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6 Temperament as Premorbid Traits of Mental Illness

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Thinking Adult in Adolescent Psychiatry



In this chapter we will briefly address aspects of adolescent psychiatry of special

significance for adult psychiatry. Mental illness often makes its first appearance

in the early years. Mental difficulties in childhood and adolescence predict adult

mental difficulties. The early course of schizophrenia is characterized in most

cases by premorbid personality disorder and a prodromal break of the functional

curve. Self-disorders, considered specific of the schizophrenia spectrum, may be

detected during adolescence. Disorganized schizophrenia has an earlier (adolescent) onset than the paranoid subtype. An important differential diagnosis of

early symptom-poor schizophrenia is the autism spectrum disorders.

Temperamental and behavioral traits in childhood and adolescence portend bipolar disorder. The early course of bipolar disorder is often neglected, and especially hypomania is misjudged or overlooked.

Mental illness has been associated with specific premorbid profiles in children and

adolescents, either as premorbid temperaments predisposing to and predicting

future illness or as subthreshold states of the very mental illnesses. Their value for

early detection depends on the specificity of these characteristics. The ethics of

early intervention also rests on this due to the risk of stigmatization and the unnecessary treatment of healthy individuals. This chapter will focus on means of detecting and differentiating between (adult) mental illnesses in adolescents.

The life history of adult psychiatric patients, including areas such as school

achievement (premorbid cognitive functioning), socialization, and capacity for

work, reflects the course of the mental illness. Breaks of the social trajectory give an

impression of pathological deterioration. In children and adolescents, the social history is so much shorter, but the level of functioning and the breaks of the trajectory

© Springer International Publishing Switzerland 2016

L. Jansson, J. Nordgaard, The Psychiatric Interview for Differential Diagnosis,

DOI 10.1007/978-3-319-33249-9_13




Thinking Adult in Adolescent Psychiatry

can still be detected. The evaluation is complicated by the fact that young people are

synchronously developing both physically and mentally.

Childhood and adolescence difficulties predict adult difficulties. Premorbid difficulties presenting as personality disorder in adolescence elevate the risk for major

mental illness and suicidal ideation in early adulthood (Johnson et al. 1999).

Bullying, as bully or victim, is a predictor of mental symptoms, e.g., eating problems (Striegel-Moore et al. 2014), but the causal relation between the two is ambiguous; of course, bullying may lead to psychological reactions and contribute to the

development of mental illness, but being an “easy victim” may also imply, e.g.,

deviance from the norms or loss of defensive power.

Like in adult psychiatry, symptom-poor or subthreshold cases are likely to be

diagnosed on the basis of their most salient features or chief complaints rather than

their fundamental psychopathological processes. Multiple diagnoses should, therefore, always arouse suspicion of such underlying psychopathological processes.


The Early Course of Schizophrenia

Premorbid peculiarities are detectable in the majority of schizophrenia cases. In

the Copenhagen prospective study of high-risk offspring of schizophrenic mothers, behavioral abnormalities were assessed by psychiatrist and school teachers

(Parnas and Jørgensen 1989). Affective dyscontrol in children with a mean age of

15 years, reflected in less introverted and more disturbed behavior, predicted

schizophrenia as compared with schizotypy at follow-up 10 years later. The teachers reported of early patterns of behavior that showed certain gender differences:

premorbid schizophrenia males had disciplinary problems, the females being

more anhedonic, withdrawn, disengaged, and isolated, but poorly controlled (John

et al. 1982).

Self-disorders (see Sect. 8.3) dating back to childhood or early adolescence are

frequently reported by adult patients with schizophrenia (Nordgaard and Parnas

2014). Valid descriptions by the young patients of such subjective experiences cannot usually be obtained until adolescence. Self-disorders are prevalent among helpseeking, nonpsychotic adolescents (aged 14–18 years). They overlap with prodromal

symptoms assessed by prodromal instruments but constitute a distinct dimension of

risk of psychosis (Koren et al. 2013).

The symptoms of the early phases of childhood- and adolescence-onset schizophrenia are nonspecific, and it is difficult to separate the premorbid, prodromal,

and psychotic phases (Stenstrøm 2011). Boys had earlier onset and higher incidence rates than girls, and prior to the schizophrenia diagnosis, significantly more

girls had received diagnoses within the affective, nervous, stress-related, eating

disorder and personality disorder categories, and more boys had received diagnoses within the drug abuse and developmental disorder categories. Self-disorders,

showing themselves mostly as social withdrawal, were found in early schizophrenia (ibid.). Here is one example of early prodromal symptoms presented by the


13.1 The Early Course of Schizophrenia


According to his parents Jeppe fell ill in the 8th grade coughing a lot. They considered

whether he was ill or lazy. The X-ray was normal and the doctor said he was well. He later

told that he didn’t feel well, he was not himself, and his body felt unreal. (p. 96)

A birth cohort study indicates that the risk of being diagnosed with schizophrenia

spectrum disorders is significantly increased after being diagnosed with any child

and adolescent psychiatric disorder, particularly in the short term—within the first

year (Maibing et al. 2015). The significance of these findings is debatable. Among

these disorders we find autism spectrum disorders a fact which may, tautologically,

be explicable by autistic traits inherent in schizophrenia spectrum disorders.

Psychotic symptoms dating back to childhood are frequently reported by adult

patients, too. In many cases, these patients never told anybody about their experiences (hallucinations, persecutory ideas, etc.) thinking that these were normal experiences or, if they did, their parents or schoolteachers seem to have taken the

phenomena as expressive of inner speech or a vivid imagination. Some adult patients

refer to “my voice,” the voice they have been hearing since childhood. In a prospective birth cohort study (Poulton et al. 2000), psychotic symptoms at age 11 predicted schizophreniform disorder at 26. This finding was replicated in another

cohort study by Welham et al. (2009) showing that self-reported hallucinations at

age 14 predicted non-affective psychosis at 21.

Kahn (1923) points out that in the majority of schizophrenia cases, a “break”

(knick) in the development can be recognized: a radical change, something “new”

taking place (p. 40)—as opposed to the insidious course of development in other

cases. Such a break, indicative of a prodromal change, can be detected in intellectual, functional (school performance), and interpersonal (friendships) areas, in the

form of affective changes and changes in interests (cf. existential change, see Sect.

8.5). Actually, in many cases we may observe two or more breaks in turn in different

areas, e.g., social isolation followed by functional decline. But an apparent break in

the functional curve may also be seen in poorly structured individuals as a direct

consequence of moving from highly to less supportive living conditions. This phenomenon is often observed in young people “cracking up” when leaving primary

school or leaving home and, conversely, often profiting from structured measures

like doing military service and sharing an apartment. Yet another cause of breaking

the curve may be undetected drug abuse.

Hebephrenia as a subtype of schizophrenia (DSM: disorganized type), emblematic of this diagnosis, is traditionally related to early, teenage onset, as reflected in

the term (Hebe being the Greek goddess of youth). Hecker ([1871] Hecker and

Kraam 2009a, b) assumes that hebephrenia emerges from the affective and bodily

changes at the onset of puberty. “Body and soul stretch and expand in clumsy turns

back and forth to adjust to the new feelings and ideas.” All the characteristic aspects

of self-dissolution (see Sect. 8.3) present in Hecker’s description are viewed as

derivative from these puberty changes: a strange confrontation of thoughts and feelings appearing in an unbalanced manner, seriousness along with silliness, tender

sensations with coarseness, thought, speech, movement, and action missing precision. Schneider speaks of a pathoplastic impress of youth features indicating the

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