A 27-year-old man is brought to the office by his wife due to her concerns that "he is not himself." The patient has been very irritable and hyperactive with difficulty sleeping since returning from a family funeral a week ago. His wife reports that he has been very distracted and unproductive at the factory where he works, to the point that his employer has placed him on probation. Two days ago, he nearly sustained a serious injury while performing risky maneuvers with heavy machinery. When asked about his job, the patient says he has had no difficulties and describes his idea to "use special robot prosthetics to make the production line faster than ever and double everyone's productivity." The patient adds, "I don't know what my wife is worried about. If this job doesn't work out, I'll start my own company." His wife reports that he behaved similarly about 2 years ago and embarrassed her at a party by talking incessantly about his idea for a robotic invention. The patient has no history of depression. He drinks 2 or 3 beers on weekends and has been smoking marijuana approximately once a month for the past year. Temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, and pulse is 86/min. Urine toxicology screen is positive for tetrahydrocannabinol. Except for marked restlessness and fidgeting, physical examination is unremarkable. Which of the following is the most likely explanation for the patient's behavior?

Question

A 27-year-old man is brought to the office by his wife due to her concerns that "he is not himself."  The patient has been very irritable and hyperactive with difficulty sleeping since returning from a family funeral a week ago.  His wife reports that he has been very distracted and unproductive at the factory where he works, to the point that his employer has placed him on probation.  Two days ago, he nearly sustained a serious injury while performing risky maneuvers with heavy machinery.  When asked about his job, the patient says he has had no difficulties and describes his idea to "use special robot prosthetics to make the production line faster than ever and double everyone's productivity."  The patient adds, "I don't know what my wife is worried about.  If this job doesn't work out, I'll start my own company."  His wife reports that he behaved similarly about 2 years ago and embarrassed her at a party by talking incessantly about his idea for a robotic invention.  The patient has no history of depression.  He drinks 2 or 3 beers on weekends and has been smoking marijuana approximately once a month for the past year.  Temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, and pulse is 86/min.  Urine toxicology screen is positive for tetrahydrocannabinol.  Except for marked restlessness and fidgeting, physical examination is unremarkable.  Which of the following is the most likely explanation for the patient's behavior?

Quizplus · Accepted Answer

Explanation: This patient's 1-week history of irritable mood, hyperactivity, distractibility, impulsivity, decreased sleep, and grandiosity resulting in severe impairment (risky behavior at work resulting in probation and a near serious injury) suggest a manic episode. The presence of a manic episode makes bipolar I disorder the most likely diagnosis. The diagnosis of hypomanic and manic episodes requires elevated/irritable mood and increased energy, plus 3 of the following (or 4 if mood is irritable): D - Distractibility I - Impulsivity (high-risk behaviors [eg, spending, sexual]) G - Grandiosity F - Flight of ideas/racing thoughts A - Activity (increased goal-directed activity/psychomotor agitation) S - Sleep (decreased need) T - Talkativeness/pressured speech In hypomania, symptoms are less severe and functioning is improved or only slightly impaired, unlike in this patient who is on probation and whose risky behavior could have resulted in serious injury. If psychotic symptoms are present, the episode is manic by definition. Diagnosis of bipolar I disorder does not require a history of major depressive episodes. Bipolar II disorder is characterized by episodes of major depression and hypomania (not mania, as in this patient) (Choice C). (Choice A) Some symptoms of mania overlap with those of attention-deficit hyperactivity disorder (ADHD) (eg, hyperactivity, distractibility, impulsivity). However, ADHD symptoms are chronic, not episodic. (Choice D) Cyclothymic disorder involves 2 years of fluctuating periods with mild depressive symptoms as well as symptoms of hypomania that never meet the full criteria for hypomanic, manic, or major depressive episodes. (Choice E) The diagnosis of schizoaffective disorder requires a depressive or manic episode co-occurring with symptoms of schizophrenia and a lifetime history of ≥2 weeks of psychotic symptoms in the absence of mood episodes. (Choice F) Although this patient's urine toxicology screen is positive for tetrahydrocannabinol (eg, marijuana), he has a history suggestive of a mood episode prior to his use of marijuana, which started within the past year. In addition, although cannabis intoxication can present with euphoria, anxiety, or psychosis, it is more likely to cause psychomotor slowing rather than hyperactivity. Intoxication with stimulants or cocaine is more likely to induce manic symptoms. Educational objective: Bipolar I disorder includes manic episode(s) with or without a history of major depressive episodes. Bipolar II is distinguished from bipolar I by hypomanic episodes (less severe, less functional impairment, no psychotic symptoms) and a history of ≥1 depressive episodes. References: Differentiating bipolar I and II disorders and the likely contribution of DSM-5 classification to their cleavage. (http://www.ncbi.nlm.nih.gov/pubmed/24446541) Adult ADHD vs. bipolar disorder in the DSM-5 era: a challenging differentiation for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/25406047) Bipolar disorder diagnosis: challenges and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/23663952)

A 27-Year-Old Man Is Brought to the Office by His