Nancy Ingram, a 33-year-old stock analyst and maried mother of two children, was brought to the emergency room (ER) after 10 days of what her hus- band described as "another cycle of de- pression," marked by a hair-trigger tem- per, 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 symp- toms, because she routinely ramped up their use when the dark periods began. Ms. Ingram's husband said he had de- cided to bring her to the ER after he dis- 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 psychother- apy sporadically and taken a series of an- tidepressant medications, but her hus- band 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 dur- ing her periods of edginess and insom- nia-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 pac- ing angrily in the exam room. She was dressed in jeans and a shirt that was carelessly unbuttoned. Her eyes ap- peared glazed and unfocused. She re- sponded 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 imme- diately 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 prob- lem. She denied hallucinations but ad- mitted, with a smile, to a unique ability to predict the stock market. She refused cognitive testing, saying she would de- cline the opportunity to be a "trained seal, a guinea pig, Mr. Ed, and a barking dog, thank you very much, and leave now?" Her insight into her situa- tion appeared poor, and her judgment was deemed to be impaired. 3.2. vered that she had recently created a g entitled Nancy Ingram's Best Stock ks. Such an activity not only was out character but, given her job as a stock alyst for a large investment bank, was ctly against company policy. He said t she had been working on these stock ks around the clock, forgoing her own als as well as her responsibilities at rk and with her children. She coun- ed that she was fine and that her blog uld "make them as rich as Croesus." The patient had first been diagnosed h depression in college, after the death er father from suicide. He had been a ily erratic, alcohol-abusing business- whom the patient loved very much. paternal grandrmother had several vous breakdowns," but her diagnosts may