The nurse is taking the history of a patient found in the street trying to stop traffic. The patient admits to multiple recent long episodes of severe depression. Then, 12 days ago, the patient described feeling elated and “on top of the world.” He recounts many days planning far-reaching projects that would “change the world,” and required only an hour of sleep once or twice. Patient is talking continuously in a rapid, rushed manner and cannot seem to complete a thought without jumping to the next. He sometimes sees things that others do not see. The nurse anticipates which diagnosis?

Question

The nurse is taking the history of a patient found in the street trying to stop traffic.  The patient admits to multiple recent long episodes of severe depression.   Then, 12 days ago, the patient described feeling elated and &ldquo;on top of the world.&rdquo;  He recounts many days planning far-reaching projects that would &ldquo;change the world,&rdquo; and required only an hour of sleep once or twice.  Patient is talking continuously in a rapid, rushed manner and cannot seem to complete a thought without jumping to the next. He sometimes sees things that others do not see. The nurse anticipates which diagnosis?

Accepted Answer

Bipolar 1 disorder. Bipolar 1 disorder is characterized by multiple prolonged periods of severe depression alternating with manic episodes.  Importantly, only one manic episode is required to make the diagnosis.  This patient has multiple long periods of severe depression.  Most recently, this patient had and is likely still currently in a manic episode, characterized by at least 1 week of continuous profound elation, irritability or expansiveness as well as 3 of many common characteristics, which includes not needing sleep, continuous pressured speech, and flight of ideas or racing thoughts.  The presence of a hallucination indicates true mania in this context and distinguishes it from borderline personality disorder. Borderline personality disorder is characterized by emotional instability and impaired functioning, affect, mood and interpersonal relationships. Major depressive disorder would not present with any symptoms of mania but rather continuous profoundly depressed mood.  Schizophrenia would present with hallucinations and at least 6 months of loss of affect and disorder thoughts and ideas. Depression would be absent.

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