Psychosis May Mean Schizophrenia
When adolescents present symptoms that may suggest a psychotic disorder, there are a number of diagnostic and treatment challenges. However, Consultants in Adolescent Psychiatry at the Young Persons Directorate of the Greater Manchester West Mental Health NHS Foundation Trust Shermin Imran, MRCPsych, and Andrew Clark, FRCPsych discuss the assessment and management of adolescents who present severe psychotic illness, including schizophrenia, schizophrenia-like disorders, and bipolar disorder in their article “Adolescent Psychosis: A Practical Guide to Assessment and Management.”
The diagnosis of schizophrenia, or early-onset psychosis for adolescents younger than 18, is based upon the same criteria as it is for adult patients, focused on three characteristic symptoms: reality distortion, such as hallucinations or delusions; disorganization; and psychomotor poverty, such as speech poverty, poor motivation, social withdrawal, and flat affect. Also, the DSM-IV schizophrenia diagnosis requires there to be a six-month period of disturbance that includes both a prodromal period of deterioration before psychotic symptom onset and a residual phase.1 However, for adolescents the diagnostic criteria “failure to achieve age-appropriate interpersonal, academic, and occupational progress” may be substituted for “significant deterioration in self-care and social, educational, and occupational functioning.”1
Episodes lasting between one and six months may allow for a diagnosis of schizophrenia to be made; however, briefer episodes that consist of sudden onset and rapid resolve within a month’s time and are free of evidence of an organic cause are instead diagnosed as brief psychotic disorders.1 Ongoing follow-up is required, as this may develop into schizophrenia later on. In adolescents, affective disorder may present psychotic symptoms, such as delusions, hallucinations, and thought disorder.1 While it may be easy to distinguish affective disorder from schizophrenia in adolescents who present symptoms that are mood-congruent with affective episodes and show no negative symptoms, it may be more difficult to diagnose in adolescents who present odd delusions, mood-incongruent hallucinations, or significant functional deterioration.1 According to Imran and Clark, in cases as such, diagnostic uncertainty must be accepted and the adolescent must be observed as their symptoms evolve.1 Psychotic, manic, or hypomanic symptoms may also appear when substances are being abused or when organic conditions appear.
Imran and Clark state that there are a wide-range of possible causes of adolescent psychotic symptoms; therefore, a correct diagnosis leads to effective treatment and management.1 A comprehensive assessment aids in correct diagnosis and should always be completed before a diagnosis is made. First, a detailed history should be taken from multiple sources, including the patient, their parents or guardians, and their teachers.1 Family history of psychosis and developmental level of cognitive, social, and linguistic abilities should be an important focus.1 Also, there are diagnostic interview tools that are useful in examining mental status. For example, the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children—Present and Lifetime Version (K-SADS-PL) is especially useful as it is consistent with the DSM-IV diagnostic criteria. Second, a detailed physical examination should be completed in order to rule out any neurological, endocrine, or other systemic abnormality that may cause psychosis.1 Also, routine measurement of complete blood cell counts, urea and electrolytes levels, and liver and thyroid function should be taken as a baseline and repeated periodically in order to closely monitor for adverse effects of pharmacotherapy treatments.1 Urinary drug screenings and hair analysis should also be completed periodically, even if no history of substance abuse is present.1 Other psychological disorders also present hallucinatory experiences, such as emotional and conduct disorders, history of sexual or physical abuse, and borderline personality disorder; however, following the strict diagnostic criteria will usually clarify the diagnosis.
Medical Reasons for Schizophrenia
According to Imran and Clark, there are several organic conditions that can cause psychotic symptoms, such as frontal and temporal lobe epilepsies, systemic lupus erythematosus, multiple sclerosis, hyperthyroidism, cerebral tumors or infections, and neurodegenerative conditions, such as Wilson disease and metachromatic leukodystrophy. A fluctuating mental state paired with changes in orientation and cognitive functioning may indicate an organic condition.1
Schizophrenia and Substance Abuse
Also, adolescents who show symptoms of schizophrenia or mania-like psychotic episodes often have a history of substance abuse; therefore, the following should be considered when diagnosing the individual: whether the episode was induced by a psychoactive substance that usually causes acute onset and rapid resolution, such as cocaine, amphetamines, or Ecstasy; whether there is an underlying psychotic disorder that is being accelerated by substance abuse; or whether there is merely a substance abuse disorder not related to psychosis.1 However, psychotic symptoms that do not cease after a period of one to two weeks in a controlled setting without substance abuse is an indication of a psychotic illness.
Treatment of Schizophrenia
Management of an adolescent psychotic disorder should be based upon a comprehensive assessment of the adolescent and their environment, emphasizing predisposing, precipitating, and maintaining factors, state Imran and Clark.1 First, an assessment of risk to self and others is required, and may be taken from the patient’s history, their current mental state, their insight into their own illness, and their likely adherence to treatment.1 Also, an assessment of vulnerability is important, to determine the level of support available to counteract any of the potential risk factors.1 Treatment is usually guided by the stage of the adolescent’s illness. Usually, the first-line of treatment is atypical antipsychotics despite the limited evidence base of use in adolescents.1 According to Imran and Clark, they often have better tolerability than adverse outcomes.1
Imran and Clark state that while it may be difficult to diagnose adolescent psychotic disorders, there are a series of steps that may be followed in which symptoms may be clarified and a correct diagnosis of illness may be made, which they outline in their article. It is important to take detailed histories of the patient and family, as well as perform several detailed physical tests and examinations to rule out organic causes of psychosis. It is also important for clinicians to ensure that the management of the adolescent’s illness is in responsible hands at home and that there is not a risk of injury or suicide.
 Imran, S. and Clark, A. (2008, Oct. 1) Adolescent Psychosis: A practical guide to assessment and management. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/display/article/10168/1336526
 Liddle PF. The symptoms of chronic schizophrenia: a re-examination of the positive-negative dichotomy. Br J Psychiatry. 1987;151:145-151.
 Kaufman J, Birmaher B, Brent D, et al. Kiddie-SADS-Present and Lifetime Version (K-SADS-PL). Pittsburgh: Western Psychiatric Institute and Clinic; 1996.
 Altman H, Collins M, Mundy P. Subclinical hallucinations and delusions in nonpsychotic adolescents. J Child Psychol Psychiatry. 1997;38:413-420.
 Clark AF. Psychotic disorders. In: Gowers S, ed. Clinical Practice in Adolescent Psychiatry. London: Arnold; 2001:193-210.
 McClellan J, Werry, J; American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl 10):157S-176S. schizophrenia.