Clinical skills (MRCP) Flashcards
Which of the following is NOT a facilitative message? A. ‘Run on’ question B. Self disclosure C. ‘I want’ message D. Silence E. Interpretation
A. Questions used in clinical interviews can be either facilitative or obstructive. Facilitative
messages help the interview to fl ow, establish a rapport and gain the confi dence of the patient.
For example, open-ended questions, facilitating statements, refl ections, silence, interpretations,
positive reinforcements, etc. Run on or polythematic questioning refers to the process of asking
the patient a number of questions at the same time. For example, ‘Have you felt high in spirits,
gone on spending sprees and made foolish investments in the past week?’ These questions can be
obstructive. Self disclosures are statements about oneself (the psychiatrist) that may help
establish a rapport with the patient. I want messages are generally used when the interview fails
to progress because the patient is stuck on the same topic. In this case, the psychiatrist could say
politely that he or she wants to move on to other topics.
A psychiatrist at an early stage of his initial assessment interview asks the patient, ‘Can you tell me about your depression?’ Which of the following interview techniques is he utilizing? A. Closed-ended questions B. Open-ended questions C. Refl ecting D. Facilitation E. Put down question
B. Open-ended questions refl ect a topic that the psychiatrist may want to explore, but
leaves it open to the patient to say what he/she thinks is important. These questions are used to
start the interview and, later on, can lead to specifi c closed-ended questions. Put down questions
are where the underlying message is a criticism. For example ‘How can you complain when you
have got an A grade in your GCSE?’ Facilitation statements encourage the patient to continue
along a particular line of thought. For example, statements such as ‘Go on’; ‘Proceed’; ‘What else’
are facilitation statements.
Which of the following is an open-ended question?
A. Tell me about yourself?
B. Could you tell me the name of the prime minister?
C. It seems as if you feel people are against you?
D. What do you fi nd stressful in your job?
E. Do you have trouble falling asleep?
A. A question whose answer cannot be a simple yes or no, or a single factual answer that
can be classifi ed as right or wrong, is an open-ended question, such as the question given in 3. A.
(See also Question 2).
‘So you have been anxious since these changes occurred at your work place.’ Which of the following interview technique best describes the above statement? A. Facilitation B. Open-ended question C. Closed-ended question D. Interpretation E. Refl ecting
E. Refl ections are statements where the psychiatrist repeats what the patient has just said.
This gives an opportunity to correct one’s understanding of what the patient said and to let the
patient know that the clinician is listening and trying to understand the situation the patient is in.
Interpretations are inferences reached by examining patterns of behaviour or thoughts expressed
at a clinical interview
Which of the following interview techniques is least directive? A. Limit setting B. Summarizing C. Re-direction D. Repetitive questioning E. Narrow-focused questions
B. Directiveness in the interview ensures that a clinician has all the information needed
from a patient. Highly directive intervention aims to focus and restrict the patient’s speech
content and behaviour. These may include check lists or yes/no questions. Limit setting and
redirection include situations where a clinician attempts to change the direction of the interview,
especially when the interview is not progressing in the detail of information transferred.
Which of the following is a supportive intervention during a clinical interview process? A. Open-ended questions B. Acknowledgement of affect C. Confrontation D. Taking a medical history E. Summarization
B. Being empathetic and acknowledging a patient’s emotional state helps in facilitating
progression of clinical interview. These are supportive interventions required in various degrees
by patients. Summarization is not an intervention but a technique facilitating a clinician’s
understanding of a patient’s story. Confrontation may be helpful in some situations, but it cannot
be considered as a supportive intervention during clinical interview
Which of the following statements is true when enquiring about suicidal
ideation?
A. This should not be asked unless the patient volunteers information
B. Asking about suicidal ideation can instil suicidal ideas in a person
C. A person who intends to attempt suicide will never divulge
D. Passive suicidal ideas must be enquired further for any plans made
E. The aim of the assessment is to corner the patient into a disclosure
D. Thoughts of self harm should always be enquired about. Contemplation of suicide is very
common among the mentally ill. There is no evidence that enquiring about suicidal ideations
increases the risk of committing suicide. In fact many patients would welcome an opportunity to
discuss any suicidal thoughts with a professional.
‘Do you ever hear voices commenting on what you are doing?’ This question
is usually asked to ascertain the presence of which one of the following?
A. Bleuler’s primary symptoms
B. Schneider’s fi rst-rank symptoms
C. Command hallucinations
D. Catatonic symptoms of schizophrenia
E. Negative symptoms of schizophrenia
B. First rank symptoms (FRS), proposed by Kurt Schneider, suggest a diagnosis of
schizophrenia. These symptoms are not specifi c for schizophrenia. The prevalence of FRS in
schizophrenia ranges from 28% to 72%. First rank symptoms do not carry any prognostic
signifi cance. The stated question in this case enquires for the presence of ‘running commentary’
hallucinations – voices commenting on patients’ thoughts or actions. Bleuler’s primary or
fundamental symptoms consist of loosening of association, blunting of affect, ambivalence, and
autism (the four A’s). All delusions and hallucinations were classed as secondary symptoms
according to Bleuler. Negative symptoms include alogia, affective fl attening, avolition, apathy,
anhedonia, asociality, and attentional impairment.
Regarding the Mini Mental State Examination (MMSE), which of the
following statements is true?
A. The subject is asked to guess the answer if unsure
B. If a person scores 3 on serial sevens, and scores 4 on spelling WORLD backwards then
the score for attention is 3
C. On the reading test one point is scored if the patient reads ‘Close your eyes’ out loud
D. Education affects the rate of change of scores in normal and dementia subjects
E. MMSE scores are not affected by socioeconomic status of a subject
A. While administering the MMSE, the subject is asked to guess the answer if he is unsure.
This could possibly differentiate patients with pseudodementia who usually answer ‘I don’t know’
while truly demented patients often give wrong responses. On the attention subtest, initially the
patient is asked to do the serial seven. If the score is less than 5, we do the WORLD backwards.
The higher score among the two is taken. It is not enough for the patient to read the sentence
out loud. It is a test of comprehension, so the patient needs to close his/her eyes after reading
the command. Education affects the scores on the MMSE. Patients with higher educational status
tend to score higher on the test. But education does not affect the rate of change of scores in
both normal and dementia subject, and hence change in scores is a good index of worsening
dementia. MMSE is not independent of socioeconomic status. This may be because
socioeconomic status is indirectly linked to educational status.
Assessment of insight is an integral part of mental state examination in
psychiatric practice. Regarding insight, which of the following statements
is true?
A. Patients with schizophrenia will never have insight into their illness
B. OCD being a neurosis, insight is always intact
C. Intellectual insight is present when patients’ awareness and understanding of their
symptoms lead to a change in behaviour
D. Intellectual insight is the highest level of insight
E. Loss of insight is similar to the concept of anosognosia in neurological illness
E. The three dimensions of insight proposed by David include: the ability to label unusual
experiences as pathological, to recognize that one has mental illness, and to comply with
treatment. In a different approach to the concept of insight, emotional insight is considered the
highest level of insight. This is the awareness and understanding of the illness which leads to a
change in behaviour. Intellectual insight is the admission of illness and recognition of symptoms,
without the ability to apply this knowledge to change or shape future behaviour. Patients with
OCD may present with poor insight. DSM IV has a specifi er ‘with poor insight’ for OCD where
poor insight is associated with poor prognosis. Patients with schizophrenia show variable levels of
insight at various stages of their illness. Some exhibit a good level of insight when recovered,
while at the worst phase of their illness they may deny having any mental illness.
A patient with schizophrenia vividly describes how Martians are ‘reverse
freezing’ earth to produce global warming. He stops to ask what you think
about this. Choose the best response.
A. This is a fantastic theory. But I want to know more about this. Tell me, have you ever
seen these Martians?
B. This seems possible but there is no proof for all this. Tell me, have you ever seen these
Martians?
C. This cannot be true. Martians do not exist. Tell me, have you ever seen these Martians?
D. Tell me, have you ever seen these Martians?
E. What I think is not so important. I want to know more about what you think of this. Tell
me, have you ever seen these Martians?
E. Option A and B indicate collusion with the patient’s belief. Option C is a direct
confrontation while D is evasion from the topic which can reduce engagement.
Which one of the following is NOT an advisable fi rst response when a
patient discloses past sexual abuse at a clinical encounter?
A. Postpone discussing the issue
B. Ask if she wants to say anything more about this now
C. Ask if she has ever disclosed this to anyone
D. Ask if she sees a link between this and her current diffi culties
E. None of the above
A. Childhood physical, sexual abuse, and neglect are extremely common experiences among
those who develop serious mental health problems. But victims are typically reluctant to disclose
their histories of abuse and psychiatrists are often reluctant to seek this important information.
Though clinicians are not comfortable exploring sexual abuse in the fi rst interview, postponing
the discussion once it is disclosed is not an advisable strategy
Closed questions are best avoided in which of the following scenarios?
A. A patient with suspected malingering
B. A guarded patient not answering spontaneously
C. A suggestible patient with learning diffi culty
D. A psychotic patient who is actively hallucinating
E. All of the above
C. While interviewing people with limited intelligence, questions should be brief and
worded in a simple way. Closed and leading questions are best avoided as suggestibility is
prominent in this population. Suggestibility in patients with limited intelligence can be assessed
using the Gudjonnson Suggestibility Scale. Closed questions are a good way of eliciting
information from a disturbed psychotic patient who is guarded or distracted by hallucinations.
Confrontation through closed questions may be useful in malingerers.
Which of the following is the single best question to discern premorbid
personality of a patient?
A. How would you describe yourself?
B. How would your friends describe you?
C. What were you like before you became unwell?
D. If we had met 10 years ago, what sort of person would I be talking to?
E. None of the above
E. There is no single question that can reliably elicit premorbid personality traits. A detailed
discourse that includes enquiry about hobbies, leisure, predominant mood state, character, and
descriptions – both self and by friends – is necessary to understand one’s premorbid personality.
Which of the following is not a discriminating question to screen for
harmful use of alcohol?
A. Have you ever attempted to cut down your drinking?
B. Do you get annoyed when people talk about your drinking?
C. Have you ever felt guilty for drinking excessively?
D. Do you drink every evening?
E. Do you need a drink as soon as you wake up?
D. The CAGE questionnaire includes questions on ‘Cut down’, ‘Annoyed’, ‘Guilty’, and ‘Eye
opener’. Early morning drinking (not evening as indicated in the question) indicates a problem use
of alcohol.
A patient looks dishevelled, with unkempt hair and dirty, unwashed clothes.
Self neglect is commonly noted in all of the following EXCEPT
A. Alcoholism
B. Chronic schizophrenia
C. Depression
D. Dementia
E. Social phobia
E. While self neglect can be seen in any severe mental illness, it is not very common in
isolated anxiety disorders. In alcoholism self neglect indicates a higher risk of vitamin and nutritional
defi ciencies. In schizophrenia, this may be secondary to negative symptoms or depression
A 57-year-old lady with many previous hospitalizations is brought by police
to casualty. She is wearing full make-up, green lipstick, shiny green nail
polish, and green jewellery. She asks everyone at the admission unit to call
her Ms Green. Which of the following diagnoses is most consistent with the
above presentation?
A. Mania
B. Depression
C. Panic attacks
D. Obsessive compulsive disorder
E. Learning disability
A. Exuberant dressing and makeup suggests elevated mood. It is possible that the lady
described in this scenario has bipolar illness.
Which of the following domains of cognition is tested by administering Serial Sevens Test? A. Short-term memory B. Attention C. Language D. Registration E. Recall
B. Serial sevens test is a part of Mini Mental State Examination. In this test, the subject is
asked to subtract seven from 100 serially for fi ve times. One point is given for each correct
subtraction. Though it has arithmetic properties, in MMSE this test is primarily administered to
test attention. Alternatively, the subject may be asked to spell the word ‘WORLD’ backwards to
test attention. The better of two scores is used to calculate fi nal MMSE scores.
A 33-year-old man attending an out-patient clinic turns towards his left and
spits out, muttering unintelligibly. He does this act at least three times in
half an hour and appears very guarded. This gesture is suggestive of which of
the following?
A. Depression
B. Suicidal thinking
C. Low self esteem
D. Responding to hallucination
E. Acute confusion
D. Hallucinatory behaviours, such as the one described in this example, are often noted in
acutely psychotic patients with poor insight. Questioning the behaviour gently could elicit more
information from the patient
A depressed patient does not smile or laugh when a joke is shared by a fellow patient. She shows a defect in which of the following aspects of mental state examination? A. Stability of affect B. Reactivity of affect C. Congruence of affect D. All of the above E. None of the above
B. Reactivity of affect refers to change in affect in response to environmental cues. Lack of
reactivity is common in depression. Congruity is the appropriateness of the person’s affect to the
symptoms or the thought content. In this case, the affect is appropriate to the symptom of
depression.
An elderly patient in a stroke ward laughs all of a sudden inappropriately,
and within a few minutes becomes tearful and cries for no reason. She
exhibits an abnormality in which of the following aspects of mental state
examination?
A. Stability of affect
B. Reactivity of affect
C. Congruence of affect
D. All of the above
E. None of the above
A. Stability of affect refers to maintaining a particular affective state for a reasonable period
of time. Unstable or labile affect – when extreme – presents as emotional incontinence seen in
stroke. Severe lability of affect seen in stroke, especially in pseudobulbar palsy, is also called the
PLAC (pathological laughter and crying) syndrome. Labile affect is also a feature of mania and
delirium.
Which of the following is the major difference between mood and affect in
mental state examination?
A. Mood is short-lived while affect is longer lasting
B. Mood is objective while affect is subjective
C. Affect is transient but diffi cult to interpret
D. Affect is transient and self reported
E. None of the above
E. Various schools of thought exist in distinguishing mood from affect. It is generally
accepted that mood refers to a more pervasive emotional state than affect. (Climate = mood vs.
weather = affect!) Both mood and affect can have objective and subjective components though
one school maintains that mood is subjective while affect is objective.
Nihilistic delusions will be congruent with which of the following fi ndings of mental state examination? A. Depression B. Mania C. Depersonalization D. Grandiose delusion E. None of the above
A. Nihilism is similar to pessimism with self reference of an extreme belief, for example
‘My brain is rotten’. Congruence refers to ‘in keeping with’ a particular state of mind – nihilism is
usually congruent with depression. Nihilism with delusional intensity is seen in psychotic
depression.
When eliciting suicide risk, which of the following questions should be
avoided if possible?
A. Do you have any plans to kill yourself?
B. How are you feeling in your mood?
C. Have you ever considered life is not worth living?
D. Have you ever wanted to go to sleep and never wake up?
E. None of the above
E. Direct questioning about suicidality does not increase risk of suicide, so evasive
questioning is not recommended. A step-wise approach, starting from enquiry about mood state,
hopelessness and thoughts of death, passive wishes to die, and active suicidal plans, is often useful
in assessment of suicidal thoughts.
Which of the following is not a manifestation of hypothyroidism?
A. Hypothermia
B. Sparing of the posterior column sensations
C. Dementia
D. Cerebellar ataxia
E. Loss of deep tendon refl exes
B. Features suggestive of hypothyroidism include, slowing of EEG, excessive daytime
sleepiness, hypothermia, cerebellar ataxia, dementia, psychosis. The peripheral neuropathy in
hypothyroidism is a sensorimotor polyneuropathy with loss of refl exes, diminution in vibratory,
joint position, and touch–pressure sensations, and weakness in the distal parts of the limbs.
Myopathy may also be present. Nerve conduction studies typically show a slowing of nerve
conduction velocities. Hypothyroidism is observed to be common in patients with Down’s
syndrome.
Russell’s sign is usually associated with which one of the following disorders? A. Schizophrenia B. Bipolar disorder C. Bulimia nervosa D. Panic disorder E. Somatization disorder
C. Russell’s sign was fi rst described in bulimia nervosa. This refers to the skin abrasions, on
the dorsum of the hand overlying the fi ngers, found in patients with symptoms of bulimia. These
are caused by repeated contact between the incisors and the skin of the hand which occurs
during self-induced vomiting
On physical examination, you notice that a person with a history of
substance misuse now has pilo-erection, dilated pupils, rhinorrhea, and he is
yawning frequently. Withdrawal from which of the following substances can
cause this presentation?
A. Cocaine
B. Opiate
C. Cannabis
D. Alcohol
E. Amphetamine
B. These features are suggestive of opiate withdrawal. Classical withdrawal from opiates
appears in 4 to 12 hours, peaks in 48 to 72 hours, and subsides in a week. It is characterized by
symptoms of muscle aches and cramps, severe anxiety and agitation, insomnia, diarrhoea,
shivering, yawning, and fatigue. Signs include tachycardia and hypertension, lacrimation,
rhinorrhoea, dilated pupils, and ‘goose-fl eshing’ (piloerection) of the skin (hence ‘cold turkey’ or
‘clucking’). Insomnia (with increase in REM sleep) and craving for the drug may persist for weeks.
Opiate withdrawal is not usually life threatening.
A 50-year-old patient was brought to the A and E department in a confused
state. On physical examination he has nystagmus, ocular palsy, and ataxia.
Which of the following parts of clinical assessment is likely to be most
relevant to this presentation?
A. Past psychiatric history
B. Assessment of insight
C. Alcohol use history
D. Developmental history
E. Family history of dementia
C. The features of acute confusion, nystagmus, ocular palsy, and ataxia are suggestive of
Wernicke’s encephalopathy, possibly secondary to alcohol use in a 50-year-old male. In females,
an additional likely cause of Wernicke’s encephalopathy is hyperemesis secondary to pregnancy
or anorexia. Wernicke’s encephalopathy is an indirect result of thiamine defi ciency. It may be
precipitated on administration of glucose to a confused patient in the casualty department.
Glucose causes a sudden depletion of the available thiamine stores (via thiamine-dependent
transketolase). In people recovering from Wernicke’s encephalopathy, 80% develop a Korsakoff ’s
syndrome which is characterized by defi cits in anterograde and retrograde memory, apathy, an
intact sensorium, and relative preservation of other intellectual abilities.
An 18-year-old male, recently started on a medication, presents to the
A and E department with slow, long-sustained, contorting, involuntary
movements and postures involving proximal limb and axial muscles. Which
of the following medications is most likely to cause the above presentation?
A. Propranolol
B. Diazepam
C. Risperidone
D. Procyclidine
E. Sertraline
C. The clinical situation given here is an example of an acute dystonic reaction in a young
male, possibly a psychotic patient, who has been started on an antipsychotic. Given the options,
risperidone is the most likely causative agent. Procyclidine may relieve the dystonic attack.
Alternatively, a benzodiazepine or an antihistamine with anticholinergic action may be used. Risk
factors of dystonia include male gender, age younger than 30 years, and using high dosages of
high-potency, typical antipsychotics.
A 21-year-old female presented to the emergency department with
complaints of recurrent attacks of severe dizziness, lasting for 10 to 20
minutes. On examination during the episode of dizziness, there was no
evidence of nystagmus. Which one of the following is true?
A. Her symptoms may be associated with fear of going to places from where escape is
impossible
B. Deafness is usually present
C. Vertigo without nystagmus is suggestive of central vertigo of brainstem origin
D. Antihistaminic medications are likely to be effective in this case
E. None of the above
A. Absence of nystagmus during an attack of dizziness almost always rules out vertigo
secondary to labyrinthine or brain stem pathology. The dizziness here is most likely to be
psychogenic in origin – related to panic attacks. This may be accompanied by agoraphobia, which
is described as a fear of being in places from where escape may seem impossible or diffi cult.
