Mood Problem Case Study

Sample Case

Miss M is a 30 year old single lady who lives alone. She works as a secretary. She has a history of thyrotoxicosis for which she takes carbimazole. She was admitted to an acute psychiatric ward after being found singing loudly in a neighbour’s garden dressed only in her nightclothes.

Her neighbours reported that she had not been herself since breaking up with her boyfriend two weeks ago. She had become verbally aggressive and started asking them to join her plan to save the world. She had also started playing loud music during the night which had led to a visit by the police.

She was admitted to a psychiatric unit 2 years ago following an overdose of an antidepressant. She was seen by a psychiatrist in the community 10 months ago when she was reported to be “very happy and overfamiliar with strangers in the street.” She was prescribed lithium but did not take it regularly.

During the psychiatric interview on this occasion, her speech was rapid and difficult to follow. She referred to being God and her need to save the world. She would often break into song or laughter in mid-sentence. On the ward, Miss M was sexually disinhibited, asking other patients to sleep with her and became angry when they refused.

She denied any substance misuse. The urine screen was negative. Her mother, who committed suicide when Miss M was 15 years old, according to her father, experienced similar problems to Miss M in her life.

Explain Miss M’s clinical presentation. Outline possible aetiological factors and the management of her condition.

Problem

Mania

Management

Acutely

• Antipsychotic - 5mg haloperidol
• Tranquilizer - 2mg lorazipam

Chronic

• Lithium to stabilize her mood

Common Questions

Mania Case Study
Appearance & Behaviour: Sexual, social and financial disinhibition, Self neglect
Speech: Rapid, Pressure of speech, Loud
Mood & Affect: Ridiculously high, Volatile affect
Thoughts: Process - flight of ideas, Content - grandiose delusions, religious
Perceptions: Normal
Cognition: Normal
Insight: None

Describe the symptoms and signs of mania

Basically, mania is elevated mood. See the Mental State Examination on the right for more information.

Describe the symptoms and signs of depression

Depression has two main groups of symptoms:

Psychological

• Guilt
• Reduced concentration/attention
• Loss of interest/pleasure in normal activities (anhedonia)
• Reduced emotional activity
• Reduced self esteem
• Hopelessness

Physical

• Low mood
• Fatigueability (anergia)
• Early morning waking
• Weight loss
• Loss of appetite
• Depression worse in morning
• Loss of libido
• Psychomotor retardation

Understand the difference between bipolar affective disorder and unipolar depression

Unipolar depression is exactly the same as depression. It just allows perspective on the idea that bipolar and depression are linked.

• A bipolar patient will experience periods of low mood, and those of high mood. One being depression, the other mania.
• A unipolar patient only experiences the low mood

The recommended management for this band of street preachers is intramuscular haloperidol

Describe possible aetiological factors for mood disorder

• Monoamine- too much/not enough serotonin/noradrenaline
• Family History - may be relevant
• Life event - most important risk factor for depression or mania

Understand the management of acute mania and bipolar affective disorder

Mania IS the state experience in bipolar episodes of elevated mood. So management for both is:

• Tranquilizer, to calm them down.
• Anti-psychotic, to stop the delusions.

Know how to screen for depressive symptoms

Use screening tools (PHQ-9 or HADS) to assess this. Without a screening tool, just use a question for each symptom on the symptom list: ie. Guilt, "Have you had had any feelings of guilt recently?"

Know how to assess a patient’s suicide risk following an episode of self harm

See the suicide risk page for more information on that one. The basics are below:

Demographics

• Age
• Sex
• Occupation
• Marital Status - recent seperation is a risk factor
• Children - a protective factor

Information On Attempt

• Suicide Note - a risk factor for suicide.
• Efforts Not To Be Found - those making a cry for help tend not to try to ensure that their attempt succeeds. A real attempt may include locking the door, or telling no-one to call.
• Remorse (at not dying) - if patient regrets failing to die, it was probably more serious.
• Planning a second attempt - if they tell you they are going to try again tomorrow, that may be a risk...
• Collecting of affairs or writing a will - implies serious attempt.
• Use of Alcohol - often gives people the courage to attempt.
• Violence of method - those using a gun, or trying to build a guillotine are probably more serious than those who took three paracetemol.

Reasons/Stressors

• Bereavement
• Life Event, such as divorce, loss of job, stolen umbrella.
• Mental Illness; particularly depression and schizophrenia
• Drugs/Alcohol