A 26-year-old man is brought to the emergency department by police after assaulting customers in a restaurant. He explains that he meant no harm and was just trying to talk to people and touch them to "heal their pain." The patient has been up all night for the past 10 days devising a global strategy to end world hunger and has written a hundred-page manifesto documenting his ideas. Over this same period, he began hearing a voice telling him that he is "God's true son" and will need to sacrifice his life. The patient has no psychiatric or medical history. He drinks alcohol socially but does not use illicit drugs. Physical examination is normal. On mental status examination, the patient paces continuously. His mood is very irritable, and his speech is loud, rapid, and difficult to interrupt. Which of the following is the most likely diagnosis in this patient?

Question

A 26-year-old man is brought to the emergency department by police after assaulting customers in a restaurant.  He explains that he meant no harm and was just trying to talk to people and touch them to "heal their pain."  The patient has been up all night for the past 10 days devising a global strategy to end world hunger and has written a hundred-page manifesto documenting his ideas.  Over this same period, he began hearing a voice telling him that he is "God's true son" and will need to sacrifice his life.  The patient has no psychiatric or medical history.  He drinks alcohol socially but does not use illicit drugs.  Physical examination is normal.  On mental status examination, the patient paces continuously.  His mood is very irritable, and his speech is loud, rapid, and difficult to interrupt.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_3609_dc7c_9249_016108369be7_MD0001_00 This patient's symptoms of irritable mood, impulsivity, hyperactivity, pressured speech, decreased need for sleep, and grandiose delusions lasting ≥1 week meet the criteria for a manic episode (Table). Although an elevated mood typifies a manic episode, an irritable mood is commonly seen. Patients with ≥1 manic episodes are diagnosed with bipolar I disorder; although most bipolar I patients will experience both major depressive and manic episodes, depressive episodes are not required for diagnosis of bipolar I. Manic episodes can occur with or without psychotic features (eg, delusions, hallucinations). Bipolar disorder with psychotic features may be differentiated from a primary psychotic disorder (eg, schizoaffective disorder bipolar type) based on the temporal relationship between the mood disturbance and the psychosis. In psychotic disorders, psychotic symptoms must persist in the absence of mood symptoms. This patient's psychosis has occurred only in the presence of severe manic symptoms, making bipolar I disorder the more likely diagnosis. (Choice B) Bipolar II disorder involves hypomanic episodes (less severe than mania and without psychotic features) and major depressive episodes. (Choice C) Brief psychotic disorder is characterized by acute onset of ≥1 psychotic symptoms lasting ≥1 days but <1 month, with eventual complete resolution. The diagnosis cannot be made when psychotic symptoms occur only in the context of a manic episode, as in this patient. (Choice D) Delusional disorder is characterized by ≥1 delusions in the absence of other psychotic symptoms. Functioning may be normal apart from the direct impact of the delusion. Mood symptoms, if present, are not prominent. (Choice E) In schizophreniform disorder, symptoms of schizophrenia (delusions, hallucinations, disorganized speech and behavior, negative symptoms) are present for >1 month but <6 months. This patient's psychotic symptoms have occurred only in the context of a manic episode and have been present for <1 month. (Choice F) Substance-induced disorders should be ruled out prior to diagnosing primary psychiatric illness. The extent of this patient's alcohol use would be unlikely to cause his current symptoms. Cocaine and stimulants are more likely to induce manic symptoms. Educational objective: Bipolar I disorder is diagnosed in patients with ≥1 episodes of mania. Manic episodes are characterized by elevated/irritable mood, impulsivity, hyperactivity, decreased need for sleep, pressured speech, and grandiosity and may occur with psychotic features. __________ References: Bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26388529)

A 26-Year-Old Man Is Brought to the Emergency Department by Police