A 15-year-old girl comes to the office with her mother for follow-up 1 week after a prolonged hospitalization for an acute asthma exacerbation. The patient is taking inhaled albuterol and an oral corticosteroid, and her respiratory symptoms have improved significantly. Her mother states that since hospital discharge, the girl has been acting strangely. She is "talking over people instead of listening" and is unable to sit still. The patient also has started to ignore requests to complete her daily chores and has been refusing dinner because she is "too busy" with organizing a school club for environmental protection. She says she has been under a lot of pressure due to upcoming final exams but now feels "better than ever," explaining how she will have more time to "save the oceans and Mother Earth" after she is done studying. The patient has a history of depression and takes sertraline. She has used marijuana occasionally but does not use tobacco, alcohol, or other illicit drugs. Vital signs are within normal limits, and cardiopulmonary examination shows no abnormalities. The patient appears impatient and checks her watch frequently throughout the evaluation. Which of the following is the most likely diagnosis?

Question

A 15-year-old girl comes to the office with her mother for follow-up 1 week after a prolonged hospitalization for an acute asthma exacerbation.  The patient is taking inhaled albuterol and an oral corticosteroid, and her respiratory symptoms have improved significantly.  Her mother states that since hospital discharge, the girl has been acting strangely.  She is "talking over people instead of listening" and is unable to sit still.  The patient also has started to ignore requests to complete her daily chores and has been refusing dinner because she is "too busy" with organizing a school club for environmental protection.  She says she has been under a lot of pressure due to upcoming final exams but now feels "better than ever," explaining how she will have more time to "save the oceans and Mother Earth" after she is done studying.  The patient has a history of depression and takes sertraline.  She has used marijuana occasionally but does not use tobacco, alcohol, or other illicit drugs.  Vital signs are within normal limits, and cardiopulmonary examination shows no abnormalities.  The patient appears impatient and checks her watch frequently throughout the evaluation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's acute onset of hypomanic symptoms that include elevated mood, hyperactivity, talkativeness, goal-directed activity, and grandiosity (believing she can save the earth) in the context of corticosteroid use is suggestive of a medication-induced mood disorder. In the case of new-onset psychiatric symptoms, it is essential to rule out medical and substance-induced causes. This patient's symptoms developed suddenly after a prolonged hospitalization for an asthmatic episode in which high-dose corticosteroids were likely administered. The psychiatric and cognitive effects of glucocorticoids may be mild and include euphoria, irritability, restlessness, anxiety, and sleep disturbance. Severe effects are more common with high doses or prolonged use and include depression, hypomania (as in this case) or mania, psychosis, and confusion. Mood symptoms typically resolve after the offending agent is discontinued. (Choice A) Acute stress disorder is characterized by symptoms of intrusive re-experiencing, avoidance, dissociation, and arousal lasting for ≤4 weeks in response to a traumatic event. (Choice B) Adjustment disorder is diagnosed when an individual responds to a stressor with an emotional and/or behavioral disturbance that does not meet criteria for a more specific disorder, such as medication-induced mood disorder (as in this patient). (Choices C and D) Diagnosis of bipolar II and related primary psychiatric disorders requires that hypomania not be caused by substances or medication. Cyclothymia requires a duration of ≥1 year in adolescents (≥ 2 years in adults) and involves cyclical mood disturbances that do not meet all criteria for a full-blown depressive or hypomanic episode. The diagnosis of bipolar II disorder requires ≥1 hypomanic episode and ≥1 depressive episode. (Choice F) Although adolescents may be impulsive, overconfident, and limit-testing, this girl's acute onset of behavioral changes representing a marked change from her baseline is more likely due to a medication-induced mood disorder. Educational objective: Evaluation of new-onset mood symptoms requires that medical and substance-induced causes be ruled out. The neuropsychiatric side effects of glucocorticoids include euphoria, depression, hypomania or mania, and psychosis. References: Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. (http://www.ncbi.nlm.nih.gov/pubmed/25272344) Suicidal behavior and severe neuropsychiatric disorders following glucocorticoid therapy in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/22764363)

A 15-Year-Old Girl Comes to the Office with Her Mother