A 25-year-old man comes to the office due to problems with concentration and restlessness. His younger brother takes stimulants for attention-deficit hyperactivity disorder, and the patient wonders if medication will help him to focus. He is accompanied by his girlfriend, who says, "Over the past month, he has been uncharacteristically hyperactive and irritable, jumping from one activity to another but getting little accomplished." The patient is frustrated with his current job as a computer data entry clerk, which he feels is beneath him, and he was upset when his boss recently criticized him for making several mistakes. His girlfriend says that he is on the verge of losing his job. The patient stays up late developing plans for a new business that he believes will make him a millionaire. He is sleeping 2-3 hours a night. He drinks 3-4 alcoholic drinks a week and uses marijuana twice a month.
Physical examination is unremarkable. Urine toxicology is positive for tetrahydrocannabinol. On mental status examination, the patient appears restless and easily distracted. He is very talkative and leaves his chair to pace during the interview. His mood is irritable. He has no suicidal ideation or psychotic features.
Which of the following is the most likely diagnosis?

Question

A 25-year-old man comes to the office due to problems with concentration and restlessness.  His younger brother takes stimulants for attention-deficit hyperactivity disorder, and the patient wonders if medication will help him to focus.  He is accompanied by his girlfriend, who says, "Over the past month, he has been uncharacteristically hyperactive and irritable, jumping from one activity to another but getting little accomplished."  The patient is frustrated with his current job as a computer data entry clerk, which he feels is beneath him, and he was upset when his boss recently criticized him for making several mistakes.  His girlfriend says that he is on the verge of losing his job.  The patient stays up late developing plans for a new business that he believes will make him a millionaire.  He is sleeping 2-3 hours a night.  He drinks 3-4 alcoholic drinks a week and uses marijuana twice a month.
Physical examination is unremarkable.  Urine toxicology is positive for tetrahydrocannabinol.  On mental status examination, the patient appears restless and easily distracted.  He is very talkative and leaves his chair to pace during the interview.  His mood is irritable.  He has no suicidal ideation or psychotic features.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's one-month history of hyperactivity, irritability, grandiosity, and decreased need for sleep is suggestive of a manic episode of bipolar disorder. Irritable (rather than elevated) mood is common, and patients typically exhibit increased energy, distractibility due to racing thoughts, impulsivity in taking on new and foolish business ventures, and inability to complete the many projects they start. His increased physical activity on mental status examination (restlessness, pacing) and talkativeness are also consistent with this disorder. Patients with bipolar disorder frequently have poor insight into their behavior, and collateral information is often needed to make the diagnosis. Bipolar disorder can be distinguished from attention-deficit hyperactivity disorder (ADHD) in adults by an episodic course. Although hyperactivity, irritability, distractibility, restlessness, and hypertalkativeness are seen in both disorders, this patient's recent onset of behavioral changes representing a marked change from his baseline makes bipolar disorder more likely than ADHD (Choice B). In addition, he lacks a history of ADHD symptoms dating back to childhood, which is necessary for the diagnosis of ADHD. (Choice A) Adjustment disorder is diagnosed when symptoms occur in response to a stressor and do not meet the criteria for another mental disorder. This patient's manic symptoms and impairment are likely the cause and not the result of his workplace stress. (Choice D) Although patients with narcissistic personality disorder may also exhibit grandiosity and sensitivity to criticism, this patient lacks the lifelong pattern of excessive need for admiration, superficial and exploitative relationships, and lack of empathy that characterize this disorder. A personality disorder would not explain his recent change in behavior. (Choice E) Substance-induced disorders should be ruled out prior to diagnosing primary psychiatric illness. However, the amount and extent of this patient's alcohol and marijuana use would be unlikely to explain his current symptoms. Stimulants such as cocaine or amphetamines are more likely causes of manic symptoms but would lead to positive results on urinary toxicology screen. Educational objective: Manic episodes are characterized by elevated or irritable mood, hyperactivity, grandiosity, distractibility, hypertalkativeness, and decreased need for sleep. An episodic, as opposed to chronic, course is helpful in differentiating bipolar disorder from adult attention-deficit hyperactivity disorder. __________ References: Adult ADHD vs. bipolar disorder in the DSM-5 era: a challenging differentiation for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/25406047) The comorbidity of adult attention-deficit/hyperactivity disorder in bipolar disorder patients. (http://www.ncbi.nlm.nih.gov/pubmed/23306036) Psychotic and bipolar disorders: bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28437059)

A 25-Year-Old Man Comes to the Office Due to Problems