A 42-year-old man comes to the office with his brother due to depressed mood following the breakup of a relationship 6 weeks prior. The patient says, "I feel hopeless. Nothing will ever work out for me. My girlfriend left me for no reason and now I'm on probation at work for missing too many days." He has been sleeping 15 hours a day and has had difficulty completing daily activities like showering and getting dressed. The patient is unable to concentrate on anything and spends time flipping through television channels to distract himself from feeling sad. He had episodes of depression in his 20s and 30s, and he was hospitalized 3 years ago after a psychotic episode in which he believed he was a world-renowned sea captain. During that episode, the patient spent all his savings buying a boat and did not sleep for days while he tried to recruit people to "join his expedition." His symptoms fully resolved with treatment in the hospital, but he did not follow up after discharge. The patient's brother says, "He was doing so well after leaving the hospital-no symptoms at all. This breakup has been really hard on him though." The patient has no history of substance abuse. Mental status examination shows slow rate of speech with mild response latency, psychomotor retardation, and depressed mood. He has no suicidal ideation. Which of the following is the most likely diagnosis?

Question

A 42-year-old man comes to the office with his brother due to depressed mood following the breakup of a relationship 6 weeks prior.  The patient says, "I feel hopeless.  Nothing will ever work out for me.  My girlfriend left me for no reason and now I'm on probation at work for missing too many days."  He has been sleeping 15 hours a day and has had difficulty completing daily activities like showering and getting dressed.  The patient is unable to concentrate on anything and spends time flipping through television channels to distract himself from feeling sad.  He had episodes of depression in his 20s and 30s, and he was hospitalized 3 years ago after a psychotic episode in which he believed he was a world-renowned sea captain.  During that episode, the patient spent all his savings buying a boat and did not sleep for days while he tried to recruit people to "join his expedition."  His symptoms fully resolved with treatment in the hospital, but he did not follow up after discharge.  The patient's brother says, "He was doing so well after leaving the hospital-no symptoms at all.  This breakup has been really hard on him though."  The patient has no history of substance abuse.  Mental status examination shows slow rate of speech with mild response latency, psychomotor retardation, and depressed mood.  He has no suicidal ideation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7a7_ad97_bc81_51a24e4cf8c9_MD0003_00 All patients who have depression should be screened for a history of mania in order to differentiate unipolar from bipolar disorders. This patient's current symptoms of a major depressive episode and history of a manic episode are consistent with bipolar I disorder. His depressive symptoms include depressed mood, hopelessness, hypersomnia, low energy/lethargy, impaired concentration, and psychomotor retardation on mental status examination. The patient's history of a psychotic episode 3 years ago, characterized by grandiose delusions, decreased need for sleep, and impulsive spending, is characteristic of a manic episode with psychotic features. Patients with bipolar I disorder may have psychotic symptoms (eg, delusions, hallucinations) when they experience severe manic and depressive episodes. The absence of psychotic symptoms outside of mood episodes, as in this patient who is only psychotic when he is manic, rules out primary psychotic disorders. (Choice A) Although the patient's current depressive episode was triggered by a romantic breakup, adjustment disorder is not diagnosed when symptoms are severe enough to meet criteria for another psychiatric disorder such as bipolar disorder. (Choice C) Patients with borderline personality disorder commonly experience mood swings in reaction to interpersonal stressors. However, a personality disorder would not adequately explain this patient's recurrent manic and depressive episodes, and he lacks key borderline personality features such as unstable identity and repetitive self-harm. (Choice D) Major depressive disorder is characterized by major depressive episodes and no history of mania. (Choices E and F) Schizophrenia and schizoaffective disorder are primary psychotic disorders characterized by psychotic symptoms that occur independent of mood episodes. This patient's psychotic symptoms occurred solely when he was clearly manic and completely resolved with treatment of his manic episode. A diagnosis of schizoaffective disorder requires a history of at least 2 weeks of psychotic symptoms in the absence of a mood episode. Educational objective: Bipolar disorder is characterized by depressive and manic episodes. If psychotic symptoms occur, they are only present in the context of a manic or major depressive episode. References: Diagnosis and management of bipolar disorder in primary care: a DSM-5 update. (http://www.ncbi.nlm.nih.gov/pubmed/25134871) Unrecognized bipolar disorder in patients with depression managed in primary care: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/30933689)

A 42-Year-Old Man Comes to the Office with His Brother