Psychotic Disorders



Psychotic Disorders


James C. Harris



Psychotic disorders are major mental illnesses that involve abnormalities in thinking, belief systems, and perception. These are demonstrated clinically through incoherence in thinking, delusions, and hallucinations and are associated with major behavioral changes. The psychotic disorders are less common in preadolescence, usually becoming evident for the first time in adolescence and adulthood. Assessment is more difficult in young children and in mentally retarded individuals because the major symptoms are identified through an interview assessment.

The conditions included are schizophrenia, affective and bipolar (manic-depressive) psychoses, organic psychotic states, and atypical psychoses. The last two conditions are not covered here. Autistic disorder and other pervasive developmental disorders are categorized separately because these conditions are neuropsychiatric developmental disorders.

The underlying brain mechanism for schizophrenia has not been identified; however, both genetic and environmental risk factors exist. Neuroimaging studies show reduced cortical gray matter volume in schizophrenia and, in childhood-onset schizophrenia, striking progressive loss of cortical gray matter following the onset of psychosis, more so than in adult onset. There is loss of gray matter in frontal, temporal, and parietal brain regions. Apoptosis (programmed cell death) has been proposed as a contributing pathophysiologic mechanism.

The identification of a chromosomal disorder in some families with bipolar disorder lends further credence to the eventual discovery of a genetic basis for some cases of this disorder. Ongoing investigations in brain imaging may provide additional information about brain dysfunction in each of these conditions.


SCHIZOPHRENIA

Schizophrenia ordinarily presents for the first time in adolescence or young adulthood. It may occur in the prepubertal years, but the diagnostic criteria for adults are difficult to apply in children younger than age 7 years. Whether the condition could be diagnosed before age 7 is a subject of disagreement. The characteristic features include the following:



  • Disorder in thinking: Thoughts are often incoherent, and the train of thought is lost. This difficulty in thinking is referred to as derailment or loosening of association.


  • Delusional beliefs: Delusions are irrational beliefs and may take on a paranoid form in older children. The delusional beliefs arise out of ordinary consciousness and are not secondary to hallucinations or the result of a mood disturbance.


  • Hallucinatory experience: The hallucination is a false perception that occurs without external sensory stimulation. In schizophrenia, hallucinations are primarily auditory and are described as voices outside the child or adolescent’s head that may speak with him or her directly or make reference to him or her in the third person.


  • Disturbance of mobility: Catatonic behavior refers to motoric immobility or certain types of excessive motor activity (purposeless agitation), extreme negativism (apparently motiveless resistance to instructions or attempts to be moved), abnormal posturing, mutism, echolalia, or echopraxia. Catatonia occurs in both schizophrenia and in affective disorders.

In addition to these classic symptoms, negative symptoms (flat affect, avolition) and, it is increasingly recognized, cognitive deficits are present to varying degrees.

Schizophrenia may have an abrupt or gradual onset. Particularly when the onset is gradual, it may be more difficult for family members to recognize the seriousness of the condition. Children who develop schizophrenia often have a history of developmental delay, although their previous presentation may be normal. When developmental delay is present, language difficulties, clumsiness, social isolation, and muscular hypotonia may be noted. The condition may follow a remitting or chronic course. There may be partial recovery with resolution of acute symptoms, but abnormal motivation and a decreased interest in routine events may follow the initial presentation as residual symptoms.



Epidemiology

In childhood-onset cases the male-to-female ratio is about 2.5:1, but by adolescence the male-to-female ratio is near 1:1. An increased risk exists in first-degree relatives. If a parent or a sibling is schizophrenic, the risk is approximately 12 times that of the general population for the child; the rate of onset in adolescence is approximately 3 per 10,000, compared with 1% in the general population. Children of schizophrenic parents who are raised in foster or adoptive homes maintain the risk for the disorder. Concordance is greater in monozygotic twins.

A schizophrenia-like presentation may occur with stress in children who have brain dysfunction. These are more often brief reactive psychoses, but they may sometimes take on a more chronic picture. Family interactions may contribute to the course of the illness. Family difficulties in adapting to the disorder and strongly expressed, often hostile emotions by family members may precipitate relapse.

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Psychotic Disorders

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