Transcription:
Time To Talk About Psychosis

Dr Anne Walters (Host): If you are a regular listener of Mindcast, you may notice we discuss topics related to mental health that are relatively common. Today, we're switching gears and we will be discussing a topic that is very much more rare, childhood psychosis.

Psychosis is a severe mental illness where children interpret reality differently than others, affecting just about 1% of young people. The timing of childhood psychosis is precarious with symptoms often presenting simultaneously with puberty, making it difficult to make an assessment sometimes until it is too late. But we do know that with early intervention, prognosis is improved in comparison to children who do not receive intervention. With childhood psychosis, the early age of onset presents special challenges for diagnosis, treatment, education, and emotional and social developement. So with that, what is psychosis?

Today, we'll be talking to expert, Dr. Elizabeth Thompson, to help us understand just that. At a high level, we know that children with the disorder show impaired thinking and emotions that cause them to lose contact with reality. Psychosis is the illness most often associated with schizophrenia. We often hear that schizophrenia cannot be diagnosed in early childhood. However, doctors like Dr. Thompson are at the forefront working to identify high risk kids so that intervention can be made, changing the trajectory of a child's life. Welcome, Dr. Thompson.

Dr Elizabeth Thompson: Hi. Thank you. Good to be here.

Dr Anne Walters (Host): This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts at Bradley Hospital. I'm Dr. Anne Walters with Dr. Greg Fritz. Thanks for listening.

Dr Greg Fritz (Host): Hi, Dr. Thompson. It's nice to see you in person and have you on the podcast today. So, this work with early identification of psychosis in children is relatively new and I find it very exciting. Can you tell us some of the symptoms that you and your colleagues are looking for to identify psychosis early?

Dr Elizabeth Thompson: Yeah, sure. So generally speaking, psychosis is talking about a disconnection from reality. So, that can come in different forms. The most common symptoms are things like hallucination, so having perceptual experiences that aren't true to life, so hearing things, seeing things, or maybe experiencing anything out of any five senses that isn't actually happening.

Delusions are another type of symptom of psychosis, and that is believing things that aren't founded in reality. So oftentimes, this can look like things like paranoia, where people are feeling like others are out to get them or feeling targeted by other people. So, those are the core symptoms of psychosis.

We also know that other experiences like having lots of disorganized thoughts can come about and that can make kids have a hard time communicating and it can sound sort of like jumbled thoughts or bizarre thoughts that are hard to make sense of. So, those are the core symptoms that we're looking for in kids.

And we know that prior to the emergence of full threshold psychosis, which would get a diagnosis from a mental health professional, oftentimes kids start to experience these things infrequently or at a level that's less severe than full threshold psychosis, but they're causing some kind of distress or impairment. So, they're starting to get in the way, they're concerning and they're causing some confusion for kids.

Dr Anne Walters (Host): So, psychosis is somewhat mainstream with terms like psychotic break and schizophrenia used often to explain and generalize mental illness. But the reality is these conditions are rare, aren't they?

Dr Elizabeth Thompson: Yeah. So, psychosis in a general sense refers to the experience of isolated symptoms, and I'll talk about that in a second. But a lot of times people think about psychosis as schizophrenia, which is a very specific presentation, a chronic presentation of the symptoms that I was explaining earlier. So, schizophrenia is very rare. In children under the age of 18, we see about one in somewhere from 500 to 10,000 kids, so that's a very broad range. I think estimates are not entirely, accurate or depend a little bit on some other factors, but it's quite rare in children under 18.

Very early psychosis is under the age of 13, and that's incredibly rare. So, we only see that in about one in 10,000 to 50,000 kids. So, we're talking about a rare disorder when we're speaking about schizophrenia in particular. If we're talking about psychosis experiences, so maybe an isolated symptom, it's actually a lot more common. And so, that's one of the things that I think is important to emphasize with families. We actually see that, in children, up to two-thirds of kids have an isolated experience that looks like psychosis. So, that could be something like a hallucination. They may hear things when nothing is actually there. And in childhood, nine to 11 years old, that's very, very frequent, again about two-thirds of kids. That doesn't mean they're going to develop a psychotic disorder. It's kind of an isolated experience, and the vast majority of kids have those experiences sort of subside, go away with time without any kind of intervention. As kids get older, we see these experiences go down in frequency. So, about 20% percent of adolescents experience these types of things at some point in their life. Again, that doesn't mean they have a diagnosed psychotic disorder. It just means that these symptoms might come and go.

And what makes them meaningful is some of the characteristics of these experiences. So, that is things like the amount of distress it's causing, the amount it's getting in the way, interfering with friends or school or other responsibilities and then also, if they're having trouble distinguishing reality from these experiences. So if there's some confusion there or disorganization, that might be a sign that these symptoms are more significant and something to talk to a doctor about.

Dr Greg Fritz (Host): I had one other question about that. In teenagers, presumably these experiences are distinguished from things that happen if they're using drugs or illicit medications or whatever, right?

Dr Elizabeth Thompson: Yeah. So, that's something we'll talk a little bit more about when we talk about assessment. But yes, if it's happening in the context of substance use, we wouldn't call that psychosis. We would call that a consequence of the substance use.

Dr Greg Fritz (Host): Got it. So, what are some of the risk factors that you and your colleagues are looking for that can help you predict a potential diagnosis of psychosis down the line?

Dr Elizabeth Thompson: So, that's a great question. I could talk a long time about that, but I'll just briefly mention some of the things. So, genetics are big. We know that psychosis tends to run in families, specifically schizophrenia. And what we know is that kids who have a parent with psychosis are at the highest risk. So, we do ask a lot about family history to get a sense of whether that might be a genetic vulnerability that an individual already has.

Then, we know that early in life there's some disruptions in central nervous system development that can make kids more prone to psychosis. So if there's difficulty during birth or if there's any kind of trauma around the birth time, that can sometimes leave an individual vulnerable for psychosis. So, we oftentimes talk about milestones and very early development. And then, some other things are more environmental. So, experiencing trauma, especially sexual abuse, is linked to future psychosis as well as substance use, as you mentioned. And in particular, we know that marijuana use, especially marijuana use early on in childhood, is linked to future psychosis, so not symptoms that are tied to the use in the sense that it's around the time they're high, but symptoms that kind of persist and continue on after a child has those drugs out of their system. So, substance use is a big one. Especially now with legalization of recreational use, I think we're going to see that coming up even more and more.

So, those are some of the factors that we look for. And then in a general sense, stress is really another thing that's linked to psychosis. So, we have a model of psychosis that is really the two-hit model, thinking that the first hit might be something like genetics or very early development that leaves someone vulnerable. And the second hit is some kind of stressor that might trigger psychosis, and that could be an isolated event, or it can be stress over time, so daily stress due to circumstances that someone is living in.

And we know that actually COVID might be one of those stressors. So, unfortunately, we've seen a rise in psychosis due to COVID, and we need a lot more research in that area. Some of that might be stress-related, some of that might actually be linked to COVID and the illness itself, so we're not quite sure about that. But we do know that, unfortunately, psychosis seems to be on the rise as a result of the pandemic.

Dr Anne Walters (Host): So, I guess in some ways the takeaway here is that it's a multifactor process that, you know, can have contributions from genetics, environment, multiple factors that sort of converge.

Dr Elizabeth Thompson: Yeah, exactly.

Dr Anne Walters (Host): So, stress does seem to be at an all time high and you referred to the pandemic as part of that, manifesting in all sorts of ways for children and teens. Can you explain how stress and other comorbidities might impact early detection?

Dr Elizabeth Thompson: Yeah, sure. So, we do know that lots of kids who develop psychosis have some comorbid concerns, and that can be quite a lot of things. But most often, it's things like depression, anxiety, trauma, and these kids are coming in for treatment oftentimes in mental health settings, hopefully. So we're seeing them in our clinics and in our hospitals.

Unfortunately, psychosis might not be at the forefront of a lot of clinician's minds, especially if they don't have a lot of experience in it. So if you're seeing a kid for depression or anxiety, you tend to focus your therapy on that need, and you might not circle back to ask about psychosis. And what we do know is, as some of these things persist longer, psychosis might start to crop up.

So as you are treating someone for these other comorbidities, it's good to have an eye on psychosis. And we know that if we don't ask kids about these experiences, oftentimes they don't bring them up spontaneously on their own. So, it's really on the clinician or the parents and to be sort of asking about these types of symptoms, especially if they might have a suspicion that some of this stuff is going on.

And in fact, some research does show that kids who are in treatment for other mental health difficulties actually go longer without appropriate treatment for psychosis compared to kids who are coming to our EDs or coming to acute crisis services for psychosis specifically. So, we actually do see a delay in getting kids the right services.

Dr Anne Walters (Host): Yeah. What's the statistic on that? It used to be that it could be sometimes up to a year before something like schizophrenia, for example, was diagnosed or identified. Is that still pretty accurate in terms of delays?

Dr Elizabeth Thompson: Yeah, I think so. It actually used to be longer in the US. It used to be closer to two years for a duration of untreated psychosis. So, that's the time between the start of symptoms and the initiation of appropriate care. We have made a lot of steps in the direction of early detection in the US, so there's a lot of funding from the National Institute of Mental Health to try to build more screening and more clinics. So, I believe that number is going down, will go down. I'm not exactly sure where it's at right now, but it's usually months, if not years.

Dr Anne Walters (Host): And could you talk a little bit about the misconception of violence and schizophrenia sort of going hand in hand, or violence and psychosis going hand in hand, I think especially when we get a lot of media coverage of mass shootings and people seem to always talk about or ask the question, you know, Was this person out of touch with reality? Were they psychotic? So, what do you think about that?

Dr Elizabeth Thompson: This is a really, really important issue. So I'm glad you brought it up. cuz there is a lot of false information that's kind of floating around out there. We see the word psychotic used in a lot of media, movies, headlines. And it's usually used to imply that someone is dangerous or violent, unpredictable, jealous, angry, things like that. And none of that is a part of a psychosis diagnosis. I want to clarify that, we have to be careful with our language to avoid perpetuating this type of stigma.

And just as a side note, a lot of kids that I work with are worried about that stigma. So, I've had kids ask me, "Does this mean I'm going to go on to kill people or hurt people?" So, they are digesting that and they are internalizing that stigma. So, it's really important that we're clarifying what psychosis is or is not if we're working with kids who are having some of these experiences. But most people with psychosis are not violent, so that's really, really important to get out there. Most people with psychosis do not perpetuate violence on others.

In adults with psychosis, much of the violence among individuals with psychosis is actually accounted for by comorbid substance use. So, we know that people with psychosis have high rates of substance use, and that explains a lot of the violence that we see. Not all of it, there are other factors that might play a role, so including things like exposure to abuse or other personality characteristics that aren't part of a diagnosis of psychosis. There's not a lot of research in children. So, I think we have a lot of work to do to understand violence and aggression specifically in kids with psychosis.

Some aggressive acts might be attributed to psychotic processes, so things like paranoia or having delusional beliefs, might cause people to be more scared and therefore maybe more likely to act out in their delusional content if they feel like they're being attacked. But again, the vast majority of people with psychosis are not violent and, in fact, people with psychosis are much more likely to have violence perpetrated against them than to perpetrate violence.

Dr Greg Fritz (Host): So, I'm imagining that a parent listening to this discussion and it seems to be quite close to home, what advice would you have for somebody like that as to what they could do for their own child after hearing this?

Dr Elizabeth Thompson: That is an excellent question. I think that some of that depends a little on the circumstance. I think that if you are noticing that your child is struggling with any type of mental health concerns, so you notice things like them withdrawing or losing interest in things they used to enjoy, not talking to you as much if you know that they're being bullied at school. Think step one is to get in to see a mental health professional and get an evaluation done, not necessarily specifically for psychosis, but that could be part of that evaluation. If you're noticing signs that a child might be having some hallucinations or they're sharing thoughts with you that sound delusional, then I think you'd want to seek out a professional that has some experience in psychosis specifically, and ask to have some of these symptoms evaluated.

For parents who are hearing some of this stuff from their kids, I think it's really, really important to listen and be open in hearing about these experiences, trying not to judge or make statements that make people feel like you don't believe them or they're going crazy, because a lot of times the first reactions parents have or clinicians have to these experiences really impact how much the kids are going to talk about these going forward. So if you're acting shocked or you're telling people that's not real, then that tells kids, "Don't talk about this and hold it inside," and that's not the message we want to send. We want to encourage kids to share these experiences early on as possible so that they can get the help they need.

Dr Greg Fritz (Host): Thank you very much, Dr. Thompson. This has been really interesting. I'm aware that you've fairly recently opened a clinic here at Bradley Hospital to help kids in early stages of psychosis and the assessment process and so forth. Could you tell us a little bit about that?

Dr Elizabeth Thompson: Yes, of course. So, we have our new clinic, it's called the Stride Clinic, and it's here at Bradley. And we see kids for all sorts of reasons referred from families and clinicians for some indication that they might have something on the psychosis spectrum. So, that can be some signs that your child might have kind of jumbled thoughts or difficulty communicating. It could be an expression of hallucinations or delusions or it could be just uncertainty about what's going on with a kid.

We start with an assessment. So, we do a comprehensive diagnostic assessment that looks at lots of different mental health conditions, not just psychosis. And that helps us to figure out kind of everything that's on the table and help the family plan for what services might be most appropriate.

Since there are really high rates of comorbidities, sometimes treatment for trauma might be the first step. Sometimes treatment for depression. So, we can help make those, recommendations and make those referrals to get kids in the services they need. We also offer monitoring through our clinic, which basically means we do an assessment and then we check in with families over time to make sure they're hooked up with the right services. And if psychosis seems to be progressing, getting worse for their kids, that might be a time to engage them in our treatment services. So, we also offer treatment for individuals and families to help manage some of these symptoms and help kids build coping skills so that they're able to do the things they want to do, make friends, be successful in school, pursue their goals. So, assessment and treatment or consultation to providers if they just have questions and they want to learn more.

Dr Greg Fritz (Host): Terrific. Thanks so much for being with us today. It's very, very enlightening. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/podcast for topics of interest to you.

This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts at Bradley Hospital. I'm Dr. Greg Fritz with Dr. Anne Walters. Thank you for listening.