A 24-year-old woman is brought to the emergency department by her roommate due to depression and suicidal thoughts. The roommate became alarmed when the patient did not get up for work as usual and reported feeling "so depressed I want to die." She currently has no suicidal ideation but describes feeling depressed, exhausted, and unable to concentrate. The patient appears distracted and speaks slowly. The roommate says, "We were up for the last 3 nights at parties where there was alcohol and other stuff," but reports that her friend was energetic and talkative and appeared to be in a great mood. However, the patient subsequently slept for 18 hours, had difficulty getting out of bed, and missed work. She has no medical or psychiatric history but describes brief periods of acute depression over the past several months. These lasted a few days and were characterized by low energy; hypersomnia; vivid, unpleasant dreams; and increased appetite. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 12/min. Physical examination is normal. Which of the following is the most likely diagnosis for this patient?

Question

A 24-year-old woman is brought to the emergency department by her roommate due to depression and suicidal thoughts.  The roommate became alarmed when the patient did not get up for work as usual and reported feeling "so depressed I want to die."  She currently has no suicidal ideation but describes feeling depressed, exhausted, and unable to concentrate.  The patient appears distracted and speaks slowly.  The roommate says, "We were up for the last 3 nights at parties where there was alcohol and other stuff," but reports that her friend was energetic and talkative and appeared to be in a great mood.  However, the patient subsequently slept for 18 hours, had difficulty getting out of bed, and missed work.  She has no medical or psychiatric history but describes brief periods of acute depression over the past several months.  These lasted a few days and were characterized by low energy; hypersomnia; vivid, unpleasant dreams; and increased appetite.  Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 12/min.  Physical examination is normal.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

This patient's acute onset of depression with pronounced fatigue following a period of increased energy is suggestive of cocaine withdrawal. Individuals often use cocaine in binges, taking the drug repeatedly over a short period to maintain their "high." Abrupt cessation is typically followed by a "crash," which can include severe depression with suicidal ideation and psychomotor slowing with milder symptoms that resolve within 1-2 weeks. Cocaine withdrawal involves predominantly psychological features. Common symptoms include depression, fatigue, hypersomnia, increased dreaming, hyperphagia, impaired concentration, and intense drug craving. Physical symptoms are minor and rarely require treatment. (Choices A and F) This patient's normal physical examination and vital signs make alcohol and opiate withdrawal syndromes unlikely. Alcohol withdrawal is characterized by CNS hyperactivity, and its symptoms include anxiety, insomnia, tremulousness, tachycardia, and hypertension. Opiate withdrawal typically presents with dysphoria and is accompanied by myalgia, yawning, and abdominal cramping. Physical findings include mydriasis, lacrimation, increased bowel sounds, and piloerection. (Choices B, D, and E) Primary mood disorders should be diagnosed only when substance-induced causes are ruled out, and they are less likely in this patient given her history of using substances at parties. In addition, the patient's episode of heightened energy does not meet the duration criteria for either a hypomanic (≥4 days) or manic (≥7 days) episode, and her mood symptoms do not meet the duration criteria for either cyclothymia (≥2 years) or major depressive disorder (≥2 weeks). Educational objective: Although physical symptoms are typically minor, cocaine withdrawal can cause acute depression with suicidal ideation. Other features include fatigue, hypersomnia, increased dreaming, hyperphagia, impaired concentration, and intense drug craving. References: Diagnosis and consequences of cocaine addiction. (http://www.ncbi.nlm.nih.gov/pubmed/22856661)

A 24-Year-Old Woman Is Brought to the Emergency Department by Her