Paediatrics: Schizophrenia

Schizophrenia

Schizophrenia is characterized by disorders of thought, perception, mood, and sometimes posture. Peak onset is in young adult life. Prevalence in mid teens is 70.25% with equal numbers of males and females. Schizophrenia is very uncommon in the pre-pubertal child, when it does occur in this age group it is more common in boys.

Causes

There is a significant genetic contribution with heritability estimates as high as 82 and first-degree relatives having a 12-fold increase in risk of developing the illness. Several pre- and perinatal factors also appear to be important. These include maternal infections, stressful events during pregnancy and obstetric complications.

Clinical features

The features of schizophrenia are complex. Refer to a standard adult psy-chiatric text for a more complete description of terms and their meaning. Onset may be insidious or acute. Core features of schizophrenia include the following:

·  Thought disorder: thoughts inserted or removed from one’s head or broadcast to others or disorganized with abnormal speech patterns.

·  Auditory hallucinations: external voices discussing the patient or commenting on his/her behaviour.

·  Delusions: fixed beliefs that are false not open to reason, and not in keeping with the patient’s developmental or cultural context.

·  Disorders of posture: holding abnormal postures.

Differential diagnosis

Important differential diagnoses include affective psychosis (bipolar dis-order/psychotic depression), drug-induced psychoses, and psychoses sec-ondary to other organic conditions, temporal lobe epilepsy, autism spectrum disorder.

Assessment

As a schizophrenia-type psychosis can be caused by organic conditions, it is essential that signs of these be sought. Include full neurological exami-nation, and check for thyroid, adrenal, or pituitary dysfunction, and drug screen.

Management

Schizophrenia is often complex and difficult to treat. Children and adoles-cents will require both:

·  Specific therapies, aimed at reducing the core symptoms.

·  General therapies, relating to the psychological, social, and educational needs of the child/young person and their family.

The aim is usually to deliver treatment on an out-patient basis, but it may occasionally be necessary to consider day or in-patient treatment.

Traditional psychotherapies have little effect, but learning based thera-pies and those that increase family support and reduce intrusive and criti-cal interactions can improve functioning and decrease relapse rates.

Antipsychotic medication, most commonly the newer atypical antipsy-chotics with preferable side-effect profiles, is often effective. Relapses are fewer when families are supportive, but not intrusive or critical.

The acute phase can progress to a chronic state with poor motiva-tion and inactivity. Clozapine (an atypical antipsychotic drug) may amel-iorate this, but can cause agranulocytosis so ongoing blood monitoring is essential.

Prognosis

Prognosis is relatively good for a single acute episode in a previously well functioning teenager. However, it is worse for insidiously developing ill-ness particularly in a child with pre-existing developmental difficulties. The differentiation between schizophrenia and affective psychosis may be par-ticularly difficult and it is not uncommon for patients’ diagnoses to switch between the two.