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." Nurses General Nursing Case Study

Updated:  

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!
Specializes in Oncology, Home Health, Patient Safety.

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
4 Votes

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! ? 

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

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.

3 Votes
Specializes in Oncology, Home Health, Patient Safety.

I will post the final answer at the end of the day today!

3 Votes
Specializes in Oncology, Home Health, Patient Safety.

After four weekly sessions, the psychologist arrives at a diagnosis of Major Depressive Disorder. The patient is surprised, stating, “I thought with all my anxiety, the racing heart and the worry that you were going to tell me I have anxiety disorder. I thought depression was defined as being sad all the time. I’m not sad all the time!”

The psychologist explains that for someone who is facing Major Depressive Disorder (MDD), the symptoms they display to the outside world may be very different than the way they’re feeling on the inside. Traditionally, symptoms of depression may cause someone to have a hopeless and helpless outlook on life. However, there are many less commonly known signs of depression.

  • Anger and irritability: anger is one of the most common symptoms of depression in men. Men are also less likely than women to acknowledge or accept depression which may explain why some men cope with their emotions by having displaced anger toward a loved one through verbal or physical abuse.
  • Anxiety: Depression can cause feelings of inferiority or guilt, which can lead to anxiety over not being able to cope with day-to-day activities. Some people report that they don’t know if they’re experiencing anxiety or depression during times of distress as the feelings associated with both can have similarities. Depression can lead to ruminating and intrusive thoughts, lack of concentration, and the inability to make decisions. Psychomotor agitation is also a symptom of anxiety, which causes a person to feel overly restless. Examples include pacing around the room, tapping your toes, or rapid talking.
  • Overcompensation through perceived happiness: People with depression may do anything they can to prevent others from knowing. They may overcompensate for feelings of depression, shame, anxiety and worthlessness by trying to seem “okay” or “happy”
  • Weight gain/loss: depression leads to changes in appetite
  • Insomnia or lethargy: some patients report wanting to sleep the day away to turn off their brain.
  • Uncontrollable emotions: Experiencing rapid changes in mood or emotion can also be a sign of depression. Not being able to control your emotions from one hour, minute, or day to the next. Someone experiencing depression may vacillate from crying to laughing, to anger, to guilt, to a feeling of numbness without reason. These feelings may also be disproportionate to the current situation or event. For example, uncontrollable crying over spilling water on the kitchen floor.
  • Loss of interest: A loss of pleasure is called anhedonia and usually experienced in all, or almost all, activities most of the day, nearly every day. These activities would include things the person once used to enjoy that they no longer find pleasure in doing. This can also include a decreased sex drive or loss of interest in sex.
  • Self-harm: include cutting the wrists, legs, hips or stomach; burning self, skin picking, or engaging in behaviors to create physical harm to self. Many report that self-harming behavior is a way to express on the outside the pain they are feeling on the inside. This can also include intrusive thoughts of death, with or without a specific suicide plan. Also, it can include a specific plan for committing suicide.

The psychologist recommended a prescription for fluoxetine, which the patient agreed to try. He decided to remain in therapy. After four weeks of taking the medication and weekly therapy, he began to experience a reduction in all of his symptoms.

References

8 Votes

Thank you so much for this interesting Case Study, @SafetyNurse1968

The following are the guesses/diagnoses/rationales from members who came to the Help Desk during the "Wild Mood Swings and Outbursts of Anger: What's Wrong with this Man?", Case Study.

Workitinurfava

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Has their ever been a diagnosis of PTSD? That is what I think it is.

NP_hopeful19

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My guess for the current case study is "late-onset borderline personality disorder".

Curious1997

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I think he has unresolved grief issues being manifested as mood swings. 

Labs are unremarkable and emotional trauma too significant to not be coincidental. 

This is about his brother's and father's deaths. 

 

We look forward to the next Case Study, @SafetyNurse1968!

Coming soon ...... 

 

3 Votes
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