A 56-year-old man is brought to the emergency department by police after being found walking down the middle of a busy highway saying he is "blessed with the power to save all souls." The patient believes he is "the reincarnation of the Savior" and was sent to "spread peace on Earth." He recently moved to the city and is renting a room at a boarding house where he says he has been "turning water into wine." The patient has been unable to hold down a steady job for most of his adult life but works intermittently in construction. Blood pressure is 168/94 mm Hg and pulse is 90/min. The patient appears thin and has stained clothing and unwashed hair. He avoids direct eye contact, mostly looking at the ceiling and smiling intermittently for no apparent reason. His speech is difficult to follow, and he repeatedly says in a monotone voice, "I am blessed." Neurological examination is otherwise unremarkable. Routine laboratory studies are within normal range, and blood alcohol level is undetectable. Which of the following is the most likely diagnosis in this patient?

Question

A 56-year-old man is brought to the emergency department by police after being found walking down the middle of a busy highway saying he is "blessed with the power to save all souls."  The patient believes he is "the reincarnation of the Savior" and was sent to "spread peace on Earth."  He recently moved to the city and is renting a room at a boarding house where he says he has been "turning water into wine."  The patient has been unable to hold down a steady job for most of his adult life but works intermittently in construction.  Blood pressure is 168/94 mm Hg and pulse is 90/min.  The patient appears thin and has stained clothing and unwashed hair.  He avoids direct eye contact, mostly looking at the ceiling and smiling intermittently for no apparent reason.  His speech is difficult to follow, and he repeatedly says in a monotone voice, "I am blessed."  Neurological examination is otherwise unremarkable.  Routine laboratory studies are within normal range, and blood alcohol level is undetectable.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7f2_c0a3_bc81_7328c6158dc7_MD0003_00 This patient's multiple delusions, disorganized speech and behavior, and history suggestive of impaired functioning for ≥6 months (eg, his inability to hold down a steady job for most of his adult life) are most consistent with schizophrenia. His poor hygiene, negative symptoms (eg, flat affect, poor eye contact, monotonous voice), and probable response to internal stimuli (eg, smiling out of context) are further clues. Patients with schizophrenia can have grandiose delusions that they possess special powers or are related to or have become someone famous. Other common types of delusions include paranoid delusions and delusions of reference (eg, receiving special messages from electronic media). (Choice A) Alcoholic hallucinosis is an alcohol withdrawal syndrome characterized by hallucinations in patients with stable vital signs. Patients are generally aware of their hallucinations and maintain insight. This patient's prominent delusions as well as disorganized speech and behavior are more consistent with schizophrenia. (Choice B) Patients experiencing a manic episode in bipolar disorder can also have grandiose delusions. However, these patients typically have associated symptoms of elated mood, increased energy, hyperactivity, and decreased need for sleep, which are not present in this patient. Patients with mania have an intense, elated, or irritable affect consistent with their mood, whereas this patient has an inappropriate or flat affect. In addition, patients with mania typically have pressured speech that is difficult to interrupt; this patient's speech is disorganized. (Choice C) Patients with delusional disorder do not have the other psychotic symptoms characteristic of schizophrenia (eg, disorganization, negative symptoms). In contrast to this patient, they may function normally apart from the impact of the delusion. (Choices D and F) Although psychosis may be associated with these medical conditions, they are much less likely causes of this patient's clinical presentation. Lead toxicity typically presents with abdominal and joint/muscle pain, headache, cognitive impairment, and irritability-symptoms notably absent in this patient. Wernicke-Korsakoff syndrome develops in the context of thiamine (vitamin B₁) deficiency and presents with the triad of oculomotor impairment (eg, lateral rectus palsy), ataxia, and encephalopathy. Educational objective: Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behavior, and negative symptoms of ≥6 months duration. The differential diagnosis includes mood disorders with psychotic features, other primary psychotic disorders, and substance and medical causes of psychosis. References: Definition and description of schizophrenia in the DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23800613) Schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/26777917) Grandiose delusions: a review and theoretical integration of cognitive and affective perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/21482326)

A 56-Year-Old Man Is Brought to the Emergency Department by Police