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Is it adolescent psychosis? Consider these 6 issues

Vol. 2, No. 9 / September 2003
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Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms. 1

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

  1. Mood disorders. Psychotic symptoms in the young:
    • often point to major depression with psychotic features 1
    • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia. 2 Conversely, negative symptoms of schizophrenia may be mistaken for major depression.

  2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms. 3,4
  3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not. 5 The younger the patient, the less likely he or she is psychotic.
  4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression. 4
  5. Family history. Genetics are an important risk factor for schizophrenia. 6 A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
  6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional. 7


1. Findling RL, Schulz SC, Kashani JH, Harlan E. Psychotic disorders in children and adolescents. Thousand Oaks, CA: Sage Publications, 2001.

2. Findling RL, Kowatch RA, Post RM. Pediatric bipolar disorder. A handbook for clinicians. London: Martin Dunitz, 2002.

3. Russell AT. The clinical presentation of childhood-onset schizophrenia. Schizophr Bull 1994;20:631-46.

4. American Academy of Child and Adolescent Psychiatry Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry 2001;40:4S-23S.

5. Häfner H, Maurer K, Löffler W, Riecher-Rössler A. The influence of age and sex on the onset and early course of schizophrenia. Br J Psychiatry 1993;162:80-6.

6. Nicolson R, Brookner FB, Lenane M, et al. Parental schizophrenia spectrum disorders in childhood-onset and adult-onset schizophrenia. Am J Psychiatry 2003;160:490-5.

7. McKenna K, Gordon CT, Lenane M, et al. Looking for childhood-onset schizophrenia: the first 71 cases screened. J Am Acad Child Adolesc Psychiatry 1994;33:636-44.

Dr. Findling is director of child and adolescent psychiatry, University Hospitals of Cleveland, Cleveland, OH.

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