A 32-year-old man is brought to the emergency department by his mother. She says that he has stayed up late every night for the past week, praying and shouting that he is "the Messiah." The patient speaks rapidly without interruption and believes that he has special powers to end all wars and save humankind. He shakes his head in response to voices, saying that there is a fight between good and evil and that he must "drown out the devil." The patient has had a history of psychiatric illness since his early 20s, when he was discharged from the military due to severe depression and suicidal ideation. At that time, he heard voices blaming him for all the suffering in war. He has been hospitalized for several depressive episodes over the past 10 years. Between hospitalizations, he has had periods lasting for several months during which his mood is stable, but he has continued to hear the voices of God and the devil. The patient lives with his mother and is able to work stocking groceries, but he spends most of his time at home alone. He has been prescribed risperidone, but his mother is unsure if he takes it regularly. Which of the following is the most likely diagnosis?

Question

A 32-year-old man is brought to the emergency department by his mother.  She says that he has stayed up late every night for the past week, praying and shouting that he is "the Messiah."  The patient speaks rapidly without interruption and believes that he has special powers to end all wars and save humankind.  He shakes his head in response to voices, saying that there is a fight between good and evil and that he must "drown out the devil."  The patient has had a history of psychiatric illness since his early 20s, when he was discharged from the military due to severe depression and suicidal ideation.  At that time, he heard voices blaming him for all the suffering in war.  He has been hospitalized for several depressive episodes over the past 10 years.  Between hospitalizations, he has had periods lasting for several months during which his mood is stable, but he has continued to hear the voices of God and the devil.  The patient lives with his mother and is able to work stocking groceries, but he spends most of his time at home alone.  He has been prescribed risperidone, but his mother is unsure if he takes it regularly.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7f5_58b6_bc81_954500dd7cea_MD0003_00 This patient's clinical presentation and history are consistent with a diagnosis of schizoaffective disorder, bipolar type. He currently exhibits symptoms of a manic episode (decreased need for sleep; grandiose delusions; loud, pressured speech). He also meets DSM-5 criterion A for schizophrenia (≥2 of the following: delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative symptoms). His history indicates periods of persistent hallucinations for ≥2 weeks in the absence of a major depressive or manic episode (ie, when his mood is stable). Schizoaffective disorder can be differentiated from schizophrenia and bipolar disorder by assessing the relationship of mood and psychotic symptoms over the course of the illness. If mood symptoms occur in schizophrenia, they are typically present for a small portion of the illness. In contrast, this patient's mood symptoms appear to be present for a significant portion of his illness, making schizophrenia less likely (Choice F). In bipolar I disorder, psychotic symptoms occur exclusively during manic or depressive episodes. The persistence of hallucinations when this patient's mood is stable rules out a bipolar I diagnosis (Choice A). (Choice B) Brief psychotic disorder is characterized by sudden onset of ≥1 psychotic symptom with full remission within a month. It would not explain this patient's longstanding illness with prominent mood episodes. (Choice C) In delusional disorder, other symptoms of psychosis (eg, hallucinations, disorganized speech or behavior) are not present. In addition, delusional disorder would not explain this patient's current manic symptoms and history of depressive episodes. (Choice D) This patient's current mood episode is consistent with a manic episode, thereby ruling out major depression with psychotic features. Educational objective: The diagnosis of schizoaffective disorder requires assessing the longitudinal course of the illness and determining if the patient has had at least 2 weeks of psychotic symptoms in the absence of a mood episode. Schizoaffective disorder is distinguished from schizophrenia by the presence of mood symptoms for a significant portion of the illness. References: Schizoaffective disorder in the DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23707642)

A 32-Year-Old Man Is Brought to the Emergency Department by His