Childhood and Early Onset Schizophrenia

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Childhood and Early Onset Schizophrenia

• Afshan Anjum, M.D.
• Assistant Professor
• Department of Child and Adolescent Psychiatry
• University of Minnesota.

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Schizophrenia The etiologic puzzle

• Age of onset during teens and late 20s,
  childhood onset is rare.
• Males have earlier age of onset
• Both genetic and environmental components
  involved
• Diverse array of both cognitive and clinical
  symptoms

• Evidence supports a neurodevelopmental hypothesis
• Drugs of abuse can mimic symptoms of
  schizophrenia
• Improvement of positive symptoms with typical
  neuroleptics
• Improvement of symptoms and cognition with
  atypical neuroleptics

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Age of onset
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Schizophrenia in Children and Adolescents

• Same criteria as that used for adults
• Rare in children
• 0.1 to 1 of patients with schizophrenia present
  prior to 10 years of age.
• 4 prior to 15 years of age
• Incidence increases after puberty
• Peak age of onset between 15 and 30 years of age
• 47 display onset (prodromal phase) prior to 21
  years of age
• 21 have psychotic symptoms prior to age 21.

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Genetic Factors
Courtesy Dr. Irv Gottesman
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Phases of Schizophrenia
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Prodromal Symptoms of Schizophrenia

• Social withdrawal
• odd or schizotypal preoccupations
• deteriorating academic performance
• Worsening hygiene and self-care skills
• dysphoria

• Idiosyncratic or bizarre behaviors
• Increase in aggressive behaviors or other conduct
  problems
• Substance abuse
• Typically the earlier the onset, the more
  insidious the prodromal phase

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Initial and follow-up diagnoses of teenage
patients with psychotic symptoms referred to the
MH-CRC
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Bipolar Affective Disorder
Gabrielle Carlson, 2000
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Child and Adolescent Schizophrenia

• Hallucinations
• Rare under 7 yrs.
• After 7 yrs. is the most common symptom
• Auditory 80
• Visual 33-46
• Delusions
• Rare under age 7 yrs.
• 41-86 will have delusions
• Less complex delusional system in younger children

• Thought disorder
• Found in 60-100 of children
• Illogical thinking and loose associations can be
  reliably detected
• Incoherence and and poverty of speech more
  difficult to assess
• Blunting of affect in 63 of children
• Catotonia is rare

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Positive Symptoms

• Hallucinations
• Auditory hallucinations
• Voices commenting
• Voices conversing
• Somatic or tactile hallucinations
• Olfactory hallucinations
• Visual hallucinations

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• Positive Symptoms - Delusions
• Persecutory delusions
• Delusions of jealousy
• Delusions of guilt or sin
• Grandiose delusions
• Religious delusions
• Somatic delusions
• Delusions of reference
• Delusions of being controlled

• Delusions of mind reading
• Thought broadcasting
• Thought insertion
• Thought withdrawal

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Positive Symptoms

• Bizarre behavior
• Clothing and appearance
• Social and sexual behavior
• Aggressive and agitated behavior
• Repetitive or stereotyped behavior

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Positive Symptoms

• Positive formal thought disorder
• Derailment
• Tangentiality
• Incoherence
• Illogicality
• Circumstantiality
• Pressure of speech
• Distractible speech
• Clanging

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Negative Symptoms

• Affective flattening or blunting
• Unchanging facial expression
• Decreased spontaneous movements
• Paucity of expressive gestures
• Poor eye contact
• Affective responsivity
• Lack of vocal inflections

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Negative Symptoms

• Inappropriate affect
• Alogia
• Poverty of speech
• Poverty of content of speech
• Blocking
• Increased latency of response

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Negative Symptoms

• Anhedonia - Asociality
• Recreational interests and activities
• Sexual activity
• Ability to feel intimacy and closeness
• Relationship with friends and peers

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Negative Symptoms

• Attention
• Social inattentiveness
• Inattentiveness during mental status testing
• Avolition - Apathy
• Grooming and hygiene
• Impersistence at work or school
• Physical anergia

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Neuropsycholgical Domains

• Verbal memory
• Nonverbal memory
• Working memory
• Language skills
• visuospatial skills
• Initiation / Speed

• Sustained and selective attention
• Problem solving
• Motor

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Cognitive Function of Adolescents and Adults
Compared to Controls
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Cognitive Function of Adolescents and Adults
Compared to ControlsNeuroleptic Naïve
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Cognitive Performance of Adults versus Youth
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The Etiology of SchizophreniaNeurodevelopmental
versus Neurodegenerative

• A case against neurodegeneration
• No evidence of excessive gliosis
• A number of studies do not demonstrate
  progression of the neurobiological findings
• Ventricular Brain Ratio
• Gray or white matter
• Neuropsychological performance

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Structural Brain Differences Reported in Previous
Studies of Children and Adolescents with
Schizophrenia
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Medical causes of psychotic symptoms

• Metabolic
• Renal failure, hepatic failure, pancreatic
  disease, hyper/hyponatremia, hyper/hypocalcemia,
  hyper/hypoglycemia, porphyria, dehydration,
  hyperosmolar states
• Endocrinopathies
• Addisons disease, Cushings disease,
  hypo/hyperthyroidism, hyperparathyroidism,
  panhypopituitarism

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Medical causes of psychotic symptoms

• Nutritional deficiency states
• Thiamine, folate, B12, niacin
• Autoimmune disorders
• Systemic Lupus Erythematosus, temporal arteritis

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Medical causes of psychotic symptoms

• Drug Induced
• Street drugs (alcohol, hallucinogens, heroin,
  inhalants, psychostimulants)
• Prescription drugs (Steroids, stimulants)
• Withdrawal (alcohol, hallucinogens, opiates,
  psychostimulants, sedative-hypnotics)
• Poisoning (Anticholinergics, carbon monoxide,
  heavy metals)

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Neurological causes of psychotic symptoms

• Infection
• Viral Herpes simplex, HIV
• Syphilis
• Parasitic
• Neoplasm, CVA, Trauma (especially frontal and
  temporal)
• Degenerative (Alzheimers disease, Picks)
• Seizure (Especially complex partial)

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Neurological causes of psychotic symptoms

• Motor Disorders
• Parkinsons, Wilsons, Huntingtons, Sydenhams
  chorea, idiopathic basal ganglia calcification,
  spinocerebellar degeneration
• Myelin Disease
• Adrenoleukodystrophy, metachromatic
  leukodystrophy, Marchiafava-Bignami disease,
  Multiple Sclerosis
• Miscellaneous
• Hydrocephalus, hypoxic encephalopathy, narcolepsy

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Ruling out medical causes of psychotic and
affective syndromes

• Laboratory studies
• CBC with differential Chemistry profile
• liver enzymes
• electrolytes, Mg, Phos, Ca, glucose
• BUN, Creat.
• Thyroid function
• T4, TSH
• Urinalysis
• Urine screen for substances of abuse

• History
• Collateral information is crucial
• Physical exam
• Especially neurological examination
• CNS Studies
• ? EEG
• ? Brain imaging

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Psychiatric Differential Diagnosisof
schizophrenia or psychotic symptoms

• Schizophrenia
• Schizoaffective disorder
• Bipolar Affective Disorder
• Brief Reactive Psychosis
• Delusional Disorder
• Postpartum Psychosis
• Psychotic Depression
• Malingering/Factitious Disorder
• Normal development

• Substance induced psychosis
• Borderline Personality Disorder
• Autism spectrum disorders
• Communication disorders
• Obsessive-Compulsive Disorder
• Schizotypal Personality Disorder
• Schizoid Personality Disorder

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As the Proton Turns Normal Brain Development
through Adolescence and Early Adulthood

• Gray matter pruning
• Linear age-related decrease in frontal and
  parietal regions and subcortical structures
  (Jernigan et al., 1991)
• Cortical GM peaks at age 4 and decreases
  thereafter (Pffererbaum et al., 1994)
• Continued myelination
• The association cortex (Yakovlev and Lecours,
  1967) and the corpus callosum (Pujol et al.,
  1993) continues to develop into the third decade
  of life.
• Steady increase in cortical WM volume until the
  age of 20 (Pffererbaum et al, 1994)

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Treatment Options
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Psychotropic Medications

• Neuroleptics
• Mood Stabilizers
• Anxiolytics
• PsychoSocial Interventions
• Psychotherapy
• Individual Therapy (CBT, CBSST)
• Family Therapy
• Psychoeducational Psychotherapy

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Prognosis

• Stability of Diagnosis
• Treatment Response