A 68-year-old man comes to the office due to headaches and unexplained weight loss. The patient says, "Something is definitely wrong with my brain." Over the past month, he has become convinced that he has brain cancer despite reassurance by another physician that his laboratory and brain MRI results are normal. The patient reports low energy and little appetite for the last 3 months. He stopped cooking when his wife died 6 months ago and has lost 9 kg (19.8 lb). The patient also quit his volunteer job due to headaches and an inability to concentrate, explaining, "I no longer enjoy the work anyway." Medical history includes hypertension and osteoarthritis. Physical and neurologic examinations are unremarkable. On mental status examination, the patient moves and speaks slowly with frequent pauses. He says, "Cancer is my punishment for sins I committed as a young child." He denies suicidal ideation but says, "It doesn't matter because I am dying of cancer anyway." Which of the following is the most likely diagnosis in this patient?

Question

A 68-year-old man comes to the office due to headaches and unexplained weight loss.  The patient says, "Something is definitely wrong with my brain."  Over the past month, he has become convinced that he has brain cancer despite reassurance by another physician that his laboratory and brain MRI results are normal.  The patient reports low energy and little appetite for the last 3 months.  He stopped cooking when his wife died 6 months ago and has lost 9 kg (19.8 lb).  The patient also quit his volunteer job due to headaches and an inability to concentrate, explaining, "I no longer enjoy the work anyway."  Medical history includes hypertension and osteoarthritis.  Physical and neurologic examinations are unremarkable.  On mental status examination, the patient moves and speaks slowly with frequent pauses.  He says, "Cancer is my punishment for sins I committed as a young child."  He denies suicidal ideation but says, "It doesn't matter because I am dying of cancer anyway."  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

In the absence of underlying medical illness, this patient's weight loss, low energy, impaired concentration, loss of interest, guilt, and psychomotor retardation are most likely due to major depression. His conviction that he has brain cancer despite normal test results and that cancer is punishment for sins he committed as a child represents a delusion that specifies the subtype as major depressive disorder with psychotic features. In this severe subtype of unipolar major depression, the depressive episode is accompanied by delusions and/or hallucinations, typically with depressive themes (eg, deserving punishment, worthlessness, nihilism). Identification of psychotic features is important because treatment for psychotic depression is different than that for nonpsychotic depression. First-line treatment of major depressive disorder with psychotic features is combination pharmacotherapy with an antidepressant and antipsychotic or with electroconvulsive therapy. (Choice A) In delusional disorder, mood symptoms, if present, are brief and not a prominent part of the illness. They would not explain this patient's severe depressive symptoms. (Choices B and E) Patients with illness anxiety disorder are excessively concerned about having a serious, undiagnosed general medical condition. Somatic symptom disorder is characterized by excessive anxiety and thoughts about the seriousness of at least 1 somatic symptom. Neither diagnosis explains this patient's severe depression, associated somatic delusions, and delusions of guilt. (Choice D) Although this patient's depression may have been triggered by his wife's death, his symptoms are severe and meet the criteria for major depressive disorder. Patients with persistent complex bereavement disorder (also referred to as complicated grief) commonly have depressive symptoms, but their sadness centers on the loss of a loved one and is characterized by intense yearning for the deceased. It would not explain this patient's pervasive depression and delusions. Educational objective: Major depressive disorder with psychotic features is a severe subtype of unipolar major depression. It is characterized by an episode of major depression accompanied by delusions and/or hallucinations, typically with depressive themes. References: Psychotic features in patients with major depressive disorder: a report from the European Group for the Study of Resistant Depression. (http://www.ncbi.nlm.nih.gov/pubmed/30677267) Challenges in the treatment of major depressive disorder with psychotic features. (http://www.ncbi.nlm.nih.gov/pubmed/23599251)

A 68-Year-Old Man Comes to the Office Due to Headaches