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Psychosis during adolescence
JOURNAL OF ADOLESCENT HEALTH CARE 1:301-307, 1981
REVIEW ARTICLE
Psychosis During Adolescence A Review LOIS FLAHERTY, M.D. A N D RICHARD M. SARLES, M.D.
All indicators of emotional illness rise sharply during adolescence including the utilization of outpatient psychiatric clinics and hospitalizations for psychiatric illness and suicide. Psychoses secondary to drug ingestion, manic-depressive illness, and schizophrenia are not uncommon. This paper reviews the various forms of psychoses during adolescence. Special emphasis is On the diagnosis and treatment of adolescent schizophrenia, the most common psychosis in this developmental period. KEY WORDS:
Adolescents Confusional state Drug-induced psychoses Manic-depressive Psychoses Schizophrenia There is little question that adolescence is accompanied by increased emotional stress. All indicators of emotional illness rise sharply during this period, including suicides, hospitalizations for psychiatric illness, and the utilization of outpatient psychiatric clinics. Psychoses secondary to drug ingestion, schizophrenia, manic-depressive illness, or as an isolated episode of decompensation are often seen during the adolescent years. Onset of schizophrenia occurs before the age of 25 in approximately 60% of those affected; onset of manic-depressive illness occurs between the age of 10 and 19 in approximately
From the Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, and Child and Adolescent Services, Walter P. Carter Center, Baltimore, Maryland. Direct reprint requests to: Lois Flaherty, M.D., Walter P. Carter Center, 630 W. Fayette Street, Baltimore, MD 21201. Manuscript accepted February 25, 1981.
30% of those affected (1,2). Although the incidence of drug-induced psychoses during adolescence is unknown, clinical evidence suggests that it occurs far more frequently during the adolescent years than at any other age. Although the majority of adolescents do not become emotionally ill, all adolescents must undergo major psychic reorganization if they are to reach some semblance of functional adulthood. Briefly, this reorganization involves the following processes: (1) reorganization of the body image; (2) separation from parents and formation of an individual identity concurrent with the evolution of the parent-child relationship into an adult-adult relationship; (3) development of a capacity for intimacy with a peer (4) formation of vocational goals and ideals (3). These developmental tasks involve profound changes in one's perceptions of self and the outside world. Although many adolescents show surprisingly little turmoil as they proceed through these processes, other show signs of disturbance that range from extremely mild to very severe dysfunction. Often some regression occurs, i.e., the adolescent may become depressed, careless and temporarily irresponsible in response to developmental pressures. In addition, there i~ often confusion within the adolescent about who he really is, the well-known "identity crisis." The prevalance of such manifestations in many normal adolescents can make it extremely difficult to recognize early forms of schizophrenia, manic-depressive illness, or mild or transient episodes of drug-induced psychoses. In general, psychoses refer to a gross disorganization of mental functioning that significantly impairs psychosocial function and severely interferes with the individual's capacity to meet the ordinary demands of life.
© Society for Adolescent Medicine, 1981 Published by Elsevier North Holland, Inc., 52 Vanderbilt Ave., New York, NY 10017
301 ISSN 0197-0070/81/040301-07/$02.25
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Schizophrenia The manifestations of schizophrenia are so diverse, the clinical course so variable, and the etiology unknown, that many authors refer to a group of schizophrenias, assuming that there are probably multiple forms, perhaps with different pathological mechanisms. In a recent review, Feinstein and Miller define schizophrenia "proper," as opposed to other psychotic states, as an illness characterized by "a pattern of isolation, apathy, poor interpersonal relationships, internal disorganization and incompetence" as well as "a disorder of thinking and feeling" (4). Symptoms seen in other kinds of psychoses such as altered states of consciousness and regressed and disorganized behavior may also occur. The terms schizophreniform disorder, brief reactive psychosis, and atypical psychosis all refer to acute, self-limiting illnesses which resemble schizophrenia in some ways but differ from it in duration and/or symptom patterns. Usually, clinical observation over a period of time is necessary in order to effectively establish a diagnosis. To what extent these illnesses are related to schizophrenia in terms of etiology or pathogenesis is u n k n o w n (5). Bleuler, through careful clinical observation, was of the opinion that some of the signs and symptoms he saw in individuals w h o m he described as schizophrenic were primary and others were secondary, or a result of the deterioration in function which accompanies the illness (6, 7).
PrimarySymptoms Primary, fundamental symptoms, often referred to as the "Four A's," include loosening of associative thought, inappropriate affect, ambivalence, and autism. (Table 1).
Loosening of associative thought. In waking and sleeping states, the human mind is constantly bombarded by external and internal stimuli. In normal, nonpsychotic waking states the integrative functions of the ego permit the censoring and ordering of these stimuli to ensure a relatively congruent and coherent stream of thought and speech. This is termed secondary process cognition. In the sleeping and psychotic state the ego does not function well and is severley impaired in its capacity to exclude irrelevant material or focus on one subject, thus leading to an inability to maintain a congruent set of
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Table 1. Classification of Symptoms (Bleuler) Primary (Fundamental)
Secondary (Accessory)
Associative disturbances Inappropriate affect Ambivalence Autism
Perceptual disturbances Impaired reality testing Behavioral disturbances Somatic symptoms
thoughts. This is termed primary process thinking. Thoughts and subsequently speech take on a dreamlike quality manifested by switches from concrete to abstract ideas, thus making thought irrational, incoherent, disconnected, and bizarre: A 16-year old schizophrenic girl commented, "why can't I go out . . . . the world is cold, old, bold; never again. My hair is a mess. No wonder he does like me, summer, sun and salt. Oh God, if birds could fly why oh why can't I? Soft skin is important, you know, snow, milk, stale, pale hospitals. Needles, knives, Christ died for your sins, will I die?, will you die? Nope, no, absolutely not. Why can't I go out?" When loosening of association is less severe the flow of speech may be comprehensible but the listener may recognize that little meaningful conversation has taken place. There is often a sense of concreteness, vagueness, or abstractness, or it may appear that two totally separate conversations are taking place at the same time.
Affect. The schizophrenic demonstrates inappropriate affect ranging from blunted or flattened, affectionless, apathetic states to periods of intense anxiety and irritation. Moods and affect are often also inappropriate for a particular context as if the patient is responding to internal stimuli. Ambivalence. Intense simultaneous opposite wishes, ideas, and feelings are common in adolescent schizophrenics. There are concurrent love-hate feelings for the same person or object. They also find it difficult to make decisions because of the simultaneous all or nothing, right or wrong, good or bad, go or stay polarity of their thinking. Autism, A gradual but marked withdrawal from peers, school, and family resulting in almost total isolation occurs in most adolescent schizophrenics. A distrust of others develops and the adolescent usually becomes preoccupied by fantasy: A 15-year old boy lost interest in school team sports and turned to fishing by himself. He soon gave up this hobby and became absorbed in stamp collecting. He enmeshed himself in his solitary interests to the exclusion of all peer
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contact, becoming known as "the ghost" of his high school class. His only contact with his family was during his silent, short stay at the dinner table. He secluded himself for longer and longer periods in his bedroom and his parents suspected that he was masturbating excessively. Within a short time more florid signs of a serious emotional problem were evident and the diagnosis of adolescent schizophrenia was made.
Secondary Symptoms Secondary, accessory symptoms include perceptual disturbances, impaired reality testing, speech and motor disturbances, behavior disturbances, and problems with sexuality. Perceptual disturbances include hallucinations, which are most commonly auditory. The voices may be single or multiple and familiar, often commenting on the individual's behavior or commanding the patient to take certain actions. Somatic hallucinations such as the rotting of the person's body or of being eaten internally by snakes or insects are occasionally noted. Psychomotor disturbances are marked by a variety of symptoms ranging from a marked decrease in activity (catatonia) to bizarre posturing, excited stereotypic movements, facial grimacing and/or waxy flexibility. , In the recent third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM II!), schizophrenia is defined as a psychotic disorder involving "deterioration from a previous level of functioning" with "characteristic disturbances in several of the following areas: content and form of thought; perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior." No single feature is invariably presen t or seen only in schizophrenia (5). Two different patterns of onset have been described, each having different prognostic implications. The acute onset, or reactive, type is usually associated with lack of serious prior personality impairment, often has a precipitating event, and is accompanied by confusion or emotionality. This type is particularly difficult to distinguish from other kinds of psychosis and has a good prognosis. The slow onset type, often called "process schizophrenia," is an insidious illness developing in a basically schizoid individual who often has a long history of maladjustment. This type tends to show progressive deterioration, hence a poorer prognosis. The etiology of schizophrenia is unknown. At present there is strong evidence that it results from a genetic predisposition interacting with environ-
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mental stresses. Whether or not these stresses are specific, such as a particular kind of family interaction, as described in the double-bind theory of Bateson (8), or nonspecific such as fetal anoxia is not clear. Some authors, most notably Anna Freud, have stated that it is at times difficult to distinguish adolescent onset schizophrenia from "adolescent turmoil" (9). The assumption underlying this view is that during adolescence there is a continuous spectrum ranging from an emotionally healthy state to severe emotional disturbance. Some degree of emotional turmoil is normal during adolescence; consequently, it may be difficult to tell where normality leaves off and schizophrenia begins. Others, however, usually drawing on studies of high school populations, have emphasized that the emotionally disturbed adolescent is clearly distinguishable from his healthy peers. They believe that the phenomenon of "adolescent turmoil" has been overemphasized (10). Studies using data gathered before the illness becomes overt, and thus not subject to retrospective falsification, indicate varying kinds of psychopathology, ranging from a delinquent pattern of behavior to withdrawal (11-13). Recently, the preexistence of learning disabilities in some children who later develop schizophrenia during adolescence has also been pointed out. None of these conditions, however, is associated exclusively with any one psychiatric illness. The relationshi p between infantile autism, childhood schizophrenia, and schizophrenia beginning in adolescence or adult life is not clear. Many children diagnosed as schizophrenic have features of organicity or brain dysfunction, such as developmental delay and soft neurologic signs. These features tend tobe less prevalent in those whose illness begins in adolescence or adulthood. Autistic children most closely resemble chronic adolescent or adult undifferentiated schizophrenics. Mentally retarded children may also show schizophrenic symptoms, which may appear during adolescence. The precise role that organic brain impairment plays in the development of schizophrenic symptomatology is not clear; however, it is certainly reasonable to suppose that the impaired ego function that exists in retarded individuals would increase their risk of psychotic decompensation (14). Interestingly, a few adolescents have been described as having classic minimal brain dysfunction in childhood, who during adolescence develop typical schizophrenic symptomatology. Whether this
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constitutes the development of a related or unrelated process is unclear. One possible answer is that the child with minimal brain dysfunction also has weakened ego functioning, as manifested by poor impulse control and a decreased ability to delay gratification, and that this weakness may predispose to the later development of other psychiatric illness, including schizophrenia. A different and often confusing clinica! picture i s presented by those adolescents who were clearly not psychotic in childhood but who have had longstanding difficulties with social adjustment, school achievement, and family relationships. Many have a pattern of behavior problems which are best described as delinquent or acting out. Frequently these youngsters have chronic difficulty with the law or school. This is a nonspecific picture that describes many troubled youngsters. What makes such adolescents schizophrenic is their peculiar, idiosyncratic way of seeing themselves, others, and the world around them. In some cases, the acting out behavior seems to be a defense against becoming schizophrenic; unfortunately, many of these youngsters end up in correctional facilities rather than psychiatric treatment programs because of inadequate diagnose s . Thus, while there does not appear to be a specific preschizophrenic personality, some preexisting disturbance in psychological functioning is common. The schizophrenic illness may then be a result of an already weakened ego development which is further compromised by the demands of the developmental tasks of adolescence. It should be clear from the above discussion that the diagnosis of schizophrenia in adolescents is a process demanding considerable expertise. Consequently, patients in w h o m it is suspected should be referred for psychiatric evaluation. Frequently psychological testing is helpful in revealing subtle disturbances in thought patterns as well as ruling out organic brain impairment.
Management Management of the adolescent with schizophrenia is a complex process best left to those with specialty training in this area. However, primary care specialists may be involved in referral and the initiation of appropriate treatment and follow-up, as well as providing concomitant medical care. Management aims at maximizing the adolescent's capacity to function in as nearly a normal manner as possible. This is done by a two-pronged approach:
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the restoration of functions that have been lost and the prevention of further decompensation. In mildly impaired adolescents, outpatient psychotherapy, antipsychotic medication, and supportive environmental manipulation may be sufficient. The adolescent patient is encouraged to use his capacity for self-observation, judgment, and rational thinking in order to achieve a more realistic picture of himself and others. Frequently; the therapist may have to engage in an "ego-lending" process, supplying these rational thought processes through comments made during therapy sessions: An 18-year old woman, who had chronic severe emotional impairment, needed to be told by her therapist that her mother's grossly inconsistent behavior and extreme emotional instability were due to an emotional disturbance within the mother, rather than solely to the patient's own "craziness" as she had so long believed. As with any adolescent, it takes time to build a therapeutic alliance so that the patient is able to see the therapist as a helping partner in the treatment. This is particularly true of the adolescent schizophrenic, who usually fears what might happen if his therapist finds out about his "crazy" thoughts: An adolescent in therapy frequently alluded to her "fantasies" but refused to talk about them. Finally when she did, she expressed the belief that they were so bizarre that the therapist would hospitalize her. The adolescent who is capable of being maintained on an outpatient basis should have enough ego strength to be able to compensate for intermittently poor reality testing: A patient in therapy commented, "yesterday I started to get the feeling of having a piece of glass in my throat. But I know I feel that way when I'm anxious." Outpatient therapy for schizophrenic adolescents frequently has to be continued on a long-term basis, often for several years, i.e., until the patient has developed sufficient strength to no longer have to depend on the therapist to lend this kind of intensive help. As time goes on, the frequency of contact may be lessened, but it is worthwhile to have such patients "keep in touch" intermittently. The therapist who treats this kind of adolescent needs to be prepared to accept that he or she will probably become an ongoing and enduring part Of the patient's life for many years.
Indications For Psychiatric Hospitalization Hospital treatment is indicated for the adolescent who is having an acute psychotic breakdown and/ or who is in need of close supervision and vigorous therapeutic intervention. In addition to allowing a
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controlled administration of antipsychotic medications, the hospital environment provides a protective atmosphere in which external stimu|i and demands are minimized, thus reducing: the stress on the exquisitely vulnerable decompensating adolescent. With the reduction of external stresses, reconstitution will begin to occur in and of itself. Psychiatric hospitalization is also indicated for the adolescent, not necessarily undergoing acute decompensation, w h o is so emotionally impaired that intensive rehabilitation or habilitation is needed. In a controlled, carefully structured environment, the adolescent can slowly and gradually learn more appropriate ways of functioning socially, and reach a higher level of personality integration: A 16-year-old boy with severe personality deterioration and an apparent need for chronic institutionalization was helped to function more normally during several months of hospitalization on an adolescent ward. At discharge, although still regarded as "different" and odd, he had improved sufficiently to return home and attend a special education class in a public school. For the adolescent who has been dysfunctional since early childhood, perhaps a childhood schizophreniG the gains during inpatien t or outpatient treatment may be limited, but there is still a possibility for emotional growth through the personality development and restructuring associated with adolescence.
The Role of Family Therapy Early family studies pointed to disordered communication within families of schizophrenics. Family therapy has n o w become a well-accepted adjunct in the treatment of adolescents including t h o s e re: covering fro m psychotic illnesses, although the exact methods and aims often vary. While it is generally considered that family therapy does not cure schizophrenia, it can provide important benefits in terms of helping families provide appropriate emotional support and develop appropriate expectations from their sch!zophrenic member, thus making it possibl e for a reasonable degree of autonomy and emotional emancipation to occur.
The Role of Psychopharmacology Major tranquilizers are an indispensible adjunct to the treatment of schizophrenia and have been so since the early 1950s w h e n chlorpromazine came into use. Lower doses than those commonly used
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in adults are often adequate for adolescents, who ~frequently have a higher degree of responsivity to these agents. Adolescents are often resistant to taking prescribed medications because of the perceived threat to their sense of autonomy; and this is no less true of the adolescent with a mental disorder. It is not u n c o m m o n for the schizophrenic adolescent to experience the improved functioning with successful drug therapy as his mind's being "controlled" or takefl over by the drug. A good patient-physician relationship is essential in trying to overcome this resistance. Extrapyramidal side effects or excessive sedation may also be frightening to the adolescent and require careful management. Because many adolescents tend to be suspicious, they may react negatively to drug side effects; thus care must be taken to reassure them that if side effects do occur they are not serious and can be reduced or eliminated. The major side effects of the commonly used antipsychotic medications are a variety of extrapyramidal symptoms including muscular rigidity, Parkinsonian tremors, and'motor restlessness (akathasias). Particularly upsetting to adolescent males are the gynecomastia and impotence that occasionally occur. Tardive dyskinesia, a sometimes irreversible disorder characterized by a variety of abnormal movements, is thought to be caused by damage to the striatal dopaminergic receptor sites. This has been rarely reported in children and adolescents treated with phenothiazines (15). The various antipsychotic drugs differ in their tendency to produce side effects as well as in their sedative properties. Detailed discussions of drug treatment for schizophrenia may be found in several texts (16, 17).
Manic-Depresswe Psychosis Manic-depressive illness is an underdiagnosed condition during adolescence, with most of these severely disturbed teenagers being labeled schizophrenic (18). Characteristically these adolescents demonstrate distinct periods of elevated, expansive, or irritable moods associated with hyperactivity, distractibility, insomnia, never feeling tired, going days without sleep~ flight of ideas, and loud, pressured, and rapid speech. They may exhibit intrusive social behavior, calling friends at all hours of the day and night, and manifest an unceasing and unselected enthusiasm for social interaction. A euphoric high exists in spite of reality. They joke, are super-lively, and may be somewhat theatrical and behave in an unusually sexually provocative fashion. Grandiose feelings and ideas are usually present. They may go
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on wild buying sprees or make outlandish intrusions into highly classified, secret government agencies. These manic behaviors may rapidly alternate with periods of severe depression or each may last for several days o r weeks. When gross impairment of reality testing with delusions or hallucinations and/or grossly bizarre behavior exists, a manicdepressive psychotic process should be suspected. The diagnosis should also be entertained w h e n manic behavior, as described above, is evident and alters with severe depression. A positive family history for manic-depressive illness is usually elicited, and in most cases the onset of the illness can be related to a specific environmental stress, particularly major separations within the family. Ps;cchiatric consultation and treatment is essential for this disorder. Hospitalization is usually required during the acute phase to protect the adolescent, his family, and friends. The use of the phenothiazines may be necessary during the early days of treatment to calm the wild, manic behavior. Lithium carbonate is clearly the drug of choice in the treatment of manic-depressive illness. On lithium the wide fluctuations of m o o d are reduced, manic behavior abates, and depressive episodes are fewer and less pronounced. Lithium carbonate is contraindicated in certain physical conditions and requires close periodic blood level determinations (19).
Acute Confusional States The exact incidence of acute confusional states during adolescence is u n k n o w n and many episodes go undetected and undiagnosed. This condition is characterized by an abrupt onset of confusion, depression, and loss of self-identity often accompanied by intense anxiety. The adolescent usually experiences a heightened awareness of self with an intensification of sensory experiences. A broadening expansive sense of self and the social environment in which the individual lives is often described. There is often no evidence of thought disorder and no clear loss of contact with reality. A variety of etiologies have been hypothesized for this disorder including acute identity probleins, homosexual panic, and drug use.
Drug-induced psychoses. Drug-abuse-related psychiatric problems seem to account for an increasing proportion of adolescent psychiatry morbidity. Of the behavioral and psychological transformations that may occur in association with drug taking, none is more dramatic than a full-blown psychotic reaction. The drugs k n o w n to precipitate such reactions
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include amphetamines, marijuana, and the hallucinogenic drugs, most notably lysergic acid (LSD) and phencyclidine (PCP). The hallmarks of an acute toxic psychosis are confusion, disorientation, anxiety, agitation, and disturbances of perception, reason, and judgment. In their most severe form, these reactions can be associated with extremely bizarre behavior, based on the user's extreme distortion of reality such as jumping out of a window in the belief that one can fly. The characteristic alterations differ somewhat depending on the responsible drug; an amphetamine-induced psychosis, for example, is classically characterized by paranoid delusions while hallucinogenic drugs tend to produce various visual alterations such as seeing rainbows or flashes of color. One of the most disturbing changes is that occasionally produced by phencyclidine with serious distortions in perception and thinking along with a release of primitive kinds of aggressive behavior (20). This type of dissociative reaction is occasionally responsible for bizarre assaults or murders. Unfortunately, phencyclidine use appears to be increasing. The management of drug-induced psychotic states can be divided into two phases: acute and long term. Acute management is best carried out in a facility that can provide intensive, 24-hour medical supervision. The length of hospitalization required varies from a few days to several weeks. Major tranquilizers are helpful in controlling agitation and extreme anxiety. Haloperidol has been recommended as particularly helpful. Physical restraint should be avoided if possible. Those who worked extensively with the "flower children" of the 1960s stressed the importance of a supportive companion who could "talk the patient down." In planning follow-up treatment for the adolescent with a drug-induced psychosis it is necessary to take into account the total environment from whence the adolescen t came, including family, community, peers, and school, the extent and chronicity of previous drug use, and the presence of preexisting psychiatric illness or impairment. The adolescent for w h o m drug use has become a way of life can seldom be treated successfully outside of a highly structured residential treatment program. In other cases outpatient counseling or therapy can be attempted on a trial basis, with residential treatment remaining an option. The extent to which drug use among adolescents leads to permanent psychiatric sequelae is unresolved. Although many adolescents who are the victims of a single drug-induced psychotic episode
June 1981
will recover completely, a significant proportion of them, even though treated appropriately, will remain persistently psychotic and eventually become indistinguishable from the chronic schizophrenic. To what extent this group was predestined to become schizophrenic, and to what extent drugs hastened or precipitated this process, is unclear. It seems likely that marijuana is capable of inducing psychosis only in susceptible individuals, since few users of this widely used drug become psychotic. Phencyclidine, on the other hand, seems to produce psychotic states relatively frequently; therefore, its effects may be less dependent on individual susceptibility. The existence of drug-induced psychotic states that to varying degrees resemble acute schizophrenic episodes raises intriguing questions about how the pathophysiology of schizophrenia and drug-induced psychoses may be related. Investigative work in this area is still in its infancy. It should be kept in mind that adolescents w h o are emotionally disturbed frequently turn to drugs in an attempt to control their distress by "self-medication." The use of hallucinogens by schizophrenic youngsters is not uncommon. Thus drug use can significantly obscure the clinical picture.
Summary Although schizophrenia and other psychoses remain in many ways enigmas, they are unquestionably serious mental disorders. There is hope, however, that through prompt and appropriate treatment, healthy functioning can be restored. Extreme degrees of deterioration, once common in schizophrenia, are rarely seen today. The response of manic-depressives to lithium therapy is often dramatic. Although it is still too soon to know to what extent modern treatments can affect the longterm outcome of these illnesses in adolescents, there are clear reasons to be optimistic. Considerable advances have been made in recent years in understanding and treating these complex illnesses.
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References 1. Holzman PS, Grinker RR: Schizophrenia in adolescence, in Feinstein, SC, Giovacchini, PL (eds): Adolescent Psychiatry, Vol. V New York, Jason Aronson, 1977, pp 276-290 2. Winaker C, Clayton DJ, Reich T: Manic-Depressive Illness. St. Louis, C.V. Mosby, 1979 3. Erikson E: Identity: Youth and Crisis. New York, W.W. Norton, 1968 4. Feinstein SC, Miller D: Psychoses of adolescence, in Noshphitz, JD (ed): Basic Handbook of Child Psychiatry. New York, Basic Books, 1979, pp 708-722 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III) American Psychiatric Association, Washington, D.C., 1980 6. Bleuler E: Die Prognose der Dementia Praecox (Schizophrenie-Gruppe) Allgemeine Zeitschrift fur Psychiatric und Psychisch. Gerichtliche Medezin 65:436-464, 1908 7. Bleuler M: Schizophrenic Psychoses. Am J Psychiatry 136:1403-1409, 1979 8. Bateson G, Jackson DD, Haley J, et ah Toward a theory of schizophrenia. Behav Sci 1:25-264, 1956 9. Freud A: Adolescence, in Eissler RS, et al (eds): Psychoanalytic Study of the Child New York, International Universities Press, 1958, 13:255-278 10. Offer D, OfferJ: Normal adolescence in perspective, in Schoolar JC (ed): Current Issues in Adolescent Psychiatry, New York, BrunnerMazel, 1973 11. Bromet E, Marrow M, Karl S: Premorbid functioning and outcome in schizophrenics and non-schizophrenics. Arch Gen Psychiatry 30:203-207, 1973 12. Rieder RO: Children at risk, in Bellak L (ed): Disorders of the Schizophrenic Syndrome. New York, Basic Books, 1979 13. Robins N: Deviant Children Grown Up. Baltimore, Williams & Wilkins, 1966 14. Kernberg PF: Childhood Schizophrenia and Autism: A Selective Review, in Bellak L (ed): Disorders of the Schizophrenic Syndrome, Grune & Stratton, New York, 1979 15. Klawans HL, Goetz CG, Perlik S: Tardive dyskinesia: Review and update. Am J Psychiatry 137:900-909,1980 16. Campbell M: Treatment of childhood and adolescent schizOphrenia, in Weiner J (ed): Psychopharmacology in Childhood and Adolescence. New York, Basic Books, 1977 17. Lipton MA, Burnett GB: Pharmacological treatment of schizophrenia, in Bellak L (ed): Disorders of the Schizophrenic Syndrome. New York, Basic Books, 1979, pp 320-352 18. Engstrom FW, Robbins: Manic-depressive illness in adolesence. J Am Acad Child Psychiatry 17:514-520, 1978 19. Weiner J: Psychopharmacolgy, in Childhood and Adolescence. New York, Basic Books, 1977 20. Allen RM, Young SJ: Phencyclidine-inducedpsychosis. Am J Psychiatry 135:1081-1083, 1978
REVIEW ARTICLE
Psychosis During Adolescence A Review LOIS FLAHERTY, M.D. A N D RICHARD M. SARLES, M.D.
All indicators of emotional illness rise sharply during adolescence including the utilization of outpatient psychiatric clinics and hospitalizations for psychiatric illness and suicide. Psychoses secondary to drug ingestion, manic-depressive illness, and schizophrenia are not uncommon. This paper reviews the various forms of psychoses during adolescence. Special emphasis is On the diagnosis and treatment of adolescent schizophrenia, the most common psychosis in this developmental period. KEY WORDS:
Adolescents Confusional state Drug-induced psychoses Manic-depressive Psychoses Schizophrenia There is little question that adolescence is accompanied by increased emotional stress. All indicators of emotional illness rise sharply during this period, including suicides, hospitalizations for psychiatric illness, and the utilization of outpatient psychiatric clinics. Psychoses secondary to drug ingestion, schizophrenia, manic-depressive illness, or as an isolated episode of decompensation are often seen during the adolescent years. Onset of schizophrenia occurs before the age of 25 in approximately 60% of those affected; onset of manic-depressive illness occurs between the age of 10 and 19 in approximately
From the Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, and Child and Adolescent Services, Walter P. Carter Center, Baltimore, Maryland. Direct reprint requests to: Lois Flaherty, M.D., Walter P. Carter Center, 630 W. Fayette Street, Baltimore, MD 21201. Manuscript accepted February 25, 1981.
30% of those affected (1,2). Although the incidence of drug-induced psychoses during adolescence is unknown, clinical evidence suggests that it occurs far more frequently during the adolescent years than at any other age. Although the majority of adolescents do not become emotionally ill, all adolescents must undergo major psychic reorganization if they are to reach some semblance of functional adulthood. Briefly, this reorganization involves the following processes: (1) reorganization of the body image; (2) separation from parents and formation of an individual identity concurrent with the evolution of the parent-child relationship into an adult-adult relationship; (3) development of a capacity for intimacy with a peer (4) formation of vocational goals and ideals (3). These developmental tasks involve profound changes in one's perceptions of self and the outside world. Although many adolescents show surprisingly little turmoil as they proceed through these processes, other show signs of disturbance that range from extremely mild to very severe dysfunction. Often some regression occurs, i.e., the adolescent may become depressed, careless and temporarily irresponsible in response to developmental pressures. In addition, there i~ often confusion within the adolescent about who he really is, the well-known "identity crisis." The prevalance of such manifestations in many normal adolescents can make it extremely difficult to recognize early forms of schizophrenia, manic-depressive illness, or mild or transient episodes of drug-induced psychoses. In general, psychoses refer to a gross disorganization of mental functioning that significantly impairs psychosocial function and severely interferes with the individual's capacity to meet the ordinary demands of life.
© Society for Adolescent Medicine, 1981 Published by Elsevier North Holland, Inc., 52 Vanderbilt Ave., New York, NY 10017
301 ISSN 0197-0070/81/040301-07/$02.25
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Schizophrenia The manifestations of schizophrenia are so diverse, the clinical course so variable, and the etiology unknown, that many authors refer to a group of schizophrenias, assuming that there are probably multiple forms, perhaps with different pathological mechanisms. In a recent review, Feinstein and Miller define schizophrenia "proper," as opposed to other psychotic states, as an illness characterized by "a pattern of isolation, apathy, poor interpersonal relationships, internal disorganization and incompetence" as well as "a disorder of thinking and feeling" (4). Symptoms seen in other kinds of psychoses such as altered states of consciousness and regressed and disorganized behavior may also occur. The terms schizophreniform disorder, brief reactive psychosis, and atypical psychosis all refer to acute, self-limiting illnesses which resemble schizophrenia in some ways but differ from it in duration and/or symptom patterns. Usually, clinical observation over a period of time is necessary in order to effectively establish a diagnosis. To what extent these illnesses are related to schizophrenia in terms of etiology or pathogenesis is u n k n o w n (5). Bleuler, through careful clinical observation, was of the opinion that some of the signs and symptoms he saw in individuals w h o m he described as schizophrenic were primary and others were secondary, or a result of the deterioration in function which accompanies the illness (6, 7).
PrimarySymptoms Primary, fundamental symptoms, often referred to as the "Four A's," include loosening of associative thought, inappropriate affect, ambivalence, and autism. (Table 1).
Loosening of associative thought. In waking and sleeping states, the human mind is constantly bombarded by external and internal stimuli. In normal, nonpsychotic waking states the integrative functions of the ego permit the censoring and ordering of these stimuli to ensure a relatively congruent and coherent stream of thought and speech. This is termed secondary process cognition. In the sleeping and psychotic state the ego does not function well and is severley impaired in its capacity to exclude irrelevant material or focus on one subject, thus leading to an inability to maintain a congruent set of
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Table 1. Classification of Symptoms (Bleuler) Primary (Fundamental)
Secondary (Accessory)
Associative disturbances Inappropriate affect Ambivalence Autism
Perceptual disturbances Impaired reality testing Behavioral disturbances Somatic symptoms
thoughts. This is termed primary process thinking. Thoughts and subsequently speech take on a dreamlike quality manifested by switches from concrete to abstract ideas, thus making thought irrational, incoherent, disconnected, and bizarre: A 16-year old schizophrenic girl commented, "why can't I go out . . . . the world is cold, old, bold; never again. My hair is a mess. No wonder he does like me, summer, sun and salt. Oh God, if birds could fly why oh why can't I? Soft skin is important, you know, snow, milk, stale, pale hospitals. Needles, knives, Christ died for your sins, will I die?, will you die? Nope, no, absolutely not. Why can't I go out?" When loosening of association is less severe the flow of speech may be comprehensible but the listener may recognize that little meaningful conversation has taken place. There is often a sense of concreteness, vagueness, or abstractness, or it may appear that two totally separate conversations are taking place at the same time.
Affect. The schizophrenic demonstrates inappropriate affect ranging from blunted or flattened, affectionless, apathetic states to periods of intense anxiety and irritation. Moods and affect are often also inappropriate for a particular context as if the patient is responding to internal stimuli. Ambivalence. Intense simultaneous opposite wishes, ideas, and feelings are common in adolescent schizophrenics. There are concurrent love-hate feelings for the same person or object. They also find it difficult to make decisions because of the simultaneous all or nothing, right or wrong, good or bad, go or stay polarity of their thinking. Autism, A gradual but marked withdrawal from peers, school, and family resulting in almost total isolation occurs in most adolescent schizophrenics. A distrust of others develops and the adolescent usually becomes preoccupied by fantasy: A 15-year old boy lost interest in school team sports and turned to fishing by himself. He soon gave up this hobby and became absorbed in stamp collecting. He enmeshed himself in his solitary interests to the exclusion of all peer
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contact, becoming known as "the ghost" of his high school class. His only contact with his family was during his silent, short stay at the dinner table. He secluded himself for longer and longer periods in his bedroom and his parents suspected that he was masturbating excessively. Within a short time more florid signs of a serious emotional problem were evident and the diagnosis of adolescent schizophrenia was made.
Secondary Symptoms Secondary, accessory symptoms include perceptual disturbances, impaired reality testing, speech and motor disturbances, behavior disturbances, and problems with sexuality. Perceptual disturbances include hallucinations, which are most commonly auditory. The voices may be single or multiple and familiar, often commenting on the individual's behavior or commanding the patient to take certain actions. Somatic hallucinations such as the rotting of the person's body or of being eaten internally by snakes or insects are occasionally noted. Psychomotor disturbances are marked by a variety of symptoms ranging from a marked decrease in activity (catatonia) to bizarre posturing, excited stereotypic movements, facial grimacing and/or waxy flexibility. , In the recent third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM II!), schizophrenia is defined as a psychotic disorder involving "deterioration from a previous level of functioning" with "characteristic disturbances in several of the following areas: content and form of thought; perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior." No single feature is invariably presen t or seen only in schizophrenia (5). Two different patterns of onset have been described, each having different prognostic implications. The acute onset, or reactive, type is usually associated with lack of serious prior personality impairment, often has a precipitating event, and is accompanied by confusion or emotionality. This type is particularly difficult to distinguish from other kinds of psychosis and has a good prognosis. The slow onset type, often called "process schizophrenia," is an insidious illness developing in a basically schizoid individual who often has a long history of maladjustment. This type tends to show progressive deterioration, hence a poorer prognosis. The etiology of schizophrenia is unknown. At present there is strong evidence that it results from a genetic predisposition interacting with environ-
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mental stresses. Whether or not these stresses are specific, such as a particular kind of family interaction, as described in the double-bind theory of Bateson (8), or nonspecific such as fetal anoxia is not clear. Some authors, most notably Anna Freud, have stated that it is at times difficult to distinguish adolescent onset schizophrenia from "adolescent turmoil" (9). The assumption underlying this view is that during adolescence there is a continuous spectrum ranging from an emotionally healthy state to severe emotional disturbance. Some degree of emotional turmoil is normal during adolescence; consequently, it may be difficult to tell where normality leaves off and schizophrenia begins. Others, however, usually drawing on studies of high school populations, have emphasized that the emotionally disturbed adolescent is clearly distinguishable from his healthy peers. They believe that the phenomenon of "adolescent turmoil" has been overemphasized (10). Studies using data gathered before the illness becomes overt, and thus not subject to retrospective falsification, indicate varying kinds of psychopathology, ranging from a delinquent pattern of behavior to withdrawal (11-13). Recently, the preexistence of learning disabilities in some children who later develop schizophrenia during adolescence has also been pointed out. None of these conditions, however, is associated exclusively with any one psychiatric illness. The relationshi p between infantile autism, childhood schizophrenia, and schizophrenia beginning in adolescence or adult life is not clear. Many children diagnosed as schizophrenic have features of organicity or brain dysfunction, such as developmental delay and soft neurologic signs. These features tend tobe less prevalent in those whose illness begins in adolescence or adulthood. Autistic children most closely resemble chronic adolescent or adult undifferentiated schizophrenics. Mentally retarded children may also show schizophrenic symptoms, which may appear during adolescence. The precise role that organic brain impairment plays in the development of schizophrenic symptomatology is not clear; however, it is certainly reasonable to suppose that the impaired ego function that exists in retarded individuals would increase their risk of psychotic decompensation (14). Interestingly, a few adolescents have been described as having classic minimal brain dysfunction in childhood, who during adolescence develop typical schizophrenic symptomatology. Whether this
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constitutes the development of a related or unrelated process is unclear. One possible answer is that the child with minimal brain dysfunction also has weakened ego functioning, as manifested by poor impulse control and a decreased ability to delay gratification, and that this weakness may predispose to the later development of other psychiatric illness, including schizophrenia. A different and often confusing clinica! picture i s presented by those adolescents who were clearly not psychotic in childhood but who have had longstanding difficulties with social adjustment, school achievement, and family relationships. Many have a pattern of behavior problems which are best described as delinquent or acting out. Frequently these youngsters have chronic difficulty with the law or school. This is a nonspecific picture that describes many troubled youngsters. What makes such adolescents schizophrenic is their peculiar, idiosyncratic way of seeing themselves, others, and the world around them. In some cases, the acting out behavior seems to be a defense against becoming schizophrenic; unfortunately, many of these youngsters end up in correctional facilities rather than psychiatric treatment programs because of inadequate diagnose s . Thus, while there does not appear to be a specific preschizophrenic personality, some preexisting disturbance in psychological functioning is common. The schizophrenic illness may then be a result of an already weakened ego development which is further compromised by the demands of the developmental tasks of adolescence. It should be clear from the above discussion that the diagnosis of schizophrenia in adolescents is a process demanding considerable expertise. Consequently, patients in w h o m it is suspected should be referred for psychiatric evaluation. Frequently psychological testing is helpful in revealing subtle disturbances in thought patterns as well as ruling out organic brain impairment.
Management Management of the adolescent with schizophrenia is a complex process best left to those with specialty training in this area. However, primary care specialists may be involved in referral and the initiation of appropriate treatment and follow-up, as well as providing concomitant medical care. Management aims at maximizing the adolescent's capacity to function in as nearly a normal manner as possible. This is done by a two-pronged approach:
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the restoration of functions that have been lost and the prevention of further decompensation. In mildly impaired adolescents, outpatient psychotherapy, antipsychotic medication, and supportive environmental manipulation may be sufficient. The adolescent patient is encouraged to use his capacity for self-observation, judgment, and rational thinking in order to achieve a more realistic picture of himself and others. Frequently; the therapist may have to engage in an "ego-lending" process, supplying these rational thought processes through comments made during therapy sessions: An 18-year old woman, who had chronic severe emotional impairment, needed to be told by her therapist that her mother's grossly inconsistent behavior and extreme emotional instability were due to an emotional disturbance within the mother, rather than solely to the patient's own "craziness" as she had so long believed. As with any adolescent, it takes time to build a therapeutic alliance so that the patient is able to see the therapist as a helping partner in the treatment. This is particularly true of the adolescent schizophrenic, who usually fears what might happen if his therapist finds out about his "crazy" thoughts: An adolescent in therapy frequently alluded to her "fantasies" but refused to talk about them. Finally when she did, she expressed the belief that they were so bizarre that the therapist would hospitalize her. The adolescent who is capable of being maintained on an outpatient basis should have enough ego strength to be able to compensate for intermittently poor reality testing: A patient in therapy commented, "yesterday I started to get the feeling of having a piece of glass in my throat. But I know I feel that way when I'm anxious." Outpatient therapy for schizophrenic adolescents frequently has to be continued on a long-term basis, often for several years, i.e., until the patient has developed sufficient strength to no longer have to depend on the therapist to lend this kind of intensive help. As time goes on, the frequency of contact may be lessened, but it is worthwhile to have such patients "keep in touch" intermittently. The therapist who treats this kind of adolescent needs to be prepared to accept that he or she will probably become an ongoing and enduring part Of the patient's life for many years.
Indications For Psychiatric Hospitalization Hospital treatment is indicated for the adolescent who is having an acute psychotic breakdown and/ or who is in need of close supervision and vigorous therapeutic intervention. In addition to allowing a
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controlled administration of antipsychotic medications, the hospital environment provides a protective atmosphere in which external stimu|i and demands are minimized, thus reducing: the stress on the exquisitely vulnerable decompensating adolescent. With the reduction of external stresses, reconstitution will begin to occur in and of itself. Psychiatric hospitalization is also indicated for the adolescent, not necessarily undergoing acute decompensation, w h o is so emotionally impaired that intensive rehabilitation or habilitation is needed. In a controlled, carefully structured environment, the adolescent can slowly and gradually learn more appropriate ways of functioning socially, and reach a higher level of personality integration: A 16-year-old boy with severe personality deterioration and an apparent need for chronic institutionalization was helped to function more normally during several months of hospitalization on an adolescent ward. At discharge, although still regarded as "different" and odd, he had improved sufficiently to return home and attend a special education class in a public school. For the adolescent who has been dysfunctional since early childhood, perhaps a childhood schizophreniG the gains during inpatien t or outpatient treatment may be limited, but there is still a possibility for emotional growth through the personality development and restructuring associated with adolescence.
The Role of Family Therapy Early family studies pointed to disordered communication within families of schizophrenics. Family therapy has n o w become a well-accepted adjunct in the treatment of adolescents including t h o s e re: covering fro m psychotic illnesses, although the exact methods and aims often vary. While it is generally considered that family therapy does not cure schizophrenia, it can provide important benefits in terms of helping families provide appropriate emotional support and develop appropriate expectations from their sch!zophrenic member, thus making it possibl e for a reasonable degree of autonomy and emotional emancipation to occur.
The Role of Psychopharmacology Major tranquilizers are an indispensible adjunct to the treatment of schizophrenia and have been so since the early 1950s w h e n chlorpromazine came into use. Lower doses than those commonly used
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in adults are often adequate for adolescents, who ~frequently have a higher degree of responsivity to these agents. Adolescents are often resistant to taking prescribed medications because of the perceived threat to their sense of autonomy; and this is no less true of the adolescent with a mental disorder. It is not u n c o m m o n for the schizophrenic adolescent to experience the improved functioning with successful drug therapy as his mind's being "controlled" or takefl over by the drug. A good patient-physician relationship is essential in trying to overcome this resistance. Extrapyramidal side effects or excessive sedation may also be frightening to the adolescent and require careful management. Because many adolescents tend to be suspicious, they may react negatively to drug side effects; thus care must be taken to reassure them that if side effects do occur they are not serious and can be reduced or eliminated. The major side effects of the commonly used antipsychotic medications are a variety of extrapyramidal symptoms including muscular rigidity, Parkinsonian tremors, and'motor restlessness (akathasias). Particularly upsetting to adolescent males are the gynecomastia and impotence that occasionally occur. Tardive dyskinesia, a sometimes irreversible disorder characterized by a variety of abnormal movements, is thought to be caused by damage to the striatal dopaminergic receptor sites. This has been rarely reported in children and adolescents treated with phenothiazines (15). The various antipsychotic drugs differ in their tendency to produce side effects as well as in their sedative properties. Detailed discussions of drug treatment for schizophrenia may be found in several texts (16, 17).
Manic-Depresswe Psychosis Manic-depressive illness is an underdiagnosed condition during adolescence, with most of these severely disturbed teenagers being labeled schizophrenic (18). Characteristically these adolescents demonstrate distinct periods of elevated, expansive, or irritable moods associated with hyperactivity, distractibility, insomnia, never feeling tired, going days without sleep~ flight of ideas, and loud, pressured, and rapid speech. They may exhibit intrusive social behavior, calling friends at all hours of the day and night, and manifest an unceasing and unselected enthusiasm for social interaction. A euphoric high exists in spite of reality. They joke, are super-lively, and may be somewhat theatrical and behave in an unusually sexually provocative fashion. Grandiose feelings and ideas are usually present. They may go
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on wild buying sprees or make outlandish intrusions into highly classified, secret government agencies. These manic behaviors may rapidly alternate with periods of severe depression or each may last for several days o r weeks. When gross impairment of reality testing with delusions or hallucinations and/or grossly bizarre behavior exists, a manicdepressive psychotic process should be suspected. The diagnosis should also be entertained w h e n manic behavior, as described above, is evident and alters with severe depression. A positive family history for manic-depressive illness is usually elicited, and in most cases the onset of the illness can be related to a specific environmental stress, particularly major separations within the family. Ps;cchiatric consultation and treatment is essential for this disorder. Hospitalization is usually required during the acute phase to protect the adolescent, his family, and friends. The use of the phenothiazines may be necessary during the early days of treatment to calm the wild, manic behavior. Lithium carbonate is clearly the drug of choice in the treatment of manic-depressive illness. On lithium the wide fluctuations of m o o d are reduced, manic behavior abates, and depressive episodes are fewer and less pronounced. Lithium carbonate is contraindicated in certain physical conditions and requires close periodic blood level determinations (19).
Acute Confusional States The exact incidence of acute confusional states during adolescence is u n k n o w n and many episodes go undetected and undiagnosed. This condition is characterized by an abrupt onset of confusion, depression, and loss of self-identity often accompanied by intense anxiety. The adolescent usually experiences a heightened awareness of self with an intensification of sensory experiences. A broadening expansive sense of self and the social environment in which the individual lives is often described. There is often no evidence of thought disorder and no clear loss of contact with reality. A variety of etiologies have been hypothesized for this disorder including acute identity probleins, homosexual panic, and drug use.
Drug-induced psychoses. Drug-abuse-related psychiatric problems seem to account for an increasing proportion of adolescent psychiatry morbidity. Of the behavioral and psychological transformations that may occur in association with drug taking, none is more dramatic than a full-blown psychotic reaction. The drugs k n o w n to precipitate such reactions
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include amphetamines, marijuana, and the hallucinogenic drugs, most notably lysergic acid (LSD) and phencyclidine (PCP). The hallmarks of an acute toxic psychosis are confusion, disorientation, anxiety, agitation, and disturbances of perception, reason, and judgment. In their most severe form, these reactions can be associated with extremely bizarre behavior, based on the user's extreme distortion of reality such as jumping out of a window in the belief that one can fly. The characteristic alterations differ somewhat depending on the responsible drug; an amphetamine-induced psychosis, for example, is classically characterized by paranoid delusions while hallucinogenic drugs tend to produce various visual alterations such as seeing rainbows or flashes of color. One of the most disturbing changes is that occasionally produced by phencyclidine with serious distortions in perception and thinking along with a release of primitive kinds of aggressive behavior (20). This type of dissociative reaction is occasionally responsible for bizarre assaults or murders. Unfortunately, phencyclidine use appears to be increasing. The management of drug-induced psychotic states can be divided into two phases: acute and long term. Acute management is best carried out in a facility that can provide intensive, 24-hour medical supervision. The length of hospitalization required varies from a few days to several weeks. Major tranquilizers are helpful in controlling agitation and extreme anxiety. Haloperidol has been recommended as particularly helpful. Physical restraint should be avoided if possible. Those who worked extensively with the "flower children" of the 1960s stressed the importance of a supportive companion who could "talk the patient down." In planning follow-up treatment for the adolescent with a drug-induced psychosis it is necessary to take into account the total environment from whence the adolescen t came, including family, community, peers, and school, the extent and chronicity of previous drug use, and the presence of preexisting psychiatric illness or impairment. The adolescent for w h o m drug use has become a way of life can seldom be treated successfully outside of a highly structured residential treatment program. In other cases outpatient counseling or therapy can be attempted on a trial basis, with residential treatment remaining an option. The extent to which drug use among adolescents leads to permanent psychiatric sequelae is unresolved. Although many adolescents who are the victims of a single drug-induced psychotic episode
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will recover completely, a significant proportion of them, even though treated appropriately, will remain persistently psychotic and eventually become indistinguishable from the chronic schizophrenic. To what extent this group was predestined to become schizophrenic, and to what extent drugs hastened or precipitated this process, is unclear. It seems likely that marijuana is capable of inducing psychosis only in susceptible individuals, since few users of this widely used drug become psychotic. Phencyclidine, on the other hand, seems to produce psychotic states relatively frequently; therefore, its effects may be less dependent on individual susceptibility. The existence of drug-induced psychotic states that to varying degrees resemble acute schizophrenic episodes raises intriguing questions about how the pathophysiology of schizophrenia and drug-induced psychoses may be related. Investigative work in this area is still in its infancy. It should be kept in mind that adolescents w h o are emotionally disturbed frequently turn to drugs in an attempt to control their distress by "self-medication." The use of hallucinogens by schizophrenic youngsters is not uncommon. Thus drug use can significantly obscure the clinical picture.
Summary Although schizophrenia and other psychoses remain in many ways enigmas, they are unquestionably serious mental disorders. There is hope, however, that through prompt and appropriate treatment, healthy functioning can be restored. Extreme degrees of deterioration, once common in schizophrenia, are rarely seen today. The response of manic-depressives to lithium therapy is often dramatic. Although it is still too soon to know to what extent modern treatments can affect the longterm outcome of these illnesses in adolescents, there are clear reasons to be optimistic. Considerable advances have been made in recent years in understanding and treating these complex illnesses.
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References 1. Holzman PS, Grinker RR: Schizophrenia in adolescence, in Feinstein, SC, Giovacchini, PL (eds): Adolescent Psychiatry, Vol. V New York, Jason Aronson, 1977, pp 276-290 2. Winaker C, Clayton DJ, Reich T: Manic-Depressive Illness. St. Louis, C.V. Mosby, 1979 3. Erikson E: Identity: Youth and Crisis. New York, W.W. Norton, 1968 4. Feinstein SC, Miller D: Psychoses of adolescence, in Noshphitz, JD (ed): Basic Handbook of Child Psychiatry. New York, Basic Books, 1979, pp 708-722 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III) American Psychiatric Association, Washington, D.C., 1980 6. Bleuler E: Die Prognose der Dementia Praecox (Schizophrenie-Gruppe) Allgemeine Zeitschrift fur Psychiatric und Psychisch. Gerichtliche Medezin 65:436-464, 1908 7. Bleuler M: Schizophrenic Psychoses. Am J Psychiatry 136:1403-1409, 1979 8. Bateson G, Jackson DD, Haley J, et ah Toward a theory of schizophrenia. Behav Sci 1:25-264, 1956 9. Freud A: Adolescence, in Eissler RS, et al (eds): Psychoanalytic Study of the Child New York, International Universities Press, 1958, 13:255-278 10. Offer D, OfferJ: Normal adolescence in perspective, in Schoolar JC (ed): Current Issues in Adolescent Psychiatry, New York, BrunnerMazel, 1973 11. Bromet E, Marrow M, Karl S: Premorbid functioning and outcome in schizophrenics and non-schizophrenics. Arch Gen Psychiatry 30:203-207, 1973 12. Rieder RO: Children at risk, in Bellak L (ed): Disorders of the Schizophrenic Syndrome. New York, Basic Books, 1979 13. Robins N: Deviant Children Grown Up. Baltimore, Williams & Wilkins, 1966 14. Kernberg PF: Childhood Schizophrenia and Autism: A Selective Review, in Bellak L (ed): Disorders of the Schizophrenic Syndrome, Grune & Stratton, New York, 1979 15. Klawans HL, Goetz CG, Perlik S: Tardive dyskinesia: Review and update. Am J Psychiatry 137:900-909,1980 16. Campbell M: Treatment of childhood and adolescent schizOphrenia, in Weiner J (ed): Psychopharmacology in Childhood and Adolescence. New York, Basic Books, 1977 17. Lipton MA, Burnett GB: Pharmacological treatment of schizophrenia, in Bellak L (ed): Disorders of the Schizophrenic Syndrome. New York, Basic Books, 1979, pp 320-352 18. Engstrom FW, Robbins: Manic-depressive illness in adolesence. J Am Acad Child Psychiatry 17:514-520, 1978 19. Weiner J: Psychopharmacolgy, in Childhood and Adolescence. New York, Basic Books, 1977 20. Allen RM, Young SJ: Phencyclidine-inducedpsychosis. Am J Psychiatry 135:1081-1083, 1978