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DELIRIUM: DIFFERENTIAL DIAGNOSIS-SCHIZOPHRENIA

Psychiatrists are sometimes asked whether patients with hypoactive-hypoalert delirium might not have catatonic schizophrenia. It is important to remember here that catatonic phenomena occur not only in psychiatric conditions (especially affective disorders) but also in a large number of medical and neurological illnesses capable of producing delirium, such as hepatic failure, viral encephalitis, and neuroleptic malignant syndrome. Catatonia, then, does not equal schizophrenia.     In the unlikely event that the differential diagnosis cannot be resolved from the patient’s history, examination, and laboratory tests, a trial of benzodiazepines may settle the matter. When such medications are given to catatonic patients with affective disorders or schizophrenia, their motor signs and mutism almost always abate. A mental status examination will then reveal that the patients have been alert and aware of their surroundings despite their withdrawn and uncommunicative behavior. In contrast, if benzodiazepines are given to patients with hypoactive-hypoalert delirium, they may become even more obtunded and inaccessible.     Delirium tremens can initially be mistaken for paranoid schizophrenia because agitation, delusions, and hallucinations occur in both. Although it may be difficult to assess an agitated patient, it should not be hard to recognize certain features of delirium tremens that are useful in differential diagnosis. The most important of these characteristics are autonomic overactivity, tremulousness, severe insomnia, and prominent visual hallucinations.     If a patient’s agitation is due to paranoid schizophrenia, it will eventually be clear that he has no fundamental disturbance of consciousness. Even when schizophrenic patients are frightened or distracted, it is possible to “make contact” with them and to prove that they are aware of their surroundings. When I asked one such patient where he was, he replied: “You say this is Johns    Hopkins Hospital in Baltimore, but I know it’s really a police station in Washington, D.C.” The first part of his answer demonstrated that he was well oriented; the second, that he was delusional. Observations of this sort help to distinguish paranoid schizophrenia from hyperactive-hyperalert delirious states, whether or not they take the form of delirium tremens.*27\172\2*

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