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Case Study

Intermediate explosive disorder with bipolar features

By: Morgan Buchenic

Youngstown State University

Abstract
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During my clinical experience on the psychiatric unit at Trumbull Memorial Hospital, I was able

to interact with a patient who was diagnosed with intermediate explosive disorder with bipolar

features. Throughout this paper, I will identify objective data which describes my patient’s date

of care, psychiatric diagnosis, behaviors on admission and day of care, medical conditions and

treatments, safety and security measures maintained and prescribed by psychiatric medications.

Next, I will summarize intermediate explosive disorder with bipolar features, identify stressors

and behaviors that precipitated his hospitalization, discuss patient and family history of mental

illness, describe psychiatric evidence based nursing care provided to this patient on the day of

care, analyze ethnic, spiritual, and cultural influences that impact my patient, evaluate the patient

outcomes related to care, summarize the plans for discharge, prioritize a list of actual diagnosis

using individualized NANDA format and list potential nursing diagnosis for my patient.

Objective Data
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My patient S.B., was a 44 year old, African American, divorced female. She was

admitted on Saturday, October 27, 2018. I was able to see and interact with her on October 30,

2018. Patient was admitted through the ED department because of increasing agitation and

aggressive behavior at Coleman office and was diagnosed by the hospitals’ psychiatrist with

intermediate explosive disorder. She tested positive for cannabis positive and active pneumonia.

She has a medical history of asthma, fibromyalgia, GERD, high cholesterol, hypertension and

migraines. Currently takes over the counter medications to help manage some symptoms.

She came into the emergency department because of increasing agitation and aggressive

behavior at Coleman office. Per patient stated, her “mental health is jacked up.” Symptoms are

severe constant. There are no exacerbating or relieving factors says she wants to hurt something.

She was then pink slipped. When sitting down and talking with her she had nowhere to go once

leaving the hospital. No home, job or insurance. She couldn’t hold a job down and needed to get

her mental health under control before she could go out and get a job and then keep it. She said

she would get very angry at someone who didn’t agree with her and would always resort to

violence. I think there was some major trauma as a child that led her to some things now later on

in life. She is aware of her anger and is trying to work through it even though was upset to be in

the hospital and wanted to get out. Patient would be going to a group home once leaving the

facility in order to try and get her life back in order. Her family all live in Warren, Oh. She stated

to possibly have a family history of some mental disorders but no one was ever tested or went

and got help. She thought her mom to have one. Most of these mental disorders stem from a

family history or stressors in your life. She currently has a ton of stress and can therefore lead her

to her actions of anger and frustration.

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Growing up her whole family lived in the same house. There were all her siblings and

their kids and her parents all living together. Most of them got along but she would fight with her

mom and sisters occasionally over issues in the house. She has two children, one boy and one

girl, who are now with their father. She has not seen them in a long time and just communicates

with them through talk or text. She has a lot of personal issues going on that need resolved

before taking part in her child's life. There was an unhealthy relationship between her and her ex

so therefore they split and she doesn’t have a good relationship with him or her kids. That is very

hard on her and is a constant stressor in everyday life. Growing up her sister had a child at a

young age and she stated, “I practically raised that child.” She took care of her sisters baby while

all living together and being home. I feel like part of her wanted that because it gave her a

purpose and a mother figure since she got hers taken away from her.

She participated in group therapy and it allowed them to talk about coping techniques and

what they enjoyed doing. One young girl stated in the group session how she really enjoyed

volunteering her time to help those in need. Either by serving food, going to animal shelters or

even helping out at the local nursing homes. I could see my patient getting heated. She then

stated how she cannot volunteer her time if she is not going to get paid money for doing so. It

then broke multiple people out into a heated discussion. They all had their own opinions and

reasonings for why they thought the way they did. Some had more money than others and had a

house and car which allowed them to volunteer their time in which she thought was what you

needed to be able to volunteer. Since volunteering is not a job and you do not get paid for doing

so. As I sat there and watched they all had valid points. No one knows what you are currently

going through or what you have gone through. As the session simmered down my patient ended

it with a simple question, “How many of you have somewhere to go once you leave here?.” She
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said nothing further as a handful of individuals raised their hands. Later talking with her she said

she asked that question because most did and she does not. She has nowhere to go and will end

up in a group home. She said if she had money and a job she would then volunteer her time but

she has no time to waste not making some kind of money off of it. It made me feel sad and feel

her pain. These group therapy session give everyone an outlet to voice their opinions and relate

to one another in a structured setting. It did not get out of hand and everyone seemed to keep

calm even though arguing. You don’t not what everyone is going through.

She had been going to Coleman’s counseling and saw the psychiatrist at the facility prior

to being admitted to the unit. She needed someone to talk to and vent with. Counseling is a good

start to getting your life on track. It allows you to talk about your family and life situations in a

nonjudgmental atmosphere. When you have such huge life altering events that are traumatic to

you in your lifetime it is important to open up about your feelings and those situations instead of

bottling them up inside. The longer you hold things in the worse it eats at you. Letting it out and

doing it with a professional is a good start. After multiple counseling sessions Coleman sent her

to the ED to get evaluated due to the increasing agitation and aggressive behavior. He felt it was

getting out of control and it was in his best interest to get her mental health much more under

control. Patient is well aware that she gets very upset and agitated easily and wanted to hurt

someone when getting that angry.

I do believe there is some bipolar features associated with her diagnosis of intermediate

explosive disorder. She seemed to be swinging back and forth between the manic phase and

depression. Started feeling very depressed at times and missing her kids. It makes me sad

thinking about those who are very depressed and have no energy to get up in the mornings and

live life. With her past and not seeing her kids that could lead to depression. She also talked
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about not sleeping for days and always being hyperactive and agitated easily. That shows

symptoms in the manic phase. She stated all this to the Dr. who did rounds on the unit and talked

with us. She was open to her story and situations and seemed nice and calm throughout it all.

Safety and security measures were maintained throughout the day of care. Interventions

to maintain this include; encouraging showering, independent of activities of daily living,

facilitate daily and PRN dental hygiene, vital signs one time a day and PRN if needed. Safety

checks were conducted every 15 minutes, but the entire time I spent with the patient we were in

either group or the common room. Before med pass the nurse asked if he was feeling like he

wanted to harm himself or others, anxious, or depressed. He responded no to each of the

questions. He was compliant with his medication, even though he was apprehensive about it

because he did not like taking pills, but he knew they would help him so he was willing to be

compliant. There were no signs of agitation, anxiety, or depression that I witnessed during the

day of care.

My patients medications include acetaminophen (Tylenol) 650 mg Q6h, atorvastatin

calcium (Lipitor) 40 mg PO QHS, azithromycin 250 mg daily, carvedilol (Coreg) 12.5 mg BID,

docusate sodium (Colace) for constipation, famotidine, haloperidol (Haldol) 5 mg Q6H which is

an antipsychotic medication, Haloperidol lactate injection, hydroxyzine HCL (Atarax) 500 mg

Q6H, mometasone furoate/ formoterol fumar (Dulera) 200 mcg or 5 mcg (inhaler), nicotine

(Nicoderm Cq 21 mg patch), oxybutynin (Ditropan), quetiapine fumarate (Seroquel), trazodone

HCL, cholecalciferol (Vitamin D) low levels of vitamin D can increase relapse/ disorders.

Summarize
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Intermediate explosive disorder can sometimes be confusing to some people. You need to

understand what it is and what happens when it occurs and manifests. Can also be scary at times

when its unexpected and randomly gets triggered off.

The Mayo Clinic (2018) states, “Intermittent explosive disorder involves repeated,

sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in

which you react grossly out of proportion to the situation. Road rage, domestic abuse,

throwing or breaking objects, or other temper tantrums may be signs of intermittent

explosive disorders. These intermittent, explosive outbursts cause you significant distress,

negatively impact your relationships, work and school, and they can have legal and

financial consequences.”

There have been some changes recently to help physicians determine which disorder a patient

may be diagnosed with. Physicians use the DSM V to diagnose patients. The Mayo Clinic also

states, “Intermittent explosive disorder is a chronic disorder that can continue for years, although

the severity of outbursts may decrease with age. Treatment involves medications and

psychotherapy to help you control your aggressive impulses.” Hopefully with more knowledge

on this disorder more people will be aware of the conditions and what it deals with.

Identify

My patient is a 44 year old female, is currently unemployed, divorced and has no one to

go once discharged from the hospital and will most likely go to a group home.. She presents with

intermediate explosive disorder with bipolar features. She has family living in warren but doesn’t

get along with them much. Not a good support system for her when dealing with issues faced.

During the interview she states, “I just get very angry a lot of the time and resort to aggression
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and violence. I haven’t slept much and have had periods of depression. My mental health is

jacked.”

Discuss

S.B., was born and raised in Warren, Ohio. She has 3 sisters and no brothers. She has two

children, one boy and one girl who she does not see and her ex has custody of them. She only

communicates with them here and there. She doesn’t have a very good support system and not

many friends. She has a hard time forming and keeping relationships with other due to her

condition. She gets aggressive and agitated easily. This is the first time the patient has been

admitted on the psych unit and does not like it at all. Wants to get out. She is prescribed

medication to help ease her mind and stabilize it working hand and hand with her condition. She

was currently receiving counseling at Coleman’s Counseling, and from there got admitted to the

unit. My family thinks she has a family history of mental illness stemming from her mother but

she said she never seeked help or went to the Dr’s about her condition so it was never diagnosed.

Describe

In order to have the best outcome for this client, the nursing staff had to individualize

their plan of care to fit his needs. This included spending time with the patient 1:1 to establish

trust and to identify needs at least three times a shift, helping the patient achieve control of

symptoms as they occur through each group interaction, monitoring desired and problematic

symptoms effects of prescribed medication at least 2 times per shift, provide medication

education prior to initiation of therapy and as needed during continuation of same at time of each

administration, educate the patient regarding his disease process 3 times as needed, and assess

signs and symptoms of delusional thinking each encounter. My patient attended two group

therapies during my shift and talked to me for an hour.

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Analyze

My patient was a 44 year old African American, married woman. Intermediate explosive

disorder was what she was diagnosed with. As stated on the website Psychology Today (2017),

”Typically beginning in late childhood or adolescence, the disorder often precedes—and may

predispose for—later depression, anxiety and substance abuse disorders. Conservative estimates

suggest that intermittent explosive disorder can be found in 2.7 percent of the general population.

The cause of intermittent explosive disorder appears to be a combination of biological and

environmental factors. Lives have been torn apart by this disorder, but medications can help

control the aggressive impulses. Treatment could involve medication or therapy, including

behavioral modification, and a combination of both offers the best prognosis. Group counseling

and anger management sessions can also be helpful. Relaxation techniques have been found to

be useful in neutralizing anger. Studies suggest that patients with intermittent explosive disorder

respond to treatment with antidepressants, anti-anxiety agents in the benzodiazepine family,

anticonvulsants, and mood stabilizers.”

Evaluate

There are many short-term goals in which the nursing staff believes the patient should be

able to accomplish within the amount of time that he is at the facility. The first goal is DH will

not refuse medication, food, or fluids more than 2 times in 5 days. Next is DH will attend group

therapy at least one time a day. Thirdly DH will state he is not hearing voices to harm others or

him. During my shift, DH did not refuse his medication. He attended three group therapies the

day of care. When given his medication he stated that he was not feeling suicidal or wanting to

harm other. He did not have episodes of auditory hallucination, agitation, depression, or thoughts

of harm to self or others.

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Summarize

The patient has been admitted to an inpatient psychiatric unite for treatment, safety and

stabilization. Her plan for discharge includes continuing to see the psychiatrist at Coleman’s

counseling, going to group therapies for anger, depression, and possibly getting a job and

seeking out help. She plans on looking for a job; therefore, she can provide for herself without

letting anger, and mental illness get in the way. Patient education is imperative for discharge.

Education on her new medication, new diagnosis, coping skills, and community resources are

needed.

Prioritize

1. Risk for other-- directed violence related to diagnosis of intermediate explosive disorder

AEB hypervigilance

2. Risk of other-- directed violence related to diagnosis of bipolar features AEB depression

3. Anxiety related to diagnosis of intermediate explosive disorder AEB new patient to psych

unit

4. Anxiety related to diagnosis of intermediate explosive disorder AEB suspiciousness

5. Anxiety related to diagnosis of intermediate explosive disorder AEB new medications

List

1. Anxiety

2. Disabled family coping

3. Disturbed thought process

4. Risk for other-- directed violence

5. Risk to self

6. Risk for injury

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7. Disturbed sleep pattern

8. Hopelessness

9. Impaired home maintenance

10. Post traumatic stress syndrome

11. Ineffective grieving

12. Ineffective coping skills

13. Impaired social interaction

14. Impaired verbal communication

Works Cited

Intermittent explosive disorder. (2018, September 19). Retrieved from

https://www.mayoclinic.org/diseases-conditions/intermittent-explosive-

disorder/symptoms-causes/syc-20373921

Intermittent Explosive Disorder. (n.d.). Retrieved from

https://www.psychologytoday.com/us/conditions/intermittent-explosive-disorder
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