02/11/2026
Mood Temperament Spectrum: Case Vignettes
A clinical teaching collection by Dr. Ehinome E. Okojie - SCMI Ward Tools. 8 temperaments x 2 vignettes = 16 vignettes, 450-525 words each. Each vignette contains ~2% thermodynamic framing (energy, entropy, equilibrium, flow, dissipation) woven subtly into clinical reasoning, preserving primacy of phenomenology.
HYPERTHYMIC - Vignette 1: The Trader Who Never Sleeps
Mr. A.B., 34, male trader from Onitsha, presented to liaison psychiatry after his wife insisted he was "becoming too much." For 3 months, he has slept 3-4 hours, waking at 4 am energized to trade crypto, call suppliers, and plan a new logistics startup. He reports racing ideas, not distressing to him, but his speech is pressured. "I have finally unlocked my brain," he says. He has increased goal-directed activity, double his previous income, but neglects meals and misses family events. No grandiosity with psychotic conviction, no spending to ruin, no substance use. Past history: lifelong "pep person," school prefect, always optimistic, top of class without much effort. Family history: father similar temperament, successful but hypertensive. Mental state exam: cheerful, expansive affect, fast but coherent thought, no flight of ideas, euthymic is not his baseline, hyperthymic is. Insight partial. Physical exam: BP 142/88, BMI 26.2, labs tier 1: glucose, TFT pending. Differential includes hypomania vs hyperthymic temperament accentuated by stress. Thermodynamic framing (2%): His affective system operates like a heat engine running at high combustion temperature with unusually efficient energy conversion and low heat loss, maintaining high kinetic output on minimal fuel. Management used SCMI: ORGANIC-13 screen negative for thyroid storm, infection, steroids. SMA triage marked low risk. Plan focused on sleep hygiene, behavioral cooling strategies, collateral with spouse, psychoeducation that temperament is trait, not episode, with boundary setting and monitoring for transition to mania. After 6 weeks of structured wind-down rituals and limiting caffeine, he retained productivity but restored 6.5 hours sleep and family meals, showing how tempering fuel input lowered output without collapsing function.
HYPERTHYMIC - Vignette 2: The Final Year Resident
Dr. S.O., 28, female surgical resident, referred for "conflict with nurses." Described as brilliant, always on call, volunteers for extra surgeries, jokes loudly, sleeps little before exams yet scores high. Colleagues say she interrupts, overpromises, and appears unfazed by criticism. She says: "I am just built to do more." For 2 years, this pattern stable, not episodic. She denies depressive dips, denies anxiety, but admits irritability when others slow her down. No history of major mood episode. She has started energy drinks, 4 cans daily. Exam: animated, euthymic mood incongruent? No, hyperthymic is her euthymia. Speech rapid but not pressured beyond control, thought goal-directed, no psychosis. ORGANIC-13: check caffeine, anemia, hyperthyroidism - TFT normal, Hb 11.8. Thermodynamic note: Her system demonstrates low entropy production in high workload states, like a superheated system that maintains order despite intense molecular agitation, until a small perturbation triggers rapid heat release as irritability. Teaching point: hyperthymic temperament confers resilience and leadership but risks interpersonal friction and burnout of surrounding team. Intervention: Use sociocultural framework - taught her to channel authority via community respect model, not volume. Introduced energy budgeting, mandatory micro-recovery, caffeine taper. Referred for coaching not medication. At 3 months, nursing conflict scores reduced, she retained leadership edge but learned to pause, showing temperamental traits can be calibrated like adjusting a thermostat set point rather than pathologized.
EUPHORIC OR CYCLOTHYMIC - Vignette 1: The Gospel Musician
Ms. C.E., 24, undergraduate music student, presents with 18-month history of mood swings noticed by choir. For 2-3 weeks she is euphoric, composing 5 songs overnight, colors brighter, spending small savings on fabrics, feels chosen by God, then for 4-5 days crashes to tearful, guilt-ridden, cancels rehearsals, says music has left her. No psychotic depression, no mania with dangerous behavior, cycles are temperamental, not fully syndromal. She describes self as "weather." Family says since adolescence she has been "up and down." Examination during euphoric phase: bright, labile affect, slightly inflated self-esteem, tangential but redirectable, no frank grandiosity. During low phase: soft speech, low energy, still attends lectures. ORGANIC-13 screen: menstrual history, substance use negative, malaria smear negative, TFT normal. Differential: cyclothymic temperament vs bipolar II. Thermodynamic logic: Her affect behaves like a small isolated system with low thermal mass, so minimal external input causes large temperature swings, yet total energy remains conserved, never reaching absolute high or low extremes. SCMI ADA daily tracking for 6 weeks showed sinusoidal pattern with period 21-28 days. Management: psychoeducation using local narrative - seasons and farming cycles, mood charting, sleep-wake stabilization, interpersonal rhythm therapy, avoid antidepressant monotherapy. She learned to schedule creative output during ascent and rest during descent, using temperamental oscillation productively while watching for phase shift into full episode. Outcome: fewer interpersonal ruptures, academic stability preserved.
EUPHORIC OR CYCLOTHYMIC - Vignette 2: The POS Business Owner
Mr. I.K., 38, POS and phone accessories dealer in Owo, brought by brother for "inconsistent business." History: Some weeks he opens 6 am, expands to 3 shops, dashing money to friends, overly familiar with customers, euphoric, then next week he sits withdrawn, says business will collapse, returns goods, suspicious of staff, then rebounds. No psychosis, no major depressive criteria, but distress due to unpredictability. He reports "my heart just moves." Since secondary school, similar pattern but amplified by debt and fuel price stress. Mental state: currently mildly euphoric, cooperative, mood congruent, insight fair. Physical: BP 138/86, BMI 29. Labs tier 1-2 unremarkable. Thermodynamic 2%: System shows rapid entropy increase and decrease without external work, like a metastable colloid flickering between ordered and disordered phases, maintaining cyclic equilibrium without settling. Management: Context-rooted workflow - Given limited 1:1 staffing, used SMA for risk, ADA for daily energy/income logs, involved brother as co-regulator. Taught stimulus control - when feeling "light", delay major financial decisions 24 hours, use checklist. Introduced low-dose mood stabilizer discussion deferred, prioritized behavioral and family psychoeducation. After 2 months, cycles persisted but amplitude reduced, business losses cut by 40%, demonstrating temperamental regulation is about dampening amplitude, not stopping oscillation.
EUTHYMIC - Vignette 1: The Balanced Teacher
Mrs. F.A., 42, secondary school teacher, referred for evaluation after husband's stroke, but not for mood disorder - for counseling. She describes normal sadness, worry proportional to event, sleep maintained 6-7 hours, appetite preserved, still enjoys teaching, cries when overwhelmed then recovers. She says: "I am sad, but I am myself." Past history: stable temperament, no affective episodes. Family history negative. MSE: affect euthymic, appropriate, congruent, reactive, range intact, no anhedonia, thought linear, cognition intact. ORGANIC-13 negative. Thermodynamic note: Her mood system illustrates thermal equilibrium with environment - heat exchange occurs, temperature fluctuates appropriately to external load, but internal set point returns to baseline without excessive energy expenditure. Teaching vignette for residents: Euthymia is not absence of emotion but proportionate response and rapid return to baseline. She demonstrates resilience not via suppression but via flexible regulation. Intervention: supportive psychotherapy, problem solving, caregiver support, no medication needed. Used to teach trainees difference between euthymic distress and hypothymic or dysthymic response. Outcome: 8 weeks later husband improving, she maintained functioning, occasional tearfulness but no syndrome, showing healthy affective homeostasis.
EUTHYMIC - Vignette 2: The Medical Officer After Malaria
Dr. L.M., 30, medical officer, seen post malaria treatment with complaint of "low mood." For 10 days during illness he was fatigued, low, but now 2 weeks post recovery he reports mood back to normal, energetic, sociable, sleeping well, planning exams. He worried he had depression. Detailed history shows mood dip correlated with fever, anorexia, isolation. Now euthymic. No anhedonia, no guilt, no suicidal ideation. He exercises, prays, maintains relationships. MSE: bright, euthymic, reactive, intact. ORGANIC-13 applied retrospectively: malaria confirmed as organic mimic. Thermodynamic 2%: His system returned to baseline like a reversible isothermal process - after external heat stress removed, internal state restored with minimal residual entropy, conserving functional capacity. This vignette teaches distinguishing organic-induced transient dysthymia from true temperament. Management: reassurance, psychoeducation on post-infectious fatigue, no psychotropics, encourage watchful waiting. Resident teaching point: Not every low mood after infection is depression; euthymic baseline reasserts quickly if underlying temperament is euthymic. Patient returned to duty, exam preparation on track, illustrating importance of longitudinal baseline assessment.
HYPOTHYMIC - Vignette 1: The Quiet Accountant
Mr. G.O., 45, accountant, self-referred: "I have always been low energy." Since adolescence, he prefers quiet, works slowly, rarely excited, content with routine, no big lows, no highs. Wife says he is "cold but reliable." He sleeps 8-9 hours, wakes unrefreshed, low drive, not unhappy but flat. He denies anhedonia but admits less joy than peers. No depressive cognitions, no guilt, no SI. He functions, never missed work, but never promoted due to lack of assertiveness. Past history: no MDD episode. Family: mother similar. MSE: affect hypothymic, restricted but not blunted, speech low volume, slow, thought linear, no psychosis. ORGANIC-13: hypothyroidism, anemia, low testosterone, depression screen - TFT normal, Hb 13.2, Vit D low. Thermodynamic framing: Low-grade combustion engine idling at low temperature, producing minimal useful work but also minimal waste heat, conserving fuel over long duration, stable but inefficient for sudden demands. Differential: hypothymic temperament vs dysthymia vs hypothyroidism. Management: Lifestyle activation, graded exercise, vitamin D replacement, sleep hygiene, assertiveness training using community authority narratives, not antidepressant. Psychoeducation that temperament is baseline, not failure. At 3 months, slight improvement in energy, still hypothymic but now understands and accepts, wife reframed expectation, job crafting to roles needing steadiness not speed, demonstrating functional adaptation without pathologizing.
HYPOTHYMIC - Vignette 2: The Postpartum Mother Not Depressed
Mrs. H.T., 27, 4 months postpartum, referred for suspected postpartum depression. She reports low energy, less talk, prefers staying home, but denies sadness, guilt, bonding normal, breastfeeding good, baby thriving. Husband worried. History: lifelong quiet, introverted, low initiative, always needed push. During pregnancy she was similar. No prior depression, no psychosis, no anxiety. MSE: hypothymic affect, not dysphoric, eye contact fair, mother-infant interaction warm though subdued, no thought disorder. ORGANIC-13: anemia postpartum, thyroiditis, infection - labs normal except mild iron deficiency. Thermodynamic 2%: System operates at low enthalpy state, requiring larger activation energy to initiate phase transition to active engagement, yet once engaged remains stable. Teaching: Distinguish hypothymic temperament accentuated by postpartum physiological load from postpartum depression. Intervention: Iron, nutrition, sleep support via family rota, gentle activation, mother support group, no antidepressant. At 6 weeks, energy marginally better, but temperament unchanged, mothering competent, family reassured, illustrating need for temperamental baseline history to avoid over-diagnosis in low-resource setting where maternal mental health resources scarce.
DYSTHYMIC - Vignette 1: The Civil Servant Since NYSC
Mr. J.N., 39, civil servant, presents with 6-year history of low mood, low self-esteem, pessimism. Says: "I have been dull since youth service." Most days down, feels inadequate, criticizes self, sleeps poorly, appetite low, concentration reduced, anhedonia partial but not total, still goes to work, attends church but no joy. No period of 2 months symptom free. No major depressive episode superimposed? He had 2 episodes of worsening meeting MDD 2 years ago. Family history: uncle with depression. MSE: dysthymic affect, down, self-deprecating, hopelessness present but not suicidal now, thought ruminative. ORGANIC-13: chronic malaria, HIV screen negative, TFT normal. Thermodynamic note: Chronic low-grade heat leak causing continuous entropy gain within system, requiring constant internal work to maintain basic structure, leaving little free energy for growth or repair, resulting in cold, ordered but brittle state. Diagnosis: Persistent depressive disorder, dysthymic temperament with double depression history. Management: SCMI approach - ADA tracking, behavioral activation adapted to civil service schedule, cognitive restructuring using local proverbs, interpersonal therapy, sertraline 50mg titrated to 100mg, psychoeducation on chronicity. Context: limited therapy slots, used group sessions. At 4 months, dysthymic baseline improved 30% on PHQ-9 from 16 to 11, functioning improved, understanding that dysthymia is long-burning fuel, not sudden fire, requiring sustained intervention, not quick fix.
DYSTHYMIC - Vignette 2: The Final Year Nursing Student
Ms. K.B., 22, nursing student, self-referred for "always sad." Since age 13, feels inferior, sad most days, expects failure, easily tired, difficulty making decisions, socially withdrawn but not isolated. Says: "Others are bright, I am shadow." Academic performance average, never failed but never excelled. No frank MDD, but chronic. No mania. She reports early loss of mother at 10. MSE: dysthymic, downcast, low self-esteem evident, tearful but not dysphoric agitation, thought self-critical. ORGANIC-13: nutritional, anemia, thyroid - mild anemia corrected. Thermodynamic 2%: Like a system stuck in a shallow potential well near low energy, random fluctuations insufficient to escape to higher functional state without external activation energy input. Teaching: Dysthymic temperament shaped by early loss and reinforced by sociocultural expectations for girls. Management: Trauma-informed counseling, self-compassion exercises, peer mentorship, behavioral activation, academic support, no immediate medication due to mild severity and preference, watchful. Used local storytelling to reframe identity. At 10 weeks, mood slightly brighter, decision making improved, still dysthymic but less self-critical, engaged in student association, showing dysthymia responds to sustained relational heat input rather than single intervention.
DYSPHORIC - Vignette 1: The Okada Rider After Accident
Mr. L.C., 31, okada rider, presents 3 months post minor road accident with persistent unpleasant mood. He reports constant dissatisfaction, feels "pepper in body," easily annoyed, restless, cannot enjoy previous activities, sleep broken, appetite irritable. Says: "I am not sad, I am not happy, I am somehow." No guilt, no anhedonia typical of depression, but dysphoric. No PTSD full criteria, but subthreshold. History: prior temperament irritable-anxious mix. MSE: dysphoric affect, tense, fidgety, speech normal, thought preoccupied with injustice of accident, no psychosis. ORGANIC-13: TBI, pain, substance use, infection - CT not done, exam neuro intact, pain present low back. Thermodynamic framing: High internal friction generating waste heat without productive work, system highly entropic, energy dissipated as irritability and somatic tension rather than directed action. Differential: dysphoric temperament, adjustment disorder, persistent post-concussive dysphoria. Management: Pain management, sleep hygiene, anger management using breathing and community elder mediation model, graded return to work, ADA tracking for dysphoria triggers. Avoid benzodiazepine. Psychoeducation that dysphoria is signal of unsettled equilibrium, not moral failing. At 2 months, dysphoria reduced, able to work half days, still occasional unpleasant tension but less externalized to customers, showing need to dissipate heat via adaptive channels.
DYSPHORIC - Vignette 2: The Market Woman
Mrs. M.D., 48, trader in Owo market, referred by family for constant complaints, quarreling. For 2 years, she is never satisfied, complains about husband, children, market levies, body hot, mood "sour." She reports anhedonia? No, she enjoys gossip and sales when they go well, but quickly shifts to dissatisfaction. Sleep okay, appetite okay, but mood persistently unpleasant. History: lifelong sensitive to injustice, prior temperament dysphoric-anxious. MSE: dysphoric affect, tense, verbose complaints, thought not delusional, cognition intact. ORGANIC-13: menopause, thyroid, hypertension, chronic pain - FSH perimenopausal range, BP 150/90. Thermodynamic 2%: System in non-equilibrium steady state where influx of small stressors maintains high internal temperature without reaching boiling point, constant low-grade boiling keeps surface turbulent. Management: Validate, screen for depression - PHQ-9 10 moderate, but dysphoria predominant. Interventions: behavioral - scheduled pleasant events, menopause counseling, BP control, family meeting using communal resolution framework, breathing. No antidepressant initially, watch. At 3 months, complaints reduced, family reports less quarrel, she reports "body still hot but mouth cooler," illustrating dysphoric temperament management is cooling internal friction via outlet not suppression.
ANXIOUS - Vignette 1: The JAMB Candidate
Mr. N.E., 19, JAMB candidate, presents with 1-year excessive worry about exams, future, family finances. He worries daily, difficulty controlling, muscle tension, palpitations, sweating, insomnia initial, concentration poor. Says: "My chest carries load." He avoids applying, procrastinates. No panic attacks full, no depression syndrome, but anxious temperament since childhood - shy, careful, always needed reassurance. Family: father anxious. MSE: anxious affect, fidgety, thought ruminative about catastrophe, no psychosis, cognition intact but attention biased to threat. ORGANIC-13: hyperthyroidism, caffeine, asthma inhaler, substance - TFT normal, no substance. Thermodynamic note: High free energy stored as potential worry, system hypervigilant, constantly expending work to anticipate future heat spikes, increasing baseline entropy through wasted prediction cycles. Differential: anxious temperament, GAD. Management: Psychoeducation using local narrative - worry as overactive vigilante guarding village, CBT for anxiety adapted to low-resource - worry time, thought record in pidgin, breathing, problem solving for finances, study skills, family support, no medication first line. At 6 weeks, worry reduced, applied for JAMB, sleep improved, showing anxious temperament benefits from structured containment of future-oriented energy, reducing unnecessary thermodynamic work.
ANXIOUS - Vignette 2: The Nurse in Charge
Mrs. O.F., 36, nurse, presents with chronic anxiety about ward errors. For 3 years, checks charts repeatedly, fears patient death due to her mistake, palpitations before shift, GI upset, reassurance seeking from doctors. Says: "If I relax, someone will die." She functions but exhausted. History: anxious since childhood, perfectionistic. No OCD full? Some checking but not ritualistic neutralizing beyond anxiety. MSE: anxious affect, tense, speech pressured with worries, thought anxious rumination, no delusion. ORGANIC-13: anemia, hyperthyroid, pheo - labs normal. Thermodynamic 2%: System maintains low-entropy ordered state via continuous energy expenditure on surveillance, like Maxwell's demon sorting molecules, costly to maintain, leading to fatigue when energy reservoir depletes. Management: SCMI - SMA risk low, ADA worry log, cognitive restructuring, exposure to uncertainty, mindfulness, workload negotiation with matron, assertiveness. Used sociocultural model - community responsibility shared, not individual. No benzodiazepine long-term. At 3 months, checking reduced 50%, anxiety scores down, able to handover without repeated calls, showing anxious temperament needs redistribution of monitoring load to system not self.
IRRITABLE - Vignette 1: The Bus Driver
Mr. P.G., 40, commercial bus driver, brought by park chairman after fight with passenger. History: lifelong quick temper, small provocation triggers shouting, sometimes throwing objects, remorse after, no sustained mood elevation, no depression. Says: "My blood dey hot quick." For past 6 months, increased frequency due to fuel cost stress, poor sleep, financial pressure. No substance except alcohol occasional. No head injury. MSE: currently calm but irritable affect when discussing provocation, speech loud at times, thought not paranoid but interprets neutral as disrespect. Insight partial. ORGANIC-13: hypoglycemia, TBI, substance, hyperthyroid, pain - random glucose normal, no neuro deficit. Thermodynamic note: Low activation energy for exothermic anger reaction, minimal spark ignites rapid heat release, then quick cooling with residual ash of regret, system prone to runaway without damping. Differential: irritable temperament vs intermittent explosive disorder. Management: Anger management - trigger log ADA, time-out, breathing, sleep, alcohol reduction, communication training using respect hierarchy model, family collateral, problem solving for finance. At 2 months, fights reduced from weekly to monthly, chairman reports improvement, patient reports ability to pause, illustrating irritable temperament regulation via increasing activation threshold and providing alternative heat dissipation pathways.
IRRITABLE - Vignette 2: The Teenage Secondary Student
Ms. Q.H., 16, SS2 student, referred by school for defiance and snapping at teachers. Mother reports since age 8 she is easily annoyed, argues, blames others, low frustration tolerance, not cruel, not rule breaking beyond argument, but irritable most days. Academic performance dropped. No depression, no mania, no conduct disorder severe. She says: "Everyone provokes me." MSE: irritable affect, eye roll, defensive, speech normal, thought not delusional, self-esteem low due to constant reprimand. ORGANIC-13: substance, me**es, anemia, thyroid, sleep deprivation - sleep 5 hours due to phone, Hb 12.1. Thermodynamic 2%: System with high thermal conductivity for negative stimuli but low for positive, so minor insults conduct rapidly to core causing temperature spike, while praise dissipates quickly without warming core. Management: Sleep hygiene, phone curfew, emotion regulation skills - DBT-informed for adolescents adapted to Nigerian parenting, family psychoeducation avoiding shaming, school behavior plan with positive reinforcement, not punishment alone. Taught parents to model cooling. At 8 weeks, irritability less, school reports improved, still quick to annoy but recovers faster, showing temperamental irritable style benefits from environmental thermal insulation and skill-based heat sinks.
