Any of the following new or worsening signs in an adolescent or young adult should trigger assessment for psychosis:
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AATYPICAL |
CCOGNITION |
TTHOUGHTS |
SSPEECH |
Functional decline
Because psychotic experiences are not observable by others, the following observable changes should prompt careful inquiry into a young person’s internal experience:
Often the initial signs of a psychotic disorder include shifts in a person’s emotions or behavior:
Because psychotic experiences are not observable by others, the following observable changes should prompt careful inquiry into a young person’s internal experience:
- Decline in self-care
- Decline in attendance or performance at school/work
- Withdrawal from family, friends, and usual activities
- Reduced emotional expression
- Reduced interest in activities previously enjoyed
- Decreased ability to handle everyday stress
- Insomnia or altered sleep
- Decline in the amount or content of speech
Often the initial signs of a psychotic disorder include shifts in a person’s emotions or behavior:
- Increased dysphoria, irritability, agitation, hopelessness, anxiety
- Preoccupation with new ideas or causes (ex. religion, politics, philosophy)
- Behavioral such as pacing, staring, talking to self, or seeming disconnected and disengaged
Atypical perceptual experiences
These include false perceptions or misperceptions involving one or more of the five senses: hearing, sight, touch, taste or smell. The most common are auditory (hearing noises or voices). Visual disturbances can include distortions in color, lines, or perspective, as well as seeing things no one else can see.
People with psychosis experience these as real, although many may realize that even vivid experiences are the product of their own minds. Individuals with psychotic disorders describe feeling more sensitive to or overwhelmed by stimulation. Examples include:
These include false perceptions or misperceptions involving one or more of the five senses: hearing, sight, touch, taste or smell. The most common are auditory (hearing noises or voices). Visual disturbances can include distortions in color, lines, or perspective, as well as seeing things no one else can see.
People with psychosis experience these as real, although many may realize that even vivid experiences are the product of their own minds. Individuals with psychotic disorders describe feeling more sensitive to or overwhelmed by stimulation. Examples include:
- Sounds seeming louder than usual
- Seeing movement, shadows, or vague figures out of the corner of the eye
- Finding that everyday noises sound like words
- Hearing voices talking, giving commands, or narrating a person’s day
- Seeing people or animals outside a window or in the room
Cognitive difficulties
Basic neurocognitive disabilities are typically among the earliest signs of an emerging psychotic disorder. These difficulties may begin years before psychotic symptoms appear, and make a significant contribution to functional difficulties:
Basic neurocognitive disabilities are typically among the earliest signs of an emerging psychotic disorder. These difficulties may begin years before psychotic symptoms appear, and make a significant contribution to functional difficulties:
- Trouble with learning, memory, attention, mental speed, planning and organization
- Trouble with abstract reasoning and social cues
- Trouble with motivation or initiative
- Trouble with basic receptive and expressive language (the person may talk very little as a result)
Thought disturbance or unusual beliefs
The content of one’s thoughts can also be altered in psychosis. Delusions are false beliefs that do not fit within a person’s cultural, familial, or religious context. Even though delusions may seem odd or obviously irrational to others, they are captivating or compelling to the young person. In the early stages of psychosis, an individual may recognize these beliefs as illogical. Take note when your patients:
The content of one’s thoughts can also be altered in psychosis. Delusions are false beliefs that do not fit within a person’s cultural, familial, or religious context. Even though delusions may seem odd or obviously irrational to others, they are captivating or compelling to the young person. In the early stages of psychosis, an individual may recognize these beliefs as illogical. Take note when your patients:
- Feel suspicious of friends or family without clear reasons
- Have concerns that there is something wrong with their bodies or brains for bizarre reasons or without medical findings
- Have unusual beliefs about their capacity to eat, or about physical sensations or pain
- Feel that their body or mind has been altered by an external force
Speech or behavior that is disorganized
A person experiencing psychosis may have trouble thinking clearly or putting their thoughts into words. They may speak in jumbled or hard to follow sentences, lose their train of thought, or be unable to put a thought into words. They may also have trouble following conversations, thinking abstractly, or capturing the “gist.” They may make meaningful connections between ideas and events that have no logical connection, leading them to say or do things that confuse others.
Psychotic individuals may dress inappropriately for the weather, wander aimlessly, shout at strangers, or otherwise behave in ways that appear bizarre or even dangerous. This behavior is often more obviously recognized as psychotic, but also can be mistaken for substance use or erratic youthful behavior.
A person experiencing psychosis may have trouble thinking clearly or putting their thoughts into words. They may speak in jumbled or hard to follow sentences, lose their train of thought, or be unable to put a thought into words. They may also have trouble following conversations, thinking abstractly, or capturing the “gist.” They may make meaningful connections between ideas and events that have no logical connection, leading them to say or do things that confuse others.
Psychotic individuals may dress inappropriately for the weather, wander aimlessly, shout at strangers, or otherwise behave in ways that appear bizarre or even dangerous. This behavior is often more obviously recognized as psychotic, but also can be mistaken for substance use or erratic youthful behavior.
The Look, Feel, & Importance of Early Signs
The earliest changes in psychosis-spectrum illnesses can be subtle. These early changes are often not specific to psychosis or psychotic disorders; the majority of young people with these symptoms will have mental health problems other than psychosis. For those in the very early stages of a psychotic illness, however, these changes are important warning signs.
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Some people may begin to:
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Others may notice that someone is:
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When several signs or symptoms occur together, become more intense over time, cannot be clearly explained by other factors, or occur alongside a family history of psychosis, it is particularly important that the person be assessed by a skilled mental health provider who has some knowledge about early psychosis.
Other early warning signs are more obviously “psychotic-like,” albeit milder or more easily dismissed; for example, rather than hearing a clear voice they believe is real, a person may initially hear mumbling or whispers. We call these “attenuated” psychotic symptoms. When these symptoms are new or increasing in frequency or intensity, the risk for acute psychosis may be imminent. However, a surprising number of adolescents and even some young adults will report attenuated psychotic symptoms that are longstanding and stable. Depending on the nature of their symptoms, these individuals may not be at imminent risk for a psychotic disorder, but they are at higher long-term risk for psychosis and other serious mental health challenges. Early intervention is particularly warranted for youth with recurrent or impairing, even if attenuated, psychotic symptoms.
Other early warning signs are more obviously “psychotic-like,” albeit milder or more easily dismissed; for example, rather than hearing a clear voice they believe is real, a person may initially hear mumbling or whispers. We call these “attenuated” psychotic symptoms. When these symptoms are new or increasing in frequency or intensity, the risk for acute psychosis may be imminent. However, a surprising number of adolescents and even some young adults will report attenuated psychotic symptoms that are longstanding and stable. Depending on the nature of their symptoms, these individuals may not be at imminent risk for a psychotic disorder, but they are at higher long-term risk for psychosis and other serious mental health challenges. Early intervention is particularly warranted for youth with recurrent or impairing, even if attenuated, psychotic symptoms.
NOTE REGARDING CHILDREN <10
The prevalence of psychotic disorders in children is significantly less than in adolescents and young adults. However, awareness and assessment tools remain an important aspect of care for children with and at risk for severe mental illness. In a recent study by Kelleher and colleagues (2012), data suggest that 17% of children ages 9-12 experience psychotic-like symptoms. At this time, the screening of nonspecific risk factors and symptoms, as well as more specific psychotic-like experiences, remains similar for children and adolescents. Differences in care for children and adolescents at risk for severe mental illness emerge at the time of evaluation. When evaluating children, we are careful to consider what is developmentally appropriate for the child; for example, having imaginary friends may be a typical and developmentally appropriate phenomenon for a child. Additionally, the evaluation process necessarily involves parent report and observation, more so than may be seen with adolescents or young adults. When screening children for the possible presence of severe mental illness, we strongly encourage non-mental health professionals to refrain from offering a diagnostic statement, but rather emphasize that there is a question or concern that needs to be clarified for the child.
For additional tips on talking with a young person about whom you have concerns, see the guidelines from HeadsUp here.
The prevalence of psychotic disorders in children is significantly less than in adolescents and young adults. However, awareness and assessment tools remain an important aspect of care for children with and at risk for severe mental illness. In a recent study by Kelleher and colleagues (2012), data suggest that 17% of children ages 9-12 experience psychotic-like symptoms. At this time, the screening of nonspecific risk factors and symptoms, as well as more specific psychotic-like experiences, remains similar for children and adolescents. Differences in care for children and adolescents at risk for severe mental illness emerge at the time of evaluation. When evaluating children, we are careful to consider what is developmentally appropriate for the child; for example, having imaginary friends may be a typical and developmentally appropriate phenomenon for a child. Additionally, the evaluation process necessarily involves parent report and observation, more so than may be seen with adolescents or young adults. When screening children for the possible presence of severe mental illness, we strongly encourage non-mental health professionals to refrain from offering a diagnostic statement, but rather emphasize that there is a question or concern that needs to be clarified for the child.
For additional tips on talking with a young person about whom you have concerns, see the guidelines from HeadsUp here.
