Navigating Adolescent Psychosis

The prime time for developing a psychotic disorder is in the late teens to early 30s, according to the National Institutes of Health. But sometimes psychosis can develop earlier in the teens. Some public figures, such as Cecilia McGough, who leads the organization Students With Psychosis, have reported symptoms as early as childhood. So when can you expect to see symptoms, and what might you see?

This is an interview with Alexander Moxam, MD, a psychiatrist at the Children’s Hospital of Philadelphia's First Episode of Psychosis Program about adolescent psychosis.

SM: How is adolescent psychosis different than adult psychosis? And how can parents and friends watch out for signs and symptoms?

AM: The prototypical psychotic disorder, schizophrenia, as well as other psychotic disorders, are diagnosed with the same criteria, or constellation of symptoms, in adolescents as they are in adults.

That being said, the already dynamic and often emotionally daunting developmental phase of adolescence offers a complex background in which psychosis symptoms can present. Misdiagnosis is common, especially at the time of onset, as psychosis symptoms can be present across psychiatric and medical diagnoses. One needs to account for the developmental phase and cultural context of individual presentations. This is also complicated by the fact that psychosis experiences (e.g., hearing voices, delusional-type thinking) are more common in adolescence than in adults, and most children who report hallucinations do not meet the criteria for a psychotic illness.

The most concerning marker for the presence of a psychotic illness is the combination of a decline in functioning in the context of disorganized behavior.

Parents and friends can watch for the following signs:

• Hallucinations—whispering or talking to themself, looking somewhere and you don’t know why.
• Delusions—voicing persistent beliefs that are not shared by others, feeling that people are watching them or colluding against them, feeling as though the television/music/media is communicating with them directly.
• Social withdrawal—pulling away from typical social activities, demonstrating a sort of suspiciousness.
• A decline in school performance.
• Cognitive disorganization—speech no longer making sense, difficult-to-follow thought process, drawing connections between words or terms that seem illogical.

SM: Is there more hope for recovery for adolescents with psychosis if you catch it earlier versus waiting until their adult years to treat it?

AM: The duration of untreated psychosis is an important prognostic factor in a person’s recovery. There is good evidence that if you can shorten the duration of untreated psychosis you can improve your chance of staying engaged in school/work, decrease rehospitalizations, and improve quality-of-life measures.

There is a validated treatment for individuals in the early stages of psychosis called coordinated specialty care comprising talk therapy, supported education and employment services, medication management, peer support, case management, and family psychoeducation. There are multiple trials demonstrating the effectiveness of this intervention. In those trials, individuals who had a shorter duration of untreated psychosis showed greater improvement in the reduction of symptoms and quality of life.

Psychosis can make it extremely difficult for a person to attend to the developmental task at hand and their value-based pursuits. A major goal of treatment is to support individuals in reengaging with the world (family, friends, school, work, hobbies). We know it can be easier to resume relationships and activities if the pause is brief rather than protracted. This is my thought on one of the reasons it’s important to shorten the duration of untreated psychosis and for people to enter treatment early rather than wait.

SM: What would you like patients and families to know about the physician's side of treating individuals with psychosis?

AM: The courses of psychotic illnesses are often difficult to predict and can be diagnostically unclear for months to years. It takes time working with individuals and families to come to a diagnosis and to find an effective medication regimen.

Medication is not the only treatment required for psychosis. It is important that families understand that medication only has limited effects, and it is just as important for individuals to engage in therapy and other aspects of care.

I also try to engage families in treatment as much as possible. As a physician, I have such a limited amount of time with individuals. Families provide such critical information about the people I work with, and I often inform choices I make in terms of medication management based on family observations.