A 27-year-old woman is brought to the emergency department by police after she was found trespassing on a local newscaster's property. The patient informed police that she has been dating the newscaster for a few months and was surprising him for his birthday. She reports their relationship started after she met him briefly when they were both eating at the same restaurant. The patient says, "We've been so busy we haven't met up since then. But every night, he makes sure to send me a special message when he's presenting the evening news. I know he is in love with me because he always wears my favorite color. He's the most amazing man I've ever known." The patient is completing her final year of graduate school and lives alone. Medical and psychiatric history are noncontributory. Family history is significant for schizophrenia in her father. The patient's thoughts are linear, and she has no hallucinations. She is irritated that the police spoiled the surprise she had planned and repeatedly asks the staff to call her boyfriend so that he can "clear everything up." Which of the following is the most likely diagnosis in this patient?

Question

A 27-year-old woman is brought to the emergency department by police after she was found trespassing on a local newscaster's property.  The patient informed police that she has been dating the newscaster for a few months and was surprising him for his birthday.  She reports their relationship started after she met him briefly when they were both eating at the same restaurant.  The patient says, "We've been so busy we haven't met up since then.  But every night, he makes sure to send me a special message when he's presenting the evening news.  I know he is in love with me because he always wears my favorite color.  He's the most amazing man I've ever known."  The patient is completing her final year of graduate school and lives alone.  Medical and psychiatric history are noncontributory.  Family history is significant for schizophrenia in her father.  The patient's thoughts are linear, and she has no hallucinations.  She is irritated that the police spoiled the surprise she had planned and repeatedly asks the staff to call her boyfriend so that he can "clear everything up."  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7b3_4665_bc81_4d8954374281_MD0003_00 This patient's belief that a newscaster is in love with her, combined with the absence of other prominent psychotic symptoms or significant mood disturbance, is most consistent with delusional disorder, erotomanic subtype. Delusions are fixed beliefs that are firmly held despite conflicting evidence. Delusional disorder is subtyped based on the delusional theme (ie, erotomanic, grandiose, jealous, persecutory, somatic). In the erotomanic type, efforts to contact the object of the delusion are common and may result in legal difficulties. In comparison with patients with schizophrenia, individuals with delusional disorder lack other prominent psychotic symptoms; they do not have prominent hallucinations or grossly disorganized behavior. They are typically higher functioning, and their behavior unrelated to their delusional concern is often normal. (Choice A) Although erotomanic delusions could be seen in a manic episode of bipolar I disorder with psychotic features, this patient lacks other symptoms (eg, increased energy, pressured speech, decreased need for sleep) required for this diagnosis. (Choices B, D, and F) Personality disorders are characterized by long-standing patterns of interpersonal issues but no persistent delusions or other psychotic symptoms. This patient lacks key features of borderline personality disorder (eg, abandonment fears, feelings of emptiness, identity disturbance, recurrent suicidal behavior). She does not have the pervasive emotionality or the need to be the center of attention seen in histrionic personality disorder. Individuals with schizotypal personality disorder exhibit eccentric behavior and odd beliefs or magical thinking (eg, superstitions, clairvoyance), but their beliefs are not held with delusional conviction as in delusional disorder. (Choice E) Schizophreniform disorder is diagnosed when the symptoms of schizophrenia are present for ≥1 month but <6 months. These symptoms include ≥2 of the following: delusions, hallucinations, disorganized speech (eg, frequent derailment, incoherence), grossly disorganized or catatonic behavior, and negative symptoms (eg, flat affect, social withdrawal). The lack of other psychotic symptoms in this patient makes delusional disorder more likely. Educational objective: Delusional disorder is characterized by at least 1 persistent delusion and no other prominent psychotic symptoms. Apart from the impact of the delusion or delusions, functioning is not markedly impaired. References: A psychopathological comparison between delusional disorder and schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/28595494) Delusional disorder and schizophrenia: a comparative study across multiple domains. (http://www.ncbi.nlm.nih.gov/pubmed/27468631)

A 27-Year-Old Woman Is Brought to the Emergency Department by Police