psych osce lmao

Psychiatric History Taking - Establishing Rapport

**Steps:** Greet the patient, introduce yourself, take consent, and ensure confidentiality.





**Importance:** Builds trust and gains the patient's confidence.

Psychiatric History Taking - Demographics (Age)

**Significance:** Certain disorders are more prevalent in specific age groups.





**Examples:**



- **Child:** Points toward ASD or ADHD.



- **Adult:** Points toward Depression or other mood disorders.

Psychiatric History Taking - Demographics (Education & Occupation)

**Significance:**



- Psychiatric illness can negatively impact work/studies.



- Conversely, stress from work/studies can precipitate mental illness.



- Gives an idea of the patient's **socioeconomic status**.

Psychiatric History Taking - Demographics (Residence)

**Significance:** Important to understand the patient's cultural background to effectively differentiate **cultural beliefs** from actual **delusions**.

Psychiatric History Taking - Admission Type

**Voluntary Admission:** Usually indicates the patient has **good insight** into their condition.





**Involuntary Admission:** Usually indicates **poor insight**.

Psychiatric History Taking - Specific Demographics (Natal, Military, Menstrual)

**Natal (Children):** Check for perinatal insults linked to ADHD or ASD.





**Military (Men):** Check for trauma or psychological impact.





**Menstrual (Women):** Rule out perimenstrual dysphoric disorder or hypothyroidism.

Psychiatric History Taking - History of Present Illness (HPI) Mnemonic

**OCD + 5S:**



- **O**nset (Acute/Gradual)



- **C**ourse (Progressive/Regressive/Stationary/Relapsing)



- **D**uration



- **S**ymptoms (DSM-V criteria)



- **S**ocial & Occupational functioning



- **S**uicide



- **S**ubstance abuse & Medical problems



- **S**tate of Premorbid Personality

Mental Status Examination (MSE) - Appearance & Behavior

**Appearance (Observed):** Hygiene, grooming, and clothing.





**Behavior (Observed):**



- **Eye contact:** Present or absent.



- **Psychomotor activity:** Restless/agitated vs. slow/lethargic.



- **Mannerisms:** Any repeated, unusual movements.

Mental Status Examination (MSE) - Attitude & Speech

**Attitude:** Cooperative, hostile, or guarded.





**Speech:**



- **Rate:** Slow, average, rapid.



- **Volume:** Soft, average, loud.



- **Fluency:** Well-articulated or slurred.



- **Tone:** Angry, anxious, monotonous.

Mental Status Examination (MSE) - Language Assessment

**Tasks to ask the patient:**



1. Identify common objects.



2. Repeat a phrase.



3. Follow a 3-step written order.



4. Write a complete sentence.



5. Copy a complex drawing.

Mental Status Examination (MSE) - Thought Process

**How thoughts flow:**



- **Circumstantiality:** Wandering but eventually reaching the point.



- **Tangentiality:** Wandering and never reaching the point.



- **Thought blocking:** Sudden stop in the middle of a thought.

Mental Status Examination (MSE) - Thought Content

**What the patient is thinking:**



- **Delusions:** Persecutory, grandiosity, reference (must ask about all).



- **Suicidal/Homicidal thoughts:** Must assess risk.



- **Obsessions:** Intrusive, uncontrollable thoughts causing anxiety.

Mental Status Examination (MSE) - Perception

**Hallucinations:** False sensory perceptions (Auditory, Visual, Olfactory, Tactile).





**Illusions:** Misinterpreting actual external stimuli (e.g., seeing a rope as a snake).

Mental Status Examination (MSE) - Mood vs. Affect

**Mood (Subjective):** What the patient *says* they feel (e.g., sad, angry, euphoric). Must ask them directly.





**Affect (Objective):** What the doctor *observes*. Check for **appropriateness** (e.g., inappropriate laughter when discussing trauma).

Mental Status Examination (MSE) - Sensorium & Orientation

**Consciousness:** Ranges from Alert -> Drowsy -> Lethargic -> Stuporous -> Coma.





**Orientation:** Assess awareness of **Time** (date/day), **Person** (who you are), and **Place** (where they are).

Mental Status Examination (MSE) - Memory

**Immediate:** Repeat 3 words.



**Short-term:** Recall those 3 words later in the interview.



**Recent:** What they ate yesterday.



**Recent Past:** Major event from a few months ago.



**Remote:** Name of their primary school.

Mental Status Examination (MSE) - Cognition

**General Knowledge:** E.g., "What is the capital of Egypt?"





**Attention & Concentration:** Serial 7s (subtract 7 from 100 repeatedly) or Reverse spelling (e.g., spelling a word backward).





**Abstraction:** Proverb testing or finding similarities (e.g., Apple vs. Orange).

Mental Status Examination (MSE) - Insight & Judgment

**Insight:** The patient's awareness that they have a mental illness and need treatment.





**Judgment:** How they respond to a hypothetical situation (e.g., "What would you do if there was a fire in your house?").

1. Bipolar I (Manic) - Confirming Clue

**Decreased need for sleep** with elevated/irritable mood and **increased goal-directed/risky activity** lasting for at least **1 week**.

2. Bipolar I (Manic) - DSM-5 Criteria

**Core:** Abnormally elevated, expansive, or irritable mood + increased energy for **1+ week** (or any duration if hospitalized).






**Requires 3+ of:**



- Grandiosity



- Decreased sleep need



- Pressured speech



- Flight of ideas



- Distractibility



- Increased goal-directed activity



- Risky activities.

3. Bipolar I (Manic) - Differential Diagnosis

- Substance/medication-induced (stimulants, steroids)



- Hyperthyroidism



- Schizoaffective disorder or Schizophrenia



- ADHD or Personality disorder.

4. Bipolar I (Manic) - Causes & Risk Factors

- Genetics / Family history



- Monoamine and circadian rhythm disturbance



- Psychosocial stressors



- Sleep deprivation



- Substances (stimulants, corticosteroids, antidepressants).

5. Bipolar I (Manic) - MSE Findings

**Appearance:** Overactive, restless, colorful/disinhibited.



**Speech:** Rapid, loud, pressured.



**Mood/Affect:** Euphoric or irritable / labile.



**Thought:** Flight of ideas, grandiose delusions.



**Insight/Judgment:** Impaired.

6. Bipolar I (Manic) - Treatment

- **Safety first:** Hospitalize if severe, psychotic, suicidal, or violent.



- **Meds:** Stop antidepressants. Start **Mood stabilizers** (Lithium or Valproate) or **Atypical antipsychotics**.



- Short-term benzos for agitation.



- Sleep regulation & psychoeducation.

7. MDD - Confirming Clue

**Persistent depressed mood or anhedonia** plus biological symptoms and suicidal thoughts lasting for **more than 2 weeks**.

8. MDD - DSM-5 Criteria

**Core:** At least **5 symptoms** during the same **2-week period**.






**Must include:** Depressed mood OR Loss of interest/pleasure.






**Other symptoms:** Sleep/appetite changes, fatigue, psychomotor change, guilt, poor concentration, suicidal ideation.

9. MDD - Differential Diagnosis

- Bipolar depression (must ask about past mania)



- Persistent depressive disorder (Dysthymia)



- Grief/adjustment disorder



- Hypothyroidism, anemia, chronic illness



- Substance-induced.

10. MDD - MSE Findings

**Appearance:** Neglected, reduced eye contact, psychomotor retardation.



**Speech:** Slow, low volume.



**Mood/Affect:** Depressed / Constricted or tearful.



**Thought:** Guilt, hopelessness, suicidal ideas.



**Cognition:** Reduced concentration.

11. MDD - Treatment

- **Immediate:** Assess suicide risk.



- **Mild/Moderate:** CBT, interpersonal therapy, lifestyle changes.



- **Moderate/Severe:** **SSRI** (first-line).



- **Severe/Psychotic/Suicidal:** Urgent specialist care, consider **ECT**.

12. Dysthymia - Confirming Clue

**Chronic depressive mood** for at least **2 years** with low self-esteem and hopelessness, **without** full manic episodes.

13. Dysthymia - DSM-5 Criteria

**Core:** Depressed mood for most of the day, more days than not, for at least **2 years**.






**Requires 2+ of:** Poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, hopelessness.



**Key rule:** Never without symptoms for >2 months.

14. Dysthymia - Differential Diagnosis & Treatment

**Differential:** MDD, Bipolar (rule out past hypomania), Medical/Substance-induced, Personality disorder.






**Treatment:**



- Psychoeducation, CBT, Interpersonal therapy.



- SSRI/SNRI when moderate, persistent, or impairing.



- Treat comorbid anxiety/substance use.

15. GAD - Confirming Clue

Excessive, **uncontrollable worry about multiple domains** for at least **6 months** accompanied by muscle tension and sleep disturbance.

16. GAD - DSM-5 Criteria

**Core:** Excessive worry about several events/activities for **6+ months**. Difficult to control.






**Requires 3+ of:**



- Restlessness



- Fatigue



- Poor concentration



- Irritability



- Muscle tension



- Sleep disturbance.

17. GAD - Differential Diagnosis & Treatment

**Differential:** Panic disorder, Social anxiety, OCD, Hyperthyroidism, Stimulants.






**Treatment:** Exclude medical causes. CBT (worry exposure, relaxation). **SSRI/SNRI** (first-line). Short-term benzos with caution. Sleep hygiene.

18. Panic Disorder - Confirming Clue

**Unexpected panic attacks** peaking within minutes, followed by persistent **anticipatory anxiety or avoidance** for at least **1 month**.

19. Panic Disorder - DSM-5 Criteria

- Recurrent unexpected panic attacks.



- At least one attack followed by **1+ month** of concern about more attacks or maladaptive avoidance behavior.



- **Symptoms peak in minutes:** Palpitations, sweating, trembling, dyspnea, chest pain, fear of dying/losing control.

20. Panic Disorder - Differential Diagnosis & Treatment

**Differential:** Myocardial ischemia, Arrhythmia, Asthma, Hyperthyroidism, Pheochromocytoma, Stimulants.






**Treatment:** Exclude acute medical causes. CBT with interoceptive exposure. **SSRI/SNRI**. Brief use of benzos only in severe acute anxiety.

21. Social Anxiety - Confirming Clue

Fear of **scrutiny and negative evaluation** causing avoidance of social or performance situations for at least **6 months**.

22. Social Anxiety - DSM-5 Criteria

- Marked fear of social situations involving possible scrutiny.



- Fear of acting in a way that will be **negatively evaluated**.



- Situations almost always provoke anxiety and are avoided.



- Out of proportion, lasting **6+ months**.

23. Social Anxiety - Treatment

- **Therapy:** CBT with graded exposure and cognitive restructuring. Social skills training.



- **Meds:** **SSRI/SNRI** first-line. **Beta-blockers** for performance-only anxiety.

24. OCD - Confirming Clue

**Ego-dystonic** (unwanted) intrusive obsessions that are temporarily relieved by repetitive, **compulsive washing or checking**.

25. OCD - DSM-5 Criteria

- **Obsessions:** Recurrent intrusive, unwanted thoughts/urges causing anxiety.



- **Compulsions:** Repetitive behaviors/mental acts performed to reduce anxiety or prevent a feared event.



- Must be **time-consuming** or cause severe distress/impairment.

26. OCD - Treatment

- **Therapy:** CBT with **Exposure and Response Prevention (ERP)**.



- **Meds:** **SSRI** (needs adequate dose/duration) or Clomipramine.



- **Family Education:** Teach family not to reinforce or accommodate rituals.

27. Adjustment Disorder - Confirming Clue & DSM-5

**Confirming Clue:** Symptoms start **within 3 months of a clear stressor** and are excessive, but do *not* meet the criteria for another full psychiatric syndrome.






**DSM-5 Limits:** Symptoms do **not persist more than 6 months** after the stressor ends.

28. Adjustment Disorder - Treatment

- **Primary:** Supportive psychotherapy, problem-solving, strengthen coping skills.



- Brief CBT if persistent.



- Meds only for severe short-term symptoms.



- Always conduct a **safety/suicide assessment**.

29. Somatic Symptom Disorder - Confirming Clue & DSM-5

**Confirming Clue:** **Distressing somatic symptoms** combined with **excessive health-related thoughts/behaviors**, not intentionally produced.






**DSM-5:** 1+ distressing somatic symptoms. Disproportionate anxiety/time spent. Persistent state (typically **>6 months**).

30. Somatic Symptom Disorder - Treatment

- **Regular, scheduled visits** with a single primary clinician.



- Validate suffering; **avoid unnecessary repeated investigations**.



- CBT focusing on coping and functioning.

31. Illness Anxiety Disorder - Confirming Clue & DSM-5

**Confirming Clue:** Fear of having a **serious illness** for at least **6 months** with **absent or mild physical symptoms** and repeated checking/reassurance seeking.






**DSM-5:** Preoccupation with illness. Excessive health-related behaviors.

32. Illness Anxiety Disorder - Treatment

- Consistent follow-up with one clinician.



- **Avoid excessive investigations** while remaining medically vigilant.



- CBT for health anxiety.



- SSRI if severe or comorbid with depression.

33. Conversion Disorder - Confirming Clue & DSM-5

**Confirming Clue:** A **neurological motor/sensory symptom** appearing after a psychological conflict, with **inconsistency on physical examination** and no conscious production.






**DSM-5:** Altered voluntary motor/sensory function incompatible with medical conditions.

34. Conversion Disorder - MSE & Treatment

**MSE:** Consciousness intact. Patient may be surprisingly calm about the deficit (**la belle indifference**).






**Treatment:** Explain diagnosis positively (real symptoms, reversible functional problem). **Never accuse the patient of faking.** Psychotherapy and physical rehab.

35. Dissociative Amnesia - Confirming Clue & DSM-5

**Confirming Clue:** Loss of **autobiographical memory** after trauma, with **intact consciousness** and no neurological/substance cause.






**DSM-5:** Inability to recall important autobiographical info, inconsistent with ordinary forgetting. Causes distress.

36. Dissociative Amnesia - Treatment

- Ensure safety and a supportive environment.



- Supportive psychotherapy; trauma-focused therapy when stable.



- **Avoid aggressive memory recovery** (memories usually return gradually).

37. Dissociative Fugue - Confirming Clue & Treatment

**Confirming Clue:** **Sudden travel or wandering** combined with an inability to recall one's identity after severe stress.






**Treatment:** Ensure safety and verify identity. Supportive psychotherapy to help gradual reintegration of memories.

38. Schizophrenia - Confirming Clue

Psychosis (hallucinations/delusions) plus **functional decline** for **more than 6 months** with no primary mood or substance cause.

39. Schizophrenia - DSM-5 Criteria

- **2+ active-phase symptoms** for at least 1 month (Must include: Delusions, Hallucinations, or Disorganized speech).



- Other symptoms: Disorganized/catatonic behavior, Negative symptoms.



- **Continuous signs for 6+ months.**



- Marked social/occupational dysfunction.

40. Schizophrenia - MSE Findings

**Appearance:** Poor grooming, odd behavior.



**Speech:** Poverty, loosening, tangentiality.



**Mood/Affect:** Blunted, inappropriate, or labile.



**Thought/Perception:** Delusions & Auditory hallucinations.



**Insight:** Commonly impaired.

41. Schizophrenia - Treatment

- **Meds:** Antipsychotic medication; monitor side effects and adherence.



- **Hospitalize if:** Risk to self/others, severe neglect, or first episode needing assessment.



- Psychosocial rehabilitation, supported employment, family intervention.

42. Brief Psychotic Disorder - Confirming Clue & DSM-5

**Confirming Clue:** Acute psychosis lasting **more than 1 day but less than 1 month**, followed by a **full return** to baseline functioning.






**DSM-5:** 1+ of Delusions, hallucinations, disorganized speech.

43. Schizophreniform Disorder - Confirming Clue & DSM-5

**Confirming Clue:** A Schizophrenia-like psychosis lasting between **1 and 6 months**.






**DSM-5:** Same active-phase symptoms as Schizophrenia, but duration is <6 months. Functional decline is *not* required.

44. Delusional Disorder - Confirming Clue & DSM-5

**Confirming Clue:** A **fixed, non-bizarre delusion** lasting for at least **1 month** with otherwise relatively **preserved functioning**.






**DSM-5:** Criterion A for schizophrenia never met. Behavior is not obviously bizarre.

45. Delusional Disorder - Treatment

- **Crucial:** Build rapport; **do not directly argue with the delusion**.



- Antipsychotic medication.



- CBT and supportive therapy.



- Manage risk related to the specific delusional content (e.g., erotomanic, persecutory).

46. Dementia (Major Neurocognitive Disorder) - Confirming Clue

**Gradual, progressive cognitive decline** that interferes with independent functioning, occurring with **clear consciousness** (no delirium).

47. Dementia - DSM-5 Criteria & Differential

**DSM-5:** Significant cognitive decline in 1+ domains (memory, attention, executive, language). Deficits **interfere with independence**.






**Differential:** Delirium (acute/fluctuating), Depression (pseudodementia), Normal aging, Reversible causes (B12, thyroid).

48. Dementia - Treatment

- **Rule out reversible causes:** CBC, electrolytes, thyroid, B12, neuroimaging.



- **Safety:** Address driving, falls, wandering.



- **Meds:** Cholinesterase inhibitors or memantine.



- Psychoeducation and caregiver support.

49. Delirium - Confirming Clue & DSM-5

**Confirming Clue:** **Acute, fluctuating** disturbance of attention and awareness, triggered by a **medical condition** or substance.






**DSM-5:** Develops over a short period (hours/days), represents a change from baseline.

50. Delirium - Causes & MSE

**Causes:** Infection, hypoxia, metabolic issues, dehydration, polypharmacy, substance withdrawal.






**MSE:** Clouded consciousness, impaired attention, disorientation, **visual hallucinations/illusions**, fluctuating psychomotor activity.

51. Delirium - Treatment

- **Medical Emergency:** Identify and treat the underlying cause immediately.



- Ensure safety, hydration, oxygen.



- Stop precipitating drugs. Reorientation.



- Low-dose antipsychotic ONLY for severe agitation. **Avoid benzos** (unless alcohol withdrawal).

52. Opioid Use Disorder - Confirming Clue & DSM-5

**Confirming Clue:** **Compulsive opioid use** accompanied by tolerance, withdrawal symptoms, and continued use **despite harm**.






**DSM-5:** Problematic use causing impairment with **2+ criteria within 12 months** (larger amounts, craving, role failure, etc.).

53. Opioid Use Disorder - MSE & Treatment

**Intoxication:** Drowsy, constricted pupils (miosis), slow speech.



**Withdrawal:** Anxious, sweating, rhinorrhea, lacrimation, diarrhea, myalgia, yawning.






**Treatment:** Overdose: **Naloxone**, ABCs. Maintenance: Buprenorphine or Methadone.

54. Cannabis Use Disorder - Confirming Clue & DSM-5

**Confirming Clue:** **Daily cannabis use** with impaired academic or social functioning and inability to cut down.






**DSM-5:** Problematic use causing impairment with **2+ criteria within 12 months** (craving, role impairment, tolerance, withdrawal).

55. Cannabis Use Disorder - MSE & Treatment

**MSE:** Conjunctival injection (red eyes), slowed reaction, impaired concentration, apathetic/anxious mood.






**Treatment:** Motivational interviewing, CBT, contingency management. Psychoeducation on cognitive and psychosis risks.

56. Stimulant Use Disorder - Confirming Clue & DSM-5

**Confirming Clue:** **Compulsive stimulant use** with tolerance, functional impairment, and paranoia or psychosis after binges.






**DSM-5:** Problematic use causing impairment with **2+ criteria within 12 months**.

57. Stimulant Use Disorder - MSE & Treatment

**Intoxication:** Agitation, pressured speech, suspiciousness, dilated pupils (mydriasis), tachycardia.



**Withdrawal:** Fatigue, hypersomnia, depression, hyperphagia (increased appetite).






**Treatment:** Calm environment, benzos for agitation, CBT. No established substitution medication.

58. ADHD - Confirming Clue & DSM-5

**Confirming Clue:** Inattention and hyperactivity or impulsivity starting **before age 12**, present in **more than one setting**, causing impairment.






**DSM-5:** Persistent pattern of inattention/hyperactivity. Symptoms in 2+ settings (e.g., home and school).

59. ADHD - Causes & Treatment

**Causes:** Genetic/neurodevelopmental, Frontal-striatal deficits, prematurity.






**Treatment:** Psychoeducation, behavioral parent training, classroom strategies. **Stimulants** (methylphenidate) as first-line, or Atomoxetine/guanfacine.

60. Autism Spectrum Disorder (ASD) - Confirming Clue & DSM-5

**Confirming Clue:** **Early-onset** social communication deficits plus restricted and repetitive behavior.






**DSM-5:** Persistent deficits in social communication/interaction across contexts. Restricted, repetitive patterns of behavior. Present in early developmental period.

61. Autism Spectrum Disorder (ASD) - MSE & Treatment

**MSE:** Reduced eye contact, limited gestures, restricted interests, repetitive movements, insistence on sameness.






**Treatment:** Early intensive behavioral and educational intervention, speech/occupational therapy, parent training.

62. Suicidal Patient (Risk Assessment) - Confirming Clue

**High Risk Indicators:** Specific lethal plan, access to means, hopelessness, previous attempt, and rescue unlikely.

63. Suicidal Patient - Assessment & Treatment

**Assessment:** Evaluate ideation, intent, plan, lethality, protective factors, and command hallucinations.






**Treatment:** **Do not leave patient alone if high risk.** Remove lethal means. Emergency psychiatric admission. Treat underlying disorder (MDD, Schizophrenia, etc.).

64. Anorexia Nervosa - Confirming Clue & DSM-5

**Confirming Clue:** **Significantly low body weight** with intense fear of weight gain and body image distortion.






**DSM-5:** Restriction of energy intake leading to low weight. Lack of recognition of the seriousness of the low weight.

65. Anorexia Nervosa - Treatment & Prognosis

**Treatment:** Medical stabilization (admit if severe low weight, bradycardia, suicidality). Nutritional rehabilitation. Family-based therapy for adolescents, CBT-E for adults. Monitor for **refeeding syndrome**.






**Prognosis:** Better with early treatment, short duration, supportive family.

66. Bulimia Nervosa - Confirming Clue & DSM-5

**Confirming Clue:** Recurrent **binge eating** plus compensatory **purging** at least weekly for 3 months, with overvaluation of shape and weight.






**DSM-5:** Binge eating with loss of control. Inappropriate compensatory behaviors (vomiting, laxatives, excessive exercise).

67. Bulimia Nervosa - MSE & Treatment

**MSE:** Often **normal weight**. Preoccupation with shape. Look for parotid enlargement, dental erosion, calluses over knuckles (Russell's sign).






**Treatment:** **CBT-E** is first-line psychotherapy. SSRIs (fluoxetine). Correct electrolyte imbalances.