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Author Gonzalo Romero, M.D. (Reviewed by Will Gibson and Yazan Daaboul)
Exam Type USMLE Step 1
Main Category Behavioral Science/Psychiatry
Sub Category General Principles
Prompt A 26-year-old man is brought by his girlfriend to his primary care physician because she is concerned he has been acting odd lately. She reports that he has been very socially withdrawn for the last 3 weeks. She also describes several instances where he keeps whispering: "Aliens are chasing me and want to get me; I hear them talking about me." His employer called him several times in the past week complaining about his job performance and frequent absences. His girlfriend denies he has had any trauma, exposure to alcohol or illicit substances, or mood disturbances. His family history is remarkable for an uncle with schizophrenia. His blood pressure is 126/74 mmHg, heart rate is 74/min, and temperature is 36.9 °C (98.4 °F). He has a flat affect, appears unkempt, and laughs inappropriately. What is the most likely diagnosis?
Answer A Paranoid personality disorder
Answer A Explanation [[AnswerAExp::Personality disorders are pervasive as they involve multiple areas of life, are inflexible, and are lifelong. The paranoid personality disorder is a part of cluster A (eccentric) that is characterized by a chronic mistrust of others. These patients do not have hallucinations or positive symptoms.]]
Answer B Schizophreniform disorder
Answer B Explanation Schizophreniform disorder is the diagnosis ascribed to individuals whose behavior is consistent with schizophrenia, with the absence of manic or depressive mood, and whose symptoms last more than 1 month but less than 6 months.
Answer C Brief psychotic disorder
Answer C Explanation [[AnswerCExp::Brief psychotic disorder is the diagnosis ascribed to individuals whose behavior is consistent with schizophrenia, also with the absence of manic or depressive mood, and whose symptoms last more than 1 day and less than 1 month.]]
Answer D Schizophrenia
Answer D Explanation This patient has many symptoms consistent with schizophrenia, such as delusions and auditory hallucinations. For the diagnosis of schizophrenia to be made, however, symptoms must last longer than 6 months.
Answer E Schizoaffective disorder
Answer E Explanation The patient's symptoms do not include any major mood disorders, such as manic or depressive episodes. For the diagnosis of schizoaffective disorder to be made, the DSM 5 criteria require that the patient have a prominent mood disorder that occur during the majority of the total active and residual course of the disease. This is in contrast to older DSM reports on episodic occurrences of mood disorders in patients with symptoms of schizophrenia.
Right Answer C
Explanation [[Explanation::This vignette describes a young man presenting with recent onset of delusions, auditory hallucinations, blunted affect, and behavioral disturbances that are consistent with the diagnosis of schizophrenia spectrum disorder.

The positive symptoms of schizophrenia are bizarre delusions and auditory hallucinations. The negative symptoms include blunted affect, social withdrawal, and changes in behavior. While most cases of schizophrenia are sporadic, there is an increased risk of developing schizophrenia among patients with positive family history. Along with a thorough history and physical examination to rule out other causes of hallucinations and delusions, the time-frame of symptoms is important in establishing the correct diagnosis in schizophrenia spectrum disorders. While all disorders have similar symptoms and signs, brief psychotic disorder lasts up to 1 month, schizophreniform disorder lasts more than 1 month but less than 6 months, and schizophrenia lasts more than 6 months. Because the onset of the patient's symptoms is 3 weeks prior to his presentation, the diagnoses of schizophreniform disorder and schizophrenia cannot be made. Instead, the patient is diagnosed with brief psychotic disorder. Such patients require frequent monitoring for either resolution of symptoms or progression into schizophreniform disorder and schizophrenia.
Educational Objective: Schizophrenia spectrum disroders should always be considered in young patients who have no identifiable causes of hallucinations and delirium. While all disorders in the spectrum share similar symptoms, the time frame is key in making the correct diagnosis. Brief psychotic disorder is characterized by positive and negative symptoms of schizophrenia that last between 1 day and less than 1 month.
References: First Aid 2014 page 505]]

Approved No
Keyword Psychiatry, Schizophrenia, Psychosis, Hallucination, Hallucinations, delusion, schizophreniform, brief, psychotic, disorder
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