A 27-year-old man comes to the office at his wife's insistence due to issues with concentration that are affecting his job performance. The patient works in information technology and has been easily distracted and unable to complete his assignments after returning from a business trip 4 weeks ago. The trip was stressful because it involved giving multiple presentations. Since his return, instead of working on current projects with assigned deadlines, he has spent hours developing new computer programs and is at risk of losing his job. He hardly sleeps at night and is increasingly anxious and irritable, behavior that is uncharacteristic. Last week, the patient became angry when his wife was skeptical of his idea to leave his job and start an internet company with no resources or investors. The patient has a history of attention-deficit hyperactivity disorder, for which he was treated with cognitive-behavioral therapy for 4 years beginning at age 8. He used cocaine in his early 20s but has not used illicit drugs in 3 years, apart from marijuana on occasion, which he says "helps me feel less anxious." Family history is significant for depression in his mother. On physical examination, the patient is cooperative but appears tense and anxious. He is talkative, easily distracted, and has difficulty sitting still; at one point he gets up to walk around the room. The patient has no psychotic symptoms or suicidal ideation. Urine drug screen is negative. Which of the following is the most likely explanation of the patient's recent behavior?

Question

A 27-year-old man comes to the office at his wife's insistence due to issues with concentration that are affecting his job performance.  The patient works in information technology and has been easily distracted and unable to complete his assignments after returning from a business trip 4 weeks ago.  The trip was stressful because it involved giving multiple presentations.  Since his return, instead of working on current projects with assigned deadlines, he has spent hours developing new computer programs and is at risk of losing his job.  He hardly sleeps at night and is increasingly anxious and irritable, behavior that is uncharacteristic.  Last week, the patient became angry when his wife was skeptical of his idea to leave his job and start an internet company with no resources or investors.  The patient has a history of attention-deficit hyperactivity disorder, for which he was treated with cognitive-behavioral therapy for 4 years beginning at age 8.  He used cocaine in his early 20s but has not used illicit drugs in 3 years, apart from marijuana on occasion, which he says "helps me feel less anxious."  Family history is significant for depression in his mother.  On physical examination, the patient is cooperative but appears tense and anxious.  He is talkative, easily distracted, and has difficulty sitting still; at one point he gets up to walk around the room.  The patient has no psychotic symptoms or suicidal ideation.  Urine drug screen is negative.  Which of the following is the most likely explanation of the patient's recent behavior?

Quizplus · Accepted Answer

11ec25c8_d2a1_d1b0_bc81_c774591aea89_MD0003_00 This patient's 4-week episode of irritability, talkativeness, decreased need for sleep, distractibility, and excessive involvement in new and risky projects is resulting in both relational and occupational impairment and is suggestive of a manic episode of bipolar I disorder. In manic episodes of bipolar I disorder, the predominant mood may be irritability rather than euphoria. This patient's difficulty sitting still and hyperactivity during the interview are also characteristic. History of a major depressive episode is not required for diagnosis of bipolar I disorder, although most patients will later have multiple manic and depressive episodes. manic and depressive episodes Bipolar disorder and attention-deficit hyperactivity disorder (ADHD) can be difficult to differentiate due to overlapping symptoms (eg, distractibility, hyperactivity, impulsivity), and the conditions can be comorbid. However, ADHD has a chronic (not episodic) course and presents with ongoing difficulties that begin in childhood. It would not explain this patient's abrupt change in behavior compared to his baseline 4 weeks ago (Choice B). More prominent mood symptoms and, in some cases, psychotic symptoms are other features that distinguish bipolar disorder from ADHD. (Choice A) Adjustment disorder is diagnosed when symptoms occur in direct response to an identified psychosocial stressor and cannot be explained by another disorder. Although this patient's symptoms began shortly after a stressful business trip, his behavior is consistent with a manic episode of bipolar disorder. (Choice D) Although patients with generalized anxiety disorder may experience irritable mood, poor sleep, and difficulty concentrating, this patient does not display other key features (eg, ≥6 month of uncontrollable concern about multiple daily issues). (Choice E) Although cocaine and other drugs with stimulant properties can cause manic symptoms, this patient has not used any illicit drugs other than marijuana for 3 years. Marijuana use can result in irritability and anxiety, but it would not cause the other symptoms of mania evident in this patient (eg, hyperactivity, decreased need for sleep, increased goal-directed activity, pressured speech). Educational objective: Patients with bipolar disorder may exhibit distractibility and hyperactivity that are difficult to distinguish from symptoms of attention-deficit hyperactivity disorder. An episodic (not chronic) course and prominent mood symptoms are more characteristic of bipolar disorder. References: Bipolar disorder and ADHD: comorbidity and diagnostic distinctions. (http://www.ncbi.nlm.nih.gov/pubmed/26084666) Adult ADHD vs. bipolar disorder in the DSM-5 era: a challenging differentiation for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/25406047)

A 27-Year-Old Man Comes to the Office at His Wife's