OSCEs – Examination

1. Mental State Exam

Suicidal ideation and psychosis

Subject and Curriculum Reference

Communication

Mental state exam

  • Psychosis
  • Suicidality

Mini-mental state exam

  • Level of consciousness
  • Concentration

Expand

Clinical scenario stem

A 20 year old man, Jake Smith, is brought in by ambulance after an attempted suicide. He was found by his mother in his room with a rope tied to the door frame and stated that he was going to hang himself. He had been discovered before attempting to hang himself and the ambulance officers found no physical injuries. He offered no resistance when asked to come to hospital and has not been violent but the ambulance officers’ state that he appears agitated and distracted. His mother states that his behaviour has been abnormal in the last few months and he has stated that he is hearing voices.

He has no previous mental or physical health issues.

He has been placed in one of the seclusion rooms.

Please take a history from Jake. After 5 minutes you will be asked to summarise your findings, give a brief differential diagnosis and recommend his disposition.

Patient Instructions

The Character

Jake Smith is a 20 year old man who lives with his mother and brother in suburban Melbourne. He went to the local high school and did well in his exams. He then moved on to an Interior Design degree at university and was doing well. His father died when he was quite young from suicide and he has been raised by his mother. He has a good relationship with his younger brother Mat who is 18 years old. He had a part-time job at the local cinema.

Jake has never been diagnosed with a mental health disorder and has no past medical history.

Jake is suffering from a psychotic mental illness which has now caused him so much distress and distraction that he is no longer able to function and wants to kill himself. He has never been assessed for this condition before today.

The symptoms started 6 months ago when he noticed that there were voices talking to him from his IPod. They told him that he was a terrorist sleeper and had been programmed to carry out a terrorist act.  At first he tried to ignore them but they became more and more persistent. He does not want to do the things the voices are telling him to do but feels that he has been brainwashed and will be forced to carry them out. This is the main cause of his distress.

As his disease evolved he has also become more paranoid. He believes that the police think he is the mastermind behind a number of terrorist plots and are watching him. He misinterprets normal events around him as part of this surveillance e.g. the postman is delivering letters more frequently to keep an eye on him; a random person walking down the street is actually following him.

He is also ascribing meaning to seemingly normal events e.g. an advertisement on TV is actually a message to him to prepare for the terrorist act; a song played on the radio is actually a message to him about how to carry out a terrorist plot.

He has become more and more distracted and distressed by these intrusive thoughts. Six months ago he started to fail at university as he was unable to complete assignments and study for exams. In the last month he has failed out of his course completely. He has also been sacked from his job as he was not turning up for work and acting strangely. In the last 2 weeks he has become so distracted that he has stopped showering and is wearing the same clothes for days at a time. He has become more and more desperate as he is terrified he will carry out a terrorist act and harm people.

 

The Scene

Today Jake got a message through the IPod that he was to carry out a terrorist act tomorrow. This caused him a lot of distress as he feels like he has no control over his actions and he will carry it out if given the trigger. This is what caused him to attempt suicide today. However, because he is no longer able to function logically, he was unable to carry out the suicide i.e. did not realise that the tying the rope to the door frame would not be high enough to produce tension on the rope around his neck.

His mother came into his room just as he was trying to tie the rope to the door frame. When she screamed at Jake to stop he was very upset, sat down on the floor and started to cry.

He is not a violent person. He is dejected and feels defeated and trapped by the voices.

He is very dishevelled, unkempt and agitated. The voices are now talking to him from the security camera in the room he has been put in and are telling him he is a failure. He thinks the security guards at the hospital know all about the terrorist plot and are contacting the police.

Jake is cowering in the corner of the room, wringing his hands and rubbing his head. He is intermittently talking to the security camera. His mood changes abruptly from crying to being scared. Sometimes he is apologetic “I’m sorry”; “I just couldn’t do it”; “I can’t hurt anyone”. At times imploring the voices to go away “leave me alone!”, “Stop it!”, “Please go away”. He is also expressing his paranoia “the police are coming” “they’re going to lock me up”.

Jake is going to be interviewed by a doctor. During this interview he is able to answer questions but is agitated and distracted and at times starts to talk to the voices coming from the security camera. He is also perplexed. He doesn’t understand that no one else can hear the voices and he is confused by the questions. If asked, he explains to the doctor about the terrorist plot, the voices and the fact that the police are on to him i.e. “they’re talking through the IPod and the TV and the camera” “they want me to kill people” “ they wanted me to do it tomorrow” ” “the police are watching me” “the police know all about me”. If asked he also explains why he tried to kill himself that morning i.e. “I couldn’t do it so I wanted to kill myself”. He also expresses that he can’t understand why no one else can hear the voices i.e. “Can’t you hear them?” “they’re shouting at me right now”.

If Jake is asked orientation questions like “where are you” “what day is it” then he is able to answer them accurately. If given simple maths to do or work phrases to repeat he can do these accurately but he gets distracted by the voices.

NB:

  • The “Scenario” in the preceding page is ALL the information provided to the candidate before s/he interacts with Jake. That is, s/he will NOT be aware of Jake’s own circumstances.
  • Candidates will only have 5 minutes to interact with the actor & 2 minutes to talk to the examiners. Successive candidates will be interrupted by 3-minute breaks, during which the examiners and actor discuss the preceding candidate.
  • After a succession of 10 or less candidates, there is a longer break to permit rest and refreshments.

 

Scoring Sheet

Not met Partly met Fully met
Safety

  • Places him/herself in place where can escape if patient escalates
Establishing rapport and trust

  • Introduction including role
  • Explains what he/she is going to do
  • Reassurance
  • Gains trust
Establishes key aspects of history

  • Events of today
  • Events leading up to today
Mental State Exam

  • Appearance
  • Behaviour
  • Attitude
  • Affect
  • Mood
  • Appropriateness
  • Speech
  • Perceptual disturbances
  • Thought form
  • Thought content
  • Cognition
    • Level of consciousness
    • Orientation
    • Memory (short and long-term)
    • Concentration
  • Judgement
  • Insight
Mini-Mental state exam(cognition)

  • LOC
  • Orientation
    • Year/season/date/day/month (5)
    • Country/state/town/hospital/ward (5)
  • Registration
    • Repeat 3 objects (3)
  • Attention and calculation
    • Count backwards from 100 by 7s or spell world backwards (5)
  • Recall
    • Recall objects (3)
  • Language
    • Name 2 objects (2)
    • Repeat the following “no ifs and or buts” (1)
    • 3 stage command (3)
    • Read and obey (1)
    • Write a sentence (1)
    • Copy a design (1)
Summary of findings

  • Psychotic features
    • Dishevelled
    • Agitated
    • Affect & mood – scared, distressed
    • Thought content – delusions
    • Perceptual disturbances – auditory hallucinations
  • Suicidality
    • Intent
    • Caused by psychosis
  • No indicators of delirium
Differential diagnosis

  • Psychotic illness
    • Schizophrenia
    • Drug induced psychosis
    • Mood disorder with psychosis
Disposition – for admission due to high risk suicide and active psychosis
Time management

  • Covers main aspects of MSE and MMSE important to this scenario in time
PASS/FAIL   – Needs to meet 5/6 criteria

  • Establishes trust/rapport
  • Mental State exam – looks for recognises abnormalities
    • Appearance
    • Behaviour
    • Affect
    • Mood
    • Thought content
  • Mini-mental state exam
    • LOC
    • Orientation
      • Year/season/date/day/month (5)
      • Country/state/town/hospital/ward (5)

Summary of findings

  • Psychotic features
  • Suicidality

Differential diagnosis

  • Psychotic illness

Disposition – admission

Author: J Haire 

 

One Comment:

  1. Ric Todhunter

    Awesome work you guys. You have obviously been busy while I have been gallivanting around the world (and avoiding earthquakes).

    How about we make a *.pdf version available for download so that the OSCEs can be run by an educator in “close to exam conditions”?

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