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BIBLIOGRAPHY
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Flacker JM, Marcantonio ER: Delirium in the elderly. Drugs and Aging 12(2):1 19-1 30, 1998. Inouye SK: Delirium in hospitalized older patients. Clin in Geriatric Med 14(4):745-764, 1998. Jacobson SA: Delirium in the elderly. Psych Clin North Am 20(1):91-110, 1997. Jacobson S, Schreibman B: Behavioral and pharmacologic treatment of delirium. Am Fam Phys 56(8):20052012, 1997. Mcartnery JR, Boland RJ: Anxiety and delirium in the intensive care unit. Crit Care Clin 10:673-680, 1994. Trzepaca PT: Delirium. Advances in diagnosis, pathophysiology, and treatment. Psych Clin North Am 19(3):429-448, 1996. van der Mast RC: Pathophysiology of delirium. Jnl Geriatric Psych & Neuro 11(3):138-145, 1998. Wise MJ: Delirium. In Hales RE, Yudofsky SC (eds): Textbook of Neuropsychiatry, 2nd ed. Washington, DC, American Psychiatric Press, 1992. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.
1. What is psychosis? Psychosis is an impairment of reality testing manifested by delusions, hallucinations, and/or disordered thought processes. Psychotic symptoms define mental illnesses such as schizophrenia and delusional disorder, but also occur in neurologic disease or CNS dysfunction due to systemic disorders. It is important to differentiate between the mental illnesses and other forms of CNS dysfunction that cause psychotic symptoms because of the differences in treatment and prognosis, but in the acute phase, schizophrenia or mania may be indistinguishable from psychosis secondary to neurologic/systemic disease (see Question 3).
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SYMPTOM
PSYCHIATRIC DISORDER
NEUROLOGICISYSTEMIC DISORDER
Fixed, with more stable themes and elaborate contents, bizarre Prominent in psychiatric disorders. Accusatory in schizophrenia, moodcongruent in bipolar disorder or depression Less common: typically related to delusional themes, usually frightening Rare Uncommon
Visual
Tactile Olfactory
Incoherent or neologis- Meanings of neologisms tend to be consistent and context-specific tic speech Bizarre behavior May be related to delusional themes and tend to be stereotyped
As with any set of symptoms, the clinical history is critical, including an assessment of the initial onset, frequency, changes over time, and context in which they occur. Psychotic symptoms may have vastly different etiologies and prognosis. For example, an adolescent who begins to withdraw socially and who slowly develops the delusion that he is being persecuted by classmates because he has special powers differs greatly in treatment and prognosis from another adolescent who experiences the sudden onset of persecutory delusions, visual hallucinations, and violent behavior during a time when he and friends are using illicit drugs. The frightening hallucinations of mental illness are of persecutors, while the homely hallucinations in persons with neurologic/systemic disorders often include friends and relatives. Benign hallucinations include the imaginary companions of young children and unformed or vague hallucinations that may occur on going to sleep and awakening. A thorough medical work-up is indicated in any patient with new-onset psychotic symptoms, but the worsening of psychotic symptoms in mentally ill persons must also be investigated; persons with schizophrenia or other psychiatric disorders may develop neurologic or systemic disease that may present initially as an increase in psychosis.
4. What is the frequency of psychotic symptoms in neurologic disorders? Psychotic symptoms may arise in association with a host of disorders affecting the CNS. Chronic metabolic disturbances or drug effects are common causes, although given the overlap between some psychiatric and neurological symptoms, it is not surprising that many neurologic conditions result in at least transient psychotic symptoms.
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This list represents only a handful of the conditions in which psychotic symptoms have been reported. Specific estimates of the frequency of psychotic symptoms or full-blown psychosis in any of these diagnostic categories are not easily derived from the existing literature. Some reliable data exist for Alzheimers disease: up to 20% of patients have been reported to demonstrate hallucinations, and up to 50% experience delusions at some point during their illness. Similar estimates of psychotic symptoms in general are as high as 50% among persons with various types of epilepsy.
5. How can psychotic symptoms of mental illness be distinguished from those of neurologicaYsystemic conditions? Obtain a detailed history from the patient and a knowledgeable informant. Review all available
medical and psychological records. Perfom physical, neurological, and mental status examinations. Depending on the patient and symptoms, many of the following studies may be useful in the differential diagnosis.
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