Question: What is the diagnosis according to Dsm 5 and also indicate differential diagnosis too

Mr.Mis26yearsold,single,andunemployed.Hehasa6-yearhistoryof

emotional;illness and is being treated in theaftercare program of auniver sity hospital. He lives in a supervised apartment and is supported by Sup plemental Security Income and Medicaid. The staff, frustrated by Mr. M's limited gains despite their active psychopharmacological and rehabilitative interventions, have prompted his presentation at a grand rounds for review and reassessment. Mr. M remains partly symptomatic and cannot function either vocationally or in peer relationships.Nevertheless,heandhis parents continuetoexpectthathewillbecome"normal"andbe able towork.

Asachild, Mr.Mmanifested apeculiardetached mannerandconse quentlyhadtroubleformingfriendships.WhenhewasI2,psychiatric consultation revealed a "personality problem." When he was 13, Mr. M'smother was diagnosed withcancer, and she diedafter 3yearsof debilitating illness.Duringthisperiod,Mr.Mbeganweeklypsychiatrictreatmentthat continued for 5 years.

Despitedecliningschoolperformance, Mr.Mgraduatedfromhighschool atage18andstartedcollege.Hefailedallhisfirst-semestercoursesandre

turnedhomewherehewassociallyisolated andunemployed.When hewas19yearsold,anewpsychiatristdiagnosedMr.Mwith

Psychological testing suggested "passive-aggressiveindividual with highanxiety and marked passive-dependency needs."

Mr.M'sfirst_ _ episodeandhospitalizationoccurredwhenhewas 20,withinaweekofhisfather'sremarriage.Hehaddelusionsofgrandeur, in sistinghecouldfly,andbecamesexuallypreoccupiedandaggressive.Mental statusexaminationrevealedasuspicious,agitatedmanwithinappropriateand blunted affectandthought processescharacterized byderailment and racing. Hefeltthat hecould readmindsandthatsometimeshisthoughts werenothis own. He had vague suicidal and homicidal ideation without suicidal intent. Chlorpromazine 400 mg/day was prescribed. Mr. M's symptoms improved somewhat, and he was discharged after 3weeks.

Mr. M returnedhome to his family, began treatment with a new pri vatepsychiatrist,andenteredarehabilitativedayhospitalprogramand

family therapy. At home, Mr. M had a very sheltered, undemanding role characterized by parental overinvolvement, protectiveness, and infantiliza tion. For the next 2 years in the day program, he wassocially isolated, had poor concentration, and frequently displayed provocative and intrusive be havior and depressive symptoms. Although Mr. M'sparents were critical of his poor performance, they also showed strong denial about his degree of dysfunction.

when hewas22,hisstepmother gavebirthtoason.Mr.M'ssymptoms grewworse,andhisparentsdecidedtoplacehiminanout-of-stateresidential program. Soon after, he had a second florid decompensationandwashospitalizedin a condition similar to his first episode.

Mr.Mwastreatedwithanaverageof 40mg/dayof haloperidoland im provedslightly.Becauseofthemanicfeaturesinhispresentation, hisdiagnosis was changed: Hewasstarted on lithium andsoongrew moresubdued andbetter ableto focus. He hada moreap propriate affect and was less hypersexual and delusional, although de creased concentration and intermittent childish impulsivity persisted.

After 2months, Mr.M wasdischarged on haloperidol (IOmg/day) and lithium (900 mg/day). His lithium level was stable at I mEq/L. He was placed inasupervised apartment program and continued in the day pro gram. He also continued outpatient treatment with his inpatient resident physicianandoverthenext2yearswasmaintained onlowdosesofhalo peridol(5-10mg/day) and lithium(900mg/day). Although periodically symptomatic, he was never overtly psychotic.

Despite extensive work rehabilitation programs, Mr. M's prevocational andsocial functioning remained marginal. Atage 23, hewas referred toa newday program forongoingsocial and vocational rehabilitation while continuing in thehospital's outpatient clinic, an "alumni group,"and a fam ily group with his parents.

Several months later, Mr. M was reassigned to a new female resident psychiatrist. The patient showed a resurgence of paranoid symptoms and would often call home for reassurance. Because mood symptoms were not prominent,thenew residentreformulatedthe diagnosis.

Haloperidolwasincreased from5-20mg/day, and lithium was discontinued without any evident change in symptoms.

Five months later, Mr. M's paranoid symptomsincreased again despite the additional haloperidol. This development convinced another new resi dent to try a higher doseof antipsychotics, and thehaloperidolwas pushed to SO mg/day. After 2 months, Mr. M showed minimal symptom improve ment. Medications wereswitched from haloperidol to fluphenazine hydro chloride with moderate improvement.

StillanotherresidentwasassignedtoMr.M's case4monthslater. Mr.Mcontinuedtohave"paranoidepisodes"every2or3days,accompa-

niedbyintenseanxiety.His stepmothernotedthatforthepast6months hiscalls home had increased in frequency. Hecomplained of being afraid to leave his apartment and showed suicidal ideation, which he denied. During these episodes,he usuallyresponded toneurolepticmedication,support, and reassurance.