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M.8., id"RC.P., D.P.M.

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F. J. Fish
M.8., M.R.G.P., D.P.M.

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it is cversible ancl
does respond to anti-Parkinsonin compounds such as benzhexol
hydrochloride (artane), benztropine methanesulphate (cogentin), and
orphedrine hyclrochloriclc (disipal). This latter compound is also a
mild stimulant and antidepressive an<l is given in doses of 3-4 tablets of
50 mg. per clay. As a general principle, it is questionable whether one
phelothiazinc colnpoutrds is troublesomc, but

'

should give a scconcl drug to remove the side-ellects of the therapeutic

drug, but until effective phenothiazines are produced which do not
cause Prkinsonism, then it $,i11 be necessary in some cases to give an
anti-Parkinsonian drug in order to control the paticnt's symptoms
adequately with a large dose of the phenothiazine compound.
Recently, non-phenothiazine tranquillizing drugs have been introcluced, such ns librium, trrct.Ln, and lralopcridol. It is too early to
know wht placc tlrcse drugs heve itr thc trcatmcnt of schizophrenia.
Iiinally, it shoulcl bc poirlted out that the trancluillizers are not the
sole treatment of schizophrenia. They should be considered as means by
which thc patient can be helped to participate more fully in psychotherapy, social therapy, and lvork therapy.

CHAP'['ER

IX

DIFFER,ENTIAL DIAGNOSIS
Solrt points of di$ereritiatiotr betrveen schizophretia and other mental
disorders have already been discussed, notably in Chapter V on

Paranoid States, but it is nolv necessq, to discuss dif]ereutil diagnosis

in detail.

Atrictive Disorders.-Schneider's symptoms of the first rank are

very useful in the diagnosis of patients sufiering from atypical affective
disorders, but, unfortunately, they are o{ten bsent in doubtful cases.
Usually i{ one of these first-rank symptoms is clearly present, then
quite a number of the others are also. Often it is difficutt to be sure that
apaticnthas adclusionalperccption, Gedatl.cnlutzaerde, orexperiences
of passivity. Thus some patients have a vcry vivid auditory imagery
which is easily mistahen for Gedanl*nlautwerden, rvhile in others an
apparent delusional perccption may turn out to be a delusion-like
experience, o a sudden delusional idea provoked by a perception.
When askecl about experiences of passivity, some patients admit such
experiences, but on close questioning it appears that they felt'as if'
they were being controlled.
Auditory hallucinations may occur in depression, but they usually
consist of odd words or brief phrases, rvhich ae herd when the patient
is severely dcpressecl. The hallucinations are phonemes vhich make
odd, abusive cmarks or suggest suicide, but they are flagmetary or.
disjointed. Continuous halluciratory voices do not occur in tncomplicated depressions ancl vhen they appcar in otherwise fairly
typical depressivc clinical pictures, thcn thc possibility of dehyclration,
overclosage with drugs (especially hyoscine and bromidc), dictary
deficiencies, and other coarse brain disorders shoulcl be considered, as
well as schizophrenia.
At times the depressive mood is not obvious, so that the diagosis
may depend on depressive thought content and the typical sleep
disturbance. A few clepressed middle-agecl and elderly patients are able
to put on a good front, so that they may smile and make wry, selfdeprecitory jokes. I'his 'gallorvs hurnour' rnay lead the untrained
observer to misiuterprct this apparent discrepancy bctrvcen thought ancl
alfective expressi<r s (ltlc to schizophrer:ia. IIo*evor, skillirl intcr.rogtioD lea(ls to :l rnorc obvious cxrrcssion of thc dcprcssivc aliict.