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This group includes a wide range of conditions with psychotic symptoms The cause is often not clear, but later events (eg, new symptoms) may clarify the diagnosis The most common example is chronic psychosis developing either during periods of heavy abuse of drugs or at some time after the drug use has ceased Other conditions include temporal lobe dysfunction, HIV infection, and a number of the conditions noted in the differential diagnosis (see below) They often have a good premorbid history, a precipitous onset, and an episodic course with symptom-free intervals

The symptoms and signs of schizophrenia vary markedly among individuals as well as in the same person at different times The patient s appearance may be bizarre, although the usual finding is a mild to moderate unkempt blandness Motor activity is generally reduced, although extremes ranging from catatonic stupor to frenzied excitement occur Social behavior is characterized by marked withdrawal coupled with disturbed interpersonal relationships and a reduced ability to experience pleasure Dependency and a poor self-image are common Verbal utterances are variable, the language being concrete yet symbolic, with unassociated rambling statements (at times interspersed with mutism) during an acute episode Neologisms (made-up words or phrases), echolalia (repetition of words spoken by others), and verbigeration (repetition of senseless words or phrases) are occasionally present Affect is usually flattened, with occasional inappropriateness Depression is present in almost all cases but may be less apparent during the acute psychotic episode and more obvious during recovery Depression is sometimes confused with akinetic side effects of antipsychotic drugs It is also related to boredom, which increases symptoms and decreases the response to treatment Work is generally unavailable and time unfilled, providing opportunities for counterproductive activities such as drug abuse, withdrawal, and increased psychotic symptoms Thought content may vary from a paucity of ideas to a rich complex of delusional fantasy with archaic thinking One frequently notes after a period of conversation that little if any information has actually been conveyed Incoming stimuli produce varied responses In some cases a simple question

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Ventricular enlargement and cortical atrophy, as seen on CT scan, have been correlated with chronic course, severe cognitive impairment, and nonresponsiveness to neuroleptic medications Decreased frontal lobe activity seen on PET scan has been associated with negative symptoms

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One should not hesitate to reconsider the diagnosis of schizophrenia in any person who has received that diagnosis in the past, particularly when the clinical course has been atypical A number of these patients have been found to actually have atypical episodic affective disorders that have responded well to lithium Manic episodes often mimic schizophrenia Furthermore, schizophrenia has been diagnosed in many individuals because of inadequacies in psychiatric nomenclature Thus, schizophrenia was often inappropriately diagnosed in persons with brief reactive psychoses, OCD, paranoid disorders, and schizophreniform disorders Psychotic depressions, psychotic organic mental states, and any illness with psychotic ideation tend to be confused with schizophrenia, partly because of the regrettable tendency to use the terms interchangeably Adolescent phases of growth and counterculture behaviors constitute another area of diagnostic confusion It is particularly important to avoid a misdiagnosis in these groups, because of the long-term implications arising from having such a serious diagnosis made in a formative stage of life Medical disorders such as thyroid dysfunction, adrenal and pituitary disorders, reactions to toxic materials (eg, mercury, PCBs), and almost all of the organic mental states in the early stages must be ruled out Postpartum psychosis is discussed under Mood Disorders Complex partial seizures, especially when psychosensory phenomena are present, are an important differential consideration Toxic drug states arising from prescription, over-the-counter, herbal and street drugs may mimic all of the psychotic disorders The chronic use of amphetamines, cocaine, and other stimulants frequently produces a psychosis that is almost identical to the acute paranoid schizophrenic episode The presence of formication and stereotypy suggests the possibility of stimulant abuse Phencyclidine (see below), a very common street drug, may cause a reaction that is difficult to distinguish from other psychotic disorders Cerebellar signs, excessive salivation, dilated pupils, and increased deep tendon reflexes should alert the clinician to the possibility of a toxic psychosis Industrial chemical toxicity (both organic and metallic), degenerative disorders, and metabolic deficiencies must be considered in the differential diagnosis Catatonic syndrome, frequently assumed to exist solely as a component of schizophrenic disorders, is actually the end product of a number of illnesses, including various organic conditions Neoplasms, viral and bacterial encephalopathies, central nervous system hemorrhage, metabolic derangements such as diabetic ketoacidosis, sedative withdrawal, and hepatic and renal malfunction have all been implicated It is particularly important to realize that drug toxicity (eg, overdoses of antipsychotic medications such as fluphenazine or haloperidol) can cause catatonic syndrome, which may be misdiagnosed as a catatonic schizophrenic disorder and inappropriately treated with more antipsychotic medication.

FIGURE 7-25

Hospitalization is often necessary, particularly when the patient s behavior shows gross disorganization The presence

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