PSYCHIATRIC DISORDERS DIAGNOSIS & CLINICAL FEATURES
Dr. A. Chua
July 11, 2013
By Group 2Big
EARLY ONSET SCHIZOPHRENIA
 Childhood-onset schizophrenia (COS)
 rare and severe form of schizophrenia
 onset of psychotic symptoms by age 12
years
 heritable etiology
 decreased anterior cingulated gyrus (ACG)
volumes with age
 absence of normal decreased left- to right-
ACG volume asymmetry ( influencing
attention and emotion regulation)
 extremely high rates of comorbid
psychiatric disorders, ADHD, depressive
disorders, separation anxiety disorder
EPIDEMIOLOGY
 in prepubertal children is exceedingly rare
 In adolescents, estimated to be 50 times
that in younger children
 Boys have a slight preponderance
 Boys often identified at a younger age than
girls
 Schizophrenia rarely is diagnosed in
children younger than 5 years of age
 Psychotic symptoms emerge insidiously
 Diagnostic criteria are met gradually over
time
 onset of schizophrenia is sudden in a
previously well-functioning child
 prevalence of schizophrenia among the
parents
 Schizotypal personality disorder similar but
it does not have psychotic features like in
schizophrenia
ETIOLOGY
 Heritability- 80 %
 Neurodevelopmental abnormalities
 disturbed communication styles :High
expressed emotion, critical responses in
families
 All of the symptoms included in adult-onset
schizophrenia may be manifest in children
with the disorder
 onset is frequently insidious
 may take months or years to meet all of the
diagnostic criteria for schizophrenia
 Eventually becomes socially rejected and
clingy and have limited social skills.
 have histories of delayed motor and verbal
milestones
 do poorly in school despite having normal
intelligence
 may experience deterioration of function,
emergence of psychotic symptoms, or may
never achieve expected level of functioning
 Auditory hallucinations commonly occur
 Visual hallucinations are often frightening
 Delusions are present , increase in
frequency with increased age: persecutory,
grandiose, and religious
 Blunted or inappropriate affects appear
almost universally
 giggle inappropriately or cry without being
able to explain why.
 Formal thought disorders, including
loosening of associations and thought
blocking are common
 Unlike adults with schizophrenia, children
with schizophrenia do not have poverty of
speech content, but they speak less than
other children of the same intelligence;
ambiguous in the way in which they refer to
persons, objects, and events
 frequently have poor motor functioning,
visuospatial impairments, and attention
deficits
  DSM-IV-TR delineates five types of  Blunted affect
schizophrenia:  social isolation
1. Paranoid  eccentric thoughts
2. Disorganized  ideas of reference
3. Catatonic  bizarre behavior
4. Undifferentiated  In schizotypal personality disorder,
5. residual hallucinations, delusions, incoherence are
not present
PATHOLOGY & LAB EXAMS  Hallucinations alone are not
 No specific laboratory tests are evidence of schizophrenia; patient must
diagnostically specific for COS show either a deterioration of function or
 neuroimaging studies suggest: decreased an inability to meet an expected
ACG volumes with age and an absence of developmental level to warrant the
the normal decreased left- to right-ACG diagnosis of schizophrenia
volume asymmetry  Hallucinations and delusions of
 High incidences of pregnancy and birth schizophrenia are more likely to have a
complications bizarre quality than those of children with
 Electroencephalogram studies have not depressive disorders hallucinations,
been helpful in distinguishing children with delusions, and formal thought disorder are
schizophrenia from other children core features of schizophrenia ; not
expected features of pervasive
DIFFERENTIAL DIAGNOSIS developmental disorders
 autistic disorder  Pervasive developmental disorders usually
 bipolar disorders are diagnosed by 3 years of age, but
 depressive psychotic disorders schizophrenia with childhood onset can
 multicomplex developmental syndromes rarely be diagnosed before 5 years of age.
 Asperger’s syndrome,
 drug-induced psychosis COURSE & PROGNOSIS
Important predictors:
CONCURRENT DISORDERS  child’s level of functioning before the onset
 ADHD of schizophrenia
 oppositional defiant disorder  the age of onset
 depression  IQ
 response to pharmacologic interventions
DIAGNOSTIC CRITERIA  how much functioning the child regained
 hallucinations after the first episode
 delusions  amount of support available from the family
 incoherence
  Children with developmental delays,
learning disorders, lower IQ, and premorbid
behavioral disorders, such as ADHD and
conduct disorder are likely to have the most
guarded prognoses
 Worst prognoses occurred in children with
schizophrenia that was diagnosed before
they were 10 years of age and who had
preexisting personality disorders.
PSYCHOLOGICAL MODELS
 Psychoanalytic
 Hallucinations as the breakthrough of the
unconscious, the material projected into
the world and then perceived as coming
from the outside
o Possible long term side effects:
dyskinesia (informed consent, careful
monitoring, reevaluation
 Psychotherapy - supportive
 Educational and family interventions
o Behavior modification to reduce
maladaptive behaviors
o Appropriate family involvement and
interaction
o Address learning and developmental
problems
The Four A’s
1. Association- looseness of thought
2. Affect
3. Autism
4. Ambivalence
Positive and Negative Symptoms

+ Positive - Negative
ASSESSMENT Hallucinations Affective flattening
 Historical information Delusions Alogia
o Early development and characteristics Bizarre behaviors Avoliton-Apathy
of development Formal Thought Attention
o Age and nature of onset Disorder
o Medical and family history
 Psychological information
o Assessment of IQ *pls refer to your books with regards to DSM IV
o Assessment of adaptive behavior Criteria for Schizophrenia*
o Projective testing
 Medical and Psychiatric evaluation Reference:
o Evaluate thought disturbance, 10th Ed. Kaplan & Sadocks
hallucinations, delusions, etc. Notes from Upper Class
o Evaluate associated affective problems
o Note unusual features of course/
presentation
o PE for signs of associated medical
conditions
o Evaluate possible substance abuse
o Neurologic exam (including EEG)
o Toxicology screen if indicated

TREATMENT
 Pharmacotherapy
o Antipsychotics: second generation
antipsychotics are the first line
treatment
o Serotonin-Dopamine Agonist- act as
antagonist,decreases EPS side effects