MRCPsych CASC: Assessment of School Refusal

This MRCPsych CASC Sample Case assesses a child's refusal to attend school. It is important to consider several key factors when evaluating the situation.

First, it is crucial to determine the age of the child and whether they desired to attend the scheduled appointment. It is also important to determine who is currently responsible for their care and if they have any connections to CAMHS (Child and Adolescent Mental Health Services) or social services.

The duration of the child's refusal to attend school should also be considered, as well as the different perspectives on the cause of the refusal from the child, their parents, and the school. It is important to determine if the child is refusing other situations.

If the child is exhibiting signs of separation anxiety, it is important to note that they may have worries about the safety of their caregiver and follow them closely in all situations. It is also important to assess the potential risks to the child, to others, from others, and for neglect.

It is important to consider any history of drug and alcohol use and the impact of the school refusal on the child's life at home, at school (academically), and with their friends. A mental state examination should be performed, evaluating the child's mood (such as low mood) and any potential symptoms of psychosis. The child's level of anxiety should also be assessed, including any possible experiences of bullying, checking and washing behaviours, and any specific concerns they may have about the school or a teacher.

A comprehensive developmental and psychiatric history should be obtained, as well as any history of medication use. The child's past medical history and family history should also be considered.

The management of the child's refusal to attend school may involve a gradual return to school, liaison with the school to address any potential bullying, and involving an educational social worker and psychologist as necessary. Incentives for attending school may also be implemented, and group tutorials should be considered if the child falls academically behind.

Virtual Scenario

Psychiatrist: Good afternoon, thank you for coming in today. Can you tell me a little bit about your child and their recent refusal to attend school?

Parent: Yes, my son has been refusing to go to school for the past few weeks. He used to love going to school, but now he just refuses to leave the house in the morning.

Psychiatrist: I see. How old is your son?

Parent: He is 11 years old.

Psychiatrist: Is he refusing to attend any other activities or events besides school?

Parent: No, just school. He seems to have a lot of anxiety about it.

Psychiatrist: I understand. Have you or the school noticed any changes in his behavior, mood, or overall functioning?

Parent: He has become increasingly withdrawn and has been complaining of low mood. He used to have a lot of friends, but now he just wants to be alone all the time.

Psychiatrist: That's concerning. Has there been any history of bullying or other adverse events at school?

Parent: Not that we're aware of. The school hasn't mentioned anything, and my son hasn't talked about it.

Psychiatrist: I see. Can you tell me about his developmental and psychiatric history?

Parent: He has never had any major developmental or psychiatric issues. He's always been a happy and healthy child.

Psychiatrist: Okay, thank you. Can you tell me about any medications he is currently taking and his past medical history?

Parent: He is not currently taking any medications, and he has no significant past medical history.

Psychiatrist: Alright. And what about his family history, is there any history of mental illness or substance abuse in the family?

Parent: No, there is no history of mental illness or substance abuse in our family.

Psychiatrist: Okay, thank you. Based on what you've told me, it seems like there may be some anxiety or mood-related issues contributing to his school refusal. I would like to perform a mental state examination to get a better understanding of his current state.

Parent: Yes, of course.

Psychiatrist: After the examination, we can discuss potential management options, such as graded exposure to school, liaising with the school to address any potential bullying, and involving an educational social worker and psychologist as necessary. We may also consider using incentives for attending school and providing group tutorials if necessary.

Parent: That sounds like a good plan. Thank you for your help.

Psychiatrist: You're welcome. We'll work together to help your son get back to school and feel more comfortable.

MRCPsych CASC: Assessment of an aggressive Patient in the Emergency Department

Scenario:

A patient with a severe psychiatric disorder has become aggressive. You have been called to assess him in the psychiatric emergency department. 

Introduction 

Assessing a patient with a severe psychiatric disorder can be a challenging task, especially if the patient is aggressive. It is essential to approach the assessment with caution and to prioritize the safety of both the patient and the assessing psychiatrist. Here are the steps for assessing a patient with a severe psychiatric disorder:

Establish rapport: 

The first step is to establish a rapport with the patient. This can be done by introducing oneself and explaining the purpose of the assessment. For example, the trainee psychiatrist can say, "Hello, I am Dr. [Name]. I am here to talk to you and assess how you are feeling."

Gather information:

The next step is to gather information about the patient's current symptoms and past medical history. This can be done by asking open-ended questions, such as "Can you tell me about your symptoms?" or "What led you to come to the emergency department today?"

Assess the patient's level of agitation:

The trainee psychiatrist should assess the patient's level of agitation by observing their behavior, body language, and speech. This can help to determine the level of risk the patient poses and whether additional safety measures, such as restraints, are needed.

Assess for suicidal and homicidal ideation:

The trainee psychiatrist should also assess the patient for suicidal and homicidal ideation by asking questions such as "Have you been thinking about hurting yourself or others?" or "Do you have any plans to harm yourself or others?"

Conduct a mental status examination:

 
The trainee psychiatrist should conduct a mental status examination, which includes assessment of the patient's mood, affect, thought process, and cognitive functioning. This can help to diagnose any underlying psychiatric disorders and determine the patient's level of functioning.

Make a diagnosis:

Based on the information gathered, the trainee psychiatrist should make a diagnosis and develop a treatment plan.

Sample Conversation

Here is a sample conversation between the trainee psychiatrist and the patient:

Trainee psychiatrist: "Hello, I am Dr. [Name]. I am here to talk to you and assess how you are feeling."

Patient: "I don't want to talk to you. Just leave me alone."

Trainee psychiatrist: "I understand that you may not feel like talking, but it's important that I assess how you're feeling to determine the best course of treatment. Can you tell me what led you to come to the emergency department today?"

Patient: "I just can't handle it anymore. Everything is too much."

Trainee psychiatrist: "I'm sorry to hear that. Can you tell me more about what's been bothering you? Have you been having any thoughts of hurting yourself or others?"

Patient: "Yes, I have been thinking about hurting myself."

Trainee psychiatrist: "Thank you for telling me that. I am here to help. I am going to make sure you get the care you need to feel better."

This is just a sample conversation and the exact questions and responses will vary based on the specific patient and their situation. The trainee psychiatrist should adapt the conversation to fit the patient's needs and level of cooperation.

MRCPsych CASC: Emergency Assessment of an Angry or Anxious Patient or Relative

CASC Notes: Emergency Assessment of an Angry or Anxious Patient or Relative

As you enter the station, it is important to show your badge to the examiner and nod while saying a quiet "Thanks". When you meet the relative or patient, they may be standing up, so it's best to start by taking a seat yourself. You can say, "Hello, my name is Dr Waleed. Thank you so much for agreeing to see me today. Do you mind if I take a seat?"

Starting with a calm and friendly approach is crucial in building rapport with the patient or relative. You can say, "First of all, thank you so much for coming to see me today. Good communication between patients or relatives and the psychiatry team is very important to us, and we value it greatly."

You can also express your empathy and acknowledge their difficult situation by saying, "I can't imagine how difficult it must be as a mother/father/sister/carer to see your loved one suffering like this."

If the relative or patient is angry with another staff member for not caring or communicating, you can assure them that you will address the issue immediately. You can say, "I will talk with that member of staff straight after" or "Thank you for telling me. It is really important that we know this. We will look into it as soon as possible."

In case the patient or relative mentions side effects of medications, you can inform them that you have an official complaints procedure they can follow if they wish to take the matter further.

If the patient or relative says they are leaving, it's important not to block the exit, but you can try to calm them down and offer help by saying, "I can see that you're really anxious. Perhaps we could sit down and talk about it. I'm here to help. You're in a safe place now."

If the patient or relative says they are not mad, you can respond by saying, "I'm absolutely not suggesting you are mad, but I can see that you are suffering, and I'm here to help. It must be very distressing for you. Perhaps we can sit down and talk about it."

If the patient or relative asks to be removed from the section, you can explain the process and say, "I do understand your concerns, but the decision to remove the section is not just up to me. It's a team decision. I can assure you that as soon as the team feels that you no longer need to be on a section, it will be lifted. Have you been told how you can appeal against the section?"

If the patient or relative asks to speak to a male or female doctor, you can apologize for the unavailability of the preferred gender and ask if a nurse of the preferred gender can be present. You can also ask the reason for their discomfort and continue the interview by saying, "You seem quite distressed at the moment. Could I ask what's been troubling you?"

To increase empathy, it's important to lower the tone and volume of your voice and make eye contact with the patient or relative. This makes you sound more convincing. When wrapping up the station, it's best to come up with a short and concise summary of the important issues discussed and offer support and resources, such as psychology, carer's assessment, occupational therapy, and medication options. Don't forget to thank the patient or relative for talking to you.

Look at the examiner and nod while saying a quick "Thanks".

Assessment and Management of The Risk of Violence in Schizophrenia

Assessment and Management of The Risk of Violence in Schizophrenia

Scenario

A 21-year-old lady with the diagnosis of schizophrenia informs you she will kill her neighbour tomorrow as she has ruined her life. She tells not to disclose this to anyone.

1. How will you assess the homicidal risk in this patient?
2. What treatment and follow up recommendations will you make in this case?

Clinical Assessment 

Listen to the patient and develop a therapeutic relationship. 

begin the assessment and enquire about her demographics. 

Enquire about the issue that she brought up—she will kill her neighbour. 

Elaborate on how she thinks her neighbour has ruined her life. 

Explore her thoughts and whether the patient may have persecutory delusions

Assess how much resentment she feels?

Follow up with inquiry about her mood, esp. about irritability and depression

How she plans to commit the act

Has she threatened the person?

Whether she has done so in the past

If so, what provoked such an incident

Whether the provoking factor is still present

Whether she possesses a weapon.

How easily she can access her

Whether she uses alcohol or substance

Psychiatric history and mental state

Whether she has other psychotic symptoms, e.g., commanding hallucinations

Negative symptoms (reduced likelihood)

Elicit relevant personal history

Especially whether she is single, divorced or separated

Who she lives with?

Her socioeconomic circumstances

Any stressful circumstances she might be passing through

 

Tools to Assess the Risk of Violence

Buss-Durkee Hostility Inventory

•       75 (true/false)-item questionnaire

•       Used to assess cynicism and distrust

Hostility and Direction of Hostility Questionnaire

The 51-item self-report questionnaire with 5 subscales. 

Used to assess the range of manifestations of aggression, hostility, and punitiveness; distinguishes hostility as they direct it either externally (extra-punitive: psychopathic, paranoid, hysterical) or internally (internal-punitive: guilt, self-criticism)

Aggression Risk Profile

•       39-item rating scale

• Identifies the characteristics of chronically aggressive patients, to foresee future manifestations of violent behaviour

Suicide and Aggression Survey

• Semi-structured clinician-administered interview and research tool; divided into 5 parts

• Elicits a brief medical history, recent and lifetime suicidality, and tendency to social violence; measures recent and past aggressiveness expressed by suicidal acts and thoughts

Management

1. Clozapine for schizophrenia, which also reduces the risk of violence (Farooq and Taylor 2011)
2. Address the modifiable risk factors identified
3. Inform the potential victim as a precautionary measure (which is also a legal/ethical responsibility)
4. If community services are available, we should consider assertive outreach.
5. If the patient is violent, we can also consider ECT.
6. Family therapy, CBT and other psychosocial interventions for schizophrenia.

Important Questions About History of Drug Use

Important Points about the History of Drug Use

1. Regular or intermittent
2. Amount (know the units)
3. Pattern dependence/withdrawal 
4. Impact on work, relationships, money, police 
5. Screening questionnaires e.g. CAGE

Behavior and Body Language During History Taking

1. Establish and maintain eye-contact and rapport. 
2. Relaxed non-threatening posture and appear unhurried. 
3. Use facilitated noises (I see, okay, etc.)
4. Pick up on nonverbal cues 
5. Acknowledge what they are saying 
6. Show a willingness to understand 
7. Do not offer opinion/advice to early 
8. Control over-talkativeness with polite authority at the right time

Differentiating Factors of Epileptic and Non-epileptic Fits

Factors That Favor Epileptic Fits

The following Favor epileptic fits. 

An abrupt onset
A stereotyped course lasting seconds to a few minutes.
Tongue biting, especially on the sides
Urinary incontinence during the fit
Evidence of cyanosis, for example, face turning blue.
Injury during the episode
Prolonged postictal confusion

Favour Non-Epileptic Fits

Treatment resistance to over two antiepileptic drugs.
Antiepileptics do not affect seizures.
Fits occur with specific environmental or emotional triggers.
Presence of witnesses, for example, family members at the time of an event.
History of chronic pain, fibromyalgia, chronic fatigue, syndromes.
History of comorbid psychiatric illness, personality disorder or substance abuse.
History of remote or current abuse or trauma.
Presence of repeatedly normal EEGs in the presence of recurrent seizures.
Drawn from Benbadis and LaFrance (2010).

Sociological features of Psychogenic Non-Epileptic fits

Gradual onset.
Rapid postictal re-orientation.
Undulating motor activity.
Side-to-side, head shaking.
Closed eyelids during the event.
An event lasting over two minutes.
Resisted eyelid opening.
Lack of cyanosis.
Partial responsiveness during a fit.
Drawn from Benbadis and LaFrance (2010) and Syed et al. (2011).

What are the points you would elicit to differentiate between epileptic and non-epileptic fits?
Does the fit present in diverse ways, or does it always present the same way?
What is the duration of the fits? Does that vary? 
Do you experience any post-ictal headache?
How do you feel after the fit? 
Do you think clearly or do you feel confused?
How soon do you recover after the fit?
Have you noticed any factors that trigger the fits? 
How frequently does the fit occur?
Has it ever occurred while you were sleeping, and someone noticed you having a fit?
Have you injured your tongue ever? Can you show me if the injury is to the side of your tongue?
Sometimes people may void urine because of the fits. Has that ever happened while you had a fit?
Has anyone noticed and told you that your face turned blue? 
Does it occur all sudden or do you feel like it will happen and then the fits happen?
Do you take any treatment for a psychiatric disorder?
Have you ever experienced an injury during the Episode?
Does the fit occur in a specific situation or place?
Is there any pattern to the episodes that you may have noticed?
Okay, this last question is slightly sensitive, but this is relevant so I must ask you: Do you have any childhood history of adverse experiences like punishment, abuse? The information you provide we always treat that confidential. Is there any history of sexual abuse? 

1. Anwar H, Khan QU, Nadeem N, Pervaiz I, Ali M, Cheema FF. Epileptic seizures. Discoveries (Craiova). 2020;8(2):e110-e110. doi:10.15190/d.2020.7
2. Benbadis SR, LaFrance Jr. WC. Clinical features and the role of video-EEG monitoring. In: Schachter SC, LaFrance Jr WC, eds. Gates and Rowan’s Nonepileptic Seizures, 3rd ed. New York: Cambridge University Press, 2010.
3. Syed TU, LaFrance Jr. WC, Kahriman ES, et al. Can semiology predict psychogenic nonepileptic seizures? A prospective study. Ann Neurol 2011; 69(6): 997-1004.