Adolescent psychoses: treatment and service provision.

The generic term 'psychosis' is enduring but imprecise and the traditional division between neurosis and psychosis will be discouraged in the 10th revision oftheIntemnational Classification of Diseases (ICD-10), to be published in 1992.' However, it is used in ICD-92 and in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). It still has an established place in psychiatric parlance, indicating the presence of hallucinations, delusions or certain types of abnormal behaviour, namely, gross excitement and over-activity; severe, prolonged, social withdrawal; marked psychomotor retardation and catatonic behaviour. Its use does not imply either greater severity, although this is often the case, or impairment of insight or reality testing. With these reservations, it is permissible to refer to a group of adolescent psychoses. Categories of psychoses in ICD-9 include those with origin specific to childhood, principally infantile autism, but this condition is viewed currently as a pervasive developmental disorder and no longer a form of childhood psychosis. This review is concerned chiefly with schizophrenia, schizotypal disorders, drug induced psychoses, and affective disorders arising in adolescence. There is no unique adolescent psychosis and the view that 'adolescent turmoil' represents a 'normal psychosis' is outdated.4 Instead, adolescent disorders need to be seen in the context of all psychoses occurring in children and adults, and it is generally accepted that adult diagnostic criteria are applicable. Nevertheless, adolescence has a pathoplastic influence, giving disorders staged characteristics and colouring the content of psychotic symptomatology, sometimes making recognition difficult. Morbidity surveys suggest that the one year prevalence of psychosis in mid-adolescence is less than one per thousand.5 The proportion of psychotic patients in adolescent outpatient clinics is commonly about 5% of referrals6 and reported figures for inpatients vary from 2% to over 22%. About 3% of all psychiatric first admissions for children aged 10-14 years are for psychoses, but the figure rises to 21% for those aged 15-19 years.7 The psychoses occupy a neglected place in adolescent medicine and psychiatry. Services for psychotic adolescents are not well developed and academic interest has been limited. This is explained partly by the fact that the prominent interests of staff drawn to work with adolescents are in maturational, social, and family processes. Disorders construed in terms of disturbance of these processes suit multidisciplinary team consensus, as the emergent treatments are interdisciplinary, for example, family therapy. Psychotic disorders, traditionally the prerogative of doctors and nurses, however, have not fitted readily into this social dynamic model. The unknown aetiology, with genetic and possible organic factors, precludes developmental or psychodynamic explanations and pharmacotherapy tends to exclude non-medical staff. Interest in psychosis may be diluted also if staff have little or no formal psychiatric training or experience of adult disorders, because the incomprehensibility of psychosis can be alienating.