The Psychoses of
Childhood
Introduction
Group of conditions
• Characterised by loss of contact with reality
• (neuroses .. morbid ways of dealing with reality)
• Uncommon in childhood
• Difficult to diagnose from fantasy and imagination
• Children’s thoughts not confined to the logical
Diagnosis
• Reluctance to diagnose in children
• Rarely diagnosed before 7
• Onset often insidious
• Diagnosis often made retrospectively
• Incidence highest in late adolescence
• Autism not a psychosis
Pathology
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A major psychosis:
delusions
hallucinations
thought disorder
communication disorder
deterioration of social functioning
Difficult to identify what is real and what is unreal
Not a split personality Schizo - split, Phrenia - mind
Term (Eugen Bleuer) meant perception reality split
Split (multiple) personality very rare - not schizophrenia
Demography
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1% of the population at some time in their lives
Equal distribution race, sex, culture, class, intelligence
Equally distributed across the world
Higher incidence in late adolescence (more males)
After 25, more females
On the whole sex incidence equal
Presentation unusual after 40 and in childhood
Can occur at any age
Has never been diagnosed before 5 years
Aetiology
• Cause largely unknown
• Main aetiological factors
• genetic (there is known to be an increased risk where family members have
developed schizophrenia, c.f. Long 1996)
• one immediate family member affected = 10% risk
• one non-immediate family member affected = 3% risk
• both parents affected = 40% risk
• identical twin affected = 35-50% risk
• interpersonal environment (never supported by research)
• high level of expressed emotion within the family (never supported by research)
• parental communication deviance, a less severe form of the disordered thinking
that occurs in schizophrenia (never supported by research)
• biological (chemical and functional disturbances have been identified in
schizophrenic individuals, c.f. Long 1996).
Aetiology -2
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Most likely cause .. neurotransmitter imbalance
Limbic system most likely site (emotion and perception)
Controls incoming stimuli (acts as a gate)
Dopamine (manipulated in treatment) may be involved
Cause of the imbalance not known, may be:
virus or virus like proteins
genetic predisposition.
EEG often abnormal
CT, MRI sometimes show microscopic brain abnormality
1/3 have enlarged ventricles
 blood flow and glucose utilisation .. frontal lobes
Shown by Positron Emission Tomography (PET)
Not caused by:
• It is now clear that schizophrenia is not caused by
or related to:
• childhood experiences
• poverty
• parenting behaviour
• stress
• drug abuse. Drug abuse can mimic schizophrenia
and can make schizophrenia less well controlled.
There is no evidence that a moderate amount of
alcohol will exacerbate schizophrenia.
Clinical features
• Reduced ability with academic work
• Difficulty in maintaining relationships
• Lack of volition
• Reduced basic hygiene and nutrition
Personality changes
• Loss of feeling and emotion
• Lack of interest and motivation
• Quiet, withdrawn
• Moody
• Inappropriate emotion
• May initially try to hide symptoms
• Becomes less popular
• Becomes unhappy and isolated
Delusions
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False beliefs held in the presence of contradictory information.
There may be delusions of:
persecution (paranoid delusion)
grandeur, where the sufferer believes that he is important or
particularly capable of a feat
delusions of reference (that events in the media refer to oneself)
thought insertion (ideas are being put into one’s head),
thought withdrawal (taken out of one’s head),
thought broadcasting (thoughts from one’s head are taken out and
broadcast by the media)
the belief that one’s thoughts are being controlled by an external agency
there may be a strong drive in connection with a particular mission or
religious activity.
Sufferer not always removed from reality
Often upset because effect on loved ones is understood
Thought disorder
• Move from subject to subject in unrelated manner
• Conversation hard to follow
• Each sentence on its own makes sense
• The individual knows what s/he is saying
• May become incoherent and obviously confused
• The becomes anxious and frightened
Hallucinations and perceptual
changes
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May be auditory or visual (commonly auditory)
Unusually can be tactile or somatic
May be hypersensitivity to tough, sounds or smells
A quiet voice may be perceived as shouting
Hallucinations occur in periods of clear consciousness
Often third part instructing a course of action
Two voices may be heard arguing with each other about the individual
Sufferer is likely to obey the commands
May be a perceived void of perceptions
Feel nothing, no emotion
Absence of pain
May feel ‘out of time and person’
In a floating void of non existence (Long 1996)
Affect and volition
Disorders of affect
• Sudden changes in mood
• Emotional reaction blunted or inappropriate
• May be unconcerned re physical injury
Depressed volition
• Lack of interest and drive
• May feel that emotions are controlled by external
power
• May appear to lack intelligence
• Often present with conduct disorder, depression
5 types of Schizophrenia
1. Disorganised or hebephrenic (general)
2. Paranoid (characterised by paranoid delusions)
3. Catatonic (characterised by a decrease in
response to the environment, together with
bizarre movements and posture)
4. residual (there is some evidence of schizophrenia
but no obvious ongoing features of psychosis)
5. undifferentiated (cannot be classified into any of
the above).
Borderline Schizophrenia
• May be ‘eccentric’ or ‘borderline personality disorder’ or ‘rather strange’
• Some communities more accepting of strange behaviour
• a change in personality has occurred at some point in the person’s life. There
may be sudden excesses where the individual becomes heavily preoccupied
with some theme
• the individual seems overly occupied with the possibility that others are
watching him or her
• the individual sometimes has difficulty in controlling the train of thought and
jumps from one thought to another. Sometimes the individual seems to be
incoherent
• things are seen and heard (fairies, ghosts) that (probably) do not exist
• the individual is socially withdrawn and not liked by the community, the
individual is often rude and unkind to other people
• sleeplessness and frequent agitation
• the individual fails to look after him or herself, often fails to wash or keep the
accommodation tidy.
Treatment
• You name it, it’s been
done
• Some of them:
• Anti-psychotic drugs
• Parentectomy
• Psychoanalysis (both
parents and child)
• Behaviour therapy
• Family therapy (family
intervention)
• Long term support
almost always needed!!
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Needs understanding
Patience
Reassurance
Stable environment
Supportive environment
Loving relationship
Non critical, non
judgmental relationship
• Especially from loved
ones
• Therapy can help the
family (etc.) provide this
Family
Long (1996, p. 9) quotes a parent:
‘The typical family of mentally ill person is often in
chaos. The parents look frantically for an answer that
usually cannot be found. Hope turns to despair, and
some families are destroyed no matter how hard
they try to survive.’
Family: feelings
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sorrow (for the child they have lost)
fear for the child’s safety
fear for their own safety and the safety of other members of the family
guilt that they may be to blame for the disorder
social isolation
bitterness and anger that the problem has happened to them, blaming
the child and other members of the family
depression
denial
a feeling that everything orientates around the schizophrenia
wanting to move away to escape the problem or the social
consequences of the problem
physical consequences of chronic stress and discord
concern for the future.
Family therapy
• Family therapy supports the family and helps them support the sufferer e.g. by
reducing communication deviance
• ensuring they work together with the child’s psychiatrist and the mental health
team
• help the child to accept the diagnosis
• help the child to see that there is hope and that life can still be enjoyable, being
positive
• help child maintain record of symptoms, their timing and what treatment
employed
• ensuring that child complies with agreed treatments
• providing structured, predictable environment, reducing sensory overload and
stress.
• Keep unusual events to a minimum. Being consistent in behaviour
• maintaining a calm interpersonal environment
• avoid arguments centred on the child’s delusions
• encourage setting of realistic goals, using time constructively
• encourage gradual independence
• encourage gradual integration with the community.
Drugs
• Anti-psychotic drugs have important long term side
effects
• Antipsychotic drugs
• Modecate Heldol
• Thorazine Flupenthixol
• Stelazine
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Reduce hallucinations and thought disorder
Dose individually tailored
Long term effects
Also .. antidepressants, tranquillisers used
The stigma of schizophrenia
Is main problem - society’s reaction?
Common misconceptions:
• Danger to others:
• Most withdrawn and frightened
• More likely to hurt themselves
• Most people who kill, are sane
• Media generated fear
• We don’t like to think that sane (like us) could kill
• Treatment of S. encouraged belief in their danger
• Fear of unknown, unpredictable
• We associate unpredictability with danger
• Can reduce unpredictability through understanding
Prognosis
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Approximately:
33% only one episode of schizophrenia in the lifetime
33% recurrent episodes that are largely controllable
33% lifetime requirement continuing management
For many, remains intractable and damaging
• Major effect on health, happiness and life chances
• Major handicap
• Aim should be to provide the person with a satisfying
place in society and to maintain their relationship with
the people they love
The Reactive psychoses
• Where a psychotic episode results from a severely stressful experience.
• The experience would cause severe stress in anyone.
• The presentation may be sudden and dramatic but the condition is usually short lived.
• Transient psychoses have been known to occur without the exposure to stress.
• The presentation may include:
• incoherence and loosening of associations
• delusions
• hallucinations
• disorganised behaviour
• Usually treated with a short course of anti-psychotic drugs.
• May be admitted to a quiet, stress-free environment.
• May be subjected to therapy in an attempt to help him or her deal with the experience of the
stressful event.
• These children usually make a full recovery.
Not psychosis
Non psychogenic causes of delirium
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Manifestation of delirium may mimic acute psychotic episode.
systemic infections and fever (still a very common cause of delirium)
metabolic disturbances, including hypoglycaemia
brain damage
meningitis and encephalitis
some forms of epilepsy
the action of drugs, ‘therapeutic’ or of misuse
glue sniffing and other forms of substance misuse
Fever, especially in a young child, still very commonly causes delirium.
Hallucinations are also very common in these circumstances.
References
Barker P (1995). Basic Child Psychiatry. Blackwell Science.
London.
Long P W (1996). Schizophrenia: youth’s greatest disabler.
Http://www.mentalhealth.com/book/p40-sc02.html
Russell AT, Bott L, Sammons C (1989). The phenomenology of
schizophrenia occurring in childhood. Journal of the American
Academy of Child and Adolescent Psychiatry. 28: 399-407
Tanguay PE and Cantor SL (1986). Schizophrenia in children:
introduction. Journal of the American Academy of Psychiatry.
25: 591-594.