This patient presented with pressured speech, lack of need for sleep, irritability, and claims of having solved geopolitical issues. She was diagnosed with bipolar I disorder based on her manic episode lasting over a week. She requires hospitalization and treatment with antipsychotics or benzodiazepines to stabilize her mood and psychosis. Long-term treatment will involve a mood stabilizer like lithium to prevent future manic episodes from occurring.

1. Chief Complaint
“Let’sparty.”
Historyand Physical Examination
Police are calledtoa 34-year-oldwoman’sapartmentafterneighborscomplainthatshe hasbeen
playingloudmusicall nightforthe past 10 days.Theydiscoverherpacingthe floorinher brightlylit
apartmentat 2:00 a.m.Anyattemptsto talkto herresultinher becomingirritableandabusive.She
reportedlygreetsthemcheerfullyandinvitestheminfor“a party.”She thenattemptstoengage the
officersinapolitical discussion,sayingthatshe hasdiscoveredthe solutiontothe “Middle East
crisis”and has justbeentryingtobuya plane tickettoWashingtonsoshe can explainittothe
president.
Whenthe police bringherto the emergencydepartment,the patientisangryandresistant.There is
no historyof trauma or significantmedical illness.Physical examinationisnormal.However,the
patient’smoodislabile andexpansive.She speaksinapressuredmanner,revealingthatshe hasfelt
verylittle needtosleepoverthe pastweek orso,that she was firedfromherjobfor “inappropriate
behavior,”andthatshe has beenunable topurchase herplane ticketbecause hercreditcardhad
reacheditslimit.The patientseemsquite undisturbedbythese events.
Differential Diagnosis
1. Substance-inducedmooddisorder
2. BipolarI disorder
3. Cyclothymicdisorder
4. Psychoticdisorder(e.g.,schizoaffectivedisorder,schizophrenia)
5. Hyperthyroidism
Initial DiagnosticPlan/TestResults
Urine toxicologyscreen:negative
Thyroidfunctiontests:normal
Assessment
The differential diagnosisbetweenbipolarIdisorderanda psychoticdisorderissometimesdifficult.
In the psychoticdisorders,psychoticsymptomsare usuallypresentinthe absence of mood
symptomsduringsome periods.BipolarII disorderisthe occurrence of ≥1 major depressive episodes
accompaniedbyat least1 hypomanicepisode.
FurtherDiagnosticPlan/TestResults
Past personal andfamilyhistory:nohistoryof psychoticillness,withthe exceptionof 1
previousmanicepisode1yearago; respondedtolitium;nopreviousdepressive episodes
Detailedinterviewwithpatient’srelative,if available
TreatmentPlan
Hospitalize

2. Antipsychotics,initially
Lithium,antipsychotics,lamotrigine,orvalproicacid
Discussion
Thispatientneedstobe hospitalizeduntilshe isstable because she needstobe protectedfromthe
consequencesof poorjudgment,elevatedmood,andgrandiose delusions.Acutely,she shouldbe
treatedwithantipsychoticsorbenzodiazepinesinaquietsettingwithminimumstimuli andfirm
limits.
Once the patienthas beenstabilized,startmaintenance therapywithamoodstabilizersuchas
lithiumorlamotrigine.Itisalsoimportanttoenlistanotherpersoninthe patient’slife (e.g.,afamily
member) tohelpmonitormedication,because patientsoftenbecome noncompliantwith
medications.Some begintofeel “normal”andstoptakingit,whereasothersfeel “down”whenthey
are notmanic and wishtofeel better.
DiagnosticcriteriaforbipolarIdisorderinclude amanicepisode thatmayhave beenprecededby
and maybe followedbyhypomanicormajordepressive episodes.A manicepisode isadistinct
periodof abnormallyandpersistentlyelevated,expansive,orirritable moodandabnormallyand
persistentlyincreasedgoal-directedactivityorenergy,lastingatleast1 weekandpresentmostof
the day, nearlyeveryday.Emotional labilityisalsoseen.Duringmooddisturbance,othersymptoms
may include increasedself-esteemorgrandiosity,decreasedneedforsleep,talkativeness,flightof
ideas,distractibility,psychomotoragitation,orexcessive involvementinpleasurable,high-risk
activities.
If there is only1 manicepisode withnohistoryof majordepressive episodes,the diagnosisis
bipolarIdisorder,single manicepisode. If there has alreadybeenatleast1 manic or mixed
episode,the diagnosiscanbe bipolardisorder,mostrecentepisode mixed,ormostrecentepisode
depressed,dependingoncurrentsymptomatology. Evenwithno historyof depressionor
hypomania,the diagnosisof bipolarIisgiven.
An episode ishypomanicwhenitisnotsevere enoughtocause markedimpairmentinsocial and
occupational functioning,hospitalizationisnotnecessary,andif there are nopsychoticfeatures.
Cyclothymicdisorderisa chronicdisorderof fluctuatingmooddisturbancesinvolvinghypomanic
periodsanddepressive periodsthatdonotmeetcriteriaformajor depression.The above patient’s
symptomsare too severe tobe characterizedashypomanic.
Basic Science Correlate
Lithiumiscommonlyusedasmaintenance treatmentforbipolardisorder.Itpreventsthe recycling
of inositol (decreasingPIP2) byblockinginositol monophosphataseanddecreasingcAMP.Lithium
has a relativelynarrowtherapeuticindexthatpredisposespatientstotoxicity,whichcanbe acute or
chronic.
Acute toxicityisofteninitiallyassociatedwithGIsymptoms(nausea,vomiting,cramping)
whichcan progressto tremulousness,hyperreflexia,ataxiaandpotentiallycardiacdysrhythmias(T-
wave flattening).
Chronictoxicityincludesthe developmentof nephrogenicDI(mostsevere renal
manifestation),hypothyroidism,andasyndrome of irreversible lithium-effectuatedneurotoxicity

3. (SILENT) suchas cognitive impairment,sensorimotorperipheral neuropathy,andcerebellar
dysfunction.
— NephrogenicDIcan occur withchronic lithiumuse since itinhibitsthe actionof antidiuretic
hormone (ADH) onthe distal renal tubule therebyimpairingsodiumandwaterreabsorption.This
conditioncanbe treated withamiloride.
— Hypothyroidismcanoccurwithchroniclithiumuse since itisrapidlytakenupbythyroid
cells.Lithiumresultsinablockade of thyroidhormone releasefromthyroglobulin,whichinhibits
adenylate cyclase andthuspreventsTSHfromstimulatingthyroidcellsviathe TSHreceptor.Lithium
alsoinhibitsthe activityof 5’deiodinase.
Final Diagnosis
BipolarI disorder,singlemanicepisode
BipolarDisorder
Historyof at least1 manic episode
May have evidenceof amajor depressive episode
Treat withmoodstabilizers,suchaslithium, antipsychoticsorvalproicacid,as first-line therapyfor
manicsymptomsandlithium,lamotrigine,quetiapineorlurasidone fordepressive symptoms
Substance-InducedMoodDisorder
Characterizedbydepressedmood;diminished
interest/pleasure;orelevated,expansive,orirritable mood No evidencefromthe physical exam
that the symptomsdevelopedwithinamonthof drug use or intoxicationorthatmedicationuse is
relatedtoetiology
Onlyusedwhenthe symptomsare severe enoughtomeritindependentclinicalattention
Treat on the basisof whichsymptomsare present
CyclothymicDisorder
2 yearsof hypomaniaanddepressivesymptomsnottothe level of MDD