Question

A 45-year-old man presents to a psychiatrist at his wife’s prompting. He is an English profes- sor at the University of Virginia and regularly wins accolades for his well-organized and ar- ticulate lectures. In the past three months, he has become convinced that his wife is having an affair with a co-worker, despite her protests to the contrary. His wife recently discovered that he hired a private investigator to track her whereabouts. He is very defensive when the counselor questions his suspicions about his wife. Mental status examination reveals a well- dressed, middle-aged man without hallucina- tions or other mood disturbances. His speech is normal and displays an appropriate affec- tive range. Which of the following is the most likely diagnosis?

(A) Antisocial personality disorder

 (B) Avoidant personality disorder 

(C) Delusional disorder
(D) Schizoid personality disorder 

(E) Schizophrenia

(F) Schizophreniform disorder

Answer 1

The correct answer is C. Delusional disor- der is diagnosed following one month of non- bizarre delusions that are usually focused around a particular topic, in this case, the fi- delity of the patient’s wife. The delusions are not attributable to another psychiatric disorder such as schizophrenia. Delusional disorder does not markedly impair the person’s func- tioning in daily activities. The ramifications are limited to the delusional content.

Answer A is incorrect. Cluster B personality disorders include antisocial, borderline, histri- onic, and narcissistic types. Patients with anti- social personality disorder show a disregard for and often violate the rights of others. These in- dividuals often have a criminal history. This is the only personality disorder with an age limit (18 years). Minors with similar behavior are classified as having conduct disorder.

Answer B is incorrect. Cluster C personal- ity disorders are characterized by anxiety and include avoidant, obsessive-compulsive, and dependent personality types. Individuals with avoidant personality disorder are sensitive to rejection, are socially inhibited, and have over- whelming feelings of inadequacy.

Answer D is incorrect. Patients with schiz- oid personality disorder exhibit voluntary so- cial withdrawal (unlike avoidant patients) and have limited emotional expressions. They lack strange beliefs and thoughts of the schizotypal personality disorder.

Answer E is incorrect. Schizophrenia is a chronic psychiatric condition. It affects 1% of the population and usually begins before age 25. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, specifies the active phase of the disease and requires that at least two of the following symptoms be present during a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and nega- tive symptoms (eg, flat affect, lack of motiva- tion, or poverty of speech). Moreover, signs of the disturbance must be present for at least six months, such as one of the above symptoms in an attenuated form (eg, magical thinking, so- cial withdrawal, or other negative symptoms).

Answer F is incorrect. Schizophreniform dis- order is similar to schizophrenia except that its symptoms have lasted between one and six months. In contrast, patients with schizophre- nia must have had symptoms for longer than six months.