A 30-year-old man is brought to the emergency depament by police, who arrested him because he was in the parking lot of a local mall, yelling "I am a golden god" as he stepped in front of moving cars. When questioned about his identity, he talks incessantly in a rapid fashion and threatens to "unleash God's wrath on those who do not submit." He repos that he has not slept in a week, and does not need sleep. He has spent the last week preparing for a secret government mission that only the president knows about. When asked if he ever hears God talking to him, he says, "Of course not, I am God!" Police repo that he has had several prior arrests for reckless driving and lewd acts. On examination, he is disheveled and malodorous. It is nearly impossible to get any fuher history, as he rapidly paces about and mutters, "I must go, I must go" over and over again.Which of the following is the most likely preliminary diagnosis?
This patient is displaying many of the diagnostic criteria for bipolar disorder. He has had a distinct period of abnormally and persistently elevated mood lasting at least one week. In addition, his thoughts are grandiose ("I am a golden god"), he has a decreased need for sleep, and he has pressured and excessive speech. His arrest history indicates possible previous sexual indiscretions, which are a hallmark of bipolar disorder (excessive involvement in pleasurable activities that have a high potential for painful consequences). His pacing indicates psychomotor agitation, also a hallmark of bipolar disorder. This patient probably has a history of severe depressive episodes, but the occurrence of a single manic episode allows the diagnosis of bipolar disorder to be made. Antisocial personality disorder refers to a long-standing pattern of socially irresponsible behavior that reflects a disregard for the rights of others. These individuals were formerly called psychopaths, and generally lack a conscience. Many people with this disorder engage in unlawful acts. The most pervasive characteristic is a lack of remorse for the harm they cause others. Borderline personality disorder refers to a lifelong pattern of unstable affect and self-image with erratic behavior. Borderlines have interpersonal relationships that are intense, but very unstable ("love-hate" relationships). They are prone to self-mutilation and the defense mechanism of splitting. But they have a life of chaos, not a sense of grandeur and power, so the diagnosis does not fit this case. Posttraumatic stress disorder is an anxiety disorder that develops surrounding a traumatic event. Symptoms revolve around the event and include reexperiencing of the trauma, avoidance of associated stimuli, psychic numbing, and increased autonomic arousal Ref: Brent D.A., Pan R.J. (2008). Chapter 39. Bipolar Disorder. In M.H. Ebe, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds), CURRENT Diagnosis & Treatment: Psychiatry, 2e.
Antisocial personality disorder
Bipolar disorder
Borderline personality disorder
Post traumatic stress disorder