Differential diagnosis

• Organic brain disease, such as temporal lobe epilepsy, head injury, or any form of physical condition affecting the brain. HIV may produce similar pictures in developing countries.

• Drug-induced psychosis: relevant drugs include cannabis, LSD, amphetamines, cocaine, 'magic mushrooms', and MDMA ('Ecstasy'). This is a common diagnostic question - and management problem - in everyday clinical practice. The drugs involved vary from place to place and from time to time. In the UK, cannabis is the main culprit. Cannabis use is a frequent contributory cause of psychosis. Stimulants such as amphetamine and cocaine can produce major psychotic states, often with persecutory delusions and disturbed behaviour including aggression.

• Affective psychosis: in other words, schizophrenia needs to be distinguished from depressive psychosis, and from manic states in which there are delusions and hallucinations as part of the picture.

• Obsessive-compulsive disorder. In severe obsessional states, the behaviours and thoughts can almost take over the patient's life, and if they are of a bizarre nature may be difficult to distinguish from psychosis.

• Personality disorder.

• Acute reactions to stress, especially in adolescents.

• Simulation of mental illness: rare, but sometimes seen in forensic settings.

Some of these conditions may present as indistinguishable from schizophrenia, and the correct diagnosis can be made only after investigation of physical factors;

a period of observation, especially if the episode was triggered by drug misuse; and/or a trial of antipsychotic treatment.

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