Table Of ContentPsychotic Symptoms
in Children and
Adolescents
Psychotic Symptoms
in Children and
Adolescents
Assessment, Differential Diagnosis,
and Treatment
Claudio Cepeda
New York London
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Table of Contents
Preface vii
Acknowledgments ix
Chapter 1 Overview of Psychotic Symptoms in Childhood 1
Chapter 2 Psychiatric Assessment 25
Chapter 3 Examination of Other Psychotic Symptoms 51
Chapter 4 Examination of Mood and Af ect 83
Chapter 5 Aids in the Diagnostic Process 93
Chapter 6 Dif erential Diagnosis of Psychotic Disorders:
Medical Conditions Associated with Psychosis 117
Chapter 7 Dif erential Diagnosis of Psychotic Disorders:
Psychiatric Disorders Associated with Psychosis 153
Chapter 8 Etiology and Pathogenesis 203
Chapter 9 Psychosocial Interventions for Chronic Psychoses 237
Chapter 10 Psychopharmacological Treatment: Considerations
in the Clinical Use of Antipsychotic Medications 273
Chapter 11 Mood Stabilizing Medications in the Treatment
of Psychotic Disorders of Children and Adolescents,
Other Treatments, and Alternative Treatments 313
Chapter 12 Overview of Atypical Antipsychotics 331
Chapter 13 Side Ef ects of Mood Stabilizers and
Atypical Antipsychotics 359
Chapter 14 Treatment of Atypical Side Ef ects 419
v
vi Contents
Appendix A Drug Interactions 443
Appendix B Conventional or Classic Antipsychotics 447
Notes 457
References 489
Index 525
h e author has received consultation fees from Lilly, AstraZeneca, Bristol-Myers
Squibb, and Pi zer Pharmaceuticals, but does not have any i nancial ai liation
to any of these companies or to any other pharmaceutical manufacturer.
Preface
Psychosis in childhood is not rare. Actually, psychosis is a rather common
phenomenon in severe psychiatric conditions. Although psychotic features
may go unrecognized for a long time, quite ot en these features are inl uential
if not determinative of maladaptive behaviors. Psychotic symptoms may be
reliably identii ed with simple questions. Identifying psychotic features is rather
simple. Deliberate engagement and systematic and nonleading questioning are
the main diagnostic skills that examiners should apply in this area.
Psychiatric examination places a great deal of attention on the nature of
the clinical communication and on the detailed analysis of issues related to the
presenting symptoms.
h e author has extensive experience in dealing with moderate to severe
child and adolescent psychopathology, and has developed a simple and sys-
tematic method of inquiry to explore these symptoms.
On one occasion, the author made a presentation on psychotic disorders
in children and adolescents. One member of the audience objected to the
presenter’s recommendation for a methodic and systematic exploration of
perceptual disorders and delusional symptoms. h e objecting psychiatrist
asserted that exploring psychotic symptoms in the manner recommended by
the author would be very time consuming. To this, the author retorted that
to not explore psychotic features in a systematic fashion was a risky practice
psychiatrists could not af ord. h e author reminded the audience that a com-
prehensive and systematic examination is the most cost-ef ective intervention
that a physician can of er to his or her patients.
Some physicians and some child and adolescent clinicians feel mystii ed by
the process of evaluating psychotic behavior. It should not be so. Children give
reliable responses to an interviewer’s questions about subjective experiences.
Rarely, parents know about the child’s psychotic experiences, and usually they
are skeptical about the existence of psychotic features in their children. For this
reason, in very small children, the author conducts the evaluation of psychotic
experiences in the parents’ presence and, as indicated in the text, the author
engages parents in the diagnostic enquiry.
vii
viii Preface
All the cited cases were seen by the author at the Southwest Mental Health
Center (SMHC).1
h is book is preeminently a clinical text, mostly descriptive. It will be
useful to child psychiatrists and child psychologists, to adolescent and general
psychiatrists, and to the great variety of mental health professionals (nurses,
clinical social workers, special education specialists, and other clinicians) who
specialize in the child and adolescent i eld.
h e author agrees with experts who maintain that psychosis in childhood is
consequential. Psychotic experiences can certainly submerge, leaving no trace.
On the other hand, a signii cant number of psychotic experiences endure, and
they either become organizing psychopathological cores, or they aggravate
other comorbid psychiatric conditions.
Chapters 1, 2, 3, 4, 6, 7, and 9 are readily accessible to nonmedical readers;
the rest of the book is rather technical and requires some medical or biological
background. No matter what the reader’s background may be, the chapters on
the use of medication with children (chapters 10, 11, 12), and the ones that
overview medication side ef ects (chapter 13) and the treatment of medication
side ef ects (chapter 14), will benei t any reader involved in the process of as-
sessing and treating children and adolescents.
In contemporary psychiatry, biochemical issues at the subcellular levels
are the order of the day. h e author overviews the most relevant aspects of
biological psychiatry that he considers fundamental in clinical practice. It is
hoped that the technical aspects of the book do not become too overbearing
to nonmedical readers.
h e author is sympathetic with international readers who may want to
pursue some of the cited references. About 15% of the bibliography relates
to Continuing Medical Education (CME) literature that may be inaccessible
in foreign countries. In the same vein, another 15% of references are found
in new clinical publications that have limited international distribution. h e
CME presentations were chosen among other things for the relevance of the
topics, the clarity of the expositions, the didactic aspects of the programs, the
reputation of the faculty, and/or the visual aspects of the programs including
graphs and tables.
Acknowledgments
h e late Otto Will, M.D., a superb Sullivanian psychotherapist of schizophrenia
in the 1970s, used to say that his best teachers were his patients. I do agree with
him; we owe a great deal to the people we serve. Each child and each family
leave teachings and memories that contribute to our expertise and personal
growth. I want to express my gratitude to the multiple children and parents I
have had the privilege to treat.
I was invited to organize a conference on Psychosis in Childhood at the
Annual Meeting of the Puerto Rico Academy of Psychiatry in 2001. h e idea for
this book germinated during the preparation for that conference. I am grateful
to Jose Manuel Pou, M.D., for such an invitation.
If the best git of love is the provision of time, I want to express my im-
mense gratitude to so many persons who in one way or another contributed
to the culmination of this book. I appreciate and recognize that without the
collaboration of so many persons this book might not have reached a successful
conclusion. It is likely that my recollection would betray me in remembering
many persons who to greater or lesser degree have contributed to making this
endeavor a success. h at risk notwithstanding, I take such a risk and give public
recognition to a number of persons who assisted me in a signii cant way in the
preparation, content, and readability of the text. Nonetheless, I take sole and
complete responsibility for the quality of the content.
If being lucky is to have a good wife and a good boss, I am very lucky in-
deed. I am particularly grateful to my “boss,” Graham Rogeness, M.D., for the
moral, logistic, and intellectual support of this project. As Medical Director of
the Southwest Mental Health Center (SMHC) and President of the Southwest
Psychiatric Physicians (SPP), to which I belong, he allowed our busy secretarial
staf to assist me in many practical aspects of the preparation of the manuscript.
In the same vein, I am very grateful to Fred Hines, CEO of SMHC at San Anto-
nio, for his support of this ef ort, and for the staf and logistic support provided
during the last four years.
Special gratitude is due to Sheila Ortiz, Director of Operations, for the inter-
est she demonstrated in this project, and for the time she spent proofreading a
number of chapters. I want to express many thanks to the SPP secretarial staf ,
ix
Description:As a child psychologist, I work with kids with varying degrees of mental illness. Trying to diagnose a psychotic disorder can be tough, however, since it sometimes isn't clear if it is true psychosis, versus an exaggerated depressive or possttraumatic response. Especially in my work with foster and
