A 37-year-old woman comes to the office due to low energy and fatigue. She recently received a promotion at work and was very excited and motivated at first, but she now finds herself procrastinating and having difficulty concentrating. Her mother was recently diagnosed with thyroiditis, and the patient requests a blood test to see if she has it as well. Further history indicates that the patient has had unpredictable "mood swings" for many years, consisting of periods of low energy and "up periods" in which she feels more energetic, confident, and optimistic. These periods vary in length from days to weeks and have no clear relationship to situations in her life. The patient engaged in cutting and self-induced vomiting during her sophomore year in high school but has not exhibited these behaviors since. She has no history of major depressive episodes or psychosis. She uses marijuana "to relax" several times a month, drinks 1 or 2 glasses of wine several times a week, and has tried cocaine twice. The patient takes no medications. Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 64/min. Physical examination shows no abnormalities. Mental status examination shows a sad affect and some lapses in concentration, although the patient brightens easily. Which of the following is the most likely diagnosis?

Question

A 37-year-old woman comes to the office due to low energy and fatigue.  She recently received a promotion at work and was very excited and motivated at first, but she now finds herself procrastinating and having difficulty concentrating.  Her mother was recently diagnosed with thyroiditis, and the patient requests a blood test to see if she has it as well.  Further history indicates that the patient has had unpredictable "mood swings" for many years, consisting of periods of low energy and "up periods" in which she feels more energetic, confident, and optimistic.  These periods vary in length from days to weeks and have no clear relationship to situations in her life.  The patient engaged in cutting and self-induced vomiting during her sophomore year in high school but has not exhibited these behaviors since.  She has no history of major depressive episodes or psychosis.  She uses marijuana "to relax" several times a month, drinks 1 or 2 glasses of wine several times a week, and has tried cocaine twice.  The patient takes no medications.  Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 64/min.  Physical examination shows no abnormalities.  Mental status examination shows a sad affect and some lapses in concentration, although the patient brightens easily.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's history of chronic, fluctuating mood disturbance for many years is suggestive of cyclothymic disorder. Her symptoms are mild, and she does not have sufficient history to diagnose either a current or past major depressive or hypomanic/manic episode. Cyclothymic disorder falls within the bipolar spectrum and represents a less severe form of the illness. Diagnosis requires ≥2 years duration (1 year in children) and insufficient number of symptoms and severity to meet full criteria for hypomanic, manic, or depressive episodes. bipolar spectrum Criteria for a major depressive episode include ≥5 of the following symptoms over ≥2 weeks: Depressed mood and SIGECAPS (Sleep disturbance, loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts). Patients should be evaluated for a bipolar II diagnosis if they meet these criteria and have a history of hypomanic episodes (ie, ≥4 days of elevated/irritable mood, increased energy, and ≥3 of the following: Grandiosity, decreased need for sleep, talkativeness, racing thoughts, distractibility, hyperactivity, and risky behavior) (Choice B). (Choice A) Bipolar I disorder is characterized by manic episodes with or without major depressive episodes. (Choice C) Borderline personality disorder (BPD) is characterized by mood instability that is typically reactive to interpersonal stressors (unlike in this patient, whose moods do not appear reactive to situations). It is also marked by pervasive interpersonal difficulties and an unstable sense of identity, which this patient does not describe. The self-harm in BPD is recurrent, whereas this patient's history of nonsuicidal self-injury and bulimic behavior is remote and nonspecific. She has insufficient symptoms to diagnose borderline personality. (Choices E and F) Fluctuating mood disturbance may be due to medical conditions (eg, hypothyroidism) or substances (eg, heavy alcohol use, cocaine, marijuana). However, the long-standing nature of this patient's cyclical mood changes, normal physical examination, absence of heavy substance use, and other physical symptoms make these diagnoses less likely. Educational objective: Cyclothymic disorder is a chronic mood disturbance characterized by ≥2 years of numerous periods of hypomanic and depressive symptoms that are subthreshold for diagnosing major depressive or hypomanic/manic episodes. References: Cyclothymic disorder: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/22459786) Cyclothymia reloaded: a reappraisal of the most misconceived affective disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26005206)

A 37-Year-Old Woman Comes to the Office Due to Low