A 28-year-old woman is brought to the emergency department by her boyfriend due to bizarre behavior over the past week. The patient abruptly quit her job as a congressional aide, saying, "My boss was trying to sabotage me because she's jealous of my intellect. The job was beneath me anyway. The time has come for me to run for public office myself." She feels annoyed and exclaims that she needs to leave immediately so that she can organize her campaign. The patient yells at her boyfriend for bringing her to the hospital; a minute later, she hugs him and tearfully says, "I can't imagine my life without you." She rarely drinks alcohol and does not use illicit substances. The patient has no history of psychiatric or medical illness. Blood pressure is 130/90 mm Hg and pulse is 88/min. BMI is 26 kg/m². Physical examination shows no abnormalities. On mental status examination, the patient is easily agitated when interrupted and jumps from one topic to another. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d7a7_1156_bc81_a7c00dc9908b_MD0003_00 This patient's weeklong history of abrupt change in behavior characterized by irritable mood, increased activity, impulsivity, and grandiose delusions, together with pressured speech and flight of ideas (jumping from topic to topic) on mental status examination, is consistent with a manic episode of bipolar I disorder. In addition to marked mood symptoms, patients in a manic episode may exhibit psychotic features, which must be differentiated from primary psychotic disorders. Delusions in mania often involve grandiose themes in which patients believe that they have special abilities or powers or that others are jealous of them. The mood episode at the onset of bipolar disorder may be manic (as in this patient), hypomanic, depressed, or mixed. At least one manic episode is required to diagnose bipolar I disorder. A history of depressive episodes is not required for the diagnosis of bipolar I disorder, although most patients experience both manic and depressive episodes during the course of the illness. (Choices B and E) This patient has labile moods (ie, rapid shifts from anger to tears), which are common in bipolar disorder and may also be seen in borderline personality disorder. Her grandiose sense of self, which is a core feature of bipolar mania, can also be seen in narcissistic personality disorder. However, personality disorders are characterized by long-standing patterns of behavior and would not explain this patient's weeklong history of abrupt change in behavior, pressured speech, and flight of ideas. (Choices C and D) Brief psychotic disorder is characterized by psychotic symptoms lasting up to a month, and delusional disorder involves delusions lasting ≥1 month. Neither diagnosis would account for this patient's prominent manic symptoms. (Choice F) This patient's psychosis has occurred only in the context of her manic episode. A diagnosis of schizoaffective disorder requires a period of psychosis lasting at least 2 weeks in the absence of a mood episode. Educational objective: Patients with ≥1 manic episode are diagnosed with bipolar I disorder. Depressive episodes are not required for diagnosis but are common. Manic episodes may include psychotic symptoms, often with grandiose themes. References: Bipolar disorder diagnosis: challenges and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/23663952)

A 28-Year-Old Woman Is Brought to the Emergency Department by Her