Presentation issues
Organic conditions such as frontal and temporal lobe epilepsies, systemic lupus erythematosus, multiple sclerosis, hyperthyroidism, cerebral tumors or infections, and neurodegenerative conditions such as Wilson disease and metachromatic leukodystrophy, can sometimes present with symptoms of psychosis, and must be distinguished from severe mental disorders for appropriate management.16
A fluctuating mental state with changes in orientation and cognitive functioning may be an indication of an organic condition. The challenge is to establish that the organic condition has a clear temporal and causal relationship with the psychotic presentation and that it is not a chance co-occurrence with a severe mental health disorder. Consultation with pediatric and neurological colleagues and negotiation about a suitable setting for assessment and management of such disorders are required.
Adolescents with schizophrenia or mania-like psychotic presentations often have a history of substance abuse. Consider whether the psychotic episode:
- Was induced by a psychoactive substance (eg, amphetamines, cocaine, Ecstasy) that typically presents with an acute onset and rapid resolution.
- Is an underlying psychotic disorder precipitated by a substance of abuse (eg, cannabis).
- Is merely a comorbid substance abuse disorder not directly related to psychosis.
Psychotic symptoms that do not abate after 1 or 2 weeks in a controlled setting with no substance abuse indicate an underlying psychotic illness.17 Uncertainty may have to be tolerated and pragmatically managed in some cases where distinction is difficult to achieve. A detailed assessment is essential to devise a management plan that targets continued substance abuse in an adolescent with schizophrenia or bipolar disorder.17-19
Hallucinatory experiences may occur in dissociative states in adolescents.20 Emotional and conduct disorders, a history of sexual or physical abuse, and borderline personality disorders may also present with nonspecific hallucinations. Adherence to strict diagnostic criteria in the context of a detailed history will usually clarify the diagnosis.
The social and cognitive impairments in young people with schizophrenia may be difficult to distinguish from similar impairments observed in developmental histories of higher functioning adolescents with pervasive development disorders. Adherence to diagnostic criteria with a clear history of hallucinations or delusions along with a careful developmental history can clarify the diagnosis.12,21
Management issues
Management of adolescent psychotic disorder is based on a comprehensive assessment of the adolescent and his environment with an emphasis on identifying any predisposing, precipitating, or maintaining factors and any protective aspects.
A detailed assessment of risk to self and others is required. This information may be inferred from the patient’s history; risk assessment must also take into account the patient’s mental state, his own insight into illness, and likely adherence to treatment. An assessment of vulnerability (eg, physical or sexual abuse or neglect) is particularly important, as is a determination of the level of support available to counter any of these potential risk factors. Such risk assessment must be an ongoing and dynamic process throughout treatment.
An appropriate legal mandate is needed as well; this includes informed consent for treatment from the patient or a parent or guardian. Consider how to treat against the wishes of the adolescent while providing adequate safeguards.
Treatment priorities are guided by the stage of illness, whether it is an acute (resolution of acute symptoms), maintenance (maintaining treatment gains), or recovery phase (rehabilitation and adjustment to any residual deficits). A multimodal approach is required that focuses on the bio-psychosocial needs of the patient (Figures 1 and 2).8
Despite the limited evidence base and off-label use in adolescents with psychotic disorders, atypical antipsychotics have become the first-line treatment choice. These agents are presumed to have better tolerability and outcomes. (Patients and their parents need to be informed of the off-label use of these drugs.)22 We have no data with which to differentiate the atypical antipsychotics, other than clozapine(Drug information on clozapine), on the basis of relative efficacy. Thus, the choice of agent is mainly dictated by the adverse-effect profile. Start with a low dosage and slowly titrate to therapeutic level.
Conclusion
Sharing a range of possible outcomes rather than a definitive prognostic outlook for adolescent psychosis with patients and their parents may be appropriate because of the possibility of changes over time. Findings from long-term treatment outcome studies in adolescents with psychotic disorders show relatively poor results.16 Adolescents with schizophrenia and those whose symptoms have an insidious onset with marked negative features have poorer outcomes than those with concomitant affective features. Substance abuse comorbidity increases the risk for relapse. Family intervention adapted for the developmental needs of adolescents as well as strategies to reduce hostility and criticism directed at the patient are likely to be helpful, although they have not been formally evaluated within this population.16
| Drugs Mentioned in this Article |
| Carbamazepine (Carbatrol, Tegretol, others) |
| Clozapine (Clozaril) |
| Lithium (Eskalith, Lithane, Lithobid) |
| Valproate/valproic acid (Depakote, others) |
