A 76-year-old man comes to the office for follow-up of hypertension. He says, "I wouldn't be surprised if my blood pressure is up with all the stress I am under. My wife has been having an ongoing affair with our accountant. I've known about this for years, and she continues to deny it. Even my children are in on it. They tell me that I'm imagining things." The patient reports that he monitors his wife closely and calls her multiple times a day to check on her whereabouts but admits that he has not found any evidence of the affair. He reports intermittent insomnia but no change in appetite. The patient occasionally forgets names and has word-finding difficulty. He continues to perform household chores and handle finances. Blood pressure is 132/85 mm Hg, pulse is 82/min, and respirations are 16/min. Physical examination, including neurologic examination, is unremarkable. The patient is alert and oriented, and his mood is irritable. Which of the following is the most likely diagnosis for this patient?

Question

A 76-year-old man comes to the office for follow-up of hypertension.  He says, "I wouldn't be surprised if my blood pressure is up with all the stress I am under.  My wife has been having an ongoing affair with our accountant.  I've known about this for years, and she continues to deny it.  Even my children are in on it.  They tell me that I'm imagining things."  The patient reports that he monitors his wife closely and calls her multiple times a day to check on her whereabouts but admits that he has not found any evidence of the affair.  He reports intermittent insomnia but no change in appetite.  The patient occasionally forgets names and has word-finding difficulty.  He continues to perform household chores and handle finances.  Blood pressure is 132/85 mm Hg, pulse is 82/min, and respirations are 16/min.  Physical examination, including neurologic examination, is unremarkable.  The patient is alert and oriented, and his mood is irritable.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d7f3_d214_bc81_cf17b8ad11af_MD0003_00 This patient's persistent belief that his wife is unfaithful in the absence of any real evidence is most consistent with delusional disorder, jealous type. Delusional disorder is characterized by delusions in the absence of other prominent psychotic symptoms (eg, hallucinations, disorganization), with subtypes based on the delusional theme: Persecutory (eg, being poisoned, harassed, plotted against) Erotomanic (eg, false belief that someone of higher status is in love with the person) Grandiose (eg, great talent, insights, achievements) Jealous (eg, unfaithful partners) Somatic (eg, bodily functions, sensations) In the jealous type, the patient typically searches for evidence to support the delusion that the partner is unfaithful, which in severe cases can lead to threatening and violent behavior toward the suspected individuals. As in this patient, individuals with delusional disorder do not appear to be obviously bizarre or odd and are still able to function in areas apart from their delusion (eg, this patient manages household chores and finances). (Choice A) Patients with Alzheimer disease may develop psychosis, including delusions of jealousy. However, this would typically occur in the middle to late course of the disease. Occasional forgetting of names and word-finding difficulty are relatively age normative, and the patient does not have evidence of the severity of cognitive impairment necessary to affect activities of daily living (eg, managing finances) and thereby fulfill a diagnosis of dementia (eg, Alzheimer disease). (Choices C and F) Delusional disorder must be differentiated from other disorders presenting with psychotic symptoms. The diagnosis of major depressive disorder (which can be associated with psychotic features) requires depressed mood or anhedonia (not seen in this patient) and would cause daily insomnia and difficulty concentrating (rather than intermittent insomnia and occasional word-finding difficulty). Patients with schizophrenia have additional psychotic symptoms (eg, hallucinations, disorganization, negative symptoms) and greater functional impairment. (Choice D) Paranoid personality disorder involves a lifelong pattern of distrust and suspicion of others, beginning in early adulthood. The paranoid beliefs are generally pervasive (not simply directly at one person) and not of delusional intensity, unlike what is evident in this patient. (Choice E) The chronic course of this patient's delusional thinking and unremarkable physical examination (including neurologic examination) make psychotic disorder due to another medical condition unlikely. Educational objective: Delusional disorder is characterized by one or more delusions. Other prominent psychotic symptoms are absent, and the individual is still able to function in areas unrelated to the delusion. References: Delusional disorder and schizophrenia: a comparative study across multiple domains. (http://www.ncbi.nlm.nih.gov/pubmed/27468631) A psychopathological comparison between delusional disorder and schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/28595494)

A 76-Year-Old Man Comes to the Office for Follow-Up of Hypertension