PSY HISTORY TAKING

MDD
Mania
PSYCHOTIC DISORDERS
Adjustment Disorder

3 groups of cases
Mood disorders
MDD
BMD
MDD with psychotic features
Adjustment disorder (both mood and anxiety disorder)
Psychotic disorders
Anxiety disorders
Others

Mania
Mania case

4 minute video – Clear cut Mania case Review mood disorder criteria
Task:
- Explain your diagnosis to the examiner with reasons
- What further history, examination and investigation will you do next to confirm your diagnosis
Answer
Task 1:
This patient is in acute mania. She's a case of bipolar mood disorder. And the reasons are:
She said she doesn't need to sleep.
She was very distracted during the consultation
She was fidgeting all over the place
She told me she feel very happy on the top of the world
She was investing, spending too much, hypersexual
The mood disturbance is sufficient to cause impairment at work or danger to the patient or
others (vs hypomania)
The mood is not the result of substance abuse or a medical condition

Task 2
Drugs
Medical mimics
Investigation: drug screen
Manic episode

Manic episodes are characterized by at least 1 week of profound mood disturbance,

characterized by elation, irritability, or expansiveness (referred to as gateway criteria). =>
Felt energetic, high, especially good at yourself?

At least 3 of the following symptoms must also be present:

1. Grandiosity
2. Diminished need for sleep
3. Excessive talking or pressured speech
4. Racing thoughts or flight of ideas
5. Clear evidence of distractibility
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments).

Let me know if you need further assistance with this!

Clinical features
 ≥1 week of elevated or irritable mood & increased energy/activity (gateway criteria)
≥3 of the following symptoms (4 if mood is irritable only) (DIGFAST mnemonic):
Distractibility
Impulsivity/indiscretion, risky behavior
Grandiosity
Flight of ideas/racing thoughts
Increased activity/psychomotor Agitation
Decreased need for Sleep
Talkativeness/pressured speech

Severity

Impaired psychosocial function

May have psychotic features (hallucinations, delusions)
May require hospitalization

Feature Manic episode Hypomanic episode

Symptom More severe Less severe
severity
Minimum ≥ 1 week (or any duration if ≥ 4 consecutive days
duration hospitalization is required)
Functional Marked impairment in Unequivocal, observable change from
change social/occupational functioning or baseline, but not severe enough to
hospitalization necessary cause marked impairment or require
hospitalization
Psychotic May be present (hallucinations, Absent
features delusions) → by definition makes
it manic

Disorder Key criteria (essentials)

Bipolar I At least one manic episode. Depressive episodes are common but not
required for diagnosis.
Bipolar II At least one hypomanic episode and at least one major depressive
episode; no history of mania.
Cyclothymic ≥ 2 years (≥ 1 year in youth) of fluctuating subthreshold hypomanic and
disorder depressive symptoms that do not meet full criteria for hypomania or
major depression.
Keypoints of BMD case
Basic structure
Have you felt energetic / high/ extremely happy/ esp good about yourself?
(Grandiosity)
Schizo pt (power to cure cancer) vs Mania pt (most talented investor)
do you think you have any special talent/ abilities/ super power?
do you feel like you are on the top of the world?
(sleep)
do you feel that you need less sleep lately?
do you find sleeping unneccessary?
(Goad directed activities)
Any recent gambling or investment?
Are you spending more than usual?
Any recent spending or shopping spree?
(Sexual hx)
Can you tell me how things are going with sex life?
(hyper talkative)
do you always talk this fast?

Differentials of BMD
MDD
Personality disorders (BPD)
ADHD
Schizoaffective disorder
Drug-induced mania
Systemic conditions

REVIEW AGAIN

BMD
Elation/Expansivenss
Have you previously or currently been feeling extremely happy, energetic, especially good
about yourself?
Grandiosity
Storyline (I'm the most intelligent person...)
Do you think you have super talent, super power?
Fast speech, flight of ideas, distracted
Observe
AND Increased pleasurable/goal focused activities

Impairment
Substances
 Systemic conditions
**brain questions
headache, fever, previous head injury
thyroid

Here is a clear list of the differential diagnoses for mania, based on the text you provided:

🩺 Differential Diagnoses for Mania

1. Substance/Medication-Induced Conditions

Caffeine intoxication
Stimulant intoxication, including:
Cocaine
Amphetamine (including methamphetamine)
PCP
Nicotine
Hallucinogen use
Excessive steroid use
Excessive human growth hormone (HGH) use

2. Other Psychiatric Disorders

Schizophrenia
Severe anxiety
Severe obsessive-compulsive disorder (OCD)
 Major depressive disorder (MDD) with psychotic features
Any mixed mood disorder

3. Personality Disorders

Histrionic personality disorder

Borderline personality disorder

4. Medical (Physiologic) Conditions

Hyperthyroidism
Hypertensive urgency
Hypercortisolemia
Hyperaldosteronism
Masses or tumors in the brain
Major neurocognitive disorders
Acromegaly
Delirium

Obsessive-compulsive disorder

Recalls March 2025

4 Minute video – In the video the diagnosis is mentioned as OCD case
Explain your diagnosis and differentials to the examiner
What further questions will you ask in the history to confirm your diagnosis

Obsessions
• Recurrent, persistent thoughts, urges, or images
• Intrusive and unwanted
• Patient attempts to ignore or suppress
• Causes distress

Compulsions
• Repetitive behaviors or mental acts
• Done to relieve obsessions
• Hand washing, checking stove
• Praying, counting, repeating words
• Patient feels driven to perform in response to obsessions
 Section Details
Clinical Obsessions
features • Recurrent, intrusive, anxiety-provoking thoughts, urges, or images

Compulsions
• Response to obsessions with repeated behaviors or mental acts
• Behaviors not connected realistically with preventing feared event

Duration/impact
• Time-consuming (>1 hr/day) or causing significant distress or
impairment
Treatment • Selective serotonin reuptake inhibitor
• Cognitive-behavioral therapy (exposure & response prevention)

MDD
MDD case
MDD with psychotic features

Among the criteria for a major depressive disorder, at least 5 of the following symptoms have to
have been present during the same 2-week period (and at least 1 of the symptoms must be
diminished interest/pleasure or depressed mood):

1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears
tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5%
of body weight in a month), or decrease or increase in appetite nearly every day. (Note:
In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.

The symptoms cause significant impairment in social, occupational or other important areas
of functioning. (Toll)
The symptoms are not attributable to another medical condition.
There has never been a manic episode or a hypomanic episode
At least one major depressive episode is not better explained by schizoaffective disorder
and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder,
or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

Keypoints of MDD = Basic structure + C.T.G + R/o mania

Concentration
Any problems concentrating?
Tireness
Are you feeling low in energy?
Guilt/ worthlessness
Do you feel guilty?
R/o mania
Have you ever had episodes of feeling extremely happy and energetic in the past?
R/o medical causes
Function
How does this affect your work, your life at home?

Important consideration — Grief

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be
understandable or considered appropriate to the loss, the presence of a major depressive
episode in addition to the normal response to a significant loss should also be carefully
considered. This decision inevitably requires the exercise of clinical judgment based on the
individual’s history and the cultural norms for the expression of distress in the context of loss.

Differentials of MDD
Systemic
Drug induced depression

Bipolar mood disorder

MDD with Psychotic features
Adjustment disorder (both mood and anxiety disorder)
Persistent depressive disorder
Schizoaffective disorder
Schizophrenia
Grief reaction

REVIEW AGAIN !

MDD 5/9= Basic structure + C. T. G (concentration, tiredness, guilt/worthlessness )

Rule out Mania

I can see you're sad now, but in the past, have you ever been extremely
happy, energetic, not need to sleep?
Impairment (3Ts)
Systemic conditions (thyroid)

MDD with psychotic features

The presentation of severe (dorminant) major depressive disorder may include

psychotic features. Psychotic features include delusions and hallucination.
Mood-congruent psychoses are often consistent with classic depressive themes, such as
personal inadequacy, guilt (delusional level, meaning you did nothing wrong but
consistently feeling guilty), disease, or deserved punishment.
Mood-incongruent psychoses are not consistent with these typical themes but may also
occur in depression.

Diagnostic challenge
MDD with psychotic features VS Schizophrenia
which feature is dominant?

Adjustment Disorder

The specific DSM-5 diagnostic criteria for adjustment disorder are as follows :

Emotional or behavioral symptoms develop in response to an identifiable stressor or

stressors within 3 months of the onset of the stressor plus either or both of
1. marked distress that is out of proportion to the severity or intensity of the stressor
2. significant impairment in social, occupational, or other areas of functioning. (toll)
3. The stress-related disturbance does not meet criteria for another mental disorder
and is not merely an exacerbation of a preexisting mental disorder
4. The symptoms do not represent normal bereavement

Specify whether:
F43.21 With depressed mood: Low mood, tearfulness, or feelings of hopelessness are
predominant.
F43.22 With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.

PSYCHOTIC DISORDERS
Psychotic features: delusion and hallucination
Schizophrenia case

Schizophrenia

At least 6 months, at least 2 of:

Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behaviour
Negative symptoms

At least 1 symptom must be the presence of delusion or hallucination or disorganized

speech

4 domains of symptoms

Mood symptoms: Cheerful or sad

Cognitive symptoms: Deficites in memory
Positive symptoms: Psychotic features: Hallucinations, disorganized speech and
behaviour
Negative symptoms: Decrease in emotional range, poverty of speech, loss of interest
(vs MDD)

young man , 2 years ago, admitted due to schizophreniform , now presents with psychosis.
What is your diagnosis?

Brief psychotic disorder

Duration: at least 1 day but less than 1 month, with eventual full return to premorbid level of
functioning
Not be better explained by MDD or BMD with psychotic features or by another psychotic
disorder

Schizoaffective is between Schizophrenia and MDD with psychotic features

Anxiety disorders

(stress => anxious)

Phobia, panic, GAD, OCD, adjustment disorder, PTSD

Specific phobia
Diagnostic Criteria
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by
crying, tantrums, freezing, or clinging.

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or
situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder,
including fear, anxiety, and avoidance of situations associated with panic-like symptoms or
other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions
(as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic
stress disorder); separation from home or attachment figures (as in separation anxiety
disorder); or social situations (as in social anxiety disorder).

Specific phobia

Markes and excessive fear – Object/Situation

Immediate anxiety response
Avoidance or extreme distress
Fear is out of proportion to the danger
Life-limiting & impairment
Six months or more duration
Not caused by another disorder

Bacsic structure

how do you feel if you see/experience the phobia?

have you been avoiding it?

Social anxiety disorder

Agoraphobia
Claustrophobia

Social anxiety disorder

A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g., having a
conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and
performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interactions
with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will
be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection
or offend others).
 C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns
or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Marked fear about social situations

Fears of negative evaluation
Avoidance
Out of proportion
More than 6 months
Significant distress and impairment

Basic structure

do you always feel anxious when you have a social interaction?

are you worried about what other people think about you in that situation?
are you avoiding it?
do think this reaction and anxiety is reasonable?

Agporaphobia (specific phobia)

DSM-5-TR criteria for agoraphobia, patients must have marked, persistent (≥6 months) fear
of or anxiety about 2 or more of the following situations:

Using public transportation (e.g., automobiles, buses, trains, ships, planes)

Being in open spaces (eg, parking lot, marketplace)
Being in an enclosed place (eg, shop, theater)
 Standing in line or being in a crowd
Being alone outside the home

B. The individual fears or avoids these situations because of thoughts that escape might
be difficult or help might not be available in the event of developing panic-like symptoms
or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly: fear of
incontinence).

Panic disorder +/- Agporaphobia

Panic disorder

Panic Attack Specifier

Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic
attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of
any anxiety disorder as well as other mental disorders (e.g., depressive disorders,
posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g.,
cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is
identified, it should be noted as a specifier

Panic attack is the base of panic disorder, is a package of symptoms

The following are potential symptom manifestations of a panic attack :

Palpitations, pounding heart, or accelerated heart rate

Sweating
Trembling or shaking
Sense of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization or depersonalization
Fear of losing control or going crazy
Numbness or tingling sensations
Chills or hot flushes
Fear of dying (anxiety response due to above sx) (keypoints)
During the episode the patient has a sense of impending doom as though they are dying
from a heart attack or suffocation.
Features
The essential feature of a panic attack is an abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes and during which time 4 or more of 13 physical and
cognitive symptoms occur. Eleven of these 13 symptoms are physical (e.g., palpitations,
sweating), while 2

Note

During the attack, did you feel an intense fear that you may die/ your life might end?

Panic disorder:
Recurrent unexpected panic attacks
Fear of recurrent attacks resulting in significant behavioral changes and worry about the
implications or consequences of the attack

Note

Have you ever been worried of having another panic attack?

has this led to any change in your daily activities/ daily routines?

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary
disorders).

D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks
do not occur only in response to feared social situations, as in social anxiety disorder; in
response to circumscribed phobic objects or situations, as in specific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events,
as in posttraumatic stress disorder; or in response to separation from attachment figures, as in
separation anxiety disorder).

GAD

This disorder is characterized by excessive anxiety and worry about a number of events
and activities (day-to-day) ( Such as Work or school performance )
Worrying is difficult to control.

Anxiety and worry are associated with at least 3 of the following 6 symptoms occurring more
days than not for at least 6 months:

1. Restlessness or feeling keyed-up or on edge

2. Being easily fatigued
 3. Difficulty concentrating
4. Irritability
5. Sleep disturbance
6. Muscle tension

Note

Can you tell me a list of things that you are worried about?
Have you ever tried to control the anxiety?
Any difficulties to maintain concentration? (C)
Do you easily get tired? (T)
do you feel on the edge? (E)

A number of medical conditions are known to include anxiety as a symptomatic

manifestation. Examples include endocrine disease (e.g., hyperthyroidism,
pheochromocytoma, hypoglycemia, hyperadrenocortisolism), cardiovascular disorders (e.g.,
congestive heart failure, pulmonary embolism, arrhythmia such as atrial fibrillation),
respiratory illness (e.g., chronic obstructive pulmonary disease, asthma, pneumonia),
metabolic disturbances (e.g., vitamin B12 deficiency, porphyria), and neurological illness
(e.g., neoplasms, vestibular dysfunction, encephalitis, seizure disorders).

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry
about having panic attacks in panic disorder, negative evaluation in social anxiety disorder,
contamination or other obsessions in obsessive-compulsive disorder, separation from
attachment figures in separation anxiety disorder, reminders of traumatic events in
posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in
somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder,
having a serious illness in illness anxiety disorder, or the content of delusional beliefs in
schizophrenia or delusional disorder).

OCD

Obsession

1. Recurrent and persistent thoughts as intrusive and unwanted, and cause marked anxiety
and distress
2. The person attempts to suppress or ignore such thoughts or to neutralize them with some
other thought or action (ie. by performing a compulsion).
Compulsion

1. Repetitive behaviors or mental acts (eg. praying, counting, repeating words silently) in
response to an obsession.
2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situation.

To be time-consuming and cause significant impairement

Body Dysmorphic Disorder (specific subtype/OCD)

A. Preoccupation with one or more perceived defects or flaws in physical appearance that
are not observable or appear slight to others. (<obsession: can ignore it , can stop thinking
about it)

B. At some point during the course of the disorder, the individual has performed repetitive
behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or
mental acts (e.g., comparing his or her appearance with that of others) in response to the
appearance concerns. (< compulsion)

C. The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The appearance preoccupation is not better explained by concerns with body fat or weight
(eating disorders) in an individual whose symptoms meet diagnostic criteria for an eating
disorder.

OCPD (PD: personality disorder)

A pervasive pattern of preoccupation (not an obsession) with orderliness, perfectionism,

and mental and interpersonal control, at the expense of flexibility, openness, and efficiency,
beginning by early adulthood and present in a variety of contexts, as indicated by four (or
more) of the following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the

extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete
a project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities
and friendships (not accounted for by obvious economic necessity).
4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or
values (not accounted for by cultural or religious identification).
 5. Is unable to discard worn-out or worthless objects even when they have no
sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or
her way of doing thing.
7. Adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.

OCD vs OCPD
Video stem: She's a perfectionist, she's upset about the assignment, she does it over and over
again. She asks to repeat it because she does not feel good about it. It causes anxiety. And it's
a compulsion, she asks to start it again.

=> She can't not stop it (compulsion) = OCD though stem says she's a perfectionist

PTSD
(remember timeframe: PTSD and Schizo.)

Dx in adults, aldolescents and children older than 6 yrs of age using DSM5 requires:

After a certain type and level of traumatic event

a combination of required symptoms
and the absence of exclusionary criteria

1. Causation / Trauma

Directly experiencing the traumatic event

Witnessing, in person, the event as it occurred to others
Learning that the traumatic event occurred to a close family member or friend
Experiencing repeated or extreme exposure to aversive details of the traumatic event; this
does not apply to exposure through media such as television, movies, or pictures

2. Re-experienced

Nightmares (Q)
Intrusive thoughts of the traumatic event
Flashbacks (living the incident) (Q)
Marked emotional & Psychological distress when exposed to traumatic reminders

3. Avoidance

Avoidance of thoughts, feelings, or conversations associated with the event

Avoidance of people, places, or activities that may trigger recollections of the event
 4. Hyperarrousal

Irritable behavior and angry outbursts

Reckless or self-destructive behavior
Hypervigilance
Concentration problems
Sleep disturbance

5. Negative alterations in cognition and mood

Inability to remember an important aspect of the event

Persistent and exaggerated negative beliefs about oneself, others, or the world
Persistent negative emotional state
Markedly diminished interest or participation in significant activities

vs MDD (no flashback, nightmare, trauma event....)

ACUTE STRESS DISORDER

Diagnostic Criteria F43.0

Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3
days and up to a month is needed to meet disorder criteria.
PTSD : lasting more than 1 m
Specify if:
With delayed expression (Delayed PTSD): If the full diagnostic criteria are not met until at
least 6 months after the event (although the onset and expression of some symptoms may be
immediate).