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“Ms. V,” a 60-year-old college-educated woman, was brought by her daughter to the emergency department at a teaching hospital for the evaluation of heart palpitations. Ms. V had personality changes and mood swings with aggressive verbal and physical behaviors that had progressively worsened over the past year. A psychiatric consultation was requested to evaluate these emotional outbursts. On the day of admission, Ms. V had had a court hearing for assaulting her brother, who is disabled due to mental retardation. One month before presentation, she had held a pillow over his face in front of the brother’s social worker, who then called the police. After this event, her brother, who has been dependent on others for self-care since childhood, disappeared for several days. She was unconcerned about her legal situation and appeared cold and indifferent. She did not report that she did anything more than throw a pillow at her brother’s face, and she laughed when she heard that he was missing. Ms. V’s daughter reported that her mother had become increasingly irritable, with episodes of unprovoked shouting of profanities at strangers and family members. These behaviors were uncharacteristic of the patient’s personality at baseline. She had had an increase in goal-directed activities, cleaning the house constantly, checking the locks, and checking the stove. Two years before, Ms. V was fired from her job as a school administrative assistant because of difficulties managing her relationships with the students’ parents. Since then, she had not made any attempts to seek other employment. There was no history of head trauma, loss of consciousness, seizures, or previous contact with mental health providers. Ms. V reported no new stressors but did report some “moodiness” over the last 6 months. She reported no angry outbursts or violence but endorsed a decreased need for sleep (now 6 hours, down from 8, per night). Although she did not report feeling euphoric, she reported increased irritability, daytime energy, task-oriented behavior, impulsivity, distractibility, racing thoughts, and pressured speech. Ms. V did not report feeling depressed or experiencing anhedonia. She reported no anxiety or psychotic symptoms, substance use, or recent changes in medications. Ms. V did not report any specific memory complaints, word-finding difficulties, misplacing or losing objects, or problems using transportation, following directions, or navigating. Her family history was notable for a brother with mental retardation and a sister with unipolar depression. Ms. V’s vital signs were within normal limits, and complete physical and neurologic examinations were unremarkable. A CBC, a Chem 10 (basic chemistries), liver function tests, tests of thyroid-stimulating hormone, free thyroxine, rapid plasma reagin, B12, and folate, an ECG, a chest X-ray, and a head computerized tomography with and without contrast showed no abnormalities.