Presentation on theme: "The Psychoses of Childhood. Introduction Group of conditions Characterised by loss of contact with reality (neuroses.. morbid ways of dealing with reality)"— Presentation transcript:
The Psychoses of Childhood
Introduction Group of conditions Characterised by loss of contact with reality (neuroses.. morbid ways of dealing with reality) Uncommon in childhood Difficult to diagnose from fantasy and imagination Children’s thoughts not confined to the logical
Diagnosis Reluctance to diagnose in children Rarely diagnosed before 7 Onset often insidious Diagnosis often made retrospectively Incidence highest in late adolescence Autism not a psychosis
Pathology A major psychosis: delusions hallucinations thought disorder communication disorder deterioration of social functioning Difficult to identify what is real and what is unreal Not a split personality Schizo - split, Phrenia - mind Term (Eugen Bleuer) meant perception reality split Split (multiple) personality very rare - not schizophrenia
Demography 1% of the population at some time in their lives Equal distribution race, sex, culture, class, intelligence Equally distributed across the world Higher incidence in late adolescence (more males) After 25, more females On the whole sex incidence equal Presentation unusual after 40 and in childhood Can occur at any age Has never been diagnosed before 5 years
Aetiology 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% risk one non-immediate family member affected = 3% risk both parents affected = 40% risk identical twin affected = 35-50% risk interpersonal 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).
Aetiology -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 involved Cause of the imbalance not known, may be: virus or virus like proteins genetic predisposition. EEG often abnormal CT, MRI sometimes show microscopic brain abnormality 1/3 have enlarged ventricles blood flow and glucose utilisation.. frontal lobes Shown by Positron Emission Tomography (PET)
Not caused by: It is now clear that schizophrenia is not caused by or related to: childhood experiences poverty parenting behaviour stress drug 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.
Clinical features Reduced ability with academic work Difficulty in maintaining relationships Lack of volition Reduced basic hygiene and nutrition
Personality changes Loss of feeling and emotion Lack of interest and motivation Quiet, withdrawn Moody Inappropriate emotion May initially try to hide symptoms Becomes less popular Becomes unhappy and isolated
Delusions False 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 feat delusions 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 agency there may be a strong drive in connection with a particular mission or religious activity. Sufferer not always removed from reality Often upset because effect on loved ones is understood
Thought disorder Move from subject to subject in unrelated manner Conversation hard to follow Each sentence on its own makes sense The individual knows what s/he is saying May become incoherent and obviously confused The becomes anxious and frightened
Hallucinations and perceptual changes May be auditory or visual (commonly auditory) Unusually can be tactile or somatic May be hypersensitivity to tough, sounds or smells A quiet voice may be perceived as shouting Hallucinations occur in periods of clear consciousness Often third part instructing a course of action Two voices may be heard arguing with each other about the individual Sufferer is likely to obey the commands May be a perceived void of perceptions Feel nothing, no emotion Absence of pain May feel ‘out of time and person’ In a floating void of non existence (Long 1996)
Affect and volition Disorders of affect Sudden changes in mood Emotional reaction blunted or inappropriate May be unconcerned re physical injury Depressed volition Lack of interest and drive May feel that emotions are controlled by external power May appear to lack intelligence Often present with conduct disorder, depression
5 types of Schizophrenia 1.Disorganised or hebephrenic (general) 2.Paranoid (characterised by paranoid delusions) 3.Catatonic (characterised by a decrease in response to the environment, together with bizarre movements and posture) 4.residual (there is some evidence of schizophrenia but no obvious ongoing features of psychosis) 5.undifferentiated (cannot be classified into any of the above).
Borderline Schizophrenia May be ‘eccentric’ or ‘borderline personality disorder’ or ‘rather strange’ Some communities more accepting of strange behaviour a 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 theme the individual seems overly occupied with the possibility that others are watching him or her the individual sometimes has difficulty in controlling the train of thought and jumps from one thought to another. Sometimes the individual seems to be incoherent things are seen and heard (fairies, ghosts) that (probably) do not exist the individual is socially withdrawn and not liked by the community, the individual is often rude and unkind to other people sleeplessness and frequent agitation the individual fails to look after him or herself, often fails to wash or keep the accommodation tidy.
Treatment You name it, it’s been done Some of them: Anti-psychotic drugs Parentectomy Psychoanalysis (both parents and child) Behaviour therapy Family therapy (family intervention) Long term support almost always needed!! Needs understanding Patience Reassurance Stable environment Supportive environment Loving relationship Non critical, non judgmental relationship Especially from loved ones Therapy can help the family (etc.) provide this
Family Long (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.’
Family: feelings sorrow (for the child they have lost) fear for the child’s safety fear for their own safety and the safety of other members of the family guilt that they may be to blame for the disorder social isolation bitterness and anger that the problem has happened to them, blaming the child and other members of the family depression denial a feeling that everything orientates around the schizophrenia wanting to move away to escape the problem or the social consequences of the problem physical consequences of chronic stress and discord concern for the future.
Family therapy Family therapy supports the family and helps them support the sufferer e.g. by reducing communication deviance ensuring they work together with the child’s psychiatrist and the mental health team help the child to accept the diagnosis help the child to see that there is hope and that life can still be enjoyable, being positive help child maintain record of symptoms, their timing and what treatment employed ensuring that child complies with agreed treatments providing structured, predictable environment, reducing sensory overload and stress. Keep unusual events to a minimum. Being consistent in behaviour maintaining a calm interpersonal environment avoid arguments centred on the child’s delusions encourage setting of realistic goals, using time constructively encourage gradual independence encourage gradual integration with the community.
Drugs Anti-psychotic drugs have important long term side effects Antipsychotic drugs Modecate Heldol Thorazine Flupenthixol Stelazine Reduce hallucinations and thought disorder Dose individually tailored Long term effects Also.. antidepressants, tranquillisers used
The stigma of schizophrenia Is main problem - society’s reaction? Common misconceptions: Danger to others: Most withdrawn and frightened More likely to hurt themselves Most people who kill, are sane Media generated fear We don’t like to think that sane (like us) could kill Treatment of S. encouraged belief in their danger Fear of unknown, unpredictable We associate unpredictability with danger Can reduce unpredictability through understanding
Prognosis Approximately: 33% only one episode of schizophrenia in the lifetime 33% recurrent episodes that are largely controllable 33% lifetime requirement continuing management For many, remains intractable and damaging Major effect on health, happiness and life chances Major handicap Aim should be to provide the person with a satisfying place in society and to maintain their relationship with the people they love
The 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 associations delusions hallucinations disorganised behaviour Usually 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.
Not 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 hypoglycaemia brain damage meningitis and encephalitis some forms of epilepsy the action of drugs, ‘therapeutic’ or of misuse glue sniffing and other forms of substance misuse Fever, especially in a young child, still very commonly causes delirium. Hallucinations are also very common in these circumstances.
References Barker 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: