The Triad of Childhood-Onset Schizophrenia, Autism Spectrum Disorder, and Catatonia: A Case Report

Childhood-onset schizophrenia (COS) is a rare and severe form of schizophrenia with an estimated prevalence of 1/10,000. Schizophrenia and Autism spectrum disorder (ASD) have shared phenotypic features and shared genetic etiology. There is growing research surrounding the co-occurrence of psychomotor syndromes like catatonia with neurodevelopmental disorders like ASD or psychiatric disorders like schizophrenia. In 2013, Shorter and Wachtel described a phenomenon of the 'Iron Triangle' where COS, ASD, and catatonia often co-occur. The Iron Triangle theory is based on observation of historical case literature, which showed that all three diagnoses in the Iron Triangle were routinely assigned to children and adolescents. The pattern of this "Iron Triangle" suggests there may be a single underlying pathology resulting in a unique mixed form of catatonia, autism, and psychosis. We describe the case of a boy with sequential development of COS, ASD, and catatonia who also has syndromic facial and musculoskeletal features. This case highlights overlapping diagnostic features of these three disorders and can help us better understand how "hidden" features of catatonia may occur in patients with COS or ASD but go unrecognized, because they are grouped as features under autism/schizophrenia rather than a distinct diagnosis of catatonia. Further study is warranted to elucidate if this phenotypic pattern constitutes a new single diagnosis that is not well understood, an endophenotype of schizophrenia, or if this is the result of phenomenological overlap between catatonia, ASD, and COS.

Childhood-Onset Schizophrenia: Insights from Induced Pluripotent Stem Cells

Childhood-onset schizophrenia (COS) is a rare psychiatric disorder characterized by earlier onset, more severe course, and poorer outcome relative to adult-onset schizophrenia (AOS). Even though, clinical, neuroimaging, and genetic studies support that COS is continuous to AOS. Early neurodevelopmental deviations in COS are thought to be significantly mediated through poorly understood genetic risk factors that may also predispose to long-term outcome. In this review, we discuss findings from induced pluripotent stem cells (iPSCs) that allow the generation of disease-relevant cell types from early brain development. Because iPSCs capture each donor's genotype, case/control studies can uncover molecular and cellular underpinnings of COS. Indeed, recent studies identified alterations in neural progenitor and neuronal cell function, comprising dendrites, synapses, electrical activity, glutamate signaling, and miRNA expression. Interestingly, transcriptional signatures of iPSC-derived cells from patients with COS showed concordance with postmortem brain samples from SCZ, indicating that changes in vitro may recapitulate changes from the diseased brain. Considering this progress, we discuss also current caveats from the field of iPSC-based disease modeling and how to proceed from basic studies to improved diagnosis and treatment of COS.

Reality Testing in Children with Childhood-Onset Schizophrenia and Normal Children: A Comparison using the Ego Impairment Index on the Rorschach

OBJECTIVE

The aim of this study was to examine reality testing in schizophrenic children and compare it with normal children using minus responses subcomponent in ego impairment index of the Rorschach test.

METHODS

In a descriptive design, 20 accidentally sampled children, including 10 schizophrenic and 10 normal children, were recruited in to two groups and were compared in terms of reality testing subcomponent of Ego Impairment Index (EII). After initial interview, the Rorschach inkblot test was administered on the two groups, and Distorted Quality responses (FQ-) were calculated. The results were then analyzed by independent t-test and Cohen's d for effect size.

RESULTS

The result of independent t-test revealed that the mean of minus responses in schizophrenic children was significantly higher than that of normal children. In addition, the usefulness of the Rorschach ego impairment index (EII) in evaluating reality testing in schizophrenic children was confirmed. In addition, it was found that defect in reality testing is one of the prominent characteristics of schizophrenic children.

CONCLUSION

The higher minus responses in schizophrenic children indicate that schizophrenic children have weaker functioning in reality testing compared with normal children.