Psychiatry History

Question 1

Depression

Answer 1

History

• Symptoms
  
  • Screening
    
    • Low mood
    • Anhedonia
  • Biological symptoms (SCALED W)
    
    • Sleep (EMW)
    • Concentration
    • Appetite (+/- weight loss)
    • Libido
    • Energy
    • Diurnal mood variation
    • Worthlessness / Guilt
• Precipitating factors
• Risk assessment (suicidal ideation)
  
  • Previous history of self harm
  • Future
• PMH
  
  • Prior episodes
    
    • ‘High’
  • Other psychiatric conditions
  • Chronic illness
• FH
• DH
  
  • Alcohol and drug use
• SH

Differentials

• Bipolar
• Schizophrenia
• Hypothyroidism

Investigations

• Bloods to rule out organic cause
• CT/MRI if atypical presentation or features suspicious of intracranial lesion (e.g. unexplained headache, personality change)

Management

• Mild-moderate
  
  • CBT
• Moderate-severe
  
  • SSRI + CBT
    
    • Citalopram / Sertraline
    • Fluoxetine (young)
      
      • SEs: GI upset
• Refractory / life-threatening
  
  • ECT

Question 2

Bipolar affective disorder

Answer 2

History

• PC
  
  • Symptoms (HIGH CDT)
    
    • Hyperactivity
    • Insomnia / Irritable
    • Grandiosity
    • Happy (euphoria)
    • Concentration
    • Disinhibition / Distractable (leave tasks unfinished?)
    • Thoughts (racing)
  • Psychotic symptoms
    
    • Delusions
    • Hallucinations
• ‘Low’
• Risk assessment
• PMH
  
  • Infections
  • Hyperthyroidism
• DRUG USE
  
  • ​Amphetamines
  • Cocaine
• FH
• SH

Differentials

• Hyperthyroidism
• Drug intoxication/withdrawal

Management

• Mood stabiliser
  
  • Lithium
    
    • Monitor serum levels regularly
    • Check U&E + TFTs regularly
    • SE: hypothyroidism, nephrogenic diabetes insipidus (nephrotoxic)
• Benzodiazepine
  
  • Reduce irritability, improve sleep

Question 3

Schizophrenia

Answer 3

History

• PC
  
  • Positive symptoms
    
    • Hallucinations
      
      • 3rd person, Commentary
    • Delusions
      
      • External control
      • Plotting against you
    • Disorganised thoughts
      
      • Insertion
      • Withdrawal
      • Broadcasting
    • Lack of insight
      
      • Can you think of any other explanation for these symptoms?
  • Negative symptoms
    
    • Lack of motivation
    • Social withdrawal
    • Self neglect
• ​​Precipitating factors
• Risk assessment
• PMH
  
  • Other psychiatric conditions
• DH + Alcohol
• FH
• SH

Differentials

• Drug-induced psychosis
• Alcoholic hallucinosis
• Mania
• Psychotic depression

Investigations

• FBC + LFT - alcohol abuse
• Urine screen - drug abuse
• Syphilis serology

Management

• Drugs
  
  • Risperidone or olanzapine
    
    • SE: weight gain, EPSE
  • Clozapine
    
    • Refractory to other antipsychotics
    • SE: agranulocytosis (regular bloods)
• CBT

Question 4

Anxiety

Answer 4

History

• PC
  
  • Onset, frequency, duration
  • Do you feel anxious for any particular reason/in certain situations?
    
    • Avoidance
  • Physical symptoms
    
    • Tension headache
    • Autonomic
      
      • Tachycardia
      • Palpitations
      • Sweating
      • Tremor
      • Nausea
    • ‘Lump in throat’
  • SCALED
    
    • Sleep (difficulty getting to sleep)
    • Concentration
    • Appetite (+/- weight loss)
    • (Libido)
    • Energy
    • Diurnal variation
• Panic attacks
• ICE
• Impact on life
• Depression screen
• Psychiatric History
• PMH
  
  • Cardiac
  • Hyperthyroidism
  • Substance abuse
• DH
• FH
• SH

Management

• Psychotherapy
  
  • Exercise + relaxation (e.g. breathing)
• CBT
• Behavioural therapy
  
  • Graded exposure to stimulus
• Drugs
  
  • Diazepam
    
    • For rapid relief
    • < 4 weeks due to dependence
  • SSRI - Sertraline or paroxetine
    
    • Transient increase in anxiety initially
    • Delay of onset
    • Discontinuation symptoms
  • Beta-blockers