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Welcome
The Psychiatric Interview
by Danny Smith
Anxiety and obsessions
Suicidality
Psychosis
Infancy
Adolescence and Education (including handedness)
Occupational Record
Relationships, sexual history and marriage
Present social circumstances
Attitudes to others
Moral and religious attitudes
Leisure activities and interests
Fantasy life
How they react to stress
Mood and Affect
Speech
Thought Processes
Thought Content
Abnormal Beliefs
Perceptual Abnormalities
Cognition: "GOAL-CRAMP"
Insight and Judgement
Further Information
Differential Diagnosis
Aetiology Matrix
Management (short and long-term)
Prognosis (short and long-term)
SOCIO-DEMOGRAPHIC DETAILS
Name, age, DOB, address, occupation, marital status
PRESENTING PROBLEMS
Reason for referral.
What are the main problems?
Which of these are the worst?
When did you first notice that?
What have other people said?
How has that affected you?
When did you last feel well?
Record verbatim the first five or six sentences
Obtain a clear chronological account of symptoms and the effects of these symptoms on behaviour
PAST PSYCHIATRIC HISTORY
In the past have you ever had problems with your mental health/nerves/depression
Have you ever seen a psychiatrist before?
Have you ever been admitted to a psychiatric hospital?
What treatments have you had?
Has there ever been a time that you felt completely well?
PAST MEDICAL HISTORY
Do you have any problems with your physical health?
What about in the past?
Have you ever had any operations or been in hospital?
CURRENT MEDICATIONS
What medications do you take regularly?
What medications have you had in the past?
FAMILY HISTORY
Are your parents still living? Are they well?
Do you mind me asking how they died?
What did your parents work at?
Do you have any brothers or sisters?
As far as you know, has anyone in your family ever had problems with their mental health?
PERSONAL HISTORY
Infancy and early childhood
I’d like to talk now about your childhood. Where were you born?
Where did you grow up?
As far as you know was your mother’s pregnancy normal?
Was it a normal delivery?
Were there any problems around the time of your birth?
Did you have any serious illnesses as a young child?
Were you walking and talking at the correct times?
Are you right-handed or left-handed?
Adolescence and education
Which schools did you go to?
Did you enjoy school?
What are your lasting memories of school?
Did you have many friends at school?
Do you keep in contact with those friends today?
Did you gain any qualifications at school?
Were you ever in touble at school?
Did you play truant, or were you ever expelled or suspended?
Occupational record
When did you leave school?
What did you work at? For how long? Then what happened?
Sexual development, relationships and marriage
Are you married at present? How would you describe your marriage?
Have you had many relationships?
Tell me more about them?
Were they successful?
Do you have any children? How old are they?
Present social circumstances
Who lives at home with you at the moment?
Do you have any worries about debt or money in general?
Do you have friends or family who live nearby?
PREMORBID PERSONALITY
When you are feeling well, how would you describe yourself?
How would other people describe you?
When you find yourself in difficult situations, what do you do to cope?
What sort of things do you like to do to relax?
Do you have any hobbies?
Do you like to be around other people or do you prefer your own company?
Are you religious?
Do you have any ambitions or plans?
ALCOHOL, DRUGS AND FORENSIC HISTORY
Do you smoke?
Do you take a drink?
How much do you drink?
Have you been drinking any more or less than normal recently?
Have you ever taken drugs? Tell me more about that.
Have you ever been in trouble with the police, or been convicted of anything?
MENTAL STATE EXAMINATION
APPEARANCE, ATTITUDE, ACTIVITY
Describe appearance:
Body habitus
Prominent physical characteristics: tattoos, scars, needle sites
Grooming and attire
Level of consciousness
Apparent age
Position and posture
Eye contact
Facial expressions
Describe attitude:
Degree and type of co-operativeness
Resistance
Describe activity:
Voluntary movements and their intensity
Involuntary movements
Automatic movements
Tics, mannerisms, compulsions
MOOD AND AFFECT
Describe predominant mood in patients own words
Associated biological symptoms and suicidality or homicidality
Describe affect: Six clusters (euthymic, apathetic, angry, dysphoric, apprehensive, euphoric):
Type
Intensity
Range
Mobility
Reactivity
Congruency
SPEECH AND LANGUAGE
Assess for:
Fluency of speech (rate and volume)
Repetition
Comprehension
Naming
Reading and writing
Prosody
Quality of speech
THOUGHT PROCESSES
Describe thought processes:
Degree of connectedness (loose associations, tangentiality, etc., )
Presence of peculiarites (clang associations, blocking, neologisms, etc., )
THOUGHT CONTENT
Descibe thought content:
Predominant topic or issues
Preoccupations, ruminations, obsessions
Suicidal or homicidal ideation
Phobias
ABNORMAL BELIEFS
Describe any delusions:
Thought interference
Reference or persecution
Control or passivity
Nihilistic or grandiose
PERCEPTUAL ABNORMALITIES
Describe perceptual abnormalities:
Illusions
Hallucinations
Depersonalisation, derealisation, déjà vu, etc.,
COGNITION
Mnemonic: "GOAL-CRAMP":
‘I’d like to start off by asking you a few questions to test your concentration and memory……….’
General: Alertness and Co-operation
[STM: Name, Address, Flower to remember]
Orientation: Time and Place
Attention: WORLD backwards and Serial Sevens
Language: Naming and Repetition
Calculation: Division and Subtraction
Right Hemisphere Function: Intersecting pentagons and Clock-face
Abstraction: Proverbs and Similarities
Memory: STM and Long-term memory
Praxis: Wave good-bye and Comb hair
INSIGHT AND JUDGEMENT
Awareness of disease:
Do you consider that you are ill in any way?
Why have you come into hospital?
Do you have a physical or a mental illness?
Are you suffering from a mental health problem? What is it?
Correct labelling of abnormality:
You described several symptoms…..namely….
What is your explanation of these experiences?
Willingness to take treatment:
How do you feel about being in hospital….. coming to the clinic….?
How do you feel about taking medication?
Has the medication been helpful? Have any other treatments been helpful?
Do you think that medication helps you to remain well?
PHYSICAL EXAMINATION
General observations: Vital signs : HR, BP, RR, Temp: Autonomic arousal, tremor, sweating etc.,
Important features: scars, tattoos, signs of liver disease, signs of thyroid or Cushings disease, etc.,
Specific CVS, RS, GI, and CNS examination findings and important negative findings
THE PRESENTATION
Clear account of presenting problems (5 mins), mental state (3 mins) and physical examination (2 mins). 30 marks.
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Factors involved |
PHYSICAL |
SOCIAL |
PSYCHOLOGICAL |
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PREDISPOSING |
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eg, early parental loss |
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PRECIPITATING |
eg, recent stroke |
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PERPETUATING |
eg, social deprivation |
Presenting the case (remember to announce the headings and pause before presenting them)
"I saw………… who is a 35 year old single woman who has been an informal inpatient on this ward for the last 3 weeks." She has quite a complex history and I would like to concentrate on……………
Presenting problems and history of presenting complaint
She told me that her main problems were………
This began…………..
As a result……………..
Direct questions regarding depressive, anviety, obsessional and psychotic symptoms revealled…….
Past psychiatry history
In 1992 she was treated as an out-patient……….
Past Medical History
This includes……………
Current medications
At present she is taking……….
In the past……..
Family History
Of particular importance in her family history……..
Personal History
Of particular note in her personal history is the death of her mother when she was eight years old.
Premorbid personality
She told me that………….. Her friends would describe her as…………She tends to dealt with stress….
Alcohol, Drugs and Forensic History
At present…….
In the past……….
Mental State Examination
Appearance and Behaviour
Today she was casually dressed with no evidence of self neglect…….
Mood and Affect
She described her mood as … and her affect was one of………….
Speech
She spoke at a normal rate and volume.
Thought Processes
There was no evidence of any disorder of the form of thought
Thought Content
She tended to concentrate on………..
She was not suicidal……
Abnormal Beliefs
There was no evidence of any delusions.
Perceptual abnormalities
She denied any hallucinations.
Cognitive assessment
She was well orientated in time and place and tests of her attention, short term memory……..
Insight and Judgement
She believed that she was experiencing an episode of depression…………….
Physical Examination
On examination……Her vital signs were… there was no evidence of… Specific examination of…..
Would you like me to proceed to my differential diagnosis?
My preferred diagnosis is……….. (ICD-10)
I would also consider……………………..
A possible additional diagnosis would be………………
The evidence for this diagnosis is…….
Against …….
There are several important aetiological factors in this patient’s history
A possible predisposing factor……………….
This episode appears to have been precipitated by……..
Possible perpetuating factors would include……….
There are several investigations and sources of further information which I would like to find out
Physical investigations would include………
Social investigations would include an informant history from family or GP…….
Psychological investigations that may be useful.
Asking about depressive symptoms
Over the last two weeks, how would you describe your mood?
Is that all the time, or for part of the day?
Have you been tearful?
Do you notice that you feel better at any time of the day?
Does anything make you feel more cheerful?
What have your energy levels been like?
Are you still able to enjoy doing some things?
Are you able to cope with day-to-day tasks? Do you still go out? Are you still able to speak to people as in the past, or do you prefer to be alone? Have you lost confidence?
How do you feel about the future?
Are things completely hopeless or is there still some reason to go on trying?
When you compare yourself to others what do you think?
What sort of things have you been thinking about?
Have you been feeling guilty at all?
Have you been blaming yourself for anything recently?
Sometimes when people are feeling low they have thoughts about harming themselves. Have you felt like this recently? What did you think you might do? Have you had thoughts like that in the past? Have you ever harmed yourself in any way in the past?
What is your concentration like at the moment? And your memory? Have you noticed any slowing down in your thinking? Have you felt that your movements have slowed down?
What is you appetite like at the moment? Have you lost any weight recently?
Tell me about your sleeping? What keeps you awake at night? When do you finally get off to sleep? Do you feel refreshed in the morning? At what time do you wake up?
Has anyone commented on you being more irritable recently?
Have you been feeling anxious or keyed-up?
Have you been worrying a lot?
Do you have any problems with your general health? Headaches, dizziness, sweating, tummy pains, diarrhoea, pins and needles, difficulty breathing?
Have you noticed any change in your interest in sex?
Sometimes when people are feeling very low they have unusual experiences. Have you heard anything unusual recently? For example, sometimes people hear noises or voices when there is no-one in the room? Do they speak to you directly? What do they say? Are these voices with you all the time or do they go away?
Remember:
Somatic symptoms:
MANIA:
Asking about Manic symptoms
Recently, have you been feeling particularly cheerful or on top of the world?
Have you been feeling especially healthy?
What about your energy levels? Do things seem to go too slowly for you?
How are you sleeping at the moment?
Has anyone commented on your behaviour recently?
Do you think that you are thinking or speaking any more quickly than usual?
Have you found yourself full of exciting ideas or plans?
Have you developed any new interests or hobbies?
How have things been at work?
Do you have any special talents or abilities which are out of the ordinary?
Have you been buying any interesting things recently?
Asking about anxiety symptoms
Have there been times recently when you have been very anxious or frightened? Tell me more about that.
Do you tend to get anxious in certain situations, such as travelling, being on a bus, or when you try to leave the house? Have you ever had a panic attack? Can you describe what happened?
When you have been anxious have you ever felt afraid that you might pass out, lose control or even die?
Have you noticed any changes in your body when this happens, such as palpitations, dizziness, churning in your stomach…..? When do these episodes occur? How long do they last? How often do they occur?
Are you able to explain why you are anxious or does it just come out of the blue?
Do you avoid certain situations or certain things because you know you will get anxious?
Do you have any special fear, like some people are scared of spiders or birds?
Do you find it difficult to meet people, for example, going into a crowded room, or making conversation?
Do you feel that when you are in the company of others that you might say or do something embarrassing or make a fool of yourself? Do you feel that other people look at you when you are in company?
Do you ever have the feeling that you are unreal or that things happening around you are unreal?
Asking about obsessional symptoms
Do you find yourself checking things again and again even though you know you have done them correctly?
Do you wash very often even though you know you are clean? Do you worry about contamination?
Do you have to touch or count things many times or repeat the same actions over and over?
Do you have any other rituals?
Do you find it difficult to make decisions, even about trivial things?
Do you get awful thoughts coming into your head even when you try to keep them out?
What does that feel like? What happens when you try to stop?
Are there any particular themes?
Asking about delusions
Delusions of thought interference
Can you think quite clearly? Does there seem to be some kind of interference with your thoughts or actions? What is that like?
Are you fully in control of your thoughts and actions?
Have you experienced any interference with your thoughts? What happens exactly?
Does anyone control your thoughts? Give me an example of that.
Thought echo:
Does a thought in your mind seem to be repeated over again, like an echo? Can you describe it for me?
Do you ever hear your own thoughts spoken aloud? gedenkenlautwerden
Do you ever have a thought and then experience the same thought again? echo de la pense
Have you experienced thoughts in your mind which do not belong to you or were put there by someone else? How do you think they get in your mind? Do there seem to be thoughts in your mind which are not your own; which seem to come from elsewhere? thought insertion
Are your thoughts ever taken out of your mind and transmitted to other people? Are your thoughts actually taken out or sent out of your mind? Do they actually feel like that? So that they are outside your head? thought withdrawal
Do your thoughts seem to be somehow public; not private to yourself, so that others can know what you are thinking? Can they hear your thoughts? thought broadcast
Do you ever find that your thoughts stop dead and leave your mind a complete blank? Is it as though your thoughts have been taken away or is it just that they have stopped? thought block
Delusions of control
Do you ever feel controlled from the outside like a puppet or a robot?
Is there any force or power other than yourself trying to take control of you?
Do you feel that something or someone else takes control of your body? made will and made impulses
Do you feel that someone or something else makes you have certain feelings or emotions that you wouldn’t normally have? made emotions
Delusions of reference
Did you at any time realise that things had a special meaning for you? delusional perception
Do some people, who may even be strangers, talk about you? What do they say?
Has there been any reference to you recently in the newspapers, on the radio or on the television?
Do you see any special meaning for yourself in the way things are arranged or in the colours of objects?
Persecutory delusions
Is any person, or any group of people, or any force trying to harm you?
Are you afraid that people are plotting against you?
Other delusions
Are there people around you who are not what they seem to be? delusion of misidentification
Do you ever feel that the place you are in is not what it seems to be? delusion of misinterpretation
Are you special in any way? Do you have any special talents or powers? Are you a famous person or are you related to a famous person? grandiose delusions
Do you feel as if you have commited a crime or a sin? Have you harmed your family or anybody else? Do you deserved to be punished? delusions of guilt
Are you suffering from any serious disease or is any part of your body unhealthy? hypochondriacal delusions
Do you ever feel that you do not exist?
Is something terrible about to happen? nihilistic delusions
Are you especially Holy, perhaps even a Saint?
Are you specially close to God?
Does He communicate with you in any special way? religious delusions
Are you particularly jealous of anyone?
Are you worried that your partner is unfaithful?
Have you experienced any unusual sexual feelings lately? sexual delusions
delusional mood
Have you had the feeling that something odd is going on that you can't explain?
- What is it like?
- Do you feel puzzled by strange happenings that are difficult to account for?
- Do familiar surroundings seem strange?
Does the world around seem to have changed in some way that you can’t quite explain?
Asking about hallucinations
Have you heard anything unusual recently?
Have you heard people speaking when there is no-one in the room?
What do they say? Can you give me an example?
Are the voices talking directly to you (second person auditory hallucinations) or do they talk about you? (third person auditory hallucinations)
Where do these voices come from? Who do they belong to?
Do you see visions or images that other people can’t see? visual hallucinations
Have you noticed a peculiar taste in your food or drink? What is this due to? gustatory hallucinations
Have you noticed any peculiar smell lately? What is it due to? olfactory hallucinations
Do you feel some-one touch you when there is no-one there? Do you have any unusual feelings in your body? What are they due to? tactile and somatic hallucinations
Assessing Suicidal Risk
I’d like to ask you some more detailed questions about your mood……
Over the last two weeks, how would you describe your mood?
How do you feel about the future?
Do things feel completely hopeless, or is there still a reason to keep trying?
Sometimes when people are feeling low they have thoughts about harming themselves.
Have you felt like this? What did you think you might do?
How do you feel about this today?
What would stop you from harming yourself?
Have you ever harmed yourself in the past? Can you tell me more about that?
Taking an Alcohol History
I’d like to ask you a few questions about your drinking.
Recently, have you ever felt that you should cut down on your drinking?
Have you ever been annoyed when people criticised your drinking?
Have you ever felt guilty about your drinking?
Have you ever taken a drink in the morning, for example as an eye-opener?
When do you tend to drink?
How much would you drink at the week-end?
Do you drink during the week?
Describe a typical day for me. Have you noticed any changes in your tolerance to alcohol?
Is it ever the case that you simply must have a drink?
How important is drinking in your life?
What did you used to drink in the past? What do you drink now?
What would happen if you didn’t have a drink every day?
Have you ever had extended periods of time when you didn’t drink?
What happened to make you start drinking again?
What do you think are the consequences of your drinking?
Has it had any effects on your physical health?
How has it affected your family life?
Has you drinking ever had an effect on your job?
Have you ever been convicted of drink-driving or been arrested because of your drinking?
Edwards and Gross’ Alcohol Dependance Syndrome 1976:
Eliciting First Rank Symptoms of Schizophrenia (Kurt Schneider, 1959).
Delusions of Thought Interference:
Can you think quite clearly or have you noticed any interference with your thoughts?
Can you describe what that feels like exactly?
Are you in full control of your thoughts?
Can people read your mind, or is there anything like hypnotism or telepathy going on?
For example, do you ever seem to hear your own thoughts spoken aloud in your head, so that someone standing near might be able to hear them?
Can other people know what you are thinking? How do you explain that?
Have you ever had the experience of your thoughts being removed from your head?
Can you describe what that feels like?
Have any thoughts been put into your head which you know are not your own?
How do you know that they are not your own thoughts?
Where do they come from?
Auditory Hallucinations:
Have you had any unusual experiences recently?
For example, have you heard anything unusual?
Do you ever seem to hear noises or voices when there is no-one about, and nothing else to explain it?
Can you describe that for me? How many voices do you hear?
Do you ever hear several voices talking about you? How do they refer to you?
Can you give me an example of what you hear?
Do they ever comment on what you are doing or on what you are thinking?
Do you ever seem to hear your own thoughts repeated out loud?
What is that like? How do you explain it? Where does it come from?
Passivity experiences:
I’d like to ask you some questions about your feelings and emotions.
Do you ever seem to have feelings which you know are not your own? What does that feel like?
Is it as if these feelings are being forced upon you in some way?
Do you ever feel under the control of some force or power other than yourself?
Does it ever feel as if you were a robot or a zombie, without a will of your own?
Are you possessed? What does that feel like? How does this force influence you?
Does it ever make you want to do something? Does it ever make your movements for you?
Does this force have any other influence on your body? Can you describe that for me?
Delusional Perception:
Did you at any time realise that things had a special meaning for you?
Can you explain that?
What happened exactly?
Physical illnesses which cause psychiatric symptoms
Depression Malignancy
Hypothyroidism
Hyperparathyroidism
Cushing’s syndrome
Multiple sclerosis
Post-infection
Cerebrovascular disease
Congestive cardiac failure
Collagen disorders
Porphyria
Vitamin and mineral disorders
Iatrogenic
Anxiety Hyperthyroidism
Phaeochromocytoma
Hypoglycaemia
Partial seizures
Alcohol or drug withdrawal
Behavioural disorder Epilepsy
Toxic confusional states
Dementia
Porphyria
Hypoglycaemia
Irritability Head injury
Premenstrual Tension
Early dementia
Hypoglycaemia
Fatigue Anaemia
Sleep disorders
Infections
Carcinoma
Alcohol Misuse
General obesity, palmar erythema, Dupuytren’s, spider naevi, peripheral oedema, jaundice, clubbing, muscle wasting, signs of poor nutrition and self-neglect, plethoric complexion
CVS tachycardia, cardiomyopathy, arrythmia, hypertension
RS chest infections
GI scars from previous peptic surgery, hepatomegaly, splenomegaly, nodular liver, ascites
CNS conscious level, tremor, cranial nerve palsies, focal neurological signs, peripheral neuropathy, memory impairment, cerebellar signs: ataxia, intention tremor, past-pointing, dysdiadochokinesis, nystagmus, ophthalmoplegia
Cushing’s syndrome
Hyperthyroidism
Hypothyroidism
Assessing for Abnormal Involuntary Movements
Part 1 Cases
Mood Disorders
F30 Manic Episode
F31 Bipolar Affective Disorder
F32 Depressive Episode
F33 Recurrent Depressive Episode
F34 Persistent Mood Disorders
F38 Other
Case 1. Depression
List current symptoms: low mood, anhedonia, low energy, easy fatiguability, poor memory and concentration, low self-esteem, guilty ruminations, suicidal thoughts, hopelessness, anorexia, sleep disturbance, diurnal variatioin, psychomotor retardation or excitation, decreased libido.
Decide if mild, moderate, severe. Degree of functional impairment.
Somatic syndrome present?
Psychotic symptoms present?
Suicidality?
Look for predipsosing, prcipitating and perpetuating factors in the history.
Why has this patient developed this disorder at this point in their life?
Differential Diagnosis: "I would also consider………………….."
Metabolic: iron-deficiency anaemia, hypercalcaemia, B12/folate deficiency, niacin deficiency (pellagra)
Infective: encephalitis, post-viral, hepatitis, infectious mononucleosis, HIV
Neurological: post-stroke, Parkinson’s disease, multiple sclerosis, intracranial tumours (eg, frontal)
Non-metastatic manifestation of Neoplasm, eg., pancreatic carcinoma
Endocrine Disorders: hypothyroidism, Cushing’s syndrome, Addison’s disease, hyperparathyroidism
Substance misuse: Alcohol, amphetamine, heroin, cocaine, etc.,
Iatrogenic: reserpine, propranolol, methyldopa, corticosteroids
Risk factors for depression:
Predisposing:
Previous episode of depression
Positive family history
Emotional, physical or sexual childhood abuse
Brown and Harris’ vulnerability factors, eg., 3 children under 15 at home
Absence of parent or carer as a child (neglect)
Loss events, eg., of mother before 11 years
Learned helplessness and Beck’s negative cognitive triad
Premorbid personality
Precipitating:
Loss events
Traumatic experience
Physical illness
Non-compliance with medication
Perpetuating:
Substance abuse, eg., alcohol
Unemployment
Loss of role
Negative cognitive style
Lack of percieved control over future
Lack of social support
Further Information:
Physical:
FBC and blood film, B12 and folate, renal, calcium, phosphate, hepatic, ESR, thyroid, glucose, cortisol, monospot, urine drug screen. Other investigations dictated by findings on physical examination, eg, CT brain, MRI, EEG, rheumatoid factor, HIV, VDRL, Hep B and C etc.
Social:
Informant history, discuss with GP, old medical notes, nursing observations, OT assessment, forensic reports.
Psychological:
Previous involvement with clinical psychology or psychotherapy? Consider psychometric testing if dementia suspected.
Case 2. Mania
List current symptoms: Elevated mood, over-activity, accelerated thoughts and speech, decreased need for sleep, disinhibition, excessive spending, appetite disturbance, increased libido, psychotic symptoms: gradiose delusions, hallucinations, stupor etc.
Decide if Hypomania, Mania without psychotic symptoms, or Mania with psychotic symptoms.
(Note that Mania indicates complete disruption of work and social activities)
Differential diagnosis of Mania: "I would also consider…………………………."
Intoxication: amphetamines, hallucinogens, cocaine
Withdrawal: alcohol, benzodiazepines, opiates
Iatrogenic: antidepressants, corticosteroids, cimetidine, procyclidine
Infective, traumatic, inflammatory, neoplastic, drug toxicity, etc.,
Risk Factors:
Family history
Non-compliance with medication
Intercurrent substance misuse
Recent life event
Further Information:
Physical:
FBC and blood film, B12 and folate, renal, calcium, phosphate, hepatic, ESR, thyroid, glucose, cortisol, monospot, urine drug screen. Other investigations dictated by findings on physical examination, eg, CT brain, MRI, EEG, rheumatoid factor, HIV, VDRL, Hep B and C etc.
Lithium work up: pregnancy test, renal function, thyroid function, calcium and ECG
Social:
Informant history, discuss with GP, old medical notes, nursing observations, OT assessment, forensic reports. Family history particularly important.
Psychological:
Previous involvement with clinical psychology or psychotherapy? Consider psychometric testing if dementia suspected.
Schizophrenia, Schizotypal disorder and Delusional disorders
F20 Schizophrenia:
Paranoid
Hebephrenic
Catatonic
Undifferentiated
Post-schizophrenic depression
Residual
Simple
Other
Schizophreniform, unspecified
F21 Schizotypal disorder
F22 Persisitent delusional disorders
F23 Acute and transient psychotic disorders
F24 Induced delusional disorder
F25 Schizoaffective disorder
Case 3. Paranoid schizophrenia
Diagnosis: One month history of….
At least one of:
Or at least two from:
Or at least a year of:
Differential Diagnosis:
Metabolic: electrolyte imbalance, hypoglycaemia, hepatic or renal disease
Infective: encephalitis
Neurological: temporal lobe epilepsy, cerebral neoplasm, multiple sclerosis, cerebral lupus
Endocrine: hyper- and hypo-thyroidism, Addison’s disease, hyper- and hypo-parathyroidism
Risk factors
Perinatal trauma/infection
Positive family history
Substance abuse
Brain injury
Further information:
Physical:
FBC, blood film, B12, folate, ESR, renal function, hepatic function, thyroid function, glucose, calcium, phosphate, urinary drug screen, EEG, CT brain.
Social:
Informant history, family history, GP discussion, old medical notes, nursing observations on the ward, OT assessment, forensic reports.
Psychological:
Consider psychometric testing as a baseline. Establish levels of expressed emotion within the family. Level of social supports.
Case 4. Anorexia Nervosa
Diagnosis:
In ICD-10 all of: mnemonic: WOAAP
Weight loss > 15%
Fear of fatness held as an Overvalued idea
Avoidance of fattening foods, with behaviours aimed at losing weight.
Amennhorrea
Pubertal delay if onset is early
Differential Diagnosis:
Also note the presence of abnormal personality traits:
Boredom and chronic emptiness
Identity confusion
Anger
Suicide threats
Impulsivity
Relationship difficulties
Affective instability
Risk factors:
Any psychiatric disorder (depression, anxiety, DSH)
Positive family history
Emotional, physical and sexual childhood abuse
Obsessional and borderline traits in the personality
Family conflict: enmeshment, over-involvement, scapegoating
Physical Examination:
Thin, anaemic, peripherally cyanosed, cold intolerance, muscle wasting, hypertrophy of salivary glands, lanugo hair, lack of pubic and axillary hair, dry skin, hypothermic with cold extremities, bradycardia, hypotension, poor dentition, scarred knuckles, scars of previous superficial lacerations, skin discolouration due to hypercarotinaemia.
Further information:
Physical:
FBC, blood film, B12 and folate: normochromic anaemia with leucopaenia.
renal function: hypokalaemia, renal impairment, dehydration, metabolic alkalosis
hepatic function: raised gamma GT, raised amylase
hypoglycaemia and hypercholesterolaemia
hormone profile: raised cortisol and growth hormone; reduced T3, FSH, LH, oestrogen and testosterone
ESR, bone profile, magnesium, zinc.
urine drug screen
Consider CT brain to exclude tumour, abdominal and pelvic USS (looking for gastric dilatation and reduced ovarian volume), consider DEXA bone densitometry. ECG (sinus bradycardia).
Social:
History from famity and GP. Personal history. Assessment of other health-care professionals involved: nurses, OT, dietician.
Psychological:
Assessment of family relationships< eg, overprotectiveness, attitudes, conflicts, dysfunction.
Neurotic, Stress-related and Somatoform Disorders
F40 Phobic anxiety disorders
F40.0 agoraphobia, with or without panic disorder
F40.1 social phobia
F40.2 specific phobias
F41 Other anviety disorders
F41.0 panic disorder
F41.1 generalized anxiety disorder
F41.2 mixed anxiety and depressive disorder
F42 Obsessive-compulsive disorder
F42.0 predominantly obsessional thoughts or ruminations
F42.1 predominantly compulsive acts
F42.3 mixed obsessional thoughts and acts
F43 Reaction to severe stress and adjustment disorders
F43.0 acute stress reaction
F43.1 post-traumatic stress disorder
F43.2 adjustment disorders (depression, anxiety, emotions, conduct)
F44 Dissociative disorders
F45 Somatoform disorders
F48 Other: neurasthenia; depersonalization-derealization symdrome
All Anxiety Disorders:
Psychological symptoms: feelings of dread and threat, irritability, panic, anxious anticipation, inner psychic terror, worrying over trivia, difficulty in concentrating, initial insomnia, difficulty relaxing.
Physical symptoms: palpitations, difficulty breathing, dry mouth, nausea, frequency of micturition, dizziness, muscular tension, sweating, abdominal churning, tremor, cold skin.
Look for ABC: antecedents, behaviuor and conseuences.
Premorbid personality:
Differential diagnosis:
Physical Examination:
Vital signs: look for tachycardia, hypertension, tachypnoea, pyrexia; autonomic arousal, hypervigilance, signs of thyroid disease, signs of Cushing’s syndrome, signs of renal or hepatic disease, signs of alcohol or drug abuse.
Further information:
Physical:
FBC, blood film, B12 and folate, ESR, CRP, renal function, electrolytes, hepatic function, thyroid function, urine drugs screen, urinary VMA, chest X-ray, ECG, EEG, CT brain.
Social:
Informant history, family history, GP discussion, nursing assessment, OT assessment. Present social circumstances. Alcohol misuse
Psychological:
Secondary gain, attitudes, premorbid personality, defence mechanisms.
Case 5. Agoraphobia with (or without) panic disorder
Diagnosis in ICD-10: all of:
Case 6. Social phobia
Social phobias usually start in adolescence and are concerned with scrutiny in small groups. There may be associated blushing, nausea, hand tremor and often leads to avoidance behaviour and alcohol misuse.
Diagnosis in ICD-10: All of:
Case 7. Specific phobias, eg, spiders
Diagnosis in ICD-10:
Case 8. Panic disorder (episodic paroxysmal anxiety)
Essential features are recurrent, unpredictable attacks of panic in a range of situations.
Diagnosis in ICD-10:
Several panic attacks within the last month:
Case 9. Generalized Anxiety Disorder
Essential features are chronic, fluctuating ‘free-floating anxiety’symptoms. Usually middle-aged female.
Diagnosis in ICD-10: several months of:
Case 10. Obsessive-compulsive disorder
Diagnosis in ICD-10:
Symptoms present on most days over the preceding 2 weeks, causing distress and interference with normal activities:
OR: " repetitive intrusion of unpleasant thoughts, images or impulses which are recognised as belonging to the patient and which cause resistance".
NB classify as predominantly thoughts, acts or mixed.
Case 11. Post-traumatic Stress Disorder
Use mnemonic: DREAMS:
Disinterest, detachment and numbness
Re-living of the event in nightmares and flash-backs
Extreme nature of traumatic event
Avoidance of situations which are a reminder of event
Months: within six
Sympathetic overarousal with exaggerated startle response.
Case 12. Adjustment Disorder, eg., culture shock, grief reaction
Onset within one month of stressful event or life-change, and duration less than 6 months.
From ICD-10:
"states of subjective distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life-changeor to the consequences of a stressfullife-event (including the presence or possibility of serios physical illness)".
Case 13. Alcohol Dependence Syndrome:
Edwards and Gross 1976:
Subjective awareness of the compulsion to drink
Salience of drinking behaviour
Narrowing of the drinking repertiore
Increased tolerance
Withdrawal symptoms
Relief of withdrawal symptoms by drinking
Reinstatement after abstinence
Associated aspects in the history:
Early drinking, life-long.
Positive family history of alcoholism or depression.
Childhood abuse or neglect
Previous membership of AA
Previous periods of in-patient or out-patient detoxification
Relationship and work difficulties
Breach of the peace and other forensic history
Co-morbid drug misuse
Physical problems related to alcohol misuse (see below)
Dissocial personality traits/disorder: use mnemonic CAR FIRM WAGER:
Conduct disorder
Age: begins young
Rule out mania and schizophrenia
Fails financial obligations
Impulsivity
Risks personal safety
Monogamous for less than one year
Work record is poor
Angry and aggressive
Grounds for repeated arrest
Empathy nil
Repeated lying
On Examination:
General obesity, palmar erythema, Dupuytren’s, spider naevi, peripheral oedema, jaundice, clubbing, muscle wasting, signs of poor nutrition and self-neglect, plethoric complexion
CVS tachycardia, cardiomyopathy, arrythmia, hypertension
RS chest infections
GI scars from previous peptic surgery, hepatomegaly, splenomegaly, nodular liver, ascites
CNS conscious level, tremor, cranial nerve palsies, focal neurological signs, peripheral neuropathy, memory impairment, cerebellar signs: ataxia, intention tremor, past-pointing, dysdiadochokinesis, nystagmus, ophthalmoplegia
Case 13. Dementia in Alzheimer’s disease
From ICD-10:
All of :
Differential Diagnosis:
Further information:
Physical:
FBC, blood film, B12 and folate, ESR, renal function, calcium and phosphate, glucose, hepatic function, thyroid function, CT brain.
Consider EEG, ECG, toxicology, ANF, VDRL, MRI, SPEC.
Social:
History from family is very important. Establish level of support. GP discussion, eg, relevant past medical history. Nursing and OT assessments.
Psychological:
Neuropsychological assessment