psychological processes, including perception, thinking, affect, capacity to relate, and behavior ( Table 126.27 ) Impaired thought content includes delusions, illogical thinking, and loose associations Auditory hallucinations are common and may include direct commands for suicide or violence to others Typically, but not always, the voices talk to the patient in the third person, with a highly critical and demeaning message Affect may be blunted and flat or inappropriate and bizarre Sudden and unpredictable changes in mood may occur These teenagers may appear extremely agitated or may be withdrawn, speaking only in monosyllables and describing only concrete objects Schizophrenic patients typically have significant distortions of their identity and their abilities and demonstrate behavior that is not goal directed TABLE 126.24 CAUSES OF MEDICALLY BASED PSYCHOSIS Medical conditions (acute and chronic) Trauma (acute and chronic) Prescribed medications (toxicity/side effects/withdrawal) Drug intoxications Accidental including misuse of proprietary medication Drug abuse/experimentation Alcohol abuse (alone or with drugs) Deliberate suicide attempt TABLE 126.25 MEDICAL CONDITIONS THAT MAY LEAD TO PSYCHOSIS Central nervous system lesions Tumors Brain abscess Cerebral hemorrhage Meningitis or encephalitis (including autoimmune encephalitis) Temporal lobe epilepsy Cerebral hypoxia Pulmonary insufficiency Severe anemia Cardiac failure Carbon monoxide poisoning Metabolic and endocrine disorders Celiac disease Electrolyte imbalance Hypoglycemia Hypocalcemia Thyroid disease (hyper and hypo) Adrenal disease (hyper and hypo) Uremia Hepatic failure Diabetes mellitus Porphyria Rheumatic diseases Systemic lupus erythematosus Polyarteritis nodosa Infections Malaria Typhoid fever Subacute bacterial endocarditis Subacute sclerosing panencephalitis Syphilis Miscellaneous conditions Wilson disease Reye syndrome The history often reveals a prodromal phase that includes social withdrawal, peculiar behavior, failure to look after one’s appearance, and significant reduction in performance in school or work An acute phase follows in which the previously described symptoms develop, sometimes as a result of an acutely stressful event The overall course of schizophrenia is often chronic and associated with remissions and exacerbations Exacerbations often occur when treatment, including medication, is suspended However, other individuals experience a schizophrenic-like acute psychosis and recover completely with appropriate treatment, experiencing no further deterioration