MEDizzy - A 42-year-old woman is brought to the emergency department

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Mood disorders

A 42-year-old woman is brought to the emergency department by police after attempting to rob a liquor store because it is what “God wanted her to do.” The patient reports that she believes she is “the Messiah” and is carrying “the word of the Almighty.” She reports she hears God talking to her often throughout the day. She states she feels “fantastic,” and has gone almost a week without sleeping. Her speech is significantly pressured, and she is easily distracted. Her medical record indicates she has had three prior episodes of psychotic symptoms associated with elevated mood. Which of the following is the most likely diagnosis?

ExplanationThe correct answer is A. The patient is having a manic episode with psychotic symptoms. Psychosis is defined as a psychiatric disorder in which conceptions of reality are severely impaired. In her medical record, there is no incident reported in which the patient displayed psychotic symptoms in the absence of significant mood changes, which would change the patient’s diagnosis to schizoaffective disorder, thus the patient is given the diagnosis of bipolar I disorder. This can be a difficult distinction to make clinically. Answer B is incorrect. Bipolar II disorder involves episodes of hypomania rather than mania. Hypomania can be thought of as a less severe form of mania that does not significantly impact social functioning. A hypomanic may engage in reckless or objectionable behaviors, but does not exhibit psychotic features such as hallucinations or delusions. Answer C is incorrect. Cyclothymic disorder involves hypomanic episodes interspersed between several years of depressive symptoms. Hypomania can be thought of as a less severe form of mania that does not significantly impact social functioning. Answer D is incorrect. For the diagnosis of schizoaffective disorder to be made, the patient must have had psychotic symptoms in the absence of mood symptoms at some point. Since she does not fulfill this criterion, bipolar I is the better diagnosis at this point. Psychosis is defined as a psychiatric disorder in which conceptions of reality are severely impaired.