History of head injury. Noticed significant change in behaviour and mood. Any proper diagnosis?
XXXXXXX is a hostile interviewee. He does not want to talk to you, and has made it clear that he is here against his will. In recent weeks, according to his wife, XXXXXXX he has been moody, irritable, and increasingly inappropriate in his actions and comments. For instance, XXXXXXX tells you that last Friday night at a neighborhood party, he went up to an attractive young neighbor and, after asking if she was having as good a time as he was, put his hand on her breast. She reacted furiously, and XXXXXXX seemed surprised at her reaction. The young woman's husband pushed XXXXXXX away, and XXXXXXX became furious and struck the man. XXXXXXX is embarrassed and says XXXXXXX has never been like this before now. In the past, she says, he has always been kind and respectful, "even a little shy XXXXXXX
Yesterday morning, XXXXXXX began to eat his breakfast cereal with his fingers. XXXXXXX says he left for work much later than usual and seemed to be having a hard time organizing his briefcase, his keys, and so on. "Lately, he has been making all kinds of plans and then just not following through on them, which is so unlike him. He has always been real careful, real well-organized, and when XXXXXXX makes plans, he always keeps them XXXXXXX But yesterday, after XXXXXXX left the car running in the driveway and took the bus to work, XXXXXXX became alarmed. She called their family doctor, who sent XXXXXXX to the hospital for this evaluation.
XXXXXXX says nothing has happened to XXXXXXX that might explain his change. XXXXXXX admits he has had lots of work stress lately, "because of my goddamn boss's stupidity XXXXXXX He is surly. He snaps at his wife, "What do you mean, nothing has happened? You idiot, what about that asshole boss of mine?" His wife is embarrassed at his crude language. When you ask XXXXXXX if anything else has gone wrong lately that might explain his irritability, he snaps, "Isn’t that enough?" but then considers the question. He starts to speak, then seems distracted by something on your bookshelf and shrugs his answer off.
XXXXXXX mentions that about six months ago, XXXXXXX was in an auto accident in which his car rear-ended the vehicle in front of him. XXXXXXX who was a passenger, hit his head on the rear-view mirror. XXXXXXX was taken to the emergency room for an X-ray, which had negative findings. XXXXXXX was instructed to monitor him for 24 to 48 hours for any signs of brain injury, but nothing appeared. Other than a slight headache, XXXXXXX was his normal self the next day. The irritability and erratic behavior did not start until about five days ago, nearly six and a half months after the accident. No other traumas were noted.
XXXXXXX works 50 hours a week for a software company, earning about $130,000 per year. He has always had excellent reviews and never missed a promotion. He is close friends with many coworkers and always had a lot of friends. He is still close with a number of his high school and college friends, and frequently calls old neighbors on the telephone. "Everybody likes XXXXXXX ” says XXXXXXX “That is why I was so shocked by what he did last Friday and by how he’s started swearing and acting so . . . gross.”
XXXXXXX and XXXXXXX met and married about 23 years ago. It is the first marriage for both of them, and XXXXXXX says it has always been a good marriage. "We had some fights a few years ago, a kind of rough spot. Everybody goes through that. I think XXXXXXX got a bit over involved with one of the women at work, but we got through that okay. That was maybe 10, 11 years ago XXXXXXX XXXXXXX laughs and says, "Over involved? I wish I'd a stuck it to her, goddamn it! She was something!" His tone is lecherous.
XXXXXXX says there has never been any separations or talk of divorce. "Nothing was ever that troubling; just a few arguments XXXXXXX she says. Their sex life has always been fine, and they have "lots of fun" when they go out together, which they have done weekly, until last Friday.
XXXXXXX did very well in high school and college, earning nearly straight As and a spot on the Dean's list nine times in college. He graduated with honors and landed the best job out of anyone in his class. His parents are still alive, living in Arizona. Neither is in great health, but there is nothing seriously wrong. XXXXXXX and XXXXXXX travel to XXXXXXX to see them twice a year and everyone gets along well. XXXXXXX says she has heard no particularly bad stories about XXXXXXX childhood, and he agrees. He is still close with his only brother, who is three years older. At this point, XXXXXXX stands up and asks you who you are and why you are here. You explain, and he seems relieved. He had seemed slightly anxious. You inquire, but he waves you off.
XXXXXXX says XXXXXXX had had a couple of glasses of wine at the party, but he has not had a drink since Friday night. Usually, he drinks two or three glasses of wine on a weekend, and perhaps one glass each evening with dinner. He has never had a drinking problem, according to XXXXXXX XXXXXXX refuses to answer, but a check of his medical records later confirms Cindy's information.
XXXXXXX also has had a remarkably healthy life. Except for a tonsillectomy when he was nine and the surgical removal of an impacted wisdom tooth, XXXXXXX has had no injuries, no illnesses, and no accidents resulting in any health problems. He takes no medication, not even aspirin. He does not get headaches. He is not overweight; in fact, he jogs four miles each day and feels in good health, he says. He smirks briefly at you and says, "You could use a few miles a day, Doc.” When XXXXXXX reacts, he snaps at her, "Oh, get with it, baby!"
• he has been moody, irritable, and increasingly inappropriate in his actions and comments.
• he went up to an attractive young neighbor and, after asking if she was having as good a time as he was, put his hand on her breast
• hard time organizing his briefcase, his keys, and so on. "Lately, he has been making all kinds of plans and then just not following through on them
• left the car running in the driveway and took the bus to work
• because of my goddamn boss's stupidity XXXXXXX
• He snaps at his wife, "What do you mean, nothing has happened? You idiot, what about that asshole boss of mine?"
• He starts to speak, then seems distracted by something on your bookshelf and shrugs his answer off.
• Over involved? I wish I'd a stuck it to her, goddamn it! She was something!" His tone is lecherous.
• he snaps at her, "Oh, get with it, baby!"
• six months ago XXXXXXX was in an auto accident in which his car rear-ended the vehicle in front of him. XXXXXXX who was a passenger, hit his head on the rear-view mirror
• The irritability and erratic behavior did not start until about five days ago, nearly six and a half months after the accident. No other traumas were noted.
Here is my diagnosis….I don’t think I’m on track on this one
AXIS I: 294.11 Dementia Due to Head Trauma with Behavioral Disturbance
AXIS II: 301.5 Histrionic Personality Disorder
AXIS III: 854.00 Head Injury
AXIS IV: Occupational problems
AXIS V: 51 – 60
1 What other diagnosis could this be if it had other circumstances?
2.What further information and/or referrals would you like to clarify XXXXXXX diagnosis?
3. Are there other psychological measures or evaluations/medical data that you would recommend to assist in your diagnosis?
Well, since this is not a straightforward case , lets list the most salient points in history...
1) Very recent onset of:
- significant change in mood (predominantly irritable mood)
- significant change in behaviour
2) Past history of head injury:
- But note that history-wise it appears to be a minor injury (hit is head in the rear view mirror); no LOC / vomiting / ENT bleeds, etc. to sugest a brain injury; examination and x-ray negative; patient was sent home; was perfectly well from the next day; no sequelae. In fact, wife doesn't even come up with this info initially and says "nothing has happened recently"
- Current symptoms are occuring 6 months after the injury (i.e. no temporal co-relation also)
So, in my opinion, there is very little likelihood that the current psychiatric diturbance is due to the head injury.
Now let's try to make sense of the recent significant change in mood and behaviour:
- irritable mood (very obvious historically and on observation in the psychiatrist's office)
- hypersexuality - sexual approaches with the woman at the party, lecherous tone and sexual comments about the woman in his office with whom he got overinvolved
- reckless behaviour
- expansive planning
- psycho-motor agitation
- hints of overtalkativeness - snapping or cutting across many times, unnecessary quirky comments ("You could use a few miles a day, Doc.”)
- with significant socio-occupational dysfunction.
My opinion on the Axis I will be a Bipolar 1 disorder, Single Manic Episode (remember, both DSM and ICD require a predominantly elated (OR) IRRITABLE mood for the diagnosis of mania).
Axis II doesnt seem to have anything significant qualifying for a personality disorder.
Axis III - nil (under the presumption that the head injury was not signifiacnt)
Axis IV - Correct (occupational problems)
Axis V - I would give him a lower score, say 30 - 40, since his illness has caused him major social and occupational dysfunction.
Qn 1: If the head injury had been significant and the current psychiatric disturbances temporally co-relating with the head injury, then the diagnosis would have been Post TBI sequelae / Post-concussional syndrome / Post-head injury Dementia (only if there is significant memory disturbance along with other cognitive deficits)
Qn 2: Further information which would be helpful in clarifying the diagnosis would be looking for other characteristic symptoms of mania, checking for the presence of psychotic symptoms and a past history of any episodes of depression, mania or hypomania.
Qn 3: Rating scales like BPRS or more specific ones like YMRS can be used to assist in the diagnosis.
Dr. Jonas Sundarakumar
•Both corroborate that XXXXXXX has never had symptoms like this before. XXXXXXX has spoken to XXXXXXX siblings, and they corroborate that nothing like this ever occurred in their knowledge of him. They also report no known history of mental health problems in XXXXXXX family.
•XXXXXXX medical evaluation after the car accident was cut short. XXXXXXX employer was in the middle of changing insurers, the new insurer had all sorts of obstructionist pre-authorization requirements, and XXXXXXX gave up trying to hassle it out with them after he felt better. Also, the physician who initially evaluated XXXXXXX transferred to another facility. Before she left, she told XXXXXXX that he really needed to follow through and get the other tests. XXXXXXX never did, and the replacement physician never contacted XXXXXXX for follow-up as promised. It is clear that XXXXXXX fell through the cracks medically.
•In the six months since the head injury, XXXXXXX has had two incidents of nosebleeds for no clear reason. These occurred at the same time as some of his oddest behavior. One of the nosebleeds was unusually profuse. XXXXXXX was unwilling to see a doctor.
•Cindy reports that XXXXXXX has a number of times apparently smelled things that were not there. He once spent three hours cleaning his car, saying there was a foul odor. She smelled nothing. Another time, they had a big argument when she served a large salad for dinner. He insisted that he smelled grilling bratwurst, his favorite food, and wanted bratwurst instead. She had not grilled any bratwurst, and she smelled nothing like that.
•Cindy reported that on a number of occasions in the last few months, XXXXXXX seemed to be having difficulty finding words, and he has recently used words in odd ways that he never did previously.
•Cindy also reports that XXXXXXX judgment has been episodically off in many ways. XXXXXXX has always managed their retirement portfolio, and has been a conservative investor, taking few risks. She recently learned that he sold some of their reliable XXXXXXX & XXXXXXX stock, and instead bought shares of "Fooled you once, shame on me" corporation, which specializes in starting tropical fruit farms in North XXXXXXX When she asked him why, he replied that they both like tropical fruit, so it is a sure thing.
•Finally, you learn that in the accident, XXXXXXX hit the rear view mirror where the nose, forehead, and eye sockets come together. He had a dark spot under the surface of his skin for a few months after that. You could only really see it in a certain light, but it was there.
• What would the new diagnostic AXIS hypotheses would be?
• What further diagnostic evaluation do you believe is warranted?
In light of this new information, the Axis hypothesis would change drastically.
The revised diagnostic formulation would be:
AXIS I: 294.11 Dementia Due to Head Trauma with Behavioral Disturbance
AXIS II: None significant
AXIS III: 854.00 Head Injury
AXIS IV: Occupational problems
AXIS V: 30 – 40
The pattern of cognitive deficits seem to indicate a predominantly fronto-temporal pattern of involvement which is evident by:
- early onset of personality and behavioural changes
- disinhibited behaviour, mood swings, inattention, poor impulse control, poor reasoning, etc.
- olfactory hallucinations
Another possibility which could be considered is a post concussional disorder, but points against this are:
- significant cognitive decline with gross disturbance in executive functioning, thus more in favour of a dementia.
- absence of typical somatic symptoms of post-concussional disorder like headaches, fatigue, disordered sleep, and dizziness.
- symptoms of a post-concussional disorder usually (80 - 100%) occur within a month of the head trauma
2) Further diagnostic evaluation would include:
- An MRI Brain to confirm the diagnosis and establish the degree and extent of brain injury.
- A complete neuro-psychological assessment, including memory scales, in order to quantify the level of cognitive decline.
Dr. Jonas Sundarakumar
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