Updated: Jun 26, 2019
This is the introduction to a 6-part series on the assessment of psychosis in children, adolescents, and young adults. The 6 parts will be (probably):
Part 1: Base Rates and When Not To Worry Part 2: Risk Factors and Usual Course of Emerging Psychosis Part 3: Positive and Negative Symptoms and the CAMPS model Part 4: Neurocognitive Correlates of Psychosis and Differential Diagnosis Part 5: Assessment Instruments and My Preferred Battery Part 6: Communicating Evaluation Results and Treatment Recommendations
Let's start with a case study:
Roger, 17, is referred to you for evaluation after being discharged from a brief hospital inpatient placement. About 6 months ago, Roger reported to his parents that he was hearing voices that commented on his day and insulted him. His parents did not know what to make of this, so they took him to a counselor, who felt the voices were likely symptoms of depression and low self-esteem. During therapy, Roger confessed he has been using alcohol and marijuana daily. The therapist also noted a trauma history, suicidal ideation, and some OCD-like symptoms, such as having to check multiple times a day to make sure there are no insects in his room. The therapy primarily focused on those concerns. Last month, Roger attempted suicide, which prompted his hospital admission. Roger's discharge papers include the following diagnoses: ADHD Inattentive Subtype, Major Depressive Disorder, Obsessive-Compulsive Disorder, rule-out Generalized Anxiety Disorder, cannabis use disorder, alcohol use disorder, parent-child relationship problem, avoidant personality features, and schizoid personality features. He was placed on fluoxetine and Abilify with some benefit reported.
When reviewing his history, you learn Roger was born at 29 weeks gestation. He was late to reach his milestones and needed physical therapy. As a young child, he had sensory issues and was socially immature. He struggled with playing reciprocally with other kids, and often seemed "in his own world." He had a few friends and was on the baseball team, but mostly pursued his own interests. Roger was an OK student in elementary school, but he started to struggle around age 12. He seemed to just "give up" according to his parents. He started saying he had a hard time focusing. He often complained of being confused or forgetful. Roger also stopped showing much interest in things, and often just sat around the house, not doing or saying anything. Around age 14, he started pacing a lot. He also started taking hours-long aimless walks. Sometimes he would leave school and just go walking, which had resulted in some disciplinary actions. Roger also seemed to start muttering or laughing to himself sometimes, although his parents weren't sure.
Around age 15, significant anxiety emerged. Roger's parents felt he seemed to think other people were aligned against him. He also worried all the time about bugs, and he developed some rituals to keep bugs out of his room and off of him. Around this time, Roger stopped socializing with any friends, even online. He seemed depressed and anxious all the time. He also seemed confused, and sometimes his parents weren't sure he was fully in touch with reality. He sometimes said things that didn't make sense, or confused something that really happened with something from a TV show. He could only give vague answers to things, and sometimes trailed off mid-sentence. He stays up all night and complains he can't fall asleep. His parents started wondering if maybe he has a thought disorder.
In Part 1 of this series, we'll be looking at the prevalence of psychosis and psychotic-like experiences in children and adolescents. This information will give us some context on Roger's risk level.
In Part 2, we'll be looking at the usual prodomal course of emerging psychosis, to see how Roger's course compares. We'll also be looking at risk factors that may raise the likelihood of an emerging psychosis for Roger. In Parts 3 & 4, we'll review the positive and negative symptoms of psychosis and potential neurocognitive correlates of psychosis. We'll also include differential diagnosis in Part 4. In Part 5, we'll look at available tests for psychosis and devise a test battery that may help us be confident in our diagnosis and treatment plan we develop.
And then in Part 6, we'll discuss how to best communicate the diagnosis and treatment plan to Roger and his family.