A 23-year-old woman is brought to the emergency department by her roommate due to bizarre behavior. The roommate reports that, over the past few days, the patient has become increasingly paranoid. She stays up almost all night and believes the apartment is bugged. The roommate became alarmed when the patient did not go to work yesterday and started speaking in a whisper. When interviewed, the patient does not respond verbally to questions but calmly writes on a piece of paper, "I've been warned not to say anything." Her parents are contacted and report a history of depression treated with bupropion. They have never observed the behavior their daughter is exhibiting. The parents report that the patient drinks alcohol socially but do not believe she uses illicit drugs. Vital signs and physical examination are unremarkable. Family history is significant for bipolar disorder in a maternal uncle. Which of the following is the most appropriate next step in management of this patient?

Question

A 23-year-old woman is brought to the emergency department by her roommate due to bizarre behavior.  The roommate reports that, over the past few days, the patient has become increasingly paranoid.  She stays up almost all night and believes the apartment is bugged.  The roommate became alarmed when the patient did not go to work yesterday and started speaking in a whisper.  When interviewed, the patient does not respond verbally to questions but calmly writes on a piece of paper, "I've been warned not to say anything."  Her parents are contacted and report a history of depression treated with bupropion.  They have never observed the behavior their daughter is exhibiting.  The parents report that the patient drinks alcohol socially but do not believe she uses illicit drugs.  Vital signs and physical examination are unremarkable.  Family history is significant for bipolar disorder in a maternal uncle.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient demonstrates signs of new-onset acute psychosis (eg, delusions, possible hallucinations) of unclear etiology. Major depressive or manic episode with psychotic features should be considered given the patient's history of depression and family history of bipolar disorder. However, before making a primary psychiatric diagnosis, substance-induced and other medical causes should be ruled out. The basic medical workup for new-onset psychosis commonly includes complete physical and mental status examinations, metabolic panel, complete blood cell count, and urine toxicology screen. It may also include tests for syphilis, HIV, vitamin B₁₂ level, thyroid function, and antinuclear antibodies, as well as neuroimaging depending on specific findings and risk factors. In a young patient with no significant medical history and normal physical examination results, obtaining a urine toxicology screen is the most appropriate next step in evaluation (eg, a screen positive for cocaine or amphetamine suggests a stimulant-induced psychosis). The parents' report cannot be relied on to rule out illicit or prescription drug use. (Choice A) Mood stabilizers (eg, lithium, valproate) are used in the treatment of bipolar disorder, which may present with psychotic features. However, the diagnosis of bipolar disorder requires evidence of at least 1 manic episode (eg, elevated or irritable mood, increased energy, flight of ideas, agitation, pressured speech), which is lacking in this patient. (Choice B) An antipsychotic medication would be appropriate for the treatment of primary mood disorder with psychotic features and/or to calm a severely agitated psychotic patient. However, the etiology of this patient's psychosis is unclear, and she is currently calm and cooperative. (Choice C) Like all antidepressants, bupropion may contribute to a manic presentation, but this is not known to correlate with bupropion levels. (Choice D) In the absence of focal neurologic findings, neuroimaging is not indicated. Educational objective: Substance-induced psychosis should be considered in the differential diagnosis of all patients who come to the emergency department with acute psychosis. Standard workup of new-onset psychosis includes obtaining a urine toxicology screen. References: Substance-induced psychoses: a critical review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/21999698) Recognition and differential diagnosis of psychosis in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/26131945) Psychosis associated with acute recreational drug toxicity: a European case series. (http://www.ncbi.nlm.nih.gov/pubmed/27538886)

A 23-Year-Old Woman Is Brought to the Emergency Department by Her