A 43-year-old woman comes to the office due to a painful and swollen knee sustained when she tripped while walking outside her home. She blames her injury on "bad energy" that she was getting from her next-door neighbor, whom she believes does not like her. The patient thinks she "has a sixth sense" to detect "negative people" but does not believe there is any specific plot to harm her. She has worked for many years sorting items in a used clothing store and lives alone, saying, "I prefer it this way." Medical history is significant for glucose intolerance and vitamin D insufficiency. The patient has been prescribed vitamin D supplements but prefers not to take them because "one can never be sure what could be in these things." Vital signs are normal. Physical examination is significant for a painful, swollen right knee with normal range of movement. On mental status examination, it is noted that the patient is dressed in multiple layers of mismatched clothing. She has flat affect and makes limited eye contact. Which of the following is the most likely diagnosis?

Question

A 43-year-old woman comes to the office due to a painful and swollen knee sustained when she tripped while walking outside her home.  She blames her injury on "bad energy" that she was getting from her next-door neighbor, whom she believes does not like her.  The patient thinks she "has a sixth sense" to detect "negative people" but does not believe there is any specific plot to harm her.  She has worked for many years sorting items in a used clothing store and lives alone, saying, "I prefer it this way."  Medical history is significant for glucose intolerance and vitamin D insufficiency.  The patient has been prescribed vitamin D supplements but prefers not to take them because "one can never be sure what could be in these things."  Vital signs are normal.  Physical examination is significant for a painful, swollen right knee with normal range of movement.  On mental status examination, it is noted that the patient is dressed in multiple layers of mismatched clothing.  She has flat affect and makes limited eye contact.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7e2_45cc_bc81_25789e2cde7d_MD0003_00 This patient's eccentric behaviors, odd beliefs, and interpersonal deficits (reduced capacity for close relationships), are characteristic of schizotypal personality disorder. Magical thinking (eg, superstition, clairvoyance), suspiciousness, and paranoid ideation can occur but are not of delusional proportions, as in psychotic disorders. For example, this patient has general paranoia and idiosyncratic thinking about negative energy, but no fixed delusions. Perceptual distortions can also occur, but there are no frank hallucinations. Individuals with schizotypal disorder are typically socially awkward, have few friends, and experience difficulty sustaining close relationships due to social anxiety that does not diminish with familiarity. Odd dress and peculiar speech are common. Schizotypal personality disorder can be differentiated from other personality disorders by the predominance of eccentric behaviors and odd beliefs. (Choices A and D) Diagnosis of schizotypal personality disorder requires ruling out psychotic disorders that are characterized by persistent delusions and/or hallucinations. Delusional disorder is typically characterized by fixed, delusional beliefs. Individuals with schizophrenia exhibit delusions, hallucinations, disorganized speech and behavior, and negative symptoms. Although this patient has a flat affect, her odd beliefs are not held with delusional intensity, and she lacks other prominent psychotic symptoms. (Choice B) Individuals with paranoid personality disorder demonstrate a pervasive pattern of suspiciousness and distrust. They do not exhibit eccentric behavior, magical thinking, or odd beliefs with nonparanoid themes. (Choice C) Individuals with schizoid personality disorder are socially detached or "loners." Although they also often lack close friends, they do not have odd thinking or perceptual distortions. Educational objective: Schizotypal personality disorder is characterized by a long-standing pattern of eccentric behaviors and social anxiety despite familiarity. Patients with this disorder typically exhibit magical thinking, unusual thoughts, and perceptual disturbances that are subthreshold for a psychotic disorder. References: Schizotypal personality disorder: a current review. (http://www.ncbi.nlm.nih.gov/pubmed/24828284) Personality disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26039856) Diagnosis and treatment of schizotypal personality disorder: evidence from a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/30282970)

A 43-Year-Old Woman Comes to the Office Due to a Painful