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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status examination will then reveal that the patients have been alert and aware of their surroundings despite their withdrawn and uncommunicative behavior.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*

DIABETES: THERE IS ONLY ONE THING YOU CAN CONTROL

DIABETES: THERE IS ONLY ONE THING YOU CAN CONTROL
I said a lot more, but the main thrust was that I chose to look at what seemed good to me rather than to anticipate all the gruesome complications that can happen at some point. Afterwards, many in the group asked me questions about my ideas on life because, evidently, no one had shared anything encouraging with them before. I told them that pain is inevitable for all of us, but that we have an option as to how we react to the pain. It is no fun to suffer; in fact, it can be awful. We are all going to have pain, but misery is optional. We can decide how we will react to the pain that inevitably comes to us all.
Since learning that I have diabetes, I have read a dozen books and even watched some video tapes to learn all I could about how to cope with this chronic, debilitating disease. The most important thing I learned is that having a proper mental attitude works wonders. If you take care of yourself and do all the things that you must do to keep it in control so that it doesn’t control you, you can live a happy, productive life.
I didn’t want this disease, and I surely empathize with others who have endured it for many years, but I choose to do all I can to care for myself and enjoy each day that I am here. I constantly remind myself:
THE ONLY THING YOU CAN REALLY CONTROL IN THIS LIFE IS YOUR OWN MENTAL ATTITUDE.
Recently I was in Sacramento speaking for a women’s retreat, and a cheerful, perky gal in a wheelchair volunteered to help me at the book table. Her name was Mary Jane. She only had one leg, and I wondered if diabetes might have claimed the other one. But she just whirled around in that wheelchair, getting change and doing a fabulous job of handling customers who wanted to buy my books.
We talked later, and Mary Jane told me that her leg had been amputated because of cancer. Then she began to laugh and told me that for years her doctor had been after her to lose weight. He had put her on diets, which were always unsuccessful, and when she finally went in for the leg amputation, she said from the operating table, “Now you be sure to weigh the leg so that you can remove that amount of weight from my chart!”
What an attitude! Her pain is inevitable, but she chooses to make her option something other than misery!
So does a man I met at the La Habra post office. You’ll be reading a lot about that place because it seems I spend a lot of my life there. My license plate says SPATULA, and the other day when I pulled in to park at the post office, I noticed the plate on the car next to me said: “2 BUM NEZ.” I thought, That’s so cute—the guy probably has arthritis or something.
As I tore around the car with my arms full of tapes and books to mail, I called out, “Oh, I just LOVE your license plate!” Suddenly I saw that he didn’t have any legs! Talk about hoof-and-mouth disease! Someone was helping him out of the car, but he put me at ease by saying, “I’m glad you like it. My wife said I should get one that said, “NO LEGS,” but I would rather have folks get a chuckle out of it like you did than have them feel sorry for me.”
Bill and I See Life Differently
I love that man’s attitude because it illustrates so beautifully how pain is inevitable, but misery is optional. We cannot escape having pain in this life, but our choice is in how we react to it. For years I’ve been trying to convince Bill, my darling but melancholy husband, that how you look at life can either bring a sparkle of joy or a handful of gloom.
Recently we had car trouble and had to be towed from San Diego to our home, a distance of nearly 100 miles at a cost of about one dollar per mile. I had never even been in a tow truck before, and it was really fun sitting up so high and looking down at all the little cars whirring by. Being up so high, I could see everything perfectly, even our car attached behind. But Bill didn’t think it was fun at all. He didn’t think it was an adventure. He didn’t think there was anything cheery about it.
Trying to lift his dark and depressing mood, I chirped loudly, “But think of all the gasoline we are saving!” For me, it was a new, fun experience. We probably would never ride that far in a tow truck again, so why not enjoy ourselves since we had to be doing it anyway? But Bill didn’t see it that way. We often view life differently, Bill seeing the glass half empty while I see it brim full and running over.
One thing I love about Bill is that he always lets me be myself. In chapter eight, I’ll explain how God put our personalities together to balance each other and to be a smoothly working team. Bill’s steady, organized ways do much to make our ministry a success!
*2\316\2*