Abstract
The number of medical diseases that can present with psychotic symptoms (delusions, hallucinations) is legion. A thorough differential diagnosis of psychosis is necessary to avoid the mistaken attribution of psychosis to a psychiatric disorder instead of a medical condition, which requires very different treatment. I outline a clinical approach for a patient with psychosis of unknown etiology that emphasizes the need to be pragmatic about the medical work-up as indiscriminate screening is neither feasible nor helpful. To organize this chapter, I use the primary (psychiatric) versus secondary (“organic”) distinction to review the medical etiologies of schizophrenia-like psychosis. In this scheme, schizophrenia due to a medical condition is referred to as secondary schizophrenia.
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Additional Resources
Books
Cahalan S. Brain on fire: my month of madness. New York: Free Press; 2012. – The personal journey of a young woman who developed a serious neuropsychiatric disorder that ultimately ends well: after the correct diagnosis of an “organic” condition, anti-NMDR encephalitis is made.
Lipska BK. The neuroscientist who lost her mind: my tale of madness and recovery. Boston: Houghton Mifflin Harcourt Publishing Company; 2018. – Excellent description of the effects of brain metastases on affect, cognition and perception as well as insight by a neuroscientist who developed metastatic melanoma.
Articles
Freudenreich O, Schulz SC, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry. 2009;3:10–8. – A conceptual article about the “organic” work-up of patients with psychosis.
Pollak TA, Rogers JP, Nagele RG, Peakman M, Stone JM, David AS, et al. Antibodies in the diagnosis, prognosis, and prediction of psychotic disorders. Schizophr Bull. 2019;45:233–46. – An excellent review of antibodies and psychosis, including diagnostic antibodies for autoimmune encephalitis. This is an area of psychiatry where I have seen progress in my life-time, including the delineation of a new syndrome (NMDA receptor encephalitis) that psychiatrist must recognize in order to assure correct medical treatment.
Hogan C, Little BP, Carlson JCT, Freudenreich O, Ivkovic A, Baron JM. Case 5–2019: a 48-year-dld woman with delusional thinking and paresthesia of the right hand. N Engl J Med. 2019;380:665–74. – A case discussion from the MGH clinico-pathological conference, highlighting the difficulties in deciding if an identified medical disease (vitamin B12 deficiency) is solely responsible for what appears to be a chronic psychotic illness.
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Freudenreich, O. (2020). Secondary Schizophrenia. In: Psychotic Disorders. Current Clinical Psychiatry. Humana, Cham. https://doi.org/10.1007/978-3-030-29450-2_5
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