Psychosis During Adolescence: Diagnosis and Treatment

New Evidence on Importance of Early Detection and Intervention for Disorders with Psychotic Features

Psychosis is one of the most loaded words in all of mental health.

It’s also one of the most misunderstood.

That’s why most parents get scared when they hear the word psychosis or psychotic associated with their child or teen. Parents don’t understand what it means, why it’s happening, or if there’s any hope their child or teen will live a life that resembles and anything approaching typical. They don’t know if there are treatments for psychosis or psychotic disorders. If they know about treatments, they may have no idea whether those treatments work or not.

They may have heard that it’s not possible to diagnose psychosis during childhood or adolescence, which causes confusion when a mental health professional diagnoses their child with a mental health disorder characterized by psychotic features, or tells them their child or teen displays prodromal symptoms of psychosis.

To parents with children or teens who show any type psychotic symptoms, we say this: it’s okay to be scared, and it’s okay to be confused. However, with some knowledge and understanding, it’s possible to address that fear and reduce the confusion. And it’s critical to understand one thing:

It’s possible for a person with psychosis or a psychotic disorder to recovery, manage their symptoms, and live a productive life.

How?

This article will introduce an evidence-based, data driven approach to the treatment of mental health disorders with psychotic features called Coordinated Specialty Care (CSC). The CSC approach first appeared in the early 2000s, and revolves around principles such as shared decision-making, lifestyle interventions, and psychotherapy as first-line supports, as opposed to relying solely on the use of anti-psychotic medication – although in most cases, medication is an important part of the treatment of psychosis and/or psychotic disorders.

Before we discuss the components of CSC in-depth, though, we’ll define psychosis, discuss the symptoms associated with psychosis and psychotic disorders, identify risk factors, and share the warning signs common to early onset psychosis and/or psychotic disorders.

What is Psychosis?

According to the National Alliance on Mental Illness (NAMI) defines psychosis is:

“…characterized as disruptions to a person’s thoughts and perceptions that make it difficult for them to recognize what is real and what isn’t. These disruptions are often experienced as seeing, hearing, and believing things that aren’t real or having strange, persistent thoughts, behaviors, and emotions.”

The thoughts and perceptions of things that aren’t real fall into two categories: hallucinations and delusions. We’ll discuss hallucinations and delusions in a moment.  First, with the above definition in mind, it’s important to understand that psychosis is not a mental health disorder, alone and in and of itself. Psychosis an psychotic features, such including hallucinations and delusions, are symptoms common to a range of diagnosable mental health disorders. The following list details the mental health disorders that include psychosis and/or psychotic symptoms.

Mental Health Disorders With Psychosis/Psychotic Symptoms

  • Schizophrenia:
    • Hallucinations and/or delusions are common
  • Schizoaffective disorder:
    • Hallucinations/delusions are common
    • Symptoms of bipolar disorder or depression may appear
    • Psychotic elements of depression may appear
  • Schizophreniform disorder
    • Hallucinations and/or delusions of limited duration may appear for a relatively short time, often for more than one month and less than six
  • Brief psychotic disorder:
    • Stress, trauma, or extreme disruption can trigger temporary psychotic symptoms
      • Symptom duration is less typically under one month
      • Symptoms dissipate as time from stressful event increases
    • Mood disorders:
      • Psychotic symptoms may accompany early onset bipolar disorder in children or adolescents
      • In some cases, psychotic symptoms may accompany early major depressive disorder (MDD) in children or adolescents
      • Psychotic symptoms may accompany the early onset of borderline personality disorder in children or adolescents
    • Substances/Drugs:
      • Heavy, chronic substance misuse or severe SUD may trigger psychotic symptoms in adolescents
      • Substance-related psychotic symptoms that do not disappear after 1-2 weeks may reveal the presence an undiagnosed psychotic disorder
    • Psychotic disorder, injury related:
      • A head injury, a brain tumor, or other neurological pathologies may trigger the onset of psychotic symptoms

We’ll now define exactly what we – and mental health professionals – mean by hallucinations and delusions.

Insight Into Psychotic Symptoms: What are Hallucinations and Delusions?

Hallucinations are things a person sees, hears, or feels – i.e. sensory perceptions – when there is nor real or identifiable source that causes those perceptions.

Delusions are thoughts or beliefs held by a person that are objectively and demonstrably false or untrue.

Here’s a list of hallucinations that are common to children or teens with psychotic symptoms:

Auditory

Auditory hallucinations occur when an individual hears things that are not there. These are the most common type of hallucination in children and teens with psychotic symptoms, and may include hearing voices. Auditory hallucinations that include voices follow common patterns:

  • Voices may tell a person they should or should not do specific things
  • They may warn them of imminent harm
  • Teens may hear voices inside their head, or they may hear voices as if they come from people near them who are not really there
  • In some cases, voices are not overtly discernable as real words, but instead sound like background noise

Visual

A teen with psychotic hallucinations may see people or objects, that do not exist. In some cases, visual hallucinations may cause confusion, but are not necessarily disturbing. For instance, a teen may see an object like a chair or table where there’s neither, or see a chair or table change color, when in reality the chair does not change color. On the other hand, visual hallucinations can be disturbing, scary, and upsetting. For instance, a teen may see a person who is not really there, see blood on a floor or wall, or look in the mirror and see a face that’s not theirs.

Olfactory

A teen with psychotic hallucinations may smell things that aren’t there. The olfactory hallucinations may be pleasant, such as perfume, flowers, or fresh-cut grass. In other cases, they may be unpleasant, such as garbage or the sulfur-like smell of rotting eggs. For some teens, these hallucinations come and go, while for others, they may be present all the time.

Tactile

A teen with psychotic hallucinations may feel sensations that are not real. Examples include insects crawling on skin, mysterious sensations under their skin, or a distinct touch on the arm or shoulder, as if by a person, when no person is there

Those are the hallucinations most common to psychotic disorders. Next, we offer a list of delusions that are common to teens with psychotic symptoms:

Grandeur

Teens with delusions of grandeur might genuinely believe they have knowledge, skills, talents, or powers that only they possess. They may believe they’re famous or have a relationship with a famous person when in reality they are not famous and don’t know they famous person with whom they believe they have a relationship. Delusions of grandeur may also involve religious or spiritual matters. For instance, a teen may believe they have a special or direct connection with religious figures or spiritual doctrines.

Persecution

Teens with delusions of persecution may believe an external, malign entity actively works to cause them harm, in the absence of any concrete evidence to prove that belief. Delusions of persecution often involve a belief in being followed, watched, plotted against, or prevented from accomplishing goals or dreams. Like delusions of grandeur, these beliefs exist in the absence of any concrete evidence or proof they’re true.

Thought-Related

A teen with psychotic delusions may think their thoughts are or have been:

  • Directed or controlled by other people, entities, or forces
  • Placed in their head by other people, entities, or forces
  • Taken, removed, or stolen from their mind by other people, entities, or forces
  • Made audible or known to others, by some outside force or entity
  • Read by others

Relationship-Related

A teen with psychosis or psychotic delusions may think a spouse or partner is unfaithful when they aren’t. They may also believe they’re loved by, or in a relationship with, a person – often a famous celebrity – they’ve never met and don’t know.

We’ve now defined psychosis, identified the mental health disorders that may include psychotic symptoms, and defined and described what mental health professionals mean when they refer to hallucinations and delusions associated with psychosis and/or psychotic disorders.

Now let’s examine the warning signs of and risk factors for psychosis in teens.

Psychosis Among Adolescents: Warning Signs and Risk Factors

There’s a phrase in mental health parents of teens with any mental health disorder – especially one even peripherally associated with psychotic symptoms – should know: first episode psychosis, or FEP. According to the NAMI psychosis resource page, FEP “refers to when a person first shows signs of beginning to lose contact with reality.”

One problem in identifying the early onset of psychosis is that the warning signs are often similar to typical teen behavior parents find mystifying. For instance, NAMI indicates the following early warning signs of psychosis:

  • Sudden/unexpected/unusual drop in academic performance
  • Problems concentrating
  • Difficulty thinking clearly
  • Unusual suspiciousness of or uneasiness with other people
  • Decline in personal hygiene or self-care
  • Spending more time alone than usual/ever before
  • Withdrawal from friends/family

Parents reading that list can see what we mean. While those are early warning signs of psychosis, they’re also not at all uncommon for teens. When those warning signs coexist or appear closely in time to this next list of warning signs, things change:

  • Seeing, hearing, and tasting things that aren’t there
  • Believing things that are not true or verifiable
  • Recurring, persistent, unusual thoughts or beliefs they can’t ignore
  • Powerful inappropriate emotions
  • Total lack of emotion
  • Inability to concentrate or think clearly
  • Rapid decline is self-care
  • Sudden withdrawal from friends or family

Several of those items overlap, but there’s a difference. When delusions or hallucinations – item one on this second list – appear alongside a rapid decline in hygiene or a sudden withdrawal from friends or family, experts say that may indicate that a teen has had, or is currently in the midst of, a first episode of psychosis, or FEP.

Now let’s look at the risk factors for psychosis.

Adolescent Psychosis: Risk Factors

  • Genetic factors:
    • Family history of psychosis or psychotic disorders
  • Trauma, which may include:
    • Problems or complications during pregnancy
    • Exposure to pathogens in utero
    • Early life adversity/adverse childhood experiences, including:
      • Physical, sexual, or emotional abuse
      • Neglect
      • Experiencing violence/war
    • Extreme substance use, misuse, or substance use disorder
    • Mental health/behavioral health disorder diagnosis, including:

Those last two bullets reflect data in new research published in the last two years. This study identified an association between FEP, substance use, and adverse childhood experiences. This study identified a relationship between ADHD and subsequent psychotic disorder. The first showed an increased likelihood of FEP with childhood adversity and substance use, while the second – a large-scale meta-analysis the examined records from close to 2 million adolescents – showed an increased likelihood of developing a psychotic disorder for children and teens diagnosed with ADHD.

That’s what makes the next section of this article essential reading for parents of teens with any kind of mental health disorder, especially those with any of the risk factors who also show the warning signs of early psychosis/psychotic symptoms.

Coordinated Specialty Care (CSC): Effective Treatment for Psychosis and Psychotic Disorders

We mention CSC in the introduction to this article. It’s a relatively new approach to treating psychosis and psychotic disorder that has a broad evidence base, is gaining recognition among mental health providers, and is now considered go-to, first-line approach to treating psychosis in children, teenagers, and adults.

Here are the core components of CSC, according to the American Psychiatric Association (APA).

Coordinated Specialty Care: An Overview

1. Shared Decision-Making Framework

  • Evidence shows that a collaborative approach between psychiatrists, teens, and family members about treatment approaches yields the most favorable outcomes. A team-based approach that places emphasis on both the psychiatrist’s expertise in mental health and the teen’s expertise in their “own lived experience, social/cultural context, and value system” is associated with “better outcomes, increased adherence with treatment recommendations, and reduced stigma.

2. Psychotherapy

    • Cognitive behavioral therapy for psychosis (CBTp): CBT for psychosis – CBTp – can happen in individual, group, or family settings. Therapists work with teens to improve functioning impaired by psychotic symptoms and reduce distress caused by psychotic symptoms. In contrast to treatment for adults, psychotherapy is the first-line treatment for adolescent psychosis. In fact, recent research shows that initial treatment with antipsychotics can result not only in inappropriate treatment, but also misdiagnosis of psychotic disorders.

3. Medication Management

    • Medication is an important part of the treatment of psychotic disorders. However, research (link in previous bullet) shows that using medication as a first-line treatment for adolescents with any indication of psychosis can mask symptoms and result in delayed treatment, and an extension of the period called the DUR, or Duration of Untreated Psychosis. An extension of DUR can lead to negative outcomes, as compared with early intervention following the CDC model.
    • With the above bullet point in mind, the two types of medication common in the treatment of psychosis and psychotic disorders are:
      • Typical antipsychotics
      • Atypical antipsychotics

4. Case Management

    • Evidence shows that when a case manager is responsible for coordinating care and communicating with all relevant participants, outcomes improve

5. Family Education and Support

    • When the family learns and understands all they can about psychotic disorders and the symptoms of psychosis – especially parents and siblings – they’re in a better position to support their loved one as they learn to manage their symptoms.

6. Peer Support

    • Mutual aid groups – think AA for people with psychosis – can help teens understand that they’re not alone. Talking with others who have learned to manage hallucination, delusions, and other aspects of psychotic disorders can have a greater impact than listening to people without direct, experiential knowledge to those types of symptoms.

7. Supported Employment, Education, and Lifestyle Changes

    • CSC is a multimodal approach that’s designed to support a person with psychosis across all phases of their life. That includes creating intentional educational spaces and employment opportunities that account for teens with psychotic disorders.
    • The multimodal approach includes lifestyle changes designed to improve overall life satisfaction, such as:
      • Exercise
      • Nutrition
      • Mindfulness
      • Social skills
      • Sleep hygiene
      • Avoiding alcohol and substance use

That last bullet point is important for parents of teens with psychosis to understand. It’s also important for the teens themselves to understand. It implies that a full and productive life is possible, and that early intervention that follows the CSC template leads to the best known outcomes for teens diagnosed with psychosis or a psychotic disorder.

The Benefits of Coordinated Specialty Care (CSC)

In early 2017, NAMI published a handbook for mental health providers called First Episode Psychosis Programs. This handbook serves as a guide for providers seeking to implement a CSC program in their state, city, or community.

The authors of the handbook identify the following benefits of CSC for teens with psychosis or a mental health disorder with psychotic features:

  • Reduced symptoms
  • Improved quality of life
  • Active engagement of family members
  • Improved social and family relationships
  • Higher rates of school completion
  • Higher rates of employment

These positive outcomes are a distinct departure from the past, when the prevailing opinion was that psychosis and psychotic disorders were virtually untreatable. We now know that early diagnosis and appropriate intervention lead to the best outcomes. We also know that appropriate intervention means an intentional combination of therapy, family/social/peer support, education, medication, and lifestyle changes. When all these components are in place, a teen with psychosis can learn to manage their symptoms and live a full and productive life.

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.