An 18-year-old man is brought to the physician by his mother after he has become increasingly withdrawn over the past year. The patient's mother says that he no longer likes to leave the house or hang out with friends, despite being a very social teenager prior to this year. She describes episodes where she hears him talking loudly and angrily in his room, but when she goes to check on him, he is not on the phone and there is no one else in the room with him. She also describes episodes where the patient refuses to leave his bed, saying he feels depressed and worthless. During these episodes, he refuses to eat, go to school, or take part in any activity, saying he is too tired and cannot focus. The patient's mother becomes tearful while explaining this to the doctor, but the patient appears unemotional and disinterested. The physician requests to speak to the patient alone.
Upon further questioning, the patient admits that he has been hearing voices for the past 9 months that tell him he is disgusting and useless. He feels that the government is trying to get into his head to manipulate him, but he doesn't want to tell his mother because he is afraid that they have already gotten to her. A few times in the last year, he admits to being so depressed that he is not able to leave his bed. However, he says that he has not felt depressed in the last several months. During the interview, the patient suddenly stops speaking to the doctor and looks around wildly, saying "Stop talking to me!" When the physician asks who he is speaking to, the patient says that the voice of an older male has been bothering him for several months.
Which of the following is the most likely diagnosis?
The correct answer is:
C) Schizoaffective disorder
Patients with schizoaffective disorder meet the criteria for schizophrenia in addition to a major mood disorder, either major depressive disorder or bipolar disorder, and have > 2 weeks of hallucinations or delusions without any major mood episode.
This patient meets criteria for schizophrenia because he hears auditory hallucinations, has a delusion about the government manipulating him, and has negative symptoms of anhedonia and flattened affect. He has been having these symptoms for 9 months, and a diagnosis of schizophrenia requires symptoms for > 6 months.
He also meets criteria for episodes of major depressive disorder, with depressed mood, changes in sleep, anhedonia, feelings of worthlessness, fatigue, concentration problems, and lack of appetite.
He says he has not felt depressed for several months, but he has continued to hear voices for several months. Thus, he has had > 2 weeks of hallucinations without a mood episode, and he meets all criteria for schizoaffective disorder.
In depression with psychotic features, patients meet criteria for major depressive disorder but only have psychotic features DURING a depressive episode. This patient hears voices even when he is not feeling depressed.
This patient does meet criteria for major depressive disorder. However, his additional psychotic symptoms warrant a more comprehensive diagnosis.
This patient does meet criteria for schizophrenia. However, his additional mood symptoms warrant a more comprehensive diagnosis.
Patients with schizophreniform disorder meet criteria for schizophrenia but only have symptoms for a period of 1-6 months. This patient has experienced symptoms for at least 9 months, and thus schizophreniform disorder is not an accurate diagnosis.
Key Learning Point
Patients with schizoaffective disorder meet criteria for schizophrenia and a major mood disorder and have had at least 2 weeks of psychotic symptoms without a major mood episode.
