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 depressive state 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 depressive condition, 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, intoxicants or 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

Early risk factors

  • Family history
    • Children with parents who have schizophrenia carry an approximately ten-fold risk of the disease.
    • Other serious mental disorders in the immediate family may also predispose to psychosis.
    • When taking the history, it is important to find out whether there are mental disorders, depression or psychoses, suicides or substance-related disorders in the family.
  • Early biopsychosocial risk factors in the environment, such as:
    • perinatal complications
    • infections during pregnancy (e.g. influenza, respiratory infections or rubella)
    • stress during pregnancy
    • gestational depression in mothers of children who also have psychoses in the immediate family
    • early disturbances of neuromotor or cognitive development
    • childhood psychic trauma, such as sexual abuse.
  • The onset of psychosis may be explained by the combined effects of genetic vulnerability and biopsychosocial stress.
  • Psychosis diathesis may derive from an underlying developmental disorder of the central nervous system.
  • Use of psychoactive substances, such as cannabis in adolescence is a predisposing factor for psychosis, at least in some adolescents genetically vulnerable to psychosis.

Symptoms preceding psychosis (prodromal symptoms)

  • At least some patients developing schizophrenia can later be found to have had unspecific prodromal symptoms preceding actual psychosis.
  • Prodromal symptoms can only be confirmed retrospectively.
  • Prodromal symptoms of psychosis may include, for example,
    • anxiety
    • depression, mood swings, irritability
    • apathy
    • inability to concentrate
    • sleep disorders
    • negative symptoms: changes in behaviour, such as impaired functional capacity and withdrawal from relationships
    • positive symptoms, such as distorted perception and suspiciousness.
  • Not nearly all those with prodromal symptoms develop psychosis.
  • Various questionnaires have been produced for assessment of the risk of psychosis (e.g. the Finnish PROD5 mental health screen), as well as interviews mainly used in specialized care, such as SIPS (Structured Interview for Prodromal Syndromes).
  • Particularly those adolescents 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.

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 of adolescents), and Substance-related disorders in adolescents (Substance abuse of adolescents).

Treatment

Treatment of prodromal symptoms

  • Treatment of prodromal symptoms may delay or even prevent the onset of psychosis. Delaying the onset of psychosis to a later stage in life facilitates positive development in adolescence and reduce the risk of social exclusion.
  • Sufficiently frequent and active monitoring is important at the prodromal stage, e.g. in cooperation with primary and specialized care.
  • It is important to have low-threshold units for adolescents where they can easily seek treatment.
  • The treatment of prodromal symptoms is not established, and it is symptomatic.
  • At an early stage, cognitive or cognitive-behavioural psychotherapy (CBT) can be used, and, as necessary, symptomatic short-acting hypnotics, anxiolytics or mood-altering drugs.
  • In patients at immediate risk of psychosis, low-dose antipsychotics may be added to psychosocial therapy.
  • Cognitive-behavioural therapy (CBT) has been found to be rather effective in preventing the development of psychosis in 12-month follow-up. Integrated psychotherapy (e.g. CBT, family meetings, psychoeducation) may reduce the development of psychosis.
  • Unsaturated omega-3 fatty acids may have a role in the prevention of psychosis, but the effect is very marginal.

Psychosocial treatment of psychosis

  • Adolescents with acute psychosis require specialized care.
  • The treatment of psychosis in adolescents should be individually tailored and can take many forms. Patients themselves should be heard when assessing them and planning their treatment. In addition, particularly if the adolescent lives at home, cooperation with parents/guardians and other close social networks (as agreed with the adolescent) is part of the treatment.
  • Treatment usually is comprised of antipsychotic drug therapy, psychosocial treatment and rehabilitation. Psychosocial treatment includes individual discussions clarifying the situation, (cognitive) psychotherapy or music therapy or other creative or occupational therapy, as well as psychoeducation, family meetings and meetings with other members of the person's social network.
  • Treatments that are based on cognitive behavioural therapy (CBT) and cognitive-analytic psychotherapy, as well as cognitive rehabilitation, such as cognitive remediation therapy, may be useful.
  • Psychoeducation possibly increases commitment to therapy and reduces recurrence of psychosis and length of hospital treatment.
  • Support in increasing physical activity and physiotherapy may be beneficial.
  • The aims of treatment and rehabilitation are to alleviate symptoms and improve functional capacity, as well as to support the adolescent's independence development.
  • Treatment of an adolescent who has developed a psychosis includes examinations by a social worker and child welfare.
  • It may be necessary to recommend vocational rehabilitation preparing for vocational studies, or application for a rehabilitation allowance or support for adolescents. Special reimbursement for medication and rehabilitation therapy, and in some cases a disability allowance, should also be applied for.
  • In addition, some adolescents with chronic psychosis may need rehabilitation to achieve more independence in everyday life, e.g. in rehabilitating housing communities for adolescents.
  • The treatment of psychosis in adolescents and their rehabilitation should be of sufficiently long duration, in schizophrenia several years. In chronic psychosis, the aim should be to build a continuous, trusting therapeutic relationship.
  • The treatment plan is reviewed regularly together with the patient and usually also with those close to the patient.

Pharmacotherapy of psychosis

  • Adolescent psychosis is usually treated with antipsychotics. In addition, antidepressants can be prescribed for psychotic depression and mood stabilizers for bipolar disorder, as necessary (valproate is usually not recommended to women in fertile age). Additionally, particularly in the acute phase of a psychosis, drug therapy for difficulties in falling asleep or anxiety may be temporarily required.
  • Second or third generation antipsychotics are usually prescribed for adolescents. Their most common adverse effects are metabolic effects and extrapyramidal symptoms. There are insufficient data available on long-term use of antipsychotics in adolescents.
  • In Finland, few drugs are officially approved for the treatment of psychosis or affective disorder in minors.
    • Of the second generation antipsychotics, aripiprazole is currently officially approved in Finland for the treatment of schizophrenia in adolescents of 15 years or older and for the treatment of moderately severe or severe manic phases of bipolar I disorder in adolescents of 13 years or older for no more than 12 weeks.
    • Risperidone is approved for short-term symptomatic treatment of chronic aggression associated with conduct disorders in children or adolescents of 5 years or older who are mentally retarded or have an intellectual disability, but it is not officially approved for the treatment of schizophrenia in minors.
    • Ziprasidone is approved for moderately severe manic or mixed phases of bipolar disorder in children or adolescents 10–17 years of age.
    • In practice, also other antipsychotics, such as quetiapine, have been used for the treatment of psychosis in minors even if this is not an official indication.
    • Of the older antipsychotics, haloperidol, for example, has been found to be effective in the treatment of schizophrenia in under age adolescents. Clozapine has been found to be more effective than haloperidol or olanzapine in the treatment of schizophrenia in adolescents. However, the use of clozapine is restricted particularly by the risk of leukopenia and agranulocytosis; see Clozapine treatment (Clozapine therapy). In severe schizophrenia refractory to other therapies, clozapine should be considered.
  • Combination of antidepressant and antipsychotic medication is recommended for the treatment of psychotic depression. Based on evidence, fluoxetine is recommended as the primary choice for patients under 18 with depression but its long half-life and possible interactions with other medicines must be kept in mind. Antidepressants may be associated with self-destructiveness or violence, particularly early in the course of treatment.
  • In adolescents with psychosis, pharmacotherapy should be combined with other forms of treatment. In pharmacotherapy, monotherapy should be preferred.
  • The use of psychopharmaceuticals should be started with caution because the adolescent brain is not completely developed, and other biological growth and psychosocial development are also incomplete.
  • Adolescents and their guardians should be provided with information regarding the treatment and its benefits as well as possible adverse effects, and these should be discussed with them.
  • Particularly in the beginning of antipsychotic medication, the patient's condition and any adverse effects should be frequently monitored.

Evidence Summaries

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.

References

1. Granö N, Karjalainen M, Anto J et al. Intervention to improve level of overall functioning and mental condition of adolescents at high risk of developing first-episode psychosis in Finland. Early Interv Psychiatry 2009;3(2):94-8.  [PMID:21352182]

2. Merikangas KR, Jin R, He JP et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 2011;68(3):241-51.  [PMID:21383262]

3. Mäki P, Riekki T, Miettunen J et al. Schizophrenia in the offspring of antenatally depressed mothers in the northern Finland 1966 birth cohort: relationship to family history of psychosis. Am J Psychiatry 2010;167(1):70-7.  [PMID:19833791]

4. Paus T, Keshavan M, Giedd JN. Why do many psychiatric disorders emerge during adolescence? Nat Rev Neurosci 2008;9(12):947-57.  [PMID:19002191]

5. Stafford MR, Jackson H, Mayo-Wilson E et al. Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ 2013;346():f185.  [PMID:23335473]

6. Pagsberg AK, Tarp S, Glintborg D ym. Acute Antipsychotic Treatment of Children and Adolescents With Schizophrenia-Spectrum Disorders: A Systematic Review and Network Meta-Analysis. J Am Acad Child Adolesc Psychiatry 2017;56(3):191-202.  [PMID:28219485]


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