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Difficulty: HardSchizophrenia and Psychotic Disorders

Match each patient's clinical presentation to the most accurate psychiatric diagnosis.

  • A 25-year-old man with a 6-month history of auditory hallucinations and persecutory delusions. During this 24-week period, he experienced a single 3-week episode of severe depressed mood and anhedonia. His mood has been euthymic for the past month, but the hallucinations persist.Schizophrenia
  • A 32-year-old woman with a 2-year history of pervasive auditory hallucinations. Over the past two years, she has had four discrete episodes of major depression, each lasting 3-4 months. Her hallucinations continue even when her mood is completely normal.Schizoaffective disorder
  • A 40-year-old man who has exhibited severe psychomotor retardation, profound guilt, and insomnia for the past 6 weeks. For the last 2 weeks, he has also heard voices telling him he is 'damned.' He had no psychiatric symptoms prior to 6 weeks ago.Major depressive disorder with psychotic features
  • A 22-year-old woman presenting with 5 days of decreased need for sleep, pressured speech, and grandiose delusions of being royalty. After treatment with a mood stabilizer, her mood normalizes within 2 weeks, and her delusions completely resolve simultaneously.Bipolar I disorder with psychotic features
  • A 45-year-old man who is absolutely convinced that his coworkers are monitoring his emails to steal his ideas, a belief he has held for 4 months. He has no hallucinations, negative symptoms, or disorganized speech. He continues to perform well at his job.Delusional disorder

Answer

The correct pairings rely on calculating the temporal relationship and proportional duration of mood symptoms relative to psychotic symptoms.
The correct pairings depend on the precise DSM-5 timeline criteria for psychotic disorders. Major depressive disorder and Bipolar I with psychotic features require psychosis to occur strictly during the mood episode. Schizoaffective disorder requires >2 weeks of isolated psychosis, but mood symptoms must be present for the majority of the total illness. Schizophrenia may have brief mood episodes, but they constitute a minority of the illness duration. Delusional disorder involves isolated delusions without other psychotic features.

Step-by-Step Solution

1
Determine if psychosis occurs exclusively during mood episodes.
If yes, the diagnosis is a primary mood disorder with psychotic features (e.g., MDD or Bipolar I).
Primary mood disorders can manifest psychotic features, but these only occur concurrently with the severe mood disturbance.
2
If psychosis occurs outside of mood episodes, determine the duration of the isolated psychosis.
Psychosis persisting for 2 or more weeks in the absence of mood symptoms indicates a primary psychotic disorder (Schizophrenia or Schizoaffective).
This 2-week criterion is the hallmark requirement for diagnosing schizoaffective disorder and ruling out mood disorders with psychosis.
3
Calculate the proportional duration of mood episodes over the total course of the illness.
If mood symptoms are present for the majority (>50%) of the total illness duration, the diagnosis is schizoaffective disorder. If present for a minority, it is schizophrenia.
The DSM-5 differentiates schizoaffective disorder from schizophrenia strictly based on whether mood symptoms dominate the longitudinal course of the disease.

Key Concept

Differentiating primary psychotic disorders from mood disorders with psychotic features based on the temporal relationship of symptoms.
Estimated Time:2m 0s
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Topics

Schizophrenia and Psychotic Disorders

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