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Common psychological histories

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-Anxiety and worry on most days
-Generalised (about everything)
-Long-term
Panic disorder-Panic attacks (palpitations, sweating, SOB, chest pain etc.)
-Unpredictable but certain situations may predispose (e.g. busy places)
Phobic disorder-Intense fear triggered by predictable stimulus
-Common examples: agoraphobia, isolated phobia (e.g. snakes, flying), social phobia
Post-traumatic stress disorder-Caused by stressful life event
-Intense anxiety with flashbacks, insomnia, nightmares, avoidance, emotional detachment 
Obsessive compulsive disorder-Obsessive thoughts
-Constant need to check everything
-Only relieved by acting on compulsions, e.g. cleaning hands, checking lights or locks
Depression-Positive depression screen

Organic:

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

Differential diagnoses and clues

Psychiatric:

Schizophrenia-Schizophrenia first rank symptoms
-Other positive symptoms: bizarre delusions, odd behaviour, somatic hallucinations
-Negative symptoms: apathy, anhedonia, asociality, lack of motivation
Delusional disorders-Non-bizarre delusions
-Absence of other psychiatric symptoms
Bipolar disorder-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
Schizoaffective disorder-Features of bipolar disorder and schizophrenia in same episode
Psychotic depression-Depression associated with psychotic symptoms, e.g. delusions or hallucinations
Puerperal psychosis-Severe mental illness days/weeks after childbirth
Delirium-Elderly patient with current/recent infection
-Reduced level of consciousness
-Fluctuating
-Inversion of day/night cycle
Dementia (esp. Lewy body)-Long history of progressive memory loss
-Related cognitive deficits (comprehension, orientation, inhibition etc.)

Organic:

OrganicDrugs (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:

Depression-Positive depression screen   
Bipolar disorder-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
Adjustment disorder-Triggered by stressful life event
-Stress, upset, anxiety, hopelessness 
-Reaction greater than expected for the event
Psychotic depression-Depression associated with psychotic symptoms, e.g. delusions or hallucinations
Postnatal depression-Depression days/weeks after childbirth
-Often recurrent 

Organic:

OrganicHypothyroidism, 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:

Alzheimer’s disease-Relentlessly progressive decline
-Disinhibition
-Dysphasia and dyspraxia
Vascular dementia-Stepwise decline
-Cardiovascular risk factors
-Preserved insight
Lewy body dementia-Fluctuating dementia
-Visual hallucinations-Parkinsonism
-Delirium like phases
Other rarer types– Fronto-temporal dementia (Pick’s disease)
– Creutzfeldt-Jakob disease

Psychiatric:

Depression(pseudodementia)-Positive depression screen
Delirium-Reduced level of consciousness
-Fluctuating
-Inversion of day/night cycle
-Evidence of infection

Others:

Other differentialsDegenerative 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:

Anorexia nervosa-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
Bulimia nervosa-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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Test yourself here!

  1. Strange behaviour history
  2. Psychosis
  3. Anxiety
  4. Low mood
  5. Find more here
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