Psychiatry - Differential diagnoses Flashcards
What symptoms does the anxious patient present with?
Emotions: anxiety, tension, irritability
Cognitions: exaggerated fears and worries
Behaviour: avoidance of feared situation, checking, seeking reassurance
Somatic features: tight chest, hyperventilation, palpitations, decreased appetite, nausea, tremor, aches and pains, insomnia, frequent desire to urinate
What differential diagnosis should be considered in the anxious patient?
Psychiatric: GAD Panic disorder Phobias OCD PTSD Acute stress reaction Depression Substance misuse - esp withdrawal syndromes Personality disorder Dementia
Medical: Hypoglycaemia Hyperthyroidism Phaeochromocytoma Delirium
Management of the anxious patient
Psychiatric history and MSE
Exclude medical causes - blood pressure, glucose, FBC, TFT
Acute anxiety may be relieved by anxiolytics - e.g. BDZ, but for short courses only as patients may become dependent on them if they are used long term
Certain antidepressants can be used for treatment of anxiety disorder, even if the patient is not depressed - e.g. citalopram for panic disorder, and venlafaxine for GAD
CBT
What symptoms would a depressed patient present with?
Core features: persistent low mood, anhedonia, anergia
Cognitive features: decreased concentration and attention, low self-esteem, bleak and pessimistic views of the future, feelings of guilt or worthlessness, ideas of self harm or suicide
Somatic features: poor sleep, early morning wakening, decreased appetite leading to weight loss, decreased libido, constipation, amenorrhoea, diurnal variation of mood, psychomotor retardation
Differential psychoses to consider in the depressed patients
Psychiatric: Depression Severe depression with psychotic symptoms Bipolar affective disorder Anxiety disorder PTSD Schizophrenia Schizoaffective disorder Dementia Substance misuse (chronic alcohol misuse) Personality disorder
Medical: Hypothyroidism Cushing's syndrome Hypercalcaemia (malignancy) Infections (HIV, syphilis) MS PD Medication (sedatives, anticonvulsants, beta blockers)
Management of the depressed patient
Psychiatric history and MSE (assess for suicidal ideation and manic and psychotic features)
Exclude medical causes
Antidepressants
CBT
What features might the elated patient present with?
Main features: elevation of mood, overactivity, pressure of speech, disinhibition
Other features: irritability, flight of ideas, distractibility, grandiose ideas, decreased sleep, impaired judgment, irresponsibility, decreased appetite
What differential diagnoses should be considered in patients presenting with elated mood?
Psychiatric: Hypomania Mania Mania with psychotic symptoms Schizoaffective disorder Schizophrenia Acute intoxication with cocaine or amphetamines Acute and transient psychotic disorder
Medical: Brain disorders affecting the frontal lobes (e.g. space occupying lesion, dementia, HIV, syphilis, infection) Alcohol withdrawal Corticosteroids Anabolic androgenic steroids Hyperthyroidism
Management of the elated patient
Psychiatric history and MSE
During the interview maintain a calm, non confrontational manner. Manic patients may become aggressive, or violent in response to even minor irritations
Exclude other medical causes
Antipsychotics and benzodiazepines are used in acute episodes
Lithium and other mood stabilisers are used as prophylaxis in bipolar effective disorder
ECT can be used in severe cases of mania resistant to other treatment
What symptoms might a hallucinating patient present with?
Auditory, visual, somatic olfactory, or gustatory hallucinations. Auditory and somatic are more likely in psychiatric disorders, while visual and olfactory suggest an organic disorder
Differential diagnosis to consider in the hallucinating patient
Psychiatric: Schizophrenia Schizoaffective disorder Delusional disorder Mania with psychotic symptoms Severe depression with psychotic symptoms Acute and transient psychotic disorder Alcohol and drug misuse - e.g. hallucinogenic drugs, LSD, magic mushrooms DT
Medical: Temporal lobe epilepsy SOL Delirium Metabolic disturbances, liver failure Infection - e.g. encephalitis Head injury
Management of the hallucinating patient
Psychiatric history and MSE (including risk assessment)
Exclude organic causes
Antipsychotic drugs for psychosis
Consideration should be given to admitting the patient to hospital
Symptoms that the obsessive or compulsive patient may present with
Obsessions = unwanted, distressing thoughts or images that enter the patients mind even though they try to resist them. The thoughts are recognised as the patients own
Compulsions = acts performed to ease the anxiety caused by obsessions and become repetitive and are recognised as senseless
Differential diagnosis in the obsessive or compulsive patient
OCD Anakastic personality disorder Depression Schizophrenia Anorexia nervosa Phobic disorders Tourette's syndrome
Management of the obsessive/ compulsive patient
Psychiatric history and mental state examination
Consider if there is any other symptoms that might suggest depression or psychosis
Antidepressants - clomipramine and SSRIs have the greatest efficacy
CBT
