Reference no: EM133429653

Read the following case vignette. You will then be asked to provide an open response regarding the key symptoms and signs that you noticed that would contribute to your diagnosis. After that, you can choose what you believe to be the correct diagnosis in a multiple-choice question.

Cycles of Depression

Nancy Ingram, a 33-year-old stock analyst and married mother of two children, was brought to the emergency room (ER) after 10 days of what her husband described as "another cycle of depression," marked by a hair-trigger temper, tearfulness, and almost no sleep. He noted that these "dark periods" had gone on as long as he had known her but that she had experienced at least a half dozen of these episodes in the prior year. He said they typically improved within a few weeks of restarting her fluoxetine. He added that he wondered whether alcohol and clonazepam worsened her symptoms, because she routinely ramped up their use when the dark periods began.

Ms. Ingram's husband said he had decided to bring her to the ER after he discovered that she had recently created a blog entitled Ms. Ingram's Best Stock Picks. Such an activity not only was out of character but, given her job as a stock analyst for a large investment bank, was strictly against company policy. He said that she had been working on these stock picks around the clock, forgoing her own meals as well as her responsibilities at work and with her children. She countered that she was fine and that her blog would "make them as rich as Croesus."

The patient had first been diagnosed with depression in college, after the death of her father from suicide. He had been a wildly erratic, alcohol-abusing businessman whom the patient loved very much. Her paternal grandmother had several "nervous breakdowns," but her diagnosis and treatment history were unknown. Since college, her mood had generally been "down," interspersed with recurrent bouts of enhanced dysphoria, insomnia, and uncharacteristically rapid speech and hyperalertness. She had tried psychotherapy sporadically and taken a series of antidepressant medications, but her husband noted that the baseline depression persisted and that the dark periods were increasing in frequency.

Her outpatient psychiatrist noted that Ms. Ingram appeared to have dysthymia and a recurrent major depression. He also said that he had never seen her during her periods of edginess and insomnia-she always refused to see him until the "really down" periods improved-and that she had refused him access to her husband or to any other source of collateral information.

On examination, the patient was pacing angrily in the exam room. She was dressed in jeans and a shirt that was carelessly unbuttoned. Her eyes appeared glazed and unfocused. She responded to the examiner's entrance by sitting down and explaining that this was all a miscommunication, that she was fine and needed to get home immediately to tend to her business. Her speech was rapid, pressured, and very difficult to interrupt. She admitted to not sleeping but denied that it was a problem. She denied hallucinations but admitted, with a smile, to a unique ability to predict the stock market. She refused cognitive testing, saying she would decline the opportunity to be a "trained seal, a guinea pig, Mr. Ed, and a barking dog, thank you very much, and may I leave now?" Her insight into her situation appeared poor, and her judgment was deemed to be impaired.

QUESTION

Use this space to take notes regarding prominent symptoms and signs that you noticed, which will help guide your selection of the most likely diagnosis. Feel free to use your DSM-5.