eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Schizophrenia and Other Psychoses: Differential Diagnoses & Workup

Author: Rajkumar K Kalapatapu, MD, Fellow in Child/Adolescent Psychiatry, Department of Psychiatry, Indiana University School of Medicine
Coauthor(s): David W Dunn, MD, Program Director, Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Neurology, Indiana University
Contributor Information and Disclosures

Updated: Mar 10, 2008

Differential Diagnoses

Anxiety Disorder: Obsessive-Compulsive Disorder
Pervasive Developmental Disorder: Autism
Cognitive Deficits
Pervasive Developmental Disorder: Rett Syndrome
Mood Disorder: Bipolar Disorder
Porphyria, Acute
Mood Disorder: Depression
Wilson Disease
Personality Disorder: Borderline
Pervasive Developmental Disorder
Pervasive Developmental Disorder: Asperger Syndrome

Other Problems to Be Considered

Psychosis secondary to epilepsy
Neurodegenerative disorders
Multidimensionally impaired syndrome (not a DSM-IV diagnosis, characterized by emotional lability, distractibility, poor social skills, brief hallucinations, and trouble distinguishing fact from fiction)
CNS tumor
Progressive organic CNS disorder (eg, sclerosing panencephalitis)
Psychosis not otherwise specified
Psychosis, single episode
Schizoaffective disorder
Chromosomal disorder - 22q11 deletion syndrome

Workup

Laboratory Studies

  • Laboratory studies are performed as part of an assessment for differential diagnosis.
    • Toxicology screens may be needed if substance abuse is suggested.
    • Liver function studies, copper, and ceruloplasmin are part of the workup for Wilson disease.
    • Obtain porphobilinogen for porphyria.
    • Human immunodeficiency virus (HIV) titers, Venereal Disease Research Laboratory (VDRL) testing, or heavy metal screening may be needed.
  • Prior to starting psychopharmacologic therapy, perform standard laboratory studies.
    • Typical neuroleptics and risperidone have caused abnormalities in hematologic and liver functions. The atypical antipsychotics have caused glucose and lipid abnormalities; thus, glucose, cholesterol, and triglycerides need to be monitored.
    • Clozapine may cause severe leukopenia.
    • Thyroid and renal functions are required prior to starting lithium.
  • If the child has mental retardation or dysmorphic features, include a karyotype in the genetic assessment. One example is the 22q11 deletion syndrome, or velocardiofacial syndrome.23 Other preliminary reports suggest 5q involvement.

Imaging Studies

  • Neuroimaging using MRI or CT scanning (if MRI is not available) should be part of the evaluation of new-onset psychosis.
  • MRI helps exclude certain organic causes of psychosis.
  • Demyelination is observed in the child with leukodystrophy.
  • Atrophy is observed in some children with neuronal ceroid lipofuscinosis.
  • Ventricular enlargement and gray matter loss are consistent with, but not diagnostic of, childhood-onset schizophrenia.

Other Tests

  • Structured or semistructured interviews
    • These tests are beneficial for initial assessment and monitoring symptoms during follow-up care.
    • Initially, the recommended Mental Status Examination forms a baseline diagnostic framework.
    • Other standard instruments include the following:
      • Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS)6
      • Brief psychiatric rating scale (BPRS)
      • Positive and Negative Syndrome Scale (PANSS)
  • Psychological testing of cognitive function: This testing is essential for treatment planning.
  • Projective tests
    • Projective tests, such as the Rorschach, may be helpful in eliciting further symptoms.
    • The Thematic Apperception Test may also be helpful in eliciting additional information.
    • However, diagnosis is confirmed by comprehensive clinical assessment.
  • EEG
    • Perform an EEG if episodic symptoms or signs are present in the evaluation of a child with psychosis.
    • In children who receive clozapine, obtain an EEG because of the increased risk of seizures associated with clozapine.
  • ECG
    • Obtain an ECG prior to starting a low-potency antipsychotic.
    • Perform ECG prior to starting medication and as part of follow-up care of a child who receives pimozide.

Histologic Findings

Neuropathologic studies are available for persons with later-onset schizophrenia but not for children with schizophrenia. Postmortem studies have demonstrated reduced volume of the hippocampus. Gliosis has not been found, suggesting that no active inflammatory process occurs.

More on Schizophrenia and Other Psychoses

Overview: Schizophrenia and Other Psychoses
Differential Diagnoses & Workup: Schizophrenia and Other Psychoses
Treatment & Medication: Schizophrenia and Other Psychoses
Follow-up: Schizophrenia and Other Psychoses
Multimedia: Schizophrenia and Other Psychoses
References
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Further Reading

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Keywords

earlier-onset schizophrenia, EOS, very earlier-onset schizophrenia, VEOS, childhood-onset schizophrenia, childhood schizophrenia, dementia praecox, hallucinations, delusions, schizophrenic disorder, mental illness, mental disorder, dopamine, autism, psychotic disorder, schizophreniform psychosis, speech and language delays, inattention, aggression, rage, pervasive developmental disorder, PDD, attention deficit hyperactivity disorder, ADHD, internalizing disorders, bipolar disorder, depression, anxiety disorder, disorganized speech, catatonia, auditory hallucination, visual hallucination

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Contributor Information and Disclosures

Author

Rajkumar K Kalapatapu, MD, Fellow in Child/Adolescent Psychiatry, Department of Psychiatry, Indiana University School of Medicine
Rajkumar K Kalapatapu, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

David W Dunn, MD, Program Director, Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Neurology, Indiana University
David W Dunn, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, American Epilepsy Society, American Psychiatric Association, and Child Neurology Society
Disclosure: McNeil Honoraria Speaking and teaching; Lilly Grant/research funds Other; Novartis Grant/research funds Other; Shire Grant/research funds Other

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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