Feedbackand Examination technique

Dr Rebeca Martinez and Dr Chris Williams

Aims of the attachment

The aims of the psychiatry attachment are that by the end of the attachment you can:

• take a psychiatric history and perform a mental state examination.

• recognise mental disorders which commonly present in hospital and community settings and describe the features of these disorders.

• competently assess the severity of these mental disorders and start early management of psychiatric emergencies.

• be particularly familiar with the role of psychiatry in the general hospital, primary care and community settings.

Objectives of the attachment.

• Take a comprehensive psychiatric history • Be aware of specific aspects of the history which may be relevant to

the mental disorder, the age group concerned, and the circumstances of the patient (e.g. relevant physical, social, cultural and ethnic factors).

• are able to assess the mental state of a patient • assess any risk that the patient may pose to themselves or to others• are familiar with the features of mental disorders commonly presenting

in hospital, primary care, community and psychiatric practice, (e.g. depressive illness, anxiety and related disorders, confusion, alcohol withdrawal schizophrenia) and that you can differentiate these from other conditions including normal and abnormal responses to stress.

• can assess whether the severity of the mental disorder suggests that emergency treatment is needed (i.e. whether admission or other suitable alternatives are required under the Mental Health Act) and which psychological, social or physical interventions may be needed.

Have the attachments covered these?

• Range of cases covered?• Cases written up in detail?• Ward rounds/OPD clinic experience?• Visits with CPN’s, OT’s, SW’s and others?• What about fact-gaining – reading?• Need all of these things by the end of the

Psychiatry block – there’s no more psychiatry until finals

Feedback: Starting your placement

• Welcome: were you met?• Were the contact details sufficient?• Did you receive the ticklist of suggested learning

points?• Was this reviewed with you half way through the

placement?• Did you receive a written weekly timetable?• Have you completed and returned the Feedback

form to Doreen Lovett? If not please can you do this now

Revision (with Finals in Mind)

• Need the following information for the exams

• But also as a doctor – it’s all very relevant

Preparing for OSCE’s You are likely to see a station addressing a common

condition:• Anxiety/Affective disorders• Schizophrenia• Alcohol abuse/dependence• Dementia• Eating disorders• OCD• Consent issues/MHA (principles)• Try to see/assess each of these and read about these

conditions

OSCE topics• History taking skills may ask you to take a basic history from a

patient with a mental illness of e.g. anxiety, obsessive-compulsive disorder, depression, memory problems or a drinking problem.

• Mental State Examination stations will test your ability to elicit symptoms from the MSE such as first rank symptoms of schizophrenia.

• Communication skills are assessed throughout the OSCE and particularly in stations such as instructing a patient regarding discharge from hospital, consent to ECT or explaining a subject to a patient or to a carer.

• Examination skills can be tested by getting you to examine a variety of mental state systems (also don’t forget link to the rest of medicine: e.g. cranial nerves, a different part of a neurological examination, blood pressure estimation, fundoscopy etc)

OSCE topics

• Practical skills such as application of ECT electrodes, or introducing how to use a drink diary may be examined.

• Emergency management stations may centre on the treatment of severe drug side effects such as neuroleptic malignant syndrome or a violent patient.

• Miscellaneous topics could include data interpretation e.g. analysing blood result or interpreting an ECG or CT / MRI scan.

Affective disorders: assessment and management

• Basic history taking of depression and hypomania from patient or relative.

• Postnatal depression assessment.• Explaining to a relative the proposed treatment or

illness/diagnosis.• Psychological treatments of depression.• Describing the need for/compliance with or side effects of

antidepressants medication.• Lithium pharmacology.• Essentials of relapse prevention• Medication adherence/concordance/side effects of

common drugs.

Anxiety: assessment and management

• Basic anxiety history to determine a diagnosis of anxiety disorder.

• Aetiology e.g. role of hyperventilation, avoidance and the vicious spiral of anxiety.

• Psychological Treatments e.g. explain systematic desensitisation or an overview of the CBT approach.

• Biological Treatments.

Capacity

• Key questions to test capacity

• Very poorly answered in last years exams

Cognitive assessment and management

• Mini Mental State Examination (MMSE).

• Collateral information from relative on dementia.

• Assessing functionality of patient with dementia.

• Cognitive enhancers.

Eating Disorders: assessment and management

• Basic eating disorder history.• Eating Diary (use/rationale).• Differentiating between Anorexia and

Bulimia Nervosa.• Different reversing behaviours (e.g. abuse

of thyroxine, exercise, laxatives and insulin).

Psychotherapy

• Explain CBT: essentials of model, key interventions

• Explain Psychodynamic Psychotherapy

• Key elements of problem solving (7 –step plan)

• Overcoming avoidance – for example in phobias

Schizophrenia: assessment and management

• Basic history.• Explaining to a relative the illness / treatment.• Eliciting first rank symptoms.• Eliciting other psychotic symptoms e.g. passivity, auditory

hallucinations.• Starting treatment.• Treatment resistance.• Extra-pyramidal side effect (EPSE) examination.• Explanation of medication/prognosis to a relative

Substance Misuse: assessment and management

• Basic alcohol history.

• Basic drug misuse history.

• Alcohol diaries (use/rationale).

• Advice on how to reduce consumption.

• Assessing motivation to stop drinking.

• Key elements.

Suicide /self-harm

• Basic risk assessment history.

Data Analysis

• Blood results e.g. TFTs, LFTs e.g. in depression/anxiety

• Neuroleptic Malignant Syndrome (NMS).• Biochemical complications of an eating disorder.• Interpret a CT / MRI scan e.g. in dementia• Analyse a nursing kardex ( e.g. looking for an

drug interactions or dangerous prescriptions).

Emergency Management

• Violent patient.

• Rapid tranquillisation.

• Neuroleptic Malignant Syndrome (NMS).

• Serotonin syndrome.

Some more potential OSCE topics

ECT• Explanation of procedure.• Gaining consent.

Insight• Important questions to test insight.

Premorbid personality• Important questions to determine pre-morbid

personality

Standardised Differential Diagnosis

Task: In pairs generate Standardised Differential Diagnoses for:

1. Depression2. Paranoid ideas3. Alcohol problems4. Worry5. Panic/phobias6. Obsessions/compulsions7. Confusion

Aetiology

Q. What would you say here? 

The three P’s:

• Predisposing

• Precipitating

• Perpetuating

Investigations.

“Physical”• Think out in advance appropriate investigations

for each condition• “These could include ...”• Bloods. State which and why.• ?EEG/?CT/?Urine drug analysis• ?Blood alcohol levels etc. • Use common sense. Say what you do in practice.

“Social”

• “Obtain old notes and read them.”• “Speak to a relative, with the patients

consent.”• “Speak to the ward staff - do they

eat/sleep/mix”.• “I would consider other sources of

information…” (GP/consultant etc.)• Specialised reports: OT, social report.

“Psychological”

• “I would admit for a period of assessment”• Psychometric testing• Mood rating scales: some now stated as

one’s you should know about• Thought challenge worksheets• Self-monitor: Drinking/Eating/Checking

diaries.•  Always say why.

PrognosisConsider:1). The classical prognosis of this condition2). Specific features of this patient which affect it.State your experience, not papers• Previous history• Response to medication• Compliance with treatment/medication.• Social supports/ characteristics and strengths of the

patient.• Degree of intelligence and willingness to work.

Structured management plans

Task: Generate structured treatment plans for the treatment of GAD/Panic/Schizophrenia/Depression.

1). Physical.

2). Psychological 3). Social/behavioural.

OSCEs in Practice

On entering the station• Introduce yourself and in simple terms e.g. as a medical

student• Describe the task you have been asked to carry out.• Interact with the actor / actress not the examiner.• Listen to the actor / actress as they have much more

information to give if asked the right questions.• Communication skills are important in all stations.• Don’t write too much and avoid paying attention to the

patient as a result. This is likely to irritate the examiner and probably the actor too.

• Stick to the task asked.

Other techniques for the OSCE• Risk assessment issues are prominent in importance.• Think of the whole picture (e.g. for a mother with postnatal

depression you need to show that you have considered possible risk to the baby as well as to the mother).

• Remember biological, psychological and social aspects to a case (e.g. in the postnatal depression assessment mentioned above – is the mother able to interact with the child, play and smile at them? What impact might this be having on the child’s development, and the mother’s relationship with the father?).

• If you run out of time you can always say “at our next meeting we will discuss ….”

• If you have spare time or run out of questions, reflect whether there are any additional questions you should be asking. You can always summarise back out loud what the patient has said and check you

Before entering the Station

• Read the vignette carefully, not just one word and jump to conclusions (e.g. see the word “alcohol” and assume it means “alcohol dependent”).

• Try and determine quickly what the station is trying to assess and what areas you should cover to gain marks.

• If you run out of time reading the vignette (they can be quite long), make sure you read the task you have to carry out.

How to relate to the actors

• You need to make sure that you maintain a polite and professional stance in your relationship with the actors. Address them exactly as you would a real patient.

• Check their name.• Avoid jargon.• Look for non-verbal clues.• Conversation not interrogation.• If you make a mistake, apologise and start again (e.g.

rephrase jargon into normal language more understandable to the actor / patient).

• Thank the actor at the end.

Feedback and Any Questions