A 25-year-old graduate student comes to the physician requesting treatment for attention-deficit hyperactivity disorder (ADHD). He has a childhood history of ADHD treated with stimulant medication and depression as a teenager. The patient says he is under a lot of stress and currently feels anxious, restless, and unable to concentrate. He has been up all night the past week because he is on the verge of a major scientific breakthrough in his research and is worried that someone might steal his data. His girlfriend reports that he has been uncharacteristically irritable and hyperactive, with angry outbursts for no apparent reason. The patient drinks several beers on weekends and uses marijuana twice a month. Physical examination is normal and urine drug screen is negative.
Which of the following is the most likely diagnosis?

Question

A 25-year-old graduate student comes to the physician requesting treatment for attention-deficit hyperactivity disorder (ADHD).  He has a childhood history of ADHD treated with stimulant medication and depression as a teenager.  The patient says he is under a lot of stress and currently feels anxious, restless, and unable to concentrate.  He has been up all night the past week because he is on the verge of a major scientific breakthrough in his research and is worried that someone might steal his data.  His girlfriend reports that he has been uncharacteristically irritable and hyperactive, with angry outbursts for no apparent reason.  The patient drinks several beers on weekends and uses marijuana twice a month.  Physical examination is normal and urine drug screen is negative.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's recent distractibility, hyperactivity, sleep disturbance, and irritability represent a change in his baseline behavior and suggest a diagnosis of bipolar disorder. His history of depression as a teen and possible grandiosity are further clues that his current symptoms are manifestations of a mood disorder. Patients with bipolar disorder frequently come initially to primary care, and physicians must be alert for signs and symptoms of hypomania and mania (euphoric or irritable mood, grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, hyperactivity, impulsivity). (Choice A) Adjustment disorder is diagnosed when symptoms occur in response to a stressor and do not meet the criteria for another mental disorder. (Choice B) Although this patient has a history of attention-deficit hyperactivity disorder (ADHD) as a child, patients with adult ADHD have chronic, not episodic, symptoms; this diagnosis would not explain his recent, severe sleep disturbance and irritability. Studies show that patients with bipolar disorder frequently have a history of ADHD. (Choice D) Generalized anxiety disorder involves chronic worry, anxiety, and tension related to multiple life issues and would not adequately explain this patient's manic symptoms. (Choice E) Substance-induced disorders must always be ruled out prior to diagnosing primary psychiatric illness. However, this patient's urine drug screen is negative, and the amount and extent of his alcohol and marijuana use would be unlikely to cause his current symptoms. Cocaine and stimulants are more likely to induce manic symptoms. Educational objective: Bipolar disorder is frequently misdiagnosed. Physicians must be alert to signs of mania or hypomania and consider bipolar disorder in the differential diagnosis of patients with hyperactivity and decreased sleep. __________ References: When to suspect bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/21135922) The diagnosis and treatment of bipolar disorder: decision-making in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/25317368)

A 25-Year-Old Graduate Student Comes to the Physician Requesting Treatment