Intérêt du concept d’émergences psychotiques à l’adolescence : autour de deux situations cliniques

Abstract

ObjectivesPsychotic symptoms are common in the adolescent population and can occur even in those who have no underlying mental health disorders. For the practicing clinician, psychotic symptoms can represent a myriad of underlying pathologies that can be identified within a range of different circumstances. These include both organic (neurocognitive disorders, genetic disorders, brain lesions, etc.) and non-organic disorders (schizophrenia and bipolar). They can also represent non-pathological processes such as sensory deprivation. Regarding mental health, the positive symptoms of psychosis are associated with many disorders none of which are pathognomonic to any particular diagnosis. However, classically they are associated with the beginning of a schizophrenic disorder. Psychotic symptoms presenting during adolescence pose a unique diagnostic challenge. The emotional instability during this period proves to be an unsteady platform and the symptoms of psychosis are associated with a much broader differential diagnosis. Consequently, psychotic symptoms during this period can be misleading. Therefore, it remains very difficult to decide clinically between the onset of psychosis, an affective or thymic reaction, certain autistic spectrum disorders or the expression of neurocognitive particularities such as attention deficit disorder with or without hyperactivity. The objective of this article is to stress the difficulty of making a diagnosis in the adolescent population with regard to psychosis and to explore the concept of emergent psychosis applied to this age group. We have illustrated our propositions with two case reports. PatientsThe first patient is a 13-year-old teenager hospitalized for severe heteroaggresive behavior. We identified school bullying in his past medical history with a positive family history for ADHD. At first, he described having difficulties with his peers, moderate anxiety and a low-level mood. We observed hyperactivity and impulsivity in the service. The initial diagnosis suggested ADHD and social anxiety. Finally, without any clear positive symptomatology, the use of a screening scale (CAARMs) pointed out a disturbance in thought, which could correspond to a high risk of psychotic transition, which would require early treatment. The second patient is a 12-year-old teenager who presented with intense psychotic symptoms, suicidal tendencies and severe anxiety associated with a low-level mood. He described moments of experiencing a disassociation from reality, auditory hallucinations and interpretative delirious ideas. His mood seemed correlated to those psychotic symptoms. Our first hypothesis was a schizophrenic process. However, we found restricted interest and difficulties in social interaction. An ADOS-2 and an ADI suggested a high probability of autistic spectrum disorder. Finally, by effectively treating his anxiety, the patient showed great improvement with a dramatic reduction in the positive symptoms he had previously exhibited. DiscussionIn the first case report, we found no psychotic symptoms. The patient showed discrete symptoms of disorganization and discrete negative symptoms that suggested a very high risk of psychotic transition. In contrast, the second case report showed very severe positive symptoms. However, we did not find any disorganization or negative symptoms in his presentation. Finally, his anxiety seemed to exacerbate the psychotic symptoms in the context of autism. ConclusionsThe early detection of psychotic prodromes represents a major prognostic challenge in the functional disability that a low-grade psychotic process can generate. However, the appearance of the first positive symptoms does not presume an assured outcome. Thus, the notion of emergent psychosis in young adolescents has the advantage of not excluding the risks of future evolution towards a psychotic pathology, while keeping in mind other hypotheses.