A 10-year-old boy with ‘voices in my head’: Is it a psychotic disorder?
M, age 10, reports hearing 'voices in my head' that tell him he is going to choke on his food, and this causes fear and anxiety. Is a psychotic illness the correct diagnosis?
M’s symptomatology did not appear to be psychotic. He was screened for positive or negative symptoms of psychosis, which he and his family clearly denied. Moreover, M’s compulsions (going to the restroom) were typically performed in response to his obsessions (urge to void his bladder) to reduce his distress, which is different from schizophrenia, in which repetitive behaviors are performed in response to psychotic ideation, and not obsessions (Table 23-5).
M’s inattentiveness in the classroom was found to be related to his obsessions and compulsions, and not part of a symptom cluster characterizing ADHD. Teachers often interpret inattention and poor classroom performance as ADHD, but having detailed conversations with teachers often is helpful in understanding the nature of a child’s symptomology and making the appropriate diagnosis.
Establishing the correct clinical diagnosis is critical because it is the starting point in treatment. First-line medication for one condition may exacerbate the symptoms of others. For example, in addition to having a large adverse-effect burden, antipsychotics can induce de novo obsessive–compulsive symptoms (OCS) or exacerbate preexisting OCS, and selective serotonin reuptake inhibitors (SSRIs) may exacerbate psychosis in schizo-obsessive patients with a history of impulsivity and aggressiveness.6 Similarly, stimulant medications for ADHD may exacerbate OCS and may even induce them on their own.7,8
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