Boy with a scar

Hi there, can help me with a station which came sometime back? 
”a young man with a cap on his head. GP referred as he was paranoid. Underneath was a scar. very vague historian.
different views—social anxiety, early onset psychosis, dysmorphophobia.”

If was faced with a task to take a relevant history because a GP believes the boy is paranoid I would ensure to use a systematic and structured approach so an examiner sees that I am exploring what the underlying issues could be in a logical way.

As we discussed in Key 2: Know the Exam,  I would use the ICD-10 hierarchy to help structure the interview:

Halo-intro-set the scene:

Hello (name), my name is Dr. x, I’ve got some information as to what has been happening could you share with me yourself as to what the main problems have been?/Your GP was worried that haven’t been yourself recently, do you have any idea why your GP might be so concerned?”

HPC: O,D,P,I

“I’d just like to ask you some questions if I may..”

Ask about onset, duration, progression and impact of symptoms on current level of functioning.

“How did the scar appear?”

(Then explore possible causes with the headings below which demonstrates the ‘range’ of possible causes and then go into further ‘depth’ if you identify a potential cause e.g. drugs/alcohol, evidence of psychosis or evidence of an anxiety disorder)

ORGANIC – does he have any medical problems, started on any new medications, any recent physical injuries? – did he have a head injury? If so did he lose consciousness > Did he have a scan? Has he been involved in drugs and alcohol at all? (if so ask about amounts of use, evidence of dependence etc.)

PSYCHOSIS –

“Mr. X, what is it that concerns you most about the scar?”

“Do you feel the scar is responsible for anything you are experiencing at the moment?”

“I’m going to ask a few questions that are going to sound strange, but they are just part of the assessment”

“Can the scar control your thoughts in anyway?” > insertion/withdrawal/broadcast

“Do you ever experience any noises, whispers or even voices when there is no-one else around?”

“Is there any possibility that the scar is not responsible for these experiences?” (checks conviction and insight)

“Is there a family history of psychiatric illness?” (if family history of psychosis then could be prodromal phase)

MOOD –

“You’re obviously having an extremely difficult time at the moment, how has this effected your mood?”

If there is there any evidence of mood disturbance. > ask how long they have felt this way for? > check energy and current activities to confirm a depressive illness. Additionally look for any other evidence e.g. delusions of grandeur if elated or nilhistic delusions if low in mood. Do of course check their SUICIDE risk.

NEUROTIC – Are there any current feelings of anxiety? Are these feelings generalised or specific?  What sorts of thoughts go through your mind when he looks at the scar? How much time does he spend looking at it? Is he concerned that he is the centre of attention?  Any thoughts of self-correction of the scar?  

PERSONALITY – How would your friends describe you when feeling 100% in yourself? Did the scar come about by self-harm? Does he get mood swings? How often? (if there is you could check for evidence of an emerging emotionally unstable personality)

If there is is nothing specific in the station then I would suggest that the question is just testing your ability to ask relevant questions to identify a potential causes with sufficient range and depth. If the case is non-psychosis and just an anxiety disorder then you will identify this from the approach above and can then explore the anxiety symptoms in further depth. However, it could be also be a prodromal psychotic phase as this can present with either anxiety, depression or quasi-psychotic symptoms.