A 22-year-old man is brought to the emergency department by his roommate for evaluation of "weird behavior." Eight days ago, the patient's father died in a car accident. Since then, the patient has been sleeping poorly and eating minimally. His roommate says, "He's been keeping all the lights off in the apartment. Yesterday when I walked in, he was sitting alone in the dark and whispering as if someone else was there. When I switched on the lights, he immediately closed his eyes and covered his ears." The roommate reports that the patient is studying computer science and has been on the honor roll every semester, but for the past week, he has not gone to class or spent time with friends. As an adolescent, the patient was treated for a depressive episode shortly after his parents divorced. He has no significant medical history and does not take any medications. Vital signs are normal and physical examination is unremarkable. On mental status examination, he appears unkempt and hypervigilant. His responses are short and unrelated to the questions being asked. Which of the following is the most likely diagnosis?

Question

A 22-year-old man is brought to the emergency department by his roommate for evaluation of "weird behavior."  Eight days ago, the patient's father died in a car accident.  Since then, the patient has been sleeping poorly and eating minimally.  His roommate says, "He's been keeping all the lights off in the apartment.  Yesterday when I walked in, he was sitting alone in the dark and whispering as if someone else was there.  When I switched on the lights, he immediately closed his eyes and covered his ears."  The roommate reports that the patient is studying computer science and has been on the honor roll every semester, but for the past week, he has not gone to class or spent time with friends.  As an adolescent, the patient was treated for a depressive episode shortly after his parents divorced.  He has no significant medical history and does not take any medications.  Vital signs are normal and physical examination is unremarkable.  On mental status examination, he appears unkempt and hypervigilant.  His responses are short and unrelated to the questions being asked.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This man's acute onset of disorganized, bizarre behavior (eg, keeping lights off, closing eyes, covering ears), disorganized speech (eg, nonsensical responses), and probable hallucinations (eg, whispering to himself in the dark) following the traumatic death of his father is consistent with brief psychotic disorder (BPD). BPD is characterized by psychotic symptoms lasting between 1 day and 1 month. As in this case, it is often triggered by a traumatic or stressful event and can be specified as "with marked stressor(s)." When triggered by the loss of a loved one, BPD should be differentiated from a normal grief reaction. In a normal grief reaction, individuals may have hallucinatory experiences that are centered on maintaining a connection with the deceased (such as seeing, hearing, or being touched by the deceased) (Choice E). Their behavior and speech, however, are not disorganized and they are still able to relate to others. In contrast, this man's behavior is bizarre and his responses on examination are nonsensical. (Choice A) Acute stress disorder is characterized by an intrusive re-experiencing of a traumatic event accompanied by symptoms of hyperarousal, dissociation, and avoidance lasting for ≤1 month. (Choice C) In delusional disorder, individuals have 1 or more delusions that have been present for at least 1 month. It is not accompanied by markedly bizarre behavior or impairment. (Choice D) Although psychotic symptoms and poor sleep can be seen in a manic episode of bipolar disorder, this patient does not display other key features of mania (eg, prominent mood symptoms, increased energy, grandiosity, talkativeness, excessive engagement in pleasurable activities). (Choice F) Persistent complex bereavement disorder is a prolonged and disabling grief reaction characterized by extreme and persistent yearning for the deceased that causes functional impairment and inability to resume normal life. (Choice G) In schizophreniform disorder, psychotic symptoms last ≥1 month and <6 months. If this man's psychotic symptoms persisted beyond 1 month, a diagnosis of schizophreniform disorder could be considered. If symptoms persisted for ≥6 months, the accurate diagnosis would be schizophrenia. Educational objective: Brief psychotic disorder is characterized by the acute onset of psychotic symptoms (eg, disorganized speech and behavior, delusions, hallucinations) lasting between 1 day and 1 month. It can be triggered by a marked stressor such as the loss of a loved one. References: Structure of the psychotic disorders classification in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23707641)

A 22-Year-Old Man Is Brought to the Emergency Department by His