Red flag symptoms: Mood changes

How to differentiate normal behaviour and significant mood changes.

Mood is influenced by many external elements (Photo: SPL)
Mood is influenced by many external elements (Photo: SPL)

Red flags:

  • Changes of behaviour or mood in multiple areas of life and functioning, even if relatively subtle
  • Potentially adverse or complicated social circumstances
  • Potential risk of harm for patient or others owing to mood and behavioural change
  • Unexplained onset or persistent/disruptive mood changes in adolescents or children
  • At-risk patient, owing to existing chronic physical or mental health condition

Physical and mental illness (including schizophrenia and bipolar disorder) rarely appears without early signs.

With regard to mood changes, individuals themselves, or their family, friends, colleagues, neighbours, teachers or other people around them, typically recognise something has not been quite right about their thinking, feelings or behaviour for a while, before a condition eventually shows all of its typical features.

Although mood may be difficult to define because of individual differences and subjective perception, cultures develop a consensus about what is the norm and what would be regarded as unusually lowered, elevated or eccentric mood.

History

Mood is immediately influenced by many external elements, such as social context, environmental surroundings and other circumstances, and may even be mostly dependent on them.

It is often more important to recognise and identify minor changes in several arenas of the patient's life situation, rather than only looking for a significant change in one area alone. These changes may include:

  • Social withdrawal
  • Loss of interest in, or concern about, others
  • Apathy or overactivity
  • Unusual or unexpected disengagement from usual involvements (sports, clubs, volunteering, hobbies)
  • Difficulties with intellectual or practical, usually familiar tasks
  • Increased and exaggerated concern or preoccupation with specific aspects of life or society and their perceived significance
  • A vague sense of unreality or disconnection from things or people; illogical interpretations of events or influences
  • Onset of unexplained rapid mood swings, with irritability, anger, fear, panic, agitation, suspicions or disinhibition, significantly increased overall sensory response or fragility, and unexplained changes in sleep patterns, appetite, personal hygiene or speech

When taking the history, gathering information from third parties can be at least as important as information from patients themselves.

The patient's or relatives' concerns and ideas may give helpful hints regarding triggering events, as well as the impact of the mood changes on the patient's life and functioning.

The medical notes review would need to include previous mental and physical conditions (even if seemingly controlled or resolved), current medication and social factors, if known.

Possible causes of mood change
  • Psychiatric (schizophrenia, bipolar disorder, dementia, severe depression, attention deficit disorder, borderline personalities)
  • Impaired brain function (malignancy, metastases, trauma, infection, Parkinson's disease, MS)
  • Metabolic disturbances (blood sugar, renal and liver function, anaemia, hypoor hyperthyroidism)
  • Effects of prescribed medication or illegal drug use, alcohol, potential poisoning
  • Adverse social events or circumstances (abnormal bereavement reaction or other loss, potential neglect or physical/emotional/sexual abuse, isolation, stress, burnout at work or as a carer)
  • Cardiovascular decline (stroke, other circulation problems)
  • Hormonal influences (puberty, menstrual, pregnancy, menopause, hormone-producing tumours)
  • Undetected or unappreciated sensory impairment or disability

Examination, investigations

Are there any signs of thought disorders, delusions, hallucinations, memory problems, inability to engage or fluctuating engagement and disengagement, agitation or aggression, fear, suspicion, flatness, suicide risk, apparent neurological deficits, or abnormal temperature, BP, pulse, urine dipstick, BMI or blood sugar?

Consider a brief memory test, such as the GP Assessment of Cognition. If possible, gather extra information from sources who know the patient, if considerations of consent or confidentiality and privacy allow this.

Consider baseline blood tests to check for signs of inflammation or infection or apparent deficiencies (anaemia), as well as metabolic dysfunction (liver, renal, thyroid function, random glucose).

When to refer

Immediately refer or admit the patient if there could be a potential risk of physical harm to them or others. Consider social services involvement, for children as well as adults. Keep a low threshold for obtaining a rapid second opinion from a specialist in cases of concern, even though (or especially when) the situation does not fit a clear referral pathway - consider a brief telephone discussion or Choose and Book advice, if available.

  • Dr Jacobi is a GP in York

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