A 37-year-old factory worker comes to your office because his wife thinks he has a problem. He takes no drugs and has no significant past medical history other than an episode of depression. He is not currently depressed. He says that he feels “great,” has plenty of energy, and is the “fastest assembler in the plant.” However, he does admit to being more irritable than usual and often feeling restless. On weekends and holidays he goes 48 hours without sleeping, choosing instead to spend time on the Internet, “looking at stuff I shouldn’t see and buying stuff I can’t afford.” He admits that he sometimes oversteps social boundaries by calling friends at inappropriate times of the day or expounding on his intense religious convictions.
Which one of the following is the most likely diagnosis?
Correct Answer B:
This patient’s symptoms are most consistent with bipolar II disorder/hypomania. According to the DSM-IV, bipolar II disorder is characterized by one or more major depressive episodes accompanied by at least one hypomanic episode. Hypomanic episodes consist of an elevated mood, often with expansive or irritable qualities. Patients with hypomania feel like they have abundant energy and often speak rapidly or interrupt others repeatedly. They usually are convinced of their own talent and often have intense religious and/or sexual interests. They usually have a decreased need for sleep, spend money beyond their means, and take unnecessary risks. Their intense social interest may cause them to call friends at inappropriate times, especially late at night.
A diagnosis of bipolar II disorder requires a history of depression and a hypomanic state at some time in the past that caused impaired relationships or function and that is not explained by a medical condition, drugs, or other psychiatric diagnosis (i.e., schizophrenia). However, if symptoms have ever been fully manic, the diagnosis would be bipolar I disorder.
→ Symptoms of attention deficit disorder (ADD) (choice A) persist into adulthood in up to 50% of children diagnosed with ADD, and can be similar to those in this patient. There is insufficient information from his history regarding childhood symptomatology to support a diagnosis of ADHD.
→ Although the patient notes irritability and restlessness, he does not report excessive anxiety and worry, which are the central symptoms of generalized anxiety disorder (choice c).
→ Borderline personality disorder (choice D) is characterized by a similar pattern of marked impulsivity and poor social boundaries. However, it is diagnosed primarily in women (75%), and this patient apparently has been able to maintain a stable marital relationship up to this point, which would be unusual.
→ Schizophrenia (choice E) is characterized by positive (hallucinations, delusions) and negative symptoms (flattened affect, loss of a sense of pleasure, loss of will or drive, and social withdrawal). Given this patient's symptoms, he's unlikely to fit this diagnosis.
A 30-year-old female presents with a complaint of years of recurrent insomnia. She often lies awake with her mind “racing,” so she uses alcohol nightly to help her fall asleep. She also has trouble focusing at work. She has been treated for depression several times since age 22, but she does not improve with antidepressant therapy. She has no family history of psychiatric disorders.
Which one of the following statements is true regarding this patient?
This patient has many features of bipolar II disorder, which is defined as hypomania plus at least one episode of depression. While the patient does not have a family history suggestive of bipolar disorder (which is highly heritable), her insomnia, racing thoughts, and trouble focusing are compatible with hypomania. Unresponsiveness or worsening with antidepressant treatment also suggests bipolar disorder; therefore, trying another antidepressant without a concomitant mood stabilizer is inappropriate. Stimulant therapy also is inappropriate, at least until the mania is controlled, especially with a history of alcohol misuse. This patient has many psychiatric clues that make obstructive sleep apnea unlikely.
A 60-year-old female patient comes in with a complaint of multiple episodes of abnormally elevated energy levels and sudden mood changes in one week, followed by one or more depressive episodes, the next week. According to this description, you think she is suffering from bipolar disorder.
A number of reasons exist to obtain all of the following studies, except:
Correct Answer C:
First, one needs to perform the tests to determine the diagnosis. Because bipolar disorder encompasses both depression and mania and because a significant number of medical causes for each state exists, an extensive range of tests is indicated. The basic principle remains, "do not miss a treatable medical cause for the mental status."
→ Substance and alcohol screen: Alcohol abuse and abuse of a wide variety of drugs can present as either mania or depression. For example, speed (ie, amphetamines) and cocaine abuse can present as a mania like disorder, and barbiturate abuse can present as a depression like disorder.
→ Electrolytes: This test is used to diagnose electrolyte problems, especially with sodium, that are related to depression. Hyponatremia, ie, low sodium can manifest as a depression. Treatment with lithium can lead to renal problems and electrolyte problems.
→ CBC count with differential: This test is used to rule out anemia as a cause of depression.
→ Serum proteins: Low serum proteins found in patients who are depressed may be a result of not eating. Low serum proteins increase the availability of certain medications because they have less protein to which to bind.
An agitated 30 year old businessman is brought to the ER by two police officers.
The patient was trying to get into the governor’s residence and when the security guards made an attempt to stop him, he was combative and tried to attack them. When asked about his behavior, he replies “I found the solution for the Middle East crisis; I am so excited to tell the governor and Mr. President about it”. The patient is very talkative, his speech is pressured and jumps from one idea to the other rapidly.
His past medical history is non contributory. Physical exam is within normal limits except for irritability as the patient feels that you are wasting his time and there is nothing wrong with him. Lab tests, including a urine toxicology screen, are normal.
Which of the following is the most likely diagnosis of this patient?
Correct Answer A:
Only one acute attack of mania is enough for the diagnosis of bipolar disorder type I. An acute manic attack is characterized by an abnormally elevated and irritable mood for more than 1 week. Mania is often accompanied by Distractibility, Decreased need for sleep, Increased energy, Increased self esteem, Grandiosity, Flight of ideas, Agitation, hyper-Sexuality and Talkativeness “remember the famous mnemonic DIG FAST”
Bipolar disorder type II is characterized by the presence of hypomania and major depression.
Dysthymia is a chronic depressive state for more than 2 years.
Cyclothymia is a slow cycling between hypomania and depressed mood for more than 2 years.
Schizophrenia is characterized by hallucinations, bizarre delusions, disorganized behavior and speech for more than 6 months.
Loosening of association is most commonly associated with which of the following?
Loosening of association (derailment) is a manifestation of a severe thought disorder characterized by the lack of an obvious connection between one thought or phrase and the next. In moving from one sentence or clause to another, the person shifts the topic idiosyncratically from one frame of reference to another and things may be said in juxtaposition that lack a meaningful relationship.
This disturbance occurs in schizophrenic patients.
Note: This is in contrast to flight of ideas where a person jumps from one topic to another and there is a connection among the topics (seen in bipolar).
Click to expand