Patient Presentation
A 16-year-old male came to clinic for his health supervision and sports physical visit. Overall he was doing well in school and was looking forward to his upcoming cross-country, basketball and baseball seasons. His mother was worried because his cousin, who attended the same high school, had just been released from inpatient psychiatric treatment for newly diagnosed schizophrenia. The past medical history was non-contributory. The family history was positive for his mother and aunt having anxiety. There was no known depression, but in his uncle’s family there was some unknown mental illness where the uncle’s brother had needed inpatient psychiatric treatment. The review of systems was negative.

The pertinent physical exam showed normal vital signs and normal growth. His weight was 15% and height was 75% consistent with his family.
His examination was normal.

The diagnosis of a healthy male was made. During the interview the mother voiced concern for the nephew, her sister and the family. The patient said that he didn’t know how to really talk with his cousin about this and what to say to other students at school. Options for handling these situations were discussed, and during this time the patient said, “He was just like me and then got weird over this last year. I’m worried it might happen to me. He started saying weird things, not all the time, but enough. He also got paranoid and would want to sit in the corner of the locker room where he could see his stuff. If you left him alone he was okay but would get really angry and physical if you went near him or his stuff. I could kind of handle this so my locker was next to his, but sometimes he would hit me.” The pediatrician said that he didn’t know a lot about schizophrenia but that it was treatable but could be difficult to treat. He also said that it can be inherited but noted that it was less likely as he was a cousin and not a brother. “I don’t know the exact numbers. This is a tough diagnosis because patients with it need long-term treatment and support. You both need support too. I can refer you to a therapist who can help with some of the questions you have as well as helping you sort out some of the feelings you have. You could do this now or sometime in the future if you want. Your school counselor could also be someone to talk to and also knows the school situation,” he offered. The patient said he was going to talk with the counselor. “I’m friends with his son ’cause we run together. He’s okay and I think I can ask him some questions,” the patient said. His mother was also offered mental health support for herself and 13 year old daughter, but declined at the time.

Discussion
“Psychosis [is] characterized by aberrant thinking, perceptions and behavior….”
Psychosis includes the presence of hallucinations and delusions without insight into them.

Psychosis can be seen in a mental health disorder such as schizophrenia spectrum disorders, autism spectrum disorders, mood disorders and also medical conditions.
Common medical conditions where psychosis can be a feature in the teen and young adult population includes:

• Substance abuse – most common
• Medication side effects or toxin
• Epilepsy
• Traumatic brain injury
• Brain tumor
• Stroke
• Metabolic diseases

In the adult population other medical conditions include dementia, adrenoleukodystrophy, Huntington disease, multiple sclerosis, Parkinson disease, and other metabolic abnormalities.

Psychosis-like experiences can be normative childhood experiences such as an overactive imagination or explaining egregious behavior done for secondary gain. They can also be common in various mood disorders such as anxiety or psychological trauma.

Characteristics of a potential psychotic state in a child or youth includes:

• Consciousness is clear. Patient is oriented to surroundings, time, and space
• Hallucinations and delusions
• Socially withdrawn
• Bizarre behavior including talking or responding to invisible objects or people
• Language is abnormal. Production can be minimal or patient can be mute. It may be repetitive or incoherent.
• Inappropriate emotional response – excessive emotional response (i.e. excessively giggling) or laughing over a serious matter
• Activity changes – often hypoactivity but may be hyperactivity

Learning Point
Childhood onset (<13 years old) or early onset (teens) schizophrenia is rare at about 1:10,000 prevalence but this increases to 4:1000 lifetime prevalence in the adult population. Males have an increased risk. Overall risk is about 0.7-1% but is higher in families. In twin studies there is ~60-80% risk. “…[T]he morbid schizophrenia risk for parents and siblings of [adult onset schizophrenia] probands was 6% and 9% respectively, compared to 1% in the general population.”

The genetics are very complex, and polygenetic involving possibly thousands of genes. Currently there appears to be some environmental risk factors as well including complications of pregnancy/delivery, older father, born in winter/spring, living in an urban setting and cannabis use. Antipsychotic medication can significantly decrease the symptoms and reduce the relapse risk. Schizophrenia is also a chronic illness that requires continued treatment and support for patients and families.

Schizophrenia usually doesn’t appear suddenly but there are cognitive and mood symptoms often before other symptoms. For the diagnosis of schizophrenia the symptoms must be occurring for longer than 1 month and need to include at least 2 of more of the following:

• Hallucinations – beliefs of sensory perception in the absence of a stimuli
• Delusions – wrong beliefs or thoughts that continue to be held even when contradictory evidence is presented or can be logically reasoned
• Disordered speech – i.e. incoherent or derailment (frequent interruptions, jumping from idea to idea)
• Disorganized or catatonic behavior
• Negative symptoms such as lack of motivation, speaking less, flat affect, reduced pleasure in life events

Questions for Further Discussion
1. What is included in the differential diagnosis of hallucinations? A review can be found here
2. How common is Bipolar Disorder? A review can be found here
3. What are the resources in your community for substance abuse?
4. What are some of the chronic mental and physical health issues that people with schizophrenia are at risk for?

Related Cases

Disease: Schizophrenia | Psychotic Disorders

Symptom/Presentation: Health Maintenance and Disease Prevention | Genetic Disorder

Specialty: Psychiatry and Psychology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Schizophrenia and Psychotic Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Arciniegas DB. Psychosis. Continuum (Minneap Minn). 2015;21(3 Behavioral Neurology and Neuropsychiatry):715-736. doi:10.1212/01.CON.0000466662.89908.e7

McClellan J. Psychosis in Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2018;57(5):308-312. doi:10.1016/j.jaac.2018.01.021

Forsyth JK, Asarnow RF. Genetics of Childhood-Onset Schizophrenia: 2019 Update. Child Adolesc Psychiatr Clin N Am. 2020;29(1):157-170. doi:10.1016/j.chc.2019.08.007

Tandon R, Nasrallah H, Akbarian S, et al. The schizophrenia syndrome, circa 2024: What we know and how that informs its nature. Schizophr Res. 2024;264:1-28. doi:10.1016/j.schres.2023.11.015

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa