Psychiatry OSCEs

Module 4

 
Part 1. Structured approach to the psychiatric OSCE.

Every diet MRCEM Part C/OSCE exam has at least one, and usually more than one, psychiatry station. The psychiatry station is typically much feared by candidates and as a result often poorly performed. This is for two reasons: firstly, in the UK at least, emergency doctors rarely (if ever) carry out psychiatric assessments, this now being the role of psychiatric liaison teams and their equivalents; and second, the mock psychiatric patients encountered may be deliberately uncooperative, causing great anxiety in candidates as to what they are expected to do. Thus, candidates attempting psychiatry OSCEs are often unfamiliar with the assessments required and, even more so, are unsure how to approach the psychiatric patient – and this more often than not shows! The good news, however, is that psychiatric stations are actually very easy to pass, provided you recognise that there are only a limited number of possible psychiatric OSCE scenarios and that the same structured approach – with a little variation – can be used to negotiate them all. Below is a list of the major psychiatric presentations that can form the basis of an MRCEM OSCE station:

• The depressed patient • The self-harm patient (with or without ongoing suicidal intent) • The acutely psychotic patient (mania, schizophrenia, other cause) • The patient who may lack capacity • The cognitively impaired patient • The patient with a known or possible alcohol or drug use disorder

As with all OSCEs, a structured approach is best and for psychiatry stations, we recommend the following two stage structure:

• First,Take a history with a psychiatric focus (psychiatric history)

• Second,Use an assessment tool appropriate for the patient’s presentation and use it to reach a diagnosis, from which a management plan can be formulated.

Let’s look at each part in turn and then return to pull it together in an outline for success in the psychiatric OSCE. Click through tabs below then watch the example videos of psychiatric assessments.

Introduction Similar to medical history taking, history taking in psychiatry OSCEs follows a definite structure but differs in emphasis and questions posed. Key areas of the history are easily recognised:

• Introduction • Presenting complaint • History of presenting complaint • Past psychiatric history • Past medical history • Medication • Alcohol and illicit drug use • Social history.

Elements of the Psychiatric History INTRODUCTION Empathy is required from the beginning. Introduce yourself, check the patient’s identity and set out your purpose. For example, “I know this is a difficult time for you but do you mind if I ask you some questions about what has happened so that I can help?” PRESENTING COMPLAINT The presenting complaint may be obvious (for example, an overdose) or require skillful questioning to discover (for example, from a cognitively impaired patient found wandering). Start with open-ended questions as always, but explore the replies with more closed questions until you have a clear idea of exactly why this patient is in the ED on this occasion. Establish early on whether they self-presented, were brought by a relative or friend or brought by the police (voluntarily or involuntarily). HISTORY OF THE PRESENTING COMPLAINT Here you are exploring the background to the presentation and in particular the patient’s feelings, thoughts, and actions around the events leading up to the presentation. In patients with longstanding mental health problems, it is important to find out what has caused THIS particular crisis and ED attendance: “I know it’s difficult and I understand you have been depressed for some time, but can you tell me, why did you take the overdose last night, as opposed to any other night recently?”. PAST PSYCHIATRIC HISTORY This is very important. Ask about previous psychiatric illnesses/diagnoses, similar episodes to this in the past, ask about contact with psychiatric services – psychiatrists, community psychiatric health teams and CPNs, ask about hospital admissions and were they voluntary or involuntary. Beware of asking general questions like “Have you got any mental health problems?”. A clearly unwell patient who lacks insight may well answer “No” initially, but on more careful, specific questioning will admit that “Yes”, they do see a community psychiatric nurse (CPN). Better would be, “Can I ask, have you ever had any mental health problems before?”, “Have you ever been treated for any problems with your mental health before?”, “Have you ever seen a psychiatrist or do you see a community psychiatric nurse?”, “Have you ever stayed overnight in a psychiatric hospital/psychiatric ward before?”. Don’t be afraid of asking these questions in the OSCE, the actor, playing even an uncooperative patient, will reply appropriately when the right question is asked. PAST MEDICAL HISTORY Ask about past medical history. Most patients you encounter in the OSCE will have little so keep this brief, but it is possible an older patient may have a painful or terminal illness prompting their depression or self-harm. MEDICATION Always ask about medication, both in general and specifically about any medications taken for their mental health or medications given by a psychiatrist or started in a psychiatric hospital. If so, an all important question is of course, “Are they still taking the medication?” or “When did they last take your tablets?” ALCOHOL AND SUBSTANCE ABUSE HISTORY Many patients with mental health disorders also abuse alcohol and illicit drugs. Furthermore, alcohol or drug use often underlies mental health crisis and acute psychiatric presentations. Be direct “Do you drink alcohol?” “How much in a week? “Has alcohol ever been a problem for you? “Do you take illegal drugs? “When did you last take them?”. If posed in a direct but honest and non-judgemental manner the patient will not become upset. SOCIAL HISTORY The aim here is to ask a few focused questions to sketch a picture of the patient’s personal and family life. Ask about relationship status, employment situation, accommodation and whom they live with. How much social support do they have, where are their family and friends? Summary This may seem like a lot of questioning to undertake in an OSCE station but most questions will receive brief replies, allowing for swift movement through the history. They trick is not to get bogged down unnecessarily in any one line of questioning, even in the absence of clear replies. Ask the questions, probe a little deeper where necessary, otherwise move on to the next part of the history. The only exception might be the history of the presenting complaint, where it is necessary to establish a clear idea of the crisis that occurred to bring the patient to the ED on this occasion. However, as soon as you have this, move on in the history – you will have gained the relevant marks. Also, don’t be unsettled if the patient is uncooperative with your questioning or gives unexpected or bizarre answers. Check that your questions are specific and intelligible, but if that is the case, don’t worry, the marks are awarded to you for asking the questions appropriately, not for the answers you obtain!

Assessment methods and tools for mental health presentations. The second stage of the STRUCTURED approach to the psychiatric OSCE is to perform an assessment appropriate to the patient’s presentation, from which a conclusion or diagnosis is drawn and a management plan formulated. After taking the history (see above) you should have a good idea of the circumstances of the patient and their current presentation and this informs your choice of assessment tool. Let’s revisit the list of possible psychiatry OSCES, this time matching them up with assessment methods and tools:

• The depressed patient – an assessment for features of severe depression and of thoughts of suicide.

• The self-harm patient – the SAD PERSONS score (or other suitable suicide risk assessment for use with self-harm patients)

• The acutely psychotic patient – the mental state exam (MSE)

• The cognitively impaired patient – the 30 point mini mental state exam (MMSE)

• The patient who may lack capacity – a capacity assessment

• The patient with possible alcohol or drug misuse – CAGE, Paddington or AUDIT-C score.

Let’s take a brief look at each assessment in turn and how to use the results.

The assessment of depression The patient with depression may be quiet, uncommunicative and withdrawn. Gentle, empathic questioning is required to unearth the features of severe depression. Respect silence it gives the patient space to open up to you. To diagnose severe depression ask about organic and non-organic symptoms and signs and about thoughts or plans of suicide:

• Anhedonia. Does the patient still enjoy life or anything that they do? • Early waking with/without mood swings • Poor appetite and weight loss • Psychomotor retardation. Are they as active as usual or do they feel slow and sluggish? • Decreased libido • Difficulty concentrating • Ideas of worthlessness, hopelessness, and guilt • Recurring thoughts about death • Have they thought about suicide or made any attempts or plans to kill themselves?

Conclusion and management Patients with severe depression, particularly those with thoughts of self-harm or suicide, should be referred on to the psychiatric team for further assessment, with likely admission to the psychiatric hospital if considered at genuine risk of suicide.

The modified SAD PERSONS scale. The psychiatry station may well have a depressed patient who has self-harmed or attempted suicide and the stratification of the patient’s imminent risk is essential. A common tool to do this is the SAD PERSONS scale which places the individual into one of three categories shown below. There are many other scores and tools in use in different departments for this purpose but the modified SAD PERSONS scale is widely known (it is described in the Oxford Handbook of Emergency Medicine), simple and easy to remember via its mnemonic. It is important to have the scale committed to memory so as to ensure quick progress through the various questions without leaving any out. Note that much of the information will already have been obtained during the psychiatric history and doesn’t need repeat questioning, while other points may have been touched upon in the history but need further clarification in order to decide the score.

Sex male 1 point
Age <19, > 45 yrs 1 point
Depression or hopelessness 2 points
Previous suicide attempts/psychiatric care 1 Point
Excess Alcohol or drug use 1 Point
Rational thought loss 2 Points
Separated, widowed or divorced 1 Point
Organised or serious attempt 2 Points
No social support (1 Point
Stated future intent (2 Point)

• Score < 6 – may be safe to discharge depending upon circumstances and with community follow up • Score 6-8 – probably warrants further psychiatric assessment • Score > 8 – probably requires hospital admission

  Conclusion and management In most cases encountered in OSCEs, the patient will be obviously low risk and suitable for discharge with early community psychiatric team follow up or be clearly at risk and requires further psychiatric evaluation as an in-patient.

The Mental State Examination (MSE) The mental State exam is used to assess the patient with behavioural disturbance and is designed to identify patients with acute psychotic illness – mania, schizophrenia and drug induced psychosis being major causes. The psychotic OSCE patient is usually young, a bit disheveled, behaving or speaking bizarrely and variably uncooperative. Your job is to gather information following the structured approach of mental state exam (MSE) below so that a clear diagnosis of an acute psychotic illness can be made and an appropriate management plan formulated. The headings of the mental state exam must be committed to memory, and more so, you must have two or three pre-rehearsed questions up you sleeve to ask where relevant so that you do not stumble on the day. APPEARANCE AND BEHAVIOUR You can start to gather this information from the moment you enter the room. Points to think about are the patients dress, posture and movements, eye contact, are they hallucinating, appear distracted or obviously delusional. If they are dressed bizarrely ask about it, “I notice you aren’t wearing any shoes, is that normal for you?” SPEECH Think about the rate (pressure or paucity of speech), volume and intonation of their speech, any made up new words (neologisms) or unusual phrases. Are they vague, over precise or jump between unconnected subjects (flight of ideas). MOOD Take cues from the patient’s behaviour. Ask them about their mood, and about any disturbances in sleep, appetite, libido and concentration (may signal depression or mania). Be direct “How do you feel your mood has been recently?”, “How are your sleeping?”, “How is your concentration now compared to a month ago?”. THOUGHT ABNORMALITIES (HALLUCINATIONS AND DELUSIONS) This is the area most candidates find most difficulty when performing a MSE, but also the most important as evidence of thought disorder strongly suggests the presence of psychotic illness. Remember, thought disorders are either hallucinations or delusions. Hallucinations are sensory perceptions – voices, images and tactile feelings – that are experienced but are not real. Auditory hallucinations in particular, are a sign of severe psychotic disturbance and are often uncovered simply by listening to and observing the patient during the interview. Nonetheless, in the OSCE, it is essential to ask two or three questions in this category to indicate the examiner that you are looking for thought disorder. The difficulty candidates have is: ‘what questions do I ask to examine for hallucinations?’. Again, in the OSCE, be direct.

• “Do you hear voices when you know no-one is there with you?” • “Do you ever hear voices from the television set or radio or anything else like that?” • “What do those voices say?”. “Do they talk about you?” • “Are they nice voices or do they tell you to harm yourself or anyone else?”.

This short sequence of questions examines for the presence of auditory hallucinations, looks for evidence of paranoia and investigates whether the hallucinations pose a threat to the patient or others – and is quite sufficient to gain the mark for examining for thought disorder as part of the MSE. Other possible questions assess for specific phenomena: thought insertion (“Is anyone putting ideas into your head that are not your own?”, thought broadcasting (“Do you feel others can hear your thoughts as if they were spoken out loud?”), thought interruption (“Is someone stealing thoughts from your mind before you finish thinking them?”). Delusions are firmly held beliefs that are unreal or irrational. Grandiose delusions usually manifest as the person believing they are a well-known figure – the King, or Jesus Christ, for example – while patients with persecutory delusions often talk about the neighbors trying to poison them, electrical devices observing them and so on. Delusions are usually obvious from the patient’s behaviour and speech, but it does no harm to ask a simple question to indicate to the examiner that you are aware of them, “You say you are the King, do you really think that is true?” In the OSE, don’t be afraid of upsetting the patient with such direct questions. As long as you do it politely and empathically, showing that you understand the whole experience is likely very distressing for the patient, then it is exactly what the examiner wants to hear. The actor playing the psychotic patient will answer appropriately while staying ‘in role’. COGNITION It is unlikely that you will be required to perform a full Mini-Mental State Exam (MMSE) as part of the Mental State Exam (MSE), there simply isn’t time in a 7-minute OSCE. Instead, assess cognition by asking about orientation in person, time, place and situation. “Can I ask, do you know where you are?”, “Do you know what date it is today?”, “Just remind me, what are you doing here?”. Tell the examiner that ideally you would assess cognition with a full Mini Mental State Exam (see MMSE later) but due to time constraints, you will finish the MSE first. INSIGHT It may be obvious from the patient’s behaviour and speech that they lack insight into their current mental illness, but nonetheless ask the question to gain the mark, “This may seem an odd question, but can I ask you if you think your behaviour is normal at the moment”, “Is it normal for you?”, “Was it like this when you last went into the hospital?” Conclusion and management Patients with evidence of acute psychosis on the mental state exam require referral to the in-patient psychiatric team and almost certainly hospital admission.

Cognitive assessment: The Mini Mental State Exam (MMSE) The mini-mental state exam (MMSE) assesses cognitive ability and is most commonly used where an elderly patient requires assessment for possible dementia. The full 30 point MMSE may seem bit daunting, but in fact, the questions are a logical extension of the well known 10 point abbreviated mental test score (AMT) and, if you are practiced, the majority can be completed in a 7-minute OSCE. The questions of the MMSE are conveniently grouped under the following headings: ORIENTATION • Time – year, season, date, day and month (1 point for each; max total 5 points). • Place: town, county, country, hospital, department (1 point for each; max 5 points). REGISTRATION • Say the names of three unrelated objects (e.g. apple, table, penny) and ask the patient to repeat them (1 point for each; max 3 points). • They will also need to remember these for the test of short term memory later ATTENTION AND CONCENTRATION • E.g. serial 7s, or spell WORLD backward (1 point for each correct answer or letter in correct place; max 5 points) RECALL • Ask for the 3 objects repeated above (1 point for each correct object; max 3 points) LANGUAGE • Name 2 objects: e.g. wrist-watch, pen. (1 for each correct answer; max 2 points). • Repetition of phrase: “No ifs, ands or buts” (1 if the repetition is completely correct) • 3-stage command: Instruct the patient “Take a paper in your right hand, fold it in half and put it on the floor” (1 point for each part that is correctly followed; max 3 points). • Reading: Write “CLOSE YOUR EYES” in large letters and show it to the patient. Ask them to read the message and do what it says (1 point). • Write a sentence: the sentence must make sense. Spelling, punctuation, and grammar are not important (1 point). • Copy this diagram: Draw a 5 pointed star or overlapping pentamers and ask the patient to copy it out (1 point). Maximum total is 30 points. Conclusion and management A score of 23 is taken as the cut off for significant cognitive impairment. A patient with significant cognitive impairment needs to have a physical examination, baseline observations including blood pressure, blood sugar, urine dipstick, baseline blood tests and TFTs and be referred to a memory clinic. If they are unmanageable, unsafe at home, or a danger to themselves or others then they will likely need hospitalisation and assessment by the elderly persons psychiatry service.

The capacity Assessment. OSCE stations may ask you to assess a patient’s capacity. This may relate, for example, to a patient declining treatment or attempting to self-discharge. It is of paramount importance that you can clearly demonstrate to the examiners that you understand what the assessment of capacity means, as well as the implications for emergency treatment of a patient who does not have capacity. Bear in mind that BEFORE a capacity assessment is undertaken, the Mental Capacity Act stipulates that the doctor must take all reasonable steps to help the patient in making an independent decision. A simple and straightforward way to indicate that you know this, would be to ask the patient if there is anyone who can help them with the decision, “I know this is a lot of information and a difficult decision, is there anyone I can ask to come and help you with it, perhaps a son or daughter?”, “Is there any other way I can help you with this decision?”. There are four parts to assessing capacity and you will need to verbalise each part clearly to be sure of obtaining full marks. You need to check that the patient:

• UNDERSTANDS the information relevant to the decision. Explain the information as clearly as you can to the patient, without medical terms or technical jargon, then ask “can you tell me what you understand about what I have just told you?”

• Is able to RETAIN that information: “Can you repeat back to me the information I have just given you about your condition and treatment?”

• can WEIGH UP that information as part of the process of making the decision and realizes the consequence of refusing treatment. “Can you tell me why you don’t want the treatment and what you think might happen to you if you don’t have treatment?”

• Is able to COMMUNICATE their decision back to you. “Bearing in mind everything that we have discussed, can you tell me what you have decided, whether you want the treatment or not?

Only a patient that satisfies all four of these sections is deemed to have capacity. Conclusion and management If the patient fails the capacity test, then tell them so sympathetically and unthreateningly, “From our discussion I’m afraid I don’t think you are making the right decision and I’m worried that you might become more unwell if you don’t have the treatment, so ….”. Offer again to contact someone they know to be with/help them.

Alcohol and drug assessment snd screening tools A number of alcohol screening tools exist and are in use in different departments. It doesn’t matter which one you use as long as you can use it correctly. Two simple ones are CAGE and AUDIT-C. CAGE is appropriate for a patient with suspected alcohol use disorder. AUDIT-C is a more versatile screening tool which for identifying hazardous drinking and alcohol use disorders following an alcohol-related presentation. The CAGE questionnaire is a simple, validated tool for identifying problem drinking, and alcoholism. It asks the following questions:

• Have you ever felt you needed to Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt Guilty about drinking? • Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Two “yes” responses indicate that the possibility of alcoholism should be investigated further. The Alcohol Use Disorders Identification Test (AUDIT-C) is recommended by NICE and the RCEM as an alcohol-screening tool designed to identify hazardous drinkers as well as those with active alcohol use disorders (alcohol abuse or abuse or dependence). It is appropriate for use in patients of all ages with alcohol-related presentations. It asks three questions and scores the responses 0-4, giving a total score out of 12.

1. How often do you have a drink containing alcohol? Never (0 points), monthly (1), weekly (2), 2-3 times a week (3), Daily or almost daily (4)

2. How many standard drinks do you drink on a typical day when you are drinking? 1-2 (0 points), 3-4 (1), 5-6 (2), 7-9 (3), >10 (4)

3. How often have you had more than 6 drinks on a single occasion? Never (0 points), less than monthly (1, monthly (2), weekly (3), Daily or almost daily (4)

A score or >4 (men) or >3 (women) is considered positive and may indicate hazardous drinking or alcohol use disorder. Conclusion and management Once a problem drinker, or patent with alcohol use disorder, is identified, management to propose includes:

• More comprehensive alcohol assessment, perhaps using the full AUDIT questionnaire

• Give advice on safe levels alcohol consumption and on reducing alcohol consumption

• Referring/providing written contact detail of community alcohol and drug services

• Referring to the alcohol nurse for a brief intervention and or referral to community alcohol and drug service for follow up

• Making the GP aware of the attendance.

Pulling it together: The Psychiatric OSCE. Good preparation and structured approach are necessary for success in the psychiatric OSCE. Prepare by reviewing the questions of the psychiatric history and by learning and practicing the various assessments methods and tools above. Then combine them into a structured approach:

• Introduce yourself, establish the patient’s identity and explain your purpose. Politely ask if you can ask some questions.

• Then take a psychiatric history ensuring you discover the reason for the current crisis that has led to this presentation and gaining all the important information.

• Based on the outcome of the history select an appropriate assessment tool (see previously) to use and use it to make a diagnosis or come to a conclusion from which a management plan can be formulated.

• Usually, you will be required to either discuss the management plan with the patient or, in most cases, summarise your findings and propose a management plan to examiner in the last minute of the OSCE (see presenting to the examiner module).

• If appropriate – and in most cases it is – also say that you would perform a physical examination. The physical examination completes the psychiatric evaluation and includes asking for baseline observations – temperature, blood sugar, urine dipstick and in some cases baseline blood tests. This is to make sure you do not miss an organic cause for their apparent psychiatric symptoms.

This structure may need some variation depending on the particular situation or task but should form the basis of your approach to most, if not all, psychiatric OSCEs you may be presented with. It is also a good basis for psychiatric assessment in the ED! Tips:

• Read the instructions to the station carefully. Most of the time, you can decide upon the assessment tool you are going to use based on the patient vignette in the instructions. • Move through the history taking swiftly to ensure you have time for the assessment. It helps of you have thought about and practiced the questions beforehand • Make it clear to the examiner when you are moving on to the assessment step, “OK, thank you for answering my questions, I’d like now to assess your mental health by asking a few more questions, is that OK?” • Learn and practice the mental health assessment tools, including exactly what questions you will ask during the assessments. • Make sure you can correctly interpret the result of your assessment • Keep to a structured approach • Leave time to present the findings and management plan at the end • Practice summarising the key findings and conclusion of the mental health assessments outline above in 1 minute so that you can do it well to the examiner on the day. • Show off your best communications skills and use empathy and understanding throughout

A final pitfall to avoid:

• Don’t confuse the mental state exam (MSE) and mini-mental state exam (MMSE) they sound very similar but are completely different assessments – be clear on how and when to use each one.

Part 2. The uncooperative patient.

Not infrequently, the patient in the psychiatric OSCE is deliberately uncooperative. The may be virtually silent and give brief, uninformative replies to questions or be floridly psychotic and ignore your questioning all together whilst insisting they are the king of England! Many candidates become unnerved by the uncooperative patient and forget their structured approach, instead either insisting the patient behaves normally (“Please why won’t you just sit down….?) or colluding with them to achieve more interaction at the expense of any value in the assessment “If you’re the King then, do you live in a palace?”, “Yes of course, where do you think a king lives!”). The best approach is to stay calm, introduce yourself and ask whom they are. If the patient is agitated, then ask ONCE if they would like to sit down, followed by asking if they mind if you sit. Sit down and launch into the structured approach to the psychiatric OSCE outlined previously. Take a thorough psychiatric history followed by an appropriate assessment. Don’t miss anything out just because you don’t think the patient will answer properly. If you get sparse or bizarre answers, simply make a note of what that tells you about the patient and move on to the next question in your history or assessment. Keep up a respectful, empathic tone throughout. Avoid collusion with any hallucinations or delusions. Remain calm and seated, to avoid further stimulating the agitated patient or appearing threatening to a withdrawn patient. Remember that the marks are awarded to you for asking the right questions and performing an appropriate assessment, not for the replies given by the actor playing the patient!

Part 3. Example psychiatric assessment videos.

Part 4. Improving your psychiatric assessment skills.

Psychiatric OSCE stations are easy to pass with a well rehearsed and structured approach. Commit the psychiatric history to memory and learn the various assessment methods and tools. Then practice them, with patients – pick up the cards of psychiatric presentations and see them before the liaison team does, with Seniors to critique you and with colleagues in practice groups. Go on a course which includes mock OSCEs. This is the only way to improve and become competent in, what is for most, a difficult area of the MRCEM Part C/OSCE exam.

 

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