A 33-year-old man is hospitalized after neighbors called the police to report that he has been singing loudly and playing the piano "nonstop" all day and night for the last month. The patient says his mood is "terrific," claims he is related to the President, and hears voices telling him he is going to be a famous entertainer. While in the hospital, he makes inappropriate sexual advances toward some of the female nurses. He has a history of 9 psychiatric hospitalizations starting at age 22 for mood and psychotic symptoms. In between hospitalizations, the patient has heard voices commenting on his appearance and has believed that secret cameras have been monitoring him, but he has had no mood symptoms. Which of the following is the most likely diagnosis in this patient?

Question

A 33-year-old man is hospitalized after neighbors called the police to report that he has been singing loudly and playing the piano "nonstop" all day and night for the last month.  The patient says his mood is "terrific," claims he is related to the President, and hears voices telling him he is going to be a famous entertainer.  While in the hospital, he makes inappropriate sexual advances toward some of the female nurses.  He has a history of 9 psychiatric hospitalizations starting at age 22 for mood and psychotic symptoms.  In between hospitalizations, the patient has heard voices commenting on his appearance and has believed that secret cameras have been monitoring him, but he has had no mood symptoms.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_3642_78e8_9249_bd322b5785b5_MD0001_00 This patient's current symptoms and psychiatric history are consistent with schizoaffective disorder. In addition to currently exhibiting symptoms of mania (eg, elevated mood, decreased need for sleep, hypersexuality, grandiose delusions), he also has a history of delusions and hallucinations occurring in the absence of a major mood episode (ie, psychotic symptoms without mood symptoms in between hospitalizations). A lifetime history of at least 2 weeks of psychotic symptoms in the absence of a mood episode is a key requirement for the schizoaffective disorder diagnosis. Differentiating schizoaffective disorder from bipolar disorder with psychotic features or major depression with psychotic features requires determining the temporal relationship between psychotic symptoms and mood symptoms. In bipolar disorder and major depression with psychotic features, psychotic symptoms occur exclusively during manic or depressive episodes (Choices A and C); there are no psychotic symptoms outside of mood episodes. Unlike schizoaffective disorder, a diagnosis of schizophrenia does not include prominent mood symptoms that meet the criteria for manic and/or depressive episodes (Choice E). (Choice B) Delusional disorder involves ≥1 delusions for at least 1 month in the absence of other psychotic symptoms (eg, hallucinations, disorganized speech and behavior). (Choice F) Schizophreniform disorder has the same symptoms as schizophrenia (eg, delusions, hallucinations, disorganized speech and/or behavior, negative symptoms), but the duration is ≥1 month and <6 months. Educational objective: For diagnosis of schizoaffective disorder, psychosis must occur in the absence of major mood episodes, but mood episodes must be present for a majority of this lifelong illness. In bipolar disorder and major depression with psychotic features, psychotic symptoms occur exclusively during mood episodes. __________ References: Schizoaffective disorder in the DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23707642)

A 33-Year-Old Man Is Hospitalized After Neighbors Called the Police