NURS 751 Week 2 Symptom Analysis Evaluation 1 on Chronic Mood Swings Example

Up for Days, Flat for a Week, Since Sophomore Year: A Symptom Analysis Evaluation of Chronic Mood Swings in a 27-Year-Old Dental Hygienist That Arrives at Cyclothymic Disorder

Case Presentation

Ms. R., a 27-year-old dental hygienist, was referred to the psychiatric clinic by her primary care nurse practitioner after an emergency visit for chest tightness that was attributed to anxiety. She describes her chief concern as "mood swings I've had since sophomore year of college." She reports stretches of four to six days in which she sleeps five hours a night, feels sharp and talkative, takes on extra shifts, rearranges her apartment and spends more than she planned, followed by a week or more of feeling flat, tired, unmotivated and self-critical, during which she calls in sick and avoids friends. She has never been hospitalized, never had a period of a week or more of continuous high energy, and denies psychotic symptoms. She has never had two weeks of depression severe enough that she stopped functioning entirely, although she describes the low weeks as "barely getting through."

Her history includes a sertraline trial at 22 for low mood, which she stopped after three weeks because she felt "wired and irritable and couldn't sleep." She drinks two to four drinks on weekend nights during high periods, denies other substances and takes an oral contraceptive. Her mother was treated for depression; a maternal uncle had what the family calls a breakdown and was hospitalized in his thirties. She denies suicidal ideation now but says that during two low stretches she hoped, passively, that she might simply not wake in the past year.

Symptom Analysis

The chronic symptom under evaluation is mood instability: recurring alternation between periods of elevated and depressed mood.

Three features stand out. The symptoms are chronic and nearly continuous, not episodic. The highs and lows each fall short of the duration and severity of full episodes. And the shifts often occur without an external trigger, which suggests an endogenous mood process rather than a reaction to events.

Assessment

Interview

Hypomania is easy to miss because patients rarely see it as a problem. Carlat (2017) recommends asking about it directly and normalizing the question, for example by asking whether there have been times the patient felt so good or energetic that others noticed, or needed much less sleep without feeling tired. I asked Ms. R. to describe her most recent high in detail, day by day, and asked her sister, with permission, to describe what she sees. Her sister described "weeks when she's a ball of fire" and confirmed that the pattern began in college.

Mental Status Examination

Ms. R. was casually dressed and well groomed, cooperative, with normal psychomotor activity. Speech was slightly rapid but interruptible. She described her mood as "in between" and her affect was mildly anxious with full range. Thought process was linear, with no delusions, hallucinations, suicidal or homicidal ideation at the time of the visit. Cognition was intact, and insight and judgment were fair.

Screening Tools and Mood Charting

She completed the Mood Disorder Questionnaire, endorsing 8 of 13 symptoms occurring together, with moderate problems, which is a positive screen. Her PHQ-9 score was 9 on a day she described as average. Because screening tools cannot establish duration, she kept a daily mood and sleep chart for two weeks, rating mood from minus 3 to plus 3. The chart showed a five-day elevated stretch with four to five hours of sleep a night and a nine-day low stretch with ten hours a night, with no day at either extreme.

Medical Workup

To exclude medical and substance causes, I ordered thyroid studies (TSH with free thyroxine), blood counts, a metabolic panel and a urine drug screen, and reviewed her medications. All results were normal and the drug screen was negative. A pregnancy test was negative, which matters for any medication decision.

Strengths and Protective Factors

The assessment also identified strengths the plan can build on. Ms. R. has stable employment she values, a sister who lives nearby and noticed the pattern before she did, no history of suicide attempts and a record of feeling better when her routine is regular. She is curious about her symptoms rather than defensive, and she completed the mood chart every day without reminders. She described her church small group as a place she misses during low weeks and would like to return to, which offers both social rhythm and spiritual support. These factors lower her immediate risk and make a psychotherapy-first plan realistic.

Differential Diagnosis

The strongest alternative is bipolar II disorder. Cyclothymic temperament is closely linked to bipolarity, and in a study of 1,723 adult outpatients it was a strong predictor of bipolar disorder, especially bipolar II and substance-induced bipolarity (Karam et al., 2023). A systematic review of features that distinguish bipolar from unipolar depression in general practice also names cyclothymic temperament, early onset, family history and suicide attempts among the most consistent indicators (Niktabe & Massoubre, 2026). Ms. R.'s history makes progression to bipolar II disorder a real risk to monitor. Borderline personality disorder was the second alternative. Ruffalo and Ray (2026) distinguish cyclothymia, which reflects subsyndromal, endogenous mood fluctuations, from borderline personality disorder, which involves identity disturbance, interpersonal hypersensitivity and primitive defenses. Ms. R.'s shifts are endogenous and last days, and she shows none of the identity or abandonment features, although the possibility should be revisited if new information emerges.

Diagnosis

Ms. R. meets DSM-5 criteria for cyclothymic disorder (American Psychiatric Association, 2013): for at least two years, numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode; the symptoms have been present at least half the time without a symptom-free interval of more than two months; criteria for a major depressive, manic or hypomanic episode have never been met; the symptoms are not better explained by a psychotic disorder, cannot be traced to a drug, a medication or another medical illness, and cause clinically significant distress and impairment. What makes this cyclothymia rather than a milder bipolar II is not severity alone but the absence, so far, of a single full episode.

Treatment Plan

Education and Self-Monitoring

I explained the diagnosis to Ms. R. and her sister, framing it as a lifelong tendency toward mood swings that can be managed, and naming the risk of progression to bipolar II disorder. She will continue the daily mood and sleep chart, which will serve both as a self-management tool and as the main way to detect a full episode.

Psychotherapy and Rhythm Regulation

Psychotherapy is the first-line treatment. I referred her for cognitive behavioral therapy adapted for mood instability with elements of interpersonal and social rhythm therapy, focusing on regular sleep and wake times, consistent meals and activity, recognition of early warning signs of highs and lows and a plan for each. She agreed to cap drinking at a single drink on any given day and to skip alcohol entirely during high periods, since alcohol worsened her lows and disrupts the sleep her plan depends on.

Pharmacologic Considerations

I did not start an antidepressant. Her earlier activation on sertraline is a warning sign, and most clinicians avoid antidepressant monotherapy for patients on the bipolar spectrum. The evidence is not simple. A 2025 network meta-analysis of 13 randomized controlled trials in bipolar depression found that no antidepressant significantly increased switching to mania compared with placebo, although venlafaxine had the highest risk estimate and most trials studied antidepressants added to a mood stabilizer rather than given alone (Oliva et al., 2025). That finding does not apply directly to monotherapy in cyclothymia, and given her history I judged the risk not worth taking. If her symptoms remain impairing after eight to twelve weeks of therapy and routine, we will discuss a mood stabilizer, with lamotrigine or lithium as options, through shared decision-making that includes her contraceptive use and plans for pregnancy.

Safety and Follow-Up

Because she has had passive death wishes during lows, we completed a written safety plan with warning signs, coping steps, her sister and a crisis line. She will return in three weeks and then monthly, bringing her mood chart. At each visit I will reassess for a full hypomanic or major depressive episode, which would change the diagnosis to bipolar II disorder and the plan to include a mood stabilizer. I will also repeat the PHQ-9 at each visit, review her work attendance and spending as functional markers, and coordinate with her primary care nurse practitioner, who will be told to avoid prescribing an antidepressant for her anxiety without consulting the psychiatric clinic.

Conclusion

Ms. R.'s chronic mood swings, analyzed by onset, pattern, triggers and impact and confirmed with collateral history, screening and two weeks of charting, meet DSM-5 criteria for cyclothymic disorder after bipolar II disorder, borderline personality disorder and other alternatives were considered and set aside for specific reasons. The plan relies on education, self-monitoring, psychotherapy and rhythm regulation, avoids antidepressant monotherapy and watches closely for progression, so that if a full episode does come, it will be recognized early and treated quickly.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Karam, E. G., Saab, D., Jabbour, S., Karam, G. E., Hantouche, E., & Angst, J. (2023). The role of affective temperaments in bipolar disorder: The solid role of the cyclothymic, the contentious role of the hyperthymic, and the neglected role of the irritable temperaments. European Psychiatry, 66(1), Article e37. https://doi.org/10.1192/j.eurpsy.2023.16

Niktabe, D. S., & Massoubre, C. (2026). Distinguishing bipolar disorder from unipolar depression in general practice: A systematic review. European Journal of General Practice, 32(1), Article 2733396. https://doi.org/10.1080/13814788.2026.2733396

Oliva, V., De Prisco, M., La Spina, E., Paolucci, S., Fico, G., Anmella, G., Hidalgo-Mazzei, D., Murru, A., Pompili, M., Fornaro, M., Solmi, M., Yildiz, A., Leucht, S., Vieta, E., & Radua, J. (2025). Switch to mania after acute antidepressant treatment for bipolar depression: A systematic review and network meta-analysis of randomised controlled trials. EClinicalMedicine, 87, Article 103413. https://doi.org/10.1016/j.eclinm.2025.103413

Ruffalo, M. L., & Ray, A. M. (2026). Distinguishing mood temperaments from personality disorders: Diagnostic and clinical implications. Psychodynamic Psychiatry, 54(3), 381-388. https://doi.org/10.1521/pdps.2026.54.3.381