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:

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

Some questions….

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1. Strange behaviour history
2. Psychosis
3. Anxiety
4. Low mood
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