A 15-year-old boy is brought to the office due to unusual behavior. The patient's mother reports that his behavior began to change 2 months ago, when he started withdrawing from his friends and losing interest in his classes and school activities. During this time, his grades declined, and he spent hours each day developing a code in which certain colors had specific, personal meanings. His mother says, "He insists on wearing the same blue shirt every day. He doesn't even wash it anymore." The patient refuses to ride in the family's gray car because "only primary colors are good." His mother has heard him talking to himself late at night and worries that he is not getting enough sleep. The patient does not use alcohol or illicit drugs. Medical and family history are unremarkable. Vital signs are within normal limits. The patient is tracking appropriately on growth curves. On physical examination, the patient is wearing a stained blue shirt and jeans. Cardiopulmonary examination is normal, and the abdomen is soft and nontender with no hepatosplenomegaly. Neurologic examination is unremarkable. The patient makes minimal eye contact and is slow to respond, but he becomes eager to describe his color system when asked about it. Which of the following is the most likely diagnosis for this patient?

Question

A 15-year-old boy is brought to the office due to unusual behavior.  The patient's mother reports that his behavior began to change 2 months ago, when he started withdrawing from his friends and losing interest in his classes and school activities.  During this time, his grades declined, and he spent hours each day developing a code in which certain colors had specific, personal meanings.  His mother says, "He insists on wearing the same blue shirt every day.  He doesn't even wash it anymore."  The patient refuses to ride in the family's gray car because "only primary colors are good."  His mother has heard him talking to himself late at night and worries that he is not getting enough sleep.  The patient does not use alcohol or illicit drugs.  Medical and family history are unremarkable.  Vital signs are within normal limits.  The patient is tracking appropriately on growth curves.  On physical examination, the patient is wearing a stained blue shirt and jeans.  Cardiopulmonary examination is normal, and the abdomen is soft and nontender with no hepatosplenomegaly.  Neurologic examination is unremarkable.  The patient makes minimal eye contact and is slow to respond, but he becomes eager to describe his color system when asked about it.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d7f1_8821_bc81_9b27a18e9ad1_MD0003_00 This patient's 2-month history of behavioral change, which is characterized by delusional thinking and behavior, possible hallucinations (ie, talking to himself), and negative symptoms (eg, social withdrawal, poor eye contact, neglect of personal hygiene), is consistent with schizophreniform disorder. Schizophreniform disorder is diagnosed when the symptoms of schizophrenia are present for ≥1 month but <6 months. These symptoms include ≥2 of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. Impairment in functioning may be present but is not required for the diagnosis. The diagnosis of schizophreniform disorder is made provisionally; if symptoms persist ≥6 months, the diagnosis is changed to schizophrenia. The psychotic features of schizophrenia typically emerge between the late teens and the mid-30s; childhood onset is rare and is associated with a poorer prognosis. (Choice A) Although this patient has fixated interests characteristic of an autism spectrum disorder, symptoms of autism are usually recognized by age 2 and include chronic deficits in social communication and repetitive behaviors. It would not explain this patient's recent social withdrawal and development of psychosis. (Choice B) Brief psychotic disorder is diagnosed when positive psychotic symptoms last ≥1 day and <1 month. It is characterized by a sudden onset and a full return to premorbid level of functioning. (Choice C) Delusional disorder is characterized by ≥1 delusion in the absence of other psychotic symptoms. Functioning may be normal apart from the direct impact of the delusion. (Choice D) Although obsessive-compulsive disorder can present with obsessions related to color coding, these obsessions do not appear to be associated with a feared event or anxiety in this patient (who is eager to discuss his color system). In addition, his negative symptoms, possible hallucinations, and progressive functional impairment are more consistent with schizophreniform disorder. (Choice F) Schizotypal personality disorder is characterized by a pervasive pattern of social deficits, cognitive or perceptual distortions, and eccentric behavior with no clear delusions or hallucinations. In this patient, the abrupt onset and short-lived timeline of symptoms make a personality disorder unlikely and are more consistent with schizophreniform disorder. Educational objective: Schizophreniform disorder is differentiated from schizophrenia by the duration of symptoms. In schizophreniform disorder, symptoms must last for ≥1 month but <6 months. The diagnosis of schizophrenia requires symptoms to persist for ≥6 months. References: Schizophrenia and other psychotic disorders in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23538289) Adolescent vs. adult onset of a first episode psychosis: impact on remission of positive and negative symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/27102425)

A 15-Year-Old Boy Is Brought to the Office Due to Unusual