A follow-up study of early onset psychosis: comparison between outcome diagnoses of schizophrenia, mood disorders, and personality disorders

Clinical correlates of therapeutic response in bipolar disorder

Interest in the factors associated with responsiveness to therapy in bipolar disorder has increased with evidence that lithium has differential rather than uniform effectiveness in bipolar disorder, and also with the broadening of therapeutic options, illustrated especially by the use of divalproex sodium (valproate). Lithium is effective acutely in patients with pure or elated mania, and in its prophylaxis, but may worsen depressive symptoms in such patients when used for long-term maintenance therapy. The nature of previous responses to lithium treatment predicts the type of response that can be expected during a further episode of the disorder. Mixed mania, secondary mania, and mania associated with substance abuse--as well as rapid cycling --generally respond poorly to lithium therapy. Divalproex sodium has a broader spectrum of efficacy and fewer factors that determine differential responsiveness. Data related to treatment with carbamazepine are sparse, but patients with rapid cycling may respond less well to this agent; on the other hand, limited data support the utility of carbamazepine in bipolar patients with extreme psychosis, including those with mood-incongruent features. Both classical and atypical neuroleptics (e.g. olanzapine) could profitably be used in acute mania and mixed states. Lamotrigine has recently been shown effective in bipolar depression and rapid cycling. Patients unresponsive to a single agent may show improvement with combined regimens, though this impression is based more on clinical experience than controlled randomized assignment.

Electroconvulsive therapy in adolescents: similarities to and differences from adults

OBJECTIVE

Information on the indications, technique, and effectiveness of electroconvulsive therapy (ECT) in adolescent patients is scarce. The recommendations for the use of ECT in this age group are similar to those in adults. This study compares the experience with ECT in the two age groups in the same community psychiatric institution, which adheres to the accepted protocols for diagnosis and treatment.

METHOD

The files of 24 consecutive adolescent patients treated in an ECT unit located in the center of Israel in the years 1991-1995 were retrospectively examined, and the findings were compared with those in 33 adult patients who started their ECT course on the same day. The technique for applying ECT was essentially the same in the two age groups.

RESULTS

ECT was equally effective for adolescents and adults (58% in each group achieved remission). The main difference was the diagnosis for which patients were referred: most of the adolescents were in the "psychotic spectrum, whereas most of the adults were in the "affective spectrum."

CONCLUSIONS

The findings support the current medical recommendations for the use of ECT in adolescents. Possible explanations for the differences in diagnosis between the two age groups are discussed.

Stability of diagnosis: a 20-year retrospective cohort study of Israeli psychiatric adolescent inpatients

Outcome according to diagnosis and stability of diagnosis were investigated in a follow-back study of 351 adolescents with various psychiatric disorders hospitalized in a closed psychiatric ward. The duration of follow-back was 15-19 years. All diagnoses were based on the ICD-9. Data were collected from the Health Ministry registry and, in the patients who could be located, by structured telephone interview. Special attention was directed at the diagnosis of transient adolescent psychosis (TAP) vs. schizophrenia and prognostic indicators of suicide. The results showed that the most stable diagnosis was anxiety disorder. The stability of the different diagnoses over time was greater between the second and last admission than between the first and last (for patients with three or more admissions). Number of hospitalizations correlated negatively with prognosis. TAP at second admission was an unstable diagnosis; 66% of these patients had a final diagnosis of schizophrenia. However, patients with a diagnosis of TAP at first admission had a higher predictive index score and a higher outcome score than schizophrenic patients. TAP appeared to be a valid diagnostic entity, distinguishable from schizophrenia in course, frequency of suicidal behaviour and social-occupational outcome. Suicide victims had a higher cumulative length of stay than age- and sex-matched non-suicidal patients. Fifty per cent of the suicide victims had a final diagnosis of schizophrenia, compared to 30 per cent for the whole sample. In conclusion, these findings indicate that TAP is associated with a relatively good prognosis and should probably be differentiated from schizophrenia. Further retrospective and prospective studies of adolescent psychiatric inpatients may help delineate the nature and course of psychosis and other psychopathology in this age group.

Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

This practice parameter reviews the literature on the assessment and treatment of children and adolescents with schizophrenia. Recommendations are based on the limited research available, the adult literature, and clinical experience. Early-onset schizophrenia is diagnosed using the same criteria as in adults, and it appears to be continuous with the adult form of the disorder. Noted characteristics of youth with schizophrenia include predominance in males, high rates of premorbid abnormalities, and often poor outcome. Differential diagnosis includes psychotic mood disorders, developmental disorders, organic conditions, and nonpsychotic emotional/behavioral disorders. Treatment strategies incorporate antipsychotic medications with psychoeducational, psychotherapeutic, and social and educational support programs. The advent of atypical antipsychotic agents has enhanced the potential for effective treatment.

Identification and management of schizophrenia in childhood

TOPIC

The identification and management of schizophrenia in childhood.

PURPOSE

To provide an overview of what is currently known about childhood schizophrenia.

SOURCES

Published literature and personal observations and experiences.

CONCLUSIONS

Early identification and treatment of childhood schizophrenia are critical, and more research and education on the part of all mental health professionals are needed in order to identify, provide treatment, and/or make referrals for children with this serious mental disorder.

Bipolar Disorder in CHILDREN

This article presents an overview of bipolar disorder (BPD) in children, a condition that only recently has been recognized as a legitimate diagnosis. Bipolar disorder in children is underrecognized for many reasons including lack of awareness, diagnostic confusion, and the different clinical picture in children. Available data strongly suggest that prepubertal childhood BPD is a non-episodic, chronic, rapid cycling, mixed manic state. It may be comorbid with attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) or it may demonstrate features of ADHD and CD, further complicating recognition and subsequent treatment. Treatment issues are discussed, and some reasons for the urgency of early recognition and treatment are explained.

First-episode psychosis: a comparative review of diagnostic evolution and predictive variables in adolescents versus adults

OBJECTIVE

To review the diagnostic evolution and predictive variables of diagnosis and outcome in first-episode psychosis in adolescents (age 13-19 years) and adults.

METHOD

Literature was reviewed through MEDLINE, Psycinfo, and PubMed, and supplemented by selected bibliographies.

RESULTS

First-episode psychosis in the adolescent population has greater diagnostic instability than in adults. We identified trends in the predictive variables of diagnosis and outcome: 1) Premorbid adjustment (that is, personality) in adolescents and Global Assessment of Functioning (GAF) both before and after first-episode psychosis in adolescents and adults are the best predictors of diagnosis; 2) GAF (before and after) is the best predictor of outcome in both adolescents and adults.

CONCLUSION

Adolescent-onset psychosis appears to be in continuity with adult-onset psychosis. The greater diagnostic instability in adolescents and the absence of significant data on predictive variables suggest a need for specialized and continuous care and research in the adolescent population.

Relationship between psychotic disorders in adolescence and criminally violent behaviour. A retrospective examination

BACKGROUND

The interaction between psychosis and violence in adults is an important area of research receiving attention. To date there is little available data examining this relationship in adolescence.

AIMS

To investigate the possible relationships between criminally violent types of behaviour, and psychopathology and social factors, among adolescents suffering from a psychotic disorder.

METHOD

A retrospective case note study of 39 in-patients diagnosed as having a psychotic disorder and admitted to one of two adolescent psychiatry units (one secure, one open). Cases were divided into a 'violent' and a 'non-violent' group, and these two groups were then compared for social and psychopathological variables.

RESULTS

There was no association between recorded psychopathology and criminally violent behaviour. Criminally violent behaviour was associated with a history of emotional or physical abuse, contact with social or mental health services, and previous criminal behaviour.

CONCLUSIONS

These findings fail to echo results of studies in adult schizophrenia; they suggest that violent behaviour in psychosis is associated more closely with social factors than with specific symptoms of the psychotic illness. Potential explanations are discussed.

Schizophrenia with onset before the age of eleven: clinical characteristics of onset and course

This study reports on the long-term course of 11 patients (6 girls, 5 boys) with childhood onset schizophrenia (COS, age at onset < 10 years). Patients were examined twice (mean follow-up period 38 years after onset). The premorbid development is assessed in terms of the Modified Premorbid Adjustment Scale (M-PAS) and additionally described by distinct psychopathological categories. The psychopathology at the onset of psychosis and at the second follow-up examination was assessed by categorical application of the Positive and Negative Syndrome Scale (PANSS). The outcome was rated with the Disability Assessment Score (DAS). The course of psychotic episodes and intervals between them is presented according to DSM-IV subtype classifications. Ten of 11 patients presented premorbid developmental peculiarities that were not adequately covered by the M-PAS subscales. Whereas in the 4 patients with acute onset of psychosis the positive PANSS-type was predominant, in the 7 patients with an insidious onset the negative PANSS-type prevailed. The nature of the diagnostic subtypes varied markedly across the course of the illness. In case of a continuous predominant catatonic symptomatology the outcome was poor. Detailed case descriptions help to illuminate the heterogeneous psychopathology of COS. Various temporary premorbid behavioral peculiarities were precursors of COS. A differentiation between premorbid and prodromal signs proved to be arbitrary. Our results contradict the assumption that COS is characterized only by a negative symptomatology.

Early onset psychotic disorders: diagnostic stability and clinical characteristics

OBJECTIVES

To examine the clinical features and diagnostic stability of early-onset psychotic disorders.

METHODS

These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline and at one and two-year's follow-up.

RESULTS

Fifty-one subjects have been recruited to date; 18 with schizophrenia, 14 with bipolar disorder, 7 with schizoaffective disorder, 1 with an organic psychosis, and 11 subjects whose symptoms where either questionable and/or did not meet diagnostic criteria for another disorder (classified as psychosis nos). Thirty-nine subjects were reassessed at year one, twenty-four at year two. Three subjects have been lost to follow-up. The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 50% of subjects. Over the two-year period of the study, the diagnosis remained unchanged in over 90% of subjects. Subjects with schizophrenia had higher ratings of premorbid impairment, including social withdrawal and dysfunctional peer relationships, than those with bipolar disorder. At the one-year follow-up, subjects with schizophrenia and schizoaffective disorder had significantly higher rates of delusions, bizarre behavior, and negative symptoms than those with bipolar disorder. Subjects with bipolar disorder tended to have cyclical courses, whereas those with schizophrenia and schizoaffective disorder were often chronically impaired. Subjects with psychosis nos had higher rates of dissociative symptoms and histories of child maltreatment.

CONCLUSIONS

Early-onset psychotic disorders can be reliably diagnosed using standardized assessments and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and persistent positive and negative symptoms.

The ESSEN study of childhood-onset schizophrenia: selected results

INTRODUCTION

We present the results of a 42 year long-term follow-up of 44 patients (19 males, 25 females) with childhood-onset schizophrenia (COS, age at onset: 7-14 years) who could be traced for a second follow-up examination 27 years after the first follow-up.

METHOD

Data from interviews, clinical records, premorbid and social disability assessments were evaluated for statistical analyses. The symptomatology observed during the whole course of illness was rediagnosed by DSM-IV criteria.

RESULTS

The paranoid, catatonic, and schizoaffectives subtypes appeared most frequently. There have been no gender differences in age of first psychiatric symptoms (AFS), AFPS, and age of first hospitalization. Kaplan-Meier's survival-analysis carried out for AFPS with sex as the grouping factor revealed that the cumulative prevalence appears to be earlier in females (between 7 and 15 years) than in males (between 10 and 18 years). Of the 44 patients 50 % had a continuing severe course. Patients with onset before 12 years of age were characterized by a chronic/insidious onset, marked premorbid abnormalities, and by a poorer remission. Premorbid features of social withdrawal and reluctance indicated a risk for social disability within the later course.

CONCLUSION

COS, as a rare but severe variant of schizophrenia, frequently develops from premorbid social maladaptation to an insidious onset but is subsequently followed by a transition to a course and outcome not distinguishable from that of adult-onset schizophrenia.

Early-onset psychotic disorders: course and outcome over a 2-year period

OBJECTIVE

To examine the course and outcome of early-onset psychotic disorders.

METHOD

These are data from a longitudinal, prospective study of youths with psychotic disorders. Standardized diagnostic and symptom rating measures were used.

RESULTS

Fifty-five subjects with the following disorders have been recruited: schizophrenia (n = 18), bipolar disorder (n = 15), psychosis not otherwise specified (n = 15), schizoaffective disorder (n = 6), and organic psychosis (n = 1). Follow-up assessments were obtained on 42 subjects at year 1 and 31 subjects at year 2. Youths with schizophrenia had more chronic global dysfunction, whereas subjects with bipolar disorder overall had better functioning, with a cyclical course of illness. However, according to results of a regression model, premorbid functioning and ratings of negative symptoms, but not diagnosis, significantly predicted the highest level of functioning over years 1 and 2.

CONCLUSIONS

Course and level of functioning differentiated bipolar disorder from schizophrenia. However, premorbid functioning and ratings of negative symptoms were the best predictors of functioning over the follow-up period. These findings are consistent with the adult literature, and they further support that psychotic illnesses in young people are continuous with the adult-onset forms.

Bipolarity in children

Childhood and adolescent bipolar disorder have been less studied than adult onset bipolar illness. However, case reports of mania in childhood can be found as early as the mid 19th century. Historically, several factors have made the accurate diagnosis of bipolar disorder in childhood difficult: clinical bias against the diagnosis of mania in children; low base rate of disorder; symptom overlap between bipolar disorder and other more prevalent childhood-onset psychiatric disorders; and developmental constraints and variability in clinical presentation. The epidemiology of juvenile-onset bipolar disorder remains an open topic for research. The disorder appears to increase in prevalence with advancing age until young adulthood. Reported phenomenology of bipolar disorder in children and adolescents indicates a highly variable presentation with a developmental trend towards increased resemblance to the adult phenotype with increasing age of onset. Diagnostic accuracy for the disorder is improved by adherence to diagnostic and statistical manual of mental disorders (DSM) criteria and may be aided by structured or semistructured diagnostic interviews. The course of bipolar disorder in children and adolescents has also received limited systematic study. However, research to date supports a clinical picture of a relapsing, recurrent illness with substantial morbidity. Systematic studies of pharmacologic treatments of acute mania in children and adolescents are limited in number and scope. Clinical justification for the use of acute antimanic treatments such as lithium and valproic acid is still based upon studies conducted in adults. There remains an immediate and significant need for additional research into all aspects of juvenile-onset bipolar disorder.

Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters describe the assessment and treatment of early-onset bipolar disorder based on scientific evidence regarding diagnosis and effective treatment and on the current state of clinical practice. Given the paucity of research on bipolar disorder in children and adolescents, many of the treatment recommendations are drawn from the adult literature. Although the same diagnostic criteria are used as for adults, youth may differ with regard to the developmental presentation of symptoms and comorbid psychiatric disorders. Treatment involves the combination of pharmacotherapy and adjunctive psychosocial interventions. Antimanic agents (primarily lithium or valproic acid) are the mainstays of pharmacotherapy. The treatment focuses on (1) amelioration of acute symptoms; (2) the prevention of relapse; (3) the reduction of long-term morbidity; and (4) the promotion of long-term growth and development. These parameters were approved by Council of the American Academy of Child and Adolescent Psychiatry on June 5, 1996, and were previously published in J. Am. Acad. Chil Adolesc. Psychiatry, 1997, 36:138-157.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs. These parameters were previously published in J. Am. Acad. Child Adolesc. Psychiatry, 1994, 33:616-635.

Course of adolescent psychotic disorder with schizoaffective episodes

This study examines educational/occupational outcome and social functioning of adolescents treated for psychosis (mean onset age 16.1 yrs +/- 1.3). In a sample of 157 subjects, 26 patients with schizoaffective episodes (defined as any episode meeting ICD-9 criteria for schizoaffective psychosis, occurring at any time during the course of illness) were compared to 101 patients with schizophrenia, and to 30 affective disordered patients, all without schizoaffective episodes. Follow-up information (mean interval 7.3 yrs +/- 4.3) was obtained on 130 subjects. The three groups did not differ concerning sex, duration of first inpatient treatment, symptoms and social competence at discharge, nor at follow-up. At the time of outcome subjects with schizoaffective episodes showed greater similarities to schizophrenic than to severe affective disorder. Educational and occupational impairment was found in 72% of the schizoaffective group (schizophrenic group 79%, affective group 40%), obvious or more severe social disability in 86% of the schizoaffective group (schizophrenic 79%, affective 40%). Disabilities regarding performance of specific social roles and specific downward educational and occupational drifts were found to be more marked in schizoaffective than in affective disorder. Implications for further research and clinical practice are discussed.

AACAP official action. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder

These practice parameters describe the assessment and treatment of early-onset bipolar disorder based on scientific evidence regarding diagnosis and effective treatment and on the current state of clinical practice. Given the paucity of research on bipolar disorder in children and adolescents, many of the treatment recommendations are drawn from the adult literature. Although the same diagnostic criteria are used as for adults, youth may differ with regard to the developmental presentation of symptoms and comorbid psychiatric disorders. Treatment involves the combination of pharmacotherapy and adjunctive psychosocial interventions. Antimanic agents (primarily lithium or valproic acid) are the mainstays of pharmacotherapy. The treatment focuses on (1) amelioration of acute symptoms; (2) the prevention of relapse; (3) the reduction of long-term morbidity; and (4) the promotion of long-term growth and development. These parameters were approved by Council of the American Academy of Child and Adolescent Psychiatry on June 5, 1996.

Adolescent schizophrenia: a methodologic review of the current neuroimaging and neuropsychologic literature

This paper reviews all relevant articles that reported structural neuroimaging or neuropsychological data in adolescent patients with schizophrenia. These papers were subsequently examined from a methodological perspective. Few papers have been written that have examined whether adolescent schizophrenia is associated with structural neuroimaging abnormalities or cognitive dysfunction. In these studies, major methodologic issues exist. Therefore, at present, firm conclusions cannot be made regarding the presence or absence of neuropsychologic dysfunction or structural neuroimaging abnormalities in this population. Attention to certain methodologic issues may improve future studies of this topic.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs.

Looking for childhood-onset schizophrenia: the first 71 cases screened

OBJECTIVE

To review psychiatric referrals to a study of childhood-onset schizophrenia.

METHOD

Children and adolescents (N = 71) and their parents selected from a total of 260 patients referred to the National Institute of Mental Health between 1990 and 1993, with onset of psychosis at or before age 12 years, were screened in person, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version, portions of the Diagnostic Interview for Children and Adolescents-Parent Version, and clinical interview. Best-estimate diagnoses using all sources of information were determined. Thought disorder was rated on a subset of subjects using standardized videotaped speech samples.

RESULTS

Interrater reliability (kappa) between two child psychiatrists for best-estimate primary diagnoses ranged from .65 to .81. Schizophrenia was diagnosed for 19 children who by history had had onset at or before age 12, but all were in puberty when interviewed. Affect disorders (N = 14) and Asperger's syndrome and pervasive developmental disorder not otherwise specified (N = 6) were also diagnosed. A large group of reliably identifiable children not completely described by any DSM-III-R category and provisionally called "multidimensionally impaired" (N = 21) with multiple language or learning disorders, mood lability, and transient psychotic symptoms was seen.

CONCLUSIONS

Childhood-onset schizophrenia is often misdiagnosed, perhaps is often misdiagnosed, perhaps because of the rarity of the disorder and the ambiguity in applying primary criteria. An array of developmental disturbances are seen with less pervasive childhood-onset psychotic symptoms.