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Affective and Psychotic Psychopathology in Hospitalized Adolescents
Affective and Psychotic Psychopathology in Hospitalized Adolescents ALAN APTER, M.D., AVI BLEICH, M.D.,
AND
S. TY ANO, M.D.
Abstract. The authors report on 100adolescents, ages 12 to 17, consecutively admitted to a hospital unit in Israel for severely disturbed adolescents. The Hebrew version of the K-SADS was administered, with follow-up final research diagnosis made 10 to 12 weeks after admission. Although psychotic and affective symptomatology was widespread among the inpatients, the authors found that it was possible to delineate quantitative and qualitative differences in their distribution amongsubjects grouped according to DSM-III diagnoses. J. Am. Acad. Child Adolesc. Psychiatry., 1988,27, 1:116-120. Key Words: psychopathology. affective symptomatology. psychotic behavior. disorders in this age group (Carlson and Strober, 1978, 1979; Fard et aI., 1978; Friedman et aI., 1982, Robins et aI., 1982; Strober et al., 1981). A major diagnostic dilemma has been whether or not affective disorders occur in children and adolescents. There now appears to be a definite trend toward the view that affective disorders occurring in these age groups can be diagnosed by adult DSM-III criteria but are often misdiagnosed. Misdiagnosis is most often caused by mistaking mood disorder for normative adolescent moodiness, overemphasis on behavioral manifestations with insufficient emphasis on elicitation of affective symptomatology, confusion surrounding the amorphous term "masked depression," as well as overdiagnosis of adjustment reaction of adolescence and of schizophrenia (Robins et al., 1982). Both in the United States and Israel, the differential diagnosis of schizophrenia and affective disorder may be a very difficult one to make (Biederman et al., 1979). Pope and Lipinski (1978) maintained that schizophrenia is overdiagnosed in the United States at the expense of affective disorder, and that if strict RDC or DSM-III criteria were to be applied, many patients diagnosed as suffering from schizophrenia would be reclassified as suffering from affective disorder. In U.S. studies, 20 to 25% of adolescent inpatients were diagnosed with affective disorders when operational criteria were used (Carlson and Strober, 1978, 1979; Carlson and Cantwell, 1980; Friedman et aI., 1982; Robins et aI., 1982; Strober et aI., 1981), and Loranger and Levine (1978) estimate that 20 to 35% of bipolar disorder begins during or before adolescence. As affective symptomatology is common in schizophrenia and other adolescent psychiatric disorders, however, the issue is not so easily resolved. Our own preliminary study found that in II of 68 cases, there was interrater disagreement as to diagnosis. In all II cases one of the raters diagnosed affective disorder by DSM-III criteria, the major snag being the question of mood-incongruent psychotic features (Apter and Tyano, 1982). For this reason we felt that it would be important to undertake a detailed study of the qualitative and quantitative nature of affective symptomatology across the spectrum of DSM-III diagnoses. In addition, psychotic symptomatology should likewise be studied because, in our inpatient population, these two groups of symptoms are extremely prevalent and make for much diagnostic confusion. Our working hypothesis could thus be stated as follows: affective and psychotic symptomatology will be common among adolescents hospitalized in psychiatric wards. They will, however, be distributed differently across the various diagnostic (DSM-II!) groupings.
Diagnosis has always been a vexing clinical and theoretical problem for psychiatrists. In part, this is because of the necessity of relying on subjective evaluation without the possibility of back-up laboratory investigation. Nonetheless, recent advances in diagnostic theory have enabled psychiatric diagnosis to become more reliable and valid (Endicott and Spitzer, 1978). "Criterion variance" has been limited by the introduction of operational criteria for research and clinical practice, the most widely used being those of the DSM-III. "Information variance," the other source of diagnostic error, has been reduced by the use of semistructured interviews such as the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978). These approaches have not been widely used by child psychiatrists. In general, diagnosis of children has been based on analytic formulations, family dynamics, or specific behaviors. Recently, however, there has been increasing interest in the use of structured interviews and operational criteria in child and adolescent psychiatry. The SADS Interview, which was modified for use in children and adolescents by Chambers et al. (1985), has been translated into Hebrew and has been found to have high reliability over a wide range of symptomatology and in regard to final diagnosis (Apter and Tyano, 1982). The psychiatric diagnosis of adolescents has been particularly controversial. Many investigators consider adolescence to be a period of "turmoil" marked by considerable emotional and behavioral lability (Bloss, 1968; Freud, A., 1958). This attitude rejects a descriptive approach to adolescent psychopathology and is reflected in a report by Nicholi (1967), which found "adolescent adjustment reaction" to be the most common psychopathological entity among Harvard dropouts. Several systematic investigations in the field have disputed this view and have found it possible to diagnose psychopathological entities in adolescents using child and adult psychiatric classifications (Masterson, 1967; Offer, 1969; Rutter et aI., 1976). More specifically, DSM-III criteria have been found to be reliable and valid over a wide range of psychiatric Received Feb. 13, 1986; revised Oct. 6. 1986; accepted May 7, 1987. From the Department of Child and Adolescent Psychiatry. Geha Psychiatric Hospital. Beilinson Medical Center, Petah Tiqva 49 /00. and Sackler School of Medicine. Tel Aviv University, Israel. Reprint requests to Dr. Apter, who is on sabbaticalfor the academic year 1987-88, at the Dept. of Psychiatry, Albert Einstein College (If Medicine, Yeshiva University. 1300 Morris Avenue Bldg.. Bronx. NY 10046. 0890-8567/87/2606-0116 $02.00/0 (c) 1987 bythe American Acad-
emy of Childand Adolescent Psychiatry. 116
117
AFFECTIVE AND PSYCHOTIC PSYCHOPATHOLOGY
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Evaluation ofMethod The 100 adolescents were grouped according to DSM-III diagnoses. The scale scores for each diagnostic group (mean and S.D.) were then computed and formed the basis for comparison among the diagnostic groups. Significant differences were then statistically confirmed by t tests from which p was derived.
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Population Studied One hundred eight adolescents. between the ages of 12 and 17. consecutively admitted to the unit. were studied. Eight patients (7.4%) were excluded because of ( I) organic brain disease (4 patients). (2) lack of cooperation or refusal to sign an informed consent form (1 patient). or (3) too short a hospital stay for ascertaining the DSM-III diagnosis (3 patients). We feel that the 100 remaining patients are representative of severely ill adolescent inpatients with functional psychiatric disease.
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The project was carried out in the adolescent unit of the Geha Hospital. This is a closed. or locked. unit. which admits severely disturbed adolescents from throughout Israel. Patients are referred by family practitioners from other psychiatric units where they are found to be unmanageable. and from educational. social welfare. and judicial authorities. and. in a small minority of cases. by self-referral.
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118
APTER ET AL.
Results The individual scale scores are listed in Table I according to the diagnostic groupings. As might be expected, depressed mood and thoughts were most severe in those adolescents diagnosed as having major affective disorder, depressed type (mean, 17.85; S.D ., 5.02). Patients with borderline personality disorder (mean, 16.44; S.D., 3.53), obsessive compulsive disorder (mean, 14.25; S.D., 4.7), and anorexia nervosa (mean, 13; S.D., 3.42) also had high scores, however , which were not significantl y different from those of the major depressive disorder patients. When endogenous (melancholic) features are considered, the rank order changes somewhat. Major depressives still have the highest scores (mean, 28.78; S.D., 4.82), anorexics are next (mean, 27.44; S.D ., 3.57), followed by dysthymic disorder (mean, 25.8; S.D., 6.97) and borderline personality (mean, 25.77; S.D., 2.45). Obsessive compulsive patients have relatively low endogenous features (mean, 22; S.D., 7.38), however. Features associated with depression (i.e., nonendogenous or non melancholic symptoms) are found mainly in major depressive and borderline pat ients (mean, 34; S.D., 5.29 and mean, 33; S.D., 4.21, respectively). They are also found commonly in anorexic patients (mean, 30.44; S.D., 4.69) and dysthymics (mean, 29.4; S.D., 7.33). Again, obsessive compulsive patients have relat ively low scores (mean, 24.75; S.D., 4.92). Suicidal behavior is strikingly more common in the borderline patients. This is reflected in their scale score (mean, 10.22; S.D. , 5.07), relative to major depressi ves (mean , 7.64; S.D., 4.0 I), who had the second highest average score. In addition, five of nine borderline patients (56 %) had actually made serious suicide attempts, whereas only five of 14 patients with major depression (36 %) had much such attempts. Other groups of patients with high scores on the first three depressive scales (the anorexics, obsessives, and dysthymics) had low suicide scores. Low scores were found for all depressive scales in the conduct disorder group (A surprising finding) and in the schizotypal group. Schizophrenic patients were low in all depressive scale scores apart from "associated features " (mean, 27.19; S.D., 6.09) (see Table 4). Psychotic features were common among our patients (Tables 2, 3, and 4). They were found in 100% of schizophrenic TABl.E 4.
Diagnosis
patients and in 72% of those with affective disorder. Eleven of 14 depressed patients and 7 of II manic patients were psychotic . Delusions and hallucinations were more serious in the schizophrenic group (mean, 45.19 ; S.D., 7.31) than in the affective disorder adolescents (mean, 33; S.D., 9.01), as was thought disorder (mean, 17.5; S.D., 5.9 versus mean, 11.64; S.D., 4.81). Thought disorder in schizophrenic patients was not significantly greater than in the manic patients (Table 3), however. A group of seven patients seemed to fit the DSM-III criteria for adult schizotypal personality. This corresponds to what was formerly known as "simple schizophrenia." These children were low on all the affective scales and were significantly less delusional and hallucinatory than the schizophrenics (p < 0.001), but they did have thought disorder. Discussion Although both affective and psychotic symptoms were widespread among our adolescent patients, we were able to TABLE
2. Psychotic Symptoms in Adolescent Patients With
Affective Disorderand Schizophrenia
Congruence of Psychotic Featuresand
Presence of Psychotic Features Majoraffective disorder Manictype Depressive type Schizophrenic disorder TABLE
N= N= N= N=
Mood
25 18/25 (72%) 11 7/11 (64%) 14 11/14 (79%) 26 26/26 (100%)
13/18 (72%) 5/7 (71%) 8/11 (73%) (0%)
3. Comparison of Psychotic Features BetweenSchizophrenic and Affectively IIIAdolescents
Diagnosis
Hallucinations and Delusions (mean ± S.D.)
Majoraffective disorder 32 ± 7.86··· Manictype Depressive type 33.78 ± 10.05"· Schizophrenia 45.19 ± 7.31
Thought Disorder (mean ± S.D.) 14.09 ± 4.15· 9.85 ± 4.58··· 17.5 ± 5.9
... Significance of p < 0.00 I difference between schizophrenia and affective disorder. • No significant difference between schizophrenia and affective disorder, manic type.
Comparison of Affective Features Between Schizophrenic and Affectively IIIAdolescents Features Depressive Suicidal Endogenous Associated Manic Mood and Thoughts Features" With Syndrome " Thought" and Behavior" Depression "
Affective disorder Mean S.D. Schizophrenia Mean S.D. T p
- -- - - - a Only depressed patients included. h Only manic patients included.
17.85 5.02
28.78 4.82
34 5.29
7.64 4.01
39.9 6.45
10.26 3.14 5.7 0.001
20.69 5.24 4.6 0.001
27.19 6.09 3.4 0.01
4.73 2.03 2.98 0.01
12.34 5.48 9.02 0.001
119
AFFECTIVE AND PSYCHOTIC PSYCHOPATHOLOGY
make DSM-IIl diagnosis in all of the patients. A striking feature was the change in diagnosis brought about by the use of DSM-IIl criteria. In 1976, using DSM-IIl, we reported on 140 adolescents hospitalized in our unit (Apter et al., 1976). Not one patient received an affective diagnosis, whereas in the present study 25% were so designated. This supports the contention of Fox (1981) that the use of DSM-III criteria for diagnosis broadens the concept of affective disorder and restricts the diagnosis of schizophrenia. Mania and depression are well recognized today in adolescent patients (Carlson and Strober, 1979), with many patients previously diagnosed as schizophrenics now being diagnosed as suffering from affective disorder (Faux and Rowley, 1967; Friedman et al., 1982; Mezzich and Mezzich, 1979). Another reason for the high incidence of affective disorder reported may be the decline of the use of "adolescent turmoil" and "adjustment reaction of adolescence" to describe serious adolescent psychopathology. Many of these adolescents are probably now diagnosed as borderline (Masterson, 1967), however. Certainly, our borderline personality disorder patients showed very marked mood psychopathology. Although DSMIII specifies age 18 for determining this diagnosis, this group showed the described typical features to such a degree that we felt justified in so labeling these children. The use of terms such as major affective disorder (depressed type) or adjustment reaction with depression would not have reflected their extreme instability in many areas of life. There may well be a close relationship between this condition and affective disorder (Friedman et al., 1982; Spitzer et al., 1979; Stone, 1979), and these patients may have difficulty relating to the regulation of affect. These adolescents are also very angry and resentful, and this combination of depression, aggression, mood deregulation, and instability may account for their propensity to suicide (Pfeffer, 1985). Indeed, although Shaffer (1982) considers suicide in children and adolescents not to be related to diagnosis, in our sample, II of 20 cases of severe attempted suicide were related to either depressive or borderline patients. In this regard we would like to stress that, although physically self-damaging acts and recurrent thoughts of death form part of the criteria for making the DSM-III diagnoses of Borderline Personality Disorder, or Depressive Episode, respectively, all these patients would have received the same DSM-III diagnosis even if suicidal behavior were not present. As might be expected, depressed mood was common in the anorexic and obsessive adolescents. Both disorders seem in some way to be connected to affective disease although these relationships are highly controversial (Bolton et al., 1983; Cantwell et al., 1977; Carlson and Cantwell. 1980. Feighner et al., 1972; Swift et al., 1986). In our study, the obsessive patients had severely depressed mood but few specific symptoms (endogenous, associated, or suicidal), whereas the anorectics denied being very depressed but admitted to many other endogenous and associated features of depressive disorder. Our speculation is that the obsessive children are secondarily depressed because of their serious disease, whereas denial of affect is characteristic of many anorectics. Our sample seems to differ from others reported in the literature in that many of our patients (II of 100) were manic,
although Hudgens (1974) found 10% of manic episodes in a similar sample. Our psychosis rate for depressed patients (II of 14) is also high, perhaps because our patients, all severely ill, were in our locked unit. Severity of illness as an indication for admission may also account for the lack of adjustment reactions in our sample. A surprising finding was the low incidence of mood disorder among conduct disorder patients. Possibly this reflects our decision to prefer a borderline diagnostic labeling. The four patients with organic brain disease were excluded from the study. The K-SADS does not tap organic symptoms, and these patients are very difficult to interview. Although we do quite extensive routine laboratory examinations and often order EEGs and CT scans, we are not convinced as to the extent of their value (Gabel and Hsu, 1986); on the other hand, we may be underdiagnosing these conditions. Conclusion Our study shows that psychotic and affective psychopathology are widespread among adolescent psychiatric inpatients, but that it is possible, to a great extent, to delineate quantitative and qualitative differences when these adolescents are grouped according to DSM-III diagnosis. Having shown this, we now hope to examine the validity of these diagnostic subgroups by enlarging our cohort, undertaking follow-up and treatment-response studies and family studies, as well as trying to look for biological markers such as dexamethazone suppression, H 3 imipramine uptake, TRH response, and x-ray studies of ventricular size. We hope that we will then be able to define more rigorous diagnostic criteria and indications for specific treatments, such as lithium, in the severely psychiatrically ill adolescent. References Apter, A., Tyano, S. & Wijsenbeek, H. (1976). Dimensions ofadolescent in-patient behavior. Acta Psychiat. Scand., 53:277-282. - - - - (1982), The use of a structured psychiatric interview in adolescent psychiatric inpatients. Congress of Child Psychiatry, Dublin, Ireland. Biederman, J., Lerner, J. & Belmaker, R. H. (1979), Diagnostic problems in manic psychosis. Harefuah, 97:28-30. Bloss, P. (1968), Character formation in adolescence. The Psychoanalytic Study of the Child, 23:245-263. Bolton, D., Collins, S. & Steinberg, D. (1983), The treatment of obsessive compulsive disorder in adolescents: a report of 15 cases. Brit. 1. Psychiat., 142:456-466. Cantwell, D. P., Strazenbergcr, S.. Burrough, S. J., et at. (1977), Anorexia nervosa: an affective disorder. Arch. Gen. Psychiat., 34: 1087-1093.
Carlson, G. & Strober, M. (1978), Manic depressive illness in early adolescence. 1. Am. Acad. Child Adolesc. Psychiatry, 17: 138-153. - - Strober, M. (1979), Affective disorders in ·adole~encc. Psychiat, Clin. N. Amer., 2:51 1-526. - - Cantwell, D. P. (1980), Unmasking masked depression in children and adolescents. Amer. J. Psychiat.. 137:445-449. Chambers, W. J., Puig-Antich, J. & Hirsch, M. (1985), The assessment of affective disorders in children and adolescents by semistructured interview. Arch. Gen Psychiat., 42:696-702. Endicott, J. & Spitzer, R. L. (1978), A diagnostic interview: the schedule for affective disorder and schizophrenia (SADS). Arch. Gen. Psychiat., 35:837-844. Fard, K., Hudgens, R. W. & Weiner, A. (1978), Undiagnosed psychiatric illness in adolescents: a prospective study and seven-year follow up. Arch. Gen. Psychiat., 35:279-282. Faux, E. J. & Rowley, M. C. (1967), Detecting depression in childhood. Hosp. Community Psychiatry. 18:51-58.
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Feighner, J. P., Robins, E., Goze, et al. (1972). Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiat .. 26:57-63. Fox, H. A. (1981), The DSM-I11 concept of schizophrenia. Brit. 1. Psychiat., 138:60-63. Friedman, R. C, Clarkin. J. F., Com. R., et al. (1982). DSM-I11 and affective pathology in hospitalized adolescents. J. Nerv. Ment. Dis.. 170:511-521. Freud, A. (1958), Adolescence. The Psychoanalytic Study ofthe Child. 13:255-278. Gabel, S. & Hsu, L. (1986). Routine laboratory tests in adolescent psychiatric inpatients: their value in making psychiatric diagnoses and in detecting medical disorders. J. Am. Acad. Child Adolesc. Psychiatry, 25: 113-119. Hudgens, R. W. (1974), Psychiatric Disorders In Adolescence. Baltimore: Williams & Wilkins. Loranger, A. W. & Levine, P. M. (1978), Age at onset of bipolar affective illness. Arch. Gen. Psychiat.• 35: 1345-1348. Masterson, J. F. (1967), The psychiatric dilemma of adolescence. Boston: Little, Brown. Mezzich, A. C & Mezzich, J. E. (1979). Symptomatology of depression in adolescence. J. Pers. Assess.• 43:267-275. Nicholi, A. M. (1967), Harvard dropouts: some psychiatric findings. Amer. J. Psychiat., 126:1588-1595. Offer, D. (1969), The psychological world of teenager: a study of normal adolescent boys. Amer. 1. Psychiat .. 126:917-924.
Pfeffer, C R. (1985), Self-destructive behavior in children and adolescents. Psychiat. Clin. N. Amer.. 8:215-226. Pope. H. G., & Lipinski, J. F. (1978), Schizophrenia and manic depressive illness in the light of current research. Arch. Gen. Psychiat .• 35:811-828. Robins. D. R.. Alessi. N. E.. Cook, S. C. et al. (1982). The use of the research diagnostic criteria for depression in adolescent psychiatric inpatients. J. Am. Acad. Child Adolesc. Psychiatry, 21:251-255. Rutter, M., Graham, P., Chadwich, F. D. et al. (1976), Adolescent turmoil: fact or fiction? J. Child Psychol. Psvchiat., 17:35-56. Shaffer, D. (1982), Diagnostic considerations in suicidal behavior in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 21:414-416. Spitzer, R. L., Endicott. J. & Gibbon, M. (1979), Crossing the border into borderline personality and borderline schizophrenia: the development and criteria. Arch. Gen. Psychiat.• 36: 17-24. Stone, M. H. (1979). Contemporary shift of the borderline concept from a subschizophrenic disorder to a subaffective disorder. Psvchiat. Clin. N. Amer., 3:577-594. . Strober, M.. Green. J. & Carlson. G. (1981). Reliability of psychiatric diagnosis in hospitalized adolescents. Arch. Gen. Psychiat., 38: 141145. Swift. W. J., Andrews, D. & Barklage, N. (1986), The relationship between affective disorders and eating disorders: a review of the literature. Amer. 1. Psychiat.. 143:290-299.
AND
S. TY ANO, M.D.
Abstract. The authors report on 100adolescents, ages 12 to 17, consecutively admitted to a hospital unit in Israel for severely disturbed adolescents. The Hebrew version of the K-SADS was administered, with follow-up final research diagnosis made 10 to 12 weeks after admission. Although psychotic and affective symptomatology was widespread among the inpatients, the authors found that it was possible to delineate quantitative and qualitative differences in their distribution amongsubjects grouped according to DSM-III diagnoses. J. Am. Acad. Child Adolesc. Psychiatry., 1988,27, 1:116-120. Key Words: psychopathology. affective symptomatology. psychotic behavior. disorders in this age group (Carlson and Strober, 1978, 1979; Fard et aI., 1978; Friedman et aI., 1982, Robins et aI., 1982; Strober et al., 1981). A major diagnostic dilemma has been whether or not affective disorders occur in children and adolescents. There now appears to be a definite trend toward the view that affective disorders occurring in these age groups can be diagnosed by adult DSM-III criteria but are often misdiagnosed. Misdiagnosis is most often caused by mistaking mood disorder for normative adolescent moodiness, overemphasis on behavioral manifestations with insufficient emphasis on elicitation of affective symptomatology, confusion surrounding the amorphous term "masked depression," as well as overdiagnosis of adjustment reaction of adolescence and of schizophrenia (Robins et al., 1982). Both in the United States and Israel, the differential diagnosis of schizophrenia and affective disorder may be a very difficult one to make (Biederman et al., 1979). Pope and Lipinski (1978) maintained that schizophrenia is overdiagnosed in the United States at the expense of affective disorder, and that if strict RDC or DSM-III criteria were to be applied, many patients diagnosed as suffering from schizophrenia would be reclassified as suffering from affective disorder. In U.S. studies, 20 to 25% of adolescent inpatients were diagnosed with affective disorders when operational criteria were used (Carlson and Strober, 1978, 1979; Carlson and Cantwell, 1980; Friedman et aI., 1982; Robins et aI., 1982; Strober et aI., 1981), and Loranger and Levine (1978) estimate that 20 to 35% of bipolar disorder begins during or before adolescence. As affective symptomatology is common in schizophrenia and other adolescent psychiatric disorders, however, the issue is not so easily resolved. Our own preliminary study found that in II of 68 cases, there was interrater disagreement as to diagnosis. In all II cases one of the raters diagnosed affective disorder by DSM-III criteria, the major snag being the question of mood-incongruent psychotic features (Apter and Tyano, 1982). For this reason we felt that it would be important to undertake a detailed study of the qualitative and quantitative nature of affective symptomatology across the spectrum of DSM-III diagnoses. In addition, psychotic symptomatology should likewise be studied because, in our inpatient population, these two groups of symptoms are extremely prevalent and make for much diagnostic confusion. Our working hypothesis could thus be stated as follows: affective and psychotic symptomatology will be common among adolescents hospitalized in psychiatric wards. They will, however, be distributed differently across the various diagnostic (DSM-II!) groupings.
Diagnosis has always been a vexing clinical and theoretical problem for psychiatrists. In part, this is because of the necessity of relying on subjective evaluation without the possibility of back-up laboratory investigation. Nonetheless, recent advances in diagnostic theory have enabled psychiatric diagnosis to become more reliable and valid (Endicott and Spitzer, 1978). "Criterion variance" has been limited by the introduction of operational criteria for research and clinical practice, the most widely used being those of the DSM-III. "Information variance," the other source of diagnostic error, has been reduced by the use of semistructured interviews such as the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978). These approaches have not been widely used by child psychiatrists. In general, diagnosis of children has been based on analytic formulations, family dynamics, or specific behaviors. Recently, however, there has been increasing interest in the use of structured interviews and operational criteria in child and adolescent psychiatry. The SADS Interview, which was modified for use in children and adolescents by Chambers et al. (1985), has been translated into Hebrew and has been found to have high reliability over a wide range of symptomatology and in regard to final diagnosis (Apter and Tyano, 1982). The psychiatric diagnosis of adolescents has been particularly controversial. Many investigators consider adolescence to be a period of "turmoil" marked by considerable emotional and behavioral lability (Bloss, 1968; Freud, A., 1958). This attitude rejects a descriptive approach to adolescent psychopathology and is reflected in a report by Nicholi (1967), which found "adolescent adjustment reaction" to be the most common psychopathological entity among Harvard dropouts. Several systematic investigations in the field have disputed this view and have found it possible to diagnose psychopathological entities in adolescents using child and adult psychiatric classifications (Masterson, 1967; Offer, 1969; Rutter et aI., 1976). More specifically, DSM-III criteria have been found to be reliable and valid over a wide range of psychiatric Received Feb. 13, 1986; revised Oct. 6. 1986; accepted May 7, 1987. From the Department of Child and Adolescent Psychiatry. Geha Psychiatric Hospital. Beilinson Medical Center, Petah Tiqva 49 /00. and Sackler School of Medicine. Tel Aviv University, Israel. Reprint requests to Dr. Apter, who is on sabbaticalfor the academic year 1987-88, at the Dept. of Psychiatry, Albert Einstein College (If Medicine, Yeshiva University. 1300 Morris Avenue Bldg.. Bronx. NY 10046. 0890-8567/87/2606-0116 $02.00/0 (c) 1987 bythe American Acad-
emy of Childand Adolescent Psychiatry. 116
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AFFECTIVE AND PSYCHOTIC PSYCHOPATHOLOGY
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Population Studied One hundred eight adolescents. between the ages of 12 and 17. consecutively admitted to the unit. were studied. Eight patients (7.4%) were excluded because of ( I) organic brain disease (4 patients). (2) lack of cooperation or refusal to sign an informed consent form (1 patient). or (3) too short a hospital stay for ascertaining the DSM-III diagnosis (3 patients). We feel that the 100 remaining patients are representative of severely ill adolescent inpatients with functional psychiatric disease.
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118
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Results The individual scale scores are listed in Table I according to the diagnostic groupings. As might be expected, depressed mood and thoughts were most severe in those adolescents diagnosed as having major affective disorder, depressed type (mean, 17.85; S.D ., 5.02). Patients with borderline personality disorder (mean, 16.44; S.D., 3.53), obsessive compulsive disorder (mean, 14.25; S.D., 4.7), and anorexia nervosa (mean, 13; S.D., 3.42) also had high scores, however , which were not significantl y different from those of the major depressive disorder patients. When endogenous (melancholic) features are considered, the rank order changes somewhat. Major depressives still have the highest scores (mean, 28.78; S.D., 4.82), anorexics are next (mean, 27.44; S.D ., 3.57), followed by dysthymic disorder (mean, 25.8; S.D., 6.97) and borderline personality (mean, 25.77; S.D., 2.45). Obsessive compulsive patients have relatively low endogenous features (mean, 22; S.D., 7.38), however. Features associated with depression (i.e., nonendogenous or non melancholic symptoms) are found mainly in major depressive and borderline pat ients (mean, 34; S.D., 5.29 and mean, 33; S.D., 4.21, respectively). They are also found commonly in anorexic patients (mean, 30.44; S.D., 4.69) and dysthymics (mean, 29.4; S.D., 7.33). Again, obsessive compulsive patients have relat ively low scores (mean, 24.75; S.D., 4.92). Suicidal behavior is strikingly more common in the borderline patients. This is reflected in their scale score (mean, 10.22; S.D. , 5.07), relative to major depressi ves (mean , 7.64; S.D., 4.0 I), who had the second highest average score. In addition, five of nine borderline patients (56 %) had actually made serious suicide attempts, whereas only five of 14 patients with major depression (36 %) had much such attempts. Other groups of patients with high scores on the first three depressive scales (the anorexics, obsessives, and dysthymics) had low suicide scores. Low scores were found for all depressive scales in the conduct disorder group (A surprising finding) and in the schizotypal group. Schizophrenic patients were low in all depressive scale scores apart from "associated features " (mean, 27.19; S.D., 6.09) (see Table 4). Psychotic features were common among our patients (Tables 2, 3, and 4). They were found in 100% of schizophrenic TABl.E 4.
Diagnosis
patients and in 72% of those with affective disorder. Eleven of 14 depressed patients and 7 of II manic patients were psychotic . Delusions and hallucinations were more serious in the schizophrenic group (mean, 45.19 ; S.D., 7.31) than in the affective disorder adolescents (mean, 33; S.D., 9.01), as was thought disorder (mean, 17.5; S.D., 5.9 versus mean, 11.64; S.D., 4.81). Thought disorder in schizophrenic patients was not significantly greater than in the manic patients (Table 3), however. A group of seven patients seemed to fit the DSM-III criteria for adult schizotypal personality. This corresponds to what was formerly known as "simple schizophrenia." These children were low on all the affective scales and were significantly less delusional and hallucinatory than the schizophrenics (p < 0.001), but they did have thought disorder. Discussion Although both affective and psychotic symptoms were widespread among our adolescent patients, we were able to TABLE
2. Psychotic Symptoms in Adolescent Patients With
Affective Disorderand Schizophrenia
Congruence of Psychotic Featuresand
Presence of Psychotic Features Majoraffective disorder Manictype Depressive type Schizophrenic disorder TABLE
N= N= N= N=
Mood
25 18/25 (72%) 11 7/11 (64%) 14 11/14 (79%) 26 26/26 (100%)
13/18 (72%) 5/7 (71%) 8/11 (73%) (0%)
3. Comparison of Psychotic Features BetweenSchizophrenic and Affectively IIIAdolescents
Diagnosis
Hallucinations and Delusions (mean ± S.D.)
Majoraffective disorder 32 ± 7.86··· Manictype Depressive type 33.78 ± 10.05"· Schizophrenia 45.19 ± 7.31
Thought Disorder (mean ± S.D.) 14.09 ± 4.15· 9.85 ± 4.58··· 17.5 ± 5.9
... Significance of p < 0.00 I difference between schizophrenia and affective disorder. • No significant difference between schizophrenia and affective disorder, manic type.
Comparison of Affective Features Between Schizophrenic and Affectively IIIAdolescents Features Depressive Suicidal Endogenous Associated Manic Mood and Thoughts Features" With Syndrome " Thought" and Behavior" Depression "
Affective disorder Mean S.D. Schizophrenia Mean S.D. T p
- -- - - - a Only depressed patients included. h Only manic patients included.
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28.78 4.82
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39.9 6.45
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20.69 5.24 4.6 0.001
27.19 6.09 3.4 0.01
4.73 2.03 2.98 0.01
12.34 5.48 9.02 0.001
119
AFFECTIVE AND PSYCHOTIC PSYCHOPATHOLOGY
make DSM-IIl diagnosis in all of the patients. A striking feature was the change in diagnosis brought about by the use of DSM-IIl criteria. In 1976, using DSM-IIl, we reported on 140 adolescents hospitalized in our unit (Apter et al., 1976). Not one patient received an affective diagnosis, whereas in the present study 25% were so designated. This supports the contention of Fox (1981) that the use of DSM-III criteria for diagnosis broadens the concept of affective disorder and restricts the diagnosis of schizophrenia. Mania and depression are well recognized today in adolescent patients (Carlson and Strober, 1979), with many patients previously diagnosed as schizophrenics now being diagnosed as suffering from affective disorder (Faux and Rowley, 1967; Friedman et al., 1982; Mezzich and Mezzich, 1979). Another reason for the high incidence of affective disorder reported may be the decline of the use of "adolescent turmoil" and "adjustment reaction of adolescence" to describe serious adolescent psychopathology. Many of these adolescents are probably now diagnosed as borderline (Masterson, 1967), however. Certainly, our borderline personality disorder patients showed very marked mood psychopathology. Although DSMIII specifies age 18 for determining this diagnosis, this group showed the described typical features to such a degree that we felt justified in so labeling these children. The use of terms such as major affective disorder (depressed type) or adjustment reaction with depression would not have reflected their extreme instability in many areas of life. There may well be a close relationship between this condition and affective disorder (Friedman et al., 1982; Spitzer et al., 1979; Stone, 1979), and these patients may have difficulty relating to the regulation of affect. These adolescents are also very angry and resentful, and this combination of depression, aggression, mood deregulation, and instability may account for their propensity to suicide (Pfeffer, 1985). Indeed, although Shaffer (1982) considers suicide in children and adolescents not to be related to diagnosis, in our sample, II of 20 cases of severe attempted suicide were related to either depressive or borderline patients. In this regard we would like to stress that, although physically self-damaging acts and recurrent thoughts of death form part of the criteria for making the DSM-III diagnoses of Borderline Personality Disorder, or Depressive Episode, respectively, all these patients would have received the same DSM-III diagnosis even if suicidal behavior were not present. As might be expected, depressed mood was common in the anorexic and obsessive adolescents. Both disorders seem in some way to be connected to affective disease although these relationships are highly controversial (Bolton et al., 1983; Cantwell et al., 1977; Carlson and Cantwell. 1980. Feighner et al., 1972; Swift et al., 1986). In our study, the obsessive patients had severely depressed mood but few specific symptoms (endogenous, associated, or suicidal), whereas the anorectics denied being very depressed but admitted to many other endogenous and associated features of depressive disorder. Our speculation is that the obsessive children are secondarily depressed because of their serious disease, whereas denial of affect is characteristic of many anorectics. Our sample seems to differ from others reported in the literature in that many of our patients (II of 100) were manic,
although Hudgens (1974) found 10% of manic episodes in a similar sample. Our psychosis rate for depressed patients (II of 14) is also high, perhaps because our patients, all severely ill, were in our locked unit. Severity of illness as an indication for admission may also account for the lack of adjustment reactions in our sample. A surprising finding was the low incidence of mood disorder among conduct disorder patients. Possibly this reflects our decision to prefer a borderline diagnostic labeling. The four patients with organic brain disease were excluded from the study. The K-SADS does not tap organic symptoms, and these patients are very difficult to interview. Although we do quite extensive routine laboratory examinations and often order EEGs and CT scans, we are not convinced as to the extent of their value (Gabel and Hsu, 1986); on the other hand, we may be underdiagnosing these conditions. Conclusion Our study shows that psychotic and affective psychopathology are widespread among adolescent psychiatric inpatients, but that it is possible, to a great extent, to delineate quantitative and qualitative differences when these adolescents are grouped according to DSM-III diagnosis. Having shown this, we now hope to examine the validity of these diagnostic subgroups by enlarging our cohort, undertaking follow-up and treatment-response studies and family studies, as well as trying to look for biological markers such as dexamethazone suppression, H 3 imipramine uptake, TRH response, and x-ray studies of ventricular size. We hope that we will then be able to define more rigorous diagnostic criteria and indications for specific treatments, such as lithium, in the severely psychiatrically ill adolescent. References Apter, A., Tyano, S. & Wijsenbeek, H. (1976). Dimensions ofadolescent in-patient behavior. Acta Psychiat. Scand., 53:277-282. - - - - (1982), The use of a structured psychiatric interview in adolescent psychiatric inpatients. Congress of Child Psychiatry, Dublin, Ireland. Biederman, J., Lerner, J. & Belmaker, R. H. (1979), Diagnostic problems in manic psychosis. Harefuah, 97:28-30. Bloss, P. (1968), Character formation in adolescence. The Psychoanalytic Study of the Child, 23:245-263. Bolton, D., Collins, S. & Steinberg, D. (1983), The treatment of obsessive compulsive disorder in adolescents: a report of 15 cases. Brit. 1. Psychiat., 142:456-466. Cantwell, D. P., Strazenbergcr, S.. Burrough, S. J., et at. (1977), Anorexia nervosa: an affective disorder. Arch. Gen. Psychiat., 34: 1087-1093.
Carlson, G. & Strober, M. (1978), Manic depressive illness in early adolescence. 1. Am. Acad. Child Adolesc. Psychiatry, 17: 138-153. - - Strober, M. (1979), Affective disorders in ·adole~encc. Psychiat, Clin. N. Amer., 2:51 1-526. - - Cantwell, D. P. (1980), Unmasking masked depression in children and adolescents. Amer. J. Psychiat.. 137:445-449. Chambers, W. J., Puig-Antich, J. & Hirsch, M. (1985), The assessment of affective disorders in children and adolescents by semistructured interview. Arch. Gen Psychiat., 42:696-702. Endicott, J. & Spitzer, R. L. (1978), A diagnostic interview: the schedule for affective disorder and schizophrenia (SADS). Arch. Gen. Psychiat., 35:837-844. Fard, K., Hudgens, R. W. & Weiner, A. (1978), Undiagnosed psychiatric illness in adolescents: a prospective study and seven-year follow up. Arch. Gen. Psychiat., 35:279-282. Faux, E. J. & Rowley, M. C. (1967), Detecting depression in childhood. Hosp. Community Psychiatry. 18:51-58.
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APTER ET AL.
Feighner, J. P., Robins, E., Goze, et al. (1972). Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiat .. 26:57-63. Fox, H. A. (1981), The DSM-I11 concept of schizophrenia. Brit. 1. Psychiat., 138:60-63. Friedman, R. C, Clarkin. J. F., Com. R., et al. (1982). DSM-I11 and affective pathology in hospitalized adolescents. J. Nerv. Ment. Dis.. 170:511-521. Freud, A. (1958), Adolescence. The Psychoanalytic Study ofthe Child. 13:255-278. Gabel, S. & Hsu, L. (1986). Routine laboratory tests in adolescent psychiatric inpatients: their value in making psychiatric diagnoses and in detecting medical disorders. J. Am. Acad. Child Adolesc. Psychiatry, 25: 113-119. Hudgens, R. W. (1974), Psychiatric Disorders In Adolescence. Baltimore: Williams & Wilkins. Loranger, A. W. & Levine, P. M. (1978), Age at onset of bipolar affective illness. Arch. Gen. Psychiat.• 35: 1345-1348. Masterson, J. F. (1967), The psychiatric dilemma of adolescence. Boston: Little, Brown. Mezzich, A. C & Mezzich, J. E. (1979). Symptomatology of depression in adolescence. J. Pers. Assess.• 43:267-275. Nicholi, A. M. (1967), Harvard dropouts: some psychiatric findings. Amer. J. Psychiat., 126:1588-1595. Offer, D. (1969), The psychological world of teenager: a study of normal adolescent boys. Amer. 1. Psychiat .. 126:917-924.
Pfeffer, C R. (1985), Self-destructive behavior in children and adolescents. Psychiat. Clin. N. Amer.. 8:215-226. Pope. H. G., & Lipinski, J. F. (1978), Schizophrenia and manic depressive illness in the light of current research. Arch. Gen. Psychiat .• 35:811-828. Robins. D. R.. Alessi. N. E.. Cook, S. C. et al. (1982). The use of the research diagnostic criteria for depression in adolescent psychiatric inpatients. J. Am. Acad. Child Adolesc. Psychiatry, 21:251-255. Rutter, M., Graham, P., Chadwich, F. D. et al. (1976), Adolescent turmoil: fact or fiction? J. Child Psychol. Psvchiat., 17:35-56. Shaffer, D. (1982), Diagnostic considerations in suicidal behavior in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 21:414-416. Spitzer, R. L., Endicott. J. & Gibbon, M. (1979), Crossing the border into borderline personality and borderline schizophrenia: the development and criteria. Arch. Gen. Psychiat.• 36: 17-24. Stone, M. H. (1979). Contemporary shift of the borderline concept from a subschizophrenic disorder to a subaffective disorder. Psvchiat. Clin. N. Amer., 3:577-594. . Strober, M.. Green. J. & Carlson. G. (1981). Reliability of psychiatric diagnosis in hospitalized adolescents. Arch. Gen. Psychiat., 38: 141145. Swift. W. J., Andrews, D. & Barklage, N. (1986), The relationship between affective disorders and eating disorders: a review of the literature. Amer. 1. Psychiat.. 143:290-299.