Scenario 1: Initial Presentation

Mood Disorder Case Study

Noreen, aged 32 years, had always been described as “moody.” Depending on what was happening in her life at the time, she could be very sad and depressed or very lighthearted and happy. During her “down” times, she would feel tired, experience loss of appetite, and sleep a lot. During her “happy” times, she would party a lot, be very outgoing, and have a remarkable amount of energy.

Noreen did well in college and graduated at the age of 26 years with an MBA. Since that time, she has been employed in the administration department of a large corporation, where she has had several promotions. Two weeks ago, management was to make the announcement of who would fulfill the position. It was a choice position that Noreen desperately wanted. She became very depressed when the announcement was made that she had not been chosen. She stayed at home in bed and slept a lot for several days.

On about the fourth day, she got up feeling exhilarated, and decided to go shopping. She spent over $1000 on clothing. She then decided to have a party for several hundred people, having it catered and planning all the details. Tuesday night was the party. Noreen wore a new, very expensive dress, drank a lot of champagne, was very jovial and seductive, and bragged to everyone who would listen that she would soon be getting a new job and that the people at her old organization would be sorry they had failed to promote her. She left the party with a man she hardly knew.

On Wednesday at 0300, she was picked up by the police under the grandstand at the local baseball stadium, wearing only her underclothes and high-heeled shoes and carrying a half-filled bottle of champagne. She was alone and speaking very loudly and rapidly. The police initiated an involuntarily commitment and brought her to the emergency department, where she was admitted to the inpatient psychiatric unit with a diagnosis of bipolar type 1, manic episode.

Medical History: None

MAR: lorazepam (Ativan) 2 mg PO q6hr PRN anxiety
        haloperidol (Haldol) 2 mg PO/IM q8hr PRN agitation

Labs: All within normal limits

UDS: BAL: 205

Questions:

Correct Answer & Rationale:

Immediate Concern: Safety (hers and others). She is manic, possibly disinhibited, intoxicated (BAL 205), and her judgment is impaired.

Relevant Information:

  • Her recent sudden change in mood and behavior.
  • High BAL, indicating intoxication.
  • Impulsive spending, sexual disinhibition, and impaired judgment.
  • Need for possible sedation or rapid tranquilization.

Scenario 2: Manic Behavior on Unit

30-minutes later you try to find Noreen to conduct your head-to-toe assessment. She is in the dayroom loudly and rapidly speaking to two other male patients and is becoming intrusive in their personal space and is seen making a sexual gesture towards one of the male patients while rubbing his leg. You introduce yourself to Noreen and tell her you need to conduct an assessment on her and ask her to follow you to her room. After quickly getting irritated, coming within 3 inches of your face and loudly cursing at you, she says “Fine, I’ll follow you. My favorite song is ‘Follow Me’. I love to sing. I should have sung to get my promotion. I can’t believe I didn’t get the promotion. I don’t need a promotion because I am the CEO of the company. I worth millions.”

Head-to-toe assessment:
Neuro: Disorganized, A&O x 2
Cardiovascular: WNL
Respiratory: WNL
GI: WNL
GU: WNL
Musculoskeletal: WNL
Integumentary: WNL
Pain: Patient hyperverbal and went on a tangent when asked about current pain. Did not answer.
Vital signs: 98.3F, 92, 18, 128/76, 99% RA

MSE:
Appearance: Poor hygiene, disheveled.
Behavior: Labile. One moment pt is seen crying and sad, moments later pt is seen yelling at and threatening staff. Pt is intrusive with staff and other patients.
Speech: Hyperverbal, pressured, loud. Pt uses vulgar language at times with staff.
Mood: “I am the best I have ever been! I am forever a CEO!”
Affect: Labile, Pt changes from crying to irritated as evidenced by screaming at staff frequently. Matches mood.
Thought Process: Abnormal - disorganized. Loose associations.
Thought Content: Delusions of grandeur as evidence by pt believing she is the CEO of a company “worth millions”.
Insight/Judgment: Poor

Questions:

Correct Answer & Rationale:

Immediate Concern & What Matters Most:
Ensure safety: She’s intrusive, labile, and potentially threatening or at risk. We must protect her and others from impulsive behavior.

Relevant Info:

  • Hyperverbal, easily irritated, delusional, poor impulse control.
  • Recent manic episode with possible intoxication residue and poor insight.
  • Stable vitals but disorganized mental status.

What Could It Mean?:
She is in an acute manic phase with psychotic features and is at risk for escalation.

Desired Outcome:
Patient is safe, less intrusive, and shows a stable mood with clear boundaries.

Actions to Meet Outcome:

  • Set clear, concise boundaries.
  • Administer PRN medications (lorazepam, haloperidol) if necessary.
  • Consider 1:1 observation for safety.
  • Create a low-stimulus environment with regular rest and nourishment.

Scenario 3: Intervention & 3-Week Follow Up

After you conduct your head-to-toe assessment and MSE, you set limits with Noreen about respecting other patients and staff’s personal space. Noreen begins to cry hysterically and says “You hate me! I hate you! I will hurt you if you hurt me!”. You then use short concise sentences to set limits about threatening staff and other patients. Noreen continues to cry hysterically.

You administer lorazepam 2mg PO PRN anxiety to Noreen, then call the doctor to receive an order for a 1-to-1 for safety.

The doctor sees Noreen a few hours later and deems her incompetent and changes her legal status to Involuntary. Her mother becomes her health care proxy (HCP), signs all her consents and agrees to having Noreen started on lithium ER 900 mg PO BID and risperidone (Risperdal) 1mg PO BID.

Over the next few days, the nurses offer frequent high calorie finger foods to Noreen as she is too hyperactive to sit down during a full meal. You also offer frequent rest periods as well.

Below is your assessment for Noreen 3 weeks after starting the lithium:

MAR: lithium ER 900 mg PO BID
        lorazepam (Ativan) 2 mg PO q6hr PRN anxiety
        haloperidol (Haldol) 2mg PO/IM q8hr PRN agitation
Labs: lithium level: 1.1 mEq/L
UDS: Negative

Head-to-toe assessment:
Neuro: Alert and oriented x3.
Cardiovascular: WNL
Respiratory: WNL
GI: WNL
GU: WNL
Musculoskeletal: WNL
Integumentary: WNL
Pain: 0/10
Vital signs: 98.2F, 81, 14, 124/72, 99% RA

MSE:
Appearance: Appropriate
Behavior: Hyperactive at times, but easily redirectable.
Speech: Pressured at times.
Mood: “Feeling more like me”
Affect: Appropriate, matches mood
Thought Process: Goal-directed
Thought Content: Currently denying SI/HI, delusions and hallucinations.
Insight/Judgment: Fair

Correct Answer & Rationale:

Did the Actions Work? Yes, the interventions stabilized her mood.

Evidence of Improvement:

  • Stable vital signs and alert mental status.
  • Reduction in hyperactivity and improved speech.
  • Therapeutic lithium level and better insight/judgment.

Scenario 4: Depressive Episode & Suicidality

Noreen was discharged home the next day. A few months go by, and Noreen begins to have increased feelings of emptiness. She loses her job due to frequent no-shows because she doesn’t have the energy or motivation to get out of bed. After a few more weeks, the bills start piling up and she feel increasingly overwhelmed. She calls her mom and tells her “Goodbye, I love you, but I don’t want to be here anymore.” Noreen’s mother frantically calls the police. The police arrive at Noreen’s house to find her sitting in her car in her closed garage about to turn her vehicle on. The police initiate an involuntarily commitment and bring her to the emergency department, where she is admitted to the inpatient psychiatric unit with a diagnosis of bipolar depression.

MAR: lithium ER 900 mg PO BID
Labs: lithium level: 0.9 mEq/L
UDS: Negative

Correct Answer & Rationale:

Immediate Concern: Acute suicide risk. She has expressed suicidal ideation and has a plan.

Relevant Information:

  • Her expressed feelings of hopelessness and suicidal statements.
  • Recent depressive symptoms including job loss and overwhelming stress.

Scenario 5: Assessment After Admission

You conduct a suicide assessment on Noreen, including contracting for safety, which she agrees to. She states she is currently having suicidal ideations and her plan is “anything that will work”. You then check for hazards and put her on suicidal precautions. Once on the unit, Noreen goes straight to her room and lays down and tries to sleep. Her assessment is as follows:

Head-to-toe assessment:
Neuro: Alert and oriented x3.
Cardiovascular: WNL
Respiratory: WNL
GI: WNL
GU: WNL
Musculoskeletal: WNL
Integumentary: WNL
Pain: 0/10
Vital signs: 98.3F, 83, 14, 126/70, 98% RA

MSE:
Appearance: Disheveled
Behavior: Withdrawn, guarded towards staff, hypoactive, poor eye contact.
Speech: soft and monotone.
Mood: “Terrible, I don’t want to be alive anymore”
Affect: Flat
Thought Process: Goal directed
Thought Content: +SI, plan is “anything that will work”. Pt is contracting for safety currently.
Insight/Judgment: Poor

Correct Answer & Rationale:

Immediate Concern: High risk of suicide.

Relevant Information: Withdrawn behavior, expressed suicidal ideation, and vague plan.

Meaning: Indicates imminent risk needing close monitoring and intervention.

Desired Outcome: Ensure patient safety and stabilize mood, while engaging in therapeutic intervention.

Appropriate Actions:

  • Maintain suicide precautions (close observation/1:1).
  • Regular suicide risk reassessments.
  • Therapeutic engagement and possible medication adjustments.

Scenario 6: Possible Serotonin Syndrome

Three hours later, the psychiatrist conducts a psychiatric assessment and deems her competent, as a result Noreen signs Voluntary. The psychiatrist starts her on fluoxetine (Prozac) 20mg PO qDay and continues the lithium ER 900 mg PO BID.

48 hours after the first dose of fluoxetine (Prozac), Noreen calls out for help from her room. As you approach her, you notice she is shaking and has chills. Her assessment is as follows:

Head-to-toe assessment:
Neuro: Mild confusion. c/o restlessness
Cardiovascular: tachycardic
Respiratory: tachypnea
GI: diarrhea, c/o pain in abdomen
GU: WNL
Musculoskeletal: Shivering and tremors present.
Integumentary: diaphoretic
Pain: 3/10 abdomen
Vital signs: 103.5F, 125, 24, 162/95, 99% RA
Noreen admits she started taking St. John's wort (Hypericum perforatum) about three weeks prior to admission to help her with her feeling of “sadness” after reading an article online.

Correct Answer & Rationale:

Immediate Concern: Serotonin syndrome, a potentially life-threatening condition.

Relevant Information:

  • Recent initiation of fluoxetine (Prozac).
  • Presentation with hyperthermia, tachycardia, tremors, confusion, restlessness, GI symptoms.
  • Noreen also admits to taking St. John's wort (increases risk).

What Could It Mean?: Classic symptoms of serotonin syndrome.

Actions:

  • Discontinue the offending agent (fluoxetine).
  • Provide supportive care (IV fluids, cooling measures).
  • Administer cyproheptadine and monitor vital signs closely.

Scenario 7: Recovery & Final Outcome

Noreen admits she started taking St. John's wort (Hypericum perforatum) about three weeks prior to admission to help her with her feeling of “sadness” after reading an article online.

You hold the next dose of fluoxetine and apply a cooling blanket. You then call the provider and notify them of your assessment findings and recommendations. You receive the following new orders:

  • Discontinue fluoxetine (Prozac) 20mg PO qDay
  • Administer 0.9%NS @ 75mL/hr
  • Cyproheptadine 12 mg initially PO, followed by 4 mg PO q6hr PRN to control symptoms
  • clonidine 0.1 mg PO q6hr PRN FOR SBP > 160
  • acetaminophen 1000mg PO q4hr PRN fever

Noreen continues to be monitored.

72 hours later, your assessment of Noreen is as follows:

Head-to-toe assessment:
Neuro: Alert and oriented x3.
Cardiovascular: WNL
Respiratory: WNL
GI: WNL
GU: WNL
Musculoskeletal: WNL
Integumentary: WNL
Pain: 0/10
Vital signs: 98.9F, 89, 14, 130/78, 99% RA

On week later, the provider modifies Noreen’s orders, discontinuing the previous orders and initiating her back on an antidepressant. Her orders are as follows:

  • Start fluoxetine (Prozac) 20mg PO qDay
  • Continue lithium ER 900 mg PO BID
  • Discontinue 0.9%NS @ 75mL/hr
  • Discontinue Cyproheptadine
  • Discontinue clonidine
  • Discontinue acetaminophen

Eight days after starting back on her antidepressant, Noreen reports feeling “much better”. She is seen attending groups and interacting with peers on the unit. She verbalizes to you she understands the importance of taking both her lithium and fluoxetine. She denies having suicidal ideations and states she is “looking forward to going home and searching for a new job”.

Correct Answer & Rationale:

Did the actions work? Yes, she stabilized from serotonin syndrome and her depressive symptoms are improving.

Evidence of Improvement:

  • Participation in groups and engagement with peers.
  • Denial of suicidal ideation and expression of hope for the future.
  • Stable mood and medication compliance.