A 28-year-old woman is brought to the hospital by her family due to depressed mood, disorganized behavior, and hearing voices. Over the past 2 months, the patient has developed worsening auditory hallucinations and now fears that her family has been replaced by imposters. She is afraid to leave the house, stays in bed most of the day, and is unable to care for herself. The patient's psychiatric history is significant for 4 previous hospitalizations for depressive and psychotic symptoms over the past 8 years. During the first hospitalization, she was suicidal and heard voices. During her most recent hospitalization a year ago, she was severely depressed and preoccupied with paranoid delusions and auditory hallucinations. Between hospitalizations, the patient has had rare month-long periods during which she is not depressed but continues to hear voices. On mental status examination, she makes poor eye contact. Her mood is depressed, but she has no suicidal ideation. She is convinced that her mother is an imposter trying to harm her. The patient does not use alcohol or illicit drugs. Physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?

Question

A 28-year-old woman is brought to the hospital by her family due to depressed mood, disorganized behavior, and hearing voices.  Over the past 2 months, the patient has developed worsening auditory hallucinations and now fears that her family has been replaced by imposters.  She is afraid to leave the house, stays in bed most of the day, and is unable to care for herself.  The patient's psychiatric history is significant for 4 previous hospitalizations for depressive and psychotic symptoms over the past 8 years.  During the first hospitalization, she was suicidal and heard voices.  During her most recent hospitalization a year ago, she was severely depressed and preoccupied with paranoid delusions and auditory hallucinations.  Between hospitalizations, the patient has had rare month-long periods during which she is not depressed but continues to hear voices.  On mental status examination, she makes poor eye contact.  Her mood is depressed, but she has no suicidal ideation.  She is convinced that her mother is an imposter trying to harm her.  The patient does not use alcohol or illicit drugs.  Physical examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d7f5_cde7_bc81_1fd6f9cd17f3_MD0003_00 The course of this patient's illness is consistent with a diagnosis of schizoaffective disorder, which requires the following: Major mood (depressive or manic) episodes concurrent with symptoms of schizophrenia (≥2 of the following for ≥6 months: delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative symptoms) Delusions or hallucinations for ≥2 weeks in the absence of a major mood episode (depressive or manic) This patient has an 8-year history of psychotic symptoms with concurrent depressive symptoms but also has month-long periods during which psychosis persisted in the absence of mood symptoms (eg, hearing voices even when not depressed). This meets the criteria for schizoaffective disorder, depressive type. Differentiating schizoaffective disorder from bipolar disorder, major depression with psychotic features, and schizophrenia requires determining the temporal relationship of psychotic symptoms to mood symptoms. In bipolar disorder and major depression with psychotic features, psychotic symptoms occur exclusively during manic or depressive episodes (ie, when the patient's mood is stable, there are no psychotic symptoms). In schizophrenia, if mood symptoms occur, they are present for a small portion of the illness. (Choice A) The diagnosis of bipolar I disorder requires ≥1 manic episodes, and psychotic symptoms, if present, occur exclusively during mood episodes. There is no evidence of manic symptoms in this patient. (Choice B) In delusional disorder, other symptoms of psychosis (eg, hallucinations, disorganized speech, disorganized behavior) are not present. In addition, delusional disorder would not explain this patient's current and previous history of depression. (Choice C) The persistence of hallucinations for ≥2 weeks in the absence of a major depressive episode rules out major depressive disorder with psychotic features. (Choices E and F) Schizophrenia and schizophreniform disorder are characterized by psychotic symptoms. If mood symptoms occur, they are present for only a small portion of the illness. Duration of psychotic illness differentiates schizophreniform disorder (>1 month and <6 months) from schizophrenia (≥6 months). Educational objective: Schizoaffective disorder is diagnosed when major depressive or manic episodes co-occur with psychotic symptoms in a patient with a history of persistent psychosis for ≥2 weeks in the absence of mood symptoms. References: Schizoaffective disorder in the DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23707642) Characteristics and heterogeneity of schizoaffective disorder compared with unipolar depression and schizophrenia - a systematic literature review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26599364)

A 28-Year-Old Woman Is Brought to the Hospital by Her