What is the most likely diagnosis for a patient presenting with manic and depressive symptoms, including hyperactivity, increased energy, rapid speech, grandiose beliefs, feelings of worthlessness and guilt, and a history of slowed behavior?

Bipolar I Disorder with Mixed Features

This patient meets diagnostic criteria for Bipolar I disorder with mixed features, based on the presence of a full manic episode (hyperactivity, increased energy, rapid speech, decreased need for sleep for 3 days, grandiose delusions, and excessive involvement in risky activities) occurring simultaneously with prominent depressive symptoms (feelings of worthlessness, guilt, and anhedonia). 1

Diagnostic Reasoning

Manic Episode Criteria Met

• The patient exhibits a clear manic episode lasting at least 3 weeks, which exceeds the 7-day minimum duration required for Bipolar I disorder (or less if hospitalization is required) 1
• Core manic symptoms present include:
  • Increased energy and hyperactivity 2
  • Rapid/pressured speech 2
  • Decreased need for sleep (3 days without sleep) 2
  • Grandiose delusions (belief in god-given powers to predict roulette outcomes with 100% accuracy) 2
  • Excessive involvement in risky, goal-directed activities (internet gambling depleting savings) 2
• These symptoms represent a significant departure from baseline functioning, as evidenced by the relative's report that he "typically appears slowed down" outside this episode 1

Mixed Features Specifier Applied

• The patient simultaneously experiences prominent depressive symptoms during the manic episode: feelings of worthlessness, guilt, and anhedonia (nothing is fun) 3, 4
• Mixed features are present in approximately 40% of bipolar patients and represent concurrent manic and depressive symptomatology 3
• DSM criteria for a full mixed episode require both complete manic AND complete depressive syndromes co-occurring for at least 1 week 4, but the mixed features specifier allows diagnosis when prominent symptoms of the opposite polarity occur during a mood episode 3

Why Other Diagnoses Are Excluded

Bipolar I with Atypical Features - Incorrect

• Atypical features refer to a specific pattern of depressive symptoms (mood reactivity, increased appetite/weight gain, hypersomnia, leaden paralysis, interpersonal rejection sensitivity), not the presentation described here 5, 6

Bipolar II Disorder - Incorrect

• Bipolar II requires only hypomania (lasting at least 4 days), never full mania 1, 7
• This patient has a full manic episode with grandiose delusions, 3 days without sleep, and severe functional impairment (depleted savings), which far exceeds hypomania severity 7
• Hypomania must not cause marked impairment or require hospitalization, whereas this patient's symptoms are severe enough to warrant emergency evaluation 7

Cyclothymic Disorder - Incorrect

• Cyclothymic disorder involves chronic mood instability with hypomanic and depressive symptoms that never meet full criteria for manic or major depressive episodes 1
• This patient has a clear, discrete full manic episode, ruling out cyclothymia 1

Substance-Induced Bipolar Disorder - Incorrect

• The urine drug screen is negative and there are no medications or medical conditions reported 5, 6

Critical Clinical Implications

Prognosis and Course

• Mixed mania has worse prognosis than pure mania, with higher recurrence rates, greater risk of rapid cycling, increased suicidal ideation and attempts, and more treatment resistance 3, 4
• Patients with mixed features have more severe symptomatology and worse clinical outcomes compared to those without mixed features 3

Treatment Considerations

• Antidepressants should be discontinued or avoided during mixed episodes, as they may worsen manic symptoms without improving depressive symptoms 3, 4
• First-line treatment includes mood stabilizers (lithium, valproate) and/or atypical antipsychotics (olanzapine, aripiprazole, quetiapine) 1, 2, 8, 5
• Severe mixed episodes typically require combination therapy with valproate or lithium plus an atypical antipsychotic 4
• Time to remission is usually longer than in pure mania, and higher medication doses may be needed 4

Common Diagnostic Pitfall

• The presence of depressive symptoms during mania can lead clinicians to misdiagnose unipolar depression and prescribe antidepressant monotherapy, which is contraindicated and may worsen the manic component 6, 3, 4