Question

Case 4 A 29-year-old car salesman was referred by his girlfriend, a psychiatric nurse, who suspected he had a Mood Disorder, even though the patient was reluctant to admit that he might be a "moody" person. According to him, since age 14 he has experienced repeated alternating cycles that he terms "good times and bad times." During a "bad" period, usually lasting 4-7 days, he oversleeps 10-14 hours daily, lacks energy, confidence, and motivation. Often he abruptly shifts, characteristically upon waking up in the morning, to a 3-day to 4-day stretch of overconfidence, heightened social awareness, promiscuity, and sharpened thinking ("Things would flash in my mind"). At such times he indulges in alcohol to enhance the experience, but also to help him sleep. Occasionally the "good" periods last 7-10 days, but culminate in irritable and hostile outbursts, which often herald the transition back to another period of "bad" days. He admits to frequent use of marijuana, which he claims helps him "adjust" to daily routines. In school, A's and B's alternated with C's and D's, with the result that the patient was considered a bright student whose performance was mediocre overall because of "unstable motivation." As a car salesman his performance has also been uneven, with "good days" canceling out the "bad days"; yet even during his "good days," he is sometimes argumentative with customers and loses sales that appeared sure. Although considered a charming man in many social circles, he alienates friends when he is hostile and irritable. He typically accumulates social obligations during the "bad" days and takes care of them all at once on the first day of a "good" period. 1. What is the most appropriate diagnosis for this patient?

Case 4

A 29-year-old car salesman was referred by his girlfriend, a psychiatric nurse, who suspected he had a Mood Disorder, even though the patient was reluctant to admit that he might be a "moody" person. According to him, since age 14 he has experienced repeated alternating cycles that he terms "good times and bad times." During a "bad" period, usually lasting 4-7 days, he oversleeps 10-14 hours daily, lacks energy, confidence, and motivation. Often he abruptly shifts, characteristically upon waking up in the morning, to a 3-day to 4-day stretch of overconfidence, heightened social awareness, promiscuity, and sharpened thinking ("Things would flash in my mind"). At such times he indulges in alcohol to enhance the experience, but also to help him sleep. Occasionally the "good" periods last 7-10 days, but culminate in irritable and hostile outbursts, which often herald the transition back to another period of "bad" days. He admits to frequent use of marijuana, which he claims helps him "adjust" to daily routines.
In school, A's and B's alternated with C's and D's, with the result that the patient was considered a bright student whose performance was mediocre overall because of "unstable motivation." As a car salesman his performance has also been uneven, with "good days" canceling out the "bad days"; yet even during his "good days," he is sometimes argumentative with customers and loses sales that appeared sure. Although considered a charming man in many social circles, he alienates friends when he is hostile and irritable. He typically accumulates social obligations during the "bad" days and takes care of them all at once on the first day of a "good" period.

1. What is the most appropriate diagnosis for this patient?

Case 4

A 29-year-old car salesman was referred by his girlfriend, a psychiatric nurse, who suspected he had a Mood Disorder, even though the patient was reluctant to admit that he might be a "moody" person. According to him, since age 14 he has experienced repeated alternating cycles that he terms "good times and bad times." During a "bad" period, usually lasting 4-7 days, he oversleeps 10-14 hours daily, lacks energy, confidence, and motivation. Often he abruptly shifts, characteristically upon waking up in the morning, to a 3-day to 4-day stretch of overconfidence, heightened social awareness, promiscuity, and sharpened thinking ("Things would flash in my mind"). At such times he indulges in alcohol to enhance the experience, but also to help him sleep. Occasionally the "good" periods last 7-10 days, but culminate in irritable and hostile outbursts, which often herald the transition back to another period of "bad" days. He admits to frequent use of marijuana, which he claims helps him "adjust" to daily routines.
In school, A's and B's alternated with C's and D's, with the result that the patient was considered a bright student whose performance was mediocre overall because of "unstable motivation." As a car salesman his performance has also been uneven, with "good days" canceling out the "bad days"; yet even during his "good days," he is sometimes argumentative with customers and loses sales that appeared sure. Although considered a charming man in many social circles, he alienates friends when he is hostile and irritable. He typically accumulates social obligations during the "bad" days and takes care of them all at once on the first day of a "good" period.

1. What is the most appropriate diagnosis for this patient?

Added by Michael H.

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