Start psychosis in childhood and adolescence
It is necessary to reach a consensus with operational criteria for the definition of the first psychotic episode that is valid for clinical intervention (ex. early diagnosis and treatment) and research (eg. Get homogeneous samples) (Breitborde et al., 2009).In the last decade there has been much interest in distinguishing a group of individuals who have attenuated psychotic symptoms, a high -risk mental state of suffering from psychosis or first -degree family history of psychosis (van and cols.,2000, 2009;Schultze-lutter et al., 2011 for critical review of concepts). The identification of these mental states of psychosis risk, which can precede the development of schizophrenia (between 1 in 5 and 1 in 10 will develop it according to Ruhrmann and Cols.,2010), it has clinical and therapeutic. They are characterized by the presence of attenuated, brief or transient positive psychotic symptoms that generate a search for medical care. People with schizotypal disorder that present recent functional deterioration (Schultze-Lutter and Cols are also included in this group., 2012) .
Many of the patients suffer from other disorders such as depression or personality anomalies (Schultze-Lutter and Cols.,2011). Attenuated psychosis syndrome is a new diagnostic proposal pending more research from the DSM-5 (DSM-5, 2014).According to current diagnostic classifications, psychotic disorders are clinical syndromes that include schizophrenia, bipolar disorder, schizophreniform disorders, schizoofective disorder, psychosis induced by drug or drugs, short reactive psychosis, psychosis secondary to another organic pathology, theDeluste disorder and a residual category, unpalified psychosis (CIE-10, DSM-5).
In their first manifestations all these clinical syndromes can be indistinguishable. For this reason it is useful to speak together with psychotic syndrome.There are no different categories of psychotic disorders for the infant-juvenile population, based on diagnostic continuity from childhood to adult life based on the clinic, family history and biological characteristics of these disorders, as we will present later.
Early starting psychosis are defined as those that appear before 18 years. Morel in 1890 makes one of the first descriptions in the medical literature of a child with symptoms that would be compatible with a psychosis. At the beginning of the 20th century with the descriptions of Kraepelin (14 -year -old boy with early dementia), Sanctis (“Dementis praecocisimma”) or heller (“Children’s Dementia”) (Mardomingo, 1994), the existence of psychosis in thechildhood and adolescence. However, the nosological value of psychosis (schizophrenia) in children has been discussed for years. In the first part of the twentieth century, a very heterogeneous group of pathologies that included all serious childhood disorders, also autism, also, 1992).
In the DSM-II diagnostic manual (1968), schizophrenia and autistic disorders were included in the child psychosis category. Throughout the 60s and 70s and thanks to the excellent studies of KrolCommunication, language, socialization and interests with varying degrees of mental retard. Since the appearance of the DSM-iiien 1980, children with psychosis have been diagnosed with the same criteria as adults. Currently, the reliability and validity of the diagnosis of psychosis in children and adolescents are firmly established (Maziade and Cols., nineteen ninety six;Jarbin et al., 2003;Helgeland et al., 2005;French and cols., 2008;Castro-Fornieles et al., 2011)
Early starting psychosis can present an unstable diagnosis. French and cols. They find in a group of initial psychosis in adolescence that the most stable diagnosis at two years is schizophrenia (100%), followed by bipolar disorder (71.4%), and with less stability are schizoective disorder, psychosisBrief reactive and schizophreniform (50%) disorder and with the lowest diagnostic stability, non-specific psychosis (16.7%) is shown;On the other hand, the diagnostic agreement from the beginning to the year is 54.2% and between the first year and the second year is 95.7%, indicating that the diagnostic stability is reached in the first year (Fraguas y Cols., 2008). In another diagnostic stability study at two years that includes 83 patients between 9-17 years with the first psychotic episode, some included in this thesis, it refers that the global consistency of the diagnosis is 63.9%; the group of patients with bipolar disorder is the one that reaches the greatest diagnostic stability with 92.3%, followed by schizophrenia spectrum disorders with 90%stability. Depressive disorders have low stability (37.5%) and the lowest was for non -specified psychotic disorders (11.7%) and short psychotic disorders (0%). The initial psychosocial functioning was the best diagnosis predictor to follow-up (Castro-Fornieles y Cols., 2011).Schizophrenia is a complex and weakening brain disorder that causes alteration of perception, cognition, will, social communication and emotions, in addition, it produces hallucinatory and delusional experiences. Around a third of schizophrenia cases begin before the age of 18 (Resschmidt and Cols., 1994).
You can distinguish three Sub types of schizophrenia according to the age of onset:
- Starting schizophrenia in childhood or very early starting (before the age of 13)
- Starting schizophrenia in adolescence or early starting (between 14 and 17 years).-
- Starting schizophrenia in adulthood (from 18 years)
Starting schizophrenia in childhood is very rare, it is estimated that it affects 1/10.000 children and should not (usually) diagnose below 7 years. The early onset of psychosis -especially below the age of 13 -has been postulated that it has an important clinical and forecasting significance. (Amminger et al., 2011;Driver et al. 2013).Early starting schizophrenia presents the same clinical symptoms (hallucinations, delusions, disorganized language, social isolation, apathy and other negative symptoms for at least one month) and the same biological abnormalities as adult starting suggesting continuity and a common neurobiological substrate(Kravariti et al., 2003;Asarnow et al. 2004) . The study of bipolar disorder in children and adolescents has deserved special attention in the last two decades, however it is not a recent clinical category. The first clinical descriptions of the pediatric age mania were made at the beginning of the 20th century by Kraepelin. However, until about 20 years ago an extremely rare disorder has been considered, which contrasts with the fact that approximately two thirds of adults with bipolar disorder refer to the beginning of affective symptoms during childhood and adolescence (Goldstein & Levitt, 2006).
Some authors point out that during the last decade we have been able to go from a situation of diagnostic omission of bipolar disorders in children and adolescents to a possible over-diagnosis in some contexts (Goldstein & Birmaher, 2013). Although some clinical symptoms necessary for diagnosis are super smooth to behaviors or emotions of neurode development stages, especially in school and adolescence age, the clinical criteria of DSM-IV TR (and DSM-5) and CIE 10th forThe diagnosis of bipolar disorder are identical for children/adolescents and adults.
Given the evolutionary moment in which psychotic disorder bursts into the child-youth population offers several methodological advantages due to the least number of confusion variables: less adverse vital events in the patient’s life, less time of evolution of the disease, less use of drugs and most homogeneous sociodemographic variables (eg years of education).
Clinical course and prognosis of starting psychosis in childhood and adolescence
The clinical evolution of psychosis is variable and heterogeneous, from patients who tend to improve to those who show progressive deterioration. In addition, the study of the clinical course has some methodological difficulties, being the main one, which there is no agreement regarding the definition and the operational criteria of clinical remission and relapse. Therefore, follow-up studies offer a lot of variability in the results (Schultze-Lutter and Cols.,2011).
Most patients reach the clinical remission of the first episode, however the relapse rate is high. Naturalistic longitudinal studies show that the clinical course of psychosis is characterized by the presence of relapses. Some authors find that almost 80% of patients with first psychotic episode will suffer a relapse in the first 5 years (Robinson and Cols.1999;Rummer et al.2003). This data has clinical relevance, because the risk of persistent psychotic symptoms is increased to each relap., 2003;Stephenson et al., 2000).
In a recent meta-analysis of follow-up studies and risk factors of relapse after the first psychotic episode, it is found that the frequency of relapse per year, defined by the presence of positive psychotic symptoms, is 28%, within two years of the43% and at 3 years of 54% of patients. The most powerful associated factors to relapse in this meta-analysis are: the little adherence to treatment, the persistence of substance use/abuse, the critical comments of the caregiver and the patient’s predictive bad adjustment (Alvarez-Jimenez and Cols.2012). Most medium and long -term follow -up studies, especially in early starting schizophrenia, agree that the forecast is between "intermediate" and "bad" in 70% of patients (Clemmensen and Cols.,2012). However, in the Melbourne cohort (Epic: Early Psychosis Prevention and Intervention Center) patients with early starting schizophrenia have a better prognosis at 7 years than those of adult starters. Possibly, in relation to early detection and highly specialized treatment that these patients have received on this device (it cannot be generalized to other assistance contexts) and that must be replicated by other groups of clinicians and researchers (Amminger and Cols.,2011).Another study in the beginning psychosis in adolescence finds that positive symptoms improve during the first year, however cognitive deficits remain stable in that period of time. In addition, they find that the low intellectual quotient at the beginning of psychotic disorder increases the risk of negative symptoms per year of evolution (Wozniak and Cols.2008).
Some authors point out that early and adequate therapeutic intervention, with a good response to the beginning of the disease, is an important factor of good prognosis. They specify that the evolution of psychosis in the first two years can predict the long-term clinical result (15-20 years) (Crespo-Facorro and Cols.2007;Emsley et al.2007;Harrison et al.2001). The scientific literature proposes numerous forecast factors of the onset schizophrenia in childhood and adolescence, which include the age of onset, sex, family history of schizophrenia, early intervention, initial response to treatment, subjective response to treatment, recovery style,Severity of symptoms, presence and severity of negative symptoms, cognitive performance, latency of rapid eye movements, cerebral structural abnormalities, minor neurological signs, late dyskinesia, presence of adverse vital events, under predictive functioning, social isolation, and especially,The elapsed time between the appearance of relevant psychotic symptomatology and the first treatment or "duration of unrelated psychosis" (McClellan and Cols., 2013).
Of all of them, the factors identified as more consistent are: the level of premómbid., 2000;Addington et al., 2005;Vyas et al., 2007;Yu-Chen Kao et al., 2010).All these data suggest that early onset schizophrenia can be a more serious form of the disorder.The longitudinal studies data of the clinical course confirm that there is diagnostic continuity from childhood and adolescence to adulthood (Glasdtein & Birmaher, 2012).The clinical course of type I bipolar disorders (mania and depression episodes) onset in childhood and adolescence is similar to that of adults, with recovery and recurrence episodes.
Some particular clinical characteristics of the child and adolescent have been identified: the depressive cycle is more frequent in bipolarity, the tendency to maintain clinical symptoms for a longer time and greater number of episodes and with more mixed symptoms than in the adult, the worst prognosis inBipolar initial disorders in childhood and adolescence are associated with more early onset, rapid humor fluctuations, mixed presentations, presence of psychosis, comorbidity and parental psychopathology (Birmaher & Axelson 2006).
Leave feedback