The Question: Does the patient have a complex mood disorder, a personality disorder or both?Patient Intake • 60-year-old man • Chief complaint is “being unstable” • Patient estimates that he has spent about two thirds of the time over
The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a diffi cult patient?
Pretest Self Assessment Question (answer at the end of the case)
Frequent mood swings are more a sign or symptom of a mood disorder than they are of a personality disorder
A. True B. False
Patient Intake • 60-year-old man • Chief complaint is “being unstable” • Patient estimates that he has spent about two thirds of the time over
the past year being in a mixed dysphoric state and about one third as depressed, but waxing and waning every few days, or even every few hours
Psychiatric History: Childhood and Adolescence • As a young child, had symptoms of generalized anxiety and
separation anxiety • Also, as a child, remembers “emotional trauma” from mother, herself
with recurrent episodes of either unipolar or bipolar depression who was often physically unavailable because of hospitalizations, or emotionally distant when depressed at home
• Has had a lifetime of multiple turbulent interpersonal relationships since childhood, with family members, with friends and especially with women
• As an older child and adolescent, continued to have not only subsyndromal generalized anxiety but developed at least subsyndromal levels of OCD with ruminations, checking and rigidity
• He was told these were good traits and would make him a good student, which he was, with good grades through high school and college, gaining admission to medical school
Psychiatric History: Adulthood • Diagnosed as major depression for the fi rst time at age 23, early in
medical school – Was his worst depression so far, as other depressions previously
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PATIENT FILE
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characterized as unhappiness and transient depressed moods of a few days duration and with more anxiety than depression, improving without treatment
– Actively suicidal and overdosed on his medications at this time but recovered
– In retrospect, patient believes that he has long experienced rejection sensititivity with up to 2 depressive episodes per year since age 16 up to the present
• No clear history of any full syndromal manic or hypomanic episodes • Since age 23, however, has had many episodes lasting a week or
more of irritability, infl ated self esteem, increased goal-directed work activity, decreased need for sleep, overtalkativeness, racing thoughts, psychomotor agitation and risky behavior; could also experience euphoria or expansiveness to a signifi cant degree but only for 2 or 3 days at most and usually shorter
• He interpreted these as good traits, indicative of creative persons, and were the reason he was productive as well as creative
• In getting his history, it is not clear whether he has had an irritable dysphoric temperament since childhood, a superimposed episodic subsyndromal dysphoric mixed hypomania, or both
• First marriage ages 32–33 – Depressive episode and overdosed again when fi rst marriage
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