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A Vignette for Discussion

An 18 year old man comes with presenting complaints of irritability, severe headache, increased religious orientation, frequent cleaning of clothes, auditory hallucinations, and delusions of persecution. These symptoms started almost six weeks ago but aggression, irritability and loss of interest in daily activities were prevalent since one year. 

What could be the possible diagnosis of this case?


Hypomania does not have psychotic features. 
Could be. Ocd wd psychotic features.
MDD with psychotic features comorbid with OCD.
This patient should be explored for psychosis first as it a year-long illness with delusions and hallucinations and social dysfunction. If you can rule out psychosis then it can be mood disorder or other. Obsessional symptoms may be part of psychosis. The patient needs detailed history and serial MSE to confirm the diagnosis

But if you see the history. Hallucination and delusions started off later. Initially, the patient exhibited symptoms of depression. Hence its a high probability that depression over the course of time intensified resulting in the emergence of psychotic features.

Yes if psychosis is ruled out after a detailed history review then depression with psychotic features is the most probable diagnosis. Other possibilities Mixed affective episode ? . I feel the initial symptoms can also be prodromal symptoms of psychosis / negative symptoms / depressive symptom.

This is just an ill-sorted hodgepodge of signs and symptoms. This isn't how psychiatry works. Find out the predominant hue the patient carries and establish the progress of the illness for the last one year. Take a detailed history and MSE. From what appears here, it could be anything from Schizophrenia to BAD Manic episode. Find out, for instance, if the patient really has paranoid delusions or is he merely expressing apprehension about something. You didn't mention his mood. Is the irritability episodic or sustained? Is there declining social and occupational functioning?

When you enlist symptoms, you must juxtapose them against certain differentials.
Major depressive disorder with psychotic features along with OCD

Ocd with psychotic features, I think so

High scores on PANS (positive and negative scale both). Plus 31 on MMSE Which depicts cognitive dysfunction as well. As far as history is concerned I am more in favor of bipolar 1 with psychotic features...

Psychotic features started off six weeks ago, Delusions are paranoid. The mood remains irritable consistently. Social/occupational decline is also consistent for six weeks.

Cognitive impairment is a bummer. The rest of the picture, of course, fits bipolar with psychotic features but since there is some cognitive impairment, an organic illness has to be ruled out. Bipolarity with cognitive impairment And at this age especially is rare. Even generally, by diagnostic conventions, organicity has to be ruled out before considering a functional etiology of the psychosis.,,, You mentioned 31 on MMSE. I am assuming that's a typo.

Fahad Khan Shenwari Very interesting scenario Neha Khan. Is it what u saw urself or taken from somewhere?!  As far as the scenario I would say you always have to employ exclusion and inclusion criteria. The patient was initially experiencing prodrome symptoms of psychosis and then enter into a full-blown psychotic episode with positive symptoms of delusion and hallucinations and odd behavior
Syed Mehdi Raza Its psychotic depression fr sure as depressive features appeared first followed by psychotic
Fahad Khan Shenwari In psychotic depression u see mood-congruent phenomena
Syed Mehdi Raza Maybe but where is a mood incongruent phenomenon in this scenario? Irritability and loss of interest common in depression since it is from one yrs and from six weeks psychotic features so according to this info psychotic depression is the only diagnosis to be made
Abbas Sepah It's a mixture of multiple disorders and can not be fitted into just one..


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