Case study –
Name: Hector
Age: 38
Sex: Male
Cis-gender (he/his)
Heterosexual
Relationship status: Unmarried, long-term girlfriend of 4 years
Occupation: Customer support manager
Presenting problem: Mood swings, reckless behavior
For several years, Hector has experienced periodic mood swings and seemingly abrupt changes in behavior. He reports that he will generally feel okay, but then he has these “down in the dumps” phases for a few months and then suddenly find himself with an overabundance of energy. While Hector has been distressed with the ups and downs, he is seeking assistance at this time because people in his life have encouraged him to talk to someone after recent issues with work and his relationships. He describes his experience by using a gambling metaphor: “It’s like I’m just losing hand after hand, can’t catch a break, and everything’s just going to crap. Then, out of nowhere, I’m on a winning streak. I literally cannot lose. I can do whatever I want, bet as much as I want, and it’s no problem. It’s like a wild phase I go through now and then. Then, it just peters out, and I’m stuck with my losing hands again.” When pressed for details about what happens during these “wild phases,” Hector becomes withdrawn and expresses a great deal of guilt and shame over his behavior.
The specific nature of each wild phase varies considerably. While in this state, Hector reports feeling highly positive about himself, as evidenced by his “can’t lose” attitude. Hector states that when his energy is high, he forgets to eat, and time seems to fly by. While engaged in activities, he sometimes stays up all night or neglects to sleep all together. He says that his girlfriend has commented on multiple occasions that she gets concerned when he loses weight rapidly because she knows he is forgetting to feed himself. While at work, he is incredibly productive and uses this time as an opportunity to catch up with his workload. He states, however, that he has so many good ideas in his head that he’ll start working on one and then quickly shift his attention to something else. This has led to several half-finished projects and missed deadlines, so although he is more focused, his effort is not always used wisely.
While elevated, Hector tends to be very social, outgoing, and friendly. Often, his wild phases include spending great sums of money (buying drinks for friends, spending on new hobbies or interests, or gifts for his girlfriend) . Sometimes, his elevated state involves rampant sexual activity with people he meets on the internet. Of his most recent episode, Hector says, “I was having sex with anything that moved. It was just nonstop, no talking, no protection, and I didn’t even know their names half the time.” When questioned further about this particular topic, Hector began crying and had great difficulty discussing it. Hector states that he has been able to hide it from his girlfriend for this long, but that he worries every day that she will soon leave him. Hector says, “She is the best thing to every happen to me, and she deserves to be treated better. She is perfect and I try to make it up to her every chance I get.”
When Hector is NOT experiencing a wild phase, he feels quite negative. He states that he feels exhausted and overwhelmed with the task of attempting to manage the consequences of “having fun”. While down he is tired but has difficulty falling asleep every night and suffers from a marked lack of energy during the day. Although he feels lethargic, he forces himself to get out of bed and go to work. The lack of sleep makes it difficult for Hector to concentrate, and he often falls behind at work or misses deadlines for important projects. Recently, he was written up at work for falling asleep on the job. Hector states that he is worried that he will not be working there much longer.
While he is down, Hector withdraws socially. He sees his girlfriend regularly but rarely feels up to going out with friends. When his mood gets particularly bad, he’ll do his best to avoid everything and everyone. He stops watching sports, reading books, listening to music, and playing games. He states that it can be hard to do basic things like brush his teeth or take a shower. In his words, “I’ll just lie in bed and feel sorry for myself and then beat myself up for feeling this way.” When asked about self-harm, Hector says that sometimes he thinks things would be better if he just fell asleep and never woke up, but that he doesn’t think he could ever commit suicide.
When asked, Hector shows no evidence of substance abuse and is not currently on medication. He reports that he has never been hospitalized and is not currently on any medications. Hectors does not have a history of health issues related to endocrine or other metabolic issues.
