A 42-year-old man comes to the clinic for excision of a mole on his left forearm. He says, "I've had this mole since my youth. I acquired it from wearing sunscreen that was chemicalized with toxins to improve absorption." The patient would like the mole removed because his colleague is "sending negative zings that could cause it to enlarge." A colleague complimented his work at a staff meeting a few weeks ago, and he is now concerned that this individual is jealous of him and wishes him harm. The patient has worked as a filing clerk for the same company since college and does not have close relationships. On physical examination, he is dressed in yellow suit pants and a t-shirt. A 3-mm symmetric nevus with well-defined borders is visualized on the left arm. The patient makes minimal eye contact, has a constricted affect, and speaks in a formal manner. Which of the following is the most likely diagnosis in this patient?

Question

A 42-year-old man comes to the clinic for excision of a mole on his left forearm.  He says, "I've had this mole since my youth.  I acquired it from wearing sunscreen that was chemicalized with toxins to improve absorption."  The patient would like the mole removed because his colleague is "sending negative zings that could cause it to enlarge."  A colleague complimented his work at a staff meeting a few weeks ago, and he is now concerned that this individual is jealous of him and wishes him harm.  The patient has worked as a filing clerk for the same company since college and does not have close relationships.  On physical examination, he is dressed in yellow suit pants and a t-shirt.  A 3-mm symmetric nevus with well-defined borders is visualized on the left arm.  The patient makes minimal eye contact, has a constricted affect, and speaks in a formal manner.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7e8_d585_bc81_27f548b36e69_MD0003_00 This patient's odd beliefs/magical thinking (eg, belief that negative energy can enlarge his mole), eccentric appearance (eg, yellow suit pants and a t-shirt), and idiosyncratic speech are most consistent with schizotypal personality disorder (SPD). Individuals with SPD typically appear odd and socially awkward, often with a constricted affect. Speech may be vague, metaphorical, or idiosyncratic in nature. Patients with SPD tend to avoid social relationships and have a limited capacity for intimate relationships. Paranoid beliefs (eg, that his colleague is jealous and wishes him harm) are common and may result in social anxiety. The odd beliefs and perceptual distortions (eg, illusions, unusual bodily sensations) seen in patients with SPD do not reach psychotic proportions. SPD can be differentiated from primary psychotic disorders by the absence of well-formed, persistent delusions or frank hallucinations. (Choice A) Delusional disorder is characterized by ≥1 month of specific, well-formed delusions. It is not accompanied by the pattern of eccentric behavior, unusual speech, and social deficits seen in SPD. (Choices B and C) Although this patient shares some features with other personality disorders, such as the suspiciousness seen in paranoid personality disorder and the emotional detachment seen in schizoid personality disorder, neither of these personality disorders would explain this patient's odd beliefs, magical thinking, idiosyncratic speech, and eccentric appearance, which are characteristic of SPD. (Choice D) Schizophrenia is characterized by ≥6 months of delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms (eg, apathy, avolition), which often result in significant impairment in multiple settings. This patient, however, is able to maintain a job and is not grossly disorganized. Although his beliefs are odd, they are not of delusional intensity; hallucinations are absent. (Choice F) Patients with social anxiety disorder experience distress in situations in which they may be judged or criticized. However, they are able to maintain close relationships and do not display odd beliefs or eccentric behaviors. Educational objective: Schizotypal personality disorder is characterized by odd beliefs/magical thinking, eccentric behavior, and a reduced capacity for intimacy. Paranoid ideation often results in social anxiety and avoidance. Frank delusions and hallucinations are absent. References: Schizotypal personality disorder: a current review. (http://www.ncbi.nlm.nih.gov/pubmed/24828284) Normal personality, personality disorder and psychosis: current views and future perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/25415496)

A 42-Year-Old Man Comes to the Clinic for Excision of a Mole