SECTION 2:
DIFFERENTIAL
DIAGNOSIS
The anxious patient 21
DIFFERENTIAL DIAGNOSIS
SYMPTOMS
Emotions: tension, irritability.
Cognitions: exaggerated fears, worries.
Behaviour: avoidance of feared situation, checking, seeking reassurance.
Somatic: tight chest, hyperventilation, palpitations, decreased appetite, nausea,
tremor, aches and pains, insomnia, frequent desire to pass urine and stools.
DIFFERENTIAL DIAGNOSIS
Psychiatric
GAD
Panic disorder (see below)
Phobias
OCD
PTSD
Acute stress disorder
Depression
Substance misuse – especially withdrawal symptoms
PD
Dementia
Medical
Hypoglycaemia
Hyperthyroidism
Phaeochromocytoma
Delirium
MANAGEMENT
Full history and MSE.
Exclude medical disorders – glucose, TFT, etc.
Acute anxiety may be relieved by anxiolytics, e.g. benzodiazepines, but for
short courses only. Patients may become dependent on them if used long
term.
Antidepressants may help anxiety, even when the patient is not depressed.
Try to find out the cause/precipitants of anxiety – treat with psychological
therapy, e.g. CBT.
22
DIFFERENTIAL DIAGNOSIS The depressed patient
SYMPTOMS
Main features: persistent low mood, anhedonia, lack of energy, decreased
concentration and attention, bleak and pessimistic views of future, feelings
of guilt or worthlessness, ideas of self-harm or suicide.
Somatic features: sleep disturbance, decreased appetite, weight loss,
constipation, amenorrhoea, decreased libido, diurnal variation of mood.
DIFFERENTIAL DIAGNOSIS
Psychiatric
Depression
BAD
Anxiety
PTSD
Schizophrenia
Schizoaffective disorder
Dementia
Substance misuse (chronic alcohol)
Borderline personality disorder
Medical
Hypothyroidism
Cushing’s syndrome
Hypercalcaemia (malignancy)
Infections (HIV, syphilis)
Multiple sclerosis
Parkinson’s disease
Medication (sedatives, anticonvulsants, steroids)
Others
Life events involving loss (e.g. death of partner)
MANAGEMENT
Full psychiatric evaluation and assess for suicidal ideation and psychotic
features.
Exclude medical cause for depression.
Antidepressants.
Psychological therapies.
The elated patient 23
DIFFERENTIAL DIAGNOSIS
SYMPTOMS
Main features: elevation of mood, overactivity, overcheerfulness,
overtalkativeness.
Other features: irritability, flight of ideas, distractibility, grandiose ideas,
decreased sleep, delusions (mood-congruent), hallucinations, impaired
judgement, irresponsibility, loss of normal social inhibitions, promiscuity,
decreased appetite.
DIFFERENTIAL DIAGNOSIS
Psychiatric
Hypomania
Mania
Mania with psychosis
Schizoaffective disorder
Schizophrenia
Substance misuse (cocaine, amphetamines), acute intoxication, drug-induced
psychosis
Brief reactive psychosis (to stressful situation)
Medical
Brain disorders affecting the frontal lobes (e.g. space-occupying lesion, HIV
infection, syphilis, Alzheimer’s disease)
Alcohol withdrawal
Corticosteroids
Anabolic androgenic steroids
Hyperthyroidism
MANAGEMENT
During the interview maintain a calm, non-confrontational manner. Manic
patients may become aggressive or violent in response to even minor
irritations. Antipsychotics may be used in the acute phase (see Bipolar
Disorder for more information).
Admit if overt mania.
Exclude other/medical causes.
Antipsychotics in acute episode (e.g haloperidol).
Lithium is used as prophylaxis for recurrent mania (BAD).
ECT in severe cases resistant to other treatment.
24
DIFFERENTIAL DIAGNOSIS The hallucinating patient
SYMPTOMS
Features: 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
Psychiatric
Schizophrenia
Schizoaffective disorder
Mania with psychosis
Severe depression with psychosis
Alcohol and drug misuse, e.g. hallucinogenic drugs – LSD, ‘magic mushrooms’
Delirium tremens (medical emergency)/acute alcohol intoxication
Medical
Epilepsy, e.g. temporal lobe
Space-occupying lesion
Delirium
Metabolic disturbances, e.g. liver failure
Infection – encephalitis
Head injury
MANAGEMENT
Full psychiatric assessment.
Exclude organic disorders.
Antipsychotic drugs for psychosis.
Antipsychotic drugs may take 10–14 days to have effect, but cause sedation in
the meantime. The patient will require admission and monitoring.
The panicking patient 25
DIFFERENTIAL DIAGNOSIS
A discrete episode of extremely severe anxiety, which may occur in many of the
anxiety disorders. If the panic attacks are recurrent and cannot be explained
by other psychological or physical illness, panic disorder is diagnosed. The
circumstances of the attack need to be clarified to exclude other disorders.
In a panic attack, the anxiety starts abruptly in the absence of any objective
danger and reaches a peak within a few minutes. The anxiety is very intense,
but has a limited duration (usually 10–40 minutes).
SYMPTOMS
Autonomic
Palpitations/chest pain
Sweating
Trembling/numbness/tingling
Dry mouth/nausea
Muscle tension
Chills/hot flushes
Dizziness
Behavioural
Urge to get away from the current situation (flight)
Restlessness
Cognitive
Perception of difficulty in breathing/choking sensation
Unpleasant feeling of anticipation/threat
Fear of losing control, dying
Derealisation/depersonalisation
DISORDERS THAT FEATURE PANIC ATTACKS
Specific phobia
Agoraphobia
Social phobia
GAD
Panic disorder
OCD
26
DIFFERENTIAL DIAGNOSIS The patient with obsessions/compulsions
SYMPTOMS
Unwanted distressing thoughts/images entering the patients’ mind even though
they try to resist them (obsessions). Thoughts are recognised as the patients’
own.
The patients may feel they must perform stereotyped acts to ease their anxiety
(compulsion). May be repetitive and recognised as senseless.
DIFFERENTIAL DIAGNOSIS
OCD
Anankastic personality disorder
Depression
Psychosis, e.g. schizophrenia
AN
Phobic disorders
Gilles de la Tourette’s syndrome/tic disorders
MANAGEMENT
Full history and MSE.
In particular find out about any features of depression (it accounts for up to
30% of obsessional symptoms). Have they always been perfectionist-type of
persons?
Are they having any other symptoms that might suggest psychosis: thought
insertion, withdrawal, broadcast, hallucinations?
Treat OCD with CBT, although SRIs may reduce symptoms.
Treat depression – SRIs.
The thin patient 27
DIFFERENTIAL DIAGNOSIS
SYMPTOMS
Underweight patient: BMI < 19. The patient may complain of amenorrhoea,
constipation, cold intolerance, fatigue, irritability.
DIFFERENTIAL DIAGNOSIS
Psychiatric
AN
BN – these patients are more likely to have normal BMI
Depression/hypomania/mania
Psychosis/schizophrenia
OCD
Medical
Any disorder causing weight loss, especially:
malignancy
thyrotoxicosis
inflammatory bowel disease
MANAGEMENT
Full history and MSE. Diet history. Has there been any deliberate weight loss,
excessive exercise, restriction dieting, vomiting or laxative abuse? (Suggests
AN or BN.)
Are there any features of depression or psychosis?
Are there any other symptoms?
Exclude medical cause for weight loss – TFT, investigate any other symptoms.
Malignancy must be excluded.
Aim to increase BMI to normal range (20–25). Inpatient treatment may be
needed if weight < 65% of normal or if suicide risk.
28
DIFFERENTIAL DIAGNOSIS The patient who overeats
SYMPTOMS
Bingeing food, then vomiting/purging with laxatives. Preoccupation with body
weight and shape.
DIFFERENTIAL DIAGNOSIS
Psychiatric
BN
Atypical depression/SAD
PD
Medical
Kleine–Levin syndrome
Klüver–Bucy syndrome
MANAGEMENT
Full history and MSE. Features of depression? In SAD, patients may have
increased appetite. Antidepressants may have an antibulimic effect. Medical
stabilisation. Establish normal eating pattern.
The unresponsive patient 29
DIFFERENTIAL DIAGNOSIS
SYMPTOMS
Alert with eye movements only/absent body movements.
Mutism (absent speech).
Absent movements.
Decreased attention span for environmental stimuli.
Speech may be present but there may be amnesia for personal identity
and history.
DIFFERENTIAL DIAGNOSIS
Psychiatric
Schizophrenia (catatonic state)
Affective psychosis (depressive stupor)
Neuroleptic malignant syndrome
Psychogenic amnesia
Conversion disorder
Medical
Hypoglycaemia
Delirium
Encephalitis
Parkinson’s disease
CVA
Acute intoxication, e.g. alcohol, solvents, phencyclidine
MANAGEMENT
ABC.
Exclude life-threatening brain pathology.
Check vital observations – BP, pulse, GCS.
Initially obtain brief history from an informant (? known psychiatric illness,
medication, illicit substances; is the patient deaf and/or blind? what
language does the patient speak?).
Perform complete physical examination.
Perform investigations guided by the history and examination.
Ensure that the patient is adequately hydrated – IV fluids.
Once life-threatening brain injury has been excluded, obtain a full history from
an informant, obtain old notes and attempt MSE on the patient.
Admit the patient; further management will depend on the underlying
aetiology.
