Psychosis, from the Greek meaning of abnormality of the mind, refers to a mental state in which a person is detached from reality and experiences a number of other abnormal symptoms such as delusions, hallucinations and abnormal thinking. Psychosis is also the term given to a group of severe mental health disorders in which positive (hallucinations, delusions, abnormal thinking) or negative (blunting of emotional response, apathy, lack of motivation, poor speech, social withdrawal and self-neglect) symptoms are prominent and accompanied by impairment. It therefore does not convey any aetiological meaning. Although most will associate schizophrenia as the prototype of recurring episodes of psychosis, first-onset psychosis may be part of bipolar disorder, substance-induced psychoses, and brief psychotic episodes and less commonly caused by an organic aetiology such as temporal lobe epilepsy or neurodegenerative disorders. Rarely, psychoses may be shared as in the case of folie a deux syndrome. 

The accepted lifetime prevalence of schizophrenia is 1%, with equal rates in males and females. The peak age of onset in males is earlier (15-25 years) than in females (25-35 years). Schizophrenia is very rare in childhood, but becomes increasingly more common after puberty, where the prevalence of any psychotic disorder increases from 0.9/10,000 at age 13, to 17.6/10,000 at age 19. Schizophrenia diagnoses are responsible for a substantial 24.5% of all psychiatric admissions in young people aged 10-18 years in the UK. In Ireland alone, schizophrenia accounted for 13% of all child and adolescent admissions in 2011, 67% of which involved male patients. Ethnic and cultural risk factors identified in adults have not consistently been found in children.

What are the symptoms of psychosis?

Patients with psychotic illnesses often present with bizarre beliefs, experiences and inappropriate behaviour. 

Thought disorder

The person may have illogical or incoherent thoughts and may move rapidly and randomly from one idea to another. This is known as “loosening of associations” or in the extreme form “word salad” or “knight’s move thinking” where it is impossible to follow the logic or sequence of ideas offered. 

Delusions

Beliefs that are false, frequently obscure yet held with absolute conviction and cannot be altered using logic or reason.

Hallucinations 

The experience of a perception (auditory, visual, tactile, gustatory or olfactory) in the absence of a stimulus but having the quality of a real perception. A person may complain of people talking about him when there is no one there, or they may see or smell something that in reality is not present. They are located in external objective space, occurring in clear consciousness and distinct from illusions in which there is a misinterpretation of a real percept, ie. the coat hanging on the door is a man coming to attack you.

Negative symptoms 

Include blunting or flattening of emotional response, paucity of speech, apathy, lack of motivation, social withdrawal and self-neglect. School grades may drop and the young person may stop interacting with friends and family. 

While for many the onset of psychosis, or schizophrenia in particular, is rapid, some young people present in an insidious way, with a long history of subtle, non-specific behavioural, social and educational difficulties. This phase has been referred to as the prodromal phase, typically lasting up to 12 months. During this period, the child exhibits subtle changes in their behaviour and emotional expression. They may struggle in school or lose interest in previous hobbies. They may develop behavioural changes such as becoming defensive, paranoid or easily irritable. 

They may experience transient hallucinations and/or delusions, along with social withdrawal and the development of suspicion or paranoia. It is important to recognise these initial changes in the child’s functioning, as early detection and intervention is associated with a better prognosis. Current research is trying to discover whether medical management of this prodrome, before full-blown psychotic symptoms emerge, is associated with a reduced rate of conversion and a better outcome. 

Aetiology

The exact cause of schizophrenia is unknown – like many other mental illnesses it is accredited to a number of risk factors such as genetic, neurodevelopmental and social factors. Medical conditions (such as velo cardiofacial syndrome) and medications, both legal (eg. steroids) and illegal (eg. amphetamines, cannabis, LSD) can also induce psychotic states. There is a significant genetic component associated with schizophrenia, probably due to many genes each with small effect. The probability of developing schizophrenia in a person with no family history of the disease is one in 100, whereas this risk increases to one in 10 in those with one parent with schizophrenia, and one in two in those with an identical twin with the disorder and a 15% rate in first-degree relatives. A number of research studies showed that an association could be made between complications in biological development and the acquisition of schizophrenia. The illness has been seen to be more common in people who suffered from a viral illness during foetal development and also in those who experienced difficulties at birth that resulted in a lack of oxygen to their brain.

Recently, many studies have identified a relationship between cannabis consumption and the risk of developing schizophrenia. This is currently a topic of great concern as cannabis intake in young people today is increasing vastly and the active drug content in the marijuana is much more potent than that of previous decades. Therefore, the long-term effects and risk of developing schizophrenia are actually much greater than previously considered. Research has shown that the risk is increased by 50% in those who abuse cannabis; it is greater in those starting at a younger age and also those with higher frequency of use. It has been reported that people who have used cannabis more than 50 times are six times more likely to develop schizophrenia.

Assessment

Patients with suspected schizophrenia, presenting with psychotic symptoms (hallucinations, delusions, thought disorder) or behavioural changes (anxiety, depression, irritability) should undergo a full medical and psychiatric assessment by the clinician. The medical assessment considers underlying organic cause such as temporal lobe epilepsy, cerebrovascular disease or an adverse effect of prescribed drugs, such as anticonvulsants. The cornerstone of the psychiatric assessment is a detailed clinical history from the young person and their parent, supplemented by information from school. Both active psychotic symptoms and behavioural change will be looked for with questioning regarding changes in mood, general functioning, a history of illicit drug use, a family history of schizophrenia and specific details about the presenting symptoms. Initial assessment by a GP would typically be followed by an urgent referral to a specialist service, either child and adolescent mental health service (CAMHS) or, when in existence, specialist psychosis service. If the child is considered to be at risk to themselves or to others, they will be referred for a same-day specialist assessment and may require hospitalisation. Every effort should be made for them to agree to the hospital admission; however, if it is not the case, a compulsory admission may be made under section 25 of the Mental Health Act 2001. Most patients will ideally comply with admission, however, in 2011, 21 involuntary admissions to approved centres (12 child units and nine adult units) within Ireland were necessary.

Management

A multimodal approach to management is essential targeting both strengths and impairments in the child’s individual, family, medical and environmental domains: the ‘IFME’ model of treatment. A combination of medication, supportive and cognitive psychotherapy along with psycho-education to the young person and family is generally standard. Atypical antipsychotic medications, such as risperidone, olanzapine and aripiprazole, are generally first-line in children and target the ‘positive’ symptoms of psychosis. Onset of anti-psychotic action takes three to four weeks, although initial sedative and anxiolytic actions may be immediate and beneficial. Maintenance on medication should be for 12-24 months after symptom resolution following their first psychotic episode. It is extremely important that the child adhere to these guidelines, as the risk of relapse is greatly increased if medication is stopped within the first six months post-stabilisation. This is where it is imperative to involve their family and support system to ensure compliance. The side-effects of weight gain, drowsiness, muscle stiffness and tremor may contribute to adherence issues and need to be monitored. Cardiovascular effects also need monitoring especially if any personal or family history of cardiac illness. The old adage of start low and go slow is a useful one to follow.

Psychosocial intervention in conjunction with medication is seen as essential and has a beneficial effect on people with schizophrenia. Generally, the patient will participate in cognitive behavioural therapy with a minimum of 16 planned sessions. During sessions, the patient is encouraged to identify challenging and unwanted thoughts and behaviours through the use of a journal. They are strongly promoted to engage in healthy behaviours such as exercising, socialising with friends, reading or listening to music. It is advisable that the patient’s family partake in family intervention, typically consisting of 10 planned sessions over three months to one year where the parents receive support and education. Art therapies can often provide additional favourable results.

Outcome

It is important that the warning symptoms are recognised as early as possible and that intervention and treatment is implemented without delay. Overall, 80% of individuals will have an initial improvement with antipsychotic medication, 20% of patients with schizophrenia will return to normal functioning within five years of the onset of the illness, but 60% will experience relapses throughout the course of their life. The remaining 20% will have persistent symptoms and find it difficult to live independently. Careful and planned transition from CAMHS to adult service will ensure ongoing engagement. Comorbidities need to be carefully watched for and aggressively treated. Suicide is a particular risk in people with schizophrenia and highest within the first year following their diagnosis. Good premorbid functioning, short duration of untreated psychotic symptoms, good family functioning with low levels of expressed emotions along with absence of comorbidities, other than mood component, are all associated with a better prognosis. 

References 

1. NICE Clinical Guidelines on Psychosis and schizophrenia in children and young people, CG155- Issued: January 2013
2. M. Cooper, C. Hooper, M. Thompson. Child and Adolescent Mental Health Theory and Practice, 1st edn. 5.8: 137-140 2005
3. Fourth Annual Child & Adolescent Mental Health Service Report 2011-2012 
4. Andreasen NC. Symptoms, signs and diagnosis of schizophrenia. Lancet 1995, 346: 477-481
5. S. Buckley, B. Gavin, F. McNicholas. Mental Health in Children & Adolescents. Chapter 11: 133-142