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, hopelessness
- 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.
Oops! This section is restricted to members.
Create an account or log in to continue reading.
What is meant by ‘positive’ and ‘negative’ symptoms in schizophrenia?
Oops! This section is restricted to members.
Create an account or log in to continue reading.
What is the difference between a delusion and a hallucination? Please list some types of each
Oops! This section is restricted to members.
Create an account or log in to continue reading.
What is the differential diagnosis for psychosis? Please list some organic and non-organic causes.
Oops! This section is restricted to members.
Create an account or log in to continue reading.
