January 17, 2019
Let’s play a game.
I’m going to tell you about some hypothetical patients. These aren’t actual patients, but they could be. And it is that possibility that I want you to keep in mind as you try to figure out what, if anything, ails these individuals.
The first patient says that she is certain that she has a fantastic business idea. If she can find enough investors, she’s pretty sure that she’ll be able turn that into the start of a profitable and novel company. She’s spent the last few days scouring the internet, looking up different investment firms, and even e-mailing or calling these firms. She plans to skip school tomorrow in order to travel and meet with one of the potential funding sources.
The second patient explains that after careful consideration, he has come to realize that he is now and has indeed always been a dog. He knows this seems strange. For example, he points out, why would a dog need to wear clothes? Shouldn’t his fur keep him warm? He informs you that he will be taking his meals on the ground from this point forward, and that he will eat without utensils, placing his mouth directly into the bowl. He smiles as he tells you this, and then walks, on all fours, out of the room.
Which patient should I worry about?
As you have probably guessed, the answer is that you should absolutely worry about both patients, and that you might also have absolutely nothing to worry about.
In fact, you may have thought to yourself that these patients sound kind of crazy. In mental health, we prefer less judgmental and more specific terms, so I’ll replace the term “crazy” with “psychotic.”
In other words, both patients are potentially quite psychotic and both patients are potentially entirely normal. How do we reconcile the two very different conclusions?
We don’t, yet, or at least we shouldn’t, because we’re missing some key data points.
If the first patient is a 28-year-old M.D/Ph.D. candidate who has an idea for a new drug delivery system, (by the way, this exact scenario actually did occur for one of my medical students), then there is nothing psychotic at all. In fact, this particular medical student took the day off from class in order to meet with a biotech firm here in Boston and then sold the idea for more money than she’d made in her entire life.
On the other hand, if this first patient is an 11-year-old girl who is telling you that she’ll miss school to go meet with a car company because she has developed a new form of perpetual energy, then you need to worry that she’s not entirely in touch with reality. Of course, it is always possible that she’s on to something, but it seems unlikely that she’s solved the world’s energy challenges and you definitely need to ask a lot more questions.
How about the second patient? If that patient is a four-year-old who tells you that he’s a dog, and then he woofs like a dog and runs around on all fours, he’s almost certainly horsing (or dogging) around. At the end of playtime, that same four-year-old will run to the table for supper and eat with the rest of the family. He’s fine! He’s playing the way four-year-olds play.
Once again, however, if this dog/person hybrid is in fact a 28-year-old M.D./Ph.D. student, and if that 28-year-old refuses to break with this pretense and eats all meals off of the floor… Then we need to at least consider that this person is psychotic.
Psychosis, especially when we’re talking about children and teenagers, is all about context. A four-year-old can briefly and quite seriously pretend to be a dog. A 28-year-old had better be fooling around.
Because psychosis in children and adolescents is extremely rare, it often gets left out of the discussion of child and adolescent mental health. All of this begs an important question:
What does it mean to be psychotic?
If you wander around the internet, you’ll often see “psychosis” defined as a state of “poor reality testing.” That’s not all that helpful, though, since we still have to define the phrase “reality testing.”
Let’s put it this way. Poor reality testing means that someone experiences things that do not exist in reality, or that someone doesn’t experience things that do exist in reality. This is a bit of an oversimplification, but it helps to capture the many states of psychosis if we add to this definition that the experience of psychosis as a psychiatric syndrome must cause distress.
If you have a hallucination – the sensory perception of an event that does not exist – then you have poor reality testing for what stimulates your senses. The most common forms of psychotic hallucinations are auditory, which means that the brain manufactures sounds that are not actually present. Because nothing else is detecting the sound, we know that the experience for the person who “hears” something – most often voices – is psychotic, by definition.
Similarly, if someone thinks that they are able to create perpetual energy, and there is no evidence that this could at all be possible, then we also at least need to entertain the possibility of psychosis. This kind of psychotic symptom is called a delusion – a fixed and false belief.
Other signs of psychosis include speaking in words or sentences that don’t make sense, or having thoughts that come too fast or that are unusually disjointed. You can read about the various kinds of psychotic symptoms and disorders here.
Importantly, all of these symptoms can indicate a huge array of potential diagnoses. Someone might suffer from mania, or a psychotic depression, or a bad reaction to prednisone, or drug abuse. That’s where the doctoring comes in – different forms of psychosis have different treatments, so it’s important to nail down at least a working hypothesis for the cause. This hypothesis might change as different attempts at treatment work better or worse, but these diagnoses yield treatment guidelines.
Most importantly, purely psychotic illnesses in kids are extremely uncommon. Childhood onset schizophrenia is very rare. The odds are slightly higher if a first degree relative in that child’s family has schizophrenia or bipolar disorder, but still these syndromes are more likely to occur in late adolescent or young adulthood. On the other hand, some psychotic symptoms in children are relatively common. Young children with depression often complain that they hear a mean voice. That experience goes away as the depression is treated. Children who have been traumatized often see the things that torment them even when those things are not present. Whereas PTSD in adults is characterized by a sense that they are re-experiencing the traumatic event, children with PTSD often mistake the re-experiencing as actually happening in real time.
Finally, and maybe most importantly, age and culture play a huge role. A toddler with an imaginary friend is not even a little psychotic. That’s a normal developmental stage. There is no distress for that toddler when he chats with the imaginary friend. Similarly, a Cambodian immigrant who hears the voice of his ancestors is having a culturally normal experience. I once asked a Cambodian friend why so many people hear the voices of their ancestors in the Far East, and he expressed sadness that I was not privy to the same experience in America. In his view, I probably just couldn’t hear my ancestors.
The bottom line is that psychotic symptoms in kids usually aren’t subtle. You’ll have an instinct to call your doctor if your child starts acting or saying bizarre things that don’t seem right for his age or her culture, and you should. It’s safer that way. Your doctor will rule out certain things like a bad reaction to a medicine, or maybe even a normal experience that you think isn’t normal. Remember, your pediatrician has seen all sorts of kids. Given the rarity of psychotic symptoms in kids, if you have any concern at all, it helps to bring in the professionals. We treat these syndromes with medications and therapy and sometimes hospitalization. And the sooner we address these symptoms, the better off your child will be.