A 32-year-old man is brought by his wife to the emergency department with a hand injury. The patient "flew into a rage" and punched a mirror when his wife was late coming home from work. The wife says, "He is generally not like this, but for the past couple of weeks, he's been extremely irritable. Everything seems to set him off on a long rant, and I can't get a word in. I'd be cranky too if I were getting as little sleep as he is-he's been working around the clock." The patient has a history of behavioral conditions as a child and had a depressive episode in his twenties. He drinks alcohol socially and does not use drugs. Physical examination shows multiple lacerations on his right hand but is otherwise normal. On mental status examination, he is tense and restless. The patient has no delusions or hallucinations but says, "I can't shut my mind off." Which of the following is the most likely diagnosis?

Question

A 32-year-old man is brought by his wife to the emergency department with a hand injury.  The patient "flew into a rage" and punched a mirror when his wife was late coming home from work.  The wife says, "He is generally not like this, but for the past couple of weeks, he's been extremely irritable.  Everything seems to set him off on a long rant, and I can't get a word in.  I'd be cranky too if I were getting as little sleep as he is-he's been working around the clock."  The patient has a history of behavioral conditions as a child and had a depressive episode in his twenties.  He drinks alcohol socially and does not use drugs.  Physical examination shows multiple lacerations on his right hand but is otherwise normal.  On mental status examination, he is tense and restless.  The patient has no delusions or hallucinations but says, "I can't shut my mind off."  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7a8_97f8_bc81_179ea1a80014_MD0003_00 This patient's 2-week history of extreme irritability associated with increased activity, decreased sleep, impulsivity resulting in self-injury, pressured speech (wife "can't get a word in"), and racing thoughts ("can't shut mind off") suggests a manic episode of bipolar I disorder. His history of a depressive episode in his twenties is consistent with this diagnosis. Although the classic presentation of mania includes an elevated or euphoric mood, many patients in a manic episode have irritability instead. This may manifest as uncharacteristic angry outbursts and aggressive behavior, as in this case. Manic patients typically have markedly increased energy and activity levels. They often have a decreased need for sleep and may describe feeling energetic despite getting little to no sleep. Common findings on mental status examination include restlessness; hyperactivity; loud, pressured speech; and grandiosity. (Choices A and C) Personality disorders involve lifelong patterns of behavior. Antisocial personality disorder is characterized by a persistent violation of other people's rights. In borderline personality disorder, there is a history of unstable relationships, affects, and self-image. Neither disorder explains this patient's abrupt onset of symptoms. (Choice D) Intermittent explosive disorder presents with rage episodes but does not explain this patient's increased activity, decreased sleep, pressured speech, and racing thoughts. Aggressive outbursts in intermittent explosive disorder are generally short-lived (minutes), whereas manic episodes typically last weeks to months. (Choice E) Major depressive disorder is a unipolar disorder that can only be diagnosed in a patient without history of manic episodes. Based on this patient's current mood episode, his diagnosis is bipolar I disorder. (Choice F) Schizoaffective disorder is characterized by mood episodes and psychotic symptoms that also occur in the absence of mood episodes. This patient has no psychotic symptoms. Educational objective Patients with a manic episode of bipolar I disorder may have an irritable rather than euphoric mood, which can manifest as uncharacteristic angry outbursts and aggressive behavior. References: Bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26388529) Clinical characteristics and temperament influences on 'happy' euphoric and 'snappy' irritable bipolar hypo/manic mood states. (http://www.ncbi.nlm.nih.gov/pubmed/25497471)

A 32-Year-Old Man Is Brought by His Wife to the Emergency