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A 26-year-old medical student is arrested for threatening a neighbor with a knife. He is brought to the hospital because he tried to slit his wrists on the way to the police station. His roommate arrives and states that the patient has been "very odd" over the past 7 months. He is socially withdrawn and has been overheard saying that the FBI. is giving him tips on patient-care and that "people from the sky" are telling him to do "bad things." He stopped going to his Ob-Gyn rotation because believes that the babies were "coming to earth" to give him messages. He says he does not want to be a doctor anymore. He appears apathetic and has emotional blunting. The physical examination is otherwise normal. Toxicologic screening is negative. Which of the following is the most likely diagnosis?
A. Bipolar I disorder
B. Brief psychotic disorder
C. Delusional disorder
D. Schizophrenia
E. Schizophreniform disorder
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The correct answer is
D. This patient has schizophrenia. He hears voices, has delusional irrational thoughts, has a flattened affect and lack of motivation, and has become socially withdrawn. This has been going on for 7 months. Schizophrenia is a disease that is characterized by psychotic symptoms (positive symptoms) and flattening of affect and motivation (negative symptoms) and an impairment of social or occupational functioning for at least 6 months. The symptoms are not caused by a mood disorder, schizoaffective disorder, a medical, neurologic or a substance-induced disorder. It commonly begins in the early 20s and an abnormal premorbid level of functioning is common. 10% will commit suicide. The treatment consists of antipsychotic agents and psychosocial treatment, including reality-based therapy, patient and family support, skill training, and assistance with daily living skills. Bipolar I disorder (choice A) is diagnosed after at least one manic episode. It is often characterized by episodes of mania mixed with episodes of depression. Manic episodes must be a distinct period of elevated or irritable mood with grandiosity, pressured speech, flight of ideas, racing thoughts, a decreased need for sleep, distractibility, increased goal-directed behavior, involvement in pleasurable activities with known undesirable consequences (excessive shopping, risky sexual activity and unwise business investments). The episodes cause functional impairment and last for at least 1 week. Treatment for bipolar disorder is lithium. Brief psychotic disorder (choice B) is characterized by psychotic symptoms that last for more than one day, but less than one month. It may be preceded by a stressor, and is self-limited. Delusional disorder (choice C) is characterized by nonbizarre delusions (such as being poisoned, being followed, or having a disease) that are present for at least 1 month. Treatment is psychotherapy. Schizophreniform disorder (choice E) resembles schizophrenia but lasts for more than 1 month but less than 6 months. It is self-limited.
