A 32-year-old man is brought to the office by his wife for an evaluation after he was placed on probation at work for frequent absences and arguing with his boss. She says, "I'm not surprised it came to this. For the past 9 months he has had unpredictable mood swings. Sometimes he is irritable and paranoid about his coworkers stealing his job, and other times he is quiet and withdrawn." The wife adds that the patient recently had an outburst during a staff meeting in which he accused the company of hacking into his personal computer; he had to be restrained from throwing punches at a colleague. At today's visit, the patient is cooperative but tense, irritable, and talkative. He is physically restless, mildly tremulous, diaphoretic, and hypervigilant. His speech is pressured and difficult to interrupt. He says, "This is all an unfair plot to get rid of me, and now my wife is involved. I have contributed more to this company than anyone and my business plan is pure genius." Temperature is 37 C (98.6 F), blood pressure is 160/100 mm Hg, pulse is 105 /min, and respirations are 16/min. Pupils are dilated and reactive to light. Which of the following is the most likely explanation for this patient's behavior?

Question

A 32-year-old man is brought to the office by his wife for an evaluation after he was placed on probation at work for frequent absences and arguing with his boss.  She says, "I'm not surprised it came to this.  For the past 9 months he has had unpredictable mood swings.  Sometimes he is irritable and paranoid about his coworkers stealing his job, and other times he is quiet and withdrawn."  The wife adds that the patient recently had an outburst during a staff meeting in which he accused the company of hacking into his personal computer; he had to be restrained from throwing punches at a colleague.  At today's visit, the patient is cooperative but tense, irritable, and talkative.  He is physically restless, mildly tremulous, diaphoretic, and hypervigilant.  His speech is pressured and difficult to interrupt.  He says, "This is all an unfair plot to get rid of me, and now my wife is involved.  I have contributed more to this company than anyone and my business plan is pure genius."  Temperature is 37 C (98.6 F), blood pressure is 160/100 mm Hg, pulse is 105 /min, and respirations are 16/min.  Pupils are dilated and reactive to light.  Which of the following is the most likely explanation for this patient's behavior?

Quizplus · Accepted Answer

This patient's history of mood swings and erratic behavior and his physical findings consistent with sympathetic nervous system stimulation (tachycardia, pupil dilation, diaphoresis, and tremors) are most likely due to cocaine use disorder. Psychiatric effects of cocaine include anxiety, irritability, mood swings, panic attacks, grandiosity, impaired judgment, and psychotic symptoms (eg, paranoia, hallucinations). When intoxicated, patients using cocaine are frequently energetic, restless, and hypervigilant and may exhibit euphoria and grandiosity that resemble an acute manic episode. Paranoid and grandiose delusions and auditory, visual, or tactile hallucinations may occur. Cocaine withdrawal frequently presents with depression and lethargy. (Choice A) A diagnosis of bipolar disorder requires distinguishable episodes of hypomania, mania and/or depression lasting for a determined period of time (≥4 days for hypomania, ≥1 week for mania, ≥2 weeks for a major depressive episode). Evidence that the patient's mood symptoms have occurred independently of substance use is also required. Vital sign abnormalities, dilated pupils, diaphoresis, and tremors are not typically seen in mania and are more likely an indication of sympathomimetic use. (Choices C, D, and F) Delusional disorder is characterized by persistent delusions and no other psychotic symptoms. Paranoid personality disorder involves a lifelong pattern of distrust and suspiciousness. Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behavior, and negative symptoms for ≥6 months. None of these disorders would explain the patient's physical findings or pressured speech. (Choice E) Phencyclidine (PCP) intoxication may cause psychotic symptoms and violent behavior; however it typically presents with nystagmus. Educational objective: Cocaine use disorder can present with anxiety, irritability, mood swings, grandiosity, and psychotic symptoms such as paranoia and hallucinations. Physical signs of sympathetic nervous system activation can help differentiate cocaine-induced symptoms from primary mood and psychotic disorders. References: Diagnosis and consequences of cocaine addiction. (http://www.ncbi.nlm.nih.gov/pubmed/22856661) Cocaine-induced psychotic symptoms in clinical setting. (http://www.ncbi.nlm.nih.gov/pubmed/24679995) Cocaine-induced psychotic disorders: presentation, mechanism, and management. (http://www.ncbi.nlm.nih.gov/pubmed/25392252)

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