Adolescent Psychosis

Assessment of adolescent psychosis

An array of possible causes may underlie psychotic symptoms in an adolescent (Table); the correct diagnosis has significant management implications. Comprehensive assessment and judicious use of physical examination and investigations aid this process.

A detailed history of presentation is required from multiple sources including the patient; the parents or caregiver; and, with consent, school or employment records. Although this history will aid in diagnosis, the clinician must face the challenge of obtaining an objective and accurate account from diverse, often emotionally involved, contributors who provide discrepant narratives.

Semistructured diagnostic interview tools can be useful in the mental status examination. The Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children (6 - 18 years)–Present and Lifetime Version (K-SADS-PL) is consistent with DSM-IV diagnoses and is particularly useful for those clinicians who rarely encounter psychosis in adolescents.¹⁵

A detailed history, including family history of psychosis, should aim to identify an accurate developmental level of cognitive, social, and linguistic abilities, supplemented where possible with an objective assessment of premorbid abilities and functioning (eg, school or employment records, psychometric assessment of strengths and difficulties). This should help assess the psychotic symptoms in the context of immature and illogical thinking or childlike fantasies in a developmentally young adolescent. The possibility of a pervasive developmental disorder that could present comorbidly with a psychotic disorder should be kept in mind.

A detailed physical examination that looks for any evidence of a focal neurological, endocrine, or other systemic abnormality is an essential part of the initial assessment. Judicious use of MRI or CT imaging or electroencephalography may be warranted to rule out a rare but possible organic cause of psychosis, as are tests to rule out possible infections or autoimmune or metabolic conditions. Routine measurement of, for example, complete blood cell counts, urea and electrolytes levels, and liver and thyroid function, as well as electrocardiography are recommended at baseline and periodically thereafter to check for adverse effects of treatment medications. Urinary drug screening or hair analysis is part of all diagnostic workups, regardless of whether there is a history of substance abuse.