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At 3 A.M. a middle-aged woman arrives at the ER escorted by police. She shouts, “I love you, Jesus! Jesus is my savior!” at the top of her lungs and throws kisses to everyone. Neighbors called the police because she had been singing church hymns for six hours. The patient tells the resident on call that two weeks earlier she had flushed her medications down the toilet because they made her go to the bathroom too much, gave her pimples, and made her food taste bad.
What is the most likely diagnosis?
a.Cocaine intoxication
b.Schizophreniform disorder
c.Acute elated mania
d.Dysphoric mania
e Manic delirium
What medication did this patient flush down the toilet?
a.Valproic acid
b.Haloperidol
c.Carbamazepine
d.Lithium
e.Sertraline
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ANSWERS
The answers are c,d. (Sadock, 7/e, pp 1347–1351.) Mood elevation, mood lability, irritability, expansive behavior, increased energy, decreased need for sleep, lack of insight, poor judgment, disinhibition, impulsivity, and pressured speech are characteristic symptoms of elated acute mania. In more severe cases, mood-congruent delusional ideations and hallucinations are present. Dysphoric mania refers to a mixed state characterized by symptoms of mania, such as grandiosity, irritability, increased energy, and agitation, coexistent with depressive symptoms, such as suicidal ideation and dysphoric mood. Although cocaine intoxication may mimic acute mania, in the scenario described in the vignette, this is an unlikely diagnosis since the patient had been on a mood stabilizer for some time. Delirious mania refers to an extremely severe form of mania, characterized by frenzied physical activity that leads to life-threatening emergencies. Lithium is still the treatment of choice for acute mania and maintenance, although anticonvulsivants such a valproate and carbamazepine have been proved effective. Newer anticonvulsivants, such as gabapentin, topiramate, and lamotrigine, have also proved to have mood-stabilizing properties, although these medications have not been extensively studied yet. Weight gain, metallic taste, acne, hypothyroidism, and polyuria are common complaints with long-term lithium treatment.
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