2Introduction Group of conditions Characterised by loss of contact with reality(neuroses .. morbid ways of dealing with reality)Uncommon in childhoodDifficult to diagnose from fantasy and imaginationChildren’s thoughts not confined to the logical
3Diagnosis Reluctance to diagnose in children Rarely diagnosed before 7 Onset often insidiousDiagnosis often made retrospectivelyIncidence highest in late adolescenceAutism not a psychosis
4Pathology A major psychosis: delusions hallucinations thought disorder communication disorderdeterioration of social functioningDifficult to identify what is real and what is unrealNot a split personality Schizo - split, Phrenia - mindTerm (Eugen Bleuer) meant perception reality splitSplit (multiple) personality very rare - not schizophrenia
5Demography 1% of the population at some time in their lives Equal distribution race, sex, culture, class, intelligenceEqually distributed across the worldHigher incidence in late adolescence (more males)After 25, more femalesOn the whole sex incidence equalPresentation unusual after 40 and in childhoodCan occur at any ageHas never been diagnosed before 5 years
6Aetiology Cause largely unknown Main aetiological factors genetic (there is known to be an increased risk where family members have developed schizophrenia, c.f. Long 1996)one immediate family member affected = 10% riskone non-immediate family member affected = 3% riskboth parents affected = 40% riskidentical twin affected = 35-50% riskinterpersonal environment (never supported by research)high level of expressed emotion within the family (never supported by research)parental communication deviance, a less severe form of the disordered thinking that occurs in schizophrenia (never supported by research)biological (chemical and functional disturbances have been identified in schizophrenic individuals, c.f. Long 1996).
7Aetiology -2 Most likely cause .. neurotransmitter imbalance Limbic system most likely site (emotion and perception)Controls incoming stimuli (acts as a gate)Dopamine (manipulated in treatment) may be involvedCause of the imbalance not known, may be:virus or virus like proteinsgenetic predisposition.EEG often abnormalCT, MRI sometimes show microscopic brain abnormality1/3 have enlarged ventricles blood flow and glucose utilisation .. frontal lobesShown by Positron Emission Tomography (PET)
8Not caused by:It is now clear that schizophrenia is not caused by or related to:childhood experiencespovertyparenting behaviourstressdrug abuse. Drug abuse can mimic schizophrenia and can make schizophrenia less well controlled. There is no evidence that a moderate amount of alcohol will exacerbate schizophrenia.
9Clinical features Reduced ability with academic work Difficulty in maintaining relationshipsLack of volitionReduced basic hygiene and nutrition
10Personality changes Loss of feeling and emotion Lack of interest and motivationQuiet, withdrawnMoodyInappropriate emotionMay initially try to hide symptomsBecomes less popularBecomes unhappy and isolated
11DelusionsFalse beliefs held in the presence of contradictory information.There may be delusions of:persecution (paranoid delusion)grandeur, where the sufferer believes that he is important or particularly capable of a featdelusions of reference (that events in the media refer to oneself)thought insertion (ideas are being put into one’s head),thought withdrawal (taken out of one’s head),thought broadcasting (thoughts from one’s head are taken out and broadcast by the media)the belief that one’s thoughts are being controlled by an external agencythere may be a strong drive in connection with a particular mission or religious activity.Sufferer not always removed from realityOften upset because effect on loved ones is understood
12Thought disorder Move from subject to subject in unrelated manner Conversation hard to followEach sentence on its own makes senseThe individual knows what s/he is sayingMay become incoherent and obviously confusedThe becomes anxious and frightened
13Hallucinations and perceptual changes May be auditory or visual (commonly auditory)Unusually can be tactile or somaticMay be hypersensitivity to tough, sounds or smellsA quiet voice may be perceived as shoutingHallucinations occur in periods of clear consciousnessOften third part instructing a course of actionTwo voices may be heard arguing with each other about the individualSufferer is likely to obey the commands May be a perceived void of perceptionsFeel nothing, no emotionAbsence of painMay feel ‘out of time and person’In a floating void of non existence (Long 1996)
14Affect and volition Disorders of affect Sudden changes in mood Emotional reaction blunted or inappropriateMay be unconcerned re physical injuryDepressed volitionLack of interest and driveMay feel that emotions are controlled by external powerMay appear to lack intelligenceOften present with conduct disorder, depression
155 types of Schizophrenia Disorganised or hebephrenic (general)Paranoid (characterised by paranoid delusions)Catatonic (characterised by a decrease in response to the environment, together with bizarre movements and posture)residual (there is some evidence of schizophrenia but no obvious ongoing features of psychosis)undifferentiated (cannot be classified into any of the above).
16Borderline Schizophrenia May be ‘eccentric’ or ‘borderline personality disorder’ or ‘rather strange’Some communities more accepting of strange behavioura change in personality has occurred at some point in the person’s life. There may be sudden excesses where the individual becomes heavily preoccupied with some themethe individual seems overly occupied with the possibility that others are watching him or herthe individual sometimes has difficulty in controlling the train of thought and jumps from one thought to another. Sometimes the individual seems to be incoherentthings are seen and heard (fairies, ghosts) that (probably) do not existthe individual is socially withdrawn and not liked by the community, the individual is often rude and unkind to other peoplesleeplessness and frequent agitationthe individual fails to look after him or herself, often fails to wash or keep the accommodation tidy.
17Treatment Needs understanding You name it, it’s been done Patience ReassuranceStable environmentSupportive environmentLoving relationshipNon critical, non judgmental relationshipEspecially from loved onesTherapy can help the family (etc.) provide thisYou name it, it’s been doneSome of them:Anti-psychotic drugsParentectomyPsychoanalysis (both parents and child)Behaviour therapyFamily therapy (family intervention) Long term support almost always needed!!
18FamilyLong (1996, p. 9) quotes a parent: ‘The typical family of mentally ill person is often in chaos. The parents look frantically for an answer that usually cannot be found. Hope turns to despair, and some families are destroyed no matter how hard they try to survive.’
19Family: feelings sorrow (for the child they have lost) fear for the child’s safetyfear for their own safety and the safety of other members of the familyguilt that they may be to blame for the disordersocial isolationbitterness and anger that the problem has happened to them, blaming the child and other members of the familydepressiondeniala feeling that everything orientates around the schizophreniawanting to move away to escape the problem or the social consequences of the problemphysical consequences of chronic stress and discordconcern for the future.
20Family therapyFamily therapy supports the family and helps them support the sufferer e.g. by reducing communication devianceensuring they work together with the child’s psychiatrist and the mental health teamhelp the child to accept the diagnosishelp the child to see that there is hope and that life can still be enjoyable, being positivehelp child maintain record of symptoms, their timing and what treatment employedensuring that child complies with agreed treatmentsproviding structured, predictable environment, reducing sensory overload and stress.Keep unusual events to a minimum. Being consistent in behaviourmaintaining a calm interpersonal environmentavoid arguments centred on the child’s delusionsencourage setting of realistic goals, using time constructivelyencourage gradual independenceencourage gradual integration with the community.
21Drugs Anti-psychotic drugs have important long term side effects Modecate HeldolThorazine FlupenthixolStelazineReduce hallucinations and thought disorderDose individually tailoredLong term effectsAlso .. antidepressants, tranquillisers used
22The stigma of schizophrenia Is main problem - society’s reaction?Common misconceptions:Danger to others:Most withdrawn and frightenedMore likely to hurt themselvesMost people who kill, are saneMedia generated fearWe don’t like to think that sane (like us) could killTreatment of S. encouraged belief in their dangerFear of unknown, unpredictableWe associate unpredictability with dangerCan reduce unpredictability through understanding
23Prognosis Approximately: 33% only one episode of schizophrenia in the lifetime33% recurrent episodes that are largely controllable33% lifetime requirement continuing managementFor many, remains intractable and damagingMajor effect on health, happiness and life chancesMajor handicapAim should be to provide the person with a satisfying place in society and to maintain their relationship with the people they love
24The Reactive psychoses Where a psychotic episode results from a severely stressful experience.The experience would cause severe stress in anyone.The presentation may be sudden and dramatic but the condition is usually short lived.Transient psychoses have been known to occur without the exposure to stress.The presentation may include:incoherence and loosening of associationsdelusionshallucinationsdisorganised behaviourUsually treated with a short course of anti-psychotic drugs.May be admitted to a quiet, stress-free environment.May be subjected to therapy in an attempt to help him or her deal with the experience of the stressful event.These children usually make a full recovery.
25Not psychosis Non psychogenic causes of delirium Manifestation of delirium may mimic acute psychotic episode.systemic infections and fever (still a very common cause of delirium)metabolic disturbances, including hypoglycaemiabrain damagemeningitis and encephalitissome forms of epilepsythe action of drugs, ‘therapeutic’ or of misuseglue sniffing and other forms of substance misuseFever, especially in a young child, still very commonly causes delirium. Hallucinations are also very common in these circumstances.
26ReferencesBarker P (1995). Basic Child Psychiatry. Blackwell Science. London. Long P W (1996). Schizophrenia: youth’s greatest disabler. Russell AT, Bott L, Sammons C (1989). The phenomenology of schizophrenia occurring in childhood. Journal of the American Academy of Child and Adolescent Psychiatry. 28: Tanguay PE and Cantor SL (1986). Schizophrenia in children: introduction. Journal of the American Academy of Psychiatry. 25: