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Common psychological histories

History taking > Common presenting complaints

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

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)

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

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

Especially Lewy body dementia

  • 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

Fronto-temporal dementia

  • Prominent personality changes

Psychiatric

Depression (pseudodementia)

  • Positive depression screen

Delirium

  • Reduced level of consciousness

  • Fluctuating

  • Inversion of day/night cycle

  • Evidence of infection

Others

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

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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Common presenting complaints