First-Episode Psychosis: A Comparative Review of Diagnostic Evolution and Predictive Variables in Adolescents versus Adults

Abstract

Objective: To review the diagnostic evolution andpredictive variables ofdiagnosis and outcome infirst-episode psychosis in adolescents (age 13-19 years) and adults.Method: Literature was reviewed through MEDLlNE, Psycinfo, and PubMed, and istorically, all presentations of childhood psychosis were grouped with schizophrenia, despite Kraepelin's original distinction between schizophrenia and bipolar affective disorder. With the advent of Kolvin's work (1) and the subsequent DSM-III (2), childhood schizophrenia, autism, and other childhood psychoses came to be regarded as separate entities, thus creating diagnostic challenges (3-8). In addition to substance use and the emotional instability intrinsic to adolescence, the nonspecific presentation of adolescent (age 13-19 years) first-episode psychosis (FEP) contributes to this diagnostic dilemma (5,8,9; reviewed in 4,7,10,11).The frequency ofpsychosis increases with age in adolescence (8), with 0.5% of the population developing psychotic symptoms, mostly in the 16-to-19-year-old age group (12). The manifestations of psychosis are influenced by emotional, social, and cognitive developmental processes (13), which are still developing in adolescents. Psychosis onset in adolescence can significantly affect personal development (14-16) and has been suggested to represent a vulnerability in which brain-maturation processes facilitate the development of'psychotic symptoms (17). It has been postulated that with a later onset of psychosis, there is lower probability for such a facilitating process to be present, and therefore the chances ofrecovery from an acute episode are better (16).In light ofthe general impact of psychosis on adolescents and the diagnostic dilemma of adolescent FEP, this review attempts to understand better the course and outcome of psychotic disorders by comparing the adolescent and adult literature. This review addresses 2 questions: Is the diagnosis of FEP more stable in adults than in adolescents? Are there variables that can predict the course ofdiagnosis and outcome over time? MethodWe searched MEDLINE, Psycinfo, and PubMed for literature from 1989 to 1999 using the following terms: adolescence, psychotic disorder, psychosis.first episode, diagnosis, diagnostic stability, follow-up studies, prognosis, risk factors. The key references of the selected articles were also reviewed, including pertinent articles published before 1989. Studies were selected if they met the following inclusion criteria: published in English, inclusion ofFEP data, subjects 13 years and older, and measurement ofvariables related to diagnosis or outcome over time. Studies with 1 diagnosis only, with no consideration to evolution of other diagnoses, were excluded. Notably, the literature contains an extensive array of studies that examine specific variables (such as age of onset, sex, IQ, medication, and neuroimaging) in psychotic

First admissions for psychoses in Eastern Piedmont-Italy

“…Some published data indicate that diagnostic stability is greater in adult patients than in adolescents at the time of first admission; the mean age of our sample was 34 years 47 . A four-year follow-up study has found that the diagnosis of schizophrenia is more stable over time than the other psychoses 48 .…”

Review of the literature regarding early intervention for children and adolescents aged 0–15 experiencing a first‐episode psychiatric disturbance

“…The top four diagnoses are anxiety disorders, mood disorders (depression and bipolar), disruptive behavioural disorders (including attention deficit hyperactivity disorder (ADHD), conduct disorder and oppositional defiant disorder) and pervasive developmental disorders (including autism) 30 . Accurate diagnosis of mental disorders in children depends upon differentiating the behavioural changes associated with normal childhood development and those that may be an indicator of an underlying mental illness 3,27,31 . Consequently, the rate of misdiagnosis for first‐episode mental illnesses in children is high 27,29 .…”

“…Menezes and Milovan 27 conducted a review of the literature related to first‐episode psychoses and found that females tend to have better outcomes, they exhibit higher Global Assessment Functioning scores, shorter durations of illness, fewer hospitalizations and lower risk of suicide. Gender seems to be an important element to consider in treatment approaches for young people using substances, particularly when a comorbid disorder exists.…”

“…Compared with the diagnosis of adults, there is a greater instability when diagnosing children and adolescents with first‐episode psychosis 27 . Diagnosis is usually most stable if it is derived using standardized assessment methodology 27 . The following points depict some of the challenges in diagnosing mental disorders in children and adolescents.…”

“…No clear and consistent definitions and terms exist. For example, the vocabulary ranges from early psychosis, early intervention, first‐episode psychosis, and emerging and first‐break symptoms, to very early psychosis or other disorders 18,27,33,34,48,50,93 Service providers have a limited understanding of how various mental illnesses present in adolescents and children 24–29 …”