"Multidimensionally impaired disorder": is it a variant of very early-onset schizophrenia?

Psychopharmacology Management in Autism Spectrum Disorder

Persons with autism spectrum disorder (ASD) may have other psychiatric conditions that warrant treatment. Symptoms may not be easy to discern from rigidity or irritability that are sometimes considered to be constituent parts of ASD. Pathophysiology that involves hyperexcitable neurons and anomalous connectivity may provide justification for using psychopharmacologic agents, although nonmedical strategies may also be effective. Hyperactivity, irritability, and tantrums with or without aggression may be rational targets for psychopharmacological intervention. The best-studied drug class to date has been the second-generation antipsychotics targeting irritability.

Schizophrenia among young people first admitted to psychiatric inpatient care during early and middle adolescence

OBJECTIVE

This study explored the incidence and stability of schizophrenia in a large national register data of all adolescents first admitted to psychiatric inpatient care at ages 13-17 in Finland 1980-2010.

METHODS

The study population (N 17,112) comprised all Finnish citizens aged 13-17 receiving their first ever psychiatric inpatient treatment between 1980 and 2010 in Finland. To explore incidence and stability of schizophrenia, the diagnostic information on inpatient care or disability pension was obtained from the appropriate registers.

RESULTS

The incidence of schizophrenia disorders (F20 + F25) during adolescence was higher in the study population for those admitted to psychiatric inpatient care 1980-1989 than in other decades examined. Overall, psychiatric inpatient care during adolescence was a risk factor for subsequent schizophrenia, especially if a diagnosis of F20-29 was set although a considerable share of those with psychotic disorders other than schizophrenia diagnosis did not subsequently convert to schizophrenia. The stability of adolescent onset schizophrenia diagnosis was high.

CONCLUSION

Adolescents requiring psychiatric inpatient care have a higher later rate of schizophrenia diagnosis than prevalence at community level. Whereas adolescent onset schizophrenia diagnosis is a fairly stable diagnosis, there are other adolescent psychotic disorders which are more transient in nature.

When No Diagnosis "Fits": Diagnostically Homeless and Emotionally Dysregulated Children and Adolescents

Clinical experience supports the concept of children with severe disturbances in most areas of functioning, with psychiatric symptom onset before age 6. They are emotionally dysregulated and extremely anxious and have developmental difficulties. Given the absence of an appropriate diagnostic category, it is best to consider clinical phenomenology and then categorize each dysfunction domain (mood/anxiety problems, possible psychosis, language impairment/thought disorder, and relationship/social problems).

Autism and Migraine: An Unexplored Association?

Autism spectrum disorder is characterized by neurological, psychiatric and medical comorbidities—some conditions co-occur so frequently that comorbidity in autism is the rule rather than the exception. The most common autism co-occurring conditions are intellectual disability, language disorders, attention-deficit hyperactivity disorder, epilepsy, gastrointestinal problems, sleep disorders, anxiety, depression, obsessive-compulsive disorder, psychotic disorders, oppositional defiant disorder, and eating disorders. They are well known and studied. Migraine is the most common brain disease in the world, but surprisingly only a few studies investigate the comorbidity between autism and migraine. The aim of this narrative review is to explore the literature reports about the comorbidity between autism and migraine and to investigate the common neurotransmitter, immune, anatomical and genetic abnormalities at the base of these two conditions.

Multidimensional impairments

Children and adolescents with neurodevelopmental disorders often show complex developmental disorders, including multiple areas of dysfunction such as emotional regulation and behavior, school integration, and learning difficulties. These multidimensionally impaired children share some common features with children with autism spectrum disorders (ASDs). However, paradoxically, they could qualify as diagnostically homeless. Several proposals have been formulated to categorize subgroups of these children, whose diversity and overlap in clinical expression emphasize the importance of using a multidimensional assessment inscribed in a developmental perspective. Here, we review these different classification proposals and describe a multidimensional approach that, in addition to a categorical approach, could constitute a complementary point of view. We believe that this multidimensional perspective allows one to address the child holistically, taking into account his or her interactive experience with the environment, and achieve a functional diagnosis enabling the elaboration of a tailored therapeutic plan and better school inclusion.

Childhood-Onset Schizophrenia and Early-onset Schizophrenia Spectrum Disorders: An Update

The clinical severity, impact on development, and poor prognosis of childhood-onset schizophrenia may represent a more homogeneous group. Positive symptoms in children are necessary for the diagnosis, and hallucinations are more often multimodal. In healthy children and children with a variety of other psychiatric illnesses, hallucinations are not uncommon and diagnosis should not be based on these alone. Childhood-onset schizophrenia is an extraordinarily rare illness that is poorly understood but seems continuous with the adult-onset disorder. Once a diagnosis is confirmed, aggressive medication treatment combined with family education and individual counseling may prevent further deterioration.

Neuropsychiatric Aspects in Men with Klinefelter Syndrome

BACKGROUND AND OBJECTIVE

Klinefelter Syndrome (KS) is the most common sex chromosome aneuploidy (47, XXY) and cause of male hypergonadotropic hypogonadism. It is characterized by an extreme clinical heterogeneity in presentation, including infertility, hypogonadism, language delay, metabolic comorbidities, and neurocognitive and psychiatric disorders. Since testosterone is known to have organizational, neurotrophic and neuroprotective effects on brain, the condition of primary hypogonadism could play a role. Moreover, given that KS subjects have an additional X, genes on the extra-chromosome could also exert a significant impact. The aim of this narrative review is to analyze the available literature on the relationship between KS and neuropsychiatric disorders.

METHODS

To extend to the best of published literature on the topic, appropriate keywords and MeSH terms were identified and searched in Pubmed. Finally, references of original articles and reviews were examined.

RESULTS

Both morphological and functional studies focusing on the brain showed that there were important differences in brain structure of KS subjects. Different psychiatric disorders such as Schizophrenia, autism, attention deficit hyperactivity disorder, depression and anxiety were frequently reported in KS patients according to a broad spectrum of phenotypes. T supplementation (TRT) was not able to improve the psychotic disorders in KS men with or without overt hypogonadism.

CONCLUSION

Although the risk of psychosis, depression and autism is increased in subjects with KS, no definitive evidence has been found in studies aiming at identifying the relationship between aneuploidy, T deficit and the risk of psychiatric and cognitive disorders in subjects affected by KS.

Autism: a transdiagnostic, dimensional, construct of reasoning?

The concept of autism has changed across time, from the Bleulerian concept, which defined it as one of several symptoms of dementia praecox, to the present-day concept representing a pervasive development disorder. The present theoretical contribution to this special issue of EJN on autism introduces new theoretical ideas and discusses them in light of selected prior theories, clinical examples, and recent empirical evidence. The overall aim is to identify some present challenges of diagnostic practice and autism research and to suggest new pathways that may help direct future research. Future research must agree on the definitions of core concepts such as autism and psychosis. A possible redefinition of the concept of autism may be a condition in which the rationale of an individual's behaviour differs qualitatively from that of the social environment due to characteristic cognitive impairments affecting reasoning. A broad concept of psychosis could focus on deviances in the experience of reality resulting from impairments of reasoning. In this light and consistent with recent empirical evidence, it may be appropriate to redefine dementia praecox as a developmental disorder of reasoning. A future challenge of autism research may be to develop theoretical models that can account for the impact of complex processes acting at the social level in addition to complex neurobiological and psychological processes. Such models could profit from a distinction among processes related to (i) basic susceptibility, (ii) adaptive processes and (iii) decompensating factors involved in the development of manifest illness.

Diagnosis and differential diagnosis of Asperger syndrome

Asperger syndrome is an uncommon condition, but probably more common than classic autism (the only published population study estimated prevalence at 36 per 10 000 children for Asperger syndrome and 5 per 10 000 for autism (Ehlers & Gillberg, 1993)). Misdiagnosis or delayed diagnosis of this disorder is a serious problem, and the average age at diagnosis is several years later than for autism (Gillberg, 1989). Obviously, this can be traumatic for individuals and families; furthermore, the most effective intervention programmes begin early, and establishing management strategies at an early age can minimise later behavioural problems (Howlin, 1998).

The Association Between Comorbid Autism Spectrum Disorders and Antipsychotic Treatment Failure in Early-Onset Psychosis: A Historical Cohort Study Using Electronic Health Records

OBJECTIVE

In a sample of children and adolescents with first-episode psychosis, we investigated whether multiple treatment failure (MTF, defined as the initiation of a third trial of novel antipsychotic due to nonadherence, adverse effects, or insufficient response) was associated with comorbid autism spectrum disorders.

METHODS

Data were from the electronic health records of 638 children (51% male) aged from 10 to 17 years with first-episode psychosis (per ICD-10 criteria) from January 1, 2008, to November 1, 2014, referred to mental health services in South London, United Kingdom; data were extracted using the Clinical Record Interactive Search (CRIS) system. The effect of autism spectrum disorder comorbidity on the development of MTF during a 5-year period was modeled using Cox regression.

RESULTS

There were 124 cases of MTF prior to the age of 18 (19.4% of the sample). Comorbid autism spectrum disorders were significantly associated with MTF (adjusted hazard ratio = 1.99; 95% CI, 1.19-3.31; P = .008) after controlling for a range of potential confounders. Other factors significantly associated with MTF included higher age at first presentation (P = .001), black ethnicity (P = .03), and frequency of clinical contact (P < .001). No significant association between other comorbid neurodevelopmental disorders (hyperkinetic disorder or intellectual disability) and MTF was found.

CONCLUSIONS

Children with first-episode psychosis and comorbid autism spectrum disorders at first presentation are less likely to have a beneficial response to antipsychotics.

Evaluation of Bizarre-Idiosyncratic Thinking Scale as a Measure of Thought Disorder in Children and Adolescents with Severe Psychiatric Disorders

To investigate the prevalence of thought disorder and the possible appropriateness of the Bizarre–Idiosyncratic Thinking Scale for children and adolescents with severe psychiatric disorders, 96 child and adolescent inpatients and day hospital patients, ages 6 to 18 years, at a state psychiatric hospital were rated by review of retrospective records using Marengo and Harrow's 1986 Evaluation of Bizarre–Idiosyncratic Thinking Scale for the presence of thought disorder in the Thematic Apperception Test and Rorschach Inkblot Test responses. Although the Evaluation of Bizarre–Idiosyncratic Thinking Scale had not been previously used with children and adolescents, the analysis suggested possible indications of thought disorder in several diagnostic groups. No significant differences were found on the Rorschach between patients with Schizophrenia and Psychosis, Not Otherwise Specified and those with Attention Deficit Hyperactivity Disorder, Major Depression, and Conduct Disorder. On the basis of the Thinking Scale ratings, the Thematic Apperception Test responses showed significantly higher ratings of thought disorder for patients with Schizophrenia and Psychosis, Not Otherwise Specified. There was no general relation between thought disorder and age or IQ, but schizophrenic patients, aged 13 and older, had more thought disorder than schizophrenic patients who were younger than 13.

The Clinical Presentation of Childhood-Onset Schizophrenia: A Literature Review

This literature review explores the research on the clinical presentation of childhood-onset schizophrenia (COS) that was conducted in the period 1994–2004. A literature search was done using Internet search engines and psychological databases to collect English-language journal articles from 1994 onwards. Research indicates that COS is a stable diagnosis. Generally, there is a clear history of premorbid abnormalities, an insidious onset and a deteriorating course. For the majority of cases there seems to be a poor outcome. Despite the limitations in the research conducted thus far, findings provide important insights into COS and several possibilities for future research.

Clinical predictors of antipsychotic use in children and adolescents with autism spectrum disorders: a historical open cohort study using electronic health records

Children with autism spectrum disorders (ASD) are more likely to receive antipsychotics than any other psychopharmacological medication, yet the psychiatric disorders and symptoms associated with treatment are unclear. We aimed to determine the predictors of antipsychotic use in children with ASD receiving psychiatric care. The sample consisted of 3482 children aged 3-17 with an ICD-10 diagnosis of ASD referred to mental health services between 2008 and 2013. Antipsychotic use outcome, comorbid diagnoses, and other clinical covariates, including challenging behaviours were extracted from anonymised patient records. Of the 3482 children (79 % male) with ASD, 348 (10 %) received antipsychotic medication. The fully adjusted model indicated that comorbid diagnoses including hyperkinetic (OR 1.44, 95 %CI 1.01-2.06), psychotic (5.71, 3.3-10.6), depressive (2.36, 1.37-4.09), obsessive-compulsive (2.31, 1.16-4.61) and tic disorders (2.76, 1.09-6.95) were associated with antipsychotic use. In addition, clinician-rated levels of aggression, self-injurious behaviours, reduced adaptive function, and overall parental concern for their child's presenting symptoms were significant risk factors for later antipsychotic use. In ASD, a number of comorbid psychiatric disorders are independent predictors for antipsychotic treatment, even after adjustment for familial, socio-demographic and individual factors. As current trial evidence excludes children with comorbidity, more pragmatic randomised controlled trials with long-term drug monitoring are needed.

Differential diagnosis of adolescent and adult pervasive developmental disorders/autism spectrum disorders (PDD/ASD): a not uncommon diagnostic dilemma

The failure to recognise the pervasive developmental disorders/autism spectrum disorders is probably not uncommon in adult psychiatry. Indeed some of the treatment-resistant chronic mental illnesses are due to the failure to make this diagnosis and apply more appropriate treatment.

Patients with PDD/ASD cause considerable diagnostic difficulties in both inpatient and outpatient adolescent and adult psychiatry. Clinical experience suggests that patients with PDD/ASD in adulthood have been misdiagnosed as having schizophrenia resulting in inappropriate treatment. Mesibov and Handlan state that the diagnostic situation is complicated because the characteristics of autism are less pronounced in older clients. It is critical that an accurate diagnosis is given because of the specific treatment implications. In the past decade there have been considerable developments in our understanding of autism. The importance of bringing the developmental viewpoint into adult psychiatry is now highly relevant. Unfamiliar diagnostic categories now have to be considered by adolescent and adult psychiatrists. Grounds for the deletion of adult psychiatric disorders, eg. simple schizophrenia from ICD102 may exist. Instead PDD/ASD disorder may need to be considered.

As the purpose of diagnosis is to ensure appropriate client management, it is essential that diagnostic criteria are continually reviewed in view of clinical observation and research developments. In this paper, diagnostic categories causing confusion are outlined, and that these are variants of the core deficit of autism is suggested. The major PDD/ASD diagnoses in adolescence and adulthood are listed below.

Two of the following are required for the diagnosis of autism:

"Autism-plus" spectrum disorders: intersection with psychosis and the schizophrenia spectrum

Patients are often encountered clinically who have autism spectrum disorders (ASD) and also have symptoms suggestive of a comorbid psychotic disorder. A careful assessment for the presence of comorbid disorders is important. However, the core deficits seen in ASD, in social reciprocity, communication, and restricted behaviors and interests, can be mistaken for psychosis. Also, there is a subset of patients who present with a complex neurodevelopmental disorder with impairments that cross diagnostic categories. This article reviews the connections between ASD and psychosis, and highlights the key points to consider in patients who present with these "autism-plus" disorders.

Childhood onset schizophrenia and early onset schizophrenia spectrum disorders

The clinical severity, impact on development, and poor prognosis of childhood onset schizophrenia may represent a more homogeneous group. Positive symptoms in children are necessary for the diagnosis and hallucinations are more often multimodal. In healthy children and children with a variety of other psychiatric illnesses, hallucinations are not uncommon and diagnosis should not be based on these alone. Childhood onset schizophrenia is an extraordinarily rare illness that is poorly understood but seems continuous with the adult onset disorder. Once a diagnosis is affirmed, aggressive medication treatment combined with family education and individual counseling may defer further deterioration.

Psychosis in children: diagnosis and treatment

The diagnosis of childhood psychosis raises a host of unresolved problems, despite the Diagnostic and Statistical Manual Of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) giving identical symptoms and definitions for children, adolescents, and adults. The fantasy lives of children, and issues of developing language and cognition (including retardation), all impair diagnostic accuracy, particularly when differentiating between childhood-onset schizophrenia (COS) (≤12 years), bipolar affective disorder, major depressive disorder, and even obsessive-compulsive disorder and attention-deficit/hyperactivity disorder: the catch-all classification, psychosis not otherwise specified (PNOS), is always available for conundra that prove unsolvable. Typical if nonpathognomonic features include neurocognitive difficulties. Multiple screening instruments and specialized versions of semistructured diagnostic interviews are available. Although smooth-pursuit eye-tracking movements may prove a genetic marker for COS, etiologies are likely to be oligogenetic rather than related to a single gene. No specific biological markers or neuroimages have been identified. As such, psychoses may be indicative of a more general pattern of brain dysfunction. Drug treatments are largely based on the adult literature because of a dearth of controlled data below age 18. There are still no rigorous studies of psychosocial treatments and psychotherapy specific to childhood psychosis.

Childhood onset schizophrenia: support for a progressive neurodevelopmental disorder

Structural brain abnormalities have become an established feature of schizophrenia and increasing evidence points towards the progressive nature of these abnormalities. The brain abnormalities are most profound in early onset cases, which have a severe, treatment refractory phenotype and more salient genetic features. Unique insights could thus be gained in schizophrenia pathology from studying the earliest manifestations of the illness. This paper reviews and updates the findings on anatomic brain development in patients with very early onset schizophrenia while showing preliminary data from ongoing studies. Collectively, our studies demonstrate that childhood-onset schizophrenia (COS) subjects show progressive loss of gray matter, delayed/disrupted white matter (WM) growth, and a progressive decline in cerebellar volume, some of which are shared by their healthy siblings. The developmental patterns or the 'trajectories' of brain development are often more striking than anatomic brain differences at any one point in time; highlighting the importance of longitudinal studies. The sibling findings of partially shared gray matter (GM) deficits which appear to normalize with age, along with other genetic analyses, provide evidence that the brain developmental 'patterns/trajectories' for several regions at particular ages could be useful endophenotypes (trait markers).

Shared and nonshared symptoms in youth-onset psychosis and ADHD

OBJECTIVE

We compared ratings of behavior and attention problems between youth-onset psychosis and ADHD, two disorders in which attentional impairments play a key role, and examined the effect of psychostimulant use on age of onset in psychosis.

METHOD

Parent and teacher ratings of behavioral problems and ADHD symptoms were collected using the Achenbach CBCL, TRF, and SNAP-IV Teacher Rating Scales on 42 participants with psychosis, 36 with ADHD and 57 controls (ages 8-19).

RESULTS AND CONCLUSIONS

Results suggested that academic, externalizing, and attention problems reflect symptoms shared between the disorders, whereas internalizing, social and thought problems reflect factors that differ between disorders. Furthermore, participants with psychosis who had been prescribed psychostimulants had a younger age of onset of psychotic symptoms than those who had not. This difference could reflect dissimilarities in symptom severity symptom between subgroups or potentially harmful effects of psychostimulants in individuals predisposed to develop psychosis.

Grey matter and cognitive deficits in young relatives of schizophrenia patients

Grey-matter volumetric and cognitive deficits in young, high-risk relatives of schizophrenia patients may be vulnerability markers of the illness. Although these markers may be correlated, it is unclear if their distributions in relatives overlap. We examined convergence of these markers in 94 young first and second-degree relatives (HR) and 81 healthy controls. Subjects were assessed using WCST, CPT-IP and Benton-Hamscher tests and on grey-matter volumes of brain regions related to language, attention and executive function using FreeSurfer to process T1-MR-images. K-means clustering using cognitive performance scores split relatives into sub-samples with better (HR+C, n=35) and worse (HR-C, n=59) cognition after controlling for age and gender. All regional volumes and language related regional laterality-indices were compared between HR-C, HR+C and control subjects, controlling for age, gender and intra-cranial volume. Volumes of caudate nuclei, thalami, hippocampi, inferior frontal gyri, Heschl's gyri, superior parietal cortices, supramarginal gyri, right angular gyrus, right middle frontal gyrus and right superior frontal gyrus, leftward laterality of supramarginal and inferior frontal gyri and rightward laterality of the angular gyrus were reduced in HR-C compared to controls. Volumes of Heschl's gyri, left supramarginal gyrus, inferior frontal gyri, hippocampi and caudate nuclei HR-C were smaller in HR-C compared to HR+C. HR+C showed deficits compared to controls only for the superior parietal and right angular volumes. Premorbid neuroanatomical and laterality alterations in schizophrenia may selectively manifest in cognitively compromised relatives. Overlapping structural and cognitive deficits may define a hyper vulnerable sub-sample among individuals at familial predisposition to schizophrenia.

Mapping gray matter development: implications for typical development and vulnerability to psychopathology

Recent studies with brain magnetic resonance imaging (MRI) have scanned large numbers of children and adolescents repeatedly over time, as their brains develop, tracking volumetric changes in gray and white matter in remarkable detail. Focusing on gray matter changes specifically, here we explain how earlier studies using lobar volumes of specific anatomical regions showed how different lobes of the brain matured at different rates. With the advent of more sophisticated brain mapping methods, it became possible to chart the dynamic trajectory of cortical maturation using detailed 3D and 4D (dynamic) models, showing spreading waves of changes evolving through the cortex. This led to a variety of time-lapse films revealing characteristic deviations from normal development in schizophrenia, bipolar illness, and even in siblings at genetic risk for these disorders. We describe how these methods have helped clarify how cortical development relates to cognitive performance, functional recovery or decline in illness, and ongoing myelination processes. These time-lapse maps have also been used to study effects of genotype and medication on cortical maturation, presenting a powerful framework to study factors that influence the developing brain.

Extending extant models of the pathogenesis of borderline personality disorder to childhood borderline personality symptoms: the roles of affective dysfunction, disinhibition, and self- and emotion-regulation deficits

Although research has been conducted on the course, consequences, and correlates of borderline personality disorder (BPD), little is known about its emergence in childhood, and no studies have examined the extent to which theoretical models of the pathogenesis of BPD in adults are applicable to the correlates of borderline personality symptoms in children. The goal of this study was to examine the interrelationships between two BPD-relevant personality traits (affective dysfunction and disinhibition), self- and emotion-regulation deficits, and childhood borderline personality symptoms among 263 children aged 9 to 13. We predicted that affective dysfunction, disinhibition, and their interaction would be associated with childhood borderline personality symptoms, and that self- and emotion-regulation deficits would mediate these relationships. Results provided support for the roles of both affective dysfunction and disinhibition (in the form of sensation seeking) in childhood borderline personality symptoms, as well as their hypothesized interaction. Further, both self- and emotion-regulation deficits partially mediated the relationship between affective dysfunction and childhood borderline personality symptoms. Finally, results provided evidence of different gender-based pathways to childhood borderline personality symptoms, suggesting that models of BPD among adults are more relevant to understanding the factors associated with borderline personality symptoms among girls than boys.

Predictors of remission, schizophrenia, and bipolar disorder in adolescents with brief psychotic disorder or psychotic disorder not otherwise specified considered at very high risk for schizophrenia

OBJECTIVE

The aim of this study was to examine predictors of diagnostic and symptomatic outcome in adolescents with either psychotic disorder not otherwise specified (PsyNOS) or brief psychotic disorder (BrPsy) followed in a schizophrenia prodromal program.

METHODS

As part of a naturalistic study of adolescents considered at clinical high risk for schizophrenia, 26 youths (mean age, 15.9 +/- 2.6 years, 65.4% male) with psychosis not fulfilling criteria for schizophrenia/schizoaffective disorder and diagnosed with PsyNOS or BrPsy were evaluated for predictors of diagnostic and symptomatic outcome after at least 6 (mean, 22.8 +/- 19.4) months follow up.

RESULTS

Progression to schizophrenia, schizoaffective disorder, or psychotic bipolar disorder (n = 10, 38.5%) was predicted by fulfilling criteria for schizotypal personality disorder at baseline (p = 0.046). Development of schizophrenia/schizoaffective disorder (n = 7, 27.0%) was associated with worse executive functioning (p = 0.029) and absence of anxiety disorders (p = 0.027). Conversely, progression to bipolar disorder (n = 4, 15.4%), with (n = 3, 11.5%) or without (n = 1, 3.8%) psychosis, was associated with the presence of anxiety disorders (p = 0.014). Remission of all psychotic as well as attenuated positive or negative symptoms (n = 5, 19.4%) was predicted by Hispanic ethnicity (p = 0.0047), an initial diagnosis of BrPsy (p = 0.014), longer duration of antidepressant treatment (p = 0.035), and better attention at baseline (p = 0.042).

CONCLUSIONS

Results from this preliminary study suggest that patients with PsyNOS, BrPsy, or schizotypal personality disorder features in adolescence should be followed as separate risk groups in prodromal studies of schizophrenia and bipolar disorder. Executive function deficits and absence of anxiety disorders may be risk markers for schizophrenia, while presence of anxiety disorders may be linked to bipolar disorder risk. After achieving full remission, patients with sudden onset of psychosis and brief episodes could once be given the option of careful, supervised treatment discontinuation. The potential salutary effect of antidepressants during the psychotic prodrome and presence of characteristics differentiating patients at risk for schizophrenia or bipolar disorder should be investigated further.

A comparative pilot study of second-generation antipsychotics in children and adolescents with schizophrenia-spectrum disorders

OBJECTIVE

There is a limited evidence base to guide treatment of children and adolescents with nonaffective psychoses because few comparative studies of first-line second-generation antipsychotics (SGAs) have been undertaken. To plan the design of a subsequent randomized controlled trial (RCT), the authors conducted this pilot study to demonstrate the feasibility of the treatment and measurement protocols.

METHOD

Thirty children and adolescents (20 males, 10 females), ages 10-18 years, who met unmodified Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for a schizophrenia-spectrum disorder (schizophrenia, schizoaffective, schizophreniform, psychotic disorder not otherwise specified) were randomized to receive 12 weeks of open-label, flexibly dosed treatment with either risperidone (mean [standard deviation, SD] dose = 3.4 mg [1.5]), olanzapine (mean [SD] dose = 14.0 mg [4.6]) or quetiapine (mean [SD] dose = 611 mg [253.4]).

RESULTS

Twenty one (70%) of 30 subjects completed the study. There was no overall statistically significant difference with regard to reduction in Positive and Negative Syndrome Scale (PANSS) total scores in treatment efficacy observed (F((2,24)) = 3.13, p = 0.06). However, the possibility of a large differential treatment effect with regard to change in PANSS total scores favoring risperidone relative to quetiapine (risperidone vs. quetiapine, d = 1.10 [95% confidence interval, CI, 0.09-2.01]) was suggested by the point estimate.

CONCLUSIONS

These preliminary data, viewed together with the extant literature, suggest that a future larger RCT with only two treatment arms may be warranted to establish whether there is a clinically significant differential treatment effect between risperidone and quetiapine for children and adolescents with nonaffective psychoses. Additional challenges and considerations for mounting a larger RCT are explored.

Longitudinal brain changes in early-onset psychosis

Progressive losses of cortical gray matter volumes and increases in ventricular volumes have been reported in patients with childhood-onset schizophrenia (COS) during adolescence. Longitudinal studies suggest that the rate of cortical loss seen in COS during adolescence plateaus during early adulthood. Patients with first-episode adolescent-onset schizophrenia show less marked progressive changes, although the number of studies in this population is small. Some studies show that, although less exaggerated, progressive changes are also present in nonschizophrenia early-onset psychosis. The greater loss of brain tissue seen in COS, even some years after the first episode, as compared to adolescent- or adult-onset schizophrenia may be due to variables such as sample bias (more severe, treatment refractory sample of childhood-onset patients studied), a process uniquely related to adolescent development in COS, differential brain effects of drug treatment in this population, clinical outcome, or interactions among these variables. Findings from both cross-sectional studies of first-episode patients and longitudinal studies in COS and adolescent onset support the concept of early-onset schizophrenia as a progressive neurodevelopmental disorder with both early and late developmental abnormalities. Future studies should look for correlates at a cellular level and for pathophysiological explanations of volume changes in these populations. The association of risk genes involved in circuitries associated with schizophrenia and their relationship to developmental trajectories is another promising area of future research.

Cortical brain development in schizophrenia: insights from neuroimaging studies in childhood-onset schizophrenia

Childhood-onset schizophrenia (COS; defined as onset by age 12 years) is rare, difficult to diagnose, and represents a severe and chronic phenotype of the adult-onset illness. A study of childhood-onset psychoses has been ongoing at the National Institute of Mental Health (NIMH) since 1990, where children with COS and severe atypical psychoses (provisionally labeled "multidimensionally impaired" or MDI by the NIMH team) are studied prospectively along with all first-degree relatives. COS subjects have robust cortical gray matter (GM) loss during adolescence, which appears to be an exaggeration of the normal cortical GM developmental pattern and eventually mimics the pattern seen in adult-onset cases as the children become young adults. These cortical GM changes in COS are diagnostically specific and seemingly unrelated to the effects of medications. Furthermore, the cortical GM loss is also shared by healthy full siblings of COS probands suggesting a genetic influence on the abnormal brain development.

Brain neuroplasticity in healthy, hyperactive and psychotic children: insights from neuroimaging

Noninvasive brain imaging permits longitudinal studies of anatomic brain development in healthy and psychiatrically ill children. The time course for gray matter maturation varies by region and parallels earlier histological studies, indicating dynamic patterns of overproduction and regression. Developmental trajectories vary in relation to gender, intelligence, and overall functioning. Twin studies show high heritability for brain volumes, which varies with region and with age. Diagnostically specific, illness-related changes as well as outcome-associated plastic response are observed as illustrated for two pediatric populations, childhood-onset schizophrenia and attention-deficit/hyperactivity disorder, conditions which may be, in part, disorders of brain plasticity.

Efficacy and tolerability of second-generation antipsychotics in children and adolescents with schizophrenia

Early-onset schizophrenia-spectrum (EOSS) disorders (onset of psychotic symptoms before 18 years of age) represent a severe variant associated with significant chronic functional impairment and poor response to antipsychotic treatment. All drugs with proven antipsychotic effects block dopamine D(2) receptors to some degree. The ongoing development of the dopamine and other neurotransmitter receptor systems during childhood and adolescence may affect clinical response and susceptibility to side effects in youth. A literature search was conducted of clinical trials of antipsychotics in children and adolescents with EOSS disorders between 1980 and 2007 from the Medline database, reference lists, and conference proceedings. Trials were limited to double-blind studies of duration of 4 or more weeks that included 15 or more patients. Ten clinical trials were identified. Antipsychotic medications were consistently found to reduce the severity of psychotic symptoms in children and adolescents when compared with placebo. The superiority of clozapine has been now demonstrated relative to haloperidol, standard-dose olanzapine, and "high-dose" olanzapine for EOSS disorders. However, limited comparative data are available regarding whether there are differences among the remaining second-generation antipsychotics (SGAs) in clinical effectiveness. The available data from short-term studies suggest that youth might be more sensitive than adults to developing antipsychotic-related adverse side effects (eg, extrapyramidal side effects, sedation, prolactin elevation, weight gain). In addition, preliminary data suggest that SGA use can lead to the development of diabetes in some youth, a disease which itself carries with it significant morbidity and mortality. Such a substantial risk points to the urgent need to develop therapeutic strategies to prevent and/or mitigate weight gain and diabetes early in the course of treatment in this population.

Dynamic mapping of cortical development before and after the onset of pediatric bipolar illness

BACKGROUND

There are, to date, no pre-post onset longitudinal imaging studies of bipolar disorder at any age. We report the first prospective study of cortical brain development in pediatric bipolar illness for 9 male children, visualized before and after illness onset.

METHOD

We contrast this pattern with that observed in a matched group of healthy children as well as in a matched group of 8 children with 'atypical psychosis' who had similar initial presentation marked by mood dysregulation and transient psychosis (labeled as 'multi-dimensionally impaired' (MDI)) as in the bipolar group, but have not, to date, developed bipolar illness.

RESULTS

Dynamic maps, reconstructed by applying novel cortical pattern matching algorithms, for the children who became bipolar I showed subtle, regionally specific, bilaterally asymmetrical cortical changes. Cortical GM increased over the left temporal cortex and decreased bilaterally in the anterior (and sub genual) cingulate cortex. This was seen most strikingly after the illness onset, and showed a pattern distinct from that seen in childhood onset schizophrenia. The bipolar neurodevelopmental trajectory was generally shared by the children who remained with MDI diagnosis without converting to bipolar I, suggesting that this pattern of cortical development may reflect affective dysregulation (lability) in general.

CONCLUSIONS

These dynamic trajectories of cortical development may explain age-related disparate findings from cross-sectional studies of bipolar illness, and suggest the importance of mood disordered non-bipolar control group in future studies.

Adult bipolar disorder is continuous with pediatric bipolar disorder

Considerable debate exists regarding the continuity of bipolar disorder (BD) in children and adolescents. Do affected children continue to have BD as adults? Are pediatric forms of BD distinct from adult forms of the disorder? Here, I argue that, in fact, strictly defined BD I and II in children and adolescents is continuous with adult BD. First, if we take developmental differences into account, children and adults share similar symptoms, since they are both diagnosed according to DSM-IV criteria. Next, retrospective studies indicate that 50% to 66% of adults with BD had onset of their disorder before age 19 years. Early prospective data indicate that adolescents with BD progress to become young adults with BD. Further, family studies of pediatric BD probands find high rates of BD in adult relatives, and pediatric offspring of parents with BD have elevated rates of BD, compared with control subjects. Finally, biological characteristics of pediatric BD (such as treatment response, neurobiology, and genetics) are either shared with adults having BD or fit logically into developmental models of BD. Thus, while not conclusive, a preponderance of data support the hypothesis that pediatric BD is continuous with adult BD. Prospective studies incorporating phenomenological and biological assessment are needed to decisively address this issue.

Structural brain abnormalities in early onset first-episode psychosis

BACKGROUND

Brain morphometry in children and adolescents with first-episode psychosis offer a unique opportunity for pathogenetic investigations.

METHODS

We compared high-resolution 3D T1-weighted magnetic resonance images of the brain in 29 patients (schizophrenia, schizotypal disorder, delusional disorder or other non-organic psychosis), aged 10-18 to those of 29 matched controls, using optimized voxel-based morphometry.

RESULTS

Psychotic patients had frontal white matter abnormalities, but expected (regional) gray matter reductions were not observed. Post hoc analyses revealed that schizophrenia patients (n = 15) had significantly larger lateral ventricles as compared to controls. Duration and dose of antipsychotics correlated negatively with global gray matter volume in minimally medicated patients (n = 18).

CONCLUSION

Findings of white matter changes and enlarged lateral ventricles already at illness onset in young schizophrenia spectrum patients, suggests aberrant neurodevelopmental processes in the pathogenesis of these disorders. Gray matter volume changes, however, appear not to be a key feature in early onset first-episode psychosis.

Developmental psychopathology and neurobiology of aggression

The aim of this paper is to clarify how neural mechanisms at the molecular level, specifically the serotonergic (5-HT) system and the hypothalamic-pituitary-adrenal axis system (HPA) in conjunction with early life stress may contribute to the emergence of aggression, self-directed and otherwise, in borderline personality disorder (BPD). Chronic dysregulation of these biological systems, which function to regulate stress and emotion, may potentiate the development of impulsive aggression in borderline personality conditions. Our central premise in this paper is that brain development, stress regulation, and early pathonomic experience are interactive and cumulative in their mutual influence on the development of impulsive aggression in BPD. We review the parameters of impulsive aggression in BPD, followed by a discussion of the neurobiological and neuroendocrine correlates of impulsive aggression with and without BPD. We then focus on the developmental continuities in BPD with attention to brain maturation of 5-HT and HPA axis function during the life span and the influence of early adverse experiences on these systems. Finally, we comment on the data of the relative stability of aggression in BPD, adolescence as a developmental stage of potential vulnerability, and the course of aggressive behavior during the life span.

Neurocognitive impairment as a moderator in the development of borderline personality disorder

Borderline personality disorder (BPD) is characterized by a pervasive instability of interpersonal relationships, affects, self-image, marked impulsivity, dissociation, and paranoia. The cognitive dimension of the disorder has received relatively little attention and is poorly understood. This paper proposes that neurocognitive impairment is a key moderator in the development of BPD and elaborates a possible pathway for the expression of the cognitive domain. Neurocognitive impairment is hypothesized to moderate the relationship between caretaking and insecure disorganized attachment and pathological dissociation in the formation of the disorder contributing to impaired metacognition and a range of cognitive difficulties. The empirical evidence from studies of cognitive processes, brain function, attachment, and dissociation that support this theory are reviewed and discussed. Areas for future research that might verify or refute this theory are suggested.

Transtornos invasivos do desenvolvimento não-autísticos: síndrome de Rett, transtorno desintegrativo da infância e transtornos invasivos do desenvolvimento sem outra especificação

A categoria "transtorno invasivos do desenvolvimento" inclui o autismo, a síndrome de Asperger, a síndrome de Rett, o transtorno desintegrativo da infância e uma categoria residual denominada transtornos invasivos do desenvolvimento sem outra especificação. Nesta revisão, a síndrome de Rett e o transtorno desintegrativo da infância, que são categorias bem definidas, serão discutidas, assim como as categorias não tão bem definidas que foram incluídas no grupo transtornos invasivos do desenvolvimento sem outra especificação. Diferentes propostas de categorização têm sido feitas, algumas baseadas em abordagem fenomenológica descritiva, outras baseadas em outras perspectivas teóricas, tais como a neuropsicologia. As propostas atuais são apresentadas e discutidas, seguidas por avaliações críticas sobre as vantagens e desvantagens desses conceitos.

The schizophrenia prodrome: a developmentally informed review and update for psychopharmacologic treatment

In recent years substantial strides have been made in recognizing the prodrome for schizophrenia as a prospective entity in adolescents and young adults. Preliminary data suggest that atypical antipsychotic medications may improve symptoms and delay or prevent progression to schizophrenia, but substantial additional research is needed before the balance of long-term risks and benefits can be confidently assessed. Other medications or psychotherapies might benefit these patients as well. Some centers are beginning to examine if and how currently used prodromal diagnostic strategies and intervention studies might inform recognition and treatment of younger patients possibly prodromal for childhood-onset schizophrenia.

The development of impulsivity and suicidality in borderline personality disorder

Borderline personality disorder (BPD) is characterized by a broad pattern of impulsivity and suicidality. BPD usually begins in adolescence; the full clinical picture of the disorder is associated with developmental increases in impulsivity. However, BPD also has childhood precursors. The developmental pathways are similar to those found in other impulsive spectrum disorders, but children who later develop BPD probably have both externalizing and internalizing symptoms. Research in this area has made use of retrospective data from adults, prospective data from community studies, follow-up studies from children at risk, as well as research on "borderline pathology of childhood" (a condition with symptoms similar to adult BPD). Existing evidence suggests that both temperamental and environmental risk factors play a role in the development of the behavioral patterns associated with the disorder. These pathways also help account for the life course and outcome of BPD in adulthood.

A esquizofrenia ao longo da infância

As pesquisas sobre os grupos “de alto risco” (filhos de pais esquizofrênicos), assim como os estudos prospectivos na população geral, mostram que os futuros esquizofrênicos apresentam, comparativamente aos sujeitos-controle, atrasos do desenvolvimento psicomotor, déficits cognitivos e algumas particularidades comportamentais. Tais dados parecem confirmar a idéia segundo a qual a esquizofrenia corresponderia a um distúrbio neurodesenvolvimental cuja expressão varia ao longo da vida. As especificidades clínicas e evolutivas dos raros casos de esquizofrenia iniciando-se na infância levam alguns autores a pensar que se trataria de uma entidade específica e cujo pertencimento ao “espectro autista” necessita ainda ser estudado.

Lack of evidence for elevated obstetric complications in childhood onset schizophrenia

BACKGROUND

Pre-, peri-, and postnatal obstetric complications (OC) are reported to be more frequent in adult patients with schizophrenia and have been linked to both greater severity and to "earlier" age of onset (before either age 18 or 22) in studies of adult patients. We hypothesized that by extrapolation, patients with childhood-onset schizophrenia (COS), with very early onset and very severe illness, would have had more numerous or more salient OC compared with their healthy siblings.

METHODS

We compared the obstetric records of 60 COS children and 48 healthy siblings using the Columbia Obstetrics Complication Scale, a comprehensive measurement scale consisting of 37 variables having included a separate scale for fetal hypoxia.

RESULTS

Patients with COS did not have a higher incidence of OC than the healthy sibling control group with the exception of increased incidence of maternal vomiting.

CONCLUSIONS

Obstetric complications, with the possible exception of maternal vomiting, are unlikely to play a major role in the etiopathogenesis of childhood-onset schizophrenia.

Longitudinal course of schizophrenia spectrum symptoms in offspring of psychiatrically hospitalized mothers

OBJECTIVE

The aim of this study was to describe schizophrenia spectrum symptoms (SZSD) in children and adolescents with schizotypal personality disorder (SPD) as adults.

INTRODUCTION

There are no descriptive studies of children who develop into adults with SPD.

METHOD

Twelve offspring of psychiatrically hospitalized mothers (6 mothers with schizophrenia), were compared with 11 socioeconomic status (SES)-matched offspring of control, non-ill mothers. Offspring were evaluated clinically and psychometrically between infancy and 2, 10, 15 years of age, and adulthood. Adult Axis I and II diagnoses were made blind to infant and parent status.

RESULTS

Six hospitalized mothers were diagnosed with schizophrenia, 6 with other severe psychopathology. Offspring with SZSD more likely had schizophrenic mothers, and childhood deteriorating IQs, symptoms of social isolation, constricted affect, digressive speech, suspiciousness, and excessive social anxiety. Global assessment scores in SZSD offspring were lower in childhood and adulthood than comparison offspring.

DISCUSSION

Children with SZSD met currently accepted criteria for schizotypy; 3 by 10 years of age, and 2 by 19 years of age. Differential diagnosis is discussed. An appendix of case histories is presented.

Prospective study of adolescents with subsyndromal psychosis: characteristics and outcome

OBJECTIVE

The aim of this study was to examine the characteristics and outcome of adolescents with psychotic disorder not otherwise specified (PsyNOS) and brief psychotic disorder (BrPsy), two neglected subsyndromal diagnostic entities.

METHODS

As part of an ongoing, naturalistic study investigating adolescents considered to be prodromal for schizophrenia, 29 youngsters (mean age, 16.2 +/- 2.7 years) with PsyNOS or BrPsy were identified as theoretically at highest risk for schizophrenia and followed for over 6 (mean, 22.8 +/- 19.4) months.

RESULTS

Contrary to our expectations, only 7 of the 26 individuals (27.0%) with follow-up data developed schizophrenia or schizoaffective disorder, and only 2 subjects (7.7%) retained their diagnosis of BrPsy/PsyNOS. The most frequent other diagnoses at follow-up were mood disorders (34.6%), personality disorders (11.5%), and obsessive-compulsive disorder (7.7%). Regarding severity of outcome, 38.5% of the patients progressed to a syndromal psychotic disorder, 23.1% continued to have attenuated positive symptoms, and 38.4% improved to having attenuated negative symptoms only, or no positive or negative symptoms. BrPsy was associated with lower maximum levels of negative symptoms (p = 0.02) and higher likelihood of symptom remission (p = 0.02).

CONCLUSIONS

This study indicates that psychotic symptoms not fulfilling criteria for schizophrenia or a psychotic mood disorder are unreliable predictors of a syndromal psychotic disorder outcome at 2 years. Long-term studies of PsyNOS and BrPsy are needed to clarify where these disorders fall in the developmental course of schizophrenia.

Phenomenology and diagnostic stability of youths with atypical psychotic symptoms

OBJECTIVE

This study aimed to better characterize the phenomenology and diagnostic stability of youths that report atypical psychotic symptoms.

METHOD

In a 2-year longitudinal follow-up study, youths reporting atypical psychotic symptoms (n = 20) were compared with youths with schizophrenia (n = 27) and youths with bipolar disorder with psychotic features (n = 22) on psychotic, dissociative, and general symptomatology, comorbid diagnoses, previous abuse, and overall functioning. Diagnoses were obtained using structured diagnostic interviews (i.e., the Structured Clinical Interview for DSM-IV and the Diagnostic Interview for Children and Adolescents).

RESULTS

None of the subjects reporting atypical psychotic symptoms went on to develop a classic psychotic illness by the year 2 follow-up. These subjects had significantly higher rates of abuse and dissociative symptoms, and were significantly more likely to receive a diagnosis of posttraumatic stress disorder (PTSD) or a depressive disorder than youths with schizophrenia or bipolar disorder.

CONCLUSION

Our findings suggest that youths with atypical, fleeting, or situationally specific hallucinations are more likely to have a mood or anxiety disorder (such as PTSD) than a current or prodromal psychotic illness.

Pfropfschizophrenia in the age of deinstitutionalization: whose problem?

BACKGROUND

The Kraepelinian concept of pfropfschizophrenia refers to the intertwined coexistence of mental retardation and schizophrenia. Patients with this syndrome are relatively treatment resistant and are often harmed by diverging policies and cost cuts within the framework of mental health care services. Thus, a better understanding of this syndrome has important practical implications. The multiple problems that these patients encounter in various educational and health care agencies and what questions need to be asked to better elucidate these patients' needs are assessed.

DATA

Three case reports of adult long-term inpatients fulfilling the criteria for pfropfschizophrenia are presented. Their current mental status and illness histories are discussed in relation to hypothesized pathophysiological processes and current needs.

LIMITATIONS

Small cohort, naturalistic study.

CONCLUSIONS

Pfropfschizophrenia is a phenotypically heterogeneous syndrome. The chronology of the appearance of cognitive deficits and psychotic symptoms during the course of this disorder should be carefully assessed because it may reflect diverse pathophysiological processes, necessitating differentiated, specific treatment interventions.

Phenomenology of childhood psychosis: findings from a large sample of psychiatrically referred youth

Our objective was to evaluate the scope and clinical correlates of psychotic phenomena in psychiatrically referred children and adolescents. Subjects were 1657 psychiatrically referred youth (mean age = 10.9 years) evaluated from 1991 to 2002. DSM-III-R diagnoses were obtained through maternal report by using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version. Childhood-onset psychosis was defined by the presence of delusions or hallucinations. Childhood-onset psychosis was identified in 8% of psychiatrically referred youth. It was associated with a chronic course and high levels of impairment. Comorbidity with disruptive, mood, and anxiety disorders was very severe, with only one of the 132 identified youth with psychosis not having at least one comorbidity. In conclusion, childhood-onset psychosis in referred youth is common and highly morbid. It remains an important topic of research deserving full clinical and scientific attention.

Polymorphisms in the 13q33.2 gene G72/G30 are associated with childhood-onset schizophrenia and psychosis not otherwise specified

BACKGROUND

Childhood-onset schizophrenia (COS), defined as onset of psychotic symptoms by age 12 years, is a rare and severe form of the disorder that seems to be clinically and neurobiologically continuous with the adult disorder.

METHODS

We studied a rare cohort consisting of 98 probands; 71 of these probands received a DSM-defined diagnosis of schizophrenia, and the remaining 27 were diagnosed as psychosis not otherwise specified (NOS) (upon 2-6 year follow-up, 13 have subsequently developed bipolar disorder). Two overlapping genes, G72 and G30 on 13q33.2, were identified through linkage-disequilibrium-based positional cloning. Single nucleotide polymorphisms (SNPs) at the G72/G30 locus were independently associated with both bipolar illness and schizophrenia. We analyzed SNPs at this locus with a family-based transmission disequilibrium test (TDT) and haplotype analyses for the discrete trait, as well as quantitative TDT for intermediate phenotypes, using the 88 probands (including COS and psychosis-NOS) with parental participation.

RESULTS

We observed significant pairwise and haplotype associations between SNPs at the G72/G30 locus and psychotic illness. Furthermore, these markers showed associations with scores on a premorbid phenotype measured by the Autism Screening Questionnaire, and with age of onset.

CONCLUSIONS

These findings, although limited by potential referral bias, confirm and strengthen previous reports that G72/G30 is a susceptibility locus both for schizophrenia and bipolar disorder.