Question: Could Mr. Hill be misdiagnosed with Schizoaffective Disorder but has Substance/Medication-Induced Psychotic Disorder instead?

An African American man who appeared to be in his 30s was brought to an urban emergency room (ER) by police. The referral form indicated that he wasschizophrenic and an"emotionally disturbed person." One of the police officers said that the man offered to pay them for sex while in the back seat of their patrol car.He referred to himself as the "New Jesus" and declined to offer another name.He refused to sit and instead ran through the ER. He was put into restraints and received intramuscularly administered lorazepam 2 mg andhaloperidol 5 mg. Intravenous diphenhydramine (Benadryl) 50 mg was readied in case of extrapyramidal side effects. The admitting team wrote that he had"unspecified schizophrenia spectrum and other psychotic disorders"and transferred him to the psychiatry team that worked in the ER.

Despite being restrained, he remainedgiddily agitated, talking about receiving messages from God. When asked when he last slept, he said he no longer needed sleep, indicating that he had "been touched by Heaven."His speech was rapid, disorganized, and difficult to understand.A complete blood count, blood chemistries, and a toxicology screen were drawn. After an additional 45 minutes of agitation, he received another dose oflorazepam. This calmed him, but he still did not sleep. His restraints were removed.

A review of his electronic medical record indicated that he had experienced a similar episode 2 years earlier. At that time, a toxicology screen had been negative. He had been hospitalized for 2 weeks in the inpatient psychiatric service and given a discharge diagnosis of"schizoaffective disorder." At that time, he was prescribedolanzapineand referred to an outpatient clinic for follow-up. That chart had referred to two previous admissions to the county inpatient hospital, but records were not available after hours.

An hour after receiving the initial haloperidol and lorazepam, the patient was interviewed while he sat in a chair in the ER. He was an overweight African-American man who was disheveled (untidy) and malodorous (stinking), though he did not smell of alcohol. He madepoor eye contact, instead looking at nearby people, a ticking clock, the examiner, a nearby nurse, or anything else that moved. His speech wasdisorganized, rapid, and hard to follow. His legbounced rapidly up and down, but he did not get out of his chair or threaten the interviewer.

He described his mood as "not bad."His affect was labile. He often laughed for no particular reason but would get angrily frustrated when he felt misunderstood.His thought process wasdisorganized. He hadgrandiose delusions, and his perceptions were significant for "God talking to me." He denied otherhallucinations as well as suicidality and homicidality.When asked the date, he responded with an extended discussion about the underlying meaning of the day's date, which he missed by a single day. He remembered the names of the two police officers who had brought him to the hospital. He refused more cognitive testing. His insight and judgment appeared poor.

The patient's sister arrived an hour later after having been called by a neighbor who had seen her brother, Mark Hill, taken away in a police car. The sister said her brother had seemed strange a week earlier, uncharacteristically arguing with relatives at a holiday gathering. She said he had claimed not to need sleep at that time and had been talking about his "gifts." She had tried to contact Mr. Hill since then, but he had not responded to phone, e-mail, or text messages. She said he did not like to talk about his issues, but she had twice seen a bottle ofolanzapinein his house. She knew their father had been called schizophrenic and bipolar, but she had not seen the father since she was a child. She said that Mr. Hill did not typically use drugs. She also said he was 34 years old and a middle school math teacher who had just finished a semester of teaching.

Over the next 24 hours, Mr. Hill calmed significantly. He continued to believe that he was being misunderstood and that he did not need to be hospitalized. He spokerapidly and loudly.His thoughts jumped from idea to idea. He spoke of having a direct connection to God and having "an important role on Earth," but he denied having a connection to anyone called the "New Jesus." He remained tense and jumpy but denied paranoia or fear.

Serial physical examinations revealed no abnormalities aside from blisters on his feet. The patient was not tremulous, and his deep tendon reflexes were symmetrical and graded 2 of 4. He showed no neurological asymmetry. His toxicology screen was negative, and his blood alcohol level was zero. His initial lab results were pertinent for elevated blood urea nitrogen and a blood sugar level of 210 mg/dL. His mean corpuscular volume, aspartate aminotransferase/alanine aminotransferase ratio, and magnesium level were normal.