Difference between revisions of "Schizophrenia"

Revision as of 18:39, 27 July 2012

Introduction

In preschoolers, psychosis (particularly hallucinations) are most likely caused by stress or anxiety; these are transient and benign. In school age children psychotic symptoms may be more persistent, and are more likely to be associated with drug toxicity or significant mental illness (Lewis, p. 494)

Although rare in children, early-onset schizophrenia is a frequently tested item on the PRITE and boards.

Childhood-onset Schizophrenia

Most often COS is persistent, non-episodic illness with poor prognosis. DSM-IV criteria can be applied to children and adolescents. It's important to rule out affective disorders, substance-induced psychosis as well as autism and PDD.

• Patients whose disease is of acute onset (25%), with productive schizophrenic manifestations such as hallucinations and delusions (positive manifestations), have a better prognosis than those whose disease begins insidiously (75%) and takes an unfavorable course, with depressive states and continually worsening impairment of cognitive function.

• The patient's premorbid personality plays a major role. Patients who were described as socially active, intelligent, and integrated children and adolescents before they became ill have a better prognosis than those who were intellectually impaired, timid, introverted and uncommunicative before they became ill. (1)

• The prognosis seems to be better for patients who have no family history of schizophrenia, those whose families cooperate well, and those whose condition improves rapidly during inpatient treatment.

• The few available studies on the course and outcome of schizophrenia beginning in childhood and early adolescence confirm that they are much worse than in adult-onset schizophrenia.

• A 42-year longitudinal study of patients with childhood-onset schizophrenia revealed their suicide rate to be higher than that of patients with adult-onset schizophrenia.

Treatment

Atypical antipsychotics are the mainstay of treatment, In the only Double-Blind RCT, clozapine showed somewhat better results vs olanzapine (particularly in improving negative symptoms), but also more side effects. In the open-label follow-up most children were switched from olanzapine to clozapine. (2)

Black Belt Info

• For NIMH research purposes a heterogeneous group of children with transient psychotic symptoms and multiple developmental abnormalities had been termed the Multi Dimensionally Impaired (MDI) group. These children are characterized by cognitive deficits, psychotic symptoms in response to stress without a thought disorder, impaired interpersonal skills, ADHD symptoms, and emotional dysregulation.
• For children on clozapine who develop neutropenia, lithium can be added for clozapine rechallenge [2cases:(4)]

Other Pearls

• Anxiety/stress is the most common cause of hallucinations in preschool children.

• Visual hallucinations are common in COS, and are associated with greater clinical impairment and greater compromise in overall brain functioning. (3)
• On imaging COS children show progressive loss of gray matter, delayed/disrupted white matter growth, and a progressive decline in cerebellar volume, some of which are shared by their healthy siblings

References

1. Neuropsychobiology 2012;66(1):63-9 "Early-onset schizophrenia"

2. Shaw P et.al Childhood-onset schizophrenia: A double-blind, randomized clozapine-olanzapine comparison. Arch Gen Psychiatry. 2006 Jul;63(7):721-30.

3. David Cn et. al. Childhood onset schizophrenia: high rate of visual hallucinations.J Am Acad Child Adolesc Psychiatry. 2011 Jul;50(7):681-686.e3. Epub 2011 Jun 11.

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