A 32-year-old woman is brought to the emergency department by police for agitated behavior at work. The patient, who works as an assistant editor at a publishing company, did not show up to work for the previous 2 days. This morning, on arrival in the office, she yelled, "I've written the next bestselling novel!" She then demanded a meeting with the company president to present her plan to launch a nationwide tour for the book. Her coworkers attempted to usher her into the conference room to talk, but she became angry, kicked over a trash can, and threw multiple vases against the wall. The patient has no psychiatric history. Throughout the evaluation, she is hypervigilant and restless. Temperature is 37 C (98.6 F), blood pressure is 158/92 mm Hg, pulse is 102/min, and respirations are 16/min. She appears diaphoretic; pupils are dilated. The patient speaks rapidly and loudly. She says, "They don't appreciate my genius. I'm too good for them." Which of the following is the most likely diagnosis?

Question

A 32-year-old woman is brought to the emergency department by police for agitated behavior at work.  The patient, who works as an assistant editor at a publishing company, did not show up to work for the previous 2 days.  This morning, on arrival in the office, she yelled, "I've written the next bestselling novel!"  She then demanded a meeting with the company president to present her plan to launch a nationwide tour for the book.  Her coworkers attempted to usher her into the conference room to talk, but she became angry, kicked over a trash can, and threw multiple vases against the wall.  The patient has no psychiatric history.  Throughout the evaluation, she is hypervigilant and restless.  Temperature is 37 C (98.6 F), blood pressure is 158/92 mm Hg, pulse is 102/min, and respirations are 16/min.  She appears diaphoretic; pupils are dilated.  The patient speaks rapidly and loudly.  She says, "They don't appreciate my genius.  I'm too good for them."  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's manic behavior (eg, agitation; grandiosity; loud, pressured speech) and signs of sympathetic stimulation (eg, diaphoresis, tachycardia, hypertension, mydriasis) are most consistent with cocaine intoxication. Patients under the influence of cocaine or other stimulants may exhibit elevated or irritable mood, hyperactivity, agitation, and grandiosity that are indistinguishable from an acute manic episode of bipolar disorder. Other manic symptoms, such as decreased need for sleep, racing thoughts, and distractibility, can also be seen in cocaine intoxication. Bipolar disorder is not diagnosed when there is evidence that symptoms are caused by substance use or withdrawal (Choice A). (Choices B and D) Brief psychotic disorder is characterized by the acute onset of psychotic symptoms lasting 1 day to 1 month. Delusional disorder is characterized by ≥1 delusions lasting for ≥1 month that are not accompanied by other psychotic symptoms. These primary psychiatric disorders would not explain this patient's physical findings. (Choices E and G) Hallucinogen intoxication (eg, LSD) is characterized by perceptual distortions. It does not typically cause manic behavior or severe agitation. Phencyclidine (ie, PCP) intoxication may cause agitated and violent behavior. However, it typically presents with prominent nystagmus. (Choice F) Opioid withdrawal presents with gastrointestinal distress (eg, nausea, diarrhea, abdominal cramping), myalgias, mydriasis, piloerection, and lacrimation. It would not explain this patient's manic symptoms. Educational objective: Cocaine intoxication can produce manic symptoms, including elevated or irritable mood, hyperactivity, agitation, and pressured speech. Signs of sympathetic stimulation (eg, diaphoresis, mydriasis, tachycardia, hypertension) can assist in differentiating cocaine intoxication from bipolar disorder and other primary psychiatric disorders. References: Cocaine-induced psychotic disorders: presentation, mechanism, and management. (http://www.ncbi.nlm.nih.gov/pubmed/25392252) An international perspective and review of cocaine-induced psychosis: a call to action. (http://www.ncbi.nlm.nih.gov/pubmed/24927026)

A 32-Year-Old Woman Is Brought to the Emergency Department by Police