A 24-year-old man is brought to the emergency department by police after breaking into the house of a famous singer. The singer was not home at the time, and the patient was found taking a bubble bath when police arrived. During the psychiatric evaluation, he speaks rapidly and says loudly, "I didn't realize that it was a crime to take a bath! I'm famous, you know!" The patient has not slept for days and says he has heard the singer's voice telling him that he will be "a star." He has no medical symptoms or illnesses. He has a 5-pack-year smoking history but does not use alcohol or illicit drugs. The patient takes no prescription medications. Physical examination shows no abnormalities. Laboratory results and vital signs are within normal limits, and toxicology screen is negative. The patient's mother arrives and reports that her son was fine until 4 years ago when he went into a deep depression after breaking up with his college girlfriend. During that time, he became convinced that the campus police was following him and he heard voices telling him that he was a loser. His mother says he has not been the same since. The patient was unable to return to college and has since been hospitalized at least 5 times for mood and psychotic symptoms. His mother says, "Even when he is out of the hospital and his mood is completely stable, he continues to hear multiple voices." Which of the following is the most likely diagnosis?

Question

A 24-year-old man is brought to the emergency department by police after breaking into the house of a famous singer.  The singer was not home at the time, and the patient was found taking a bubble bath when police arrived.  During the psychiatric evaluation, he speaks rapidly and says loudly, "I didn't realize that it was a crime to take a bath!  I'm famous, you know!"  The patient has not slept for days and says he has heard the singer's voice telling him that he will be "a star."  He has no medical symptoms or illnesses.  He has a 5-pack-year smoking history but does not use alcohol or illicit drugs.  The patient takes no prescription medications.  Physical examination shows no abnormalities.  Laboratory results and vital signs are within normal limits, and toxicology screen is negative.  The patient's mother arrives and reports that her son was fine until 4 years ago when he went into a deep depression after breaking up with his college girlfriend.  During that time, he became convinced that the campus police was following him and he heard voices telling him that he was a loser.  His mother says he has not been the same since.  The patient was unable to return to college and has since been hospitalized at least 5 times for mood and psychotic symptoms.  His mother says, "Even when he is out of the hospital and his mood is completely stable, he continues to hear multiple voices."  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1af_d873_8f63_9190d76534dc_MD0005_00 This patient's presentation and history are consistent with a diagnosis of schizoaffective disorder, bipolar type. He is currently exhibiting symptoms that meet both the criteria for a manic episode and criterion A for schizophrenia (≥2 of the following: Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms). The patient's manic symptoms include grandiosity, pressured speech, and decreased need for sleep. His psychotic symptoms include delusions and auditory hallucinations. The patient's history that his mother gives of persistent auditory hallucinations even when his mood is stable indicates that he had psychotic symptoms lasting ≥2 weeks in the absence of a major depressive or manic episode, thereby meeting the criteria for schizoaffective disorder. Because patients with schizoaffective disorder typically present in the midst of a mood episode, accurate diagnosis requires assessing the relationship of mood and psychotic symptoms over the course of the illness. In major depression with psychotic features and bipolar disorder, the psychotic symptoms occur exclusively during mood episodes. This patient's history of chronic psychotic symptoms (auditory hallucinations) when he is neither manic nor depressed rules out bipolar I disorder with psychotic features (Choice A). (Choice B) In delusional disorder, erotomanic type, delusions revolve around another person being in love with the patient; however, other symptoms of psychosis (eg, hallucinations, disorganized speech or behavior) are not present, and the patient is still able to function apart from the delusion. In addition, delusional disorder would not explain this patient's prominent manic symptoms. (Choice C) This patient is currently experiencing symptoms of mania, not depression. He likely experienced a major depressive episode in the past, but his history of psychotic symptoms persisting beyond the period of depression is consistent with schizoaffective disorder. (Choice E) If mood symptoms are present in schizophrenia, they are brief in relation to the total duration of illness and less severe. In contrast, this patient's mother reports multiple hospitalizations for severe mood symptoms over the years, making schizoaffective disorder the more accurate diagnosis. Educational objective: Schizoaffective disorder is differentiated from mood disorders with psychotic features by determining if the patient has had ≥2 weeks of psychotic symptoms in the absence of a major depressive or manic episode. Schizoaffective disorder is distinguished from schizophrenia by the presence of mood symptoms lasting a significant portion of the illness. 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 24-Year-Old Man Is Brought to the Emergency Department by Police