General Mental state findings – OSCE
“Remember formulation tells us How the person became depressed/manic/psychotic as a result of
their genetics, personality, psychological factors, biological factors, social circumstances (ACE and social determinants) and their
environment”
# 1 Depression
What psychiatric conditions can cause low mood?
Summary: A 19 yo female arts student previously well presenting with a 2/12 hx of persistent • MDD,
low mood since her grandmother passed away 2/12 ago. Her low mood has been associated • dysthymia,
with poor appetite, lack of motivation for social participation, difficulty concentration and • mood-disorder related to health condition
increased tiredness.
• Bipolar,
MSE:
• Substance induced mood disorder
A XX yo gentleman/lady [occupation] who:
• A, B - appears tired but well-dressed
What medical conditions can cause low mood?
o displaying poor eye contact.
• Chronic infection (HIV, hep B/C), chronic co-morbidities (DM,
• Speech HF, cancer),
o speaking with a quiet monotonous tone • metabolic/electrolyte (anaemia, ureamia, hyperCa),
o Her speech is reactive but slow. • endocrine (hypothyroidism, Addison),
• Mood/affect - She/He feels their overall mood is low, which I agree with. • neuro (SoL, dementia, Parkinson’s, epilepsy), medications
• Thoughts - She/he has experienced (no.) (type) hallucinations which feature ______
• Perception/Cognition - She/he has/hasn’t admitted to suicidal ideation. Does she How is depression managed? What type of antidepressants are
have plans on when or how? Suicide note? Notifying significant others? there? Give me one advantage and disadvantage for each drug
• Insight/Judgement – do they think their mood is an issue? Are they motivated to be class.
treated? How do they feel about it? • Non-pharm – CBT, psychoeducation, lifestyle (diet, exercise,
sleep, cessation of smoking, alcohol, recreational drugs)
Formulation (how did they become like this?): • Pharm – SSRI > SNRI > Serotonin antagonist > MAOi > TCA
1)_ Intro: A 19yo arts student presents with low mood following the death of her grandmother o Adv: SNRI (minimise OD), PO administration
2/12 ago. o Disadv: A/E, 4-6 weeks for therapeutic effect,
> notable PMHx or psychiatric hx of: ________ requires compliance/adherence, works differently
between different individuals
> genetic vulnerabilities for mental illness in her family history,
> medication compliance (sub-therapeutic, poorly compliant)
Do you know of any questionnaires used in hospitals or the
> ongoing substance abuse?
community for depressive symptoms?
2) Predisposing factors (bg hx – developmental)
• Primary care – DASS 21
• She is biologically /socially predisposed with:
• Hospitals – PHQ-9, 15-item Geriatric depression scale (GDS-15)
o FHx of depression? , alcohol/substance use disorder in the family for elderly, Edinburgh depression scale (for ante-natal and
o parental divorce, unstable home life, history of trauma post-natal)
o Underlying hx of childhood trauma (sexual, physical, emotional)
• Which has contributed to her psychological struggles of: What are some other strategies to consider?
o Fears of abandonment, invalidation, self-worth Disposition • What level of care (outpatient vs inpatient)?
o Temperament / personality (dependent, invalidating experiences, unable to – are they safe to be in community?
develop personal identity)
Biological • Non-pharm
These difficulties are reflected in her adulthood leading to them to think that:
• Pharm – sertraline 50mg PO OD (Max dose
• They are… of 200mg)
• Others are… • Anti-craving agents to reduce cravings for
• The world is… alcohl use (e.g. naltrexone, acamprosate)
3) Precipitating factors: Psych • CBT – depression
“The [major event – death, loss of job, family, cease meds, re-experiencing of trauma]” has • Motivational interviewing – alcohol use
triggered/reactivated”
• Consider specific or death-traum therapy
• More primitive defence mechanisms for long-term Mx (after CBT)
• Immature / mature Coping strategies
Social • Access support from job’s HR department
4) Perpetuating factors: Their symptoms have been perpetuated by: or student support services
• Biological factors (co-morbidities, ongoing alcohol use) • Substance use groups (e.g. AA)
• Social (financial stressors)
• Psychological (maladaptive Coping strategies, personality traits) • Increasing connections with friends and
social support
5) “However, she displays a number of protective factors including”
• Supportive family and friends
• Good insight into her mental well-being (psychologically minded)
• High-functioning status (university educated)
7) Hence, I believe her overall prognosis is good/poor and will likely benefit from
• non-pharm strategies - CBT, positive lifestyle interventions, support groups, promote
social interactions etc.
• Pharm: SSRI, anti-craving agents
DDx: She likely has a psychiatric diagnosis, likely a mood disorder. This would include
unipolar depression as she displays the core symptoms of depression (low mood, anhedonia
and anergia) alongside some somatic symptoms of reduced concentration, anorexia. Bipolar
is another ddx but is less likely given that she has not state a period of high/elevated mood
which would suggest a manic episode.
Mx: Non-pharmacological strategies with lifestyle interventions, and linkage with counselling
support through a psychologist and considerations of CBT
, ABNORMAL GRIEF REACTION
Summary: What is an abnormal grief reaction?
Ø 54 yo widow and previous headteacher presents to acute medical ward from home DSM-V [complex bereavement disorder]
after being discovered by family confused and disorientated. Ø An individual experiences the death of a loved one
Ø In the context of her husband’s of 21 years death few months ago Ø AND At least one of the following Sx, occurs for > 12 mths
Ø PMHx of rheumatoid arthritis and T2DM, no psychiatric hx (adults), > 6 mths (child)
Ø Continues to have delusions that her husband remains alive o Yearning / longing
Ø Low suicidal risk since her delusions feature her husband still alive o Pre-occupied with deceased
Ø Eating and drinking well o Pre-occupied with circumstances of death
Ø Meds – requires many painkillers, and uses metformin o Emotional pain
Ø Social Hx – no children, Regular alcohol usage (glass of sherry) Ø AND at least 6 of the following Sx for > 12 mths (adults), > 6
mths (child)
MSE: o Difficulty accepting loss
A 54 yo widow and retired headteacher who: o Disbelief
• A, B - appears restless, distressed, easily distractable , but maintains good eye contact . o Anger
• Speech o Self-blame
o She speaks rapidly, with a hint of frustration in her tone o Desire to die to re-unite with loved one
• Mood/affect – She feels her mood is fine but this incongruent to her actual affect , o Distrust of others
• Thoughts – Although she does not report any hallucinations or thought disorders, she o Loneliness
continues to have delusions about her husband being alive, whether it be waiting to
o Emptiness / meaningless in life
pick her up or waiting for her at home. Her thoughts appear to be a flight of ideas.
o Diminished sense of identity
• Perception/Cognition – She states she has not had any suicidal thoughts, since she
still believes she could never do something like that to her husband. o Amotivation
She remains disorientated to place and time.
• Insight/Judgement – She also does not have any insight into her current condition or How is abnormal grief reaction treated?
make appropriate judgements in day to day activities Non-pharm:
Ø grief counselling or therapy
Formulation (how did they become like this?): Ø psycho-education into the normal stages of grieving
1)_ Intro: A previously well 54 yo widow and retired headteacher presents to the acute medical Pharm:
ward from home after her family discovered her confused and disorientated. Ø SSRI?
2) This is in the context of the death of husband of 21 years, a few months ago with no significant
background psychiatric history and chronic usage of analgesics.
What is the difference between dementia and delirium? Can you
3) Predisposing factors (bg hx – developmental) name some causes of delirium?
• She appears to have had an unremarkable childhood upbringing, with no obvious Ø Dementia – progressive neurodegenerative disease
psychological struggles of abandonment, insecurity. characterised with cognitive and functional decline
• However, her long-standing marriage which did not feature any children suggest possible Ø Delirium – transient reversible altered state of fluctuating
difficulties in conceiving, personality conflicts between her and her husband, underlying consciousness, inattention and impaired cognition. Reversible
unspoken childhood trauma on either her or her husband’s side. causes may include:
• These challenges are reflected in her current circumstance leading to her delusions of her o Medications
husband still being alive, which can be seen as a defensive coping mechanism to manage o Infection
her insecurities when abandoned
o Pain
4) “However, she displays a number of protective factors including”
o Retention
• A supportive family and previous high-functioning role as a headteacher can seen as
protective factors. o Electrolyte disturbance
5) Hence, I believe her overall prognosis is good/poor and will likely benefit from o Metabolic (uraemia, anaemia)
• Non-pharm strategies - CBT, positive lifestyle interventions, support groups, promote o Endocrine (thyrotoxicosis, Addison, DM)
social interactions etc. o TTP, trauma, toxins
• Pharm: SSRI, anti-craving agents o Neuro (SoL, infection, bleed, stroke,
Parkinson’s)
DDx: She likely has a psychiatric diagnosis, likely an abnormal grief reaction given that it
appears specifically attributed to the death of her husband a few years ago. Can you name any drugs which may contribute to delirium?
Still possible: Ø Anti-psychotics, anti-convulsant,
Ø Delirium - polypharmacy (review analgesic usage), underlying infection, electrolyte Ø anti-depressants (anti-cholinergic)
abnormalities Ø Anti-dopaminergic
Less likely to be: Ø Corticosteroids (steroid induced psychosis)
Ø Depression – no evidence of anhedonia, low mood Ø Anti-HTN
Ø PTSD – not relieving events Ø Statins
Ø OCP
Mx: Ø Opioids
Ø Organic screen required – FBC, EUC/CMP, LFT, BSL, HbA1C, lipids, TFT,
o +/- Non-contrast CTB, ECG,
Ø Non-pharmacological strategies may include psycho-education, bereavement
counselling, family based therapies
Ø Pharm: ?SSRI – may not get rid of delusions
