by Natalie Artinian, D.O., Bay Area Clinical Associates, Psychiatry, Child & Adolescent Psychiatry.
The prodromal phase of any disease, disorder, or illness is the time between the onset of a specific set of symptoms that commonly precede it and the onset of the disease, disorder, or illness itself: the same is true for prodromal psychosis in teens.
Prodromal psychosis is a term used by mental health professionals to describe the early symptoms that can lead to – and indicate an elevated risk of – the development of a mental health disorder associated with psychosis, such as schizophrenic disorders, brief psychotic disorder, and some mood disorders.
Prodromal Psychosis in Teens: Prevalence and Prognosis
Studies published by the National Institutes of Health (NIH) show the following rates of psychosis among people in the U.S.:
- General population: 5% – 8% percent of the general population report symptoms of psychosis.
- Among teens:
- 13-18: 5% show early symptoms of psychosis.
- Pre-adolescents, age 9-12: 14% show early symptoms of psychosis.
Experts suggest that the rate of progression from prodromal psychosis to schizophrenia or another psychotic disorder – for those who show early symptoms – is around 10 percent.
Before we discuss the symptoms of prodromal psychosis, parents of teens who may be at risk of psychosis or mental health disorders with psychosis should understand an important fact:
Most studies show that a shorter duration of untreated psychosis, therefore shorter time from onset of symptoms to psychiatric assessment, identification, and treatment, is associated with better clinical outcomes and improved quality of life.
Prodromal Psychosis in Teens: Symptoms
The symptoms of prodromal psychosis in teens may resemble symptoms of other psychiatric illnesses such as depression, anxiety, bipolar disorder, or borderline personality disorder. However, prodromal psychosis is characterized by gradual changes in thoughts, behaviors, perceptions, and day-to-day functioning that can lead to extreme changes in thoughts, behaviors, and perceptions, such as hallucinations and delusions – i.e. seeing or hearing things that are not there and believing things that are objectively untrue.
Here’s what to watch for in adolescents:
- Problems screening out distracting information or sensations
- Feeling disconnected from reality
- Disturbances in sleep
- Irritability
- Paranoia/suspiciousness
- Elevated sense of self, such as belief they have special powers or abilities
- Depressed mood
- Feeling overloaded
- Strong desire to be alone/withdrawal from family and friends
- Change in perception: sounds may seem louder than usual, and visual experiences – seeing colors, etc. – may become brighter and more intense
- Difficulty focusing
- Problems understanding what they’re seeing or hearing
Again, it’s important to understand that even if someone shows all the signs above, it does not mean they’re in the prodrome phase of a psychotic disorder. In some cases, these symptoms convert to a disorder, and in others, they may fade or remain mild. Only a qualified mental health professional can make a diagnosis, and prodromal psychosis cannot be officially diagnosed until full psychosis has developed.
Prodromal Psychosis Among Teens: Early Signs
An important phrase to know when discussing anything related to psychosis is first episode psychosis (FEP). Mental health experts define FEP as “…when a person first shows signs of having trouble distinguishing what is real and what is not.”
One challenge for parents and treatment professionals is that the early indicators of psychosis may resemble typical teen behavior. Early signs that overlap with behavior common in teens can appear in the following ways:
- Rapid, uncharacteristic drop in grades
- Difficulty concentrating
- Problems forming clear thoughts
- New and heightened suspicion of others
- New and heightened discomfort around others
- Disinterest in basic hygiene/self-care
- Withdrawal from friends/family
- Spending more time alone
Those are considered signs of early or prodromal psychosis, but they’re also things most parents observe in teens who aren’t in the prodromal phase of psychosis. However, when a teenager shows or experiences the symptoms below and shows or experiences the warning signs above, it may be an indication they’re experiencing the prodromal phase of a mental health disorder associated with psychosis.
Prodromal Phase: Symptoms
- Social withdrawal and isolation
- Bizarre preoccupations
- Unexplainable and repeated need for reassurance
- Increased frequency of angry outbursts
- Frequent mood swings
- Aggressive behaviors
- Issues with memory
- Changes in mood – depressed mood and thoughts of suicide
- Loss of energy
- Sleep disturbances
- Changes in weight
- Loss of interest and pleasure
- Decreased performance in work and school
- Changes in appearance (i.e. Poor hygiene)
- Changes in perception (hearing/seeing things not there)
- Religious obsessions
Note that in a psychotic disorder, more than one of the above symptoms would occur simultaneously, without an obvious external trigger.
To help understand what happens in the prodromal phase of a mental health disorder with psychotic symptoms, please watch this video. It describes one person’s experience with the prodromal phase of schizophrenia:
How Schizophrenia Starts – My Experience with the Prodromal Phase
Here’s a quote from the video that people in the prodromal phase of psychosis need to hear:
“People who access help and support when they’re in the prodromal phase, before they have their first episode of psychosis, often have a better prognosis, in terms of the treatment of their schizophrenia, if it progresses to that.”
Granted, she’s talking about schizophrenia, specifically, but it’s safe to generalize her statement to other disorders with psychotic symptoms.
Symptoms of Psychosis: What Are They?
Symptoms of psychosis involve disruptions in thoughts and perceptions which affect the ability to accurately determine what’s real and what’s not real. Clinicians define two ways symptoms appear in psychosis: delusions and/or hallucinations.
Two types of psychotic symptoms are illogical thinking and loose associations.
Examples of Illogical Thinking:
A child/teen may use casual speech inappropriately. For example:
“I left my hat in her office because her name is Mary.”
A child/teen may use unfounded and inappropriate reasoning in noncausal utterances. For example:
“Sometimes I’ll go to bed and when I’m done laughing, I start wheezing, and that’s when I relax.”
In this context, noncausal utterance means the statement – specifically the sequence, and how the person connects the dots – does not follow logical patterns of cause and effect.
A child/teen contradicts themselves within 1-2 statements by simultaneously making and refuting statements. For example:
“I don’t like that story, but I liked it.”
In addition to disruptions in cognition that lead to illogical patterns of thought, psychotic symptoms often involve making connections between things that aren’t really connected. Experts label these disruptions as loose associations.
Example of Loose Association:
A child/teen makes a statement that is off topic without previously preparing the listener that the topic is changing. For example:
Parent: “Why do you think that’s a reason not to like Tim?”
Child/teen: “And I call my mom Sweetie.”
Based on these examples, it’s easy to see why the symptoms of psychosis can be confusing and distressing for both the child/teen experiencing them and the people around them. These are things that make you double-take, and wonder what’s going on. When the double-takes accumulate, you may start to suspect there’s a mental illness behind them, but as a parent – rather than a trained mental health professional – you don’t have the skill or experience to diagnose your child.
That’s why it’s important to understand the risk factors for early psychosis and psychotic disorders. When risk factors are present and warning signs appear, seeking a full professional psychiatric assessment is crucial, since early detection and treatment have a significant impact on long-term prognosis and outcomes.
Let’s take a look at the risk factors for early psychosis now.
Early Psychosis: What Increases Risk?
Research on psychosis in teens shows the following factors can increase risk of developing mental health disorders with psychotic symptoms:
Genetics:
- History of psychosis in family
Trauma, including:
- Complications during pregnancy
- Illness during pregnancy
Childhood trauma, including:
- Physical, sexual, or emotional abuse
- Neglect
- Experiencing violence/war
Severe/early substance use
Mental health disorders:
- Major depressive disorder (MDD)
- Bipolar disorder (BD)
- Pervasive developmental disorder (PDD)
- Attention-deficit hyperactivity disorder (ADHD)
- Obsessive-compulsive disorder (OCD)
- Developmental syndromes, such as autism spectrum disorders (ASD)
When psychiatrists diagnose psychosis, they rule these things out first:
Psychiatric conditions:
- Major Depressive Disorder with psychotic features
- Post-traumatic stress disorder
- Bipolar spectrum disorder
- Schizoaffective disorder
- Pervasive developmental disorders and autism spectrum disorder (ASD)
- Schizophrenia
Some Medical conditions
Drugs of misuse/disordered use:
- Cannabis (THC)
- Psilocybin, i.e. recreational magic mushrooms
- LSD
- Dextromethorphan
- Simulants
- Inhalants
Prescription drug use:
- Corticosteroids
- Anticholinergics
- Antihistamines
- Anesthetics
- Amphetamine
Prodromal Psychosis in Teens: What Parents Can Do
The first and most important step is to arrange a full psychiatric assessment and evaluation administered by a qualified mental health professional with extensive experience both diagnosing and treating children and teens with complex mental health disorders. In this area of mental health diagnosis and treatment, there is no substitute for direct, in-person experience with children and teens.
An insightful, intuitive clinician who knows what to look for can save everyone time and energy by arriving at an accurate diagnosis and recommending an appropriate treatment plan that can help mitigate symptoms and potentially delay the onset of the disorder.
Once you’ve completed an assessment and receive referrals for care, please understand:
- If a psychiatrist prescribes medication, adherence/compliance to the recommended medication is essential. Many treatment centers will not accept non-compliant teens.
- If a psychiatrist recommends psychotherapy and/or psychosocial interventions, adherence/compliance to the recommended medication is essential. Adherence to a treatment plan increases the likelihood of positive outcomes.
- Basic lifestyle changes can make a big difference, such as:
- Regular, healthy diet
- Consistent and adequate sleep
- Avoiding and/or reducing stress
- Avoiding drug use, especially marijuana, which can significantly increase the chance of a full-blown psychotic episode, is critical.
Next, let’s take a look two treatment modalities that help patients and families in the prodromal phase of psychosis: family support groups and acceptance and commitment therapy (ACT).
Treatment for Prodromal Psychosis in Teens
Family support groups and Acceptance and commitment therapy (ACT) and often work hand in hand. They help family members understand the goals of treatment and how they can support their loved ones on the treatment journey.
Family support groups can help families:
- Improve communication
- Resolve conflict
- Create or restore a balanced family dynamic
- Set healthy boundaries
Acceptance and commitment therapy (ACT) is a cornerstone therapy for teens. When parents take the time to learn and understand the prime tenets of ACT and realize the power of their influence on the emotional/psychological environment in which their teens live, grow, and develop, they can promote a sense of safety for their kids, which is essential for making progress in treatment.
In ACT, the key word is workability.
Workability refers to behavior: if a behavior improves life, makes life better, and makes life more meaningful, then it’s workable. On the other hand, if a behavior impairs or detracts from quality of life, then it’s unworkable. In ACT, therapists, teens, and families focus on developing and keeping workable behaviors while identifying and reducing or eliminating unworkable behaviors.
Through that lens of workability, participating in ACT:
- Helps patients acknowledge, identify, and separate themselves from their perceptual aberrations rather than being overwhelmed by them.
- Helps patients separate themselves from their perceptual changes so they can identify what emotions and feelings these trigger – i.e. fear, anger, etc. – and how these feelings influence behavior.
- Helps patients accept their perceptual changes and change their feelings about their perceptual changes.
- Helps patients create and accept a new reality that’s neutral or positive rather than the reality linked to negative emotions such as fear/anger.
- Patients can learn that despite hearing voices, everything is okay, and despite the presence of those voices, they don’t need to follow their directions to feel a certain way or do a certain thing.
Note: in ACT, outcomes are particularly strong for hallucinating patients, not as strong for delusional patients.
More About ACT: Creative Thinking, Tailored Treatment
In some cases, words fail, and basic language doesn’t get the lessons across. Therefore, clinicians may get creative, apply their experience and intuition, and use metaphorical and experiential exercises to demonstrate core elements of ACT in a way patients can relate to understand. And when abstraction in language is difficult, impossible, or creates barriers to understanding, we turn to symbolism and experience. For instance, clinicians may communicate with emojis or use concepts from a common point of cultural reference, such as The Christmas Carol.
Clinicians will use exercises based on extended metaphors that help patients fully understand the relevant lessons. Exercises in ACT have names like The River of Thoughts, Down in the Cellar, or Invitation to the Room. To learn more about ACT and explore details about exercises like these, please read or download information here: Acceptance & Commitment Therapy: 21 ACT Worksheets (+ PDF).
To explore the evidence base for ACT in the treatment of psychosis, please explore these peer-reviewed journal articles:
- The Evidence Base of Acceptance and Commitment Therapy (ACT) In Psychosis: A Systematic Review (2018)
- Blended Care In The Treatment Of Subthreshold Symptoms Of Depression And Psychosis In Emerging Adults: A Randomized Controlled Trial Of Acceptance and Commitment Therapy In Daily-Life (Act-Dl) (2020)
- The Effects of Acceptance and Commitment Therapy in Psychosis Treatment: A Systematic Review of Randomized Controlled Trials
- (2019)
There’s valuable information in those journal articles and the content we share throughout this article. The most important thing to take away from this article is what we foreground in the introduction:
A shorter time from onset of symptoms to psychiatric assessment, identification, and treatment, is associated with better clinical outcomes and improved quality of life.
In other words, the earlier a person who needs treatment gets the treatment they need, the better chance they have at successful treatment. If you’re worried your teen is in the prodromal phase of psychosis, we encourage you to seek support now.
How to Find Support: Online Resources for Families
- The American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Their treatment finder is convenient and easy to use.
- The National Institute of Mental Health (NIMH) provides a nationwide treatment locator.
- The Centers for Disease Control (CDC) maintains this helpful Find Services and Treatment
- The U.S. Department of Health and Human Services (HHS) hosts an easy-to-use treatment locator at findtreatment.gov
