Psychiatry trainees
Psychiatric disorders (ICD-10)
Acute psychotic disorders — F23
Includes: acute schizophrenia-like psychosis, acute delusional psychosis, and other acute and transient psychotic disorders
Presenting complaints
Patients may experience:
• hallucinations, eg hearing voices when no one is around
• strange beliefs or fears
• apprehension, confusion
• perceptual disturbances.
Families may ask for help with behaviour changes that cannot be explained, including strange or frightening behaviour (eg withdrawal, suspiciousness, threats).
Young adults may present with persistent changes in functioning, behaviour or personality (eg withdrawal) but without florid psychotic symptoms.N1
Diagnostic features
Recent onset of:
• hallucinations (false or imagined sensations, eg hearing voices when no one is around).
• delusions (firmly held ideas that are often false and not shared by others in the patient’s social, cultural or ethnic group, eg patients believe they are being poisoned by neighbours, receiving messages from television, or being looked at by others in some special way).
• disorganized or strange speech
• agitation or bizarre behaviour
• extreme and labile emotional states.
Differential diagnosis
• Physical disorders that can cause psychotic symptoms include:
— drug induced psychosis
— alcoholic hallucinosis
— infectious or febrile illness
— epilepsy
Adjustment disorder — F43.2
(including acute stress reaction)
Presenting complaints
• Patients feel overwhelmed or unable to cope.
• There may be stress-related physical symptoms such as insomnia, headache, abdominal pain, chest pain and palpitations
• Patients may report symptoms of acute anxiety or depression
• Alcohol use may increase.
Diagnostic features
• Acute reaction to a recent stressful or traumatic event.
• Extreme distress resulting from a recent event, or preoccupation with the event.
• Symptoms may be primarily somatic.
• Other symptoms may include:
— low or sad mood
— anxiety
— worry
— feeling unable to cope.
Acute reaction usually lasts from a few days to several weeks.
Differential diagnosis
Acute symptoms may persist or evolve over time. If significant symptoms persist longer than one month, consider an alternative diagnosis.
• If significant symptoms of depression persist, see ‘Depression — F32#’.
• If significant symptoms of anxiety persist, see ‘Generalized anxiety — F41.1’.
• If significant symptoms of both depression and anxiety persist, see ‘Chronic mixed anxiety and depression — F41.2’.
• If stress-related somatic symptoms persist, see ‘Unexplained somatic complaints — F45’.
• If symptoms are due to a loss, see ‘Bereavement — Z63’.
• If anxiety is long-lasting and focused on memories of a previous traumatic event, see ‘Post-traumatic stress disorder — F43.1’.
If dissociative symptoms (sudden onset of unusual or dramatic somatic symptoms) are present, see ‘Dissociative (conversion) disorder — F44’.
Alcohol misuse — F10
Presenting complaints
Patients may present with:
• depressed mood
• nervousness
• insomnia
• physical complications of alcohol use (eg ulcer, gastritis, liver disease, hypertension)
• accidents or injuries due to alcohol use
• poor memory or concentration
• evidence of self-neglect (eg poor hygiene)
• failed treatment for depression.
There may also be:
• legal and social problems due to alcohol use (eg marital problems, domestic violence, child abuse or neglect, missed work)
• signs of alcohol withdrawal (sweating, tremors, morning sickness, hallucinations, seizures).
Patients may sometimes deny or be unaware of alcohol problems. Family members may request help before patient does (eg because patient is irritable at home or missing work). Problems may also be identified during routine health promotion screening.
Diagnostic features
• Harmful alcohol use:
— heavy alcohol use (eg over 28 units per week for men, over 21 units per week for women)
— overuse of alcohol has caused physical harm (eg liver disease, gastrointestinal bleeding), psychological harm (eg depression or anxiety due to alcohol), or has led to harmful social consequences (eg loss of job).
• Alcohol dependence. Dependence is present when three or more of the following are present:
— Strong desire or compulsion to use alcohol
— difficulty controlling alcohol use
— withdrawal (anxiety, tremors, sweating) when drinking is ceased
• tolerance (eg drinks large amounts of alcohol without appearing intoxicated)
• continued alcohol use despite harmful consequences.
Blood tests such as gamma glutamyl transferase (GGT) and mean corpuscular volume (MCV) can help identify heavy drinkers. Administering the CAGE (R: 13–1) or AUDIT
(R: 13–2) questionnaire may also help diagnosis.
Differential diagnosis
Reducing alcohol use may be desirable for some patients who do not fit the above guidelines.
Symptoms of anxiety or depression may occur with heavy alcohol use. Alcohol use can also mask other disorders, eg agoraphobia, social phobia and generalized anxiety disorder. Assess and manage symptoms of depression or anxiety if symptoms continue after a period of abstinence. See ‘Depression — F32#’ or ‘Generalized Anxiety — F41.1’.
Drug misuse may also co-exist with this condition.
Bereavement — Z63
Presenting complaints
An acute grief reaction is a normal, understandable reaction to loss.
The patient:
• feels overwhelmed by loss
• is preoccupied with the lost loved one
• may present with somatic symptoms following loss.
Grief may be experienced on loss of a loved one and also other significant losses (eg loss of job, lifestyle, limb, breakdown of relationship). It may precipitate or exacerbate other psychiatric conditions, and may be complicated, delayed or incomplete, leading to seemingly unrelated problems years after the loss.
Diagnostic features
Normal grief includes preoccupation with loss of loved one. However, this may be accompanied by symptoms resembling depression, such as:
• low or sad mood
• disturbed sleep
• loss of interest
• guilt or self-criticism
• restlessness
• guilt about actions not taken by the person before the death of the loved one
• seeing the deceased person or hearing their voice
• thoughts of joining the deceased.
The patient may:
• withdraw from usual activities and social contacts
• find it difficult to think of the future
• increase use of drugs or alcohol.
Differential diagnosis
• ‘Depression — F32#’.
Bereavement is a process. A helpful model is to think of four tasks to be completed by the bereaved person:
— accepting the reality of the loss — the patient may feel numb
— experiencing the pain of grief
— adapting to the world without the deceased
— ‘letting go’ of the deceased and moving on.
Consider depression if:
• the person becomes stuck at any point in the process
• a full picture of depression is still present two months after the loss
• there are signs that the grief is becoming abnormal (severe depressive symptoms of retardation, guilt, feelings of worthlessness, hopelessness or suicidal ideation of a severity or duration that significantly interferes with daily living).
There is a higher risk of an abnormal grief reaction where the bereaved person is socially isolated or has a history or depression or anxiety; where the relationship between the bereaved and the dead person was ambivalent; where the dead person was a child; and where the death was violent, occurred by suicide or occurred suddenly in traumatic circumstances (especially if the body is not present).
Bipolar disorder — F31
Presenting complaints
Patients may have a period of depression, mania or excitement with the pattern described below.
Referral may be made by others due to lack of insight.
Diagnostic features
• Periods of mania with:
— increased energy and activity
— elevated mood or irritability
— rapid speech
— loss of inhibitions
— decreased need for sleep
— increased importance of self.
• The patient may be easily distracted.
• The patient may also have periods of depression with:
— low or sad mood
— loss of interest or pleasure.
• The following associated symptoms are frequently present:
— disturbed sleep
— guilt or low self-worth
— fatigue or loss of energy
— poor concentration
— disturbed appetite
— suicidal thoughts or acts.
Either type of episode may predominate. Episodes may alternate frequently or may be separated by periods of normal mood. In severe cases, patients may have hallucinations (hearing voices or seeing visions) or delusions (strange or illogical beliefs) during periods of mania or depression.
Differential diagnosis
• ‘Alcohol misuse — F10’ or ‘Drug use disorder — F11#’ can cause similar symptoms.
Essential information for patient and family
• Unexplained changes in mood and behaviour can be symptoms of an illness.
• Effective treatments are available. Long-term treatment can prevent future episodes.
• If left untreated, manic episodes may become disruptive or dangerous. Manic episodes often lead to loss of job, legal problems, financial problems or high-risk sexual behaviour. When the first, milder symptoms of mania or hypomania occur, referral is often indicated and the patient should be encouraged to see their GP straight away.
• Inform patients who are on lithium of the signs of lithium toxicity (see ‘Medication’ below). (R: 5–2)
Chronic fatigue and Chronic fatigue syndromea — F48
(may be referred to as ‘ME’)
Presenting complaints
Patients may report:
• lack of energy
• aches and pains
• feeling tired easily
• an inability to complete tasks.
Diagnostic features
• Mental and physical fatigue, made worse by physical and mental activity.
• Tiredness after minimal effort, with rest bringing little relief.
• Lack of energy.
Other common, often fluctuating, symptoms include:
• dizziness
• headache
• disturbed sleep
• inability to relax
• irritability
• aches and pains eg muscle pain, chest pain, sore throat
• decreased libido
• poor memory and concentration
• depression.
The disorder may be triggered by infection, trauma or other physical illness.
Chronic Fatigue Syndrome is diagnosed when substantial physical and mental fatigue lasts longer than six months, significantly impairs daily activities and where there are no significant findings on physical examination or laboratory investigation. It is associated with other somatic symptoms.39
Differential diagnosis
• Many medical disorders can cause fatigue. A full history and physical examination is necessary, which can be reassuring for the doctor and therapeutic for the patient. Basic investigations include a full blood count, ESR or CRP, thyroid function tests, urea and electrolytes, liver function tests, blood sugar and C-reactive protein. A medical disorder should be suspected where there is:
— any abnormal physical finding, eg weight loss
— any abnormal laboratory finding
— unusual features of the history, eg recent foreign travel, or the patient is very young or very old
— symptoms occurring only after exertion and unaccompanied by any features of mental fatigue
• Depression — F32# (if low or sad mood is prominent).
• Chronic mixed anxiety and depression — F41.2.
• Panic disorder — F41.1 (if anxiety attacks are prominent).
• Unexplained somatic complaints — F45 (if unexplained physical symptoms are prominent).
Depression and anxiety may be somatized. Social, relationship or other life problems may cause or exacerbate distress.
Chronic mixed anxiety and depression — F41.2
Presenting complaints
Patient may present with one or more physical symptoms (eg various pains, poor sleep and fatigue), accompanied by a variety of anxiety and depressive symptoms, which will have been present for more than six months. These patients may be well known to their doctors, and have often been treated by a variety of psychotropic agents over the years.
Diagnostic features
• Low or sad mood.
• Loss of interest or pleasure.
• Prominent anxiety or worry.
• Multiple associated symptoms are usually present, eg:
— disturbed sleep
— tremor
— fatigue or loss of energy
— palpitations
— poor concentration
— dizziness
— disrupted appetite
— suicidal thoughts or acts
— dry mouth
— loss of libido
— tension and restlessness
— irritability.
Differential diagnosis
• If more severe symptoms of depression or anxiety are present, see ‘Depression — F32#’ or ‘Generalized anxiety — F41.1’.
• If somatic symptoms predominate that do not appear to have an adequate physical explanation, see ‘Unexplained somatic complaints — F45’.
• If the patient has a history of manic episodes (eg excitement, elevated mood and rapid speech), see ‘Bipolar disorder — F31’.
• If the patient is drinking heavily or using drugs, see ‘Alcohol misuse — F10’ and ‘Drug use disorders — F11#’. Unexplained somatic complaints, alcohol or drug disorders may also co-exist with mixed anxiety and depression.
Chronic psychotic disorders — F20#
Includes schizophrenia, schizotypal disorder, persistent delusional disorders, induced delusional disorder, other nonorganic psychotic disorders
Presenting complaints
Patients may present with:
• difficulties with thinking or concentration
• reports of hearing voices
• strange beliefs (eg having supernatural powers or being persecuted)
• extraordinary physical complaints (eg having animals or unusual objects inside one’s body)
• problems or questions related to antipsychotic medication
• problems in managing work , studies or relationships.
Families may seek help because of apathy, withdrawal, poor hygiene, or strange behaviour.
Diagnostic features
• Chronic problems with the following features:
— social withdrawal
— low motivation, interest or self-neglect
— disordered thinking (exhibited by strange or disjointed speech).
• Periodic episodes of:
— agitation or restlessness
— bizarre behaviour
— hallucinations (false or imagined perceptions, eg hearing voices)
— delusions (firm beliefs that are often false, eg patient is related to royalty, receiving messages from television, being followed or persecuted).
Differential diagnosis
• Depression — F32# (if low or sad mood, pessimism and/or feelings of guilt).
• Bipolar disorder — F31 (if symptoms of mania excitement, elevated mood, exaggerated self-worth are prominent).
• Alcohol misuse — F10 or Drug use disorders — F11#. Chronic intoxication or withdrawal from alcohol or other substances (stimulants, hallucinogens) can cause psychotic symptoms.
Patients with chronic psychosis may also abuse drugs and/or alcohol.
Delirium — F05
Presenting complaints
• Families may request help because patient is confused or agitated.
• Patients may appear uncooperative or fearful.
• Delirium may occur in patients hospitalised for physical conditions.
Diagnostic features
Acute onset, usually over hours or days, of:
• confusion (patient appears disoriented and struggles to understand surroundings)
• clouded thinking or awareness.
This is often accompanied by:
• poor memory • withdrawal from others
• agitation • visions or illusions
• emotional upset • suspiciousness
• loss of orientation • disturbed sleep
• wandering attention (reversal of sleep pattern).
• hearing voices • autonomic features
(eg sweating, tachycardia)
Symptoms often develop rapidly and may change from hour to hour.
Delerium may occur in patients with previously normal mental function or in those with dementia. Milder stresses (eg medication and mild infections) may cause delirium in older patients or in those with dementia.
Differential diagnosis
Identify and correct possible, underlying physical causes of delirium, such as:
• alcohol intoxication or withdrawal
• drug intoxication, overdose or withdrawal (including prescribed drugs)
• infection
• metabolic changes (eg liver disease, dehydration, hypoglycaemia)
• head trauma
• hypoxia
• epilepsy.
If symptoms persist, delusions and disordered thinking predominate, and no physical cause is identified, see ‘Acute psychotic disorders — F23’.
Essential information for patient and family
• Strange behaviour or speech and confusion can be symptoms of a medical illness.
Dementia — FOO#
Presenting complaints
• Patients may complain of forgetfulness, decline in mental functioning, or feeling depressed, but may be unaware of memory loss. Patients and family may sometimes deny, or be unaware of, severity of memory loss and other deterioration in function.
• Families may ask for help initially because of failing memory, disorientation, change in personality or behaviour. In the later stages of the illness, they may seek help because of behavioural disturbance, wandering or incontinence or an episode of dangerous behaviour (eg leaving the gas on unlit).
• Dementia may also be diagnosed during consultations for other problems, as relatives may believe deterioration in memory and function are a natural part of ageing.
• Changes in behaviour and functioning (eg poor personal hygiene or social interaction) in an older patient should raise the possibility of a diagnosis of dementia.
Diagnostic features
• Decline in memory for recent events, thinking, judgement, orientation and language.
• Patients may have become apparently apathetic or disinterested, but may also appear alert and appropriate despite deterioration in memory and other cognitive function.
• Decline in everyday functioning (eg dressing, washing, cooking).
• Changes in personality or emotional control — patients may become easily upset, tearful or irritable, as well as apathetic.
• Common with advancing age (5% over 65 years; 20% over 80 years),69 very rare in youth or middle age.
Progression is classically ‘stepwise’ in vascular dementia, gradual in Alzheimers’s and fluctuating in Lewy-Body dementia (fluctuating cognition, visual hallucinations and parkinsonism) but the clinical picture is often not clear cut.
Owing to the problems inherent in taking a history from people with dementia, it is very important that information about the level of current functioning and possible decline in functioning should also be obtained from an informant (eg spouse, child or other carer).
Tests of memory and thinking include:
• ability to repeat the names of three common objects (eg apple, table, penny) immediately and recall them after three minutes
• ability to accurately identify the day of the week, the month and the year
• ability to give their name and full, postal address
A very short screening test is set out in the resource section on the disc. (R: 13–3)
Differential diagnosis
Examine and investigate for treatable causes of dementia. Common causes of cognitive worsening in the elderly are:
• urinary tract, chest, skin or ear infection
• onset or exacerbation of cardiac failure
• prescribed drugs, especially psychiatric and antiparkinsonian drugs, and alcohol
• cerebrovascular ischaemia or hypoxia.
Less common causes include:
• severe depression mimicking dementia
• severe anaemia in the very old
• vitamin B12 or folate deficiency
• hypothyroidism
• slow-growing cerebral tumour
• renal failure
• communicating hydrocephalus.
Sudden increases in confusion, wandering attention or agitation will usually indicate a physical illness (eg acute infectious illness) or toxicity from medication. See ‘Delirium — F05’.
Depression may cause memory and concentration problems similar to those of dementia, especially in older patients. If low or sad mood is prominent, or if the impairment is patchy and has developed rapidly, see ‘Depression — F32#’.
Helpful tests: MSU, FBC, B12, Folate, LFTs, TFTs, U and E, and glucose.
Depression — F32#
Presenting complaints
The patient may present initially with one or more physical symptoms, such as pain or ‘tiredness all the time’. Further enquiry will reveal low mood or loss of interest.
Irritability is sometimes the presenting problem.
A wide range of presenting complaints may accompany or conceal depression. These include anxiety or insomnia, worries about social problems such as financial or marital difficulties, increased drug or alcohol use, or (in a new mother) constant worries about her baby or fear of harming the baby.
Some groups are at higher risk (eg those who have recently given birth or had a stroke, and those with physical disorders, eg Parkinson’s disease or multiple sclerosis).
Diagnostic features
• Low or sad mood
• Loss of interest or pleasure.
At least four of the following associated symptoms are present:
• disturbed sleep • poor concentration
• disturbed appetite • suicidal thoughts or acts
• guilt or low self-worth • loss of self confidence
• pessimism or hopelessness • fatigue or loss of energy
about the future • agitation or slowing of
• decreased libido movement or speech
• diurnal mood variation
Symptoms of anxiety or nervousness are also frequently present.
Differential diagnosis
• Acute psychotic disorder — F23 (if hallucinations [eg hearing voices] or delusions [eg strange or unusual beliefs] are
present).
• Bipolar disorder — F31 (if patient has a history of manic episodes [eg excitement, rapid speech, elevated mood]).
• Alcohol misuse — F10 or Drug use disorder — F11# (if heavy alcohol or drug use is present).
• Chronic mixed anxiety and depression — F41.2.
Some medications may produce symptoms of depression (eg beta-blockers, other antihypertensives, H2 blockers, oral contraceptives, corticosteroids).
Unexplained somatic complaints, anxiety, alcohol or drug disorders may co-exist with depression
Dissociative (conversion) disorder
— F44
Presenting complaints
Patients exhibit unusual or dramatic physical symptoms, such as seizures, amnesia, trance, loss of sensation, visual disturbances, paralysis, aphonia, identity confusion or ‘possession’ states. The patient is not aware of their role in their symptoms — they are not malingering.
Diagnostic features
Physical symptoms that are:
• unusual in presentation
• not consistent with known disease.
Onset is often sudden and related to psychological stress or difficult personal circumstances.
In acute cases, symptoms may:
• be dramatic and unusual
• change from time to time
• be related to attention from others.
In more chronic cases, patients may appear unduly calm in view of the seriousness of the complaint.
Differential diagnosis
Carefully consider physical conditions that may cause symptoms. A full history and physical (including neurological) examination are essential. Early symptoms of neurological disorders (eg multiple sclerosis) may resemble conversion symptoms.
• If other unexplained physical symptoms are present, see ‘Unexplained somatic complaints — F45’.
• Depression — F32#. Atypical depression may present in this way.
Drug use disorders — F11#
Presenting complaints
Patients may have depressed mood, nervousness or insomnia.
Patients may present with a direct request for prescriptions for narcotics or other drugs, a request for help to withdraw, or for help with stabilising their drug use.
They may present in a state of intoxication or withdrawal or with physical complications of drug use, eg abscesses or thromboses. They may also present with social or legal consequences of their drug use, eg debt or prosecution. Occasionally, covert drug use may manifest itself as bizarre, unexplained behaviour.
Signs of drug withdrawal include:
• Opioids: nausea, sweating, hallucinations
• Sedatives: anxiety, tremors, hallucinations
• Stimulants: depression, moodiness.
Family may request help before the patient (eg because the patient is irritable at home or missing work.)
Whatever their motivation for seeking help, the aim of treatment is to assist the patient to remain healthy until, if motivated to do so and with appropriate help and support, he or she can achieve a drug-free life.
Diagnostic features
• Drug use has caused physical harm (eg injuries while intoxicated), psychological harm (eg symptoms of mental disorder due to drug use), or has led to harmful social consequences (eg loss of job, severe family problems, or criminality).
• Habitual and/or harmful or chaotic drug use.
• Difficulty controlling drug use.
• Strong desire to use drugs.
• Tolerance (can use large amounts of drugs without appearing intoxicated).
• Withdrawal (eg anxiety, tremors or other withdrawal symptoms after stopping use).
Diagnosis will be aided by:
• History — including reason for presentation, past and current (ie in the past four weeks) drug use, history of injecting and risk of HIV and hepatitis, past medical and psychiatric history, social (and especially child care) responsibilities, forensic history and past contact with treatment services
• Examination — motivation, physical (needle tracks, complications, eg thrombosis or viral illness), mental state
• Investigations (haemoglobin, LFTs, urine drug screen, hepatitis B and C).
Differential diagnosis
• Alcohol misuse — F10 often co-exists. Polydrug use is common.
• Symptoms of anxiety or depression may also occur with heavy drug use. If these continue after a period of abstinence (eg about four weeks), see ‘Depression — F32#’ and ‘Generalized anxiety — F41.1’
• Psychotic disorders — F23, F20#.
• Acute organic syndromes.
Eating disorders — F50
Presenting complaints
The patient may indulge in binge-eating and extreme weight-control measures such as self-induced vomiting, excessive use of diet pills and laxative abuse.
The family may ask for help because of the patient’s loss of weight, refusal to eat, vomiting or amenorrhoea.
Both anorexia and bulimia may present as physical disorders (eg amenorrhoea, seizures, or cardiac arrhythmias that require monitoring or treatment).
Diagnostic features
Common features are:
• unreasonable fear of being fat or gaining weight
• extensive efforts to control weight (eg strict dieting, vomiting, use of purgatives, excessive exercise)
• denial that weight or eating habits are a problem
• low mood, anxiety/irritability
• obsessional symptoms
• relationship difficulties
• increasing withdrawal
• school and work problems.
Patients with anorexia nervosa typically show:
• severe dieting, despite very low weight (BMI [body mass index] <17.5 kg/m2)
• distorted body image (ie an unreasonable belief that one is overweight)
• amenorrhoea.
Patients with bulimia typically show:
• binge-eating (ie eating large amounts of food in a few hours)
• purging (attempts to eliminate food by self-induced vomiting, or via diuretic or laxative use)
A patient may show both anorexic and bulimic patterns at different times.
Differential diagnosis
• Depression — F32# may occur along with bulimia or anorexia.
• Physical illness may cause weight loss.
• There may be co-existing problems such as drugs and alcohol misuse or self harm.
Medical consequences of severe weight loss include amenorrhea, dental problems, muscle weakness, renal stones, constipation and liver dysfunction. Medical complications of purging include dental problems, salivary-gland swelling, kidney stones, cardiac arrhythmias and seizures.
Generalized anxiety — F41.1
Presenting complaints
The patient may present initially with tension-related physical symptoms (eg headache or a pounding heart) or with insomnia. Enquiry will reveal prominent anxiety.
Diagnostic features
Multiple symptoms of anxiety or tension include:
• physical arousal (eg dizziness, sweating, a fast or pounding heart, a dry mouth, stomach pains, or chest pains)
• mental tension (eg worry, feeling tense or nervous, poor concentration, fear that something dangerous will happen and the patient won’t be able to cope)
• physical tension (eg restlessness, headaches, tremors, or an inability to relax).
Symptoms may last for months and recur regularly. Often, they are often triggered by stressful events in those prone to worry.
Differential diagnosis
• Depression — F32# (if low or sad mood is prominent).
• Chronic mixed anxiety and depression — F41.2.
• Panic disorder — F41.0 (if discrete attacks of unprovoked anxiety are present).
• Phobic disorders— F40 (if fear and avoidance of specific situations are present).
• Alcohol misuse — F10 or Drug-use disorders —F11# (if heavy alcohol or drug use is present).
• Certain physical conditions (eg thyrotoxicosis) or medications (eg methylxanthines and beta agonists) may cause anxiety symptoms.
• Anxiety can be a symptom of Post-traumatic stress disorder — F43.1.
Panic disorder — F41.0
Presenting complaints
Patients may present with one or more physical symptoms (eg chest pain, dizziness or shortness of breath) or unexplained episodes of intense fear. Further enquiry shows the full pattern described below.
Diagnostic features
The patient experiences unexplained attacks of anxiety or fear, which begin suddenly, develop rapidly and may last only a few minutes.
The panics often occur with physical sensations such as palpitations, chest pain, sensations of choking, churning stomach, dizziness, feelings of unreality, or fear of personal disaster (losing control or going mad, sudden death or having a heart attack).
A panic often leads to fear of another panic attack and avoidance of places where panics have occurred.
Differential diagnosis
Many medical conditions may cause symptoms similar to panic (eg arrhythmia, cerebral ischaemia, coronary disease, asthma or thyrotoxicosis). It is not uncommon for individuals with these conditions to additionally suffer from panic. History and physical examination should exclude many of these and should reassure the patient. However, avoid unnecessary medical tests or therapies
• Drugs may induce symptoms of panic.
• Phobic disorders — F40 (if panics tend to occur in specific situations).
• Depression — F32# (if low or sad mood is also present).
Phobic disorders — F40 (includes agoraphobia and social phobia)
Presenting complaints
Patients may avoid or restrict activities because of fear. They may have difficulty travelling to the doctor’s surgery, going shopping or visiting others. This may lead to unemployment and social or financial problems.
Patients sometimes present with physical symptoms (eg palpitations, shortness of breath or ‘asthma’). Questioning will reveal specific fears.
Diagnostic features
The patient experiences an unreasonably strong fear of people, specific places or events. Patients often avoid these situations altogether.
Commonly feared situations include:
• leaving home • crowds or public places
• open spaces • travelling in buses, cars, trains or planes
• speaking in public • social events.
Patients may avoid leaving home or being alone because of fear.
Differential diagnosis
• Panic disorder — F41.0 (if anxiety attacks are prominent and not brought on by anything in particular).
• Depression— F32# (if low or sad mood is prominent).
Panic disorder and depression may co-exist with phobias.
Many of the guidelines below also may be helpful for specific (simple) phobias (eg fear of water or heights).
Post-traumatic stress disorder
— F43.1
Presenting complaints
The patient may present initially with:
• irritability
• memory and/or concentration problems
• associated difficulties in interpersonal relationships
• impaired occupational functioning
• low mood
• loss of interest
• physical problems
Presentation may be delayed for several months following the trauma.
Diagnostic features
• History of a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress to almost anyone. The trigger event may have resulted in death or injury and/or the patient may have experienced intense horror, fear or helplessness.
• Intrusive symptoms: memories, flashbacks and nightmares
• Avoidance symptoms: avoidance of thoughts, activities, situations and cues reminiscent of the trauma, with a sense of ‘numbness’, emotional blunting, detachment from other people, unresponsiveness to surroundings or anhedonia.
• Symptoms of autonomic arousal (eg hypervigilance, increased startle reaction, insomnia, irritability, excessive anger, and impaired concentration and/or memory).
• Symptoms of anxiety and/or depression.
• Drug and/or alcohol abuse are commonly associated with this condition.
• Significant functional impairment.
Differential diagnosis
• Depression — F32# (if preoccupation with, and ruminations about, a past traumatic event have emerged during a depressive episode).
• Phobic disorders — F40 (if the patient avoids specific situations or activities after a traumatic event, but has no re-experiencing symptoms).
• Obsessive compulsive disorder (if recurrent, intrusive thoughts or images occur in the absence of an event of exceptionally threatening or catastrophic nature).
Sexual disorders (female) — F52
Presenting complaints
Patients may be reluctant to discuss sexual matters. They may instead complain of physical symptoms, depressed mood or relationship problems. There may have been sexual abuse — in childhood or later.
Special problems may occur in cultural minorities.
Patients may present sexual problems during a routine cervical-smear test.
Diagnostic features
Common sexual disorders presenting in women are:
• lack or loss of sexual desire, arousal or enjoyment
• vaginismus or spasmodic contraction of vaginal muscles on attempted penetration
• dyspareunia (pain in the vagina or pelvic region during intercourse)
• anorgasmia (inability to experience orgasm or climax).
Differential diagnosis
• If low or sad mood is prominent, see ‘Depression — F32#’. Depression may cause low desire, or may result from sexual and relationship problems.
• Relationship problems. Where there is persistent discord in the relationship, relationship counselling should precede or accompany specific treatment of the sexual dysfunction.
• Gynaecological disorders (eg vaginal infections, pelvic infections [salpingitis] and other pelvic lesions [leg tumours or cysts], although vaginismus rarely has a physical cause).
• Side-effects of medication, alcohol or drugs (eg SSRI antidepressants, oral contraceptives and beta-blockers).
• Physical illnesses may contribute (eg multiple sclerosis, diabetes or spinal injury).
LACK OR LOSS OF SEXUAL DESIRE
Essential information for patient and partner
The level of sexual desire varies widely between Individuals. Loss of or low sexual desire has many causes, including relationship problems, earlier traumas, fear of pregnancy, post-natal problems, physical and psychiatric illnesses and stress. The problem can be temporary or persistent.
Sexual disorders (male) — F52
Presenting complaints
Patients may be reluctant to discuss sexual matters. They may instead complain of physical symptoms, depressed mood or relationship problems.
Special problems may occur in different cultures. Sexual problems are often somatized, expectations may be high, and psychological explanations and therapies may not be readily accepted.
Diagnostic features
Common sexual disorders presenting in men are:
• erectile dysfunction or impotence
• premature ejaculation
• retarded ejaculation or orgasmic dysfunction (intravaginal ejaculation is greatly delayed or absent but can often occur normally during masturbation
• lack or loss of sexual desire.
Differential diagnosis
• Depression — F32# (if low or sad mood is prominent).
• Problems in relationships with partners often contribute to sexual disorder, especially those of desire. Where there is persistent discord in the relationship, relationship counselling should precede or accompany specific treatment of the sexual dysfunction.
• Specific organic pathology is a rare cause of orgasmic dysfunction or premature ejaculation.
• Physical factors which may contribute to erectile dysfunction include diabetes, hypertension, alcohol abuse, smoking, medication (eg antidepressants, antipsychotics, diuretics and beta-blockers), multiple sclerosis and spinal injury.
• Patients may have unreasonable expectations of their own performance.
Sleep problems (insomnia) — F51
Presenting complaints
Patients are distressed by persistent insomnia and are sometimes disabled by the daytime effects of poor sleep (eg driving).
Diagnostic features
• Difficulty falling asleep
• Restless or unrefreshing sleep
• Frequent or prolonged periods of being awake.
Differential diagnosis
• Short-term sleep problems may result from stressful life events, acute physical illnesses or changes in schedule.
• Persistent sleep problems may indicate another cause, for example:
— Depression — F32# (if low or sad mood and loss of interest in activities are prominent)
— Generalized anxiety — F41.1 (if daytime anxiety is prominent).
Sleep problems can be a presenting complaint of Alcohol misuse — F10 or Substance abuse — F11#. Enquire about current substance use.
• Consider medical conditions which may cause insomnia (eg heart failure, pulmonary disease and pain conditions).
• Consider medications which may cause insomnia (eg steroids, theophylline, decongestants and some antidepressant drugs).
• If the patient snores loudly while asleep, consider sleep apnoea. It will be helpful to take a history from the bed partner. Patients with sleep apnoea often complain of daytime sleepiness but are unaware of night-time awakenings.
Unexplained somatic complaints
— F45
Presenting complaints
• Any physical symptom may be present.
• Symptoms may vary widely across cultures.
• Complaints may be single or multiple and may change over time.
Diagnostic features
• Medically unexplained physical symptoms. (A full history and physical examination are necessary to determine this.)
• Frequent medical visits in spite of negative investigations.
• Symptoms of depression and anxiety are common.
Some patients may be primarily concerned with obtaining relief from physical symptoms. Others may be worried about having a physical illness and be unable to believe that no physical condition is present (hypochondriasis).
Differential diagnosis
• Drug use disorders — F11# (eg seeking narcotics for relief of pain).
• If low or sad mood is prominent, see ‘Depression — F32#’. (People with depression are often unaware of everyday physical aches and pains.)
• Generalized anxiety disorder — F41.1 (if anxiety symptoms are prominent).
• Panic disorder — F41.0 (misinterpretation of the somatic signs associated with panic).
• Chronic mixed anxiety and depression — F41.2.
• Acute psychotic disorders — F23 (if strange beliefs about symptoms are present [eg belief that organs are decaying]).
• An organic cause may eventually be discovered for the physical symptoms. Psychological problems can co-exist with physical problems.
Depression, anxiety, alcohol misuse or drug use disorders may co-exist with unexplained somatic complaints.
Learning disability* — F70
Presenting complaints
In children:
• delay in usual development (eg sitting up, walking, speaking and toilet training)
• difficulty managing school work, as well as other children, because of learning disabilities
• behavioural problems.
In adolescents:
• difficulties with peers, leading to social isolation
• inappropriate sexual behaviour
• difficulties making the transition to adulthood.
In adults:
• difficulties in everyday functioning, requiring extra support (eg cooking and cleaning)
• problems with normal social development and establishing an independent life in adulthood (eg finding work, marriage and child-rearing).
Diagnostic features
• Slow or incomplete mental development resulting in:
— learning difficulties
— social adjustment problems.
• The range of severity includes:
— severe learning disability (usually identified before two years of age; requires help with daily tasks and capable of only simple speech)
— moderate learning disability (usually identified by age three to five; able to do simple work with support, needs guidance or support in daily activities)
— mild or borderline learning disability (usually identified during school years; limited in school work, but able to live alone and maintain some form of paid employment).
Diagnosis of co-morbid conditions
Learning disability is associated with an increased prevalence of many other disorders. The most common include:
• epilepsy (25% people with learning disability and 50% of those with severe learning disability)
• autism
• hearing impairments (40%)
• visual impairments (40%)
• psychiatric and behavioural disorders (35%)
• hypothyroidism (people with Down’s Syndrome)
• dementia (people with Down’s Syndrome and those over 50 years of age).
Diagnosis of these conditions may be made harder by unusual presentations of illness. For example, irritability may be an indication of pain or emotional distress.
Differential diagnosis
The following may also interfere with performance at school:
• specific learning difficulties (eg dyslexia)
• attention deficit disorder
• motor disorders (eg cerebral palsy etc.)
• sensory problems (eg deafness).
Malnutrition or chronic medical illness may cause developmental delays. Most causes of learning disabilities cannot be treated. The more common, treatable causes of learning disability include hypothyroidism, lead poisoning and some inborn errors of metabolism (eg phenylketonuria).
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