Rosh Psychiatry Board Practice Exam

A young man exhibits rapid speech and paranoid delusions after stopping medication. What is the most likely diagnosis?

1. Bipolar II disorder

2. Schizoaffective disorder

3. Paranoid personality disorder

4. Substance use disorder

The correct answer is: Schizoaffective disorder

The diagnosis of schizoaffective disorder is supported by the presentation of rapid speech and paranoid delusions following the cessation of medication. Schizoaffective disorder combines symptoms of both schizophrenia and mood disorder—typically a depressive or manic episode occurring concurrently with psychotic features. In this case, the rapid speech (which can be indicative of a manic episode) alongside paranoid delusions fits well within the spectrum of symptoms associated with schizoaffective disorder. When medications are stopped, individuals with a history of schizoaffective disorder may experience a re-emergence of psychotic symptoms, as they are vulnerable to such episodes. The timing of the symptom resurgence after stopping medication aligns with this diagnosis, confirming that the individual is likely experiencing an exacerbation of their underlying condition. While bipolar II disorder could also account for rapid speech, it typically does not include paranoid delusions unless there is a separate psychotic component. Paranoid personality disorder is characterized by pervasive distrust and suspicion of others but does not typically include acute episodes with accompanying mood disturbance or rapid speech. Substance use disorder could also present with paranoia, but the context of stopping medication heavily leans toward the diagnosis of schizoaffective disorder as the most fitting explanation for the symptoms observed.