This is the story of a 33 year old woman who was brought into the emergency room by her husband who found her to be undergoing what he described as “another cycle of depression”. She was a mother of two children and a stock analyst. Her husband noted that for the last 10 days she had no sleep and was moved to tears easily. He had also noticed that she had been reacting negatively to almost anything with the slightest provocation. Such “dark” periods had been occurring ever since the husband had known her, but its frequency had increased to six episodes in the past year alone. Each time, a few weeks after taking medicines, the woman would appear better. But during such phases, she would also have a tendency to consume alcohol and sleeping pills which seemed to worsen her symptoms.

Recently, the husband was surprised to find his wife taking decisions and committing acts which were not only potentially risky but also contradictory to the woman’s innate nature. She had been actively working on risky ventures while neglecting her children and responsibilities at work, as she thought that her endeavours would make them very rich.

Since her college days, the woman had been having phases of sadness interspersed with recurrent spells of sleeplessness, hyper alertness and unusually rapid speech. This had started right after her alcoholic father, whom she was very close to, had committed suicide. Her paternal grand-mother was also known to have suffered from “nervous breakdowns”.

In the past, she had consulted a psychiatrist when she experienced a low phase and tried anti-depressant medication, as well as psychotherapy, but the fluctuations in her mood were deteriorating. A part of this could be because the woman was irregular in her visits to the doctor and in following the treatment advice. She would only visit her doctor during the low phases but never during the times of sleeplessness, irritability and restlessness which allowed her doctor limited scope evaluation and a lack of holistic view.

During evaluation in the emergency room, the woman’s mood was angry and she was restless. She declared she was fine and wanted to be excused so that she could go home and attend to urgent work. She mentioned that she had the special ability to make predictions regarding the stock market suggesting inflated self-esteem, typically seen during an excited phase. Although she admitted that she was not getting any sleep, she denied that it was a “problem”. Her speech was rapid, pressured and difficult to interrupt. She refused to cooperate for any psychological testing and insisted that the whole thing was a miscommunication. Does this case seem to require a more detailed evaluation?

i) Have you seen this kind of person around you?

ii) What you think about it? Is it a psychiatric problem which needs treatment?

iii) Is it a normal variation of mood and behaviour?

iv) Possible diagnosis?