Depression in Adolescents, and Substance-related disorders in adolescents Substance Abuse of Adolescents.

Treatment

Criteria for referral to specialized care

• If psychosis is suspected, the adolescent should be referred without delay for specialized care by urgent or emergency referral on a voluntary basis or for involuntary inpatient monitoring, as necessary.
• The adolescent's state permitting, intensive outpatient care is preferred but care within an inpatient ward is necessary, for example, if the patient is confused, has severe delusions or hallucinations or if there is a risk of suicide or violence.