Making the differential diagnosis of a psychosis associated with psychedelic drugs is a difficult and confusing, but very important, clinical problem. Understanding the interaction between the drug effect, the current stress on the individual, and his characteristic level of ego function not only makes differential diagnosis possible, but has ramifications for treatment and prognosis. This interaction can best be understood by clarifying a number of different factors including the extent of drug use, past personal history, prepsychotic level of functioning, mode of onset of the psychosis, nature of external precipitating factors, and presenting mental status. Three different clinical entities can be found when this is done, each of which presented a psychotic appearance, and in each of which past drug use was involved. These are: 1) An acute response to a drug effect, in which the weakened ego of a borderline individual is overwhelmed and not able to reintegrate when the drug effect wanes. This individual responds well to short term hospitalization with supportive treatment. 2) A gradual shift toward projection, denial and then delusions, and withdrawal even in relatively healthy individuals who take drugs very frequently at a time of a life crisis. The development of alloplastic ego defenses is to avoid a dealing with painful affect, and hospitalization or any treatment which would require confronting this was unsuccessful and just reinforces the new defense structure. 3) Occasional drug use in a schizophrenic may well have no effect on that individual's overall clinical course or response to any mode of treatment. Why the drug experience, a transient stress of ego function, does not have long range consequences is not known, but may be because the ego has learned to adapt to these transient episodes, which are much less threatening than actual events in the individual's life. Three patients were presented who demonstrated these three clinical conditions and their different responses to treatment were noted.
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