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Children and Depression

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Child Mind Institute | Transforming Children’s Lives.

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The Child Mind Institute is an independent nonprofit dedicated to transforming the lives of children struggling with mental health and learning disorders.

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Links updated, November 2021
This information in Spanish

The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years. ( 1)

We refer to mental disorders using different "umbrella" terms such as emotional disturbance, behavioral disorders, or mental illness. Beneath these umbrella terms, there is actually a wide range of specific conditions that differ from one another in their characteristics and treatment. These include (but are not limited to):

anxiety disorders;

bipolar disorder (sometimes called manic-depression);

conduct disorders;

eating disorders;

obsessive-compulsive disorder (OCD); and

psychotic disorders.

You may be reading this fact sheet with one of these specific disorders in mind, or you may be looking for information about emotional disturbances in general. In either case, keep reading to find out what different emotional distubances have in common, how they are defined in federal law, and where to find more detailed information on specific disorders.
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Definition
IDEA defines emotional disturbance as follows:
We've chosen to use the term "emotional disturbance" in this fact sheet because that is the term used in the nation's special education law, the Individuals with Disabilities Education Act (IDEA).

"...a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance:

(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.

(B) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.

(C) Inappropriate types of behavior or feelings under normal circumstances.

(D) A general pervasive mood of unhappiness or depression.

(E) A tendency to develop physical symptoms or fears associated with personal or school problems." ( 2)

As defined by IDEA, emotional disturbance includes schizophrenia but does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance. ( 3)

Characteristics

As is evident in IDEA's definition, emotional disturbances can affect an individual in areas beyond the emotional. Depending on the specific mental disorder involved, a person's physical, social, or cognitive skills may also be affected. The National Alliance on Mental Illness of Southern Arizona puts this very well:

Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. ( 4)

Some of the characteristics and behaviors seen in children who have an emotional disturbance include:

Hyperactivity (short attention span, impulsiveness);

Aggression or self-injurious behavior (acting out, fighting);

Withdrawal (not interacting socially with others, excessive fear or anxiety);

Immaturity (inappropriate crying, temper tantrums, poor coping skills); and

Learning difficulties (academically performing below grade level).

Children with the most serious emotional disturbances may exhibit distorted thinking, excessive anxiety, bizarre motor acts, and abnormal mood swings.

Many children who do not have emotional disturbance may display some of these same behaviors at various times during their development. However, when children have an emotional disturbance, these behaviors continue over long periods of time. Their behavior signals that they are not coping with their environment or peers.

Causes

No one knows the actual cause or causes of emotional disturbance, although several factors-heredity, brain disorder, diet, stress, and family functioning-have been suggested and vigorously researched. A great deal of research goes on every day, but to date, researchers have not found that any of these factors are the direct cause of behavioral or emotional problems.

According to NAMI, mental illnesses can affect persons of any age, race, religion, or income. Further:

Mental illnesses are not the result of personal weakness, lack of character, or poor upbringing. Mental illnesses are treatable. Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan. ( 5)

Frequency

Of the 74.5 million children in the United States, an estimated 17.1 million have or have had a psychiatric disorder. ( 6) Half of all psychiatric illness occurs before the age of 14, and 75% by the age of 24. The most common psychiatric disorders in childhood are anxiety disorders, AD/HD and disruptive behavior, depression and bipolar disorders, and eating disorders. ( 7)

Help for School-Aged Children

IDEA requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child's individual needs associated with the disability-in this case, emotional disturbance, as defined by IDEA (and further specified by states). In the 2016 school year, more than 349,000 children and youth with emotional disturbance received these services to address their individual needs related to emotional disturbance. ( 8)

Determining a child's eligibility for special education and related services begins with a full and individual evaluation of the child. Under IDEA, this evaluation is provided free of charge in public schools.
10 Basic Steps in Special Education Questions Often Asked by Parents about Special Education Services Evaluating Children for Disability Developing Your Child's IEP
There is a lot to know about the special education process, much of which you can learn here on the CPIR site. We invite you to read the wide range of publications we offer on the topic, especially:

A Look at Specific Emotional Disturbances

As we mentioned, emotional disturbance is a commonly used umbrella term for a number of different mental disorders. Let's take a brief look at some of the most common of these.

We all experience anxiety from time to time, but for many people, including children, anxiety can be excessive, persistent, seemingly uncontrollable, and overwhelming. An irrational fear of everyday situations may be involved. This high level of anxiety is a definite warning sign that a person may have an anxiety disorder.

The term "anxiety disorder" is a broad term covering several different disabilities that share the core symptom of irrational fear. These include such different disorders as generalized anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder (also called social phobia), and specific phobias. ( 9)

According to the Anxiety Disorders Association of America, anxiety disorders are the most common psychiatric illnesses affecting children and adults. ( 10) They are also highly treatable. Unfortunately, only about 36.9% of those affected receive treatment. ( 11)

Also known as manic-depressive illness, bipolar disorder is a serious medical condition that causes dramatic mood swings from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. ( 12)

For most people with bipolar disorder, these mood swings and related symptoms can be stabilized over time using an approach that combines medication and psychosocial treatment. ( 13)

Conduct Disorder

Conduct disorder refers to a group of behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. ( 14) This may include some of the following behaviors:

aggression to people and animals;

destruction of property;

deceitfulness, lying, or stealing; or

truancy or other serious violations of rules. (15)

Treatment will depend on the child's symptoms, age, and general health. It will also depend on how severe the condition is. Treatment may include:

helping the child learn how to better solve problems, communicate, and handle stress, as well as how to control impulses and anger (what's known as cognitive-behavioral therapy);

family therapy;

peer group therapy (to help better social and interpersonal skills); and

medications (although these are not typically used to treat conduct disorder). (16)

Eating disorders are characterized by extremes in eating behavior-either too much or too little-or feelings of extreme distress or concern about body weight or shape. Females are much more likely than males to develop an eating disorder. ( 17)

Anorexia nervosa and bulimia nervosa are the two most common types of eating disorders. Anorexia nervosa is characterized by self-starvation and dramatic loss of weight. Bulimia nervosa involves a cycle of binge eating, then self-induced vomiting or purging. Both of these disorders are potentially life-threatening. ( 18)

Binge eating is also considered an eating disorder. It's characterized by eating excessive amounts of food, while feeling unable to control how much or what is eaten. Unlike with bulimia, people who binge eat usually do not purge afterward by vomiting or using laxatives. ( 19)

According to the National Eating Disorders Association:

Treating an eating disorder generally involves a combination of psychological and nutritional counseling, along with medical and psychiatric monitoring. Treatment must address the eating disorder symptoms and medical consequences, as well as psychological, biological, interpersonal, and cultural forces that contribute to or maintain the eating disorder... Many people utilize a treatment team to treat the multi-faceted aspects of an eating disorder. ( 20)

Obsessive-Compulsive Disorder

Often referred to as OCD, obsessive-compulsive disorder is actually considered an anxiety disorder (which was discussed earlier in this fact sheet). OCD is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors (handwashing, counting, checking, or cleaning) are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called "rituals," however, provides only temporary relief, and not performing them markedly increases anxiety. ( 21)

A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain. ( 22) Treatment for most people with OCD should include one or more of the following:

therapist trained in behavior therapy;

Cognitive Behavior Therapy (CBT);

medication (usually an antidepressant). (23)

"Psychotic disorders" is another umbrella term used to refer to severe mental disorders that cause abnormal thinking and perceptions. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. Schizophrenia is one type of psychotic disorder. ( 24) There are others as well.

Treatment for psychotic disorders will differ from person to person, depending on the specific disorder involved. Most are treated with a combination of medications and psychotherapy (a type of counseling). ( 25)

More about School

As mentioned, emotional disturbance is one of the categories of disability specified in IDEA. This means that a child with an emotional disturbance may be eligible for special education and related services in public school. These services can be of tremendous help to students who have an emotional disturbance.

Typically, educational programs for children with an emotional disturbance need to include attention to providing emotional and behavioral support as well as helping them to master academics, develop social skills, and increase self-awareness, self-control, and self-esteem. A large body of research exists regarding methods of providing students with positive behavioral support (PBS) in the school environment, so that problem behaviors are minimized and positive, appropriate behaviors are fostered. (See the resource section at the end of this fact sheet for more information on PBS.) It is also important to know that, within the school setting:

For a child whose behavior impedes learning (including the learning of others), the team developing the child's Individualized Education Program (IEP) needs to consider, if appropriate, strategies to address that behavior, including positive behavioral interventions, strategies, and supports.

Students eligible for special education services under the category of emotional disturbance may have IEPs that include psychological or counseling services. These are important related services available under IDEA and are to be provided by a qualified social worker, psychologist, guidance counselor, or other qualified personnel.

Recognizing and Addressing the Impact of COVID-19 | As young people return to in-person schooling in the 2021-2022 school year, they may bring with them the impact of the pandemic's trauma. This makes it essential that schools consider the possibility that many students will need to be re-evaluated to determine if they need additional services, especially behavioral support and mental health services, than they needed prior to COVID-19. Two resources of great relevance to reopening schools and returning students are the following:

Other Considerations

Children and adolescents with an emotional disturbance should receive services based on their individual needs, and everyone involved in their education or care needs to be well-informed about the care that they are receiving. It's important to coordinate services between home, school, and community, keeping the communication channels open between all parties involved.

The Importance of Support

Families often need help in understanding their child's disability and how to address the needs that arise from the disability. Help is available from psychiatrists, psychologists, and other mental health professionals that work in the public or private sector. There is also a network of mental health support operating in every state as well as locally.

To locate systems of support in your community or state, visit the organizations we've listed below. They can connect you with local resources, including support groups that provide connection and understanding, information, referral, and advocacy for those living with emotional disturbance.

There are also support groups available from organizations that address specific mental disorders under the umbrella term of emotional disturbance. See the resources at the end of this fact sheet to identify some of these groups.

Resources of More Information

AACAP | American Academy of Child and Adolescent Psychiatry | AACAP offers Facts for Families, a series in English, Spanish, and several other languages that includes many briefs on specific mental disorders, including the ones mentioned in this publication.

AACAP also operates different Resource Centers, which offer consumer-friendly definitions, answers to frequently asked questions, clinical resources, expert videos, Facts for Families, and much more. Visit the Resource Center home page if you are concerned with one of the following:

Anxiety Disorders

Autism

Bipolar Disorder

Conduct Disorder

Depression

Oppositional Defiant Disorder

NIMH | National Institute of Mental Health | NIMH is clearly a source of authoritative information on specific mental disorders. Phone: 1.866.615.6464. TTY: 1.866.415.8051

NAMI | National Alliance on Mental Illness | NAMI is an excellent source of information and connection on mental illness, including the individual disorders mentioned in this fact sheet. NAMI's website and toll-free helpline are available in English and Spanish.

SAMHSA is the Substance Abuse & Mental Health Services Administration. It offers many resources to consumers, including:.

Detailed information on specific emotional disturbances, or related issues such as positive behavior supports, is also available from these sources:

Anxiety Disorders Association of America | https://adaa.org/

Center on Positive Behavioral Interventions and Supports | The PBIS Center provides research-based information on how to provide behavioral supports to children who need them. | https://www.pbis.org

Conduct Disorders | A soft place to land for battle-weary parents
https://www.conductdisorders.com/community/

Encyclopedia of Mental Disorders | http://www.minddisorders.com/index.html

National Eating Disorders Association
1.800.931.2237 | www.nationaleatingdisorders.org

Something Fishy | (eating disorders)
https://www.something-fishy.org

**Highly Rated Resource! This resource was reviewed by 3-member panels of Parent Center staff working independently from one another to rate the quality, relevance, and usefulness of CPIR resources. This resource was found to be of "High Quality, High Relevance, High Usefulness" to Parent Centers.
________________________________________

References

2 | Code of Federal Regulations, Title 34, §300.8(c)(4)(i)

3 | Code of Federal Regulations, Title 34, §300.8(c)(4)(ii)

5 | Ibid.

7 | Ibid.

11 | Ibid.

13 | Ibid.

14 | American Academy of Adolescent and Child Psychiatry. (2013, August). Conduct disorder: Facts for families. Washington, DC: Author. Available online at:
http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Conduct_Disorder_33.aspx

15 | Ibid.

16 | Johns Hopkins Medicine Health Library. (n.d.). Conduct disorder in children. Baltimore, MD: Author. Online at:
https://www.hopkinsmedicine.org/healthlibrary/conditions/mental_health_disorders/conduct_disorder_90,P02560

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Links updated, November 2021 This information in Spanish The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years.

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Resource: The World of Abnormal Psychology

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Teacher resources and professional development across the curriculum

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Empirical Study on Anxiety as moderated by Yoga and Mindfulness course

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Empirical Study on Anxiety as moderated by Yoga and Mindfulness course

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A Randomized Controlled Trial of Mindfullness Versus Yoga - Effects on Depression and Anxiety in College Students

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Empirical Study of Anxiety and other disorders in collegiate students

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Empirical Study of Anxiety and other disorders in collegiate students

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The Prevalence and correlates of depression, anxiety, and stress in a smaple of college students

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Dysfunction Behavior Crse

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Bipolar and Depressive Disorders

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Mood DIsorders and Your Child's Education

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Qualifying Categories

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At a glance

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education services to eligible students.

IDEA covers 13 disability categories.

Not every student who struggles in school qualifies.

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education and related services to eligible students. But not every child who struggles in school qualifies. To be covered, a child's school performance must be "adversely affected" by a disability in one of the 13 categories below.

1. Specific learning disability (SLD)

The "specific learning disability" (SLD) category covers a specific group of learning challenges. These conditions affect a child's ability to read, write, listen, speak, reason, or do math. Here are some examples of what could fall into this category:

SLD is the most common category under IDEA. In the 2018-19 school year, around 33 percent of students who qualified did so under this category.

2. Other health impairment

The "other health impairment" category covers conditions that limit a child's strength, energy, or alertness. One example is ADHD, which impacts attention and executive function.

3. Autism spectrum disorder (ASD)

ASD is a developmental disability. It involves a wide range of symptoms, but it mainly affects a child's social and communication skills. It can also impact behavior.

Various mental health issues can fall under the "emotional disturbance" category. They may include anxiety disorder, schizophrenia, bipolar disorder, obsessive-compulsive disorder, and depression. (Some of these may also be covered under "other health impairment.")

5. Speech or language impairment

This category covers difficulties with speech or language. A common example is stuttering. Other examples are trouble pronouncing words or making sounds with the voice. It also covers language problems that make it hard for kids to understand words or express themselves.

6. Visual impairment, including blindness

A child who has eyesight problems is considered to have a visual impairment. This category includes both partial sight and blindness. If eyewear can correct a vision problem, then it doesn't qualify.

Kids with a diagnosis of deafness fall under this category. These are kids who can't hear most or all sounds, even with a hearing aid.

The term "hearing impairment" refers to a hearing loss not covered by the definition of deafness. This type of loss can change over time. Being hard of hearing is not the same thing as having trouble with auditory or language processing.

Kids with a diagnosis of deaf-blindness have both severe hearing and vision loss. Their communication and other needs are so unique that programs for just the deaf or blind can't meet them.

10. Orthopedic impairment

An orthopedic impairment is when kids lack function or ability in their bodies. An example is cerebral palsy.

11. Intellectual disability

Kids with this type of disability have below-average intellectual ability. They may also have poor communication, self-care, and social skills. Down syndrome is one example of a condition that involves an intellectual disability.

12. Traumatic brain injury

This is a brain injury caused by an accident or some kind of physical force.

13. Multiple disabilities

A child with multiple disabilities has more than one condition covered by IDEA. Having multiple issues creates educational needs that can't be met in a program designed for any one disability.

Having a disability is not enough to qualify for special education. The disability has to have an "adverse effect" on a child's education.

Key takeaways

Each of the 13 disability categories in IDEA can cover a range of difficulties.

Dyslexia, dyscalculia, and written expression disorder fall under the "specific learning disability" category.

"Other health impairment" can cover ADHD.

About the author

About the author

Andrew M.I. Lee, JD is an editor and attorney who strives to help people understand complex legal, education, and parenting issues.

Reviewed by

Reviewed by

Rayma Griffin, MA, MEd has spent 40 years working with children with learning and thinking differences in the classroom and as an administrator.

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See a list of the 13 IDEA disability categories. Find out which disabilities can qualify kids for special education.

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What are the differences?

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Both Individualized Education Programs (IEPs) and 504 plans can offer formal help for K-12 students who are struggling in school. They're similar in some ways but very different in others. This chart compares them side by side to help you understand the differences.

A blueprint or plan for a child's special education experience at school.

A blueprint or plan for how the school will provide support and remove barriers for a student with a disability.

To get an IEP, there are two requirements: A child has one or more of the 13 disabilities listed in IDEA. The law lists specific challenges, like learning disabilities, ADHD, autism, and others. And the disability must affect the child's educational performance and/or ability to learn and benefit from the general education curriculum. The child must need specialized instruction to make progress in school.

To get a 504 plan, there are two requirements: A child has any disability. Section 504 covers a wide range of different struggles in school. And the disability must interfere with the child's ability to learn in a general education classroom. Section 504 has a broader definition of a disability than IDEA. (It says a disability must substantially limit one or more basic life activities. This can include learning, reading, communicating, and thinking.) That's why a child who doesn't qualify for an IEP might still be able to get a 504 plan.

There are strict legal requirements about who participates. With a few exceptions, the entire IEP team must be present for IEP meetings. The team must include:

The rules about who's on the 504 team are less specific than they are for an IEP. A 504 plan is created by a team of people who are familiar with the child and who understand the evaluation data and special services options. This might include:

* The child's parent or caregiver

* General and special education teachers

* The school principal

* The child's parent or caregiver

* At least one of the child's general education teachers

* At least one special education teacher

* A school psychologist or other specialist who can interpret evaluation results

* A district representative with authority over special education services

The IEP sets learning goals and describes the services the school will provide. It's a written document. Here are some of the most important things the IEP must include:

There is no standard 504 plan. Unlike an IEP, a 504 plan doesn't have to be a written document. A 504 plan generally includes the following:

* Specific accommodations, supports, or services for the child

* Names of who will provide each service

* Name of the person responsible for ensuring the plan is implemented

* The child's present levels of academic and functional performance - how the child is currently doing in school

* Annual education goals for the child and how the school will track progress

* The services the child will get - this may include special education, related, supplementary, and extended school year services

* The timing of services - when they start, how often they occur, and how long they last

* Any accommodations - changes to the child's learning environment

* Any modifications - changes to what the child is expected to learn or know

* How the child will participate in standardized tests

* How the child will be included in general education classes and school activities

When the school wants to change a child's services or placement, it has to tell families in writing before the change. This is called prior written notice. Notice is also required for any IEP meetings and evaluations. Families also have "stay put" rights to keep services in place while there's a disagreement about the IEP.

The school must notify families about an evaluation or a "significant change" in placement. Notice doesn't have to be in writing, but most schools do so anyway.

How to resolve disputes

IDEA gives families several ways to resolve disputes (usually in this order):

Section 504 gives families several options for resolving disagreements with the school:

* Mediation

* Alternative dispute resolution

* Impartial hearing

* Complaint to the Office for Civil Rights (OCR)

* Lawsuit

* Mediation

* Due process complaint

* Resolution session

* Civil lawsuit

* State complaint

* Lawsuit

And if you need help navigating special education law in your state, consider reaching out to your local Parent Training and Information Center. The people there can answer questions and give practical advice on issues specific to your area.

Do you want to learn more about how IEPs and 504 plans compare? Watch as an expert explains the differences between them.

About the author

About the author

The Understood Team is made up of passionate writers and editors. Many of them have kids who learn and think differently.

Reviewed by

Reviewed by

Andrew M.I. Lee, JD is an editor and attorney who strives to help people understand complex legal, education, and parenting issues.

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IEP vs. 504 Plan: What's the Difference?

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Individualized Education Programs (IEPs) and 504 plans are similar but different. See how they compare in what they provide and the processes and laws involved.

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Credit: Julius-Maximilians-Universität Würzburg, JMU

An overactive molecular signal pathway in the brain region of the amygdala can lead to obsessive-compulsive disorder (OCD). A research team from Würzburg has established this connection.

Some people have an extreme fear of dirt or bacteria. As a result, they may develop a habit of compulsive washing and repeatedly cleaning their hands or body. They are trapped in a vicious circle, as the fear of new contamination returns quickly after washing. Sufferers see no way out. They are even incapable of changing their behaviour when the excessive washing has led to skin irritation or damage.

Around two percent of the general population suffer from some kind of obsessive-compulsive disorder (OCD) at least once in their life. The disorder is characterised by persistent intrusive thoughts which the sufferers try to compensate for by repetitive ritualized behaviour.

Like depression, eating disorders and other mental diseases, OCD is treated with antidepressants. However, the drugs are non-specific, that is they are not tailored to the respective disease. Therefore, scientists have been looking for new and better targeted therapies that have fewer side effects.
Missing protein triggers urge to wash
Professor Kai Schuh from the Institute of Physiology at the Julius-Maximilians-Universität (JMU) Würzburg (Germany) and his team explore the underlying causes of obsessive-compulsive disorder in collaboration with the JMU's Departments of Psychiatry and Neurology.

"We were able to show in mouse models that the absence of the protein SPRED2 alone can trigger an excessive grooming behaviour," Schuh says. He believes that this finding is crucial as no clear trigger for this type of disorder has been identified until now. Previous research pointed to multiple factors being responsible for developing OCD.

Occurring in all cells of the body, the protein SPRED2 is found in particularly high concentrations in regions of the brain, namely in the basal ganglia and the amygdala. Normally, the protein inhibits an important signal pathway of the cell, the so-called Ras/ERK-MAP kinase cascade. When it is missing, this signal pathway is more active than usual.
Hyperactive signal cascade in the brain
"It is primarily the brain-specific initiator of the signal pathway, the receptor tyrosine kinase TrkB, that is excessively active and causes the overshooting reaction of the downstream components", biologist Dr. Melanie Ullrich explains.

Administering an inhibitor to attenuate the overactive signal cascade in the animal model improves the obsessive-compulsive symptoms. Moreover, the JMU research team was able to treat the OCD with an antidepressant, similarly to standard therapy in humans. Their detailed results have been published in the journal Molecular Psychiatry.
New targets for therapies pinpointed
"Our study delivers a valuable new model that allows the disease mechanisms to be investigated and new therapy options for obsessive-compulsive disorders to be tested," Professor Schuh says.

The recently discovered link between OCDs and the Ras/ERK-MAP kinase cascade also opens up new targets for therapy. Drugs that inhibit this cascade are already available and some of them are approved for human treatment.

According to Melanie Ullrich, these are cancer drugs, as overactivation of the Ras/ERK-MAP kinase cascade is also a frequent trigger of cancer: "So we are wondering whether such drugs could also be effective in the treatment of obsessive-compulsive disorders and whether they are beneficial in terms of side effects."

More information: M Ullrich et al. OCD-like behavior is caused by dysfunction of thalamo-amygdala circuits and upregulated TrkB/ERK-MAPK signaling as a result of SPRED2 deficiency, Molecular Psychiatry (2017). DOI: 10.1038/mp.2016.232

Provided by Julius-Maximilians-Universität Würzburg

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An overactive molecular signal pathway in the brain region of the amygdala can lead to obsessive-compulsive disorder (OCD). A research team from Würzburg has established this connection. Some people have an extreme fear of dirt or bacteria. As a result, they may develop a habit of compulsive washing and repeatedly cleaning their hands or body.

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Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry. These are called obsessions. To alleviate the anxiety caused by their obsessive thoughts, they perform repetitive, ritualized actions called compulsions. A child with OCD might need to line things up, touch things in a certain order when leaving the room or wash his hands repeatedly.

Obsessions Common in Kids With OCD

Contamination: Kids with this obsession are sometimes called "germaphobes." In schools, this plays out with kids worrying about other kids sneezing and coughing, touching things that might be dirty or getting sick in many different ways. This is the most common obsession seen in children.

Magical thinking: This is a kind of superstition, like "step on a crack, break your mother's back," taken to extremes. For example, kids might worry that their thoughts can cause someone to get hurt, or get sick. A child might think, "Unless my things are lined up in a certain way, mom will get in a car accident."

Catastrophizing: Some kids easily jump to the conclusion that something terrible has happened. For example, if her parents are five minutes late picking her up, a girl who is catastrophizing might tell herself that they've decided to abandon her.

Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.

What ifs: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

The "just right feeling": When OCD first develops, from about 6 to 9 years of age, kids may not know why they are doing something, but just that they need to do it until they get what we call the "just right feeling." So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time - in the 9- to 12-year-old range - it evolves into magical thinking and becomes more superstitious in nature.

Behaviors You Might See in Students With OCD

Frequent requests to go to the bathroom: This could be to wash hands, if someone near the child was coughing or sneezing, or if she touched something that she perceives as contaminated. She could be washing items-pens, pencils, backpacks, books. It could also be an excuse to get out the classroom and just be away from everyone, and have some respite.

Constant reassurance-seeking: This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" Checking doors, windows, lockers, desks. Over and over and over again.

Getting stuck on tasks: Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if a child is working out what he did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," he's not going to be able to shift gears.

Retracing: If a child leaves the classroom and worries that she left a pencil behind, she'll go back into the classroom and go to her desk and check. If she had a bad thought as she went through the doorway, she might have to "fix it" by going back through the doorway again saying a good word. If she had a bad thought when she went down a flight of stairs on the way to class, she might need to go back up that same stairway at the end of the period, even if it means being late to her next class.

Obsessive erasing: A child could be erasing a lot because the letters have to look perfect. Or he could have used a word that disturbs him. For example, if he has a fear of vomiting and he's written the word vomit, he might not be able to stand seeing that word, so he erases it. Kids start having erasers worn down to the metal. Teachers start to see holes in the paper. Words will be drawn over on the back of the page. A lot of different areas of writing become problematic.

Behaviors Often Confused With Another Disorder

Some behaviors associated with OCD are easy to confuse with ADHD, learning problems or being oppositional.

Distraction: If a child is busy thinking that if she doesn't turn the pen cap and count to four the right way then her mom is going to get sick, she's not going to be paying attention in class. And if her teacher calls on her to answer a question, her distraction might look like ADHD, but it isn't.

Slowness on exams, papers and tasks: Sometimes when kids take a long time, they're struggling with the perfectionism of needing to do things the right way. This could look like learning problems, or inattention, but it isn't.

Avoidance: Teachers might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. He may avoid a lot of playground activities - kids with germ fears will view the playground the way some adults view the subway: it's gross. Why touch anything there?

Tapping and touching symmetrically: If a child sits down at her desk and she accidentally kicks the chair of the kid next to her with her right foot, she's going to have to then kick it with her left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but actually it's OCD.

Complaints of anxiety and fatigue: There's one interesting theory that kids with OCD are smarter than other kids. And if you consider how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

How to Help Students With OCD

For children struggling with OCD, functioning in school can be complicated and very difficult. Here are some things you can do to help them, and the class as a whole, focus on learning:

Seating arrangement: If the school has noisy hallways, you might not want to have a child with OCD sit by the door. You might have her sit in the front, where she's less able to hear the noise and can stay more focused on her work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see her fidgeting with her hands, rocking or getting up a lot, might be better off closer to the door, toward the back of the room.

Extended time for tests and papers: If writing is a problem for a child who needs to find the perfect way to say something, he's going to need more time to finish those essay questions or papers.

Laptops for writing: If writing and rewriting/erasing is really problematic for a child, consider letting her use a laptop for taking notes, and having all assignments be typed instead of handwritten.

Private testing rooms: Research is quite clear that kids with OCD do better, are less overwhelmed and are more in control of their thoughts and their reactions if they're in a quiet place away from the other kids.

Skip reading out loud: Kids who feel they need to read perfectly may have to go back and reread sentences or whole paragraphs over and over to make sure they've got them right. So reading becomes a very laborious task, and reading in front of the class can become a nightmare. So if we know doing this is a problem for children, we can spare them.

Books on tape: If kids get so hung up reading that it takes forever, listening to the books can be a solution.

Break homework into chunks: If looking at a whole page of math makes kids feel overwhelmed and anxious - think of the potential for mistakes! - the problems can be broken up over four pages. It helps kids stay focused on doing the problems instead of worrying.

How to Minimize Behavioral Problems

Plan an escape route: Try working out a communication system so that if the student feels symptoms coming on, she can signal to you and leave the classroom, or go to a protected place in the classroom, without interrupting the class. It can prevent an embarrassing and disruptive blowup of symptoms in the classroom, and the other kids picking on or bullying her about it.

Be aware of triggering events: It's very important for teachers to know what kind of things might trigger the symptoms. Fatigue is a huge piece of OCD, and it can be exacerbated by medication. So it's important to know that if a child is drowsy in class, and maybe he's putting his head down, it's not because he's being oppositional or disrespectful, but because he's overwhelmed with fatigue.

Advance notice: Irritability and frustration are two of the longer-lasting things that kids with OCD are feeling on a daily basis. Changes in schedule can be very disruptive for a child with OCD, so it can be helpful for teachers to give advance notice of things. Kids who know what to expect are less likely to be thrown by the change.

Children with OCD are often teased and bullied because of their symptoms. Kids feel very uncomfortable about their rituals, knowing that they're being watched. It can be helpful to educate the whole class about what's going on, especially if a child is going to be in the same school for a number of years, and it can inspire a surprising amount of support from other children.

Peer understanding program: A peer understanding program includes a presentation in the classroom that explains (with the child participating) what OCD is. The child might say, "Listen, I have OCD. It's an anxiety disorder. It makes me think that my hands are dirty and I have to wash my hands a lot, so if you see me getting up and going to the sink to wash my hands, that's why." Psychologists can role-play with the teacher and child ahead of time, to anticipate questions his classmates might ask, and how to answer them.

A buddy system: A buddy is like a peer coach who sits next to the child and prompts him to keep up with note taking and staying on task. It can be great for the buddy, to foster a sense of confidence and pride and to be able to help someone in need, and great for fostering friendship.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry.

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Centers for Disease Control and Prevention

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Many children occasionally have thoughts that bother them, and they might feel like they have to do something about those thoughts, even if their actions don't actually make sense. For example, they might worry about having bad luck if they don't wear a favorite piece of clothing. For some children, the thoughts and the urges to perform certain actions persist, even if they try to ignore them or make them go away. Children may have an obsessive-compulsive disorder (OCD) when unwanted thoughts, and the behaviors they feel they must do because of the thoughts, happen frequently, take up a lot of time (more than an hour a day), interfere with their activities, or make them very upset. The thoughts are called obsessions. The behaviors are called compulsions.

Symptoms

Having OCD means having obsessions, compulsions, or both.

Examples of obsessive or compulsive behaviors include:

Having unwanted thoughts, impulses, or images that occur over and over and which cause anxiety or distress.

Having to think about or say something over and over (for example, counting, or repeating words over and over silently or out loud)

Having to do something over and over (for example, handwashing, placing things in a specific order, or checking the same things over and over, like whether a door is locked)

Having to do something over and over according to certain rules that must be followed exactly in order to make an obsession go away.

Children do these behaviors because they have the feeling that the behaviors will prevent bad things from happening or will make them feel better. However, the behavior is not typically connected to actual danger of something bad happening, or the behavior is extreme, such as washing hands multiple times per hour.

A common myth is that OCD means being really neat and orderly. Sometimes, OCD behaviors may involve cleaning, but many times someone with OCD is too focused on one thing that must be done over and over, rather than on being organized. Obsessions and compulsions can also change over time.
Learn more about OCD
Treatment for OCD

The first step to treatment is to talk with a healthcare provider to arrange an evaluation. A comprehensive evaluation by a mental health professional will determine if the anxiety or distress involves memories of a traumatic event that actually happened, or if the fears are based on other thoughts or beliefs. The mental health professional should also determine whether someone with OCD has a current or past tic disorder. Anxiety or depression and disruptive behaviors may also occur with OCD.

Treatments can include behavior therapy and medication. Behavior therapy, specifically cognitive-behavioral therapy, helps the child change negative thoughts into more positive, effective ways of thinking, leading to more effective behavior. Behavior therapy for OCD can involve gradually exposing children to their fears in a safe setting; this helps them learn that bad things do not really occur when they don't do the behavior, which eventually decreases their anxiety. Behavior therapy alone can be effective, but some children are treated with a combination of behavior therapy and medication. Families and schools can help children manage stress by being part of the therapy process and learning how to respond supportively without accidentally making obsessions or compulsions more likely to happen again.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

Prevention of OCD

It is not known exactly why some children develop OCD. There is likely to be a biological and neurological component, and some children with OCD also have Tourette syndrome or other tic disorders. There are some studies that suggest that health problems during pregnancy and birth may make OCD more likely, which is one of many important reasons to support the health of women during pregnancy.
Learn about preventing problems during pregnancy

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Obsessive-Compulsive Disorder in Children | CDC

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Many children occasionally have thoughts that bother them, and they might feel like they have to do something about those thoughts, even if their actions don't actually make sense. Learn about Obsessive-Compulsive Disorder (OCD) in children.

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There are fewer more frightening or challenging psychiatric conditions for a family to face than psychosis, an extreme mental state in which impaired thinking and emotions cause a person to lose contact with reality. This could mean hearing or seeing things that aren't there (hallucinations), or believing things that aren't true (delusions).

The illness most often associated with psychosis, schizophrenia, usually doesn't show up until very late adolescence or early adulthood. Recently, however, experts in the field have been working to identify high-risk kids who show symptoms that could serve as early warning signs of psychosis, and several academic centers have been set up to focus on this crucial period when it may be possible to change the trajectory of mental illness.

Not all the kids who are identified with what experts call "prodromal" symptoms will progress, or "convert" to full-blown psychotic illness. But early intervention has been shown to improve outcomes for those who do. And since psychotic symptoms cause disruption across a teenager's life, from school to friendships to family, researchers are hoping quick action can prevent impairment and prolong typical functioning.

What's more, some of the approaches that show promise in delaying onset of psychosis or mitigating symptoms include fairly simple lifestyle changes like stress reduction and sleep hygiene, and managing co-occurring disorders like anxiety. The key: identifying at-risk kids earlier when these low-impact measures are still effective.

What are "prodromal" symptoms?

Prodromal symptoms are "attenuated" or weak symptoms of psychosis. Moreover, "they are a warning sign," says Dr. Christoph Correll, the medical director of the Recognition and Prevention Program (RAP) at Zucker Hillside Hospital in Queens, NY, which specializes in diagnosing and treating early symptoms of mental illness in teenagers and young adults. "These signs can happen in people who don't go on to develop psychosis-but if we follow these people who are in the risk state based on these watered-down versions, one third will probably go on to develop psychosis. That's a lot more than in the general population."

Prodromal symptoms occur on a spectrum from very, very mild to severe and can include:

Withdrawing from friends and family/feeling suspicious of others

Changes in sleeping or eating patterns

Less concern with appearance, clothes or hygiene

Difficulty organizing thoughts or speech

Loss of usual interest in activities or of motivation and energy

Development of unusual ideas or behaviors

Unusual perceptions, such as visions or hearing voices (or even seeing shadows)

Feeling like things are unreal

Change in personality

Feelings of grandiosity (belief he has a superpower, etc)

In some cases, these symptoms represent the early stages of a disorder, and will eventually convert. In others, the symptoms actually fade or remain mild. Dr. Tiziano Colibazzi is a psychiatrist at Columbia Presbyterian's COPE clinic (Center for Prevention and Evaluation), which was established to research and treat prodromal symptoms. "We can identify a group of people that are at clinically high risk," says Dr. Colibazzi. "What we can't do is narrow that group down further to identify the 30 percent who will convert."

First step if you feel your child is at risk: An evaluation

The right treatment for prodromal symptoms depends entirely on how severe they are when they are diagnosed. The first step is a proper and complete diagnosis by a mental health professional with experience in assessing psychotic illness.

If you see marked changes in motivation, thinking, and/or behavior in your child, the first place to start is with her pediatrician to rule out a medical illness. Substance use also needs to be ruled out as the cause of any behavior changes in adolescents. After that, you're going to want to have your child evaluated by a qualified psychiatrist or psychologist. This in itself might be a multi-step process.

"You can't just look at the kid once and get a bit of a history and then know what's going on, " says Dr. Correll. "Kids develop; symptoms develop. And the trajectory-how things change, get better or worse, what other symptoms add on to it-will be highly informative in telling us something about the prognosis, what we expect to happen."

One aid to predicting the evolution and severity of symptoms, notes Dr. Colibazzi, is the patient's ability to doubt his symptoms. If your child retains the self-awareness to know that it's his mind that is playing tricks on him, it's an indication that symptoms are still in the very early stages. As symptoms become more severe, the patient's beliefs (whether paranoid, grandiose or hallucinatory) become increasingly difficult to challenge.

Lifestyle and mental health options

Psychotic symptoms and illnesses have been shown to vary quite a bit depending on the environment-the health of our bodies, our interpersonal relationships, our mindsets. As with any illness, but particularly important in at-risk youth, healthy living is key. Regardless of the severity of prodromal symptoms, Dr. Correll says that your child's outcome can be improved by making sure your kid sticks to a routine that includes:

Eating well

Getting regular exercise

Adhering to a regular sleep schedule

Reducing stress as much as possible

Staying away from drugs-particularly marijuana, which can interact with prodromal symptoms and increase the risk for psychosis significantly

Also, don't forget to address depression and anxiety. According to Dr. Correll, "adults who eventually developed schizophrenia identified a three to five year period during which they experienced depression or anxiety before developing the prodromal symptoms of psychosis and then developed full-blown psychosis." "So treating the depression early," he says, "might actually interrupt the progression from depression to psychosis in some patients."

Treatment for prodromal psychotic symptoms

Dr. Correll recommends trying several approaches. Mild symptoms call for more low-key treatments including:

Psycho-education: teaching both the kid and the family more about the symptoms and the illness.

Therapy, particularly cognitive behavioral therapy: "CBT can be good to change one's thinking patterns," says Correll, "and also to address developing self-esteem. We have to be careful that kids with a psychiatric diagnosis don't self-stigmatize and get into a hopeless or negative mode where they feel they can't achieve."

Lifestyle adjustments: Assessing whether the current school environment is best for the child. Perhaps a therapeutic social group to help the child cope.

Reducing Stress: Stress is often a trigger for symptoms, so reducing stress in these kids' lives is crucial and may prevent or delay conversion to psychotic illness.

Understanding prodromal symptoms and monitoring kids who are at high risk for psychotic illness means that parents can do more for their kids than wait for symptoms to get worse or merely hope for the best. Early monitoring and intervention can give high-risk kids an advantage, which researchers hope will eventually change the odds when it comes to psychotic illness.

"The duration of untreated psychosis does actually seem to affect the course of the illness," Dr. Colibazzi says. The longer the illness goes untreated, the greater the chance that it will cause serious disruption in all areas of the patient's life. "So it is reasonable to think that just following someone very closely and treating them very early, as soon as they develop symptoms, would be helpful."

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Psychosis Symptoms and Signs in Teens | Child Mind Institute

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There are fewer more frightening or challenging psychiatric conditions for a family to face than psychosis, an extreme mental state in which impaired thinking and emotions cause a person to lose contact with reality. This could mean hearing or seeing things that aren't there (hallucinations), or believing things that aren't true (delusions).

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Psychosis is a type of experience that doctors regard as a symptom. Generally psychosis is normally a symptom of some other mental health problems and not a diagnosis in itself. Sometimes psychosis is confused with schizophrenia. The term schizophrenia is normally used for psychotic states that last longer. Many young people at times can feel as if they are 'going mad'. This is generally when they are feeling stressed, confused or upset. Worries like this are rarely a sign of a severe mental illness or psychosis.

Who affected?

Psychoses are quite common and affect people of all ages but are rare before the older teenage years. The risk of becoming psychotic at some point in one's life is estimated as 1 in 100. It happens in all cultures and countries and in all social classes. Men develop psychosis at a slightly younger age than women. There are around 5 to 6 teenagers experiencing psychosis in every 1000 people at any given time.

What types of psychosis are there?

Psychosis can be classified in different ways. They can be understood by the type of difficulties young people experience (hallucinations, delusions), or they can also be classified by when these symptoms occur (onset, acute illness, brief episodes, chronic symptoms). It can also be explained by whether psychotic symptoms occur with other psychological problems (psychotic depression, schizophrenia, organic psychosis). Below is an explanation of the different types of psychosis that young people can experience. According to the symptoms of psychosis, these can be:

'positive symptoms': Called positive because they 'add' new experiences to what a young person might be perceiving, although most of these will not be positive nor pleasant in nature. 'Positive symptoms' are mostly described as delusions and hallucinations:

Delusions are thoughts or beliefs that a young person might have but that are not shared or understood by others and tend to lead to problems for the young person and others. For example, the young person might believe that he is being spied on, or that there might be messages coming out of car number plates, or that the young person might have special powers. Some delusional beliefs can be very frightening. A young person might believe that something or someone is trying to kill them. These ideas are sometimes called paranoid delusions.

Hallucinations A young person might experience hallucinations when they hear, see, taste or smell things that others do not. Most commonly, voices might start talking to the young person or amongst themselves about the young person in a negative way.

'negative symptoms': Called negative because they make it more difficult for the young person to do everyday things or that experiences have been 'taken away' from the young person. Everything becomes an effort. The young person finds it more difficult to organise things, to look after him or herself, to think, to talk, to socialise. The young person stops doing the things he enjoyed doing in the past like interests or hobbies.

Fig 1: Type of psychotic symptoms

An internationally recognised classification system is used in psychiatry to differentiate the various types of psychosis. An acute psychosis lasts only a few days. A schizophreniform psychosis lasts several weeks. Schizophrenia is diagnosed when psychosis persists for several months. Schizoaffective psychosis is a combination of psychosis and major mood swings.

Is it serious?

Most people would be at risk of experiencing some kind of psychotic symptoms if they were forced to stay awake for several days for example, or if they became physically unwell (also known as delirium). Other young people could experience short bouts of psychosis (days) that would end by themselves and do not necessarily happen again. Other young people might experience psychotic symptoms as part of a mental illness that will need the young person to learn to live with the illness for the rest of their lives, such as learning what things can make psychosis better and worse or taking medication or accepting help from others from time to time, including in rare occasions coming into hospital. Psychosis is a serious condition and needs to be assessed and treated as required. If it continues and is untreated it can limit a young person's functioning in the longer term and may pose risks to themselves and others if delusions are acted upon in an unsafe way.

How does psychosis normally start?

Psychosis might appear suddenly, making the young person really frightened or it can also creep in so gradually that only close relatives or friends notice that the young person has been behaving strangely. The first episode of psychosis is normally not expected. The first signs are so vague that it would be difficult to think of psychosis. It is normally looking back in time that things not being right become clearer. The first symptoms of psychosis are called a 'prodrome'. During the first time a young person experience psychosis, the prodromal symptoms might be so vague that neither the young person nor their family seek medical help. In later episodes, it is important to know that this is the time to do just that. Seek medical help as help and treatment at this time can stop an acute 'flare-up' of psychosis. At times, help is not sought at all at this stage and symptoms are let to get worse, in time, becoming so severe and unmanageable that they can no longer be treated at home resulting in hospitalisation.

Could I have psychosis?

While psychosis looks different from person to person, it always causes changes in your abilities and personality. Because it is so different in each person, you may experience some or all of the symptoms below.

hearing voices that other people don't hear

thoughts take a long time to form, come too fast together, or don't form at all

being convinced you are being followed

having trouble remembering things, concentrating and making decisions

acting differently or having a hard time completing basic tasks

not feeling like talking anymore, people saying they can't understand what you are saying

getting confused easily

If you are experiencing any of these symptoms it's important that you talk to your doctor. These symptoms could also be signs of other mental or physical health problems, and your doctor can help figure out what is causing them. Often, people living with psychosis also experience symptoms of anxiety and depression.

How is psychosis diagnosed?

Everyone is unique and the symptoms of psychosis are influenced by the personality of the young person. Making a diagnosis is like trying to solve a difficult puzzle. The pieces of the puzzle are the combinations of symptoms, personality, age, history, triggers, duration of symptoms, etc. The diagnosis describes the type of psychosis a young person might be suffering from. This way, a treatment plan is worked out.

The diagnosis can be made in a community service without the need to be admitted to hospital. However on occasions, the diagnosis is made after admission to hospital. Hospitalisation is at times needed because the symptoms are so serious that constant care is needed. Admission to hospital can have some advantages such as for example, an accurate diagnosis, treatment more easily started and monitored, young person and family being involved in setting up the treatment plan.

It can take a long time for people with psychosis to seek help and start treatment. There are a number of reasons for this. The start of psychosis can be gradual and the symptoms and complaints vague. Some of the symptoms are things that we can all experience at some point (feeling confused, irritable, anxious). At first young people tend to minimise these problems, ignore them or try to cope with them by themselves. Family or carers also feel that what they noticed might just get better by itself. A symptom of psychosis is that the person experiencing it is not able to judge how psychosis is changing them, including their personality and this is an obstacle to do something about it. Another reason as to why it takes at times far too long for young people with psychosis to access help is that there are a lot of prejudices about psychiatry and mental illness. Young people are frightened of being called 'mad' or 'crazy'.

What else could it be?

Psychiatric conditions such as manic-depression, severe depression, personality disorders, severe post-traumatic stress disorder can all present with psychotic symptoms.

Psychosis can also be caused by prescribed drugs or street drugs as well as physical illness such as delirium, infections, metabolic disorders, vitamin deficiencies, epilepsy, etc.

Neurodevelopmental disorders can also look like psychosis eg the thinking aloud, imaginary friends and role playing seen in Intellectual Disabilities or the sometimes unusual or strongly held beliefs in Autism Spectrum Disorders.

It is important to rule out any possible medical cause of psychosis as the treatment and outcome are likely to be very different.

What psychosis is not...

A 'split personality'. When suffering from a psychotic episode, there could be something like a split between the person and the outside -or the real- world, but there is no split within the person or personality. The term 'multiple personality disorder' has nothing to do with psychosis.

The children of someone with psychosis will be 'abnormal'. Although there is some risk of psychosis 'running in families' or 'heritability', the children of people who have suffered from psychosis, would have more chances of not suffering from it (rather than the opposite) and only a slightly higher chance of suffering from psychosis compared to the general population. Children with two parents who suffered psychosis would have a 39% chance of experiencing psychosis in their lifetime. Children with one parent with psychosis would have a 7% chance of developing psychosis. The risk for anyone else is of 1%.

Psychotics are ' dangerous' ... The risk of people suffering from psychosis being a danger to others is minimal, and not significantly higher than the general population. People with psychosis are more likely to withdraw into themselves. The idea of people with psychosis being dangerous is more a product of the media and the cinema rather than being based in reality. It might be based on the fact that people with psychosis can act or behave oddly in a way that others might find difficult to understand and therefore find frightening.

Psychosis is the result of 'bad parenting'. This is not the case. Although parents and immediate family would be a very important part of any recovery plan by offering support and help, psychosis happens regardless of the type of upbringing one experienced. There is growing evidence of the effects of psychological trauma during childhood, as a risk to develop psychosis later in life.

'Pills make you ill'. There is a lot of evidence to state clearly that medication is much more likely to make you better and also to keep you well. Medication and therapy are the main tools in the recovery from psychosis. The number of different antipsychotic medications available nowadays should ensure a good choice of medication with clear benefits in reducing symptoms whilst keeping side effects at bay.

'You will never be able to drive again' ... Again, this is not the case. Any one suffering from an acute episode of psychosis should not be driving and has an obligation to inform the DVLA. It is also important to do so in relation to medication and side effects. Most people, once the acute episode of illness is over, will be able to drive again even whilst taking medication, provided they are free from side effects that might affect their driving ability.

Once you become psychotic, 'you will never get better again'. This is another myth. 9 out of 10 people who suffered from a psychotic illness will recover, provided they receive appropriate treatment. The main risk for this people is actually, stopping medication. Between 70 and 80 percent of patients fall ill again in the first two years after recovery for this reason.

What causes it?

Psychosis can be a symptom of other different mental health problems (severe depression, schizophrenia, bipolar disorder, schizoaffective disorder, paranoid or schizotypal personality disorder, postpartum, delusional disorder). But psychosis can also happen on its own. Things that make psychotic symptoms more like to happen are:

Physical illness or injury: Head injury, high fever or poisoning eg mercury or lead can lead to hearing or seeing things.

Drugs: Hearing or seeing unusual things that others cannot is at times a result of using street or prescribed drugs or at times of coming off medication.

Lack of sleep

Hunger: When severe and as a result of having low blood sugar.

Bereavement: When recent, the person can hear the deceased talking or have a feeling that they are present.

Trauma or abuse

Spiritual experiences

Family inheritance: When a close relative has suffered from psychosis.

How is it treated?

Roads to recovery

For many young people, with the right treatment, it is possible to manage the symptoms of psychosis and recover. At times, some psychotic symptoms will not go away completely during or after treatment. There are ways to help young people learn how to cope with these experiences so they become less distressing and do not interfere with life.

In the treatment of psychosis there is no easy route to recovery. None of the treatments available work every time but there are many more chances of making a full recovery if a number of treatments or interventions are followed.

There are different treatment options for young people who suffer from psychosis. A mental health professional, would be able to discuss all options available and help choose the right treatment plan for the young person. An advocate might help accessing the treatment that might be needed at the time.

The main treatments available to treat psychosis at present are medication, Cognitive Behavioural Therapy (CBT) -talking therapies- and Family Therapy.

There are other interventions that could be of help in addition to the above including, psychoeducation, relapse prevention, adherence therapy, art therapy, smoke cessation, early intervention teams, crisis services, occupational therapy, exercise, relaxation, admission to day or inpatient hospitals, cognitive remedial therapy, etc.

Medication: Is one of the cornerstones of treatment. Tablets or injections help bringing symptoms under control. They reduce delusions and hallucinations and help young people become aware again of what is real and what is not around them. They help young people regain control of themselves and their lives again. Most young people experiencing psychosis will be offered drugs (anti-psychotic medication). There might be other drugs offered as well to treat depression (antidepressants) or mood stabilisers if the young person experiences major mood swings or drugs to reduce possible side effects from medication such as stiffness or tremor (anticholinergics).

All drugs have side-effects and antipsychotics are not an exception to this. The 'older' antipsychotics or also called 'first generation' cause what are called 'extrapyramidal side-effects' such as stiff muscles, tremor, cramps or restlessness. Newer antipsychotic drugs or 'second generation antipsychotics' have far fewer of these side effects. However, they may cause other side effects eg weight gain.

Talking therapies: They help young people understand their experiences and develop coping strategies to cope with them.

Cognitive Behavioural Therapy for psychosis (CBTp), focusses on reducing the distress caused by positive symptoms by challenging them, checking the correctness of how the young people interprets them.

Family therapy helps people with psychosis stay well. The young person is encouraged to talk to their family and explain what sort of support is helpful - and what makes things worse for them. Family therapy improves relationships in the home of the young person affected by psychosis.

Relapse prevention Helps by controlling triggers for psychosis, recognizing early warning signs of psychosis and having a good relapse prevention plan in place.

Cognitive Remediation Therapy: Helps with some of the abilities that can be lost after a severe episode of psychosis.

Fig 2: Treatments for psychosis

What makes it worse?

Getting stressed about things in life, using street drugs or drinking alcohol make psychosis worse. Not looking after oneself and not sleeping enough at night. Getting anxious about exams, friends, relationships, but not asking for help or advice from others. Disagreements with family or neighbours can make psychosis more likely to happen if susceptible, or make it worse if psychosis is already occurring.

What is the normal course of psychosis?

It is difficult to know what the long term effects of suffering from psychosis might be. In many occasions, a definite diagnosis cannot be given straight away.

Most young people diagnosed will recover from their psychotic episode when they receive early help and treatment including medication and therapy. The majority will have a permanent recovery. Unfortunately, treatment is often started late, in these young people, their recovery is not as good. It is important that a psychotic episode is detected as soon as possible. The so called 'early warning signs' are similar -although watered down- versions of the typical previous psychotic symptoms. They can include loss of energy, lack of motivation, depression, anxiety, sleep problems, attention and concentration difficulties, isolation from others and strange thoughts. It is important to do something about signs like these as soon as possible, particularly if they look like the signs that the young person might have experienced previously. It is a very real possibility that symptoms like these will not go away with time and that they will get worse as no help or treatment is sought, making long term consequences worse. The more episodes a young person experiences, the more likely it is for them to become more severe and a full recovery is less likely to happen.

With medication, rest and therapy, things generally improve. In many, the recovery is permanent. For young people who suffer from a prolonged episode of psychosis, one in three improves provided that appropriate treatment is kept. Between 10 and 15 percent of these achieve a full recovery and are free from psychosis 10 years after first diagnosis. Also one in three young people that suffer from a prolonged episode, the illness will be long term with typical ups and downs with improvements followed by symptoms coming back again. For these young people, stopping medication even when they are feeling fully recovered, often leads to a relapse. Seven out of ten will fall ill again if they stop medication.

There are people who do not recover or respond well to treatment. The more relapses they have and the longer the episodes of psychosis last, the worse their condition becomes. These young people need long term and sustained care and treatment. Some young people are at risk of becoming depressed as a result of experiencing psychosis that is difficult to treat. They can become hopeless and consider suicide. Although this is rare, it is important to be aware of it, particularly as a relative or a carer.

Does psychosis run in families?

Psychosis is a condition that can be passed down through genes. Families that already have a member with psychosis, related family members and generations to follow can inherit the condition. This is called genetic predisposition. As mentioned before, children of people who have suffered from psychosis would have more chances of not suffering from it (rather than the opposite) and only a slightly higher chance of suffering from psychosis compared to everyone else.

When to seek help?

Generally, the earlier help is sought by the young person or their family, a higher chance of the right treatment being given. Help can be sought from your immediate family, close friends, school nurses, gps, child and adolescent mental health services etc.

How can you help yourself?

The following are some of the ways you can help yourself if you suffer from psychosis,

Peer support: It works by bringing together people who have had similar experiences to support each other.

Recognise your own triggers: It could be helpful keeping a diary recording mood, diet, sleep, life events, etc. This can help understanding what triggers psychosis, what makes it worse, think about what has helped in the past, recognise warning signs that tell when the young person is becoming unwell.

Learn to relax: Learning some relaxation techniques can help when feeling busy, anxious or stressed.

Self-care: Having a good sleep gives energy to cope with difficult feelings and experiences. Having a good and regular diet helps with mood and energy. Taking some exercise is helpful for mental wellbeing and being occupied and active (gardening, cooking, making things) helps to feel connected and valuable.

Create a crisis plan: Especially when you are well as right in the middle of a crisis is not the best time to do this.

Avoiding the use of street or illicit substances: As it is clear that these can make psychotic symptoms more severe and intense.

How can others help?

Family and friends can also help spot when a young person with psychosis might be becoming unwell. There are other ways others can help:

Listen and try to understand: It is important for young people experiencing psychosis to feel they can talk to someone they can trust. They need to feel they can do this in a calm and supportive manner.

Focus on feelings rather than experiences: It's better to help by discussing how the young person might feel about the experiences he is having rather than to engage on discussions about whether the experiences are real or not.

Offer practical help.

Respect their wishes: Young people with psychosis do less well when family are critical or overprotective with them. It is important to respect the young person's wishes as much as possible.

Family therapy: Helps to understand what the young person in going through and what might and might not help them.

Plan for a crisis: When the young person is feeling well, this is the right time to plan for a possible future crisis. Discuss treatment and hospital visits and agree the things you will be able to support them with and the things you will not.

Should I tell others about my psychosis?

This is a difficult decision. It comes up when starting a new relationship, making new friends or going for a job interview. Many young people, who experienced a psychotic episode, try to hide their previous problems for fear of being rejected. It is unfortunately true that psychosis is poorly understood by many people and some can feel frightened or wary. This fear comes up as a negative or distant attitude. This is also called 'stigma'. It is a good idea to learn more about these negative attitudes and be able to protect oneself against them. Frankness and honesty are important, but feeling self-confident and being able to deal with rejection are also very important. Sometimes there may be legal requirements to disclose a diagnosis or psychiatric history eg for certain jobs or to drive a vehicle.

Famous people who had psychosis

John Nash (1928-2015), American mathematician.

William Chester Minor (1834-1920), American surgeon.

David Helfgott (1948), Australian pianist.

Syd Barrett (1946-2006), English musician. (Pink Floyd)

Vaslav Nijinsky (1890-1950), Russian ballet dancer.

Antonin Artaud (1896-1948), French dramatist.

Lionel Aldridge (1941-1998), American football player.

Charles "Buddy" Bolden (1877-1931), American musician.

Eduard Einstein (1910-1965), Son of Albert Einstein, Swiss medical student.

Zelda Fitzgerald (1900-1948), American socialite.

Peter Green (1946), British musician (Fleetwood Mac)

Jack Kerouac (1922-1969), American poet.

Veronica Lake (1922-1973), American actress.

Rufus May (1968), British psychologist.

Vincent van Gogh (1853-1890), Dutch painter.

Brian Wilson (1942), American musician. (Beach Boys)

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Psychosis is a type of experience that doctors regard as a symptom. Generally psychosis is normally a symptom of some other mental health problems and not a diagnosis in itself. Sometimes psychosis is confused with schizophrenia. The term schizophrenia is normally used for psychotic states that last longer.

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Clinical Points

■ Hallucinatory experiences and delusions are more common in our patients than we may realize and occur frequently in the pediatric population. While not a benign occurrence, psychotic symptoms do not necessarily portend the future development of schizophrenia.

■ Psychotic symptoms in children and adolescents can occur in the context of a bevy of psychiatric disorders other than schizophrenia (eg, depression, anxiety, attention-deficit/hyperactivity disorder, posttraumatic states, and autism spectrum disorders) or can be secondary to a wide variety of medical conditions.

■ The onset of psychosis is usually preceded by a period of nonpsychotic symptoms known as prodromal symptoms. In recent years, there has been substantial research in early intervention efforts (eg, with psychotherapy or antipsychotic medicines) focused on the early stages of schizophrenia and on young people with prodromal symptoms. At present, outcome data are insufficient to draw definitive conclusions.

■ The pharmacologic treatment of psychotic symptoms in a pediatric population is similar in many ways to the treatment of infection with antibiotics-the clinician needs to choose the proper medication at a sufficient dose and then await therapeutic results while monitoring for potential side effects.

Over the past decade, psychiatric illnesses and, in particular, psychotic disorders in children and adolescents have been recognized more frequently. This increase in recognition, combined with changing trends in the provision of mental health care, has led primary care physicians and pediatricians to increasingly serve as the principal treaters of psychiatrically ill youth and their families. Primary care providers and behavioral health services (eg, in colocated care, embedded care practices, patient-centered homes, and consultation) form the backbone of contemporary psychosis evaluation and management. It is unclear whether psychotic disorders in younger individuals are actually becoming more prevalent, or whether educational efforts directed at enhanced screening and treatment have improved case detection. Efficacious and safe interventions should be employed to maximize beneficial effects and to minimize medication-related complications, such as weight gain, diabetes, and heart disease.

The question for today's health care providers is not whether psychotic symptoms will be encountered in daily practice, but how to confidently and effectively diagnose and treat the conditions in which they manifest. In order to frame this discussion, several areas of inquiry will be explored: "Have you ever been unsure about whether a young person in your practice was psychotic or simply imaginative? Have you wondered how to evaluate such a patient (eg, with laboratory testing or with neuropsychological testing) and what resources to recommend? Have you been concerned about using antipsychotics in young people? Does the potential for adverse side effects of antipsychotics in the short-term or long-term concern you?" For practitioners faced with these concerns, the following discussion should prove useful.

WHAT IS PSYCHOSIS AND HOW COMMON IS IT IN YOUNG PEOPLE?

Narrowly defined, psychosis denotes the presence of either delusions (false implausible beliefs) or hallucinations (false perceptions involving any sensory modality). Broader definitions of psychosis include manifestations of thought disorders, behavioral disorganization, or catatonia. Family members, particularly parents, are often concerned that children who manifest delusions or hallucinations might have schizophrenia. Fortunately, most forms of psychosis in children and adolescents are not a result of schizophrenia.

Population-based surveys show that the prevalence of psychotic symptoms may be far greater than had been previously considered, with a meta-analysis suggesting a prevalence rate of 5%-8% in the general population (which is nearly 10 times higher than the prevalence of diagnosed psychotic disorders). Prevalence rates of such symptoms may be even higher among young people. In 2000, Poulton and colleagues reported that 14% of 11-year-old children endorsed psychotic symptoms upon interview and showed that these symptoms were associated with a 5-fold to 16-fold increased rate of psychotic illness in early adulthood (depending on the strength of the initial symptoms). Since then, large, population-based studies surveying psychotic symptoms among adolescents have found rates of 9%-14% in interview-based studies, and rates greater than 25% in some studies using self-report questionnaires. ⁻ Positive answers on self-report questionnaires have been validated on clinical interview. This emerging body of research suggests that a sizable minority of young people experience psychotic symptoms.

DOES THE PRESENCE OF PSYCHOTIC SYMPTOMS NECESSARILY PORTEND A DIAGNOSIS OF SCHIZOPHRENIA?

However, rather than being a harbinger of schizophrenia, psychotic symptoms in childhood and adolescence more likely accompany other psychiatric conditions (eg, major depression, bipolar disorder, or dissociative states). lists psychiatric disorders that can be accompanied by psychosis. Differentiating early-onset schizophrenia or childhood-onset schizophrenia from other psychiatric disorders has important treatment implications. For example, a pediatric patient with bipolar disorder often experiences hallucinations and delusions but also has the clinical characteristics of mania, depression, or both. In children with psychological trauma-related hallucinations (typically associated with nightmares and trance-like states), psychotic symptoms may quickly abate with psychotherapeutic and/or social interventions. Compared to traumatized children, children with schizophrenia are more apt to display a formal thought disorder, negative symptomatology (eg, apathy, social isolation), and impulsive aggression. Like children and adolescents with schizophrenia, those with autism spectrum disorders may also have odd beliefs (eg, believing that they are able to communicate with valued inanimate toys). Children with milder forms of autism (eg, Asperger's syndrome) may be misdiagnosed with psychosis due to their idiosyncratic beliefs, social awkwardness, and concrete thought process. Taking a comprehensive clinical history helps to disentangle diagnostic uncertainties.

Table 1

Psychotic symptoms have been associated with, or are secondary to, a wide variety of medical disorders as well. Psychosis may develop in response to central nervous system lesions, as a consequence of medical illness, or after traumatic injury or drug use. Recently, reports have linked a particularly severe form of new-onset psychosis-often associated with insomnia, catatonia, and autonomic instability-to antibodies against the glycine-binding NR ₁ subunits of the anti- N-methyl-d-aspartate (NMDA) receptor. Overall, studies from the adult literature show that about 3% of new-onset presentations of psychosis can be attributed to a medical condition., Therefore, before making a diagnosis of a primary psychotic disorder, secondary causes should be ruled out by a thorough-but not indiscriminate-medical workup.

WHAT ARE PRESENTING CHARACTERISTICS OF PSYCHOSIS IN CHILDREN AND ADOLESCENTS?

The most common manifestations in young people with psychosis are hallucinations, impaired functioning, flattened affect, and social withdrawal., Caregivers are more likely than the child patients themselves to report these problems to the clinician, as children often minimize, misinterpret, or avoid mentioning their symptoms. Hence, a comprehensive psychiatric assessment should include interviews with the child and his or her family members, review of records, information gathered from other involved adults (including a detailed description of the presentation and course of the psychotic symptoms), attention to developmental delays, a family psychiatric history, a history of abuse and/or neglect, and a mental status examination.,

Unlike adults, children with psychosis rarely demonstrate waxy flexibility or become catatonic. On the other hand, they can be emotionally reactive or agitated. The majority of children with childhood-onset schizophrenia often exhibit "soft" neurologic signs, including primitive reflexes, abnormal stereognosis, 2-point discrimination, and dysdiadochokinesia (impaired rapid alternating movements). Affected youth may manifest either a decreased or increased rate of eye blinking, as well as paroxysmal saccadic eye movements (inability to follow an object with smooth eye movements).

HOW ARE CHILDREN AND ADOLESCENTS DIAGNOSED WITH SCHIZOPHRENIA?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) made several changes to the category of schizophrenia, including raising the symptom threshold. A diagnosis of schizophrenia now requires 2 of the following conditions: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms such as affective flattening or paucity of thought or speech (in the manual's previous editions, the threshold was 1). To meet diagnostic criteria, symptoms must be present for at least 6 months (including at least 1 month of active symptoms); must result in deterioration in social, school-related, and self-care functioning; and should not be accounted for by a diagnosis of schizoaffective disorder, a mood disorder, a substance use disorder, or general medical conditions.

Additionally, an "attenuated psychosis syndrome" was included in the research section as a category for persons who do not meet criteria for a full-blown psychotic disorder but exhibit minor variations of relevant symptoms. This category seeks to identify individuals with an increased risk for developing a psychotic disorder, which may be significant for the implementation of effective early interventions.

Personality tests and projective tests should not be used to diagnose schizophrenia in youth; research indicates that tests, such as the Rorschach, do not increase the diagnostic accuracy in early-onset schizophrenia.

WHAT CAUSES SCHIZOPHRENIA IN CHILDHOOD AND ADOLESCENCE?

While there is no single confirmed etiology of childhood-onset or early-onset schizophrenia, it is likely that genetic, behavioral, and environmental factors all contribute to the development of this disease.

Genetic risk has been well-studied. First-degree relatives of patients with childhood-onset schizophrenia have a higher prevalence rate of schizophrenia and schizophrenia spectrum disorders, as well as impairment in smooth pursuit eye movements similar to those observed in patients with adult-onset schizophrenia. One study found that healthy siblings of patients with childhood-onset schizophrenia had decreased cerebral gray matter in the same pattern as was seen in the probands. In an investigation of youth identified as being at "high risk," the young relatives of patients with schizophrenia demonstrated an increased rate of Axis I psychopathology (eg, attention-deficit/hyperactivity disorder [ADHD], conduct disorder), soft neurologic signs, and a high level of outwardly expressed emotion. On neuropsychological examination, these "high-risk" nonprobands also demonstrated impairment in attention, spatial working memory, and executive function, as well as a volume reduction in the amygdala, hippocampus, and superior temporal gyrus.

WHICH NEURODEVELOPMENTAL AND NEUROBIOLOGICAL ABNORMALITIES ARE ASSOCIATED WITH YOUTH WHO DEVELOP SCHIZOPHRENIA?

Structural brain abnormalities are an established feature of schizophrenia, and recent evidence suggests a progressive nature of this pathology. Like adults with schizophrenia, youth with childhood-onset schizophrenia show bilateral enlargement of the lateral ventricles on neuroimaging. However, unlike adults, the abnormalities in brain morphology in patients with childhood-onset schizophrenia evolve during adolescence. Rapoport and associates, reported that adolescents with schizophrenia have significantly reduced frontal and temporal gray matter volumes compared with those observed in healthy age-matched controls. Moreover, youth with childhood-onset schizophrenia appear to lose more cortical gray matter compared to children who suffer from transient psychosis. Subsequent studies from this group have shown that the healthy siblings of afflicted patients also have reductions in cerebral volume and gray matter. Similar to patients with adult-onset schizophrenia, over the course of development, youth with childhood-onset schizophrenia appear to lose cortical thickness in prefrontal and temporal regions, regardless of their treatment with medications. In a systematic review of 66 articles comparing brain volume in patients with a first psychotic episode with the volume seen in healthy controls, a meta-analysis demonstrated that whole-brain and hippocampal volumes are reduced and that ventricular volumes are increased in affected patients compared to healthy controls. Future improvements in neuroimaging technology hold the potential to reveal more about neurobiological disturbances and their correlates in schizophrenia. Yet, at present, results of neuroimaging studies have not made the leap from bench to bedside.

WHICH NEUROTRANSMITTERS ARE THOUGHT TO BE INVOLVED IN SCHIZOPHRENIA?

The neurotransmitter most commonly implicated in the pathophysiology of schizophrenia is dopamine. Drugs that increase dopaminergic receptor activity (eg, cocaine, amphetamines) may induce an acute psychotic episode, whereas drugs that block postsynaptic D ₂ receptors help to alleviate psychotic symptoms. Furthermore, persons with schizophrenia also have fewer D ₁ receptors in the prefrontal cortex. Disturbances in a variety of other neurotransmitters such as glutamate, serotonin, and γ-aminobutyric acid (GABA) have been implicated in the pathophysiology of schizophrenia. Researchers are also interested in glutamate because phencyclidine (PCP or angel dust) is an NMDA/glutamine antagonist; NMDA receptor dysfunction can also cause psychotic symptoms. As mentioned earlier, anti-NMDA receptor antibodies, sometimes secondary to teratomas or autoimmune dysfunction, can cause psychosis in children, often in conjunction with autonomic instability and seizures. Serotonin may also be important; most second-generation antipsychotics share relatively potent antagonism of serotonin 5-HT 2A receptors coupled with relatively weaker antagonism of dopamine D ₂ receptors. Preliminary studies suggest that GABA may also play a role in the development of chronic psychotic syndromes. Overall, disrupted neurotransmission and cognitive functions are key components in the pathophysiology of schizophrenia; however, no single neurotransmitter is clearly responsible for the onset and progression of schizophrenia.

ARE THERE ENVIRONMENTAL RISKS FOR THE DEVELOPMENT OF SCHIZOPHRENIA?

It is clear now that "the grass is not greener," as data from 6 longitudinal studies in 5 countries have shown that regular cannabis use predicts an increased risk for schizophrenia and symptoms of psychosis. Cannabis use during early adolescence coupled with a specific genetic vulnerability and changes in brain development are correlated with risk for the development of schizophrenia and overall cognitive decline. However, the direction of the effect has been called into question. Some suggest that individuals with psychosis use cannabis to alleviate their psychotic symptoms or to improve their mood. Others, however, suggest that cannabis causes or exacerbates psychotic symptoms. A pooled analysis of 35 studies showed a dose-response effect, with greater risk of psychosis in people who used cannabis most frequently. Moreover, individuals with schizophrenia who are moderate to heavy cannabis users show a greater brain volume reduction over a 5-year follow-up compared with nonusers.

Despite the fact that fewer adolescents believe that regular cannabis use is harmful to their health and increasingly permissive state laws governing the use of medical marijuana, the medical literature presents clear evidence for a neurotoxic effect of cannabis on the adolescent brain. These findings highlight the importance of efforts targeting adolescent cannabis use, including policy measures and psychoeducation in the doctor's office.

HOW CAN ONE DISTINGUISH PRIMARY PSYCHOSIS FROM SECONDARY PSYCHOSIS?

A thorough medical workup is essential for distinguishing between primary and secondary psychotic disorders. lists medical disorders that have been associated with psychosis. Although there is no generally agreed-upon medical evaluation that every patient with psychosis should undergo,, screening tests should be ordered on the basis of a patient's personal and family history, as well as on the basis of one's clinical suspicion of conditions. Blanket testing for rare disorders may increase the risk of false-positive or false-negative results. On the other hand, the search for medical etiologies of psychosis may be expanded in the face of atypical presentations or when cases are refractory to standard treatments.

Table 2

Infections

Creutzfeldt-Jakob disease

Herpes encephalitis

Human immunodeficiency virus infection

Lyme disease

Subacute bacterial endocarditis

Sydenham's chorea

Metabolic disturbances

Adrenocortical insufficiency

Cushing's disease

Hypercalcemia or hypocalcemia

Hypermagnesemia or hypomagnesemia

Hypernatremia or hyponatremia

Hyperthyroidism

Hypoglycemia

Hypokalemia

Hypophosphatemia

Lactic acidosis

Panhypopituitarism

Parathyroid disease

Thyroid storm

Neurologic

Cerebral neoplasms

Cerebrovascular disease

Cerebral lipidoses

Complex partial auras or seizures

Creutzfeldt-Jakob disease

Encephalitis (including anti- N-methyl-d-aspartate receptor encephalitis)

Focal lesions of temporal and parietal lobe

Generalized seizures

Hepatic encephalopathy

Herpes encephalitis

Multiple sclerosis

Normal pressure hydrocephalus

Temporal arteritis

Postnoxic encephalopathy

Posttraumatic encephalopathy

Fragile X syndrome

Klinfelter's syndrome

Metachromic leukodystrophy

Prader-Willi syndrome

Velocardiofacial syndrome

Wilson's disease

Vitamin deficiencies

Folate deficiency

Niacin deficiency

Vitamin B ₁₂ deficiency

Vitamin D insufficiency

Medications

Drug classes that can cause hallucinations or delusions

Amphetamine-like drugs

Anabolic steroids

Angiotensin-converting enzyme inhibitors

Anticholinergics

Antidepressants (both tricyclic antidepressants and selective serotonin reuptake inhibitors)

Antiepileptics

Barbiturates

Benzodiazepines

β-adrenergic blockers

Calcium channel blockers

Cephalosporins

Corticosteroids (prednisone, cortisone, adrenocorticotropic hormone, others)

Dopamine receptor agonists

Fluoroquinolone antibiotics

Nonsteroidal antiinflammatory drugs

Procaine derivatives (procainamide, procaine, penicillin G)

Salicylates

Sulfonamides

Alcohol toxicity/withdrawal

Illicit use of drugs (including prescribed medications)

Amphetamines

Glue sniffing/ingestion

Lysergic acid diethylamide

Methamphetamine (crystal meth)

Phencyclidine hydrochloride (PCP)

Psilocybin (mushrooms)

Toxicologic causes

Carbon monoxide poisoning

Heavy metal poisoning (eg, mercury, lead)

Key tests in the pediatric population () may include drug screens (to rule out medication or substance-related psychosis), laboratory studies (to rule out infections, metabolic disturbances, certain genetic conditions, or vitamin deficiencies), an electroencephalogram (EEG), and structural neuroimaging (eg, magnetic resonance imaging [MRI] or computed axial tomography [CT] scanning). The clinical relevance of a given EEG tracing can be difficult to discern, as almost half of the patients with new-onset psychosis will have EEG abnormalities of unclear significance. Furthermore, EEGs read as "normal" may not capture an interictal psychosis. Likewise, incidental and non-clinically meaningful MRI findings are found in approximately 20% of the non-psychiatrically ill population. Recent guidelines suggest that structural neuroimaging should not be obtained routinely during an evaluation for a first episode of psychosis. Despite the low yield of neuroimaging, counter arguments supporting its judicious use emphasize that patients and families feel reassured by negative scans. Conversely, neuroimaging can rule out rare etiologies for psychosis (eg, brain tumors) and help patients and families understand and accept the psychotic symptoms as manifestations of a psychiatric disorder.

Table 3

Electroencephalogram

Imaging studies (eg, magnetic resonance imaging or computed tomography of the brain) in select patients based on clinical suspicion

Laboratory studies

Antinuclear antibodies

Blood urea nitrogen/creatinine

Calcium and phosphorus

Ceruloplasmin (for Wilson's disease)

Complete blood count

Electrolytes

Erythrocyte sedimentation rate

FTA-Abs (for syphilis)-preferred over rapid plasma reagin

Human immunodeficiency virus screening

Liver function tests

Thyroid-stimulating hormone

Urinalysis

Urine (and/or serum) drug screen

HOW SHOULD PSYCHOSIS DUE TO AN UNDERLYING MEDICAL CONDITION BE TREATED?

The optimal treatment for secondary psychosis is treatment of the underlying medical or neurologic condition. Concomitant treatment of the secondary psychosis (usually with an antipsychotic agent) can protect both the patient and the treatment team while medical treatment is administered. Notably, most guidelines for dosing antipsychotics are based on the treatment of patients with schizophrenia and bipolar disorder. Patients treated for psychosis related to medical causes are often antipsychotic naive and sensitive to the sedating properties of lower-potency antipsychotics and to the extrapyramidal effects of higher-potency antipsychotics.

WHAT DOES THE FIRST EPISODE OF PSYCHOSIS INVOLVE?

Once functionally impairing psychotic symptoms develop-defined in terms of symptom severity and duration-a patient is no longer considered to be in the prodromal phase of illness, but instead diagnosed with an episode of psychosis. Clinically, the demarcation between prodromal (or "attenuated") symptoms and frank psychosis is rarely clear-cut, particularly in a patient with brief or intermittent bouts of mild psychotic symptoms. Moreover, few patients receive emergency treatment for psychosis. The median duration of untreated psychosis refers to the lag between the development of symptoms and the initiation of treatment. This lag time can range from 4 to 50 weeks in first episodes, and can extend longer when mood symptoms or illicit drug use cloud the diagnostic picture. The availability of mental health resources, socioeconomic factors, and cultural attitudes toward mental illness can also affect the time to treatment. Most studies show that a longer duration of untreated psychosis is associated with worse clinical outcomes. This observation has spurred increased research interest into interventions that target the period prior to, or immediately after, the development of a psychotic disorder. The hope is that these targeted interventions might forestall the onset of psychosis or improve long-term outcomes.

WHAT PSYCHOSOCIAL TREATMENTS ARE AVAILABLE FOR YOUTH WITH PSYCHOSIS OR SCHIZOPHRENIA?

Cognitive-behavioral techniques that evaluate evidence for beliefs or thinking through explanations surrounding a patient's perceptions can help to alter dysfunctional behaviors. A consistent framework with similar words/techniques used at home, at school, and with friends may allow the patient to employ a standardized approach to events across settings and to diminish misperceptions of daily events and interactions.

Research data supporting psychosocial treatments in pediatric psychotic disorders are scant. There is a controlled study comparing cognitive-behavioral therapy (CBT) with no antipsychotic to a monitoring program in prodromal patients. CBT was associated with less progression to psychosis; however, the results of this study were limited by methodological flaws. The PACE (Personal Assessment and Crisis Evaluation) trial randomly assigned prodromal patients (aged 14-28 years) to risperidone plus CBT versus a needs-based intervention of supportive therapy and psychotropics other than antipsychotics. At 6 months, 3 of 31 patients in the risperidone plus CBT group converted to psychosis, whereas 10 of 28 patients in the supportive therapy and nonneuroleptic pharmacotherapy group converted to psychosis. Since the average risperidone dose used in this study was relatively low (1.3 mg/d), there is a suggestion that CBT was a vital ingredient to the protective effects seen in this study.

WHAT DOES THE PHARMACOTHERAPY OF SCHIZOPHRENIA IN YOUTH INVOLVE?

Pharmacologic treatment for schizophrenia in youth remains an area of active research, with several large multisite trials completed within the past few years. Six, 6-week, randomized, placebo-controlled studies of second-generation antipsychotics for early onset schizophrenia have been completed thus far. They showed that aripiprazole, olanzapine, paliperidone, quetiapine, and risperidone-but not ziprasidone-were superior to placebo. In these controlled studies, aripiprazole, olanzapine, paliperidone, quetiapine, and risperidone, were superior to placebo with regard to improvement in the Positive and Negative Syndrome Scale (PANSS) total score.

In terms of atypical antipsychotic dosing, typically, these medications are initiated at a low dose and gradually titrated upward to achieve efficacy. Risperidone, for example, is generally started at 0.25 mg twice a day and can be increased every 1 to 2 days in association with close observation. In general, olanzapine and quetiapine are more sedating; their dosing is usually started at 2.5 to 5 mg/d and 25 to 50 mg/d, respectively. As most antipsychotic medications have a relatively long half-life, they typically do not need be administered more than twice daily. For patients maintained on antipsychotics, clinicians should monitor weight, vital signs, and relevant laboratory results (eg, triglycerides, cholesterol, fasting glucose, and prolactin levels).

Newer atypical antipsychotics (eg, asenapine, iloperidone, lurasidone) may eventually have a role in the treatment of patients with childhood-onset or early onset schizophrenia and in patients deemed at-risk of developing schizophrenia due to genetic and/or environmental factors. However, at present, there is little evidence to support the safety, tolerability, or efficacy of these agents in the pediatric population.

In sum, current pharmacologic research for early-onset and childhood-onset schizophrenia focuses on the identification of antipsychotic agents that will provide optimal efficacy without also causing undue adverse events. Many typical and atypical antipsychotics have been shown (based on open trials, randomized clinical trials, and head-to-head comparisons) to be efficacious in the treatment of early-onset and childhood-onset schizophrenia; however, they are well known to cause side effects such as weight gain, extrapyramidal symptoms, and metabolic abnormalities.

WHAT IS THE ROLE OF LONG-ACTING (INJECTABLE) ANTIPSYCHOTICS IN CHILDHOOD-ONSET SCHIZOPHRENIA?

In the near future, as many as 4 new atypical antipsychotic long-acting therapy formulations may become available. In clinical situations wherein adherence with oral preparations has proven difficult, it is reasonable-especially in older adolescents-to consider using a long-acting medication. Risperidone long-acting therapy has been shown to be efficacious and well tolerated in the treatment of schizophrenia, including those with newly diagnosed schizophrenia. Short-term and long-term studies found that risperidone long-acting therapy was associated with low rates of discontinuation related to adverse events and few reports of pain from injections. Evidence for newer long-acting injectables (eg, olanzapine, paliperidone) remains limited. The available evidence suggests that long-acting injectable antipsychotics can be used safely and effectively in early stages of the illness and that they may be associated with better outcomes than with oral medications. However, this is largely supported by evidence from naturalistic cohort studies and by a small number of controlled trials of risperidone long-acting injection. Given the paucity of data of long-acting therapy in the adolescent population, the use of these preparations in adolescents remains empiric. provides the side effect risk profiles of common second-generation antipsychotic medications used in children and adolescents.,

Table 4

Second-Generation Antipsychotics
(trade name)

Anticholinergic

Diabetes

Hyperlipidemia

Hyperprolactinemia

Hypotension

Sedation

Tardive Dyskinesia

Weight
Gain

WHAT ARE THE ADVERSE EFFECTS OF ANTIPSYCHOTICS?

In reviewing the available randomized, controlled studies and head-to-head comparisons of antipsychotics, Schimmelmann and colleagues noted, "Antipsychotics are efficacious in the treatment of early-onset schizophrenia. The lack of evidence for efficacy differences between various antipsychotics (except for clozapine for treatment-refractory early-onset schizophrenia) suggests that a primum non nocere principle should be applied when choosing and antipsychotic."(p228) Therefore, the side effect profile of the antipsychotics often dictates the choice of pharmacologic agent for young people with psychotic symptoms. Antipsychotic therapy has been linked to a bevy of metabolic changes (eg, dyslipidemia, weight gain, plasma prolactin increases), sedation, extrapyramidal symptoms, and dyskinesias (see ). With the exception of tardive dyskinesia, young people with schizophrenia seem more likely to experience these side effects from atypical neuroleptics compared with their adult counterparts. Children and adolescents may gain weight, even when treated with antipsychotics that are considered "weight-neutral" in adults. Similarly, there are reports of prolactin elevations in youth treated with prolactin-sparing agents such as quetiapine.

Other common adverse effects of antipsychotics include drowsiness and anticholinergic effects (eg, dry mouth, nasal congestion, blurred vision), particularly with the low-potency phenothiazines. Caregivers can usually manage the short-term adverse effects of antipsychotics with adjustments of dose and timing of administration. One can avoid undue sedation by using less sedating agents and by prescribing most of the daily dose at bedtime. One should not confuse drowsiness with impaired cognition; drowsiness can usually be corrected by adjusting the dose and the timing of administration. Furthermore, there is no evidence that antipsychotics adversely affect cognition when used in low doses. One can minimize anticholinergic effects by choosing a medium-potency or high-potency antipsychotic.

Extrapyramidal Side Effects

Extrapyramidal side effects such as acute dystonia, akathisia (motor restlessness), and parkinsonism (bradykinesia, tremor, and lack of facial expressions) are more commonly seen with use of high-potency agents (eg, butyrophenones, thioxanthenes) and have been reported in up to 75% of children receiving these agents. The extent to which antiparkinsonian agents (eg, anticholinergic drugs such as benztropine, trihexyphenidyl, antihistamines, and the antiviral agent amantadine) should be used prophylactically when antipsychotics are introduced is controversial, although coadministration has been shown to reduce the incidence of extrapyramidal side effects by a factor of 7.

Other Movement Disorders

Abrupt cessation of antipsychotic drugs can cause withdrawal dyskinesias (typically benign, but occasionally more pronounced) and a syndrome of deteriorating behavior. As with adults, the long-term administration of antipsychotic drugs can produce tardive dyskinesia. Although children appear generally less likely to develop tardive dyskinesia than adults, the fact that tardive dyskinesia is potentially irreversible prompts caregivers to evaluate the benefits of such medications, including documenting a clear indication and identifying target symptoms; to periodically discontinue the drug to assess continued need; and to monitor closely to ensure early detection. Current practice parameters recommend monitoring neurologic side effects with standardized scales (eg, Abnormal Involuntary Movement Scale or Simpson Angus Scale) at baseline and periodically during any treatment regimen requiring antipsychotic agents.

Akathisia

Akathisia is a movement disorder characterized by anxiety and an inability to sit still; it can be a side effect of either antipsychotics or antidepressants. Akathisia may be particularly problematic in young patients because of underrecognition or misdiagnosis as ADHD or agitation. Caregivers should consider akathisia in the differential when a child or adolescent starts an antipsychotic and becomes acutely agitated with an associated inability to sit still (and/or with aggressive outbursts).

Treatment of akathisia involves reduction of the offending agent to the lowest effective dose and then using either a benzodiazepine (eg, lorazepam, 0.5 to 1 mg 3 times per day) or a β-blocker. Although all β-blockers are likely to be effective, propranolol, initiated at 10 mg 2 or 3 times per day with an increase every few days until the desired effect is achieved, is a good choice. Alternately, betaxolol hydrochloride, a long-acting β ₁-selective adrenergic antagonist with few medication interactions, may be useful.

Neuroleptic Malignant Syndrome

Little is known about the potentially lethal neuroleptic malignant syndrome in children and adolescents; however, preliminary evidence indicates that its presentation is similar to that in adults. This syndrome may be difficult to distinguish from primary central nervous system pathology, concurrent infection, anti-NMDA receptor encephalitis, or other, more benign, side effects of antipsychotic treatment, including extrapyramidal side effects or anticholinergic toxicity. Neuroleptic syndrome is a life-threatening medical emergency; treatment is largely supportive but can include dopamine reuptake inhibitors like amantadine, similar to strategies used in adults.

WHAT STRATEGIES ARE HELPFUL FOR NONRESPONDERS?

A unique head-to-head randomized controlled trial of olanzapine and clozapine in the treatment of patients with childhood-onset schizophrenia showed that clozapine led to a statistically significant reduction in all outcome measures (particularly negative symptoms of schizophrenia) even when compared to another atypical agent.

WHAT STRATEGIES ARE AVAILABLE FOR EARLY INTERVENTION AND PREVENTION OF CHILDHOOD-ONSET SCHIZOPHRENIA?

The notion of early intervention and perhaps even prevention of schizophrenia remains at the forefront of early-onset psychosis research. Further research in this area is ongoing. However, at present, the literature does not support clear treatment guidelines for these vulnerable patients.

CONCLUSION

Clinicians should be vigilant and consider psychotic illnesses when evaluating children and adolescents with emotional and behavioral disturbances. Given the high developmental, financial, and functional toll associated with chronic psychotic illness, clinicians should employ a variety of diagnostic and treatment modalities to mitigate the risks associated with this illness. These modalities may include performing careful psychiatric and physical examinations, relevant laboratory testing, neuropsychological testing, and employing relevant cognitive therapies, as well as the use of antipsychotic and other pharmacologic interventions. Advances in the understanding of childhood-onset and early-onset schizophrenia, as well as the elucidation of prodromal psychotic symptomatology, will benefit both children and adults.

Footnotes
LESSONS LEARNED AT THE INTERFACE OF MEDICINE AND PSYCHIATRY
The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Dr Stevens is physician-in-charge at Westpark (Dearborn), Henry Ford Health Systems, Dearborn, Michigan, and clinical assistant professor at Wayne State University, Detroit, Michigan. Dr Prince is director of child psychiatry at North Shore Medical Center in Salem, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Prager is director of the Child Psychiatry Emergency Service at Massachusetts General Hospital, Boston, and assistant professor of psychiatry (child psychiatry) at Harvard Medical School, Boston, Massachusetts. Dr Stern is chief of the Avery D. Weisman Psychiatry Consultation Service at Massachusetts General Hospital, Boston, and the Ned H. Cassem professor of psychiatry in the field of psychosomatic medicine/consultation at Harvard Medical School, Boston, Massachusetts.

Dr Prince has received honoraria from the American Physician Institute and has provided expert legal reviews in malpractice cases. Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Stevens and Prager report no conflicts of interest related to the subject of this article.

References

1. Freudenreich O. Psychotic Disorders: A Practical Guide. Philadelphia, PA: Lippincott Williams and Wilkens; 2008.

20. McDonell M, McClellan J. Early-onset schizophrenia. In: Mash E, Barkley R, editors. Assessment of Childhood Disorders. 4th ed. New York, NY: Guilford Press; 2007. pp. 526-550.

26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Press; 2013.

28. Kodish I, McClellan J. In: Handbook of Psychological Assessment, Case Conceptualization, and Treatment: Vol. 2, Children and Adolescents. Hersen M, Reitman D, editors. Hoboken, NJ: John Wiley & Sons; 2008. pp. 405-443.

42. Millichap JJ, Goldstein JL, Laux LC, et al. Ictal asystole and anti- N-methyl-d-aspartate receptor antibody encephalitis. Pediatrics. 2011;127(3):e781-e786.

49. Freudenreich O, Goff DC. Psychotic patients. In: Stern TA, Fricchione GH, editors. Massachusetts General Hospital Handbook of General Hospital Psychiatry. Amsterdam, The Netherlands: Elsevier Science Publishers; 2010.

52. Structural neuroimaging in first-episode psychosis. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Feb. 24 p. (technology appraisal guidance; no. 136) http://www.guideline.gov/content.aspx?id=12284. Accessed December 4, 2013.

54. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2011;(6):CD004718. [ PMC free article]

60. Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 2011;(6):CD002831. [ PMC free article]

61. Jones C, Cormac I, Silveira da Mota Neto JI, et al. Cognitive behaviour therapy for schizophrenia. Cochrane Database Syst Rev. 2004;(4)(CD000524)

71. Yan J. FDA advisors back additional antipsychotics for use in teens. Psychiatr News. 2009;44(13):1-29.

80. Celano CM, Beach SR, Huffman JC, et al. Side effects profiles of psychotropic medications from cardiovascular and other side effects of psychotropic medications. In: Stern TA, Herman JB, Gorrindo T, editors. The Massachusetts General Hospital Psychiatry Update and Board Preparation. 3rd ed. Boston, MA: MGH Psychiatry Academy Publishing; 2012.

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Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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■ Hallucinatory experiences and delusions are more common in our patients than we may realize and occur frequently in the pediatric population. While not a benign occurrence, psychotic symptoms do not necessarily portend the future development of schizophrenia.

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What is drug-induced psychosis

Psychosis is an altered state of mind or a break from reality that is often characterized by delusions and hallucinations. Psychosis can be triggered through the use of certain substances, drugs, and/or medications, which is often referred to as drug-induced psychosis.

Hallucinations are perceptual distortions that arise without an external stimulus-they can be auditory, visual, olfactory, or of any other sensorymodality. A delusion is a distorted thought or belief about reality that is rigidly held by the individual despite evidence of its untruth. About 3 outof every 100 people will suffer a psychotic episode at some point in their lifetime, according to the National Alliance on Mental Illness (NAMI).

Psychotic symptoms may develop in association with several mental health issues as well as in the context of substance use. Bipolar disorder and schizophrenia are two mental illnesses in which psychotic episodes may occur.Psychosis may also be associated with certain types of drug or alcohol abuse. Hallucinogenic drugs like LSD, PCP, peyote, and magic mushrooms may be first to come to mind. However, while these drugs may regularly elicit profoundly altered states of mind and certain psychotic features, almost any mind-altering substances taken for a long period of time and in large enough amounts can lead to a drug-induced psycho sis.

In some cases, it is not the primary intoxication that results in psychosis but the withdrawal from a substance.

There may also be some risk of certain types of substance use contributing to the onset of schizophrenia in susceptible individuals. Having a genetic riskfor schizophrenia development may also be associated with a stronger psychotic response to certain drugs, such as LSD.In a study of patients admitted to the hospital with first-episode psychosis, 74% had been diagnosed with a substance use disorder (SUD) at some point in their lives, and 62% met criteria for an SUD at the time of the psychotic episode. Studies such as these underscore the connection between substance abuse and psychosis.

The onset of Alzheimer's disease, a form of dementia sometimes associated with psychotic symptoms, may be more likely in those who use certain drugs such as benzodiazepines, especially if use continued beyond 3 months.Substance intoxication or withdrawal may bring on psychotic symptoms, and when this occurs, crisis intervention methods and medical detox may be necessary.

What are the Signs of Drug-Induced Psychosis?

It can be helpful to understand how substance abuse and psychosis are intertwined, and which one may have predated the other, when determining treatment needs. When psychosis or mental illness occurs first, patterns of substance abuse may develop later a means of self-medication.

In such an instance, treatment protocols may focus on not only managing a combination of acute intoxication and psychotic symptoms, but instituting a longer-term strategy-including behavioral therapeutic interventions and psychiatric medications-to manage the underlying mental health issue.

If the substance abuse occurred first and the psychosis is a byproduct of drug use, the focus will be on managing the acute but transient psychotic symptoms with antipsychotics or anxiolytics. Sometimes, just a quiet and safe place is all that is needed. Once symptoms resolve, standard addiction treatment can begin.

Certain drugs are associated with symptoms that could resemble certain mental illnesses. See below.

Which drugs can cause psychosis?

Stimulant drugs (amphetamines, methamphetamine, cocaine):

Delusions

Paranoia

Hallucinations, including auditory, visual, and/or tactile with the feeling of "bugs" being under the skin (particularly with meth abuse and withdrawal)

Anxiety

Mania

Increased aggression, violence, or hostility

Memory problems

Cognitive decline and difficulties concentrating

Depressants (alcohol, benzodiazepines):

Impaired cognition

Aggression

Rapid mood changes

Impaired judgment

Perceptual distortions

Hallucinations

Delirium

Withdrawal from depressants may also bring about mental health symptoms such as anxiety, perceptual disturbances, hallucinations and other perceptual disturbances, or delirium.

Marijuana:

Altered perception of time

Heightened sensory perception

Fear

Panic

Paranoia

Hallucinations

Delusions

Sense of losing personal identity

Hallucinogens/dissociatives (LSD, peyote, mushrooms, ketamine, PCP, ecstasy):

Hallucinations

Distorted sense of time and space

Mixing of perceptions such as "seeing sounds" or "hearing color"

Sense of dissociation from mind and body

Distortion of reality

Spiritual experiences

Paranoia

Panic

Persistent psychosis marked by visual disturbances, problems organizing thoughts, mood shifts, and paranoia

Hallucinogen persisting perception disorder (HPPD) marked by hallucinations and disturbances to vision, like seeing light trails or halos around objects that are moving

With some hallucinogenic drugs, "flashbacks" have been reported to occur suddenly and without warning long after the drug's effects have worn off. In some cases, long-term substance use may also be associated with depression and suicidal thoughts. In heavy meth users, psychotic symptoms may last months or even years past the point of quitting.

In a study of 400 patients from 5 psychiatric emergency departments who had used substances in the previous 30 days, 44% were diagnosed with substance-induced psychosis.

Some drugs may elicit a "bad trip," which may consist of certain psychotic symptoms, with as little as one use while for others it may take many uses of large quantities of drugs to initiate an onset of psychotic symptoms. In many cases, psychosis may go away after the substance abuse is stopped; however, in others, symptoms may persist well beyond the point of substance use. A review of some studies published by the Oxford Journals Schizophrenic Bulletin indicated that stimulant drug-induced psychosis lasted longer than a month in individuals between 1 and 15 percent of the time.

Substance intoxication withdrawal may bring on psychotic symptoms, and when this occurs, crisis intervention methods and medical detox may be necessary. A severe psychotic episode may require may require hospitalization to stabilize an individual both mentally and physically in a safe and secure environment that can provide medical and mental health monitoring and care.

What Causes Drug-Induced Psychosis

Drug-induced psychosis may seem self-explanatory as to the cause-psychotic symptoms are brought on by drug abuse. However, the situation isn't always so simple. Drugs can affect different people in a variety of ways, and what may cause psychotic symptoms in one person may not in another. It's not possible to say with certainty exactly how a substance will impact each person's mental state.

For example, a particular substance may bring on or worsen a mental illness in someone genetically predisposed that that disorder but have no lasting effects on another person with a different genetic profile.

Additionally, it is not only that drug use can contribute to the development of mental health issues, but also that mental health disorders can contribute to substance use. While in some cases, it may appear that mental health symptoms sprung from the drug use, what actually might be occurring is that untreated symptoms of an underlying mental health condition were exacerbated by the substance abuse but not caused by it.

Further, both mental illness and addiction have certain overlapping risk factors, so some individuals may be more likely to struggle with both addiction and mental illness.

There is also a phenomenon that some researchers have proposed as a potential contributor to the comorbidity of drug dependence and mood disorders such as schizophrenia called "kindling". Certain drugs sensitize neurons in the brain, and this sensitization may lead the person to use those drugs more frequently and in higher amounts over time. Mental health disorders often follow a similar pattern of increasing severity, where episodes that originally occurred only occasionally will begin to happen more and more often with increasingly brief periods of respite between. For those who are genetically vulnerable to such a kindling phenomenon, both addiction and mood disorders may be more likely to develop.

Co-occurring psychotic disorders and addiction can worsen the symptoms of both issues. Work or school production as well as interpersonal relationships may
be more likely to suffer in the setting of co-occurring conditions. Additionally, risk-taking behaviors may be more likely, which could increase the risks of physical harm, criminal acts, and legal problems.

Marijuana and Schizophrenia: Is There a Link?

One of the more controversial assertions is that cannabis, or marijuana, abuse may cause schizophrenia. A study published in the British Journal of Psychiatry (BJPsych) showed that, among a group of patients who had received treatment for cannabis-induced psychotic symptoms in a 5-year period, roughly half of them were eventually diagnosed at some point in the next several years with a schizophrenia-spectrum disorder.

In many cases, they received the diagnosis more than a year after being treated for the cannabis-induced psychosis. When compared to a separate group of individuals who had also been diagnosed with a schizophrenia-spectrum disorder but had never experienced cannabis-induced psychosis, the study group developed schizophrenia at a younger average age. This suggests that marijuana may trigger an early onset of schizophrenia in vulnerable individuals.

Research has also shown a heightened risk of psychosis in those who had used cannabis in their adolescent years and who carried a specific gene, further showing that both genetic risk and substance abuse can play into the likelihood of developing a psychotic illness.

Marijuana can also worsen the course of schizophrenia in individuals with substance-induced psychosis

When someone suffers from drug-induced psychosis, continued substance abuse can have dangerous consequences, as drugs may only serve to make psychotic symptoms worse and could make episodes of violence or self-harm more likely.

How Long Can Drug-Induced Psychosis Last?

It can be hard to determine how long drug-induced psychosis can last. This can depend on the person, the drug(s), dosage, and how long you have been using the drug(s). Some psychotic experiences last an hour, while others may last for weeks, months, or even years.

Which drugs can cause psychosis?

Certain drugs are associated with symptoms that could resemble mental illnesses or psychosis. See below:

Stimulant drugs (amphetamines, methamphetamine, cocaine):

While every stimulant is slightly different in its specific effects, all stimulants share a set of side effects that can cause damage to a user's system when abused.

Depressants (alcohol, benzodiazepines):

The body will develop a tolerance for depressants with continued use. When use is reduced or stopped, withdrawal will happen which can lead to side effects.

Marijuana:

Dependence of marijuana can occur and the effect can cause withdrawal symptoms when marijuana is no longer in a person's system.

Hallucinogens/dissociatives (LSD, peyote, mushrooms, ketamine, PCP, ecstasy):

A tolerance for hallucinogens can develop fast, tempting the user to use more to get the desired effects and making withdrawal more uncomfortable. As the drug leaves the body it will cause physical and psychological changes.

How Can I Help Someone with Substance-Induced Psychosis?

People exhibiting the signs of a psychosis could be in need of immediate medical help. Someone in a psychotic episode may be a danger to themselves or others, and crisis intervention or hospitalization may be helpful to provide initial stabilization and a starting point to get further help.

Should substance use be a factor, the best time to talk to people about their drug abuse is when they are not intoxicated and are calm and rested. A professional interventionist, or a medical, mental health, or substance abuse treatment professional, can help families and loved ones develop a plan for a structured intervention.

For someone who develops psychotic symptoms when withdrawing from substances, a medical detox will provide a safe environment where doctors and other treating professionals can manage their symptoms. Staff will also work to discover whether the symptoms are related only to drug use and/or withdrawal or are associated with an underlying mental health disorder.

Treatment for Drug-Induced Psychosis

Medications such as antipsychotics (haloperidol or chlorpromazine, for example) and atypical antipsychotics (such as quetiapine or risperidone) may be administered to alleviate acute psychotic symptoms.

Ongoing treatment after medical detox may be performed on an outpatient or residential basis, depending on the needs of individual. Treatment for co-occurring disorders, often called a "dual diagnosis," is available through a number of programs and is designed to provide comprehensive treatment for both the mental health disorder and the addiction. Cognitive-behavioral therapy is often utilized and can help a person learn what may trigger a psychotic episode or may contribute to relapse and can teach individuals new and more effective coping mechanisms.

Family therapy programs focus on the entire family as a whole and not just on the individual battling mental illness and/or substance abuse. This type of therapy can help to restore stability and positive connection within the family unit.

Recovery support groups are also usually incorporated into treatment and recommended as an ongoing relapse prevention strategy once treatment ends. These groups provide a continuous connection to the sober community and can help provide an environment where you can be honest about your journey and any struggles along the way.

Medications may also be provided post-detox for the management of mental health symptoms and/or for the treatment of the substance addiction.

Co-occurring disorders are often best treated through a comprehensive program incorporating therapy, education on mental health and drug abuse, support groups, and skills training.

Sources:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. National Institute on Drug Abuse. (2016). What are hallucinogens?

3. National Alliance on Mental Illness. (n.d.). Early Psychosis and Psychosis.

4. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 42.) 9 Substance-Induced Disorders.

5. Paparelli, A., Di Forti, M., Morrison, P. D., & Murray, R. M. (2011). Drug-induced psychosis: how to avoid star gazing in schizophrenia research by looking at more obvious sources of light. Frontiers in behavioral neuroscience, 5(1).

6. Lambert et al. (2005). The impact of substance use disorders on clinical outcome in 643 patients with first-episode psychosis. Acta Psychiatri Scan, 112(2), 141-148.

7. Merz, Beverly. (2016). Benzodiazepine use may raise risk of Alzheimer's disease.

8. Grant, K. M., LeVan, T. D., Wells, S. M., Li, M., Stoltenberg, S. F., Gendelman, H. E., Carlo, G., ... Bevins, R. A. (2011). Methamphetamine-associated psychosis. Journal of neuroimmune pharmacology : the official journal of the Society on NeuroImmune Pharmacology, 7(1), 113-39.

9. National Institute on Drug Abuse. (2013). What are the long-term effects of methamphetamine abuse?

10. National Institute on Drug Abuse. (2018). Why is there comorbidity between substance use disorders and mental illnesses?

11. Arendt, M., Rosenberg, R., Foldager, L., Perto, G., & Munk-Jørgensen, P. (2005). Cannabis-induced psychosis and subsequent schizophrenia-spectrum disorders: Follow-up study of 535 incident cases. British Journal of Psychiatry, 187(6), 510-515.

12. National Institute of Mental Health. (2016). Mental Health Medications.

13. National Institute on Drug Abuse. (2018). Marijuana.

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Drug-Induced Psychosis - Symptoms, Causes, & Treatment | Greenhouse

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Psychosis is an altered state of mind or a break from reality that is often characterized by delusions and hallucinations. Psychosis can be triggered through the use of certain substances, drugs, and/or medications, which is often referred to as drug-induced psychosis.

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Psychosis is a mental health problem which temporarily causes someone to interpret the world differently from those around them. Drug-induced psychosis, also known as 'stimulant psychosis', refers to any psychotic episode which has been caused by abuse of stimulants, an adverse reaction to prescription drugs, or excessive use of alcohol which has directly triggered a psychotic reaction.

Psychosis is often characterised by delusions or hallucinations, which are experiences that are far removed from reality. Delusions are irrational beliefs that a person holds, even when they are presented with evidence that contradicts these beliefs. Delusions may include believing that you have a serious or life-threatening physical illness, that you are responsible for terrible things happening to other people, or that you are bankrupt when you are not. Hallucinations refer to intense sensory perceptions of phenomena that are not real, and are characterised by individuals vividly feeling, seeing or hearing things that do not truly exist.

Drugs such as , and hallucinogens can worsen symptoms of existing mental illnesses, whilst taking such substances for a long period of time can also see you develop symptoms of psychosis, including paranoia. If you are diagnosed with drug-induced psychosis and have a dependency on alcohol or drugs, you may have what is called a dual diagnosis, whereby your underlying mental illness will need to be treated independently of any substance addiction.

At Priory, our nationwide network of hospitals and wellbeing centres provide highly flexible, specialist treatment to treat both underlying mental health disorders and drug or alcohol abuse across two separate treatment plans, created specifically with your needs in mind. Treatment for underlying psychiatric disorders such as bipolar disorder and schizophrenia will involve a combination of talking therapies and medication designed to reduce symptoms, while substance abuse treatment can include withdrawal and detox plans within a safe and understanding environment.

What causes someone to develop drug-induced psychosis?

Drug-induced psychosis can happen when you take too much of a certain drug, so that its level of toxicity provokes paranoia and a psychotic episode. It can also occur when if you have an adverse reaction from mixing different substances, or withdrawing from a drug, prescribed or otherwise. You may already have underlying mental health conditions such as bipolar disorder or schizophrenia, where delusions and hallucinations are associated symptoms, with psychotic episodes resulting from substance use, indicating that you may be prone to psychosis.

If your psychosis has been triggered through drug use in order to cope with underlying mental illness, a diagnosis would need to determine whether symptoms would continue without the drug present, as this would not be drug-related psychosis. Drug-induced psychosis is more apparent when your symptoms wear off after you have stopped using the drug, while the initial symptoms such as social withdrawal and lack of motivation may gradually build to include delusions or hallucinations.

Treatment for drug-induced psychosis at Priory

If you are diagnosed with drug-induced psychosis, it is vitally important that you seek treatment from specialist medical professionals. Priory's experienced therapists and consultants are trained in treating drug-induced psychosis, and can offer you a safe and understanding treatment environment as part of a bespoke treatment plan, which is aimed at reducing associated symptoms of psychosis and drug addiction, before targeting any underlying health issues which may have been triggered by substance abuse.

Medically assisted withdrawal detoxification programme

When treating drug-induced psychosis, the first step towards recovery must include termination of use of the drug which initially caused the episode. The medically assisted withdrawal detoxification programme at Priory will also ensure that you have no further interaction with drugs that could be habit forming or that could interfere with the drug being abused, with carefully selected drugs helping with symptoms of withdrawal only.

During the detox process, you will also have access to therapeutic sessions where you will learn how to manage withdrawal symptoms, and also prepare techniques for remaining drug-free after treatment. Residential secondary care programmes are available after detox, which can further help your transition and acquire healthy habits to help support clean living.

Treatment for co-occurring conditions

While removal of the drug from your system may remove symptoms of psychosis, if you have an underlying mental health condition such as anxiety or depression which prompted excessive use of a drug, or you have also been diagnosed with an existing psychotic disorder such as bipolar disorder or schizophrenia, further treatment will be required to address these conditions.

Therapies and medication can be offered on an inpatient, outpatient or day care basis depending on your circumstances, and may include:

Cognitive behavioural therapy (CBT) - once you have been medically stabilised, the practical and problem-solving talking therapy, CBT, can help you to learn more about the thoughts and moods that you experience before psychotic episodes occur, helping you to manage your emotions and paranoia more readily, and be aware of triggers.

If a mental health condition such as anxiety or depression exists, which has been masked by extensive use of drugs or alcohol to the point of psychosis, then CBT can help you to learn techniques to cope with and reduce associated symptoms so as to prevent relapse.

Family therapy - due to the serious nature of drug-induced psychosis and associated psychotic conditions, family therapy involving those closest to you, can help to ensure that there is sufficient support available at home to prevent relapse and manage associated symptoms, potentially reducing the need for extensive hospital treatment.

Anti-psychotic medication - if your underlying mental health condition features psychotic episodes as a symptom, then antidepressant, anti-psychotic or other medications such as clozapine (Clozaril) may be recommended for an extended period of time, particularly if delusions and hallucinations are frequent or particularly severe.

You can read more about the different treatment options that we offer at Priory, by accessing our approach to addiction treatment and approach to mental health treatment pages.
This page was reviewed by Stephanie Chick (FDAP) in July 2018, and is scheduled to be reviewed again in July 2020. To view all Priory drug-induced psychosis specialists, please

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Psychosis is a mental health problem which temporarily causes someone to interpret the world differently from those around them. Drug-induced psychosis, also known as 'stimulant psychosis', refers to any psychotic episode which has been caused by abuse of stimulants, an adverse reaction to prescription drugs, or excessive use of alcohol which has directly triggered a psychotic reaction.

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Psychosis (Schizophrenia) in Children and Youth

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Psychosis (Schizophrenia) Schizophrenia and other psychotic disorders are medical illnesses that result in strange or bizarre thinking, perceptions (sight, sound), behaviors, and emotions. Psychosis is a brain-based condition that is made better or worse by environmental factors - like drug use and…

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Childhood schizophrenia - Symptoms and causes

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This severe mental disorder in children involves hallucinations, delusions, and disordered thinking and behavior that can impair the ability to function.