What’s causing mood swings and outbursts of anger? 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. Not hard, but it frightened me. My dad used to knock my mother around and I don’t want to be like him. I don’t understand what’s going on – I’m a happy person.” #Case Study #Mood Swings If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. 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. 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 Is there a mental health diagnosis that fits these symptoms? If not, what’s causing his mood swings and outbursts of anger? What about the weight gain, racing heart and feelings of worry? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information. 3 Likes About SafetyNurse1968, ADN, BSN, MSN, PhD (Member) Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. 69 Articles 449 Posts Share this post Link to post Share on other sites
Davey Do Specializes in around 25 years psych, 10 years medical. Has 42 years experience. Monday 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. 2 Likes
SafetyNurse1968, ADN, BSN, MSN, PhD Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. Monday 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. 1 Likes
Davey Do Specializes in around 25 years psych, 10 years medical. Has 42 years experience. Monday 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. 4 Likes
SafetyNurse1968, ADN, BSN, MSN, PhD Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. Monday 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. 2 Likes
nursej22, MSN, RN Specializes in med/surg,CV. Has 36 years experience. Monday 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? 3 Likes
NRSKarenRN, BSN, RN Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience. Monday Any thyroid labs available ... need to rule out endocrine issues which are often overlooked in men. 2 Likes
Davey Do Specializes in around 25 years psych, 10 years medical. Has 42 years experience. Monday 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! 3 Likes
SafetyNurse1968, ADN, BSN, MSN, PhD Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. Monday 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. 4 Likes
evastone, BSN, RN Specializes in CEN. Has 4 years experience. Monday 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? 4 Likes
allnurses Admin Team Has 50 years experience. Tuesday REMEMBER .... If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. 0 Likes
NP_hopeful19 Tuesday 12 minutes ago, allnurses Admin Team said: REMEMBER .... If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Oh, I'm sorry! Was reading on my phone and completely missed that. 2 Likes
TheMoonisMyLantern, ADN, LPN, RN Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience. Wednesday 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. 3 Likes
Sha123 Wednesday 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? 0 Likes
SafetyNurse1968, ADN, BSN, MSN, PhD Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. Wednesday FIRST FORMAL FOLLOW UP POST: Thank you for the engaging conversation! I hope you'll forgive the length of this post, but I wanted to include as much information as possible to allow you to make an informed decision. I hope you find it useful! The primary care physician ordered labs, but they all came back within normal limits with the exception of his cholesterol, which was elevated (we checked Thyroid panel as well). EKG is normal. Review of Systems: feels tired much of the time, no other complaints or findings. Vital signs: BP 135/86 sitting, RA HR 100 RR 20 T 97.5oF HT 6’ 1” WT 210 lbs BMI 27.7 A referral is made to a psychologist for a mental health assessment. About one in five American adults experience at least one mental illness each year. Though the majority of gay and bisexual men have good mental health, they are at greater risk for mental health problems including major depression, bipolar disorder and generalized anxiety disorder. Ongoing stigma and homophobia can have negative effects on health. Gay and bisexual men may also face other health threats such as use of illegal drugs. They also have a greater risk for suicide. What mental health disorders fit these symptoms? Let’s take a look at the top 4 most likely problems. This patient could be experiencing more than one. Anxiety disorders: anxiety involves worry and fear that affect day to day functioning. Psychiatric disorders involving extreme fear or worry include generalized anxiety disorder, panic disorder and panic attacks and agoraphobia. National data indicates that as many as 18% of the people in the US experience an anxiety disorder in any given year. This is the most common mental illness in the US. DSM-IV criteria Excessive anxiety and worry for at least 6 months. Anxiety is clearly excessive: N. after much discussion, the patient decides that his anxiety is not excessive, and the clinician agrees. It is not interfering with his work or his sleep. The patient states, “I think my anxiety is more about the other symptoms than anything that’s organic or coming from my brain.” The anxiety is challenging to control: Y “I find myself thinking about my rage and irritability more than I’d like” The anxiety is accompanied by at least 3 of the following Edginess or restlessness Y Tiring easily; more fatigued than usual Y Impaired concentration, mind going blank N Irritability Y Increased muscle aches or soreness N Difficulty sleeping N “I wish! All I want to do is sleep.” Commonly used and well-validated diagnostic interviews for adults include the Structured Clinical Interview for DSM Disorders (SCID) and the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5). (You can find these tests online, but they are not a substitute for evaluation from a trained professional.) Bipolar disorder involves mood swings or unusual or extreme shifts in mood and energy. It occurs in up to 2.5% of the population. To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day. This is not the case for this patient and thus this is not a likely diagnosis. During a manic period, three or more of the following symptoms must be present and represent a significant change from usual behavior: Inflated self-esteem or grandiosity N Decreased need for sleep Y Increased talkativeness N Racing thoughts Y Distracted easily N Increase in goal-directed activity or psychomotor agitation N Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees N The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life (see below for information about depression) PTSD involves a traumatic life event. Response to the event involves intense fear, helplessness, or horror. 20% of people who experience a traumatic event will develop PTSD and 1/13 people will develop PTSD at some point in their life. PTSD is a possibility for the patient due to the trauma of his family refusing to speak with him after he told them he is gay. The trauma was reinforced when his father died and he was unable to attend the funeral. The event is persistently re-experienced in one or more of the following ways: Recurrent recollections Y “I think about my parents all the time. I wish our relationship could have been different. I hate them for turning their backs on my, but I love them and want them in my life. I’m a mess.” Recurrent dreams N Feeling the event is recurring N Intense psychological distress at exposure to cues that remember an aspect of the event Y “Anytime someone calls me a *** or laughs when my husband and I kiss, I think about my parents and I feel ashamed. Then I feel angry at feeling ashamed. I can’t help who I am or who I love. It’s so frustrating.” Physiological reactivity. “Yes! My heart races and I feel panic when I experience hateful behavior from others. It can take all day to recover.” Persistent avoidance of stimuli associated with trauma. N The patient reported no efforts to avoid thinking about the trauma. He has no lapses in memory about the event. In addition, his issues with sleeping all the time and irritability didn’t occur after his parents disowned him. They began after his brother died. Depression is defined as overwhelming sadness. An estimated 7% of all US adults had at least one major depressive episode in 2017. The prevalence is higher among adults reporting two or more races. To be diagnosed with major depression, a person’s symptoms must include: Feelings of sadness, low mood and loss of interest in usual activities for at least 2 weeks Y These feelings must also be accompanied by at least five other common symptoms of depression, including: Change in appetite, losing or gaining weight Y Sleeping too much or not sleeping well (insomnia) Y Fatigue and low energy most days Y “I’m exhausted” Feeling worthless, guilty, and hopeless Y “I didn’t realize it until you asked, but this is exactly how I feel.” An inability to focus and concentrate that may interfere with daily tasks at home, work, or school N “This is one area that hasn’t been affected. I am doing fine at work – I guess I am good at compartmentalizing.” Movements that are unusually slow or agitated (a change which is often noticeable to others) Y “I’m twitchy – I can’t seem to sit still.” Thinking about death and dying; suicidal ideation or suicide attempts Y “I do think about death, though I don’t want to kill myself – I just want to feel better.” These symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. Y “If pushing the man I love the most in a fit of anger isn’t an impairment, then I’d like to know what is.” Common Depression Tests and Scales Patient Health Questionnaire-9 (PHQ-9) Beck Depression Inventory Major Depression Inventory Rome Depression Inventory 3 Likes
NP_hopeful19 Thursday Thanks for all of the excellent information. I’m a student so still learning, and found this case very interesting. I’ve never personally seen uncharacteristic interpersonal violence/aggression attributable solely to underlying depression, except with psychosis - which led me to think that the patient’s brother dying maybe tipped him into development of a personality disorder. And although it seems late in life for onset of PD symptoms, I’ve personally experienced with a close family member that it can take many years into adulthood for some individuals to finally get help (if at all), and they may then spend several more years being misdiagnosed with MDD or BD, particularly if they don’t feel comfortable disclosing the years of over reactive, destructive/violent behaviors leading up to their presentation.. so that came to mind while reading this case study, but there’s a lot that I still don’t know and can’t readily differentiate. I’d love to hear more on how to tease out the details needed to rule out a personality disorder in this case. Really appreciate all the insightful thoughts & feedback being offered! 🙂 Edited Thursday by NP_hopeful19 2 Likes
TheMoonisMyLantern, ADN, LPN, RN Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience. Thursday I was leaning towards Intermittent Explosive Disorder or possibly PTSD and MDD. I also was thinking possible Panic disorder. I think providers should be cautious to diagnose a Bipolar condition on the first session since so many symptoms are shared with other disorders. Thanks for doing a psych case study, I love hearing everyone's opinion of what they're seeing. 1 Likes
