A 25-year-old man is brought to the emergency department by ambulance after being found sitting in the street drinking his own urine. The patient's mother says that a year ago he expressed the belief that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The patient's mother has noticed that he no longer seems to care about activities that used to interest him, and last month she found out that he had moved into the family garden shed with his dog. On examination, the patient is malodorous, disheveled, and laughs for no apparent reason. He later becomes angry and refuses to sit in a chair for the interview. The patient switches among unrelated topics and when asked where he lives says, "in the holy buffet of diplomacy." Temperature is 36.7 C (98 F), blood pressure is 122/79 mm Hg, and pulse is 80/min. Physical examination and laboratory evaluation, including urine toxicology, are unremarkable. Which of the following is the most likely diagnosis in this patient?

Question

A 25-year-old man is brought to the emergency department by ambulance after being found sitting in the street drinking his own urine.  The patient's mother says that a year ago he expressed the belief that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone.  The patient's mother has noticed that he no longer seems to care about activities that used to interest him, and last month she found out that he had moved into the family garden shed with his dog.  On examination, the patient is malodorous, disheveled, and laughs for no apparent reason.  He later becomes angry and refuses to sit in a chair for the interview.  The patient switches among unrelated topics and when asked where he lives says, "in the holy buffet of diplomacy."  Temperature is 36.7 C (98 F), blood pressure is 122/79 mm Hg, and pulse is 80/min.  Physical examination and laboratory evaluation, including urine toxicology, are unremarkable.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_3642_ee19_9249_57abe44e8fbf_MD0001_00 This patient's delusions, disorganized speech (eg, loosening of associations, nonsensical words), grossly disorganized behavior (eg, unpredictable agitation, bizarre behaviors, inappropriate affect), and functional decline lasting ≥6 months are consistent with schizophrenia. Other symptoms include hallucinations and negative symptoms (eg, affective flattening, apathy, alogia [poverty of speech], anhedonia, asociality). Schizophrenia has an overall international prevalence of almost 1% and is slightly more prevalent among men. Schizophrenia typically presents in the early 20s in men and the late 20s in women. The majority of patients with schizophrenia follow a fluctuating course in which symptoms peak (as seen in this patient) and then diminish, with less severe residual symptoms (eg, disorganization, mild negative symptoms, mild hallucinations) at baseline. The treatment of choice for schizophrenia is antipsychotic medication. (Choices A and C) In bipolar disorder or major depressive disorder (MDD) with psychotic features, psychotic symptoms occur exclusively during a major depressive or manic episode. This patient's apathy and anhedonia are negative symptoms of schizophrenia. Although anhedonia is also seen in MDD, this patient does not have other depressive symptoms required to diagnose MDD. (Choices B and G) Brief psychotic disorder is characterized by acute onset of psychotic symptoms lasting ≥1 day but <1 month, with full return to premorbid level of functioning. Schizophreniform disorder is distinguished from schizophrenia by a symptom duration of >1 month and <6 months. Because this patient's symptoms have lasted ≥6 months, he meets the criteria for schizophrenia. (Choice D) Although it is important to definitively rule out medical causes of psychosis, this patient's normal vital signs and unremarkable physical examination and laboratory evaluation make a primary psychiatric disorder more likely. (Choice E) Schizoaffective disorder requires that the patient meet the criteria for a major depressive or manic episode concurrent with active-phase symptoms of schizophrenia. The diagnosis also requires that delusions or hallucinations occur in the absence of mood symptoms for ≥2 weeks at some point during the illness. Educational objective: The diagnosis of schizophrenia requires ≥2 of the following 5 symptoms: delusions, hallucinations, disorganized speech, grossly disorganized behavior, and negative symptoms. The total impairment duration must be ≥6 months. __________ References: Definition and description of schizophrenia in the DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23800613)

A 25-Year-Old Man Is Brought to the Emergency Department by Ambulance