Differential diagnosis of very early onset schizophrenia with bipolar disorder and clozapine as a treatment: case report

Very early onset schizophrenia (VEOS) is a rare neurodevelopmental disorder with a poor prognosis that is characterized with loss of cognitive and social skills. Diagnostic criteria used for schizophrenia in adults are also used for the diagnosis of VEOS. However, clinical manifestations in children may occur in different ways therefore, physicians may have difficulties in treatment planning and differential diagnosis with other psychiatric disorders. Before patients are diagnosed with VEOS, they are usually diagnosed with bipolar disorder, epilepsy, mental retardation, ADHD, anxiety disorders or Obsessive compulsive disorder. As a result, most patients are diagnosed late. In this article, the clinic features of a case of VEOS with several prior diagnoses and treatments are discussed along with the challenges of differential diagnosis and treatment algorithms. The patient is a 15-year-old female, attending 10th grade in a special class. She speaks to herself and laughs, inşicting harm on herself, has fear and suspicions, and eats raw fish or meat. Starting with her infancy, she suffered neurodevelopmental deficiencies. At age of six, she started seeing an imaginary friend, who led her to an attempted suicide. During her schooling years, the patient, who had cognitive and social deficiencies, manifested moods such as extreme cheer and hyperactivity. Since then, she has been treated based on diagnoses such as mild mental retardation, bipolar disorder and ADHD. In her family history, the father has alcohol addiction, a sibling with autism spectrum disorder, and two uncles with psychotic disorder. This case was followed at other hospitals until age ten, at which time she started with our outpatient clinic with a diagnosis of bipolar disorder. Due to lack of improvement in her symptoms, she was accepted as an inpatient, and was later diagnosed with VEOS. In her treatment, due to insufficient response to risperidone and aripiprazole, clozapine was introduced. Shortly after the start this treatment, her positive and negative symptoms improved. When she achieved a level suitable for outpatient follow-up, she was discharged with partial remission. Despite clues such as premorbid features and lack of functionality, the diagnosis was finalized thanks to the positive and negative symptoms, disorganized speech and behavior that surfaced during the observation period. A successful treatment followed this accurate diagnosis. For the early diagnosis and treatment of VEOS, it is important to recognize the prodromal symptoms. Evaluation of the positive psychotic symptoms is more difficult at younger ages. It is very common that psychotic-like and real psychotic symptoms are confused, and so, the patients are diagnosed with others disorders instead of schizophrenia, and subsequent incorrect treatments are planned. Therefore, for early diagnosis and treatment, there is a need for studies aiming the recognition and interpretation of the psychotic disorders during infancy.