Psychotic disorders

A 24-year-old man is brought to the emergency department by his roommate due to increasingly bizarre behavior over the past 9 months. The roommate reports that the patient has become socially withdrawn, neglects personal hygiene, and spends most of his time alone in his room. Over the past week, he has been heard talking to himself and shouting at “voices” no one else can hear. He believes the FBI is surveilling him through his phone and refuses to eat food not prepared by himself. The patient denies alcohol or illicit drug use. He has no known medical conditions. On mental status examination, he appears disheveled, exhibits flat affect, and is internally preoccupied. He is oriented to person but not to time or place. Urine toxicology is negative.

Which of the following is the most likely diagnosis?

A 25-year-old man is brought to the clinic by his mother for a mental health evaluation. Over the past few months, he has become increasingly withdrawn and less communicative. He spends long hours in his room, often staring at the wall and speaking to himself in an unintelligible manner. He refuses to leave the house, claiming that people outside are trying to harm him. His mother also notes that he has stopped attending his college classes and has neglected his personal hygiene. On examination, the patient is mute and does not respond to questions or prompts. He has a flat affect and exhibits posturing, holding his hands in unusual positions. There is no evidence of substance use.

Which of the following is the most likely diagnosis?

A 47-year-old woman is brought to the clinic by her sister due to concerns about her mental health. Over the past year, the patient has become increasingly isolated and insists that a former coworker is in love with her, despite the coworker having moved to another state and not being in contact with her for over a year. The patient says she receives “hidden messages” through television shows and songs that confirm the coworker’s affection. She has no hallucinations, thought disorganization, or significant functional impairment aside from her preoccupation with the coworker. Her mood is stable, and she denies any substance use. Her medical history is unremarkable. He is oriented to person, place, and time.

Which of the following is the most likely diagnosis?

A 25-year-old man is brought to the emergency department by his roommate due to sudden onset of bizarre behavior over the past 3 days. The roommate reports that the patient has been talking to himself, laughing at nothing, and claiming that the government implanted a tracking chip in his brain. He has been pacing around the apartment, not sleeping, and stopped going to work. One week ago, the patient’s mother died suddenly of a heart attack, and since then he has been emotionally withdrawn. He has no prior psychiatric history, does not use drugs or alcohol, and has no medical conditions. On mental status exam, he is disheveled, agitated, and responding to internal stimuli. Orientation and memory are intact. Urine drug screen is negative.

Which of the following is the most likely diagnosis?

A 24-year-old man comes to the emergency department with sudden-onset neck stiffness and difficulty speaking that started 2 hours ago. He was recently started on haloperidol for acute psychosis during an inpatient psychiatric hospitalization. He appears anxious and is having trouble keeping his head straight, with intermittent sustained upward deviation of the eyes. His temperature is 98.6°F (37°C), pulse is 88/min, blood pressure is 132/76 mmHg, and respiratory rate is 16/min. Neurologic exam reveals no focal deficits, but intermittent muscle spasms of the neck and jaw are noted.

A 29-year-old man with a 5-year history of schizophrenia comes to the outpatient psychiatry clinic for medication adjustment. He was recently started on quetiapine 300 mg daily but discontinued it after 10 days due to excessive daytime sleepiness, difficulty waking up, and poor functioning at work. He reports good adherence otherwise and no other significant side effects. He has previously tried olanzapine, which caused significant weight gain, and risperidone, which caused sexual dysfunction. He has no history of extrapyramidal symptoms, seizures, or substance use. He is currently not on any medication

A 29-year-old man with a 5-year history of schizophrenia comes to the outpatient psychiatry clinic for medication adjustment. He was recently started on quetiapine 300 mg daily but discontinued it after 10 days due to excessive daytime sleepiness, difficulty waking up, and poor functioning at work. He reports good adherence otherwise and no other significant side effects. He has previously tried olanzapine, which caused significant weight gain, and risperidone, which caused sexual dysfunction. He has no history of extrapyramidal symptoms, seizures, or substance use. He is currently not on any medication and is experiencing auditory hallucinations and paranoid delusions. Vitals and labs are normal.

A 27-year-old man with a 6-year history of schizophrenia is evaluated for persistent auditory hallucinations and persecutory delusions. Over the past 3 years, he has had multiple hospitalizations for acute psychotic episodes. He has been trialed on risperidone, olanzapine, and aripiprazole at maximally tolerated doses for adequate durations, with minimal improvement. He is currently on haloperidol, which reduced agitation but did not significantly improve his psychosis. He has been fully adherent with medications. He has no history of seizures, neutropenia, or nonadherence. Basic labs, including a CBC, are normal. The patient expresses frustration, stating, “The voices are always there, no matter what pill I take.”

A 30-year-old man with a 10-year history of schizophrenia is brought to the clinic by his sister due to worsening hallucinations and agitation over the past 3 weeks. He believes the television is sending him messages and has been increasingly suspicious of family members. His sister reports that he has been off his medications for 2 months due to concerns about weight gain. He was previously maintained on risperidone with partial control of symptoms. Past trials of olanzapine and aripiprazole were stopped due to excessive sedation and akathisia, respectively. He has no history of agranulocytosis, seizures, or poor medication adherence. Vitals and labs are within normal limits.

A 58-year-old man is brought to the clinic by his sister due to worsening confusion and memory problems over the past several months. He was hospitalized 6 months ago for alcohol withdrawal and has since had persistent issues with memory. His sister reports that he “makes up stories to fill in gaps” in his memory and gets confused about dates and events. He has difficulty forming new memories and cannot recall what he ate for breakfast today. On exam, he is alert but disoriented to time. He appears indifferent to his condition. Neurologic examination is notable for an ataxic gait and horizontal nystagmus.

A 62-year-old man is brought to the neurology clinic by his niece for evaluation of cognitive decline. Over the past year, he has become increasingly forgetful and has difficulty remembering recent conversations. His niece reports that he often fills in gaps in his memory with events that never happened, claiming with confidence that he attended a wedding last weekend when no such event occurred. He denies any functional impairment and appears unconcerned. He has a 30-year history of alcohol use disorder and was treated for alcohol-related seizures 8 months ago. He lives alone and has no known psychiatric history. Vital signs are within normal limits. On examination, he is alert and oriented to person and place but not time. He repeats stories multiple times during the interview. Neurologic exam reveals a wide-based gait and mild bilateral horizontal nystagmus. MRI of the brain shows atrophy of the mammillary bodies.

An 81-year-old woman with advanced Alzheimer dementia is brought to the emergency department by nursing home staff due to confusion, high fever, and muscle stiffness that started this morning. She was recently started on haloperidol 3 days ago for increasing agitation. On arrival, her temperature is 104.2°F (40.1°C), blood pressure is 165/98 mm Hg, heart rate is 118/min, respiratory rate is 22/min, and oxygen saturation is 96% on room air. She appears confused and diaphoretic. Physical exam reveals generalized lead-pipe muscle rigidity, minimal responsiveness to verbal stimuli, and no clonus. Her reflexes are normal. There is no evidence of trauma, rash, or focal neurologic deficits.

Laboratory results are as follows:

An 82-year-old man is brought to the emergency department by his daughter due to progressive confusion and decreased oral intake for the past day. He has a history of Parkinson disease, Alzheimer dementia, hypertension, and insomnia. His medications are carbidopa-levodopa, donepezil, hydrochlorothiazide, haloperidol (started 5 days ago for increased agitation) and melatonin. On exam, the patient is drowsy and minimally responsive. Temperature is 101.8°F (38.8°C), blood pressure is 168/92 mm Hg, pulse is 110/min, and respirations are 20/min. He has dry mucous membranes. Neurologic exam shows generalized rigidity. Reflexes are normal. Labs reveal:

• WBC count: 14,800/mm³
  
• Creatinine: 2.0 mg/dL (baseline 1.0)
  
• Creatine kinase (CK): 9,500 U/L

UA: dark urine positive for blood but no RBCs on microscopy

Learning Objective:

Neuroleptic malignant syndrome is a life-threatening reaction to dopamine antagonists such as haloperidol. It presents with fever, “lead-pipe” rigidity, altered mental status, autonomic instability, and elevated CK due to rhabdomyolysis. It is critical to recognize and discontinue the offending agent promptly to avoid severe complications.

A 71-year-old man comes to the clinic with his daughter, who is concerned about recent changes in his behavior. He was diagnosed with Parkinson disease 4 years ago and has been managed with carbidopa-levodopa. Two months ago, pramipexole was added to his regimen due to worsening motor symptoms. Since then, he has become increasingly withdrawn and has started reporting that “people are watching him through the windows.” He sometimes speaks to people who are not present. His daughter denies any history of psychiatric illness. On examination, he is alert and oriented to person and place but not to time. He has resting tremor, rigidity, and a masked facial expression. There is no evidence of fever, leukocytosis, or metabolic derangement.

A 33-year-old woman is brought to the clinic by her sister due to unusual behavior for the past 5 days. The patient believes that her coworkers are plotting to poison her and has stopped eating food prepared outside her home. She has also been speaking rapidly, locking doors repeatedly, and accusing family members of being “in on it.” There is no past psychiatric history, and the sister says the patient had been well until she was suspended from her job a week ago after being falsely accused of stealing. She denies substance use, and urine drug screen is negative. On exam, she is alert and oriented but displays paranoid ideation and disorganized thought processes. Symptoms began abruptly and have lasted less than a week.

A 22-year-old man is brought to the emergency department by his roommate due to bizarre behavior over the past 3 weeks. The roommate reports that the patient has become increasingly withdrawn, talks to himself, and believes that neighbors are spying on him through his electrical outlets. He has been neglecting his hygiene and has not attended his college classes in over 2 weeks. He was previously a good student but has recently failed to complete assignments and forgets details of conversations they had hours earlier. He has no prior psychiatric history and does not use alcohol or illicit substances. Vital signs are within normal limits. On mental status examination, the patient is inattentive, has poor eye contact, and exhibits paranoid delusions. He endorses auditory hallucinations. Orientation is intact, but immediate and recent memory recall are impaired. There is no evidence of cognitive decline prior to the onset of symptoms.