Table of Contents
Anxiety
Exploring symptom
- Attack detail
- Timing: duration, onset, episodic/constant, triggers, effect on life, frequency, avoidance
- Somatic symptoms: palpitations, breathlessness, tight chest, sweating, dizziness
- Background to attacks
- e.g. Previous attacks, frequency, impact on life
- Associated symptoms
- Associated psychological symptoms: depression screen, stress, worry, avoidance
- Psychiatric differential questions: obsessions, compulsions, PTSD symptoms (psychological trauma, flashbacks, nightmares, hyperarousal)
- Organic differential questions: e.g. hyperthyroidism, ACS
Relevant system reviews
- Psych
- Depression screen: core (mood, anhedonia), biological (sleep, energy), future (hopelessness, suicidal thoughts)
- RISK: to self, to others
Differential diagnoses and clues
Psychiatric
- Generalised anxiety disorder
- Panic disorder
- Phobic disorder
- Post-traumatic stress disorder
- Obsessive compulsive disorder
- Depression
- Anxiety and worry on most days
- Generalised (about everything)
- Long-term
- Panic attacks (palpitations, sweating, SOB, chest pain etc.)
- Unpredictable but certain situations may predispose (e.g. busy places)
- Intense fear triggered by predictable stimulus
- Common examples: agoraphobia, isolated phobia (e.g. snakes, flying), social phobia
- Caused by stressful life event
- Intense anxiety with flashbacks, insomnia, nightmares, avoidance, emotional detachment
- Obsessive thoughts
- Constant need to check everything
- Only relieved by acting on compulsions, e.g. cleaning hands, checking lights or locks
- Positive depression screen
Organic
- Acute coronary syndrome
- Arrhythmia
- Hyperthyroidism
- Phaeochromocytoma
Psychosis
Exploring symptom
- Auditory hallucinations
- Voice detail: male/female, recognisable, always the same?, when heard
- Real/pseudo: outside/inside head
- 2nd/3rd person: to you/about you
- What they say (including commands)
- Delusions
- Explore
- Challenge the delusion
- Assess risk others/self
Relevant system reviews
- Psych
- Schizophrenia first rank symptoms:
- 1. 3rd person auditory hallucinations
- 2. Running commentary auditory hallucinations
- 3. Delusions of thought
- 4. Delusions of control
- 5. Delusional perception
- Depression screen: core (mood, anhedonia), biological (sleep, energy), future (hopelessness, suicidal thoughts)
- Other: insight
- RISK: to self, to others
- Schizophrenia first rank symptoms:
Differential diagnoses and clues
Psychiatric
- Schizophrenia
- Delusional disorders
- Bipolar disorder
- Schizoaffective disorder
- Psychotic depression
- Puerperal psychosis
- Delirium
- Dementia
- Schizophrenia first rank symptoms
- Other positive symptoms: bizarre delusions, odd behaviour, somatic hallucinations
- Negative symptoms: apathy, anhedonia, asociality, lack of motivation
- Non-bizarre delusions
- Absence of other psychiatric symptoms
- Normal mood interspersed with depressive and manic episodes
- Manic episodes: irritable, elevated mood, fast speech, flight of ideas, grandiosity, excessive spending/drinking, insomnia, auditory hallucinations, delusions of wealth/power/religion
- Features of bipolar disorder and schizophrenia in same episode
- Depression associated with psychotic symptoms, e.g. delusions or hallucinations
- Severe mental illness days/weeks after childbirth
- Elderly patient with current/recent infection
- Reduced level of consciousness
- Fluctuating
- Inversion of day/night cycle
Especially Lewy body dementia
- Long history of progressive memory loss
- Related cognitive deficits (comprehension, orientation, inhibition etc.)
Organic
- Drugs (e.g. recreational drugs, corticosteroids, levodopa, antimalarials)
- Alcohol/drug withdrawal
- Extreme fatigue
- Temporal lobe epilepsy
- Space occupying lesion
- Hypoxia
- Huntington’s
- SLE
- Neurosyphilis
- Autoimmune/paraneoplastic
- HIV
Low mood
Exploring symptom
- Depression screen
- Core: mood, anhedonia
- Biological: sleep, energy
- Future (including risk): hopelessness, suicidal thoughts
- Background
- Hx of mania/hypomania
- Previous episodes and triggers
Relevant system reviews
- Psych
- Psychosis symptoms: hallucinations, delusions
- RISK: to self, to others
Differential diagnoses and clues
Psychiatric
- Positive depression screen
- Normal mood interspersed with depressive and manic episodes
- Manic episodes: irritable, elevated mood, fast speech, flight of ideas, grandiosity, excessive spending/drinking, insomnia, auditory hallucinations, delusions of wealth/power/religion
- Triggered by stressful life event
- Stress, upset, anxiety, hopelessnessÂ
- Reaction greater than expected for the event
- Depression associated with psychotic symptoms, e.g. delusions or hallucinations
- Depression days/weeks after childbirth
- Often recurrent
Organic
- Hypothyroidism
- Drug side effects
- Intracranial lesion
- Grief reaction
Memory loss
Exploring symptom
- Memory loss
- Onset
- Short/long-term
- Insight and concerns
- Functional levels (washing, dressing etc.)
- Risk assessment (e.g. turning off gas stove)
- Mini mental state examination
Relevant system reviews
- General
- Any evidence of infection, e.g. fever, urinary symptoms
- Psych
- Psychosis symptoms: hallucinations, delusions -Depression screen: core (mood, anhedonia), biological (sleep, energy), future (hopelessness, suicidal thoughts)
- Other: insight
- RISK: to self, to others
Differential diagnoses and clues
Dementia
- Relentlessly progressive decline
- Disinhibition
- Dysphasia and dyspraxia
- Stepwise decline
- Cardiovascular risk factors
- Preserved insight
- Fluctuating dementia
- Visual hallucinations-Parkinsonism
- Delirium like phases
- Prominent personality changes
Psychiatric
- Positive depression screen
- Reduced level of consciousness
- Fluctuating
- Inversion of day/night cycle
- Evidence of infection
Others
- Creutzfeldt-Jakob disease
- Degenerative neurological diseases (e.g. Huntington’s, MS)
- Drugs and alcohol
- Vitamin deficiency (B12, thiamine, folate, nicotinic acid)
- Electrolyte imbalances/uraemia
- Organ failure
- Endocrinopathies
- Space occupying lesion
- Neurosyphilis
- Encephalitis
- Autoimmune/paraneoplastic
- HIV
Eating disorder
Exploring symptom
- BMI
- Symptoms: avoidance of weight gain/need to lose weight/look in mirror a lot, efforts to lose weight (vomiting, laxatives, exercise), binge eating/fasting
- Food diary: what they eat each day
- Consequences: menstrual cycle disturbance
- Self harm and depression symptoms
Relevant system reviews
- Psych
- Depression screen: core (mood, anhedonia), biological (sleep, energy), future (hopelessness, suicidal thoughts)
- RISK: to self
Differential diagnoses and clues
Psychiatric
- BMI <17.5-Fear of weight gain
- Feel fat when thin
- Efforts to lose weight: diuretics/laxatives, vomiting, excessive exercise
- Consequential symptoms: amenorrhoea, developmental delay, myopathy, poor sleep, GI symptoms
- BMI >17.5
- Regular binge eating
- Preoccupation with body weight control
- Means of avoiding weight gain e.g. starvation, vomiting, laxatives, exercise
Some questions….
Please list the first rank symptoms of schizophrenia.
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What is meant by ‘positive’ and ‘negative’ symptoms in schizophrenia?
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What is the difference between a delusion and a hallucination? Please list some types of each
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What is the differential diagnosis for psychosis? Please list some organic and non-organic causes.
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