CINAPS
Cambridge Independent Neuroscience and Psychiatry Services
Psychotic Disorders
Definitions
Psychosis/psychotic
This term is used when someone experiences something that is not real, such as hearing sounds or voices (auditory hallucinations), seeing images or visions (visual hallucinations) or any other experience, such as feeling something on your skin (tactile hallucinations).
Psychosis/psychotic
This term is used when someone is unable to determine what is real and what is not real.
People can believe, hear, see or experience something that is very real to them, that does not exist for anyone else and is unreal to everyone else. This can be a sound, voice, image or vision, any experience or belief. This experience can be extremely anxiety provoking. Psychosis has many possible causes, one of which is drug use.
People can believe, hear, see or experience something that is very real to them, that does not exist for anyone else and is unreal to everyone else. This can be a sound, voice, image or vision, any experience or belief. This experience can be extremely anxiety provoking. Psychosis has many possible causes, one of which is drug use.
Hallucination
This term is used when someone experiences something that is not real, such as hearing sounds or voices (auditory hallucinations), seeing images or visions (visual hallucinations) or any other experience, such as feeling something on your skin (tactile hallucinations).
It is important to know that there are other causes for "voices" and "visions" and that they are not always hallucinations.
A Child Psychiatrist can help you to understand whether or not you are experiencing hallucinations or some other psychotic phenomena, through a clinical assessment (a series of questions) and a mental state examination (spending time with you, asking you questions, but also observing your behaviour). It is also sometimes necessary to request a brain scan or refer to Neurology when serious medical causes are suspected. It is very important to seek advice when you are experiencing any of these symptoms.
An example: A 16 year old boy hearing two people having a discussion, very clearly and loudly, constantly, whilst there is no one about.
Delusion
This term is used when someone has a fixed, false belief that is not in keeping with his/her religious or cultural background or beliefs.
An example: A young girl grows herbs in her garden and looks up from her garden at the planes as they pass over her house. She says she believes that these planes are coming specifically to collect the herbs she grows.
Thought disorder
This term is used when someone describes their thoughts as "jumbled up" and finds it very difficult to think straight. The listener also finds it very difficult to follow the conversation and understand what is being said.
An example: "I am going to the sea, my cat likes mice, I am tired of having to find puzzles with roses, the neighbour is bringing his photographs."
Causes and Differential Diagnoses of 'Hearing Voices' and Psychosis
Hearing voices is not necessarily related to psychosis. Hearing voices can be a normal phenomena in certain contexts and ages. Your Child Psychiatrist will be able to consider the quality of the experience as part of a detailed assessment, and give you their opinion.
Hearing voices can also occur as part of developmental problems as well as mental health problems for instance relating to anxiety or anxiety disorders.
Medical problems such as trauma, infections, inflammatory disorders, cerebrovascular, cardiovascular, cardiopulmonary and renal disease, including substances and medication, can cause delirium in children, young people and adults. Patients with delirium often present with confusion and psychosis.
Usually, when the medical cause is resolved (for instance when an infection is treated), the delirium (and psychotic symptoms) resolves.
It is very important to rule out medical causes for psychosis. Child Psychiatrists are medical doctors and will consider your child's physical health, often working collaboratively with your GP or a Paediatrician. Urine analysis, a drug screen, FBC, ESR, UEC, CPR, LFT, THY, GLUC, Calcium and Phosphate levels may be requested to rule out medical causes. ECGs, EEGs and MRIs may also be requested (for instance if cardiovascular disease, epilepsy or neurodegenerative disease is suspected).
It can sometimes be difficult to distinguish 'voices' from auditory hallucinations (psychosis) and specialist psychiatric advice must be requested. Many medical disorders and mental illness can appear similar to 'hearing voices' or psychosis or Schizophrenia (they are called differential diagnoses) and it is important that these be ruled out. See Differential Diagnoses of Schizophrenia for more details.
It is important to not think 'Schizophrenia' immediately if you or your family member presents with 'voices', hallucinations or delusions. It is important that other causes are first considered and ruled out. It is however very important to seek advice immediately, as medical causes for delirium (often presents similar to psychosis) can be serious if not treated without delay.
It is also important to remember that a diagnosis of Schizophrenia does not mean that your life or general independent functioning is over as you know it. Early intervention and treatment can provide good outcomes/prognosis. This is another reason for seeking advice without delay.
What is Schizophrenia?
Schizophrenia is an illness that affects thinking, behaviour and emotions.
Schizophrenia affects approximately 1 in every 100 people and is very rare before puberty. The onset of the illness is most likely between age 15 and 35.
More than one type of illness exist, such as Paranoid Schizophrenia, Hebephrenic Schizophrenia or Catatonic Schizophrenia.
What are the symptoms?
Young people can present very differently to one another and especially to adults. Children frequently have a more uneven development, more negative symptoms, more disorganised behaviour and hallucinations in different modalities compared to adults. The quality of delusions can also vary.
Negative Symptoms
Apathy, withdrawn, spending time alone mostly (not social)
Poor concentration and poor energy
Alogia (poverty of speech, content or thought block)
Unemotional and detached (affective flattening)
Avolition for instance neglecting self care
Losing interest in things once liked (anhedonia)
Not being able to function and carry on with everyday activities, such as work, school or study
Positive Symptoms
Delusions
Hallucinations
Thought disorder
Disorganised presentation
Bizarre behaviour, agitation, aggression
Formal Thought Disorder such as structurally abnormal thoughts ('muddled')
Symptoms are often divided into 'First Rank Symptoms' and 'Second Rank Symptoms'.
What causes Schizophrenia?
We are not sure what causes Schizophrenia. We know that there is a genetic component, which means that Schizophrenia can run in families.
As with most mental health problems, it is often useful to consider a bio-psycho-social model when considering cause and risk factors. Risk factors are similar to other mental health problems such as premorbid personality, chronic stress and substance abuse.
How is Schizophrenia diagnosed?
Your GP will refer you to a Child Psychiatrist with your concerns. A Psychiatrist will, through a detailed history and mental state examination, make a diagnosis if appropriate.
It is important to consider other medical disorders or mental illnesses that may look like Schizophrenia, but is not Schizophrenia (differential diagnoses).
Differential Diagnoses of Schizophrenia:
Delirium (medical causes for confusion - information provided earlier)
Medical problems such as Complex Partial Seizures, Wilson's disease, Metachromatic leukodystrophy
Medication
Developmental disorders
As with most mental health problems, it is often useful to consider a bio-psycho-social model when considering cause and risk factors. Risk factors are similar to other mental health problems such as premorbid personality, chronic stress and substance abuse.
How is Schizophrenia diagnosed?
Your GP will refer you to a Child Psychiatrist with your concerns. A Psychiatrist will, through a detailed history and mental state examination, make a diagnosis if appropriate.
It is important to consider other medical disorders or mental illnesses that may look like Schizophrenia, but is not Schizophrenia (differential diagnoses).
Differential Diagnoses of Schizophrenia:
Delirium (medical causes for confusion - information provided earlier)
Medical problems such as Complex Partial Seizures, Wilson's disease, Metachromatic leukodystrophy
Medication
Developmental disorders
Neurodevelopmental disorders such as Autism Spectrum Disorder
Affective psychosis
Schizoaffective disorder
Atypical psychosis
Schizotypal personality features
Anxiety disorders
Substance Abuse (psychosis may remain after drug use has been discontinued)
This list is not comprehensive.
How is Schizophrenia treated?
Medication plays a key role in treatment. Early identification, diagnoses and treatment are very important and related to outcome/prognosis.
The aim is to treat the symptoms and to enable the young person to live a functional, healthy life.
Medication is often more effective for positive symptoms.
Psychiatrists will recommend antipsychotic medication and in a small percentage of cases it may take more than one trial to find the most suitable and effective medication and dosage.
Child Psychiatrists will need to see young people regularly, to make sure the medication is effective and that there are no harmful side-effects.
It is important to note the possible serious side-effects of the medication and to discuss these with the Psychiatrist. The risk of side-effects needs to be balanced with the risks that this illness can have for the patient's health, safety and general functioning in life.
Psychoeducation (information and discussion about the illness, treatment and prevention) is a very important part of the treatment.
Family work and individual work can and should also be offered by CAMHS.
Please see Helpful Links for further (mostly non-medical) information on support for children, young people and families.
Affective psychosis
Schizoaffective disorder
Atypical psychosis
Schizotypal personality features
Anxiety disorders
Substance Abuse (psychosis may remain after drug use has been discontinued)
This list is not comprehensive.
How is Schizophrenia treated?
Medication plays a key role in treatment. Early identification, diagnoses and treatment are very important and related to outcome/prognosis.
The aim is to treat the symptoms and to enable the young person to live a functional, healthy life.
Medication is often more effective for positive symptoms.
Psychiatrists will recommend antipsychotic medication and in a small percentage of cases it may take more than one trial to find the most suitable and effective medication and dosage.
Child Psychiatrists will need to see young people regularly, to make sure the medication is effective and that there are no harmful side-effects.
It is important to note the possible serious side-effects of the medication and to discuss these with the Psychiatrist. The risk of side-effects needs to be balanced with the risks that this illness can have for the patient's health, safety and general functioning in life.
Psychoeducation (information and discussion about the illness, treatment and prevention) is a very important part of the treatment.
Family work and individual work can and should also be offered by CAMHS.
Please see Helpful Links for further (mostly non-medical) information on support for children, young people and families.
