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Chapter 31: Psychosis

Olesya Pokorna; Emma Samelson-Jones

INTRODUCTION

Psychotic symptoms include hallucinations, delusions (fixed false beliefs, such as the belief that aliens have taken over one’s body and are controlling one’s thoughts and actions), and disorganized thinking (as demonstrated by illogical or incoherent speech) or behavior. In chronic form, these symptoms are most commonly associated with schizophrenia spectrum disorders, but they can occur in the context of many other illnesses, including major depression or bipolar disorder, substance intoxication or withdrawal, borderline personality disorder, and a wide range of other medical conditions, including neurodegenerative, infectious, inflammatory, and autoimmune diseases (Table 31-1).

Table 31-1.Differential diagnosis of new onset psychosis.
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Table 31-1. Differential diagnosis of new onset psychosis.

  • Schizophrenia spectrum disorders, including brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and delusional disorder

  • Affective psychoses, including major depression with psychotic features or bipolar disorder (bipolar depression or mania) with psychotic features

  • Other psychiatric disorders, including PTSD, borderline personality disorder

  • Substance intoxication with amphetamines, cocaine, PCP, cannabis, and synthetic cannabinoids such as spice, psychedelic drugs such as LSD, psilocybin, or ayahuasca

  • Substance withdrawal from alcohol, benzodiazepines, barbiturates

  • Medication-induced psychosis from steroids, dopamine agonists, and others

  • Delirium, characterized by fluctuating levels of attention and confusion that often presents rapidly. Broad differential diagnosis, including electrolyte abnormalities, hypoxia or hypercapnia, infections, hepatic or uremic encephalopathy, and others

  • Endocrine disorders, including hypothyroidism (myxedema madness), hyperthyroidism, adrenal insufficiency, hypo- or hyperparathyroidism, Cushing’s disease, or Cushing’s syndrome

  • Inflammatory disorders, including anti-NMDA receptor encephalitis, systemic lupus erythematosus (lupus psychosis usually occurs early in the illness in context of florid clinical and serological activity), multiple sclerosis, leukodystrophies

  • Infectious diseases involving the brain, including HIV, neurosyphilis, herpes simplex encephalitis, prion disorders

  • Neurodegenerative disorders, including Alzheimer’s disease, dementia with Lewy Bodies, Parkinson’s disease, Huntington’s disease

  • Neurological disorders, including traumatic brain injury (TBI), brain tumors, or other space occupying lesions in the head, stroke, seizures

  • Vitamin deficiency with vitamin B12

  • Metabolic disorders, including Wilson’s disease and acute intermittent porphyria

SCHIZOPHRENIA SPECTRUM DISORDERS

The schizophrenia spectrum disorders include brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and delusional disorder. They are distinguished from each other by the duration and types of psychotic symptoms, and the presence or absence of concurrent mood symptoms.

The onset of multiple types of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) in the absence of affective symptoms, a toxic exposure, or an associated medical condition defines brief psychotic disorder if it lasts less than a month, schizophreniform disorder if it lasts 1–6 months, and schizophrenia if it lasts at least 6 months. Schizophrenia tends to begin in late adolescence or early adulthood and affects between 0.3% and 0.9% of the population worldwide. Schizoaffective disorder requires the presence of multiple psychotic symptoms in addition to recurrent episodes of major depression or mania. It also commonly starts in adolescence or young ...

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