A 15-year-old boy is brought to the office by his mother due to "odd behavior." The mother says, "Since moving to a new school 8 months ago, he has started talking to his imaginary friend Henry again. He hasn't done this since kindergarten—he used to cry a lot when I dropped him off, but Henry was a big comfort to him." She adds that the patient can get easily overwhelmed by social situations and has always had a hard time making friends. The mother also notes that her son has been spending more time alone, and when passing by his bedroom she can sometimes hear him laughing and talking to Henry. His teachers have said that the patient has not been paying attention in class or completing homework. He no longer spends time with his siblings and says he "would rather play videogames with Henry." The patient states, "Henry is always with me and likes to comment on what I am doing." The patient reports no depressed mood; sleep and appetite are normal. He has tried marijuana in the past but does not drink alcohol or use other drugs. Medical history is not significant. Vital signs and physical examination are normal. On mental status examination, the patient avoids eye contact and has a flat affect. Which of the following is the most likely explanation for the patient's behavior?
Schizophrenia | |
Diagnosis |
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Treatment |
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This boy's 8-month history of auditory hallucinations and negative symptoms (social withdrawal, flat affect) resulting in significant functional decline from baseline is consistent with schizophrenia. Onset of psychotic symptoms prior to age 18 is referred to as early-onset schizophrenia and is associated with a more severe course of illness. Adolescents commonly have a prodromal phase marked by social withdrawal and academic decline, which can last for weeks to years prior to the onset of active psychotic symptoms.
Hallucinations are more frequent than delusions in pediatric schizophrenia. Auditory hallucinations may consist of comments about what the patient is doing, as in this case, or commands. Visual and tactile hallucinations as well as multisensory hallucinations may also occur. Youth with schizophrenia frequently name their hallucinations, which need to be differentiated from imaginary friends. Imaginary friends typically decline in prevalence around age 6 and are not associated with functional decline, as in this patient's case.
(Choice A) Although this patient has a history of feeling overwhelmed in social situations and difficulty making friends, he was interacting with his siblings and family prior to his decline, and he does not have a history of repetitive behaviors or the restricted interests that characterize autism spectrum disorder (ASD). ASD would not explain this patient's hallucinations or functional decline from baseline.
(Choice B) Patients with dissociative identity disorder have ≥2 distinct personality states, which are associated with memory lapses and a disruption in self-continuity.
(Choices C and E) Schizoid personality disorder is characterized by social detachment and decreased range of emotion and affect. In schizotypal personality disorder, patients have deficits in social interaction together with eccentric behaviors, odd beliefs, and idiosyncratic thought and speech patterns (eg, using metaphorical or over-elaborative language). Neither disorder would explain this patient's hallucinations. In addition, personality disorders are not typically diagnosed in youth, during which personalities are still developing.
(Choice F) Heavy marijuana use has been associated with the onset of psychotic disorders. However, this patient reports only sporadic use in the past, with ongoing symptoms of schizophrenia for the last 8 months, making substance-induced psychosis unlikely.
Educational objective:
Early-onset schizophrenia (onset age <18) is associated with a more severe and impairing course. Youth commonly have a prodromal phase marked by social withdrawal and academic decline prior to the onset of active psychotic symptoms. Hallucinations are common and need to be differentiated from imaginary friends.