Mock Writtens Examination (RANZCP, 2012) PDF

THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS MOCK WRITTENS EXAMINATION (from the Auckland New Zealand program) 2012 PAPER I Model Answers Note that these Mock Writtens papers are produced by local psychiatrists with no connection to the Examination Committee and are not vetted, tes...

THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS MOCK WRITTENS EXAMINATION (from the Auckland New Zealand program) 2012 PAPER I Model Answers Note that these Mock Writtens papers are produced by local psychiatrists with no connection to the Examination Committee and are not vetted, test driven and perfected by committee in the way that the real papers are. The main point is not to get fixated about whether the question writers were “right” and you were “wrong” in the model answers, but to practice the marathon of doing 2 full 3-hour papers and practising the technique of the various question types. If you disagree with the factual detail of an answer, research the issue and decide for yourself. 1 Critical Essay Question (40 marks) In essay form, critically discuss this statement from different points of view and provide your conclusion. "…when anyone uses the phrase 'mentally ill' about others, including me and other psychiatric survivors, the implication is that since an 'illness' is the problem then a doctor ought to be part of the solution. 'Mental illness' also says since the problem is like a materialistic physical illness, then perhaps the solution ought to be physical too, such as a chemical or drug or electricity." - David Oaks, Director, MindFreedom International (2011) Reminder about marking process: There are 5 dimensions. Each dimension scores up to 8 marks. A total of 40 marks is possible. Marking Guide: Dimension 1. Capacity to produce a logical argument (critical reasoning) There is no 0 Comments: A logical structure needs to be demonstrated, rather than the writer evidence of logical seeming to have launched into the topic with no forethought, in a random or argument or critical impulsive manner. Look for: reasoning. Reasonable opening statement clarifying the quote (ideally not just parroting it) Should be a brief definition of “depressive disorder” Points are random 1-2 A mid-section to essay with discussion addressing: or unconnected or − Arguments/examples/references against the quote (i.e. arguing that listed or Assertions Psychiatry does distinguish appropriately between ‘normal sadness’ and are unsupported or Depression) false or There is no − Arguments/examples/references in support of the quote (i.e. arguing that conclusion Psychiatry does not distinguish appropriately between ‘normal sadness’ and Depression) Points in essay 3-4 Closing statement summarising, and providing the writer’s overall “conclusions” follow logically but Ideally we want relevant examples and (ideally) references, and a good overall there is only a weak coherence and flow in the arguments and discussion. attempt at supporting the Examples of points that may be included: assertions made by 5-6 discussion about “illness” as a sociological and historical concept – as Mr Oaks correct and relevant automatically links the concept of “illness” with doctors and physical treatments. knowledge. This can be explored from both sides – agreeing with this assumption but also challenging it, e.g. re not all illnesses implying physical interventions. The points in this Examination of the concept “mental illness” and what that means to us – is it the essay follow same as “mental disorder” and how do we define that? Mention needs to be made logically to of major diagnostic systems such as DSM and ICD. Could also mention legal demonstrate the definitions as in Mental Health Act law. Ideally, candidates should not the argument; and difference between formal diagnostic categories and the wider concept of “mental assertions are illness” which may encompass any significant psychological problem causing supported by people to require mental health service intervention (e.g. personality disorders). correct and relevant The above can be argued from both sides. knowledge. Discussion of the broadening out holistically of treatment options, such that medical The candidate 7-8 treatment by a doctor is not the be-all and end-all, nor always implied, as Mr Oaks demonstrates a states. Mental health services may not offer physical/medical treatment to all highly sophisticated patients – e.g. may offer psychotherapy. Recovery model and active rehab may level of reasoning usefully be mentioned here. On the other side of the argument, need to state that and logical some mental disorders do require medical/doctor treatment and prescribing as a argument. core part of Rx, for best practice effective care (e.g. schizophrenia, severe (and extra points for depression, mania and bipolar disorder, etc.) good references) For all the above, ideally need examples at least, ideally some references (RANZCP and other College’s CPGs for instance, re the last point). 2 Dimension 2. Flexibility The candidate restricts essay to an extremely narrow and very rigid line of argument. 0 Comments: The candidate considers only one point of view. 1-2 The candidate considers more than one point of view, but the strengths and weaknesses of the views are poorly evaluated. 3-4 The candidate considers more than one point of view and the strengths and weaknesses of each view are well evaluated. 5-6 The candidate demonstrates highly sophisticated ability to set out and evaluate >1 point of view 7-8 Dimension 3. Ability to Communicate The spelling, grammar or 0 vocabulary renders the essay extremely difficult to understand; or totally unintelligible. The spelling, grammar or vocabulary significantly impedes communication. 1-2 The spelling, grammar and vocabulary are acceptable but the candidate demonstrates limited capacity for written expression. 3-4 The spelling, grammar and vocabulary are acceptable and the candidate demonstrates good capacity for written expression. 5-6 The candidate displays a highly sophisticated level of written expression. 7-8 As over, need to argue both for and against the quote for marks on this domain. If the candidate only disagrees with the quote they can only score 1-2 marks here. (or vice versa). NB: Also mark down if writing’s illegible or if there are multiple deletions and insertions 3 Dimension 4. Humanity/Experience/Maturity/Judgment The candidate demonstrates an absence 0 of any capacity for judgment; or Comments: judgments are grossly unethical. This requires a balanced and professional discussion, Judgments are naïve; or superficial; or 1-2 with mention about stigma and bias due to concepts extremely poorly thought through; or around “mental illness” and society’s perception of this, unethical. but no evidence that the candidate shares such stigma or bias. The candidate demonstrates some 3-4 reasoned judgment, maturity of thinking, Discussion about the “psychiatric survivors” clinical experience and displays some terminology and the history of this concept (e.g. awareness of the ethical issues raised by patients trying to establish their rights in what some the quote. may see as an oppressive and patriarchal “medical” system) may be included, with care that the writer is The candidate shows good capacity for 5-6 not dismissive or biased regarding this terminology. reasoned judgment, mature thinking, clinical experience, awareness of ethical issues raised by the quote. 7-8 The candidate demonstrates a highly sophisticated level of judgment, maturity, experience or ethical awareness. Dimension 5. Breadth - ability to set psychiatry in a broader context. Candidate shows no awareness of the broader 0 scientific, social, cultural or historical context. Comments: There is a very limited understanding of the scientific, social, cultural or historical context of psychiatry or mental illness. 1-2 The candidate demonstrates an ability to understand psychiatry or mental illness in only one of the following contexts: broader scientific, socio-cultural, historical context. The candidate demonstrates an ability to understand psychiatry or mental illness in two or more of the following contexts: broader scientific, socio-cultural, historical context. 3-4 Highly sophisticated scope, demonstrating a superior understanding of the broader context of psychiatry or mental illness. 7-8 Obvious “breadth” areas that may be covered are: 5-6 History – the way that mental health care has fluctuated towards and away from the medical/biological since the early asylums. Different cultural concepts ought to be addressed, ideally – i.e. the greater emphasis on holistic issues in other cultures. Examples are the inclusion of the Land in indigenous populations here for true mental health, the need to include spiritual factors, etc. Can also set discussion in the context of the wider medical field – in that mental health services tend if anything to be less medically/biologically oriented and more holistic than the rest of medicine. Mention the biopsycho-sociocultural model. 4 Reminder of actual CEQ Dimensional Scoring: 5 MODIFIED ESSAY QUESTION 1 Modified Essay Question 1: (18 marks) Sam is a 54 year old Vietnamese shopkeeper who is on day seven post- operatively after surgery for bladder cancer. You work on a Consultation-Liaison (C-L) team and are called to assess him, as staff on the ward are concerned that he has become "psychotic" and that he is becoming agitated, especially at night. He has been admitted for ten days at the point of referral. He speaks some English and no interpreter is immediately available so you initially see him without one. In your assessment, you find his attention to be variable and he is disoriented in time and intermittently in place and person. At times he speaks to you in Vietnamese, and he gives a disjointed account of recent events. There are no abnormal perceptions but he appears to have persecutory beliefs that the staff are trying to kill him so as to steal his money. He tells you that they are withholding food from him so as to starve him, but that he would not eat it anyway as it is poisoned. The staff deny withholding food other than pre-operatively, but say that he will only eat from sealed food and drink containers brought in by his wife. Question 1.1 (2 marks ) State the most appropriate cognitive test that you could use specifically to assess Sam's attention. Explain why it is the most appropriate of the attentional tests. A. Serial Sevens. Better than WORLD or word generation as English is not his 1st language – numeric tests are better. Also accept reverse counting and digit span. Up to a maximum of 2 marks in total worth mark (circle) max. 2 0 1 2 TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than x. Final Mark is to be set at not more than x. (i.e. if they score more, final mark is still x) 6 Modified Essay Question 1 contd. Sam is a 54 year old Vietnamese man who is on day seven post- operatively after surgery for prostate cancer. You work on a Consultation-Liaison (C-L) team and are called to assess him, as staff on the ward are concerned that he has become "psychotic" and that he is becoming agitated, especially at night. He has been admitted for ten days at the point of referral. In your assessment, you find his attention to be variable and he is disoriented in time and intermittently in place and person. He gives a disjointed account of recent events. There are no abnormal perceptions but he appears to have persecutory beliefs that the staff are trying to kill him so as to steal his money. He tells you that they are withholding food from him so as to starve him, but that he would not eat it anyway as it is poisoned. The staff deny withholding food other than preoperatively, but say that he will only eat from food and drink containers brought in by his wife. The staff deny withholding food other than pre-operatively, but say that he will only eat from sealed food and drink containers brought in by his wife. Question 1.2 (6 marks ) Which aspects of history would it be most urgent to clarify from the medical file and from Sam's wife? State why each is important. worth mark (circle) A. Substance use history, especially alcohol use. To assess him regarding alcohol withdrawal delirium (although this is less likely after 10 days). max. 2 0 1 2 B. Evidence of any medical condition likely to be causing a delirium, such as an infection, e.g. cystitis. Need to identify the cause so as to treat the delirium. max. 2 0 1 2 C. Psychiatric history to ensure that he does not have a pre-existing psychotic illness. max. 2 0 1 2 D. Personal History – to clarify if issues in his past, his culture or his personality are making him uncomfortable and suspicious in a hospital setting. max. 2 0 1 2 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 7 Modified Essay Question 1 contd. You attempt to assess Sam further the following day, with an interpreter. You start by reminding Sam who you are and about your role, but before you have finished explaining the interpreter's role, Sam becomes agitated and refuses to allow the interpreter to stay. The interpreter denies ever having met or heard of Sam before. Question 1.3 (4 marks ) Outline why Sam might have reacted badly on seeing the interpreter. worth mark (circle) A. Shame/cultural issues: Sam may not want someone from his culture to know that he is having a psychiatric assessment. max. 2 0 1 2 B. Delirium: Sam may well still be delirious and thus have persecutory delusions or misinterpretations about the interpreter. max. 2 0 1 2 C. Other cause of psychosis: Persecutory delusions about the interpreter might be due to an underlying psychotic disorder, rather than delirium. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) 8 Modified Essay Question 1 contd. Sam's wife brings in his 24 year old daughter to interpret the following day, as Sam will not allow an official interpreter to be present. His daughter has excellent English, having gone to school locally. Question 1.4 (6 marks ) Discuss what problems you might need to be aware of, in using Sam's daughter as the interpreter. worth mark (circle) A. Inhibition: Sam might withhold or distort aspects of his history with a family member interpreting. e.g. downplay his symptoms or drinking history. max. 2 0 1 2 B. Distortion: Sam's daughter may have her own views which could influence the translation. She might also be ashamed if Sam mentioned psychotic symptoms, and attempt to downplay or deny these. max. 2 0 1 2 C. Inexperience and accuracy: Sam's daughter may not interpret accurately, never having received any training and being unaware of medical terminology and cognitive tests like the MMSE. max. 2 0 1 2 D. Need to train the interpreter: Need to educate Sam's daughter beforehand as to your relative seating positions, and to ensure that she allowed you to address Sam directly, while she interpreted, rather than all conversation going through the interpreter. max. 2 0 1 2 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 9 MODIFIED ESSAY QUESTION 2 Modified Essay Question 2: (18 marks) Maisie Harris is an 76 year old widow who one year ago moved to live in Rosehill Gardens, a large retirement complex. The complex advertises itself as offering "a comfortable retirement" and includes gardens and some recreational facilities such as an indoor bowls club, but no rest home or private hospital care. Residents own their own apartments or units. Mrs Harris has been referred to your Old Age Psychiatry service by her General Practitioner (GP) who has received complaints from the management of Rosehill Gardens. The GP's letter states that Mrs Harris' neighbours complain that the small garden outside her unit is full of weeds and not maintained to the standard required by the complex, and that Mrs Harris has in the last few weeks begun shouting abuse at her neighbours if they complain. She is reported to have said to the man next door "I'll knock your block off" when he told her he was going to inform the complex's management. The GP says that Mrs Harris refused to come to his clinic and would not let him in the door when he attempted a home visit, but shouted through the door that he should "bugger off". The GP requests a psychiatric assessment. You and a nurse from your team also attempt a home visit. Mrs Harris refuses to let you in or to answer any questions, just shouting "bugger off" as she did with the GP. Question 2.1 (4 marks ) Outline the ethical and medico-legal issues involved in obtaining additional information about Mrs Harris to assist in your assessment. worth mark (circle) max. 2 0 1 2 A. Confidentiality: Ideally Mrs Harris should give permission for you to obtain information about her from other collateral sources. Ethical principle is respect for her autonomy. The Privacy Act may be mentioned. B. Risk Assessment: The need to obtain information so as to ascertain her risk to herself and to others must be balanced against the need to maintain her privacy/ autonomy. Risk to self or others would need to be serious to justify breaching confidentiality. max. 2 0 1 2 C. Mental Health Act: Mental Health Act assessment may be required if she continues to refuse voluntary assessment. This would increase your legal ability to override her autonomy and obtain information without her permission. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) 10 Modified Essay Question 2 contd. Mrs Maisie Harris is an 76 year old widow who one year ago moved to live in Rosehill Gardens, a large retirement complex. The complex advertises itself as offering "a comfortable retirement" and includes gardens and some recreational facilities such as an indoor bowls club, but no rest home or private hospital care. Residents own their own apartments or units. Mrs Harris has been referred to your Old Age Psychiatry service by her General Practitioner (GP) who has received complaints from the management of Rosehill Gardens. The GP's letter states that Mrs Harris' neighbours complain that the small garden outside her unit is full of weeds and not maintained to the standard required by the complex, and that Mrs Harris has in the last few weeks begun shouting abuse at her neighbours if they complain. She is reported to have said to the man next door "I'll knock your block off" when he told her he was going to inform the complex's management. The GP says that Mrs Harris refused to come to his rooms and would not let him in the door when he attempted a home visit, but shouted through the door that he should "bugger off". The GP requests a psychiatric assessment. You and a nurse from your team also attempt a home visit. Mrs Harris refuses to let you in or to answer any questions, just shouting "bugger off" as she did with the GP. Question 2.2 (4 marks ) What other sources of information might be useful before attempting to visit Mrs Harris at her unit? State why each might be useful. worth mark (circle) A. Family: get next of kin details from the GP and attempt to contact her family, even if they do not live locally. For past & family history and whether any change in her functioning in recent months. max. 2 0 1 2 B. Rosehill Gardens management/neighbours: Care is needed to maintain her privacy as far as possible, but additional information is likely to be needed from the complex management and her neighbours, to determine details of the concerns about her behaviour and to assess the risk to her neighbours. max. 2 0 1 2 C. Psychiatric Records: To ensure that she is not already known to the services and obtain past history if she is. max. 2 0 1 2 D. Medical Records: Obtain as much medical history information from the GP as possible. Access medical records if these exist. Behavioural change might be due to a medical condition. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) 11 Modified Essay Question 2 contd. Mrs Maisie Harris is an 76 year old widow who one year ago moved to live in Rosehill Gardens, a large retirement complex. The complex advertises itself as offering "a comfortable retirement" and includes gardens and some recreational facilities such as an indoor bowls club, but no rest home or private hospital care. Residents own their own apartments or units. Mrs Harris has been referred to your Old Age Psychiatry service by her General Practitioner (GP) who has received complaints from the management of Rosehill Gardens. The GP's letter states that Mrs Harris' neighbours complain that the small garden outside her unit is full of weeds and not maintained to the standard required by the complex, and that Mrs Harris has in the last few weeks begun shouting abuse at her neighbours if they complain. She is reported to have said to the man next door "I'll knock your block off" when he told her he was going to inform the complex's management. The GP says that Mrs Harris refused to come to his rooms and would not let him in the door when he attempted a home visit, but shouted through the door that he should "bugger off". The GP requests a psychiatric assessment. You and a nurse from your team also attempt a home visit. Mrs Harris refuses to let you in or to answer any questions, just shouting "bugger off" as she did with the GP. Mrs Harris is finally admitted to a psychiatric ward for patients over age 65, for assessment under the Mental Health Act. Her diagnosis remains unclear and although somewhat irritable she is not particularly behaviourally disturbed. No medication is prescribed initially, during the assessment period. Substance abuse has been ruled out as a differential. general ax Question 2.3 (8 marks ) Outline what you would ask the nursing staff to observe and document regarding Mrs Harris, to assist with the assessment. worth mark (circle) max. 2 0 1 2 A. Evidence of mood disorder: Sleep pattern, eating, energy, diurnal variation of mood, elevated, irritable or depressed mood. B. Evidence of psychosis: Any signs of psychosis such as delusions, response to unseen stimuli, response to auditory hallucinations, thought disorder. max. 2 0 1 2 C. Evidence of cognitive impairment or fluctuating level of consciousness: Any signs of memory impairment, disorientation in time, place or person, "sundowning" or other worsening later in the day, dyspraxia, disinhibition, etc. max. 2 0 1 2 D. Evidence of risk to herself or others: Evidence of suicidal ideation or intent. Any aggression or expressed intent to harm others. Destructive behaviour. max. 2 0 1 2 E. Her capacity for self-care: Her ability to care for herself – activities of daily living, general functioning. Any evidence of impaired self-care as seen in her grooming, cleanliness, eating. max. 2 0 1 2 F. Her strengths and socialisation: Her interests, abilities, relationships with staff and others on the ward, ability to join in with ward activities. max. 2 0 1 2 Up to a maximum of 8 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 8. Final Mark is to be set at not more than 8. (i.e. if they score more, final mark is still 8) 12 Modified Essay Question 2 contd. Mrs Maisie Harris is a 76 year old widow who one year ago moved to live in Rosehill Gardens, a large retirement complex. The complex advertises itself as offering "a comfortable retirement" and includes gardens and some recreational facilities such as an indoor bowls club, but no rest home or private hospital care. Residents own their own apartments or units. Mrs Harris has been referred to your Old Age Psychiatry service by her General Practitioner (GP) who has received complaints from the management of Rosehill Gardens. The GP's letter states that Mrs Harris' neighbours complain that the small garden outside her unit is full of weeds and not maintained to the standard required by the complex, and that Mrs Harris has in the last few weeks begun shouting abuse at her neighbours if they complain. She is reported to have said to the man next door "I'll knock your block off" when he told her he was going to inform the complex's management. The GP says that Mrs Harris refused to come to his rooms and would not let him in the door when he attempted a home visit, but shouted through the door that he should "bugger off". The GP requests a psychiatric assessment. You and a nurse from your team also attempt a home visit. Mrs Harris refuses to let you in or to answer any questions, just shouting "bugger off" as she did with the GP. Mrs Harris is finally admitted to a psychiatric ward for patients over age 65, for assessment under the Mental Health Act. Her diagnosis remains unclear and although somewhat irritable she is not particularly behaviourally disturbed. No medication is prescribed initially, during the assessment period. Substance abuse has been ruled out as a differential. Mrs Harris is not thought to have psychosis, a major mood disorder or to be delirious. You persuade her to let you carry out cognitive testing. She says that she used to do her own shopping each week. When asked to name as many items in the supermarket as possible in one minute she manages 15 items. core skills Question 2.4 (2 marks ) Interpret this result, with reference to the likely brain area involved in the task. A. Below normal verbal fluency. Indicates frontal lobe impairment. Up to a maximum of 2 marks in total worth mark (circle) max. 2 0 1 2 TOTAL: Note to Examiners: Accept other synonymous/similar terms (category fluency, word generation, etc.) Both the brain area involved and an accurate description of the test deficit are required for all 2 marks to be awarded. 13 MODIFIED ESSAY QUESTION 3 Modified Essay Question 3: (26 marks) Margaret is a 39 year old woman who works as a librarian. She lives with her husband David, a manager who spends considerable time travelling for his work. She is on no medication and was referred to the Community Mental Health Centre where you work after a self-harm attempt three months ago in which she took a small number of paracetamol tablets and then self-presented to the local Emergency Department. Her diagnosis at that time was of an adjustment disorder with anxious mood. You have been providing a course of cognitive behavioural therapy (CBT) to her across ten planned sessions. The identified problem was anxiety in social situations leading to some social avoidance. In the tenth session, Margaret requests a course of psychodynamic psychotherapy which she says she has been reading about on the internet. Question 3.1 (6 marks ) Outline possible reasons why Margaret may have made this request. therapy worth mark (circle) max. 2 0 1 2 A. She may have longstanding psychological issues likely to respond to psychodynamic psychotherapy B. She may not have had much benefit from the CBT which has been tried, so may want to try a different approach max. 2 0 1 2 C. She may not want to terminate therapy – e.g. due to positive transference or dependency which may be manifested as increased anxiety symptoms or described as loneliness. Also accept answers stating that she may have dependant traits or abandonment issues. max. 2 0 1 2 D. She may have been influenced by a persuasive article on-line (also accept that she may be a person who is easily influenced by others). max. 2 0 1 2 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 14 Modified Essay Question 3 contd. Margaret is a 39 year old woman who works as a librarian. She lives with her husband David, a manager who spends considerable time travelling for his work. She is on no medication and was referred to the Community Mental Health Centre where you work after a self-harm attempt three months ago in which she took a small number of paracetamol tablets and then self-presented to the local Emergency Department. Her diagnosis at that time was of an adjustment disorder with anxious mood. You have been providing a course of cognitive behavioural therapy (CBT) to her across ten planned sessions. The identified problem was anxiety in social situations leading to some social avoidance. In the tenth session, Margaret requests a course of psychodynamic psychotherapy which she says she has been reading about on the internet. Question 3.2 (10 marks ) Outline what you would need to determine in assessing Margaret for psychodynamic psychotherapy, to decide if this would be a suitable option for her. worth mark (circle) A. Her motivation, desire to change, capacity to attend appointments. max. 2 0 1 2 B. Her ability to establish a therapeutic alliance (ability to trust, underlying attachment issues, likelihood of significant resistance, etc.) max. 2 0 1 2 C. Her psychological mindedness and capacity to reflect. max. 2 0 1 2 D. Her response to stress – would need reasonable frustration tolerance, ability to tolerate delayed gratification. max. 2 0 1 2 E. That she does not have significant comorbid problems such as substance abuse, cognitive impairment, psychosis, mania etc. max. 2 0 1 2 F. That she has sufficiently mature defence and coping mechanisms - ideally she should not have primitive defences or borderline psychopathology with deliberate self harm and acting out. max. 2 0 1 2 G. That her problems are longstanding and not caused by a recent stressor. max. 2 0 1 Up to a maximum of 10 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 10. Final Mark is to be set at not more than 10. (i.e. if they score more, final mark is still 10) 15 Modified Essay Question 3 contd. Margaret is a 39 year old woman who works as a librarian. She lives with her husband David, a manager who spends considerable time travelling for his work. She is on no medication and was referred to the Community Mental Health Centre where you work after a self-harm attempt three months ago in which she took a small number of paracetamol tablets and then self-presented to the local Emergency Department. Her diagnosis at that time was of an adjustment disorder with anxious mood. You have been providing a course of cognitive behavioural therapy (CBT) to her across ten planned sessions. The identified problem was anxiety in social situations leading to some social avoidance. In the tenth session, Margaret requests a course of psychodynamic psychotherapy which she says she has been reading about on the internet. You commence psychodynamic psychotherapy with Margaret. After the initial few sessions, you notice that she frequently talks of feeling unsatisfied with her life. She and her husband elected not to have children due to her husband's career focus and Margaret's tendency to anxiety. Margaret says that she envies her work colleagues who often talk about their children and grandchildren, and she feels that this opportunity has passed her by. Question 3.3 (2 marks ) Which Eriksonian psychosocial developmental stage might Margaret be having difficulty traversing? A. Generativity versus stagnation Up to a maximum of 2 marks in total worth mark (circle) max. 2 0 1 2 TOTAL: Note to Examiners: Both terms must be given for 2 marks to be awarded 16 Modified Essay Question 3 contd. Margaret is a 39 year old woman who works as a librarian. She lives with her husband David, a manager who spends considerable time travelling for his work. She is on no medication and was referred to the Community Mental Health Centre where you work after a self-harm attempt three months ago in which she took a small number of paracetamol tablets and then self-presented to the local Emergency Department. Her diagnosis at that time was of an adjustment disorder with anxious mood. You have been providing a course of cognitive behavioural therapy (CBT) to her across ten planned sessions. The identified problem was anxiety in social situations leading to some social avoidance. In the tenth session, Margaret requests a course of psychodynamic psychotherapy which she says she has been reading about on the internet. You commence psychodynamic psychotherapy with Margaret. After the initial few sessions, you notice that she frequently talks of feeling unsatisfied with her life. She and her husband elected not to have children due to her husband's career focus and Margaret's tendency to anxiety. Margaret says that she envies her work colleagues who often talk about their children and grandchildren, and she feels that this opportunity has passed her by. Margaret has completed 19 sessions of psychodynamic psychotherapy. She has begun to talk about having married her husband David because she knew he would not challenge her and would let her avoid situations that made her anxious. In the last session she talked animatedly about how she had realised that her marriage was "a comfortable trap" and that David never encouraged her to change or develop and had expressed doubts about her having psychotherapy, feeling that it was not "good for" her. Margaret believes that this is because she has been confronting him more. She commences today's session by announcing that she has decided to end the marriage and to separate from David. Her husband is away on a business trip but Margaret intends to tell him this when he returns home in three days. Question 3.4 (8 marks ) Discuss how you would manage this situation. worth mark (circle) A. Review Margaret's mental state to ensure that she is not suffering from any condition that might impair her judgement such as a mood disorder, psychosis or a substance use problem. max. 2 0 1 2 B. Hopefully it was explained to Margaret prior to therapy that major life-change decisions are better avoided during therapy, especially the early stages. Remind Margaret of this and explain why. max. 2 0 1 2 C. Ask Margaret not to talk to her husband or make this decision until you have had a chance to address her feelings and motivations further in therapy. max. 2 0 1 2 D. Organise urgent supervision to discuss this development. max. 2 0 1 2 E. Help Margaret explore the issues behind her feelings and her decision to separate, and to gain insight into these – e.g. into any transference reactions or defences involved such as displacement, projection, splitting, etc. max. 2 0 1 2 F. If she remained adamant about her decision and was competent to decide, try to see her together with her husband for a session or sessions, to help them communicate about the marriage and come to a joint decision. This might be best done with a more experienced co-therapist, if the therapist is a novice. max. 2 0 1 2 Up to a maximum of 8 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 8. Final Mark is to be set at not more than 8. (i.e. if they score more, final mark is still 8) 17 MODIFIED ESSAY QUESTION 4 Modified Essay Question 4: (13 marks) Peter is a 10 year old Caucasian boy who is doing poorly at school. He is brought to the Child and Adolescent service where you work, for an assessment after referral by his General Practitioner. You see him with his mother, who has brought along his 3 year old sister as she was unable to get a babysitter. His father was at work and unable to come. Peter has another brother aged 6, currently at school. Peter's mother says that he "doesn't try" and "always has his head in the clouds" – ever since he started school at age 5. His school reports praise him for being quiet and not disruptive in class, and for working well 1:1 with teachers, but say he needs to "interact more with others", "try harder overall" and "put more effort into homework". His mother says he is well behaved at home but that she cannot supervise his homework as she has his sister and brother to look after as well. She has noticed he often "gets into a dream" or "blanks out" and doesn't always complete his homework. While his mother is relating all this, Peter sits with his head down and shoulders hunched and does not make eye contact. Question 4.1 (4 marks ) Outline the main differential diagnoses you would want to explore, and why. worth mark (circle) A. Attention deficit disorder (inattentive type) – would account for his poor school record and he does not sound to have hyperactivity. Mention of "inattentive type" must be made for the full 2 marks. max. 2 0 1 2 B. Organic disorder such as petit mal epilepsy – could affect his concentration and performance. max. 2 0 1 2 C. Major depression – could affect his concentration, motivation and selfconfidence and reduce classroom interactivity. max. 2 0 1 2 D. Anxiety disorder – could affect his concentration, motivation and selfconfidence and reduce classroom interactivity. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) 18 Modified Essay Question 4 contd. Peter is a 10 year old boy who is doing poorly at school. He is brought to the Child and Adolescent service where you work, for an assessment after referral by his General Practitioner. You see him with his mother, who has brought along his 3 year old sister as she was unable to get a babysitter. His father was at work and unable to come. Peter has another brother aged 6, currently at school. Peter's mother says that he "doesn't try" and "always has his head in the clouds" – ever since he started school at age 5. His school reports praise him for being quiet and not disruptive in class, and for working well 1:1 with teachers, but say he needs to "interact more with others", "try harder overall" and "put more effort into homework". His mother says he is well behaved at home but that she cannot supervise his homework as she has his sister and brother to look after as well. She has noticed he often "gets into a dream" or "blanks out" and doesn't always complete his homework. While his mother is relating all this, Peter sits with his head down and shoulders hunched and does not make eye contact. In the initial assessment you talked with Peter and his mother, and also assessed Peter by himself. Three weeks have passed and Peter's diagnosis has been clarified and a combination of medication and behavioural therapy planned by the team. You arrange for Peter's father to attend a follow-up session and Peter's mother has organised a babysitter for his sister. You find that you need to reassure Peter, who expresses some anxiety to you about the coming meeting as he says his father criticizes him a lot, and "doesn't listen". Peter's parents bring him to your clinic for the meeting. Question 4.2 (4 marks ) Describe what you would discuss with Peter and his parents about the process, content and goals of the session and describe what strategies you would use to engage Peter and his family. worth mark (circle) 0 1 A. Tell his parents that you will see them separately as well as with Peter present. max. 1 B. Outline your plan and goals for the meeting. (e.g. explaining that your goal is to find ways of helping Peter, that everyone’s opinion is valuable and that it is normal for family members to have different viewpoints. May say that you plan to gather some extra information, then to discuss what Peter's diagnosis ia likely to be, and possible interventions.) max. 2 0 1 2 C. Ask everyone (his mother, his father, and Peter) whether they also have specific goals or questions to be addressed at the meeting. max. 1 0 1 D. Engagement Strategies – environment for meeting: Make sure room is set up to be welcoming for a child and parents – suitable pictures on walls, comfortable seats, privacy, toys if appropriate. max. 2 0 1 E. Engagement Strategies – interactions with family: Aim to make the session a helpful and positive experience – e.g. facilitate it well and provide useful information and support. Thank parents, especially father, for attendance. Praise their concern and emphasise the positive nature of their attending together to help their son. Explain about confidentiality and that they can choose whether to answer questions. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) 19 Modified Essay Question 4 contd. Peter is a 10 year old boy who is doing poorly at school. He is brought to the Child and Adolescent service where you work, for an assessment after referral by his General Practitioner. You see him with his mother, who has brought along his 3 year old sister as she was unable to get a babysitter. His father was at work and unable to come. Peter has another brother aged 6, currently at school. Peter's mother says that he "doesn't try" and "always has his head in the clouds" – ever since he started school at age 5. His school reports praise him for being quiet and not disruptive in class, and for working well 1:1 with teachers, but say he needs to "interact more with others", "try harder overall" and "put more effort into homework". His mother says he is well behaved at home but that she cannot supervise his homework as she has his sister and brother to look after as well. She has noticed he often "gets into a dream" or "blanks out" and doesn't always complete his homework. While his mother is relating all this, Peter sits with his head down and shoulders hunched and does not make eye contact. In the initial assessment you talked with Peter and his mother, and also assessed Peter by himself. Three weeks have passed and Peter's diagnosis has been clarified and a combination of medication and behavioural therapy planned by the team. You arrange for Peter's father to attend a follow-up session and Peter's mother has organised a babysitter for his sister. You find that you need to reassure Peter, who expresses some anxiety to you about the coming meeting as he says his father criticizes him a lot, and "doesn't listen". A diagnosis of Attention Deficit disorder has been made. Question 4.3 (2 marks ) Outline the main additional information about the family's functioning that you would want to elicit during this session, so as to assist with Peter's management. worth mark (circle) A. How the family members relate to one another, and how affect is expressed and managed, including Peter's siblings. max. 1 0 1 B. How decisions are made, and who generally manages Peter. max. 1 0 1 C. The nature of the marital relationship, and whether any stresses in this affect Peter. max. 1 0 1 Up to a maximum of 2 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 2. Final Mark is to be set at not more than 2. (i.e. if they score more, final mark is still 2) 20 Modified Essay Question 4 contd. Peter is a 10 year old boy who is doing poorly at school. He is brought to the Child and Adolescent service where you work, for an assessment after referral by his General Practitioner. You see him with his mother, who has brought along his 3 year old sister as she was unable to get a babysitter. His father was at work and unable to come. Peter has another brother aged 6, currently at school. Peter's mother says that he "doesn't try" and "always has his head in the clouds" – ever since he started school at age 5. His school reports praise him for being quiet and not disruptive in class, and for working well 1:1 with teachers, but say he needs to "interact more with others", "try harder overall" and "put more effort into homework". His mother says he is well behaved at home but that she cannot supervise his homework as she has his sister and brother to look after as well. She has noticed he often "gets into a dream" or "blanks out" and doesn't always complete his homework. While his mother is relating all this, Peter sits with his head down and shoulders hunched and does not make eye contact. In the initial assessment you talked with Peter and his mother, and also assessed Peter by himself. Three weeks have passed and Peter's diagnosis has been clarified and a combination of medication and behavioural therapy planned by the team. You arrange for Peter's father to attend a follow-up session and Peter's mother has organised a babysitter for his sister. You find that you need to reassure Peter, who expresses some anxiety to you about the coming meeting as he says his father criticizes him a lot, and "doesn't listen". A diagnosis of Attention Defecit disorder has been made. Question 4.4 (3 marks ) Outline the general areas that you would want to cover in providing education for Peter and his family, and how you would go about conveying this. (Do not provide details in your answer about the actual condition). worth mark (circle) A. Use language and terms appropriate to Peter as well as his parents in the joint sesssion, and adapt that as needed in the session just with his parents. max. 1 0 1 B. Information about the process of diagnosis and the diagnosis itself, with discussion of differentials as appropriate. max. 1 0 1 C. Information about treatment options. max. 1 0 1 D. Information about Peter's prognosis. max. 1 0 1 E. In the session just with his parents, behavioural strategies likely to assist could be outlined. max. 1 0 1 Up to a maximum of 3 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 3. Final Mark is to be set at not more than 3. (i.e. if they score more, final mark is still 3) 21 MODIFIED ESSAY QUESTION 5 Modified Essay Question 5: (14 marks) You work on an acute adult admission ward. On your arrival one morning, the Nursing Coordinator tells you that Sally, a 24 year old female patient recovering from a manic episode, has just told her nurse that Damien, a 30 year old man diagnosed with schizophrenia, sexually assaulted her during the previous night. Damien is under your care, whereas Sally is under the care of a different catchment area team on the ward. The police have been called and are expected to arrive in an hour. Question 5.1 (6 marks ) Outline the most urgent actions you would need to take regarding Damien, on hearing this, and why you would do these things. worth mark (circle) A. Ensure safety and containment: Make sure Damien is contained on the ward – important that he and others are safe, and to avoid him going AWOL. Might mean moving him to a locked part of ward if he were on compulsory treatment, or instituting very close nursing. max. 2 0 1 2 B. Preserve evidence: If it is not too late, Damien should be prevented from showering or washing himself or otherwise removing evidence, until seen by the police. max. 2 0 1 2 C. Urgent assessment: Damien needs an urgent assessment to determine his mental state. This is both to get his account of the alleged incident, and to determine his ability to cope with a police interrogation re his degree of psychosis and possibly increased risks to self/others if he were increasingly agitated. max. 2 0 1 2 D. Manage any increased risks: If Damien were agitated and a risk to himself or others, this might need to be managed in addition to containing him. Careful use of sedative medication might be needed, bearing in mind that he would need to be interviewed by the police so heavy sedation should be avoided, and ideally medication should be avoided if he could be contained environmentally and supervised. max. 2 0 1 2 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 22 Modified Essay Question 5 contd. You work on an acute adult admission ward. On your arrival one morning, the Nursing Coordinator tells you that Sally, a 24 year old female patient recovering from a manic episode, has just told her nurse that Damien, a 30 year old man diagnosed with schizophrenia, sexually assaulted her during the previous night. Damien is under your care, whereas Sally is under the care of a different catchment area team on the ward. The police have been called and are expected to arrive in an hour. There is considerable evidence that Damien did sexually assault Sally. Damien recalls and acknowledges the sexual encounter. He has active psychotic symptoms which have not yet resolved with antipsychotic treatment. A forensic psychiatrist assesses Damien as having a "disease of the mind" and as having "distorted mens rea". Question 5.2 (4 marks ) What is "mens rea"? Explain the relevance of "distorted mens rea" in determining Damian's criminal responsibility for the sexual assault. worth mark (circle) A. Definition: Two components of any crime are actus reus (the action of committing a crime) and mens rea - their intent and judgement at the time of committing a crime. Mens rea is often translated as "guilty mind". max. 2 0 1 2 B. Relevance of "distorted mens rea" to Damien's Criminal Responsibility: Means his intent and judgement in committing the assault were distorted by his psychosis so that he cannot legally be held fully responsible. max. 2 0 1 2 C. Relevance of distorted mens rea to the possible decision in Damien's case: If Damien had distorted mens rea due to his psychosis, he would be able to use an insanity defence ("not guilty by reason of insanity"). Mention McNaughten's rules. Explanation regarding Damien having a "disease of the mind" such that he did not understand the nature or quality of his actions or did not understand they were wrong, with respect to commonly accepted standards of right and wrong. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) Note: the concept of "diminished responsibility" does not gain any marks as it relates to diminished mens rea not distorted mens rea. Also note that the answer options cover both NZ and Australia as far as possible, given that the specific wordings vary in the various jurisdictions. It is suggested that markers interpret answers according to the essential meaning of each point, rather than requiring precise wording. 23 Modified Essay Question 5 contd. You work on an acute adult admission ward. On your arrival one morning, the Nursing Coordinator tells you that Sally, a 24 year old female patient recovering from a manic episode, has just told her nurse that Damien, a 30 year old man diagnosed with schizophrenia, sexually assaulted her during the previous night. Damien is under your care, whereas Sally is under the care of a different catchment area team on the ward. The police have been called and are expected to arrive in an hour. There is considerable evidence that Damien did sexually assault Sally. Damien recalls and acknowledges the sexual encounter. He has active psychotic symptoms which have not yet resolved with antipsychotic treatment. A forensic psychiatrist assesses Damien as having a "disease of the mind" and as having "distorted mens rea". Damien is now in a forensic admission unit and you have kept in touch with the treating team. He continues to have psychotic symptoms and his forensic psychiatrist feels that Damien is not fit to stand trial. Question 5.3 (4 marks ) Outline the medico-legal issues which could result in Damien being unfit to stand trial due to his psychosis. worth mark (circle) A. This is a competency assessment on the specific issue of standing trial. Important to be clear that the assessment relates to Damien’s psychosis at the time of trial not at the time of the alleged offence. max. 2 0 1 2 B. Reference to local Criminal Justice legislation which defines the issue in a local context. Ultimately this is a legal determination assisted by expert psychiatric evidence. max. 2 0 1 2 C. Can Damien understand psycho-legal issues if these are explained: the Court, roles and responsibilities of Court officials, basic necessary technical terms. max. 2 0 1 2 D. Competency assessment: Can Damien understand the information and issues (including the seriousness of the situation), can he rationally think through and discuss the information, can he communicate his choices, can he understand the consequences of his choices. (His choices do not need to be the “best options” as long as they are arrived at competently). max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4). Also note that the answer options cover both NZ and Australia as far as possible, given that the specific wordings vary in the various jurisdictions. It is suggested that markers interpret answers according to the essential meaning of each point, rather than requiring precise wording. 24 MODIFIED ESSAY QUESTION 6 Modified Essay Question 6: (26 marks) You are working as a registrar in the consultation liaison psychiatry service of a general hospital. You are contacted by a Resident Medical Officer (RMO/PGY2/Senior House Officer) in the Emergency Department requesting an assessment for Bill, a 35-year- old man brought into hospital to investigate a possible myocardial infarction. He has been thoroughly worked up, and cardiac pathology (and respiratory pathology) has been ruled out. The Emergency Department doctor wonders whether this is a panic attack. On review, the patient gives a clear history of panic attacks, including one that evening. Question 6.1 (6 marks ) Apart from alcohol withdrawal, what is the likely differential diagnosis? worth mark (circle) A. Panic disorder max. 1 0 1 B. Other anxiety disorder max. 1 0 1 C. Affective disorder max. 1 0 1 D. Withdrawal from other substance max. 1 0 1 E. Intoxication with substance max. 1 0 1 F. Other psychiatric disorder (such as psychotic disorder) max. 1 0 1 G. Endocrine disorder (must mention at least two plausible Endocrine disorders such as Hyperthyroidism or Phaeochromocytoma) max. 2 0 1 2 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 25 Modified Essay Question 6 contd. Bill gives a vague history with regard to alcohol consumption. Collateral history is not readily available. However, the patient has had routine blood screening, and you decide to review this to assist in determining the diagnosis. Question 6.2 (2 marks ) Which result on a routine haematology test is the most likely indication of heavy alcohol consumption? A. Macrocytosis on the Full Blood Count. (Anaemia, leukopenia, and thrombocytopenia are also possible) Up to a maximum of 2 marks in total worth mark (circle) max. 2 0 1 2 TOTAL: 26 Modified Essay Question 6 contd. The blood tests seem to indicate heavy drinking is likely. You manage to get hold of the of Bill's GP who confirms not only heavy drinking but physiological dependence – the GP is also confident the patient does not use other substances, including nicotine. After discussion with the Resident Medical Officer you decide to admit Bill for a medicated detoxification. You are handed the drug chart. Question 6.3 (8 marks ) What medications would you consider charting, and why? worth mark (circle) 0 1 2 A. Oral diazepam or equivalent sedative. This medication is given primarily to reduce the risk of seizure and delirium. It also reduces unpleasant symptoms of autonomic instability, and insomnia. max. 2 B. Thiamine: reduces the risk of Korsafoff’s. Full marks only possible for parentral thiamine. Should be given before giving any glucose. max. 2 0 1 2 C. Multivitamins: to replace other vitamins which have become low through drinking max. 2 0 1 2 D. Antipsychotics: for increasing agitation or hallucinations despite adequate diazepam doses max. 2 0 1 2 E. Other medications for symptomatic relief (sleeping tablets, anti- nausea tablets, anti-diarrhoea tablets, clonidine, paracetemol, mylanta etc.) One mark for mentioning any of these, one mark for identifying them as for symptomatic treatment only. max. 2 0 1 2 F. Rectal diazepam (or suitable equivalent): PRN for seizures max. 2 0 1 2 Up to a maximum of 8 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 8. Final Mark is to be set at not more than 8. (i.e. if they score more, final mark is still 8). 27 Modified Essay Question 6 contd. You know that many of the nursing staff on the admitting ward are inexperienced when dealing with alcohol detoxifications. Question 6.4 (10 marks ) What is your approach to this situation? worth A. Clear documentation of what is required in the notes, including the use of a protocol if they exist, and clear medication charting. max. 2 mark (circle) 0 1 2 B. Regular review of patient max. 2 0 1 2 C. See if a more experienced nurse can be assigned max. 2 0 1 2 D. Discuss the issue with the medical team so as to take an agreed approach max. 2 0 1 2 E. Discuss with the charge nurse tactfully looking for practical solutions max. 2 0 1 2 F. Ongoing liaison with staff, making sure they know how to contact you max. 2 0 1 2 G. Suggest future training options and offer to be involved max. 2 0 1 2 Up to a maximum of 10 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 10. Final Mark is to be set at not more than 10. (i.e. if they score more, final mark is still 10) 28 MODIFIED ESSAY QUESTION 7 Modified Essay Question 7: (25 marks) Shayleen is a 22 year old young woman who lives with her mother, stepfather and three much younger half-siblings. Her stepfather works as a builder's labourer. She has been referred for followup to your Community Mental Health Centre with a diagnosis of post-partum psychosis. Her infant son Jake is now two weeks old. Shayleen has no prior psychiatric history and nor does anyone in her family except for her birth father who had no formal diagnosis but committed suicide when she was two years old. He is said to have been "moody" and also abused alcohol and was physically abusive to Shayleen's mother. Shayleen had a normal delivery after an unplanned and unwanted pregnancy. The child's father has left town and is not contactable. Shayleen is currently free of psychotic symptoms, having briefly been thought-disordered and with persecutory and grandiose delusions. These settled a week ago, on quetiapine 200mgs nocte. She is also taking temazepam 20mgs nocte for sleep and is not breast-feeding. Her mood is somewhat labile and irritable and her mother is having to do a lot of the feeds as Shayleen is drowsy at night and reluctant to get up if the baby wakes. During the appointment you notice that Shayleen either gives Jake to her mother or places him in his pram, and that she seems reluctant to hold him for long. Question 7.1 (9 marks ) Discuss what might be causing Shayleen's avoidance of holding her baby. worth A. B. C. Bonding: Shayleen may be having problems bonding with Jake as the pregnancy was unplanned and unwanted, and as she has been unwell since his birth. Psychiatric disorder and treatment: Shayleen is not fully recovered from her post-partum illness. The psychosis is resolved but her mood is not euthymic. This might cause her to be restless, irritable and anxious about caring for Jake. Her medication may be causing daytime sedation and impeding her coping. Post-partum physical state: Shayleen is still in a post-partum state and may be experiencing physiological changes and physical discomfort which are impeding her focusing on her child. max. 2 max. 2 max. 2 mark (circle) 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 D. Bottle-feeding: Shayleen may have mixed feelings about not breast- feeding, such as guilt and resentment, leading to reduced confidence with her child. max. 2 E. Personality factors: There may be longer-standing dysfunctional personality traits (e.g. borderline, narcissistic) impairing the bonding with Jake and her care for the baby. max. 2 F. Relationship with mother: There may be long-term dysfunction or acute relationship problems since Shayleen's psychosis. Compared to her mother, Shayleen may feel incompetent, leading to mother having to do more. max. 2 0 1 2 G. Social Situation: There may be other social factors adding to the stress on this family and hence to Shayleen. Could be financial problems, other dysfunctional relationships in the family, living in a blended family, etc. max. 2 0 1 2 Up to a maximum of 9 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 9. Final Mark is to be set at not more than 9. (i.e. if they score more, final mark is still 9) 29 Modified Essay Question 7 contd. Four weeks post-partum Shayleen and her mother have a follow-up appointment. Shayleen says she wants to cease her medication as it makes her too tired. She is still on quetiapine 200mgs nocte, but ceased the temazepam two weeks ago. There are no signs of any psychosis but her moods remain unstable, with diurnal mood change - irritability increasing later in the day. She has initial insomnia and broken sleep. Her relationship with Jake is marginally improved but she is still somewhat reluctant to hold him for long. Question 7.2 (6 marks ) Outline how you would respond to this request, giving reasons for your advice or interventions. worth mark (circle) max. 2 0 1 2 A. Engagement: acknowledge how difficult Shayleen's and her mother's situation is and encourage her to continue treatment and follow-up. Praise any positive interactions with her child when these occur. For support and engagement. B. Education: Further psychoeducation about post-partum disorders and treatment options. To help Shayleen and her mother understand her condition and the risks and benefits of the treatment options. max. 2 0 1 2 C. Change the medication: Trial a mood stabiliser instead of quetiapine. Most post-partum psychoses are mood disorders and Shayleen's moods have been unstable. She may be hypomanic or have mixed affective features. max. 2 0 1 2 D. Titrating medication: Advise Shayleen to continue quetiapine another few days while commencing the mood stabiliser, then to taper off the quetiapine rather than a sudden cessation. To avoid worsening her mental state by a sudden cessation and to allow the mood stabiliser time to work before ceasing antipsychotic. max. 2 0 1 2 E. Close follow-up: Ensure that Shayleen is seen regularly to monitor the medication changes, her mental state, and to provide her and the family with support. e.g: frequent visits by case manager, weekly medical reviews. max. 2 0 1 2 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 30 Modified Essay Question 7 contd. Despite assistance and home visits from the team social worker, the case manager and some additional parenting help from a support worker, Shayleen's relationship with Jake does not improve. She is no longer labile, but two months post-partum she appears flat and despondent. She still complains of initial insomnia and broken sleep, and is now waking early as well. The irritability has ceased but her self-care and eating have deteriorated. Shayleen's mother is tired and frustrated as Shayleen is of little help in Jake's care. Shayleen is taking 500mgs sodium valproate twice daily, and quetiapine 50mgs nocte for sleep. At the assessment, Shayleen admits that in the past few days she has begun hearing voices telling her that she is evil and a bad mother. You diagnose her as having developed a major depression. Question 7.3 (6 marks ) Outline your plan regarding Shayleen's medications. Give reasons for any changes. worth mark (circle) A. Commence a less sedating antipsychotic medication to treat the hallucinations more effectively. max. 2 0 1 2 B. Optimise her sodium valproate. Maximize the serum level provided there are no significant adverse effects. Shayleen probably has a bipolar disorder and there is a risk of a manic episode on the antidepressant, reduced by ensuring good coverage by the mood stabiliser. max. 2 0 1 2 C. An antidepressant may not be avoidable, but is somewhat risky. If other interventions don't help her depression, use an antidepressant safe in overdose such as an SSRI (reasonable first choice, no titration needed), and combine antidepressant use with optimized mood stabilizer and effective antipsychotic treatment. max. 2 0 1 2 D. Use a benzodiazepine or other hypnotic to aid sleep – especially if increasing/altering her other medications does not assist with this initially. max. 1 0 1 E. Increase the quetiapine dose to treat her psychotic symptoms and aid sleep. This is one option, but might cause too much sedation so option A as above might be preferable. max. 1 0 1 F. Monitor the effects of the medication changes closely. max. 1 0 1 Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 6. Final Mark is to be set at not more than 6. (i.e. if they score more, final mark is still 6) 31 Modified Essay Question 7 contd. Despite assistance and home visits from the team social worker, the case manager and some additional parenting help from a support worker, Shayleen's relationship with Jake does not improve. She is no longer labile, but two months post-partum she appears flat and despondent. She still complains of initial insomnia and broken sleep, and is now waking early as well. The irritability has ceased but her self-care and eating have deteriorated. Shayleen's mother is tired and frustrated as Shayleen is of little help in Jake's care. Shayleen is taking 500mgs sodium valproate twice daily, and quetiapine 50mgs nocte for sleep. At the assessment, Shayleen admits that in the past few days she has begun hearing voices telling her that she is evil and a bad mother. You diagnose her as having developed a major depression. Question 7.4 (4 marks) What are the most serious risks in this situation? Give the main causes for these risks. worth mark (circle) A. Suicide/self harm secondary to her depression and/or psychotic symptoms. max. 2 0 1 2 B. Infanticide secondary to her depression and/or psychotic symptoms. max. 2 0 1 2 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Please mark all boxes, even if the total adds up to more than 4. Final Mark is to be set at not more than 4. (i.e. if they score more, final mark is still 4) 32 THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS MOCK WRITTENS ESSAY PAPER 2020 (Produced by the New Zealand Training Programmes) Model Answers Note that these Mock Writtens papers are produced by local NZ psychiatrists rather than by the Examination Committee so they’re not vetted, test driven and perfected by committee in the way that the real papers are. The main point is not to get fixated about whether the question writers were “right” and you were “wrong” in the model answers, but to practice the marathon of doing a full 3-hour paper and mastering the technique required for the different question types. If you disagree with the factual detail of an answer, research the issue and decide for yourself. When marking, and for the MEQs in particular, it's suggested that markers also refer to the 'MEQ Instructions to Examiners' from the Essay paper page of the college website: https://www.ranzcp.org/Files/PreFellowship/2012-Fellowship-Program/ Exam-Centre/MEQInstructions-to-Examiners-1501209.aspx This is a shorter version of the Essay Paper, in line with changes made in 2019. The CEQ is worth 40 marks and is marked out of 40 (final % mark for CEQ is result/40). The MEQs in this paper are worth 126 (final % mark for the MEQs is result/126). To get the overall score, add the final % for CEQ to final % for MEQs, and divide by 2. NB: The CEQ must be passed, to pass this Mock Exam. In the real exam there's a more complex system to calculate the final marks which we can't replicate in a Mock exam. Candidates are advised to aim for well above 50% (60-65% is safer), to allow for that in the actual exam. 1 Critical Essay Question (40 marks) In essay form, critically discuss this quotation from different points of view relevant to the practice of psychiatry and provide your conclusion. "Where there is no hope, it is incumbent on us to invent it." – Albert Camus, The Stranger, 1942 Reminder about marking process: These are from the CEQ scoring domains – I’ve selected the ones most appropriate for the quote topic. 1. Communication/SPAG (Competency: Communicator) The candidate demonstrates the ability to communicate clearly The spelling, grammar or vocabulary significantly impedes communication. Proficiency level 0 The spelling, grammar and vocabulary are acceptable but the candidate demonstrates below average capacity for clear written expression. 1 The spelling, grammar and vocabulary are acceptable and the candidate demonstrates good capacity for written expression. 3 The candidate displays a highly sophisticated level of written expression. 2 This part's pretty self-evident. NB: Illegible handwriting isn't scored here, although if it's a significant problem it's likely to reduce the marks elsewhere. Illegibility won't be an issue if this paper ever switches to being done on computer, but spelling and grammatical errors will be even more evident, so being able to type accurately as well as quickly will matter a lot if that eventually happens. 4 5 2. Critical Evaluation and Grasp of the Quote (Competency: Scholar) The candidate demonstrates the ability to critically evaluate the statement/question Includes the ability to describe a valid interpretation of the statement/question. The candidate takes the statement/questions completely at face value with no attempt to explore deeper or alternative meanings. One or more interpretations are made, but may be invalid, superficial or not fully capture the meaning of the statement/question. The candidate demonstrates an understanding of the statement/question’s meaning at superficial as well as deeper or more abstract levels. One or more valid interpretations are offered that display depth and breadth of understanding around the statement/question as well as background knowledge. Proficiency level 0 1 2 3 4 5 Ideally, the first paragraph would be devoted to the trainee's understanding of the meaning of the quote, but this will also come across in the rest of the essay. Although the quote has deceptively simple wording, it would be worth giving a definition of the concept of hope. Hope refers to a positive, future orientated attitude, with the expectation of attaining personally valued goals. It is the opposite of hopelessness, a concept which trainees will want to address in the essay. Exceptional trainees may be familiar with models of hope, such as Snyder’s hope theory. This comes from the positive psychology movement and describes a cognitive and emotional model of hope that requires goals, pathways (to their achievement) and agency (or motivation) to achieve these goals. Camus asserts that in the absence of hope (hopelessness), it should be engendered. The quote doesn’t specify whether that should be done by the hopeless individual themselves or by others, but it emphasises the importance of providing hope. The word ‘invent’ suggests that hope should be made up, even if it isn’t there (or at least doesn’t seem to be from the hopeless individual’s perspective). It would be worth noting that the sense of hopelessness an individual may feel for their situation may not be shared by those around them, particularly when this is the result of mental disorder in the individual. To effect positive change, hope needs to be linked to motivation to change and to strategies to implement this (as per Snyder’s model), which could also be addressed in the essay. 2 3. Critical Reasoning/Evidence/POVs (Competency: ME, Communicator, Scholar Proficiency level Exceptional trainees may be aware that Albert Camus was a French philosopher and writer. The Stranger was published in 1942, a time of global upheaval, destruction and loss. The quote may be particularly relevant to periods of crisis and change, including the 2020 Covid-19 pandemic. This section, and (4) below, form much of the body of the essay. The quote is open to broad interpretation and there are many topics that could be addressed. These include: The candidate is able to identify and develop a number of lines of argument that are relevant to the proposition. The candidate makes reference to the research literature where this usefully informs their arguments. Includes the ability to consider counter arguments and/or argue against the proposition. - - - There is no evidence of logical argument or critical reasoning; points are random or unconnected, or simply listed. 0 There is only a weak attempt at supporting the assertions made by correct and relevant knowledge OR there is only one argument OR the arguments are not well linked. 1 The points in this essay follow logically to demonstrate the argument and are adequately developed. 3 2 4 - Hope as a mechanism for resilience or coping with stress. The presence of hope can buffer against adversity and stress, leading to a reduced risk of psychopathology and the potential for personal growth in a crisis. Where might a situation without hope arise? The absence of hope is a core phenomenon of many psychiatric disorders, including depression (especially if severe), schizophrenia, and addictions. In depression, a lack of hope features in some conceptualisations of the disorder (Beck’s depressive triad, with negative views about the future). The importance of hopelessness, such as is measured through the Beck Hopelessness Scale, in predicting suicide risk (i.e. there are strong links between a lack of hope and suicide). The ‘downward drift’ in socioeconomic status of many patients with severe mental illness into poverty, isolation, homelessness and poor physical health which predisposes to a lack of hope for the future. The centrality of clinicians (and others) in maintaining a sense of hope and modelling their own hope for a good outcome. This goes to the heart of the argument in the quote – that where people lack hope, we need to provide it. So where a patient subjectively has no hope, clinicians and others around them need to be hopeful for them (based not on lying to the person but on greater knowledge of treatment options and the illness's course) and strive to instil this (hence to ‘invent it’). The instillation of hope is a key task for treating clinicians. It's part of the therapeutic relationship, and is a non-specific positive effect in psychotherapies. This is a key argument to make. Hope is particularly important in psychotherapy of all forms, being critical in initiating any psychotherapeutic change. There are specific short term psychotherapies designed to instil or improve hope, which have been shown to have some benefits in reducing suicidality. Motivational Enhancement Therapy (based on the model of Prochaska and DiClemente) is a commonly used, manualised psychotherapy that enhances agency to achieve goals and so fits within the broad concept of instilling hope. In terms of covering different Points of View, one way is to look at different stakeholders. Providing hope features prominently in nursing literature, but is also crucial to all disciplines (including psychiatrists, psychologists, and social workers). It's particularly important in the work of peer support workers (see (7) below). You could also consider the importance of hope for families of sufferers of mental illness, and for their GPs and others, through 3 - 5 - The candidate demonstrates a sophisticated level of reasoning and logical argument, and most or all the arguments are relevant. to society at its broadest – including politicians and funding agencies. Things we're hopeless about are unlikely to get funded. Re counter-arguments to the quote, ‘inventing’ hope when it isn’t there can be dishonest and harmful if not based on something real. In medicine, lack of clarity about a terminal illness diagnosis can cause harm. Marx called religion "the opium of the masses", meaning belief in an afterlife led to the poor being oppressed by the rich. Cult leaders like Jim Jones have falsely instilled hope of salvation, causing tragedy. In psychotherapy, collusion with false hope linked to a patient's denial could be harmful. Similarly, colluding with a patient's false hope that they could safely cease crucial psychotropic medication yet stay well could be disastrous. Are there situations where there is genuinely no hope, i.e. where a clinician has no hope (either as they lose it or never had it) for a patient? The problem of 'heartsink' patients could be raised, where the clinical situation has exhausted a team or a clinician's resources. Alternatively, this could arise due to clinician burnout and would have a negative impact on patient outcomes. These could be managed by bringing in more people with a fresh perspective, support from service leaders, and by the clinician getting personal help. Similarly, a family having no hope would have a similar negative impact on an individual, and this could potentially be addressed through psychoeducation or family therapy. 'Existential crises' can arise where a clinician encounters a person whose situation genuinely appears hopeless and whose decision to attempt suicide initially seems justified. We tend to manage these by providing support and allowing time to pass (e.g. with a short crisis admission) and by broadening the people involved in instilling hope by including our wider teams and the person's friends and family. Usually, in a few days, matters seem less dire, after the provision of support. And there are many more arguments. The above are just some examples. 4 4. Critical Reasoning/Accuracy (Competency: Medical Expert, Scholar) Information cited in the essay is factually correct. There are significant errors of fact that, if used as a basis for treatment planning, could pose a risk to patients. Proficiency level 0 There are errors of fact that are multiple and/or substantial, but without the element of significant risk to patients. 1 Assertions made are generally correct, with no major errors of fact. 3 There are no major errors of fact and the level of relevant factual knowledge is higher than average (e.g. accurately quoted literature). 5. Closely linked to (3) above, this is the place to score for the accuracy of arguments made and for supportive evidence to back up any assertions, such as examples, or ideally references. 2 4 5 Breadth/Maturity/Advocacy/Culture (Competency: Medical Expert, Health Advocate, Professional) The candidate demonstrates a mature understanding of broader models of health and illness, cultural sensitivity and the cultural context of psychiatry historically and in the present time, and the role of the psychiatrist as advocate and can use this understanding to critically discuss the essay question. As relevant to the question or statement: the candidate limits themselves inappropriately rigidly to the medical model OR does not demonstrate cultural awareness or sensitivity where this was clearly required OR fails to demonstrate an appropriate awareness of a relevant cultural/historical context OR fails to consider a role for the psychiatrist as advocate. The candidate touches on the expected areas but their ideas lack depth or breadth or are inaccurate or irrelevant to the question/statement. The candidate demonstrates an acceptable level of cultural sensitivity and/or historical context and/or broader models of health and illness and/or the role of psychiatrist as advocate relevant to the question/statement. The candidate demonstrates a superior level of awareness and knowledge in these areas relevant to the statement/question. The arguments in the body of the quote need to demonstrate this breadth and maturity. Proficiency level 0 1 2 3 References to history and culture would be useful to place the quote in context. The concept of hope goes back to at least Greek mythology (hope was the last thing released from Pandora’s box, after all the evils had escaped). It's central to some religions – e.g. the concept of the resurrection in Christianity. Many other religions have a positive focus as well – the hope/goal of attaining nirvana in Buddhism, the hope of accumulating positive karma and spiritual enlightenment via reincarnation in Hinduism, etc. For breadth, it would be useful to think about the importance of hope in other areas of medicine. Trainees could consider other challenging areas such as palliative care, where instillation of hope in possible treatments, or in achieving peace and acceptance may apply. Staff working in other challenging fields may be expert at maintaining hope, an essential role in Spinal Units and Burns Services. The importance of maintaining a sense of hope via leadership applies in medicine and psychiatry, but also through national leaders modelling or instilling it at times of crisis. Comparisons between Jacinda Ardern and Donald Trump or Jair Bolsonaro in the Covid-19 pandemic spring to mind. Another example might be Winston Churchill instilling hope of victory in the UK in WWII, at the time the quote was published. 4 5 5 6. Ethical Awareness (Competency: Professional) The candidate demonstrates appropriate ethical awareness The candidate fails to address ethical issues where this was clearly required, or produces material that is unethical in content. The candidate raises ethical issues that are not relevant or are simply listed without elaboration or are described incorrectly or so unclearly as to cloud the meaning. The candidate demonstrates an appropriate awareness of relevant ethical issues. The candidate demonstrates a superior level of knowledge or awareness of relevant ethical issues. Proficiency level 0 1 2 3 4 It should be possible to discuss ethical issues regarding any quote, and trainees should assume that this will be a marking dimension in all essays. Here, one could consider the ethics of ‘inventing hope’ (apparently contravening the principle of honesty and thus damaging an individual's autonomy) with the importance of acting in the person’s best interests (beneficence). As covered in (3) above, this may be a matter of perspective, as where the instillation of hope is based on the clinician's wider knowledge and more accurate judgement (than, say, a seriously depressed person's perspective), there may be no dishonesty and thus, no ethical breach but in fact an example of beneficence. However, also as in (3) above, the instillation of hope based on a falsehood where a clinician is knowingly lying is likely to be an ethical breach (contravening respect, autonomy and potentially resulting in the patient being harmed and abused). There is a strong ethical imperative for clinicians to maintain hope for those under their care and to keep caring for them even in difficult circumstances (fidelity and the duty of care). 5 7. Patient-centred Care (Competency: Medical Expert, Collaborator) The candidate demonstrates understanding of patient-centred care, the Proficiency recovery model in psychiatry, and the role level of carers. The candidate fails to consider patientcentred care, carers, and/or recovery principles where these are relevant OR merely mentions them. The candidate mentions these concepts but does not demonstrate an accurate understanding of them or is unable to do so clearly. The candidate demonstrates understanding of patient-centred care, the recovery model in psychiatry, and the role of carers. The candidate demonstrates a superior depth or breadth of understanding of patient-centred care, the recovery model in psychiatry, and the role of carers. 0 1 2 This is an important marking domain for this quote. There are a number of points that could be made here, including: - Most people with severe mental illness have had many negative experiences such as stigmatisation, discrimination, rejection, and loss. These can make it hard to hope and lead to demoralisation. - A sense of hope is the starting point in the recovery process. Integral to this is the shift from a focus on symptoms and deficits to one on strengths and solutions to the person’s problems. With hope that things can change, people can put in the effort to make changes that show positive progress is possible. - The importance of clinicians engendering and maintaining hope as part of the recovery process. “You believed in me…even when I didn’t believe in myself” 3 4 - Peer support workers focus on engendering hope and optimism, often working with people who feel they have lost all hope in and for themselves. This can be done by modelling their own recovery attitudes, essentially ‘inventing’ hope as per the quote. 5 6 8. Conclusion (Competency: Medical Expert, Communicator, Scholar) The candidate is able to draw a conclusion that is justified by the arguments they have raised. Proficiency level There is no conclusion. 0 Any conclusion is poorly justified or not supported by the arguments that have been raised. 1 The candidate is able to draw a conclusion/s that is justified by the arguments they have raised. The candidate demonstrates an above average level of sophistication in the conclusion/s drawn, and they are well supported by the arguments raised. 2 The essay needs to wrap up with a defined conclusion. This should be justified by the arguments already made and must not introduce new information. The quote is intrinsically difficult to disagree with, unless trainees take the view that it is dishonest to invent hope when it isn’t there – and, as above, this would need to be discussed carefully, regarding the ethics and the basis for instilling hope. 4 Most essays will likely support the quote’s assertion, but the critical thinking component comes in understanding the breadth of the issues raised by the quote and their importance to psychiatric practice. 5 If the conclusion is not clearly announced and the last paragraph does not seem to be a conclusion at all (just a point where the trainee ran out of time), score zero for this domain. 3 In the real CEQ they tend to only have about 6 marking domains, and to weight them each differently. That's too complex a system for a Mock exam, so these 8 domains for the CEQ scoring add up to exactly 40 marks. Final Mark % = score / 40 7 MODIFIED ESSAY QUESTION 1 Each question within this modified essay will be marked by a different examiner. The examiner marking one question will not have access to your answers to the other questions. Therefore, please ensure you address each question separately and specifically. For example, answer question 1.4 fully, even if you believe you have partly covered its content in your answers to questions 1.2 and 1.3. Modified Essay Question 1: (22 marks) You are a junior consultant working in the consultation-liaison service at a large general hospital. You have been asked by your general medical colleagues to urgently see John, a 41 year old Samoan man under their care. John was transferred back 3 days ago from the regional neurosurgical unit and has a peripherally inserted central cannula (PICC) in situ as he requires four weeks of treatment with intravenous antibiotics. The treating physician reported that John repeatedly stated that morning that he didn’t need antibiotics because he was ‘cured’ and that “the bandage on my head proves it”. He is increasingly irritable with nursing staff trying to give him medication and has attempted to leave on two occasions today. On his second attempt to leave, he required security to contain him. John is 6' 2" and strongly built. Question 1.1 (9 marks ) Outline (list and explain) the specific information you need to gather in your assessment of John to safely manage the escalating situation. mark worth (circle) Risk: 0 Immediate risk to others given his presentation – access to 'weapons', risk of accidental harm to others, threats, level of aggression. A. 2 1 Immediate risk of harm to self – is his treatment refusal any sort of self-harm? 2 Risks of accidental harm to self (inability to keep himself safe). B. C. D. Capacity: His current capacity to make decisions about his treatment options. Does he retain information long enough to make a rational decision, understand the current situation and consequences, assess the situation rationally to make a decision, and communicate a consistent choice? Medical Status: Why was he in the regional neurosurgical unit & what treatment did he receive there? Current medical status including vital signs and screening for delirium. Past medical history. Mental State Examination and Past Psychiatric History:  Establish if there's any evidence for a primary psychiatric disorder as opposed to an organic condition at this point in time. Particular focus on tests of attention, symptoms of psychosis & symptoms of mood disorder. 2 0 1 2 2 0 1 2 2 0 1 2 0 1 0 1 E. Medications: Any medications that might precipitate acute behavioural change. 1 F. Alcohol and Substance use history: Especially around possible substance withdrawal. 1 G. Collateral information: From family and medical staff/services regarding his recent presentation, and his usual coping and behaviour. 1 0 1 H. Cultural Assessment: Clarify any cultural issues with the family. Ideally, involve an appropriate cultural team/cultural worker in the assessment. 1 0 1 Up to a maximum of 9 marks in total TOTAL: Note to Examiners: Final mark is set at not more than 9. (i.e. if they score more, final mark is still 9) 8 Modified Essay Question 1 contd. As part of your assessment, you ascertain that John has a delirium and lacks the decision-making capacity to self-discharge from the hospital at this point in time. He continues to be periodically agitated, despite his wife and sister visiting daily to help calm him down. Question 1.2 (9 marks) Outline (list and explain) how you would manage the situation, given that John still requires lifesaving care. mark worth (circle) Medico-legal Issues The delivery of care needs to be done under a legal framework for people lacking decision-making capacity (‘duty of care’): - Decisions should be taken as required for life-preserving treatment. 0 - Family should be involved in treatment decisions (his wife and sister), with 1 A. the principle that they make decisions on his behalf based on his wishes if he 3 2 had decision-making capacity. Use any EPOA if this exists. 3 - Discuss with the hospital legal team about the need to keep John in hospital against his will for treatment and the rationale behind this. - Discuss the delivery of care in these conditions with a peer/peer group. Management of John's Delirium - Arrange a 1:1 watch, taking into account his size and the safety of John and the watch - Move John to a single room ideally, avoiding bright lights and darkness 0 - Low dose antipsychotics as needed (e.g. haloperidol), with intramuscular 1 B. 3 options if required. 2 - Benzodiazepines may be used cautiously (but can exacerbate confusion). 3 - Frequent re-orientation as with any cognitively impaired person. - Distraction techniques may assist if he persistently attempts to leave. - Encourage staff to use a delirium rating scale e.g. 4-AT or CAM. Management of the Ward/Staff - Explain to the ward nursing team the issues around treatment when an 0 individual lacks decision-making capacity. 1 - Discuss with the ward nursing team how to manage his difficult behaviour. C. 3 2 - Write a clear plan in the notes. 3 - Ask the Charge Nurse to ensure nurses across all shifts know the plan. - Reassure ward staff that this is difficult, and you will review John daily. Family Interventions - Discuss with family the delivery of care given that John lacks capacity. 0 D. - Psychoeducation about his cognitive impairment. 2 1 2 - If the family become significantly distressed, arrange additional support – regular discussions, extended family support, social work, counselling, etc. Cultural Intervention 0 E. 1 - Ideally, involve a cultural advisor/cultural team for John & family. 1 Up to a maximum of 9 marks in total TOTAL: Note to Examiners: Final mark is set at not more than 9. (i.e. if they score more, final mark is still 9) 9 Modified Essay Question 1 contd. Three days later, you receive an email from the Charge Nurse about John, who demands that you ‘drug him up’ or move him to another ward because her nurses are refusing to care for him any more, as he remains verbally abusive when prevented from leaving the hospital. Question 1.3 (4 marks) Outline (list and explain) the potential factors that may have led to the charge nurse’s request. worth mark (circle) Lack of understanding about John’s delirium: A. - His cognitive impairment and behavioural change may be interpreted as deliberately disruptive behaviour. 1 0 1 Nursing staff may be struggling to manage his behavioural disturbance: B. - Staff may be avoiding John, causing his behaviour to escalate due to neglect. 1 0 1 Management strategies implemented may be inadequate: C. - He may not have enough PRN charted, or the watches may not be able to contain him. 1 0 1 Hospital systemic issues: D. - The Charge Nurse may be under significant pressure to move John, e.g. due to staff or bed shortages. 1 Racism: - The Charge Nurse and/or other staff might be racially biased and responding to E. prejudice, increasing their fear and reluctance to care for him (he's a large man and verbally aggressive). 1 0 1 0 1 Up to a maximum of 4 marks in total TOTAL: Note to Examiners: Final mark is set at not more than 4. (i.e. if they score more, final mark is still 4) 10 MODIFIED ESSAY QUESTION 2 Each question within this modified essay will be marked by a different examiner. The examiner marking one question will not have access to your answers to the other questions. Therefore, please ensure you address each question separately and specifically. For example, answer question 1.4 fully, even if you believe you have partly covered its content in your answers to questions 1.2 and 1.3. Modified Essay Question 2 (22 marks) You are a junior consultant working in a community mental health clinic and have been asked to review Joanne, an unemployed 28 year old woman who lives with her parents. Joanne was referred to your team one month ago by her GP, and was diagnosed with Obsessive Compulsive Disorder (OCD) by the psychologist on your service and a locum psychiatrist. She recently commenced psychological treatment. The psychologist has asked you to see Joanne because she has stopped medication (fluoxetine 40mg mane, previously prescribed by her GP), and is now doing poorly. She has also lost weight in the past month. Question 2.1 (10 marks) Outline (list and explain) what you will include in Joanne's assessment. worth mark (circle) A. Interact with Joanne so as to develop the therapeutic alliance 1 0 1 B. Assess the risks, especially risk to self (self-harm risk, impaired self-care) 1 0 1 C. Re-evaluate her history and symptoms. Clarify the history of obsessions and compulsions. Clarify why she stopped medication 2 0 1 2 D. In what ways is she doing poorly? Clarify the reasons for and rapidity of her weight loss 1 0 1 E. Re-evaluate her diagnosis. Specifically, screen for differentials such as psychosis or mood disorder 2 0 1 2 F. Get collateral history from parents, with her permission 1 0 1 G. Liaise with her GP 1 0 1 H. Physical examination to assess her weight/BMI, lying/sitting/ standing BP and heartrate, neurological exam 2 0 1 2 I. Arrange blood tests, including electrolytes 1 0 1 J. Consider neuroimaging to exclude organic brain disease, esp. if any abnormalities on neurological examination. 1 0 1 Up to a maximum of 10 marks in total TOTAL: Note to Examiners: Final mark is set at not more than 10. (i.e. if they score more, final mark is still 10) 10 Modified Essay Question 2 contd. Joanne reports the obsessional thought that she has done something wrong. She relates this to accidentally viewing pornography when on the internet six months earlier. This obsessional thinking leads to her constantly questioning her actions and being unable to make decisions. There is no other compulsive behaviour. After a thorough assessment, you conclude that Joanne has severe OCD. This has deteriorated since she stopped fluoxetine two weeks earlier due to her obsessional anxiety about doing something wrong. She has lost some weight but is not physically compromised. Question 2.2 (6 marks) Outline (list and explain) the key elements of your treatment plan for Joanne at this point. worth mark (circle) 1 0 1 3 0 1 2 3 1 0 1 GP/medical follow up to monitor her weight and physical wellbeing. D. Continued liaison with her GP 2 0 1 2 E. Continued involvement of her parents/family, with her consent 1 0 1 A. Consolidate the therapeutic alliance, see her regularly Pharmacotherapy – restart medication (e.g. fluoxetine, alternative SSRI, B. clomipramine) to control obsessional symptoms. Aim for a high dose of antidepressant, consider antipsychotic augmentation C. Psychotherapy – regular follow up with the psychologist and Cognitive Behavioural Therapy (CBT) for her OCD symptoms Up to a maximum of 6 marks in total TOTAL: Note to Examiners: Final mark is set at not more than 6. (i.e. if they score more, final mark is still 6) 10 Modified Essay Question 2 contd. Joanne deteriorates further. She takes medications for three days then stops again. She is nearly paralysed by indecision related to her