Wild Mood Swings and Outbursts of Anger: What's Wrong with this Man? | Case Study

A new case study in which the patient, a 50-yr-old male of mixed race visits his primary care physician with concerns about wild mood swings and outbursts of anger. "I've been screaming at my husband. The other day I even pushed him."

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Wild Mood Swings and Outbursts of Anger: What's Wrong with this Man? | Case Study

Chief Complaint

A 50-yr-old male of mixed-race states that over the past six months he has been experiencing mood swings and outbursts of anger. "I'm out of control. One minute I'm happy and the next I'm furious. I've been screaming at my poor husband. The other day I even pushed him, and all he did was break my favorite coffee mug. I didn't push him hard, but it frightened me. My dad used to knock my mother around and I don't want to be like him. If I sit still for too long, I start thinking about all the bad things in my life and my heart starts racing. It feels sometimes like the world is coming to an end. I don't understand what's going on – I'm a happy person. I hope I don't have a brain tumor or something.”

History of Present Illness

Patient states that after pushing his partner last week, they sat down and talked about the incident. "My husband helped me realize that I've been getting worse. I hadn't realized it, but when I think back I can recall these feelings being around for at least 6 months. I think I've been in denial.” Patient has gained 20 lbs since his last visit 9 months ago.

General Appearance 

Patient appears tired and is tearful. His skin is light brown in color, and he appears to be slightly overweight, though he is also muscular. He has male pattern baldness and wears glasses. His hair is cut short and he is clean-shaven and appropriately dressed. Speech is rushed at times, but content is normal. Patient has difficulty making eye contact during assessment.

Past Medical History

Unremarkable

Family History

Father died from colon cancer 5 years ago at the age of 67. Patient states his friends from back home report his mother is alive and well. His only sibling, a brother died of an opioid overdose at age 41. No other known family history of mental illness.

Social History

The patient has been married to his partner for over ten years He and his partner are physically active and enjoy hiking and gardening together. Eighteen months ago, his brother died of an overdose. He became estranged from his parents fifteen years ago after coming out. "My brother kept me posted about my father's illness, but they didn't want me to visit. I wasn't invited to the funeral. Now there's no chance for reconciliation. I don't even know if my mother knows where I live. I really wish she could accept me for who I am. I was close to my brother – I really miss him. The last few years have been hard.”

Patient drinks 1-2 beers several times a week, has never smoked. "I used to party pretty hard in college, but I don't use drugs anymore, not with my brother's situation. It just seemed wrong.”

The patient is an attorney for a low-cost legal service in his county. His partner is an elementary school teacher. They are very active in their Unitarian Church.

Medications

He takes loratadine for allergies and atorvastatin for high cholesterol. 

Allergies

NKA

Questions

  1. Is there a mental health diagnosis that fits these symptoms? If not, what's causing his mood swings and outbursts of anger?
  2. What about the weight gain, racing heart and feelings of worry?
  3. What information could you ask for that would give you the most information for a diagnosis?
  4. What labs do you want?
  5. What other diagnostic tests should we run? Ask me some questions!

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Specializes in Psych (25 years), Medical (15 years).

I need to request more information, like sleeping habits, spending habits, areas of interest, and anything where his behavior has affected other areas of his life besides his relationship- his work as a lawyer, for example.

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Specializes in Education, Informatics, Patient Safety.
18 minutes ago, Davey Do said:

I need to request more information, like sleeping habits, spending habits, areas of interest, and anything where his behavior has affected other areas of his life besides his relationship- his work as a lawyer, for example.

Thank you for asking, Davey Do! When asked about sleeping habits the patient says, "I just want to sleep all the time. I'm so tired." He has struggled with wanting to go to church and has felt too tired to garden. "The only thing that hasn't been affected is work. I'm good at compartmentalizing, I guess." His spending habits have not changed.

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Specializes in Psych (25 years), Medical (15 years).

Thank you for that additional information, SafetyNurse.

I am not giving a diagnosis, just wanted to share something I learned from a couple of situations.

In the early '90's, I worked at a state mental hospital and noted that a patient was prescribed Tegretol. I checked the patient's chart and found no history of seizures, or an axis III of a seizure d/o.

I asked the psychiatrist his reason for prescribing Tegretol, a med that I had a history of administering only for a seizure d/o. The psychiatrist told me, "We've found that seizure medication helps patients who experience explosive episodes".

Years later, after I had experienced administering meds like Tegretol, Depakote, and Lamictal to patients for symptoms of explosive episodes or mood swings, I questioned a neurologist. I asked him if an explosive episode was not unlike a seizure, with an inordinate amount of neurotransmitters being released in the brain helter skelter.

The neurologist affirmed my belief, that indeed this was what occurred in the brain during an explosive episode.

Just interesting tidbits, I thought.

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Specializes in Education, Informatics, Patient Safety.
1 hour ago, Davey Do said:

Thank you for that additional information, SafetyNurse.

I am not giving a diagnosis, just wanted to share something I learned from a couple of situations.

In the early '90's, I worked at a state mental hospital and noted that a patient was prescribed Tegretol. I checked the patient's chart and found no history of seizures, or an axis III of a seizure d/o.

I asked the psychiatrist his reason for prescribing Tegretol, a med that I had a history of administering only for a seizure d/o. The psychiatrist told me, "We've found that seizure medication helps patients who experience explosive episodes".

Years later, after I had experienced administering meds like Tegretol, Depakote, and Lamictal to patients for symptoms of explosive episodes or mood swings, I questioned a neurologist. I asked him if an explosive episode was not unlike a seizure, with an inordinate amount of neurotransmitters being released in the brain helter skelter.

The neurologist affirmed my belief, that indeed this was what occurred in the brain during an explosive episode.

Just interesting tidbits, I thought.

Yes! I love learning - thanks for that - I will squirrel that knowledge away and break it out for a future case study.

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Specializes in Public Health, TB.

I would want to check thyroid, and a CMP to rule out any metabolic issues. Also, perhaps check for hepatitis B and C, and HIV status. At his age, I would get an EKG. Perhaps not related to this crisis, but I hope he has had colon cancer screening, due to family hx and age. 

Interesting that the patient mentioned brain tumor. Is there a good reason for this? 

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Any thyroid labs available ... need to rule out endocrine issues which are often overlooked in men.

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Specializes in Psych (25 years), Medical (15 years).

Good calls, nursej and Karen!

It was a standard practice to draw labs and see if anything was off with the Chemistry and might be the underlying cause!

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Specializes in Education, Informatics, Patient Safety.

The patient mentioned concern over having a brain tumor because he is incredibly anxious and worried about his health and behavior. There are many folks who automatically think they have cancer when they start having mysterious or unexpected symptoms. 

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Specializes in CEN.

Any skin changes that he has noticed? Pigmentation or thinning of the skin? Hair loss on his legs?

EKG for heart abnormalities?

Is he getting sick more often?

What are his sugar levels and A1C?

What about testing for TSH, T3, T4, thyroid antibodies, estrogen, or cortisol?

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Specializes in Mental health, substance abuse, geriatrics, PCU.

Does he have nightmares? What is the content and how often per week? Are they distressing?

What happens when he feels "the world is coming to an end" does he become angry? Does he then have outbursts? Any reports of hypervigilance? Does he report being startled easily? Does he ever experience flash backs to events in his life that were traumatic? Are there reports or evidence of tics, tremors, skin picking, trichotillomania? Any self injurious behavior such as cutting or burning?

How is work? How many hours per week is he working, more or less than normal? Does he have any feelings of anxiety or increased stress related to work? Has he had outbursts at work? Has anyone commented on any change of behavior at work? Any attendance or performance issues?

What kind of mood does he endorse? Any reports of sadness, anhedonia, slow speaking or thoughts, suicidal thoughts, previous attempts, passive wish for death? Any homicidal thoughts?

A good medical work up is indicated as other posters have previously suggested. I would go ahead and do a UDS and BAC/breathalyzer just to objectively exclude substances. The comment about the brain tumor really doesn't concern me at this point, a lot of patients with a new onset of psychiatric symptoms feel as though they are "going crazy" and one explanation for this they fear is the possibility of a brain tumor.

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Is this started after his brother’s death? His brother used to give information about his parents, now he is not there to give him parents information, may be he miss his bro and family ? Be at of that emotional stress he started getting anger?

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