A 27-year-old man is brought to the emergency department by his roommate, who found the patient barricading himself in a closet at home and saying, "They're coming to get me. No one can be trusted." The patient was laid off from his job and broke up with his girlfriend last month. He has heard voices threatening to kill him a few times daily for the past 2 weeks. He has no medical or psychiatric history and does not use alcohol or illicit drugs. Physical examination and laboratory results are unremarkable. On mental status examination, the patient is fearful and tense. He describes being followed by men in black cars who are spying on him. Which of the following is the most likely diagnosis in this patient?

Question

A 27-year-old man is brought to the emergency department by his roommate, who found the patient barricading himself in a closet at home and saying, "They're coming to get me.  No one can be trusted."  The patient was laid off from his job and broke up with his girlfriend last month.  He has heard voices threatening to kill him a few times daily for the past 2 weeks.  He has no medical or psychiatric history and does not use alcohol or illicit drugs.  Physical examination and laboratory results are unremarkable.  On mental status examination, the patient is fearful and tense.  He describes being followed by men in black cars who are spying on him.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_363f_92b5_9249_8fe8b98c1b0f_MD0001_00 This patient's 2-week history of hearing voices and paranoid delusions is consistent with brief psychotic disorder. Onset is typically sudden in response to an overwhelming stressor. Diagnosis requires ≥1 psychotic symptoms (ie, delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) lasting >1 day and <1 month with eventual return to premorbid functioning. The diagnosis requires ruling out psychosis secondary to a mood disorder and psychosis due to substances or a medical condition. Symptom duration is a key feature in differentiating brief psychotic disorder from other psychotic disorders. If this patient's symptoms were to continue for >1 month but <6 months, the diagnosis of schizophreniform disorder would be indicated (Choice G). If the symptoms were to continue for ≥6 months, the accurate diagnosis would be schizophrenia (Choice F). (Choice A) Acute stress disorder is characterized by symptoms of intrusion (eg, flashbacks), negative mood, dissociation, avoidance, and arousal that occur in the initial month after exposure to a life-threatening traumatic event. (Choice B) Bipolar disorder can present with psychotic features; however, this patient lacks other characteristic manic symptoms (eg, elated mood, increased energy, pressured speech, decreased need for sleep, grandiosity). (Choice D) Delusional disorder is characterized by ≥1 delusions lasting ≥1 months and would not explain this patient's prominent hallucinations. (Choices E and H) Personality disorders are characterized by enduring patterns of behavior. Patients with paranoid personality disorder are generally suspicious and distrustful. Schizotypal personality disorder is characterized by odd thinking and eccentric behavior, but not frank psychosis. Neither disorder would explain this patient's acute onset of delusions and hallucinations. Educational objective: Brief psychotic disorder is characterized by ≥1 psychotic symptoms lasting >1 day and <1 month with full return to previous levels of functioning. Onset is typically sudden and associated with a stressor. __________ References: Structure of the psychotic disorders classification in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23707641) Prognosis of brief psychotic episodes: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26764163)

A 27-Year-Old Man Is Brought to the Emergency Department by His