A 26 year-old female is brought to your office by her husband because he is concerned about her symptoms. For over a year, she has been feeling less interested in things she usually enjoyed before, she is irritable ‘over little things’, she has trouble falling asleep, wakes up too early many nights, she is not eating much at the dinner table, she feels very tired ‘even after dishwashing’, when her husband gets intimate with her, she moves away, she is not able to concentrate or remember things, she expresses thoughts of emptiness and meaninglessness, and her husband is not comfortable to leave her alone at home. These symptoms dominated her life for over a year. But over the last two weeks, she is having outbursts of energy and feeling very active. She sounds so cheerful, optimistic and enthusiastic. She talks for hours without taking a break, moving from one subject to another subject. Her thoughts are difficult to follow. She is driving too fast and going on spending sprees. She sleeps only for a few minutes every night. She gets into fights with their neighbors over petty matters like where they keep their trash bags for removal by the waste disposal crew. She believes that she has ‘minds like an Einstein’ and passes judgments on things that are irrelevant to her. She is drinking too much alcohol ‘to calm herself’.  She tells inappropriate jokes in front of children, dresses in inappropriate and colorful clothing; Three days ago, she told her husband that ‘Einstein’s soul is talking to her to explain a new theory of relativity’ to her. She argues that she is smart enough to win a Nobel Prize in Physics. In the morning, she looks too depressed and in the evening she looks like ‘she is over the clouds talking to Einstein’. She urinated in her pants and her husband had to take her to the emergency room. She was hospitalized for two days and was started on medication to calm her down. What is the most likely diagnosis in this patient? 

A.Bipolar Disorder Type I

B.Bipolar Disorder Type II

C.Schizoaffective Disorder 

D.Major depressive disorder with psychotic features 

E.Borderline personality disorder

Correct Answer is A. She has symptoms of depression like feeling less interested in things she usually enjoyed before; has symptoms of mania like having outbursts of energy and going on spending sprees; has symptoms of psychosis like Einstein’s soul talking to her; has been hospitalized during mania attacks and psychosis: she fulfills the criteria for Bipolar type I disorder. A good mnemonic to remember the symptoms and signs of Bipolar disorder is: I feel SIGHTED

Incorrect Answers

B. Bipolar disorder type II is characterized by recurrent episodes of major depression and hypomania. Hypomanic symptoms are similar to manic symptoms but do not reach the same level of symptom severity or social impairment. This patient’s husband is not comfortable leaving her at home. So, her symptoms are severe. Criteria for hypomania are the same as mania but are less intense and not disruptive to normal functioning. Hypomania episodes should last more than 4 days but less than 7 days. She has had mania for over two weeks. Hypomania does not present with psychotic symptoms. This individual had psychosis and was hospitalized for it. 

C.Schizoaffective disorder. One sentence helps to rule out schizoaffective disorder from this patient’s differential diagnosis.  In the morning, she looks too depressed and in the evening she looks like ‘she is over the clouds talking to Einstein’. Psychosis must be present for at least 2 weeks without mood symptoms to make a diagnosis of schizoaffective disorder. This individual has both psychosis and mood disorder on the same days. So, Schizoaffective disorder is out. 

D.Major Depressive Disorder with psychotic features. It is critically important to distinguish MDD from bipolar disorder. The signs and symptoms of the two disorders are identical but the treatments are radically different. One key historical question to ask to rule out MDD from this patient is: Did she ever experience mania or hypomania? Our patient  experienced at least one episode of mania. So, MDD is out. 

E.Bipolar disorder and borderline personality disorder (BPD) can be difficult to distinguish because they share some symptoms, such as mood swings and impulsive behavior. Bipolar disorder is a mood disorder that involves mania and depression. BPD is a personality disorder that’s often triggered by relationships and feelings of abandonment. This patient’s symptoms do not seem to be triggered by relationship and abandonment issues. This patient’s mood swings are more random and less related to events than BPD mood swings, which are more persistent and reactive to environmental factors. She also has manic episodes that last for a few weeks. That is not seen in Borderline personality disorder. 

References: 

First Aid for the® Family Medicine Boards, 3^rd Edition

Tao, Le, MD, MHS, Michael D., Mendoza, MD, MPH, MS, FAAFP, Diana, Coffa, MD, Lamercie, Saint-Hilaire, MD