Differentiation from schizophrenia US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Differentiation from schizophrenia. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Differentiation from schizophrenia US Medical PG Question 1: A 29-year-old woman is brought to the physician by her father because of a change in her behavior over the past 8 months. The father says that his daughter has become increasingly withdrawn; she has not answered any phone calls or visited her family and friends. The patient says that she has to stay at home because a foreign intelligence service is monitoring her. She thinks that they are using a magnetic field to read her mind. Mental status exam shows disjointed and perseverative thinking. She is anxious and has a flat affect. Which of the following is the most likely diagnosis?
- A. Delusional disorder
- B. Schizophrenia (Correct Answer)
- C. Paranoid personality disorder
- D. Schizophreniform disorder
- E. Schizoid personality disorder
Differentiation from schizophrenia Explanation: ***Schizophrenia***
- The patient's presentation with **delusions of persecution and thought broadcasting**, accompanied by **disjointed, perseverative thinking**, and **flat affect** for 8 months, is highly indicative of schizophrenia.
- Schizophrenia is characterized by a combination of positive symptoms (delusions, hallucinations, disorganized speech), negative symptoms (flat affect, social withdrawal), and cognitive symptoms (disorganized thinking) lasting for at least 6 months.
*Delusional disorder*
- Delusional disorder is characterized by the presence of **non-bizarre delusions for at least 1 month** without other significant psychotic symptoms or marked impairment in functioning.
- The patient's symptoms include **disorganized thinking and flat affect**, which are not typical of delusional disorder and suggest a broader psychotic illness.
*Paranoid personality disorder*
- Characterized by a pervasive distrust and suspicion of others, where their motives are interpreted as malevolent, but **without the presence of frank delusions or other psychotic symptoms**.
- The patient is experiencing **fixed, false beliefs (delusions)** involving mind reading and foreign intelligence, which goes beyond the pervasive distrust seen in paranoid personality disorder.
*Schizophreniform disorder*
- Schizophreniform disorder presents with symptoms identical to schizophrenia, but the **duration is between 1 and 6 months**.
- Since the patient's symptoms have been present for **8 months**, it exceeds the diagnostic criteria for schizophreniform disorder, making schizophrenia a more likely diagnosis.
*Schizoid personality disorder*
- Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of expression of emotions in interpersonal settings.
- While the patient exhibits social withdrawal, this condition does **not involve delusions, disorganized thinking, or other psychotic features**.
Differentiation from schizophrenia US Medical PG Question 2: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
- A. Schizophrenia
- B. Bipolar disorder
- C. Brief psychotic disorder
- D. Schizotypal disorder
- E. Schizoaffective disorder (Correct Answer)
Differentiation from schizophrenia Explanation: ***Schizoaffective disorder***
- This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**.
- **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations).
- **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder.
- The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**.
*Bipolar disorder*
- In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive).
- This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder.
- While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis.
*Schizophrenia*
- Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture.
- This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely.
- The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia.
*Brief psychotic disorder*
- Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning.
- This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode.
*Schizotypal disorder*
- This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**.
- Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.
Differentiation from schizophrenia US Medical PG Question 3: A 23-year-old man is brought to the emergency department by his girlfriend because of acute agitation and bizarre behavior. The girlfriend reports that, over the past 3 months, the patient has become withdrawn and stopped pursuing hobbies that he used to enjoy. One month ago, he lost his job because he stopped going to work. During this time, he has barely left his apartment because he believes that the FBI is spying on him and controlling his mind. He used to smoke marijuana occasionally in high school but quit 5 years ago. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?
- A. Schizophreniform disorder (Correct Answer)
- B. Schizoid personality disorder
- C. Delusional disorder
- D. Schizoaffective disorder
- E. Brief psychotic disorder
Differentiation from schizophrenia Explanation: **Correct: Schizophreniform disorder**
- This patient presents with ***psychotic symptoms*** (delusions, disorganized speech, agitation) and ***negative symptoms*** (withdrawal, anhedonia, loss of job), which have been present for approximately ***3 months***.
- The ***duration of symptoms (1-6 months)*** is the key differentiating factor for schizophreniform disorder compared to brief psychotic disorder (<1 month) or schizophrenia (>6 months).
- Meets DSM-5 criteria: psychotic symptoms with functional impairment lasting between 1 and 6 months.
*Incorrect: Schizoid personality disorder*
- Characterized by a pervasive pattern of ***detachment from social relationships*** and a restricted range of emotional expression, which are ***ego-syntonic*** and typically stable over time.
- This is a personality disorder with chronic traits, not an acute psychotic disorder.
- Does not include acute psychotic symptoms like delusions or disorganized speech.
*Incorrect: Delusional disorder*
- Defined by the presence of ***non-bizarre delusions*** for at least one month, without other significant psychotic symptoms or major functional impairment.
- This patient has ***bizarre delusions*** (FBI controlling his mind), ***disorganized speech***, ***psychomotor agitation***, and ***marked functional impairment***, which exceed the criteria for delusional disorder.
*Incorrect: Schizoaffective disorder*
- Requires the presence of a ***major mood episode*** (depressive or manic) concurrent with symptoms of schizophrenia, AND ***delusions or hallucinations for at least 2 weeks*** in the absence of a major mood episode.
- While the patient exhibits labile affect, there is no evidence of a distinct, prolonged major mood episode (major depression or mania) as required for schizoaffective disorder.
*Incorrect: Brief psychotic disorder*
- Characterized by the sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) that last for ***at least one day but less than one month***, followed by full return to premorbid functioning.
- The patient's symptoms have been ongoing for approximately ***3 months***, which exceeds the duration criteria for brief psychotic disorder.
Differentiation from schizophrenia US Medical PG Question 4: Two dizygotic twins present to the university clinic because they believe they are being poisoned through the school's cafeteria food. They have brought these concerns up in the past, but no other students or cafeteria staff support this belief. Both of them are average students with strong and weak subject areas as demonstrated by their course grade-books. They have no known medical conditions and are not known to abuse illicit substances. Which statement best describes the condition these patients have?
- A. A trial separation is likely to worsen symptoms.
- B. The disorder is its own disease entity in DSM-5.
- C. Antipsychotic medications are rarely beneficial.
- D. Can affect two or more closely related individuals. (Correct Answer)
- E. Cognitive behavioral therapy is a good first-line.
Differentiation from schizophrenia Explanation: ***Can affect two or more closely related individuals.***
- The shared delusional belief in **folie à deux**, also known as **shared psychotic disorder**, typically occurs in two or more people who are closely associated.
- In this case, the **dizygotic twins** sharing the same delusional belief about being poisoned from cafeteria food fits this pattern.
*A trial separation is likely to worsen symptoms.*
- **Separating the individuals** involved in **folie à deux** is often a crucial step in treatment, as it can help break the cycle of shared delusion and allow for individual therapy.
- Separation typically IMPROVES rather than worsens symptoms by removing the reinforcement of the shared delusion.
*The disorder is its own disease entity in DSM-5.*
- In the **DSM-5**, **folie à deux** is no longer considered a separate diagnostic category.
- Instead, it is classified under **Other Specified Schizophrenia Spectrum and Other Psychotic Disorder** or **Unspecified Schizophrenia Spectrum and Other Psychotic Disorder**, with the specific context of shared delusion noted.
*Antipsychotic medications are rarely beneficial.*
- **Antipsychotics** are actually commonly used in treating folie à deux, particularly for the **primary individual** who initially developed the delusion.
- They can be an important component of treatment, often combined with separation and psychotherapy.
*Cognitive behavioral therapy is a good first-line.*
- **Cognitive Behavioral Therapy (CBT)** can be beneficial, particularly after separation, to help individuals challenge and reframe their delusional beliefs.
- However, the **first-line intervention** for shared psychotic disorder is **separation of the involved individuals**, followed by individual therapy (which may include CBT) and medication as needed.
Differentiation from schizophrenia US Medical PG Question 5: A 22-year-old man is brought to the emergency department by his father because he is having bizarre thoughts. The patient says that he is being haunted by aliens from outer space. The father is worried as his son has had these symptoms for the past 7 months and lately, it seems to be getting worse. He has become more self-obsessed and does not seem to have any interest in his favorite activities. He has no plans to harm himself or others but spends a lot of time and energy building ‘defenses’ in and around his room as he is absolutely sure that aliens will come to get him soon. His blood pressure is 121/79 mm Hg, pulse 86/min, respiratory rate 15/min, temperature 36.8°C (98.2°F). Which of the following is correct regarding the patient’s symptoms?
- A. It would benefit from psychosurgery.
- B. He has a fixed false belief. (Correct Answer)
- C. It is best treated with cognitive behavioral therapy alone.
- D. It is a negative symptom.
- E. It falls under the disorganized thinking domain.
Differentiation from schizophrenia Explanation: ***He has a fixed false belief.***
- The patient's conviction that he is being haunted by aliens, despite evidence to the contrary and the distress it causes, constitutes a **delusion**.
- A delusion is by definition a **fixed, false belief** that is not in keeping with the individual's cultural background.
*It would benefit from psychosurgery.*
- Psychosurgery, such as lobotomy, is an extreme and rarely used intervention for **severe, refractory mental disorders**, typically only after all other treatments have failed and with significant ethical considerations.
- While the patient's symptoms are impairing, **first-line treatments** for psychotic disorders involve antipsychotic medications and psychotherapy, not psychosurgery.
*It is best treated with cognitive behavioral therapy alone.*
- While CBT for psychosis (CBTp) can be a useful **adjunct** in managing delusions and reducing distress, it is **not sufficient as monotherapy** for active, severe psychotic symptoms.
- The primary intervention for profound delusions like those described is **antipsychotic medication**, with CBT added as an adjunctive treatment to help improve functioning and coping.
- CBT alone would be inadequate for someone with such fixed, impairing delusions actively building defenses against perceived threats.
*It is a negative symptom.*
- Negative symptoms of psychosis include features like **anhedonia** (lack of pleasure), **alogia** (poverty of speech), **avolition** (lack of motivation), and affective flattening.
- The patient's bizarre belief in aliens is a **positive symptom** as it represents an *addition* to normal experience, rather than a *reduction* or *absence* of normal functions.
- Note: The patient's decreased interest in activities suggests negative symptoms are also present, but the question asks about "the patient's symptoms" in context of the delusion described.
*It falls under the disorganized thinking domain.*
- Disorganized thinking or speech involves patterns like **loose associations, tangentiality, incoherence**, or word salad, where the logical connections between thoughts are lost.
- While the content of the patient's thoughts is bizarre, the core issue described is the *belief itself* (a delusion, which is a **positive symptom**), rather than disordered *thought processes* or the way he expresses them.
Differentiation from schizophrenia US Medical PG Question 6: A 24-year-old man is brought to the doctor's office by his mother because the patient believes aliens have begun to read his mind and will soon have him performing missions for them. The patient's mother says that the delusions have been intermittently present for periods of at least 1-month over the past year. When he is not having delusions, she says he still lacks expression and has no interest in socializing with his friends or going out. He has no past medical history and takes no prescription medications. The patient has smoked 1 pack of cigarettes daily for the past 10 years. Since the disturbance, he has not been able to maintain employment and lives at home with his mother. His vitals include: blood pressure 124/82 mm Hg, pulse 68/min, respiratory rate 14/min, temperature 37.3°C (99.1°F). On physical examination, the patient exhibits poor eye contact with a flat affect. His speech is circumferential, and he is currently experiencing bizarre delusions. The results from a urine drug screen are shown below:
Amphetamine negative
Benzodiazepine negative
Cocaine negative
GHB negative
Ketamine negative
LSD negative
Marijuana negative
Opioids negative
PCP negative
Which of the following is the correct diagnosis?
- A. Schizophrenia (Correct Answer)
- B. Schizoaffective disorder
- C. Schizotypal personality disorder
- D. Schizoid personality disorder
- E. Schizophreniform disorder
Differentiation from schizophrenia Explanation: ***Correct: Schizophrenia***
- The patient presents with **bizarre delusions** (positive symptom), **flat affect**, **lack of interest in socializing**, and **social withdrawal** (negative symptoms), characteristic of schizophrenia.
- The symptoms have been present **intermittently over the past year**, with the mother noting that even when delusions are absent, the patient continues to exhibit negative symptoms (flat affect, social withdrawal).
- This indicates **continuous signs of illness for at least 6 months** with **at least 1 month of active psychotic symptoms**, fulfilling **DSM-5 criteria** for schizophrenia.
- The patient demonstrates **significant functional impairment** (unable to maintain employment), which is required for diagnosis.
- **Substance-induced psychosis** is ruled out by negative urine drug screen.
*Incorrect: Schizoaffective disorder*
- Requires the presence of a **major mood episode (depressive or manic)** concurrent with psychotic symptoms for a substantial portion of the illness.
- Psychotic symptoms must also persist for **at least 2 weeks in the absence of a major mood episode**.
- This patient shows **no evidence of major mood symptoms** (no depression or mania described).
*Incorrect: Schizotypal personality disorder*
- Involves **cognitive or perceptual distortions** (odd beliefs, magical thinking) and eccentric behavior, but symptoms are typically **less severe** than frank psychosis.
- Patients usually maintain **better baseline functioning** than those with schizophrenia.
- This patient's **severe delusions, significant functional impairment**, and chronic deterioration are more consistent with schizophrenia than a personality disorder.
*Incorrect: Schizoid personality disorder*
- Characterized by **detachment from social relationships** and restricted emotional expression.
- **Does not include psychotic symptoms** such as delusions or hallucinations.
- This patient's bizarre delusions rule out this purely personality-based diagnosis.
*Incorrect: Schizophreniform disorder*
- Diagnosed when symptoms of schizophrenia are present for **1 to 6 months** (more than 1 month but less than 6 months).
- This patient's symptoms have been present **over the past year**, exceeding the 6-month maximum duration for schizophreniform disorder.
- The chronic nature and duration of symptoms establish the diagnosis of schizophrenia instead.
Differentiation from schizophrenia US Medical PG Question 7: A 21-year-old man presents to an outpatient psychiatrist with chief complaints of fatigue and “hearing voices.” He describes multiple voices which sometimes call his name or say nonsensical things to him before he falls asleep at night. He occasionally awakes to see “strange people” in his room, which frighten him but then disappear. The patient is particularly worried by this because his uncle developed schizophrenia when he was in his 20s. The patient also thinks he had a seizure a few days ago, saying he suddenly fell to the ground without warning, though he remembers the episode and denied any abnormal movements during it. He is in his 3rd year of college and used to be a top student, but has been getting C and D grades over the last year, as he has had trouble concentrating and fallen asleep during exams numerous times. He denies changes in mood and has continued to sleep 8 hours per night and eat 3 meals per day recently. Which of the following medications will be most beneficial for this patient?
- A. Haloperidol
- B. Valproic acid
- C. Risperidone
- D. Modafinil (Correct Answer)
- E. Levetiracetam
Differentiation from schizophrenia Explanation: ***Modafinil***
- This patient presents with **narcolepsy**, characterized by the **classic tetrad**: excessive daytime sleepiness (falling asleep during exams), **cataplexy** (sudden fall without loss of consciousness or abnormal movements), **hypnagogic hallucinations** (hearing voices before sleep), and **hypnopompic hallucinations** (seeing people upon awakening).
- The hallucinations are **not true psychotic symptoms** but rather dream-like phenomena occurring at sleep-wake transitions, which are common in narcolepsy.
- **Modafinil** is a first-line **wakefulness-promoting agent** that treats the excessive daytime sleepiness and improves alertness, addressing the primary pathology.
- The patient's family history of schizophrenia is a red herring; his symptoms are explained by narcolepsy, not a primary psychotic disorder.
*Risperidone*
- Risperidone is an **atypical antipsychotic** used for schizophrenia and other psychotic disorders.
- This patient does **not have a primary psychotic disorder**—the hallucinations are hypnagogic/hypnopompic phenomena associated with narcolepsy, not true psychotic hallucinations.
- Using an antipsychotic would be inappropriate and could **worsen daytime sleepiness** due to sedating effects, exacerbating the patient's core problem.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** with significant risk of **extrapyramidal side effects**.
- Like risperidone, it would be inappropriate here as the patient does not have a psychotic disorder, and it would worsen sedation and daytime sleepiness.
*Valproic acid*
- Valproic acid is a **mood stabilizer and anticonvulsant** used for bipolar disorder and seizure disorders.
- The described "seizure" event is actually **cataplexy** (preserved consciousness, no abnormal movements), not a true seizure, so an anticonvulsant is not indicated.
- It would not address the narcolepsy symptoms and can cause sedation.
*Levetiracetam*
- Levetiracetam is an **anticonvulsant** medication.
- The patient's description (remembering the episode, no abnormal movements) is inconsistent with a seizure and consistent with **cataplexy**, which is treated by addressing the underlying narcolepsy, not with anticonvulsants.
Differentiation from schizophrenia US Medical PG Question 8: A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?
- A. Schizophreniform disorder
- B. Schizophrenia
- C. Delusional disorder
- D. Schizoaffective disorder (Correct Answer)
- E. Brief psychotic disorder
Differentiation from schizophrenia Explanation: ***Schizoaffective disorder***
- This patient exhibits symptoms of both a **major depressive disorder** (multiple periods of profound **sadness**, persistent **insomnia**, **weight loss** over several months, feelings of **worthlessness**, and markedly **diminished interest in activities**) and a **psychotic disorder** (auditory **hallucinations**, command hallucinations, **delusions**, violent behavior).
- The total symptom duration is **9 months**, with **mood symptoms present for the majority of this period**, meeting the key DSM-5 criterion for schizoaffective disorder.
- The patient also demonstrates **psychotic symptoms (hallucinations) that persist throughout**, including periods when mood symptoms may fluctuate, satisfying the requirement for delusions or hallucinations for ≥2 weeks in the absence of a major mood episode.
- The combination of prominent mood episodes concurrent with schizophrenia-spectrum symptoms, with mood symptoms present for the majority of the illness duration, confirms schizoaffective disorder.
*Schizophreniform disorder*
- This disorder involves symptoms characteristic of **schizophrenia** lasting **between 1 and 6 months**.
- The patient's symptoms have been present for **9 months**, exceeding the maximum duration for schizophreniform disorder.
*Schizophrenia*
- Schizophrenia requires persistent psychotic symptoms lasting **at least 6 months**, with at least one month of active-phase symptoms.
- While this patient has psychotic symptoms for 9 months, the **prominent and prolonged depressive symptoms** that are present for the **majority of the illness duration** distinguish this from schizophrenia.
- In schizophrenia, mood symptoms, if present, are **brief relative to the total duration** of the psychotic illness, which is not the case here.
*Delusional disorder*
- Delusional disorder is characterized by **non-bizarre delusions** for at least 1 month, without other prominent psychotic symptoms.
- This patient experiences prominent **auditory hallucinations** ("hearing ghosts," "deceased sister talking to her") and **command hallucinations**, which are not features of delusional disorder.
- The presence of hallucinations rules out this diagnosis.
*Brief psychotic disorder*
- This diagnosis involves sudden onset of psychotic symptoms lasting **more than 1 day but less than 1 month**, with eventual full recovery.
- The patient's symptoms have persisted for **9 months**, far exceeding the duration criterion for brief psychotic disorder.
Differentiation from schizophrenia US Medical PG Question 9: A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
- A. Schizoaffective disorder
- B. Schizophrenia (Correct Answer)
- C. Schizoid personality disorder
- D. Schizophreniform disorder
- E. Schizotypal personality disorder
Differentiation from schizophrenia Explanation: ***Schizophrenia***
- The patient exhibits core symptoms of schizophrenia, including **auditory hallucinations** (hearing thoughts speaking aloud), **disorganized thinking** (difficulty focusing, fluctuating focus), and **negative symptoms** (flat affect, disheveled, foul smell, loss of job due to poor function). These symptoms have been present for **at least 6 months** (8 months of hallucinations, 7 months of job loss), which meets the diagnostic criteria.
- The duration of symptoms (over 6 months) differentiates it from schizophreniform disorder, and the absence of prominent mood episodes rules out schizoaffective disorder.
*Schizoaffective disorder*
- This diagnosis requires a **major mood episode** (depressive or manic) concurrent with Criterion A of schizophrenia, along with a period of **at least 2 weeks of delusions or hallucinations in the absence of prominent mood symptoms**.
- While the patient has some signs of distress (lost job, disorganized), a full major mood episode is not described, and the primary symptoms are clearly psychotic.
*Schizoid personality disorder*
- This is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression, often appearing indifferent to praise or criticism.
- The patient's symptoms are primarily psychotic (hallucinations, disorganized thought), not just social withdrawal or emotional flatness. She doesn't necessarily avoid social contact, but her psychosis interferes with it.
*Schizophreniform disorder*
- This disorder presents with symptoms identical to schizophrenia but with a **duration of at least 1 month but less than 6 months**.
- The patient's symptoms, particularly the auditory hallucinations, have been present for 8 months and are therefore outside the timeframe for schizophreniform disorder.
*Schizotypal personality disorder*
- This disorder involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as **cognitive or perceptual distortions** and eccentric behaviors.
- While there may be some odd beliefs or magical thinking, **full-blown psychotic symptoms like prominent auditory hallucinations** (hearing thoughts speaking aloud) are generally not present as consistently or severely as seen in this patient, who meets criteria for a major psychotic disorder.
Differentiation from schizophrenia US Medical PG Question 10: A 31-year-old woman comes to the physician because she thinks that her “right wrist is broken.” She says that she has severe pain and that “the bone is sticking out.” She has not had any trauma to the wrist. Her medical records indicate that she was diagnosed with schizophrenia 2 years ago and treated with olanzapine; she has not filled any prescriptions over the past 4 months. Three weeks ago, she stopped going to work because she “did not feel like getting up” in the morning. Vital signs are within normal limits. Physical examination of the right wrist shows no visible injury; there is no warmth, swelling, or erythema. Range of motion is limited by pain. On mental status examination, she has a flat affect. Her speech is pressured and she frequently changes the topic. She has short- and long-term memory deficits. Attention and concentration are poor. There is no evidence of suicidal ideation. Urine toxicology screening is negative. An x-ray of the wrist shows no abnormalities. Which of the following is the most appropriate response to this patient's concerns?
- A. “It seems as though you are having a schizophrenia relapse. If you don't follow my recommendations and take your medications, you will most likely have further and possibly more severe episodes.”
- B. “I cannot see any injury of your wrist and the physical exam as well as the x-ray don't show any injury. I imagine that feeling as if your wrist was broken may be very uncomfortable. Can you tell me more about what it feels like?” (Correct Answer)
- C. I understand your concerns; however, your symptoms seem to be psychological in nature. I would be happy to refer you to a mental health professional.
- D. You are clearly distressed. However, your tests do not suggest a physical problem that can be addressed with medications or surgery. I suggest that we meet and evaluate your symptoms on a regular basis.
- E. I can imagine that you are uncomfortable. That certainly looks painful. Let's take care of this injury first and then we should talk about your problems getting up in the morning.
Differentiation from schizophrenia Explanation: ***“I cannot see any injury of your wrist and the physical exam as well as the x-ray don't show any injury. I imagine that feeling as if your wrist was broken may be very uncomfortable. Can you tell me more about what it feels like?”***
- This response **validates the patient's experience of pain and distress** while gently reorienting them to the objective findings (no physical injury).
- It opens a dialog to explore the **patient's subjective experience** and build trust, which is crucial for addressing underlying psychiatric issues in a patient with schizophrenia.
*“It seems as though you are having a schizophrenia relapse. If you don't follow my recommendations and take your medications, you will most likely have further and possibly more severe episodes.”*
- This statement is **confrontational and judgmental**, potentially alienating the patient and making them less likely to engage in treatment.
- Directly labeling a relapse and warning of future severity without first building rapport can trigger **defensiveness and non-compliance**.
*I understand your concerns; however, your symptoms seem to be psychological in nature. I would be happy to refer you to a mental health professional.*
- While accurate about the psychological nature of symptoms, this response **dismisses the patient's immediate physical complaint** and might make them feel unheard.
- It prematurely jumps to a referral without fully exploring the current presentation or establishing a therapeutic alliance, which can be perceived as the physician "passing the buck."
*I can imagine that you are uncomfortable. That certainly looks painful. Let's take care of this injury first and then we should talk about your problems getting up in the morning.*
- This response **validates a non-existent injury**, reinforcing the patient's delusion and potentially diverting attention from the underlying psychiatric condition.
- Prioritizing a non-existent injury would lead to inappropriate medical interventions and delay necessary psychiatric care.
*You are clearly distressed. However, your tests do not suggest a physical problem that can be addressed with medications or surgery. I suggest that we meet and evaluate your symptoms on a regular basis.*
- While acknowledging distress and the lack of physical pathology, this response is somewhat **vague and lacks a clear plan** for addressing the primary concern of perceived injury.
- "Regular evaluation" without specific intent to explore the psychological component or re-initiate psychiatric treatment may not be sufficient for a patient experiencing a schizophrenia relapse.
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