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 | -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
- Schizophrenia first rank symptoms:
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:
| 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:
| 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:
| 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:
| 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 differentials | 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:
| 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 |
