A 23-year-old man is brought to the office by his parents due to concerns that he has become increasingly depressed and withdrawn over the past year. The patient dropped out of college in his senior year because of failing grades. Since returning to live with his parents, he broke up with his girlfriend and stopped going out with his friends. His father says, "It's frustrating because he refuses to go back to school and just seems to be wasting time. He sits in his room all day." His mother reports that for the past few months, he has been watching the same videos over and over, telling her multiple times that he is "checking for signals and listening for messages from secret channels." The patient says, "I'm fine. I don't know why everyone's upset." His appetite, sleep, and energy level are normal. He does not use alcohol or illicit drugs. Physical examination and laboratory evaluation are unremarkable. On mental status examination, the patient is cooperative and appears anxious. He avoids eye contact and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The patient has no suicidal ideation or hallucinations. Which of the following is the most likely diagnosis?

Question

A 23-year-old man is brought to the office by his parents due to concerns that he has become increasingly depressed and withdrawn over the past year.  The patient dropped out of college in his senior year because of failing grades.  Since returning to live with his parents, he broke up with his girlfriend and stopped going out with his friends.  His father says, "It's frustrating because he refuses to go back to school and just seems to be wasting time.  He sits in his room all day."  His mother reports that for the past few months, he has been watching the same videos over and over, telling her multiple times that he is "checking for signals and listening for messages from secret channels."  The patient says, "I'm fine.  I don't know why everyone's upset."  His appetite, sleep, and energy level are normal.  He does not use alcohol or illicit drugs.  Physical examination and laboratory evaluation are unremarkable.  On mental status examination, the patient is cooperative and appears anxious.  He avoids eye contact and shows little emotion.  His answers are very brief, and he asks if the interview is being secretly recorded.  The patient has no suicidal ideation or hallucinations.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7fc_f9dc_bc81_3937f9c80945_MD0003_00 This patient's delusions (receiving special messages from videos, being secretly recorded), negative symptoms, significant functional decline, and continuous impairment lasting ≥6 months are consistent with schizophrenia. Although common, hallucinations are not required for diagnosis. This patient's negative symptoms include apathy, avolition, affective flattening (lack of facial expression), alogia (very brief answers), and asociality (social withdrawal and diminished interest in relationships). His course of illness is characterized by a prodromal phase (ie, deterioration in academic functioning and progressive social withdrawal prior to the onset of psychosis) and prominent negative symptoms, which can often be mistaken for depression. Families who do not understand that negative symptoms are a core characteristic of schizophrenia may become frustrated with their family members and perceive them as lazy and unmotivated. Family intervention that includes education about the illness can help promote a supportive environment and improve outcomes. (Choice A) Delusional disorder is characterized by ≥1 delusion in the absence of other psychotic symptoms. Functioning is normal apart from the direct impact of the delusion. A diagnosis of delusional disorder would not explain this patient's prominent negative symptoms and significant functional decline. (Choice B) In major depressive disorder with psychotic features, which is a severe subtype of major depressive disorder, the patient develops delusions and/or hallucinations, typically with depressive themes of guilt and worthlessness. This patient's appetite, sleep, and energy level are normal; he does not have enough depressive symptoms to diagnose a major depressive episode. (Choice C) This patient lacks the obsessions (thoughts, images, urges) and/or compulsions (behaviors and mental acts aimed at relieving distress) necessary to diagnose obsessive compulsive disorder. (Choices D, E, and G) Personality disorders do not include psychotic symptoms and cannot be diagnosed when the pattern of behavior is better explained by another mental disorder (eg, schizophrenia). Patients with paranoid personality disorder are generally suspicious and distrustful and patients with schizoid personality disorder are emotionally detached; neither diagnosis would account for this patient's delusions. Individuals with schizotypal personality disorder typically exhibit magical beliefs, eccentric behavior, and odd perceptual experiences that are subthreshold for a diagnosis of schizophrenia. Educational objective: The diagnosis of schizophrenia requires ≥2 of the following: delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms; at least 1 of the first 3 findings is required. Negative symptoms are a core domain of schizophrenia and include apathy, avolition, lack of facial expression, alogia, social withdrawal, and diminished interest in relationships. These symptoms may be mistaken for aspects of personality or depressive disorders. References: The current conceptualization of negative symptoms in schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/28127915) Is the prevalence of the deficit syndrome in schizophrenia higher than estimated? Results of a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/29422932)

A 23-Year-Old Man Is Brought to the Office by His