PSYCHIATRIC DISORDERS DIAGNOSIS & CLINICAL FEATURES

Dr. A. Chua
July 11, 2013  All of the symptoms included in adult-onset
By Group 2Big schizophrenia may be manifest in children
with the disorder
EARLY ONSET SCHIZOPHRENIA  onset is frequently insidious
 may take months or years to meet all of the
 Childhood-onset schizophrenia (COS)
diagnostic criteria for schizophrenia
 rare and severe form of schizophrenia
 onset of psychotic symptoms by age 12  Eventually becomes socially rejected and
years clingy and have limited social skills.
 heritable etiology  have histories of delayed motor and verbal
 decreased anterior cingulated gyrus (ACG)
volumes with age milestones
 absence of normal decreased left- to right-  do poorly in school despite having normal
ACG volume asymmetry ( influencing intelligence
attention and emotion regulation)
 may experience deterioration of function,
 extremely high rates of comorbid
psychiatric disorders, ADHD, depressive emergence of psychotic symptoms, or may
disorders, separation anxiety disorder never achieve expected level of functioning
EPIDEMIOLOGY  Auditory hallucinations commonly occur
 in prepubertal children is exceedingly rare
 Visual hallucinations are often frightening
 In adolescents, estimated to be 50 times
that in younger children  Delusions are present , increase in
 Boys have a slight preponderance frequency with increased age: persecutory,
 Boys often identified at a younger age than grandiose, and religious
girls
 Schizophrenia rarely is diagnosed in  Blunted or inappropriate affects appear
children younger than 5 years of age almost universally
 Psychotic symptoms emerge insidiously  giggle inappropriately or cry without being
 Diagnostic criteria are met gradually over
able to explain why.
time
 onset of schizophrenia is sudden in a  Formal thought disorders, including
previously well-functioning child loosening of associations and thought
 prevalence of schizophrenia among the blocking are common
parents
 Schizotypal personality disorder similar but  Unlike adults with schizophrenia, children
it does not have psychotic features like in with schizophrenia do not have poverty of
schizophrenia speech content, but they speak less than
ETIOLOGY other children of the same intelligence;
 Heritability- 80 % ambiguous in the way in which they refer to
 Neurodevelopmental abnormalities persons, objects, and events
 disturbed communication styles :High  frequently have poor motor functioning,
expressed emotion, critical responses in visuospatial impairments, and attention
families deficits
  DSM-IV-TR delineates five types of  Blunted affect
schizophrenia:  social isolation
1. Paranoid  eccentric thoughts
2. Disorganized  ideas of reference
3. Catatonic  bizarre behavior
4. Undifferentiated  In schizotypal personality disorder,
5. residual hallucinations, delusions, incoherence are
not present
PATHOLOGY & LAB EXAMS  Hallucinations alone are not
 No specific laboratory tests are evidence of schizophrenia; patient must
diagnostically specific for COS show either a deterioration of function or
 neuroimaging studies suggest: decreased an inability to meet an expected
ACG volumes with age and an absence of developmental level to warrant the
the normal decreased left- to right-ACG diagnosis of schizophrenia
volume asymmetry  Hallucinations and delusions of
 High incidences of pregnancy and birth schizophrenia are more likely to have a
complications bizarre quality than those of children with
 Electroencephalogram studies have not depressive disorders hallucinations,
been helpful in distinguishing children with delusions, and formal thought disorder are
schizophrenia from other children core features of schizophrenia ; not
expected features of pervasive
DIFFERENTIAL DIAGNOSIS developmental disorders
 autistic disorder  Pervasive developmental disorders usually
 bipolar disorders are diagnosed by 3 years of age, but
 depressive psychotic disorders schizophrenia with childhood onset can
 multicomplex developmental syndromes rarely be diagnosed before 5 years of age.
 Asperger’s syndrome,
 drug-induced psychosis COURSE & PROGNOSIS
Important predictors:
CONCURRENT DISORDERS  child’s level of functioning before the onset
 ADHD of schizophrenia
 oppositional defiant disorder  the age of onset
 depression  IQ
 response to pharmacologic interventions
DIAGNOSTIC CRITERIA  how much functioning the child regained
 hallucinations after the first episode
 delusions  amount of support available from the family
 incoherence
  Children with developmental delays, o Possible long term side effects:
dyskinesia (informed consent, careful
learning disorders, lower IQ, and premorbid monitoring, reevaluation
behavioral disorders, such as ADHD and  Psychotherapy - supportive
conduct disorder are likely to have the most  Educational and family interventions
o Behavior modification to reduce
guarded prognoses
maladaptive behaviors
 Worst prognoses occurred in children with o Appropriate family involvement and
schizophrenia that was diagnosed before interaction
o Address learning and developmental
they were 10 years of age and who had
problems
preexisting personality disorders.
The Four A’s
PSYCHOLOGICAL MODELS 1. Association- looseness of thought
 Psychoanalytic 2. Affect
 Hallucinations as the breakthrough of the 3. Autism
unconscious, the material projected into 4. Ambivalence
the world and then perceived as coming
from the outside Positive and Negative Symptoms

+ Positive - Negative
ASSESSMENT Hallucinations Affective flattening
 Historical information Delusions Alogia
o Early development and characteristics Bizarre behaviors Avoliton-Apathy
of development Formal Thought Attention
o Age and nature of onset Disorder
o Medical and family history
 Psychological information
o Assessment of IQ *pls refer to your books with regards to DSM IV
o Assessment of adaptive behavior Criteria for Schizophrenia*
o Projective testing
 Medical and Psychiatric evaluation Reference:
o Evaluate thought disturbance, 10th Ed. Kaplan & Sadocks
hallucinations, delusions, etc. Notes from Upper Class
o Evaluate associated affective problems
o Note unusual features of course/
presentation
o PE for signs of associated medical
conditions
o Evaluate possible substance abuse
o Neurologic exam (including EEG)
o Toxicology screen if indicated

TREATMENT
 Pharmacotherapy
o Antipsychotics: second generation
antipsychotics are the first line
treatment
o Serotonin-Dopamine Agonist- act as
antagonist,decreases EPS side effects