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

[Davey Do]

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.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

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.

[Davey Do]

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.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

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.

[nursej22, MSN, RN]

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? 

[NRSKarenRN, BSN, RN]

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

[Davey Do]

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!

[SafetyNurse1968, ADN, BSN, MSN, PhD]

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. 

[evastone, BSN, RN]

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?

[TheMoonisMyLantern, ADN, LPN, RN]

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.

[Sha123]

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?