Psychiatric Symptoms: Common Presentations

Question 1

Key questions to ask in depression

-possible differentials to explore

Answer 1

Core symptoms
-low mood and anhedonia?

Biological

• impacts on sleep, energy, appetite
• increased restlessness or slowed movement

Mental
-increased agitation

Risk assessment
-thoughts of hoplessness, self harm, life not worth living, suicidal ideation and attempts

Possible differentials

• hypomania/mania - periods of high energy, elevated mood
• schizoaffective - any hallucinations, delusional thoughts, thought manipulation?
• hypothyroid - feeling cold, weight gain, constipation, tiredness

Question 2

Key questions to ask in anxiety

Answer 2

Timing
Onset
-within 1 month of a stressful event => acute stress reaction?
-over 1 month after a stressful event => PTSD?
Duration
-constant => GAD (6 months)
-episodic => phobias, panic attacks, OCD?

Triggers

• yes => phobias, acute stress reaction, PTSD?
• no => panic attacks, GAD?

Frequency of associated symptoms and impact on daily life

• PTSD, acute stress disorder - flashbacks, sudden panic, nightmares, intrusive thoughts
• OCD - obsessive thoughts and compulsive behaviours

Avoidance behaviours?

Somatic symptoms - fight or flight response
-palpitations, SOB, chest pain, sweating, dizzy

Organic differentials

• hyperthyroidism - weight loss, hot, restless, tremor
• ACS - CV review
• caffeine overuse

Question 3

Key questions to ask in hallucinations and delusions

Answer 3

Do you hear or see things that other people can’t seem to hear or see?
Which sense?
-auditory => schizophrenia, schizoaffective, bipolar, major depressive?
-visual => consider organic, PD/LBD, alcohol withdrawal, delirium
-sensory => DT, alcohol withdrawal?
-gustatory, olfactory => associated with persecutory delusions of being poisoned?

2nd person - depression?
3rd person - schizophrenia, schizoaffective,

Content
-running commentary, commands

Though manipulation
-thought block, broadcast, insertion?

Somatic passivity
-made actions, feelings, thoughts?

Delusions
-do you have any beliefs that other people don’t share?

Question 4

Screening for

• depression
• hypomania/mania
• GAD
• OCD
• psychosis
• panic attacks
• agoraphobia
• PTSD
• social phobia

Answer 4

Depression

• have you felt low in mood for weeks or months?
• have you lost interest in the things you used to enjoy and feel low in energy?

Hypomania/mania
-have you ever had a unusually high amount of energy where you felt you didn’t need to sleep for days at a time?

GAD

• would you describe yourself as a constant worrier
• does your worrying get in the way of your life?

OCD

• do you have any distressing thoughts that you know are irrational but cause you immense distress?
• how do you deal with these distressing thoughts?

Psychosis

• do you hear/see/smell things that others don’t seem to experience?
• do you have any beliefs that others don’t share?

Panic attacks
-do you suddenly have panic attacks that involve intense physical symptoms like shortness of breath, chest pain and feeling like you’re going to die?

Agoraphobia
-do you avoid certain places due to fear?

PTSD

• do you find it difficult to stop thinking about your experience with a distressing event?
• since the event, do you feel more anxious and avoid things that remind you of the event?

Social phobia
-do you avoid events with other people due to fears of embarrassing yourself?

Question 5

Psychiatric review

Answer 5

1st rank symptoms

• 3rd person auditory hallucinations
• running commentaries
• delusions of thought, control, perception

Depression screen
-low mood, low energy, low interest

RISK ASSESS

• feelings of hopelessness
• feelings of wanting to hurt oneself
• thoughts of ending your life
• acted on these thoughts?
• any plans
• what would stop you?

Question 6

Key questions to ask in memory loss

Answer 6

Acute change - delirium?
More insidious - mild cognitive impairment/dementia?

Impacts on daily functioning?

• washing, dressing
• shopping? - getting lost?
• cooking? - leaving the gas on?

CV system review - vascular dementia?
Neuro system review
-movement difficulties => PD, LBD?
-behavioural or difficulties in word finding/speaking => FTD?
HIV screening?

Cognitive screening - GPCOG, MMSE

Question 7

Key questions to ask in a suspected eating disorder

Answer 7

Patient is unlikely to give you information unless you ask

Take me through your daily routine

• I noticed you didn’t mention food, would you able to talk me through what you eat?
• Are there specific foods or food groups that you avoid

Eating and compensatory behaviours

• Do you avoid eating with other people?
• Do you find yourself eating a lot of food very quickly to the point where you feel extremely full and embarassed?
• Have you ever tried to compensate for what you’ve eaten (purging, laxative, excess exercise)

Weight

• How do you feel about your weight?
• Do you weigh yourself frequently?
• Do you spend a lot of time body checking or pinching at areas of your body?

Physical systems review
-SOB, fatigue, amenorrhea, aches and pains, constipation, dehydration?
Mood review

Question 8

Past medical history

• things to ask
• additional things to ask

Answer 8

Physical health
-health conditions + medications

Mental health

• past episodes + medications
• under the care of mental health services in the past? => any diagnoses?

Question 9

Family history

Answer 9

Family health
-any physical or mental conditions that run in the family?

Exploration of relationships with parents, siblings, children

Childhood

• birth, developmental problems?
• school - bullying, academic achievement?

Past trauma
-any traumatic events that you experienced growing up?

Question 10

Social history

Answer 10

Alcohol, drug use - delirium tremens, withdrawal, psychosis from cannabis use?

Social circumstances

• home - who they live with, dependents
• employment and finances

Dorensic history - have you had any interactions with the police?

Premorbid personality - how would you describe yourself before your PC?