DIAGNOSTIC DILEMMAS, PART I1

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ATYPICAL PSYCHOSIS
Michael L. Smith, MD

Psychotic illnesses often are quite obvious. Many times, however, psychosis is subtle and identified only by careful interviewing and observation in the context of a well-established therapeutic relationship. The challenge of correctly identifying psychosis is further complicated by the varied definition of psychosis. Psychosis is a major mental disorder of organic or emotional origin in which a person's ability to think, respond emotionally, remember, communicate, interpret reality, and behave appropriately is sufficiently impaired so as to interfere grossly with the capacity to meet the ordinary demands of life. Often characterized by regressive behavior, inappropriate mood, diminished impulse control, and such abnormal mental content as delusions and hallucinations. The term is applicable to conditions having a wide range of severity and duration? The Diagnostic and Statistical Manual of Mental Disorders (DSMj-IVZ discusses psychosis as follows: The term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance. The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. A slightly less restrictive definition would also include prominent hallucinations that the individual realizes'are hallucinatory experiences. Broader still is a definition that also includes other positive symptoms of schizophrenia (i.e., disorganized speech, grossly disorganized or catatonic behavior). Unlike these definitions base'd on symptoms, the definition used in earlier classifications ( e g , DSM-11, ICD-9) was probably far too inclusive and focused on the severity of functional impairment, so that a mental disorder was termed "psychotic" if it resulted in "impairment that grossly interferes with the capacity to meet ordinary demands

From the Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, Utah

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 21 NUMBER 4 * DECEMBER 1998

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of life. Finally, the term has been defined conceptually as a loss of ego boundaries or a gross impairment in reality testing. Psychosis, along with other mental disorders has been recognized since ancient times, although often in different terms (e.g., madness, mania, and so forth). Hippocrates12stated the following: Men ought to know that from nothing else but thence (from the brain) come joys, delights, laughter, and sports; and sorrows, grief, despondency, and lamentations . . . by the same organ we become mad and delirious, and fears and terrors assail us, some by night, and some by day. . . . All these things we endure from the brain when it is not healthy.
In so stating, Hippocrates12demonstrated his awareness that madness is the result of a diseased brain. The term atypical psychosis has not been included in DSM-IV, but was listed in DSM-111-R under the heading Psychosis NOS. In DSM-111-R, examples of atypical psychoses include postpartum psychotic episodesO; psychoses with unusual features (e.g., persistent auditory hallucinations as the only disturbance); and psychoses with confusing clinical features that make a more definitive diagnosis impossible. For the purpose of this discussion, schizophrenia is regarded as the typical cause of psychosis. The nonschizophrenic causes of psychosis are many and include other axis I disorders, as well as some of the personality disorders and various nonpsychiatric medical problems. TYPICAL PSYCHOSIS

In order more readily to recognize atypical presentations of psychosis, a review of the typical features of schizophrenia is helpful? The peak age at onset is in the early 20s for males and the late 20s for females. This often follows a period of prodromal symptoms of varying duration. Those prodromal symptoms may include things such as increased social awkwardness, diminished self-care, occupational or academic difficulties, and so forth. At some point in the course of the illness active symptoms occur, which include psychotic symptoms and may include disrupted thoughts (with loose associations, circumstantiality, tangentiality, derailment, thought blocking) as well as hallucinations and delusions. Most patients alternate between acute psychotic episodes and stable phases with full or partial remission. Interepisode residual symptoms are common. During the acute phase of schizophrenia florid psychotic symptoms are exhibited, such as delusions, hallucinations, and thought disorder. This phase is usually followed by a stabilization phase during which time there is a decrease in the severity of psychotic symptoms, although patients may still have symptoms. This phase may last 6 months, during which symptoms are more stable. Some patients may be asymptomatic. The course of schizophrenia is affected by a variety of variables, including the level of societal complexity. Somewhat counterintuitively, better outcomes often occur in developing countries compared with more advanced societies.
CAUSES OF ATYPICAL PSYCHOSIS

When considering atypical causes of psychosis, the clinician should keep in mind that psychotic conditions can be found on axis I, 11, and III. The presenta-

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tion of those psychotic illnesses can be flavored by factors on the fourth (psychosocial stressors) axis, and may be reflected on the fifth (global assessment of functioning) axis. Cultural variables have additional potential to alter the presentation of psychotic symptoms.
Axis I Disorders

Axis I disorders other than schizophrenia that may involve psychotic symptoms or that may appear schizophrenic-like include attention-deficithyperactivity disorder (ADHD);delirium; dementia; substance-associated disorders; shared psychotic disorder; schizophreniform disorder; brief reactive psychosis; schizoaffective disorder; delusional disorder mood disorders; obsessive-compulsive disorder (OCD); post-traumatic stress disorder; body dysmorphic disorder; factitious disorders; parasomnias (such as narcolepsy, which includes a tetrad of sleep attacks, cataplexy, sleep paralysis, and hallucinations); autistic disorder; and pervasive developmental disorder (PDD). Pine et all6 described a couple of interesting patients who presented both with ADHD and comorbid psychosis. In their article, they discussed two patients whom they treated. Both patients met DSM-111-R criteria for a diagnosis of ADHD. In addition, they both exhibited signs of psychosis, with delusions or hallucinations. They had proved refractory to treatment efforts using neuroleptics. They were treated with a combination of psychostimulants and neuroleptics and were observed to be free of psychosis for many weeks, even after neuroleptics had been withdrawn. OCD can present in diagnostically challenging ways5 In both schizophrenia and OCD senseless or irrational ideas are usually part of the clinical presentation. Insight into the irrationality of those ideas has been considered an important difference between schizophrenia and OCD. Insight is not consistently present in cases of OCD, however, and it is not necessarily absent in cases of schizophrenia, a reality that makes the distinction between OCD and schizophrenia more difficult to recognize. Other features of each illness should be considered in order to arrive at the proper diagnosis. Family history, current level of functioning, overall course of the illness, and response to treatment attempts are some of the variables that may help to clarify the diagnosis. Another axis I disorder that may be confused with schizophrenia is that of delusional di~0rder.l~ differential diagnosis for delusional disorder includes The paraphrenia; schizophrenia; severe personality disorder (e.g., schizoid, schizotypal, or paranoid); severe OCD; and somatoform disorder (e.g., body dysmorphic disorder). One of the distinguishing features between delusional disorder and schizophrenia is the nature of the delusion. In schizophrenia, the delusions are often bizarre (outside of the accepted limits of possibility, taking the patient's culture into account) and are accompanied by other features of schizophrenia, such as social and occupational decline, negative symptoms, and thought disorder. In delusional disorder, the delusions are nonbizarre2 (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease). Several subtypes of delusional disorder exist, including persecutory, jealous, erotomanic, somatic, and grandiose. The delusions are quite persistent and are likely to be well circumscribed. In the absence of a careful interview, delusions may be missed. Delusional disorder does not appear simply to be a mil? variety of schizophrenia. If such were the case, one might expect a more robust response to treatment. Efforts to treat delusional disorder with antipsychotics may prove frustrating.

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Some have reported that pimozide may be more helpful than the more commonly used anti psychotic^.'^ Psychotherapy for delusional disorder is also a challenge. The initial task is to form a therapeutic alliance with a patient who feels that they do not have a problem. They are likely to feel that the problem is that they are not believed by the therapist. The patient nonetheless is suffering because of the effects of this disorder. Delusional disorders are distinct from schizophrenia and the response to treatment also differs from schizophrenia. These disorders are not common, and much remains to be learned about the mechanism and pathophysiology of delusions.
Axis II Disorders

Axis I1 disorders that may involve psychosis or that may sometimes present with psychotic-like symptoms include the following personality disorders: paranoid; schizoid; schizotypal; borderline; histrionic; and antisocial (i.e., malingerind. "' The diagnosis of borderline personality disorder does not require the presence of psychosis; however, psychosis is not uncommonly seen in patients with borderline personality. The DSM-IVZnotes that "some individuals develop psychotic-like symptoms (e.g., hallucinations, body image distortions, ideas of reference, and hypnagogic phenomena) during times of stress." Paranoid ideation may also be part of the presentation, although this is usually transient and environmentally responsive. The auditory hallucinations associated with borderline personality disorder, as observed by this author, usually lack the intensity and clarity of typical schizophrenic hallucinations. In addition, although patients with borderline personality disorder may exhibit paranoid ideation, that ideation is not as clearly delusional as what is typically seen in schizophrenic patients with paranoia. Borderline patients generally do not have a formal thought disorder, although during exacerbations of their illness they may experience episodes of a transient thought disorder. Another important consideration in the differential diagnoses of psychosis is feigned mental illness (including both factitious disorder and malingering). Feigned mental illness may have features that are not consistent with genuine mental illness. For example, people faking auditory hallucinations may report vague hallucinations. The voices heard in those hallucinations may use stilted language and may not be associated with delusions, as opposed to genuine hallucinations that are often quite clear and direct with a coarse or crude quality of language. Most (88%) of those with genuine schizophrenic auditory hallucinations also experience delusions. Visual hallucinations may occur in schizophrenia but are not as common as auditory hallucinations. Reports of visual hallucinations are not uncommon in malingering. Visual hallucinations may be reported and are suggestive of malingering (but not proof of) if not associated with auditory hallucinations, if black and white, or if dramatic and atypical. Malingerers may overact and are likely to call attention to their "illness." This is in contrast to genuine schizophrenia, where patients are more likely to attempt to hide their psychotic symptoms. Another clue to feigned mental illness is the presence of delusions and hallucinations in the absence of a thought disorder (or a thought disorder that becomes less severe as the interview is prolonged). It does not take much skill to claim auditory or visual hallucinations; it is more difficult to maintain loose associations, flight of ideas, clanging, circumstantiality, tangentiality, and so forth for a prolonged period of

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time. Another clue is the ratio of negative to positive symptoms. Negative symptoms may be underrepresented and positive symptoms overrepresented in cases of malingering. Those who are likely to be the best at faking psychotic symptoms are those who suffer with genuine symptoms some of the time. It is important to remember, particularly in a forensic setting, that the accurate diagnosis of schizophrenia in an individual does not preclude malingering.17

Axis 111 Disorders The list of axis I11 disorders that may result in psychosis is long and has been carefully reviewed by organizing them into three groups: (1) neurologic causes, ( 2 ) metabolic causes, and (3) toxic causes of psychosis.8
Neurologic Causes of Psychosis

There are many potential neurologic causes of psychosis, including the following: cerebrovascular disease; post-traumatic encephalopathy; postanoxic encephalopathy; neoplasms; normal pressure hydrocephalus; Prader-Willi syndrome; Niemann-Pick disease; cerebral lipidoses; extrapyramidal disturbances (e.g. Parkinsons disease, Huntingtons disease, Sydenhams chorea, Wilsons diseaseI8); infections (HIV, herpes encephalitis, other viral, slow virus [JakobCreutzfeldt disease], malaria, syphilis, parasitic); myelin disorders (e.g., multiple sclerosis, metachromic leukodystrophy, adrenoleukodystrophy, Marchiafava-Bignami disease); cortical dementias (Alzheimers disease, Picks disease); and epilepsy (including generalized seizures and complex partial seizures). Huntingtons disease is an example of a nonschizophrenic illness that may present in a fashion similar to schizophrenia. If evaluated in the absence of a knowledge of the patients family history, the diagnosis of schizophrenia might be considered. A case example serves to underscore this point.
Case History. Joan, a 30-year-old mother of three children functioned well during her high school years. While in high school she was quite well adjusted, well liked by her peers, and performed well academically. She married in her early 20s. The marriage remained fairly stable until near the time of onset of her psychiatric symptoms. At the time of the evaluation, it was reported that the patient in recent years had become more socially inappropriate. For example, on one occasion while out with her family she kissed a stranger thinking he was an old boyfriend. On another occasion, she was talking and laughing to herself while writing a check at a clothing store. At another time, she reported that her soul mate had spoken to her in her head and had told her that he was coming to pick her up. She packed her bags as a result and was ready to go move away. Joans course continued to deteriorate. She was admitted to the inpatient psychiatry unit on two occasions, each time appearing catatonic, with emotional unresponsiveness, flat affect, and very little verbal production.

The diagnosis of schizophrenia may have been considered in this case were it not for her family history of Huntingtons disease, as well as her own positive test for the Huntingtons disease gene. It is noteworthy that she did not demonstrate chorea at the time of her initial presentation. Her presentatlon is similar to that of schizophrenia in several respects including the age of onset, presence

of hallucinations and delusions, affective blunting, and diminished ability to care for ones self. Another case example helps to illustrate the potential of neoplastic processes to cause psychotic symptoms.
Case History. Mr. C is an 85-year-old Hispanic man who speaks very little English, so an interpreter is necessary. His chief complaint is: The police brought me here for medications. He had been brought to the emergency department by the police on a pink sheet (i.e., involuntarily) because of increasingly bizarre behavior. His behavior had become more unusual over several months, and was quite clearly inappropriate over the 2 weeks prior to admission. On the night prior to admission the police were called to his apartment because he was outside brandishing a gun and talking about Castro. Also, there was a time when he was outside his apartment waving the American flag. The patient was seen by a physician at the local community mental health clinic approximately a week prior to admission. It was the first meeting between the physician and the patient. The patient arrived without an appointment and with a list of medications that he was asking to have filled. He had been on lorazepam, 1 mg twice a day, for a long period of time, but had discontinued it several weeks prior to his arrival at the clinic. An appointment was made for the patient to come back at a scheduled time; unfortunately, he did not show up for his appointment. The physician called him on the telephone, felt that he was disorganized and somewhat paranoid, and noted that he was talking continuously. The patient thought the physician was threatening him.The physician went in person to the apartment, but the patient would not allow him in. He had the door barricaded and stated there was a booby trap behind the door and that he should not come in. The patient stated that he was fearful and that he thought the doctor was going to hurt him. The doctor then called 911 and had him brought to the University hospital. Mr. Cs apartment was in poor condition. There was no food and according to the patient he had not eaten for about 2 weeks. He also stated that his house had speakers and microphones and that a disc jockey would make comments about him when he would go into the bathroom, making vulgar comments about women and their genital organs and breasts. He stated that this has been ongoing for about the last 2 weeks. He was friendly and cooperative upon his arrival on the inpatient psychiatry unit. His past history was unknown other than perhaps he has had some problems which led to his treatment with lorazepam. Subsequently obtained information indicated that he had also been on paroxetine for a number of years. Family members who were eventually contacted described him as always being very pleasant, happy, and as someone who talks rapidly. His past medical history showed coronary artery disease and a bypass graft in 1995. He has a history of hypertension and cardiac conduction abnormalities. He also has type I1 diabetes mellitus. He has a history of chronic renal insufficiency and has been impotent for about 5 years. The initial mental status examination was aided by an interpreter. The patient was oriented to place. He knew the date. His speech was slightly rapid. The patient seemed happy. His affect was bright. He was not depressed, suicidal, or homicidal. The patient was delusional and also appeared to have auditory hallucinations. Case Discussion. Other than for the age of onset of symptoms, this case may not seem too unusual. The patient demonstrated paranoid delusions, he

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exhibited disorganized speech, he also expressed ideas of reference. He was unable to care for himself, as demonstrated by the lack of food in his apartment. His social functioning was obviously impaired by his bizarre and threatening behavior. At the time of admission it was not clear how long these behaviors had been occurring. Subsequently obtained information indicated that his behaviors began to change several months prior to admission. Not much was known about his psychiatric history at the time of admission. He had been taking lorazepam. Available information did not suggest a prominent mood disorder or schizoaffective disorder. The patients presentation was consistent with a diagnosis of schizophrenia; however, due to the lack of sufficient information and the need for further evaluation, he was diagnosed with psychosis not otherwise specified. One feature that suggested a problem other than schizophrenia was his advanced age. Schizophrenia can occur for the first time in late life, but such a presentation is uncommon. The recent rapid withdrawal from lorazepam also suggested a possible cause or contributor to his unusual behavior. Malnourishment may also have contributed to his problems. Fortunately, the attending psychiatrist ordered an MR image that revealed a large extra-axial mass arising from the meninges over the left frontal lobe. This caused significant mass effect in the underlying parenchyma with effacement of the sulci. The lesion measured 5 x 4 x 3 cm. The impression of the radiologist was left frontal lobe extra-axial mass with imaging and signal characteristics most suggestive of meningioma. Mr. C was subsequently transferred to the neurosurgery service for removal of his menigioma. This case serves to demonstrate the need for careful evaluation of new onset psychotic symptoms.
Metabolic Causes o Psychosis f

The list of potential metabolic causes of psychosis is long and includes systemic illnesses, endocrine disturbances, deficiency states, and inflammatory disorders. Systemic illnesses that may result in psychosis include uremia, hepatic encephalopathy, pancreatic encephalopathy, anoxia, subacute bacterial endocarditis, hyponatremia, hypercalcemia, hypoglycemia, porphyria, and ICU psychoses. Endocrine disorders that may result in psychosis include Addisons disease, Cushingss disease, thyroid disease, parathyroid disease, panhypopituitarism, recurrent menstrual psychosis, and postpartum psychosis. Deficiency states, such as thiamine deficiency (Wernicke-Korsakoff syndrome), vitamin B,, deficiency, folate deficiency, and niacin deficiency, may lead to psychosis as well. Inflammatory disorders including systemic lupus erythematous, temporal arteritis, and sarcoidosis also have the potential to cause psychosis. Mitochondria1 encephalopathy (lactic acidosis and stroke-like episodes) is another interesting potential contributor to psychosis.
Pharmacologic Causes o Psychosis f

Many medications can cause psychosis and other psychiatric symptoms, either by their direct effect or as a result of withdrawal of the drug.19 Some of the drugs listed next may cause psychotic symptoms at the usual doses and others may require inappropriate use to cause such symptoms. The list of drugs that may cause psychosis is long and includes many commonly used drugs, both prescription and over-the-counter medications. Some of the drugs that may cause psychosis include isotretinoin9 (accutane); acyclovir (at high doses, particularly in patients with chronic renal failure); amantadine; stimulants; anabolic steroids (reported in cases of abuse); anticholinergics; anticonvulsants;

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antidepressants; antihistamines; baclofen; barbiturates; benzodiazepines (not limited to withdrawal);beta blockers; bromocriptine;buproprion; caffeine; captopril; chlorambucil; chloroquine; clonidine; cocaine; corticosteroids; cycloserine; dapsone; N,N diethylmethyltoluamide (DEET) (e.g., mosquito repellant, with excessive or prolonged use); digitalis; disopyramide; disulfiram; erythropoietin; fluoroquinolone antibiotics; ganciclovir, H, blockers; 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors; ifosfamide; interleukin-2; isoniazid; ketamine; levodopa; maprotiline; mefloquine; melatonin; methyldopa; methylphenidate; methysergide; metrizamide; metronidazole; narcotics; nonsteroidal anti-inflammatory drugs; pergolide; phenylpropanolamine (Dexatrim); procaine derivatives; pseudoephedrine; quinidine; selegiline; thiabendazole; tizanidine; trazodone; trimethoprim-sulfamethoxazole; vincristine; and zolpidem. Of course, some drugs are used specifically because they may cause psychosis, such as lysergic acid diethylamide, cannabis, mescaline, psilocybin, and phencyclidine hydrochloride. Heavy metal poisoning (e.g., bismuth, thallium, manganese, arsenic, mercury) has been associated with psychotic symptoms as well.
UNUSUAL SCHIZOPHRENIC PRESENTATIONS

In addition to nonschizophrenic causes of psychosis, schizophrenia itself may present in unusual ways. One variation from the usual presentation is in terms of age. Childhood schizophreniaz0has been recognized for many years, and is similar to adult onset schizophrenia except for the early age of onset. When dealing with childhood schizophrenia it is important to be familiar with the behaviors and cognitions of children. For example, many normal children differ from adults in having a very active fantasy life, including fantasy friends. It is also important to keep in mind that schizophrenia can co-occur with autism, pervasive developmental disorder, and Aspergers Syndrome. It may also occur in mental retardation and may not be readily recognized without a careful evaluation. Regarding the other end of the age spectrum, with the publication of DSMIV the age limit for the first symptoms of schizophrenia was removed. It is now officially recognized that the onset of schizophrenia may occur later in life, although this does not appear to be the norm. The diagnosis of schizophrenia in older age is made more challenging by the fact that dementing illnesses may also have psychotic features. Cummings7 stated that About 50% of patients with Alzheimers disease will have a psychotic episode during the course of their illness . . . this makes Alzheimers disease the second most common psychotic illness in the country, second only to schizophrenia.
CULTURAL CONSIDERATIONS

Culture-specific behaviors may also appear psychotic at times, particularly if viewed from outside the specific culture of concern. Some of the culturally based syndromes include amok (Malayan); ataque de nervios (Latin American); bilis and colera (Latin American); Boufee Delirante (West African and Haitian); brain fag (West African); dhat (Indian); falling out or blacking out (southern United States, Caribbean); ghost sickness (American Indian); hwa-byung (Korean); koro (Malayan); latah (Malayan); locura (Latino); ma1 de ojo (evil eye, Mediterranean); nervios (Latino); pibloktoq (Eskimos); taijin kyofu sho (Japanese); Qi-gong psychotic reaction (Chinese); voodoo, rootwork, and related states

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(Caribbean, Latin American, Haitian, West African); Wihtigo (Cree, Ojibwa, and Saltreaux Indians of North America); Sanque Dormido (Portuguese); shenjing shuariruo (Chinese); shenkui (Chinese); shinbyung (Korean); spell (African American, European American); susto (Latino); Taijin Kyofusho (Japanese); and zar (North African and Middle Eastern). Appendix I of DSM-IV provides a succinct overview of these culturally based syndromes. The reader is referred to that source for additional information on this topic.* These culture-bound syndromes may or may not correlate to specific DSM-IV diagnostic categories. . Many of them involve quite aberrant behavior that may be considered psychotic. When viewed within the context of the persons culture, however, those behaviors may be more understandable.
SUMMARY

When one considers the 100 billion or so neurons that constitute the central nervous system, along with the thousands (average of 10,000) of synaptic connections for each neuron, in addition to the growing list of neurotransmitter agents and our growing awareness of the complexity of the glial support structures, it is quite remarkable that serious malfunctions in this extremely complex system do not occur more often. Psychosis, in its various forms, is one manifestation of disturbed functioning. It is hoped that practitioners recognize psychosis as a complex symptom of a complex organ system. Patients who present with psychosis ought to receive a thorough evaluation to ensure an accurate diagnosis and appropriate treatment. Failure to accurately determine the cause of a patients psychosis likely leads to the wrong treatment. Patients who fail to respond as expected should be considered for a thorough reassessment in order to ensure an accurate diagnosis and appropriate treatment. Psychosis is a symptom that is not at all unique to a specific diagnosis. As discussed previously, many pathologic states may result in psychosis, and the presentation of the psychotic symptoms may be further influenced by cultural, social, and psychological factors. References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 3, rev. Washington, American Psychiatric Association, 1987 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, American Psychiatric Association, 1994 3. American Psychiatric Association: Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry 154(suppl):5-6, 1997 4. American Psychiatric Association: A Psychiatric Glossary, ed 5. Boston, Little, Brown and Company, 1980 5. Bermanzohn PC, Porto L, et a1 Obsessions and delusions: Separate and distinct, or overlapping? CNS Spectrums 2:58-61,1997 6. Bursztajn, et al: Recognizing postraumatic stress. Patient Care, 1995 7. Cummings J L Alzheimers disease: Comprehensive treatment approach. Neurology Reviews (suppl):8-9, 1997 8. Cummings JL: Secondary psychoses, delusions, and schizophrenia. Clinical Neuropsychiatry, 1985 9. Ellison RH: Dear Doctor letter. Roche Pharmaceuticals, 1998 10. Hamilton JA: Post partum psychiatric syndromes. Psychiatr Clin North Am 1289102, 1989

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11. Hansen L, Bedell M: Psychotic episode after melatonin. Ann Pharmacother 31:1408, 1997 12. Hippocrates: The Medical Works of Hippocrates. Oxford, Blackwell, 1950 13. Munro A: Monosymptomatic hypochondriacal psychosis. Br J Psychiatry 153(suppl 2):37, 1988 14. Munro A Psychiatric disorders characterized by delusions: Treatment in relation to specific types. Psychiatric Annals 22:5, 1992 15. Opler LA, Feinberg SS: The role of pimozide in clinical psychiatry: A review. J Clin Psychiatry 52221-233, 1991 16. Pine DS, Klein RG, Lindy DC, et a1 Attention-deficit hyperactivity disorder and comorbid psychosis: A review and two clinical presentations. J Clin Psychiatry 54140145. 1993 , 17. Resnick PJ: Resnick Malingering and feigned mental illness [audio]. Audio Digest Psychiatry 26, 1977 18. Saint-Laurent M: Schizophrenia and Wilsons disease. Can J Psychiatry 37358-360, 1992 19. Some drugs that cause psychiatric symptoms. Medical Letter 40:621428, 1998 20. Volkmar FR. Childhood schizophrenia. In Lewis M (ed): Child and Adolescent Psychiatry. Baltimore, Williams & Wilkins, 1991
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Address reprint requests to Michael L. Smith, MD Department of Psychiatry University of Utah, School of Medicine 50 North Medical Drive Salt Lake City, UT 84132
e.mail: michael.smith@hsc.utah.edu