Psychotic Syndromes

Psychosis does not describe a specific diagnosis and may be seen in patients with both primary psychiatric disease and drug intoxication and in the presence of certain medical and neurological conditions. Psychotic patients have alterations in the normal processes of thought that result in an impaired sense of reality, which may be linked to emotional and cognitive abnormalities. The patient with psychosis may talk and act in a bizarre fashion and demonstrate hallucinations. The hallucinations may occur in one or more sensory modalities including tactile (the sensation of bugs crawling on the skin), auditory (threatening, critical, or insulting voices), and visual (lilliputian figures or animals). Additionally, delusions in the presence of full wakefulness may occur. These may be systematized or fragmentary, and the content may be variable, but persecutory delusions are most common.

Schizophrenia is the most common psychotic illness, and in the United States there is a 1 to 1.5 percent lifetime prevalence of this disorder. The disorder is equally prevalent in men and women and tends to occur more frequently in urban populations and in lower socioeconomic groups. The peak age of onset in men is 15 to 25, while in women the peak occurs at 25 to 35 years of age. Numerous studies suggest that the inheritance of schizophrenia has a genetic component, which is most likely polygenetic. Fifty percent of monozygotic twins of schizophrenics develop the disorder compared with 10 percent of dizygotic twins. The diagnosis of schizophrenia is a clinical diagnosis because there are no pathognomonic findings. At present two or more of the following features must be present for a significant period of time during a 1-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. Only one of these is required if delusions are bizarre, if hallucinations consist of a voice keeping up a running commentary, or if two or more voices are conversing with each other. There are five subtypes of schizophrenia including paranoid, disorganized, catatonic, undifferentiated, and residual types. [1

Schizophrenia is a chronic disorder, but many of the dramatic and acute symptoms subside over time. Most patients have low-level delusions and hallucinations and end up in psychiatric hospitals or supervised shelters. There is an improved prognosis when the onset occurs after age 30 and the active psychotic symptoms have a rapid onset. Additionally, good premorbid social and occupational function, the presence of a probable precipitant, and the absence of a family history are associated with an improved outcome. Although the biochemical cause of schizophrenia is unknown, most of the major hypotheses implicate central dopaminergic hyperactivity.

Schizophrenia should be differentiated from other primary psychiatric disorders that may have psychosis as a feature, including schizoaffective disorder, the major affective disorders, autism, malingering, and obsessive-compulsive disorder. Symptoms of psychosis can be caused by a large number of medical and neurological conditions and may be precipitated by legal and illicit drugs („„TabJe.3-3 ). Psychosis and other psychiatric symptoms may present

TABLE 3-3 -- DIFFERENTIAL DIAGNOSIS OF PSYCHOSIS

Infections

Fahr's disease

Acquired immunodeficiency svndrome (AIDS)

Hallervorden-Spatz disease

Homocystinuria

Creutzfeldt-Jakob disease

Huntington's disease

Herpes encephalitis

Diffuse Lewy body disease

Neurosyphilis

Metachromatic leukodystrophy

Structural

Wilson's disease

Neoplasm

Drugs

Trauma

Amphetamines

Normal pressure hydrocephalus

Anticholinergics

Levodopa

Toxins

Dopaminergics

Heavy metals

Alcohol

Carbon monoxide

Barbiturate withdrawal

Nutritional

Cocaine

Vitamin B12 deficiency

Phencyclidine

Pellagra

Other

Hereditodegenerative

Cerebrovascular disease

Cerebral lipidoses

Epilepsy

Fabry's disease

early in the course of medical or neurological disorders, and the clinician must consider this in the differential diagnosis. Of note, a significant link has been established between temporal lobe tumors and psychosis, even if patients with epilepsy are not considered. Tumors of the limbic system, particularly the cingulate gyrus, amygdala-hippocampal region, and the area around the third ventricle, are also commonly associated with psychotic behaviors. Typically, patients with organic causes of psychosis have a higher amount of insight into the illness and are distressed by their symptoms. Clinicians should be aggressive in pursuing a medical or neurological cause of psychosis in patients with no diagnosed psychiatric disease, particularly if there are unusual symptoms, altered consciousness, or concomitant medical or neurological signs. Additionally, a concomitant medical or neurological condition may cause an exacerbation or recrudescence of psychosis in patients with an established psychiatric disease.

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