A 19-year-old woman is brought to the emergency department by the police after she was found trespassing at an animal shelter. The patient had keys to a rental van, as well as numerous collars and leashes. She says, "The shelter is going to sell the animals to labs, where they'll do horrible experiments on them. I'm the only one who can save them!" The patient quit her retail job a week ago to spend more time researching escape routes for the animals. Throughout the evaluation, she interrupts the physician to yell at other patients and hospital staff walking by the room. She repeatedly refers to herself as a "cat burglar" and then laughs loudly for a few minutes. Physical examination is unremarkable and urine drug screening is negative. Which of the following additional features is most likely in this patient?

Question

A 19-year-old woman is brought to the emergency department by the police after she was found trespassing at an animal shelter.  The patient had keys to a rental van, as well as numerous collars and leashes.  She says, "The shelter is going to sell the animals to labs, where they'll do horrible experiments on them.  I'm the only one who can save them!"  The patient quit her retail job a week ago to spend more time researching escape routes for the animals.  Throughout the evaluation, she interrupts the physician to yell at other patients and hospital staff walking by the room.  She repeatedly refers to herself as a "cat burglar" and then laughs loudly for a few minutes.  Physical examination is unremarkable and urine drug screening is negative.  Which of the following additional features is most likely in this patient?

Quizplus · Accepted Answer

11ec25c8_d769_1eba_bc81_31056ecb13a7_MD0003_00 This patient's recent history of abnormal mood, impulsive, risky behavior, and grandiosity (ie, belief that only she can save the animals), as well as findings of loud speech, distractibility, and inappropriate joking and laughter on mental status examination, are characteristic of a manic episode of bipolar I disorder. Patients with mania are often expansive and disinhibited, interacting with strangers without regard to social conventions (eg, yelling at others walking by). Impaired judgment is common, as with this patient abruptly quitting her job and trespassing at the animal shelter. A key feature of mania is decreased need for sleep due to increased energy. This is differentiated from insomnia, which refers to difficulty sleeping despite feeling tired. Patients in a manic episode may sleep only a few hours or go without sleep entirely for several days. Despite lack of sleep, they feel well rested and energetic. Mania typically has an acute onset with rapid progression over a few days, resulting in marked impairment in functioning. Hospitalization may be necessary to protect the patient from further destructive behaviors. (Choice A) Although psychotic features (eg, delusions, hallucinations) may develop during a manic episode, tactile hallucinations (eg, bugs crawling on the skin) are uncommon. Tactile hallucinations are most commonly associated with substance use disorders or medical conditions. (Choice B) Having intrusive, unwanted thoughts is a core feature of obsessive-compulsive disorder. Although this patient is intensely preoccupied with saving animals, her thoughts are not experienced as intrusive or disturbing, and her behavior is consistent with the increased activity commonly seen in mania. (Choice C) A feeling of detachment is a dissociative symptom more commonly seen in patients with posttraumatic stress disorder. (Choices E and F) Neglecting personal grooming and increased latency of response are examples of negative symptoms, which are a characteristic feature of schizophrenia, not bipolar disorder. Educational objective: Core features of a manic episode include elevated or irritable mood, increased energy/activity, and a decreased need for sleep. Manic patients may feel rested and energetic despite getting very little or no sleep. References: Bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26388529) The diagnosis and management of bipolar I and II disorders: clinical practice update. (http://www.ncbi.nlm.nih.gov/pubmed/28888714) Mania. (http://www.ncbi.nlm.nih.gov/pubmed/29630220)

A 19-Year-Old Woman Is Brought to the Emergency Department by the Police