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Difficulty: MediumPersonality Disorders

A 29-year-old man comes to the primary care clinic for a routine physical examination required by his employer. He works as a night-shift security guard, a job he specifically chose to minimize interaction with others. He is wearing a heavy winter coat despite the hot summer weather, and he has multiple protective amulets around his neck. He speaks in a vague, metaphorical manner, explaining that he can 'feel the auras' of people around him and often senses an invisible 'presence' when alone. However, he denies hearing voices and does not hold any fixed, false beliefs when his thoughts are gently challenged by the physician. He reports having no friends other than his parents. He experiences severe anxiety in social situations, which he attributes to others harboring 'dark energy,' and notes this anxiety does not improve even when he spends more time with people. He states he has been this way since adolescence. Which of the following statements regarding this patient's clinical presentation are correct? (Select 2)

  1. The patient's presentation is characteristic of a Cluster A personality disorder.Answer
  2. The social anxiety experienced by this patient typically does not diminish with familiarity.Answer
  3. C
    A diagnosis of schizophreniform disorder is indicated because the symptoms have been present without severe functional decline.
  4. D
    The primary mechanism for his social isolation is a profound fear of rejection and feelings of inadequacy.
  5. E
    Initiation of antidepressant monotherapy is standard protocol to completely resolve his perceptual distortions.

Answer

The correct statements identify the condition as a Cluster A personality disorder and note that the associated social anxiety does not diminish with familiarity.
The patient exhibits classic features of schizotypal personality disorder, which belongs to the Cluster A (odd/eccentric) group. Key features include magical thinking, ideas of reference, unusual perceptual experiences, and odd speech. Furthermore, a distinguishing feature of schizotypal personality disorder is that social anxiety tends to remain high even with familiar people, as it is driven by paranoid fears rather than concerns about being judged negatively.

Step-by-Step Solution

1
Analyze the patient's symptoms and timeline.
The patient exhibits eccentric behavior, magical thinking, odd speech, and social anxiety based on paranoid fears, present since adolescence.
To identify the core psychiatric syndrome and chronicity.
2
Evaluate for the presence of frank psychosis.
The patient lacks true hallucinations and fixed delusions.
To rule out primary psychotic disorders like schizophrenia or schizophreniform disorder.
3
Differentiate from other personality disorders.
The anxiety stems from paranoia rather than fear of negative evaluation.
To confirm schizotypal personality disorder and rule out avoidant personality disorder.

Key Concept

Diagnosis and clinical features of Schizotypal Personality Disorder
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Topics

Personality Disorders

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