30 Year Old Man With Low Mood

sad man
  • Introduction
  • Student Instructions
  • Examiner Instructions
  • Actor Instructions
  • Additional Instructions
  • Assessor Guidelines
This OSCE demonstrates the need to consider your process or technique of interviewing as well as the importance of gathering appropriate information in order to make a diagnosis.

INFORMATION FOR THE CANDIDATE

LEARNING OBJECTIVES TESTED:

  1. Effective and empathic communication with a patient
  2. Ability to take a relevant and focussed psychiatric history
  3. Ability to assess risk
  4. Ability to make and justify a differential diagnosis
Time:  5 minutes reading time

FORMAT: ROLE PLAY

Time:  12 minutes for role play, 3 minutes for question Instructions to the Candidate: You are an intern on a busy rural General Practice placement. Bill has been brought to the practice by his partner Mandy. She has been reading about depression and thinks Bill might be depressed. The GP asks you to see Bill yourself with a view to make a provisional diagnosis. Your Task is:
  • Take a focussed psychiatric history
  • At the 12 minutes mark the examiner will ask you a question
At 12 minutes interrupt the candidate and ask: What is the most likely diagnosis and your differential diagnosis? Please justify your answer with reference to his symptoms.
Your Role: (Bill): You are Bill, you are between 25 and 45 (depending on actor’s choice), working in the construction industry. You live with your partner Mandy who is 3 years younger than you and your 2 children, 8 year old Nathan and 6 year old Holly. You have been having increasing difficulty coping the past 2 months.  You have been married for 10 years. Recently your relationship with Mandy has recently been strained but you think you’ll get through this. Mandy works in childcare part-time. Your finances are ok, you have a mortgage and car and motorbike loans but are managing all your repayments. Mandy and a few mates are your main supports but you’re not sure how to bring this up with your mates, plus you’ve been isolating yourself lately. You know Mandy thinks you might be depressed but you don’t know and don’t know what to do. She’s insisted you see the GP. You have been working on a commercial building site the past 6 months as a carpenter. Your current supervisor is difficult, he puts pressure on you and your workmates to meet deadlines, and has been critical and verbally abusive. You feel that he is being a bully to some of your workmates, and he has been swearing at you whenever you make a mistake or if he thinks your work is substandard, calling you “useless” and “retarded”. You have not felt comfortable confronting your supervisor about this and have not spoken to anyone else about your concerns. The days are long and you have been working 6 days a week. You are exhausted after work and usually sit up watching sports and drinking alchohol. You used to drink 2 stubbies of full strength beer most nights but recently have been drinking up to 6 a night. Mandy has been angry that you aren’t spending enough time with the kids, plus her father had a serious drinking problem so you been arguing more often. You don’t drive after drinking but have felt hungover at work. If you don’t drink you find you have trouble getting to sleep and feel restless. You have been feeling exhausted, numb and angry. You used to enjoy playing physical games with the kids, watching sport with your mates, fishing, riding your motorbike, but haven’t been going out much lately. You called in sick for a couple of days last week. You are worrying about the quality of your work lately and about finding work once this contract ends; there was a lot of competition for this current job. You have never had a panic attack. You have no suicidal thoughts “I would never do that to the kids” and no thoughts of harming others. You have been eating less but haven’t noticed any weight loss. You sleep 7 hours a night with alcohol. Your libido has been lower. You feel guilty that you have been spending less time with the kids. You’re finding it difficult to concentrate at work and are worried about making mistakes. You don’t have any paranoid ideas or hallucinations. Apart from alcohol you use no other substances currently, and are a non-smoker. You only used marijuana a few times in your teens and 20s, and tried smoking ice a couple of times in your 20s. You play the pokies occasionally, but never more than $50. You have never had problems with your mental health in the past. You have no history of self-harm/suicide. You were born and raised in a small country town. You are the eldest of 3 children. You liked & did well at school and got along well with most people. You left school at 17 and started as an apprentice carpenter. You have worked in the industry since then and your work has always been of a reasonable standard. You moved here (Newcastle) for work and met Mandy here. Your parents both worked long hours and are still alive and retired. You think your grandmother might have had manic depression and been on medication but your family don’t talk about things like that. You have no history of trauma. You are in good physical health and are not on any regular medications. Instructions on how to play the role: In the lead up to coming to see the GP you have read up a little bit about depression and alcohol in the men on the internet and you are already reasonably convinced that you need to cut down your drinking and that you might be depressed. You are generally happy to talk to the intern.  You are concerned about your mental health.  You think that you might have a problem and are glad that Mandy pushed you to come today. However, you are still feeling irritable and this shows in your initial demeanour and responses. You commence the interview in a guarded manner.  You are uncomfortable talking about yourself to a stranger.  Your opening response to an initial question is: “I’ve just not been feeling myself lately” You continue with a guarded posture and short one sentence responses to questions. For example: “I guess I might be depressed” “My sleeps been ok” “I’m not suicidal” “I’ve just been sad” Once the student has responded to your discomfort you open up more and provide lengthier responses.  At this point its okay at this point to give as much information that you think is relevant to a question.  You are wanting to help the student. Towards the end of the interview a student who is performing well may ask a more general question such as: “Is there anything else you think is relevant for me to know?” It is appropriate to answer this question by providing any history that they have not already covered.
Nil

CHECKLIST – MEANT AS GUIDE ONLY

GENERAL APPROACH TO THE PATIENT

  • Introduces self appropriately
  • Clarifies role/ agenda of the meeting
  • Use of open ended questions to facilitate conversation
  • Uses appropriate language (avoids jargon or technical language)
  • Empathic and effective communication style
  • Recognizes and successfully deals with irritability and guardedness
  • Psychiatric History from Patient

HISTORY OF MOOD DISTURBANCE

  • Screens for other symptoms of depression (eg anhedonia, sleep, appetite, concentration, guilt)
  • Psychosocial stressors (work, relationship)
  • Drug and alcohol use history Screens for other problems e.g. anxiety
  • Past history of psychiatric illness
  • Family history of psychiatric illness Medical history and medications

ASSESSMENT OF RISK

  • Risk assessment (current ideation/plans/intent)
  • Past self-harm/suicide attempts

DIFFERENTIAL DIAGNOSIS

  • Identifies alcohol use as an issue (either separate to or contributing to the mood disturbance)
  • Provides at least 2 diagnostic possibilities (eg substance induced mood disorder, major depressive disorder, adjustment disorder, no mental illness)
  • Justifies answer appropriately providing examples of supporting features from the history
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