A 24-year-old man is brought to the emergency department by his wife after he attempted to barricade himself in the garage. Three weeks ago, while working at a construction site, the patient was almost hit by a falling metal beam. Since the incident, he has become increasingly distressed and believes his supervisor arranged for the beam to deliberately hit him. Earlier today, the patient received a routine work email and is now convinced it contains a hidden message warning that his life is still in danger. He used cannabis and cocaine intermittently in college but has not used either drug for the past year. The patient has no prior medical or psychiatric conditions. Vital signs are within normal limits, physical examination is unremarkable, and urine drug screen is negative. The patient appears hypervigilant and becomes agitated when hospital admission is discussed but calms down after having a conversation with his wife. The patient agrees to hospitalization; however, once admitted, he refuses to take any medications. His condition improves over the course of several days without any pharmacotherapy. The patient is discharged and returns to work without issue. Which of the following is the most likely diagnosis for this patient?

Question

A 24-year-old man is brought to the emergency department by his wife after he attempted to barricade himself in the garage.  Three weeks ago, while working at a construction site, the patient was almost hit by a falling metal beam.  Since the incident, he has become increasingly distressed and believes his supervisor arranged for the beam to deliberately hit him.  Earlier today, the patient received a routine work email and is now convinced it contains a hidden message warning that his life is still in danger.  He used cannabis and cocaine intermittently in college but has not used either drug for the past year.  The patient has no prior medical or psychiatric conditions.  Vital signs are within normal limits, physical examination is unremarkable, and urine drug screen is negative.  The patient appears hypervigilant and becomes agitated when hospital admission is discussed but calms down after having a conversation with his wife.  The patient agrees to hospitalization; however, once admitted, he refuses to take any medications.  His condition improves over the course of several days without any pharmacotherapy.  The patient is discharged and returns to work without issue.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d7ad_04ce_bc81_7d8352cf729c_MD0003_00 The presence of ≥1 psychotic symptoms (eg, delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) lasting ≥1 days and <1 month, with full return to functioning, is consistent with brief psychotic disorder. As in this case, in which the patient acutely developed paranoid delusions and bizarre behavior following a life-threatening incident, symptoms of brief psychotic disorder often develop in reaction to a marked stressor. Diagnosis requires ruling out psychotic disorders due to substances or medical conditions and longitudinal assessment to confirm remission within a month. Brief psychotic disorder can be differentiated from other psychotic disorders by duration. In delusional disorder, ≥1 delusion must be present for ≥1 months (Choice E). In schizophreniform disorder, psychotic symptoms last ≥1 months and <6 months (Choice G). This patient's symptoms resolved within a month. (Choices A and F) Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are other possible consequences of traumatic exposure. They are characterized by symptoms of intrusion (eg, flashbacks, nightmares), negative mood, dissociation, avoidance, and arousal. In ASD, symptoms last from ≥3 days to ≤1 month, and in PTSD, symptoms last for >1 month. Bizarre psychotic symptoms and disorganized behavior are not typical. (Choice B) Adjustment disorder is not characterized by psychotic symptoms and is not diagnosed when criteria are met for a more specific disorder. (Choice C) Although psychotic symptoms can be seen in a manic episode of bipolar disorder, this patient lacks other characteristic manic symptoms (eg, elated mood, increased energy, pressured speech, decreased need for sleep). (Choice H) Substance-induced psychotic disorder should always be considered in the differential diagnosis of an acute psychotic episode. Even though some substances are not identified by urine drug screening (eg, synthetic cannabinoids), this patient reports abstaining from drug use for the past year and has no signs of drug use on physical examination (eg, injected or dilated pupils, abnormal vital signs, altered reflexes, tremors), making substance-induced psychotic disorder unlikely. Educational objective: Brief psychotic disorder involves the presence of ≥1 psychotic symptoms lasting ≥1 days and <1 month, with full return to the previous level of functioning. References: Structure of the psychotic disorders classification in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23707641) Short-term course and outcome of acute and transient psychotic disorders: differences from other types of psychosis with acute onset. (http://www.ncbi.nlm.nih.gov/pubmed/26087685) Prognosis of brief psychotic episodes: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26764163)

A 24-Year-Old Man Is Brought to the Emergency Department by His