Watching for Signs of Psychosis in Teens

There are fewer more frightening or challenging psychiatric conditions for a family to face than psychosis, an extreme mental state in which impaired thinking and emotions cause a person to lose contact with reality. This could mean hearing or seeing things that aren’t there (hallucinations), or believing things that aren’t true (delusions).

The illness most often associated with psychosis, schizophrenia, usually doesn’t show up until very late adolescence or early adulthood. Recently, however, experts in the field have been working to identify high-risk kids who show symptoms that could serve as early warning signs of psychosis, and several academic centers have been set up to focus on this crucial period when it may be possible to change the trajectory of mental illness.

Not all the kids who are identified with what experts call “prodromal” symptoms will progress, or “convert” to full-blown psychotic illness. But early intervention has been shown to improve outcomes for those who do. And since psychotic symptoms cause disruption across a teenager’s life, from school to friendships to family, researchers are hoping quick action can prevent impairment and prolong typical functioning.

What’s more, some of the approaches that show promise in delaying onset of psychosis or mitigating symptoms include fairly simple lifestyle changes like stress reduction and sleep hygiene, and managing co-occurring disorders like anxiety. The key: identifying at-risk kids earlier when these low-impact measures are still effective.

Prodromal symptoms are “attenuated” or weak symptoms of psychosis. Moreover, “they are a warning sign,” says Christoph Correll, MD, the medical director of the Recognition and Prevention Program (RAP) at Zucker Hillside Hospital in Queens, NY, which specializes in diagnosing and treating early symptoms of mental illness in teenagers and young adults. “These signs can happen in people who don’t go on to develop psychosis—but if we follow these people who are in the risk state based on these watered-down versions, one third will probably go on to develop psychosis. That’s a lot more than in the general population.”

Prodromal symptoms occur on a spectrum from very, very mild to severe and can include:

• Withdrawing from friends and family/feeling suspicious of others
• Changes in sleeping or eating patterns
• Less concern with appearance, clothes or hygiene
• Difficulty organizing thoughts or speech
• Loss of usual interest in activities or of motivation and energy
• Development of unusual ideas or behaviors
• Unusual perceptions, such as visions or hearing voices (or even seeing shadows)
• Feeling like things are unreal
• Change in personality
• Feelings of grandiosity (belief he has a superpower, etc)

In some cases, these symptoms represent the early stages of a disorder, and will eventually convert. In others, the symptoms actually fade or remain mild. Tiziano Colibazzi, MD, is a psychiatrist at Columbia Presbyterian’s COPE clinic (Center for Prevention and Evaluation), which was established to research and treat prodromal symptoms. “We can identify a group of people that are at clinically high risk,” says Dr. Colibazzi. “What we can’t do is narrow that group down further to identify the 30 percent who will convert.”

The right treatment for prodromal symptoms depends entirely on how severe they are when they are diagnosed. The first step is a proper and complete diagnosis by a mental health professional with experience in assessing psychotic illness.

If you see marked changes in motivation, thinking, and/or behavior in your child, the first place to start is with her pediatrician to rule out a medical illness. Substance use also needs to be ruled out as the cause of any behavior changes in adolescents. After that, you’re going to want to have your child evaluated by a qualified psychiatrist or psychologist. This in itself might be a multi-step process.

“You can’t just look at the kid once and get a bit of a history and then know what’s going on, ” says Dr. Correll. “Kids develop; symptoms develop. And the trajectory—how things change, get better or worse, what other symptoms add on to it—will be highly informative in telling us something about the prognosis, what we expect to happen.”

One aid to predicting the evolution and severity of symptoms, notes Dr. Colibazzi, is the patient’s ability to doubt his symptoms. If your child retains the self-awareness to know that it’s his mind that is playing tricks on him, it’s an indication that symptoms are still in the very early stages. As symptoms become more severe, the patient’s beliefs (whether paranoid, grandiose or hallucinatory) become increasingly difficult to challenge.

Psychotic symptoms and illnesses have been shown to vary quite a bit depending on the environment—the health of our bodies, our interpersonal relationships, our mindsets. As with any illness, but particularly important in at-risk youth, healthy living is key. Regardless of the severity of prodromal symptoms, Dr. Correll says that your child’s outcome can be improved by making sure your kid sticks to a routine that includes:

• Eating well
• Getting regular exercise
• Adhering to a regular sleep schedule
• Reducing stress as much as possible
• Staying away from drugs—particularly marijuana, which can interact with prodromal symptoms and increase the risk for psychosis significantly

Also, don’t forget to address depression and anxiety. According to Dr. Correll, “adults who eventually developed schizophrenia identified a three to five year period during which they experienced depression or anxiety before developing the prodromal symptoms of psychosis and then developed full-blown psychosis.” “So treating the depression early,” he says, “might actually interrupt the progression from depression to psychosis in some patients.”

Dr. Correll recommends trying several approaches. Mild symptoms call for more low-key treatments including:

• Psycho-education: teaching both the kid and the family more about the symptoms and the illness.
• Therapy, particularly cognitive behavioral therapy: “CBT can be good to change one’s thinking patterns,” says Correll, “and also to address developing self-esteem. We have to be careful that kids with a psychiatric diagnosis don’t self-stigmatize and get into a hopeless or negative mode where they feel they can’t achieve.”
• Lifestyle adjustments: Assessing whether the current school environment is best for the child. Perhaps a therapeutic social group to help the child cope.
• Reducing Stress: Stress is often a trigger for symptoms, so reducing stress in these kids’ lives is crucial and may prevent or delay conversion to psychotic illness.

Understanding prodromal symptoms and monitoring kids who are at high risk for psychotic illness means that parents can do more for their kids than wait for symptoms to get worse or merely hope for the best. Early monitoring and intervention can give high-risk kids an advantage, which researchers hope will eventually change the odds when it comes to psychotic illness.

“The duration of untreated psychosis does actually seem to affect the course of the illness,” Dr. Colibazzi says. The longer the illness goes untreated, the greater the chance that it will cause serious disruption in all areas of the patient’s life. “So it is reasonable to think that just following someone very closely and treating them very early, as soon as they develop symptoms, would be helpful.”