Secondary Schizophrenia (104 page)

lack detail, the time course of improvement of psy-Variable patterns of CBF deficits have been reported,
chosis following shunting for NPH is generally swift,
the most prominent of these being reduction in tha-and in most cases mirrors resolution of core symp-lamic and basal ganglia CBF, which is reversed fol-toms of NPH
[8, 11, 23, 26].
In the absence of sur-lowing successful surgical intervention
[31].
The pre-gical intervention (for example where hydrocephalus
cise mechanism of development of psychotic symp-is said to be “compensated”) positive response of psy-toms in NPH is unclear but is likely to relate to impair-chotic symptoms to antipsychotic treatment has been
ment of subcortical and basal forebrain circuits. Psy-reported
[27].
The long-term outcome of psychotic
chotic symptoms are seen in a wide variety of “sub-symptoms following successful shunting for NPH is
cortical” disorders
[32],
including vascular dementia
unknown.

[33]
and multiple sclerosis
[34]
. Furthermore, subcortical
[35]
and basal forebrain
[36]
regions are considered pivotal regions in the pathogenesis of schizophre-

Delayed or missed diagnoses

nia. The manifestation of psychosis in only a small
Delay in diagnosis of NPH has been reported in situa-proportion of NPH cases suggests that NPH itself is
tions where psychotic symptoms have preceded classi-one of many variables influencing the development of
259

cal signs and symptoms of NPH
[11].
Given the clinical
psychosis. It is likely that the manifestation of such
Organic Syndromes of Schizophrenia – Section 3

symptoms is itself an end manifestation of an inter-establish in the latter group because of the presence
action of a number of genetic, environmental, and
of potentially shared antecedents for both disorders.

medical variables in any given case. In support of this
Various temporal relationships have been reported
notion, the limited literature available suggests psy-between psychotic symptoms and definitive manifes-chosis and NPH are more likely to coexist in cases of
tations of NPH. Although there are case reports of
secondary NPH.

improvement in psychotic symptoms following surgical treatment of NPH, predictors of improvement
in psychosis remain unclear, and the long-term out-

Summary and conclusions

come of individuals so treated has not been reported.

Despite the long recognized presentation of NPH

Clinician vigilance is required in order to minimize
with cognitive symptoms, other behavioral and psy-the likelihood of delayed or missed NPH diagnoses
chiatric manifestations of the disorder have been rel-in cases where the initial presentation is with psy-atively neglected. Schizophrenia-like symptoms have
chiatric or behavioral symptoms. The knowledge in
been reported in association with NPH, most com-this area would be augmented by large studies that
monly with secondary NPH. However, the unique con-include detailed evaluation of behavioral and psychi-tribution of NPH to psychotic symptoms is difficult to
atric symptoms.

260

Chapter 19 – Normal pressure hydrocephalus

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262

Section 3

Organic syndromes of schizophrenia: other neurological disorders

Malcolm Hopwood and Lyn-May Lim

Facts box

atric inpatients
[4]
showed that the diagnosis of brain
r

tumor was usually made only after the presence of def-Although rare, psychosis secondary to brain
inite neurological symptoms with the presenting psy-tumors, including as the primary
chotic symptoms in the majority presumed to be due
presentation, is well recognized.

to a functional disorder. McIntyre
[3]
has emphasized
r
The prevalence of brain tumors in psychiatric
the need for psychiatrists to be more “brain-tumor
patients is about 3% (range 1.7%–13.5%)

conscious.”

from autopsy series, relative to 1% to 1.5% in
Despite the high prevalence of psychiatric symp-the general population.

tomatology in patients with brain tumors, the preva-r
The presentation may be indistinguishable
lence of brain tumors in psychiatric patients is only
from primary schizophrenia, or more