A 22-Year-Old Female College Athlete With Wild Mood Swings

Claudia L. Reardon, MD

Disclosures

June 17, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 22-year-old college student and collegiate track and field athlete is referred by her primary care physician to a psychiatrist for "mood fluctuations and diagnostic clarification." The patient describes the history of her overall mood pattern/course as low moods for up to a week at a time in seventh and eighth grades, then mostly stable mood in high school. Since starting college almost 4 years ago, she says she has been "not myself." She reports fairly constant alternation between 2-3 days of feeling "on top of the world, everything is great, very motivated, and getting lots of stuff done" and 3-5 days of feeling more "down."

In the "up" phase, she describes her mood as euphoric. She has a sense that she is better than those around her, but not to the point of developing grandiose and unrealistic plans. She spends slightly more than usual on groceries during these phases but otherwise does not overspend, does not feel hypersexual, and does not engage in other uncharacteristic risky or problematic behavior. She does feel more distractible and has racing thoughts about things she wants to accomplish. These thoughts do not seem anxious to her; instead, she says, "It feels like I can process a jillion things a minute."

During these phases, she feels that others around her are moving too slowly. She states, "I almost want to push them out of my way when I am trying to get somewhere." Because she has greatly increased energy, she exercises three times per day (once with her track and field team and twice on her own) rather than her usual once-daily team workout. She typically has no changes in sleep (7-8.5 hours per night) during these phases. She notes that when she is feeling "revved up," it would be possible for her to sleep much less, but she forces herself to sleep because she believes good rest is important for her sport.

In the "low" phase, she feels sad, hopeless, upset, and unmotivated and has extremely low energy. She thinks more about death during these periods; however, she states, "I would never actually want to be dead." She still enjoys certain things but has some degree of anhedonia.

She reports very few times of being "in between" the high and low mood states. When she is, she feels what she describes as baseline anxiety.

The patient has never received evaluation or treatment for mental health symptoms before. Her parents attributed her mood symptoms in junior high school to "normal moodiness" for that age group. She then felt generally well in high school. She states, "As a busy student-athlete, I just haven't gotten around to seeing someone for these symptoms until now."

She recalls that her father had "a mental breakdown of some kind" when he was in his 20s. He reportedly was hospitalized after spending all of his money in a get-rich-quick scheme, which failed, and after crashing his car while driving dangerously fast for unknown reasons. She has no other details about the circumstances and is uncertain whether he is under psychiatric care now.

Her medical history is significant for a pelvic stress fracture during track and field participation in her freshman year of college, a hip labral cartilage tear with subsequent surgical revision in her sophomore year of college, and multiple muscle strains. Figure 1 shows a similar hip stress fracture.

Figure 1.

The patient takes no mediations. She denies any use of alcohol, cannabis, nicotine, or other drugs. She drinks approximately three cups of coffee daily.

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