MRCPsych: Passing the CASC Exam

Justin Sauer

• Publisher: CRC Press
• Year: 2017
• eBook ISBN: 9781482213287
• Topic: Medizin
• Subtopic: Psychiatrie & geistige Gesundheit

A newly-prepared revision guide tailored to the brand new Clinical Assessment of Skills and Competencies (CASC) portion of the MRCPsych exam, containing over 100 clinical scenarios and accompanied by the ideal 'answers' examiners will be looking for.

Chapter 1

General adult psychiatry

Dr David Okai

LINKED STATION 1

1a.

A 21-year-old woman (Miss Lara Tracey) has been referred to your service with bouts of depression lasting a few weeks at a time. She takes mirtazapine and has reported no change in her depressive symptoms. You have inherited this patient from your predecessor’s outpatient clinic.

Take a history of her mood and find out more about her symptoms. Explain to the patient what you think the problem is.

1b.

You decide from your history that the patient has bipolar II and is a rapid cycler with several cases of depression each year and previously unobserved episodes of hypomania. She is currently hypomanic. The patient says she would be willing to take lithium now that you have explained the illness more.

Prepare to discuss the case with your consultant, including your management plan.

LINKED STATION 2

2a.

You are asked to see a patient for a second opinion. She has a longstanding history of low mood and several admissions with suicidal thoughts and plans. She is currently prescribed amitriptyline.

Take a history of her mood symptoms and explore her previous psychiatric history.

2b.

The lady you have just seen is depressed with an atypical depression. She has symptoms of variability of mood, tension, overeating, oversleeping and fatigue.

She has also expressed thoughts of self-harm. She lost her job as she was not performing (due to depression). She has a partner who is not supportive and drinks heavily. He has been both verbally and physically abusive in the past.

Explain to your consultant how you will manage her condition.

LINKED STATION 3

3a.

An 18-year-old university student is referred for assessment by his general practitioner (GP). The patient is perplexed, frightened and expresses ideas of persecution. He is willing to be admitted to hospital. He has no previous psychiatric history.

Your consultant catches you before you see the patient and wants to discuss the differential diagnosis and how you intend to proceed over the next 48 hours.

3b.

The patient’s mother turns up and asks what is going on. She saw a programme on bipolar disorder the other day and wonders if this is what her son has. She wants to know what the management plan is and if he will be able to go back to university. If not, should she take him home? She has also heard of early-onset services, and wonders if this is an option or what other options may be available.

LINKED STATION 4

4a.

You are asked to assess Mr Jones, a 63-year-old doctor who took early retirement. Concerns have been raised by his family that he is collecting refuse in his house. You attend with a social worker (following a previous visit from the GP) to find the house in abject squalor with large collections of paper and magazines lying around.

Assess this gentleman. Towards the end of the scenario the examiner will ask your preferred diagnosis.

4b.

You discover that this gentleman collects items that he finds in his day-to-day life and subsequent thoughts of removing said items appear to generate a level of distress (i.e. where to put them, whether they are needed). He avoids such problems by setting them aside. He says he is happy to work with you as he has been reading lots about talking therapies and is particularly interested in the works of Freud. He does not believe hoarding to be the same as obsessive compulsive disorder (OCD).

Explain to the social worker how you should manage this gentleman.

SINGLE STATIONS

5.

You are asked to see a 19-year-old African man who, one month ago, witnessed the death of someone sitting next to him on a train. He has since complained of fears of going mad and poor sleep.

Assess him and manage the situation.

6.

A 34-year-old African female presents with a degree of confusion, variable agitation, distress and perplexity. It is difficult to get a clear history of her symptoms from the notes as they seemed to vary from day to day. She currently believes that she has water and electricity moving through her veins. She was admitted under the team 6 months previously. At the time, she had a full psychotic work-up. Organic causes were excluded. Her husband discharged her home after a failed trial of three different antipsychotics. She is currently on quetiapine. It seems from her history that she then lost contact with her community mental health team (CMHT). The GP has sent a letter requesting an urgent assessment. Her husband reports that she has not been well since her discharge and he can now no longer cope.

Your consultant is on the phone. He has heard the history and wishes to know what you would do next with this lady. He is thinking about starting clozapine.

7.

You are asked to see 60-year-old female twins who believe they are being visited by aliens from Jupiter. The GP mentions in his referral that they believe the aliens are controlling them in some way. The twins have only recently starting living together.

How would you proceed in the short and long term? Explain your management to the examiner.

STATION 1

1a: Bipolar disorder

KEY POINTS

History of presenting complaint

ICD-10 categories of depression, bipolar and mood disorder

Exploration of differentials

Exploration of risks

Avoiding the use of jargon

Empathy and sensitivity

INTRODUCE YOURSELF

The candidate may wish to start the station by explaining who they are and why the GP has referred them.

SET THE SCENE

This station is of a patient with bouts of depression alternating with bouts of hypomania i.e. rapid cycling. The antidepressant is not helping matters and may be contributing to her instability. She previously also discontinued lithium (prescribed by your predecessor for treatment-resistant depression). The GP and then your colleague have tried several antidepressants, none of which really seems to have improved her mood symptoms.

On history today, the patient appears euthymic but on closer questioning will slowly reveal that she is overactive, restless and irritable. She also has problems sleeping.

Questions to start should be open ended but then gradually focus on depressive (and other affective) symptoms with some degree of structure.

‘I understand you’ve been referred to me by your GP because of mood problems? Is that correct? Can you tell me a little more about this?’

COMPLETING THE TASKS

The candidate will gain marks first for demonstrating the core features of depression (low mood, anergia, anhedonia) along with additional symptoms that indicate the level of severity (ICD-10 DCR). The candidate should then ask about elevation of mood in the form of euphoria, irritability and overactivity. There should be a question as to the possibility of psychotic features as well as actively asking about suicidal ideation.

It is important to explore medication history and medical history, and briefly look for the presence of comorbidities; in particular, anxiety disorders and alcohol.

PROBLEM SOLVING

The main point of this station is that the candidate is presented with a highly atypical presentation. This is always an indication to review the diagnosis.

There is a lot to do in a short space of time. The candidate may need to make provision for this at the beginning of the interview by informing the patient that they may have to hurry them along at times due to time constraints but that they should feel free to ask any questions as they go along.

ADDITIONAL POINTS

The candidate may gain marks for delineating a clear history with an exploration of potential triggers. Additionally an exploration for the shifts in mood should be explored. They should ask about physical health, including thyroid disease, antidepressant-induced switching, suboptimal medication regimes, the effects of lithium withdrawal, and erratic compliance.

Note that at this stage it is difficult to say definitively what is wrong so this section should be approached with caution. The candidate may indicate that it would be useful to obtain information from a close relative.

FURTHER READING

National Institute for Health and Clinical Excellence (2006) Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. NICE clinical guideline 38. London: NICE.

World Health Organization (2003) The ICD 10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization.

1b: Bipolar management

KEY POINTS

Clear delineation of the issues

Clear outline of potential risks; namely relapse if poor compliance, risk of self-harm whilst hypomanic or depress...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• Contributors
• Foreword
• Preface
• Acknowledgements
• Exam guidance
• 1: General adult psychiatry David Okai
• 2: Old age psychiatry Justin Sauer
• 3: Neuropsychiatry Derek Tracy
• 4: Child and adolescent psychiatry Armin Raznahan and Dennis Ougrin
• 5: Learning disability psychiatry Justin Sauer
• 6: Liaison psychiatry Jayati Das-Munshi
• 7: Forensic psychiatry Marc Lyall
• 8: Psychotherapy Dinesh Sinha
• 9: Personality Justin Sauer
• 10: Perinatal psychiatry Justin Sauer
• 11: Addictions Virupakshi Jalihal 212
• 12: Anxiety Justin Sauer
• 13: Eating disorders Justin Sauer
• 14: Physical examination Sangita Agarwal
• 15: Investigations and procedures Russell Foster
• 16: Miscellaneous Justin Sauer
• Index