Hearing Voices and Seeing Things: Symptoms of Anxiety Misconstrued as Evidence of Schizophrenia in an Adolescent

Adolescent Psychotic Experiences and Adverse Mental Health Outcomes in Adulthood in a General Population Sample

Purpose

This study estimated risk of incident mental disorders in adulthood associated with both transient and persistent adolescent psychotic experiences (PEs).

Methods

A nested case-control design was used within the Avon Longitudinal Study of Parents and Children (ALSPAC), a birth cohort study which recruited expectant mothers from 1991-1992. Participants consisted of 8822 offspring of ALSPAC mothers who completed the Psychosis-like Symptoms Interview Questionnaire (PLIKSi-Q). PEs were assessed using the PLIKSi-Q. Depressive disorders were assessed using the Short Mood and Feelings Questionnaire (SMFQ), anxiety disorders using the General Anxiety Disorder Assessment and the Clinical Interview Schedule-Revised, and psychotic disorder using the PLIKSi. Risk of incident depressive disorder, GAD, psychotic disorder, and past-year suicide attempts were compared amongst participants who had ever versus never reported a PE and those who reported persistent versus transient PEs.

Results

Adolescent PEs were associated with increased risk for incident depressive disorder (adjusted hazard ratio (aHR) = 1.62, 95% CI = 1.42, 1.84), GAD (aHR 1.23, 95% CI = 1.03, 1.47), psychotic disorder (adjusted odds ratio (aOR) = 5.08, 95% CI = 2.02, 12.79), and past-year suicide attempts (aHR = 2.56, 95% CI = 1.97, 3.25). Persistent PEs were associated with increased risk for depressive disorder (aHR = 1.81, 95% CI = 1.55, 2.12), generalized anxiety disorder (aHR = 1.34, 95% CI = 1.07, 1.68), and psychotic disorder (aOR = 7.39, 95% CI = 2.43, 22.19) but not past-year suicide attempts.

Conclusion

Adolescent PEs are a risk factor for multiple mental disorders and suicide attempts, with persistent PEs conferring greater risk. Identifying interventions for adolescents who report PEs, particularly persistent PEs, could lessen the burden of multiple mental health disorders and suicide attempts.

Commentary: Diagnostic Challenges in Evaluating Adolescents

Three cases presented in this issue highlight diagnostic challenges in evaluating adolescents, in particular those with a constellation of symptoms that includes hallucinations. These cases raise the question of the accuracy of patient reports and the importance of further exploring symptoms before rushing to a diagnosis or treatment. The first case involved an 18-year-old female patient with Cotard syndrome. She had the syndrome's typical delusions and hallucinations, but her case was unusual because this syndrome is more common in adults and usually involves prominent mood symptoms. The second case involved a 14-year-old girl with depressive symptoms, suicidal ideas, and auditory and visual hallucinations, as well as sexually predatory behavior. This case was unusual in that girls and women are less commonly sexual predators although such behavior is more common among survivors of sexual abuse, as was the case with this patient. The authors believe that the patient's "hallucinations" were more likely related to posttraumatic stress disorder and dissociation. The third case involved a 16-year-old girl diagnosed with schizophrenia and treated with antipsychotics based merely on her report of "visions" of demons but absent any auditory hallucinations, delusions, or thought disorder. The authors, consulting on the case, identified more prominent depression, anxiety, and trauma-related symptoms as a result of school bullying and concluded that the patient did not have schizophrenia. Only the patient in the first of these 3 cases actually met the criteria for a psychotic disorder and warranted medication treatment. These cases highlight the importance of a full differential diagnosis in evaluating adolescent patients presenting with what appear to be psychotic symptoms to avoid the harm that can occur in terms of stigma and unnecessary treatment with the risk of side effects from antipsychotic medications when an incorrect diagnosis is made.