Rapid affective changes in mood disorder?

[futureapppsy2]

Thoughts on a person reporting rapid affective changes (sometimes less than hourly, sometimes hourly, several times a day) but with overall low mood and other depressive symptoms? I know some affect variation can occur in people experiencing MDEs but the amount and frequency of rapid affect variations reported is making me look for zebras... No known hx of mania/hypomania

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[LadyHalcyon]

Thoughts on a person reporting rapid affective changes (sometimes less than hourly, sometimes hourly, several times a day) but with overall low mood and other depressive symptoms? I know some affect variation can occur in people experiencing MDEs but the amount and frequency of rapid affect variations reported is making me look for zebras... No known hx of mania/hypomania

So then what are the moods changing to? Meaning are they going from depressed to angry? Depressed to happy? My initial thought would be PD or complex trauma etc.

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[barbatenussapientes]

Thoughts on a person reporting rapid affective changes (sometimes less than hourly, sometimes hourly, several times a day) but with overall low mood and other depressive symptoms? I know some affect variation can occur in people experiencing MDEs but the amount and frequency of rapid affect variations reported is making me look for zebras... No known hx of mania/hypomania

Not really much information to go on - what emotional intensity are we talking? Rapid mood swings sets off my BPD alarm.

 

[MCParent]

Thoughts on a person reporting rapid affective changes (sometimes less than hourly, sometimes hourly, several times a day) but with overall low mood and other depressive symptoms? I know some affect variation can occur in people experiencing MDEs but the amount and frequency of rapid affect variations reported is making me look for zebras... No known hx of mania/hypomania

Lying about current drug use would be my first guess.

 

[PsyDr]

What kind of “mood changes” are we talking about?

Being hostile when not getting their way and rapidly returning to baseline when people give in?

Barely keeping it together and then bursting out in tears over literal spilled milk?

Saying they're depressed and then showing complete enjoyment and having difficulty explaining how “my depression” can make it so?

 

[Therapist4Chnge]

Lying about current drug use would be my first guess.

This was my first thought. UDS In 3..2..1...

My second thought was borderline PD...if the mood is being moderated by compliance/non-compliance, as PSYDR alluded to in his post.

 

[ExecutiveDysfunction]

Ugh I just consulted with a psychiatric provider for a neuropsych that stated the patient has mood swings and “cycles” between manic and depressed every two days or so. On elaboration, the patient is actually either a little irritable or kind of bummed. I cringed, hard.

In my experience, rapid mood swings are more of a symptom of emotion dysregulation than manic cycling

 

[PsyDr]

Ugh I just consulted with a psychiatric provider for a neuropsych that stated the patient has mood swings and “cycles” between manic and depressed every two days or so. On elaboration, the patient is actually either a little irritable or kind of bummed. I cringed, hard.

In my experience, rapid mood swings are more of a symptom of emotion dysregulation than manic cycling

Everyone knows the DSM has a required length of time for an episode to be called manic or hypomanic, right?

AND that when providers are unaware of this, even though it's in the book, it should point towards them being incompetent, right?

 

[erg923]

Thoughts on a person reporting rapid affective changes (sometimes less than hourly, sometimes hourly, several times a day) but with overall low mood and other depressive symptoms? I know some affect variation can occur in people experiencing MDEs but the amount and frequency of rapid affect variations reported is making me look for zebras... No known hx of mania/hypomania

"Mood" likely isn't the best or most accurate descriptor of this. My day can be great, and when reminded of something in my past I can be quite overcome with different (and varying) emotions and thoughts for minutes...up to half hour. That's not really my "mood" shifting though. Good psychotherapy is most likely to uncover something about this. I seriously doubt it's some kind of rapid cycling, or some fundamentally different disorder from MDE. Treat what you have and learn along the way.

I would think it is more likely a variant of the patient's depressive experience/disorder. Agitated depression, melancholic depression, vegetative depression, psychotic depression (not schizophrenia of schizoaffective disorder) are all things that seems to have been lost in recent years as we have moved away from descriptive psychopathology.

 

[clausewitz2]

"Mood" likely isn't the best or most accurate descriptor of this. My day can be great, and when reminded of something in my past I can be quite overcome with different (and varying) emotions and thoughts for minutes...up to half hour. That's not really my "mood" shifting though. Good psychotherapy is most likely to uncover something about this. I seriously doubt it's some kind of rapid cycling, or some fundamentally different disorder from MDE. Treat what you have and learn along the way.

I would think it is more likely a variant of the patient's depressive experience/disorder. Agitated depression, melancholic depression, vegetative depression, psychotic depression (not schizophrenia of schizoaffective disorder) are all things that seems to have been lost in recent years as we have moved away from descriptive psychopathology.

Re: more traditional descriptive psychopathology, it should be noted that a fair proportion of people who are unquestionably bipolar I display significant inter-episode affective instability. Akiskal has written a lot on temperaments outside of acute episodes in bipolar disorders. I am not one of the bipolar imperialists but there is something to this if you have had much experience with people who have had multiple, real-deal-hospitalized-and-psychotic manic episodes longitudinally.

Obviously the DSM does have the 4 day requirement for hypomania. The -entire- evidence base for this is that the relevant DSM committee looked at a study that showed 3 days of premenstrual agitation in a certain proportion of a community sample and said "better make sure we exclude that." While understandable as a motive, this is not carving nature at the joints.

 

[ClinicalABA]

In the course of a 2 hour testing session, my clients will often display a wide range of extreme emotions, from crying to giggling/laughing. They often display intense goal-directed and pleasure seeking behavior, as well as seemingly aimless wandering about the office.

 

[futureapppsy2]

Thanks for the responses.
-Reported affective changes are from "depressed"/numb to happy/content/less sad, reported as often as occurring every few minutes to every day with no identified triggering events
-No known trauma or SUD history
-Presents as extremely calm, emotionally regulated, and interpersonally effective
-Multiple informant report aligns with presentation--universally described as extremely calm, kind, peaceful, well adjusted, etc
-Reports decades of recurrent MDEs
-Very high functioning in terms of work and social life
-No secondary gain opportunity involved, not even attention

Self-report raises a lot of Borderline PD flags but presentation and informant report indicate excellent emotional regulation, interpersonal effectiveness, etc. Honestly, they come across as very mentally healthy, but report significant distress

 

[clausewitz2]

Thanks for the responses.
-Reported affective changes are from "depressed"/numb to happy/content/less sad, reported as often as occurring every few minutes to every day with no identified triggering events
-No known trauma or SUD history
-Presents as extremely calm, emotionally regulated, and interpersonally effective
-Multiple informant report aligns with presentation--universally described as extremely calm, kind, peaceful, well adjusted, etc
-Reports decades of recurrent MDEs
-Very high functioning in terms of work and social life
-No secondary gain opportunity involved, not even attention

Self-report raises a lot of Borderline PD flags but presentation and informant report indicate excellent emotional regulation, interpersonal effectiveness, etc. Honestly, they come across as very mentally healthy, but report significant distress

I think you have to drill down much deeper into how their behavior changes when their mood changes. If there is nothing psychomotor or vegetative I would be inclined to conceptualize this person as the sort of overcontrolled dysthymic that RO-DBT was really designed to address. when you say interpersonally effective, can you elaborate? Like, just apparently good at tolerating distress and not causing a scene with people or really quite socially adept, flexible, with a good number of warm and intimate relationships?

 

[futureapppsy2]

I think you have to drill down much deeper into how their behavior changes when their mood changes. If there is nothing psychomotor or vegetative I would be inclined to conceptualize this person as the sort of overcontrolled dysthymic that RO-DBT was really designed to address. when you say interpersonally effective, can you elaborate? Like, just apparently good at tolerating distress and not causing a scene with people or really quite socially adept, flexible, with a good number of warm and intimate relationships?

Definitely socially adept, flexible, warm, lots of good social support and reciprocal relationships... Common term that came up informant report was "genuine". Honestly, they seem from presentation and informant report like the model of everything we teach in DBT but report significant depressive symptoms marked by these rapid affective changes.

 

[clausewitz2]

Definitely socially adept, flexible, warm, lots of good social support and reciprocal relationships... Common term that came up informant report was "genuine". Honestly, they seem from presentation and informant report like the model of everything we teach in DBT but report significant depressive symptoms marked by these rapid affective changes.

Huh. How old? The logical possibilities that occur to me are a) there is something that is not being reported here or b) there are some dysfunctional beliefs about negative emotions and their intrinsic harmfulness. I'd be interested to know how they describe these changes in their mood and how they can tell the difference between sad and content if there is no outward behavioral change.

 

[LadyHalcyon]

I think you have to drill down much deeper into how their behavior changes when their mood changes. If there is nothing psychomotor or vegetative I would be inclined to conceptualize this person as the sort of overcontrolled dysthymic that RO-DBT was really designed to address. when you say interpersonally effective, can you elaborate? Like, just apparently good at tolerating distress and not causing a scene with people or really quite socially adept, flexible, with a good number of warm and intimate relationships?

Are they able to identify certain triggers that result in mood changes?

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[WisNeuro]

Have you ruled out demonic possession?

 

[clausewitz2]

Have you ruled out demonic possession?

Clearly an overproduction of black bile in the liver producing an excess of melancholic humor.

 

[WisNeuro]

Clearly an overproduction of black bile in the liver producing an excess of melancholic humor.

I was going to say that we just need some trephination to release the demons from the brain.

 

[clausewitz2]

I was going to say that we just need some trephination to release the demons from the brain.

Just have the right sharps and we don't have to choose between trepanning and bloodletting!

 

[futureapppsy2]

I don’t think it’s a aversion to negative emotions. They indicate that because their emotions are so liable, how they feel “doesn’t matter”, good or bad, because their state will just change quickly, so they just ride everything out. They report depressive episodes so severe that they feel “delusional” but with no apparent objective impact on functioning and none reported by informants. Apparently this has been going on for decades.

Really baffling—this person seems severely ill by self report but extremely emotionally well-adjusted by everything else. No secondary gain potential.

 

[ExecutiveDysfunction]

I don’t think it’s a aversion to negative emotions. They indicate that because their emotions are so liable, how they feel “doesn’t matter”, good or bad, because their state will just change quickly, so they just ride everything out. They report depressive episodes so severe that they feel “delusional” but with no apparent objective impact on functioning and none reported by informants. Apparently this has been going on for decades.

Really baffling—this person seems severely ill by self report but extremely emotionally well-adjusted by everything else. No secondary gain potential.

Could it be possible that this person is engaging in some inaccurate catastrophic thinking about their symptoms? The reason i ask is that i could imagine someone who has a normal (or maybe slightly abnormal but within the realm of normal) variation in mood who overinterprets the symptoms catastrophically, ruminates on the symptoms, and is unable to do much because of the rumination. More along the lines of GAD/obsessional thinking rather than true mood “episodes”. I agree, those are more likely than a zebra.

That said, It wouldn’t be a bad idea to encourage a full medical work up to rule out anything else.