Dr. Ziad Arandi (Guidlines in Palestinian Board Exam in Psychiatry)

1. M . C . Qs , Clinical , Qral ,. OSCE
Dr . Ziad . N . Arandi
Assistant Professor of Psychiatry
An - Najaah Univrsity
D . P . L Psych - London
B . C . i, Psych - Lm.10.0.11
; . B . C Psych – Amman
Chapter “ I”
Multiple Choice
Questions
MCQs from part of the preliminary test and the Palestinian board certificate
exam .ln the MCQ there is no problem in presentation since the answer sheet
has a uniform format and are marked by computer recall is less of problem

2. in that most of the information needed is present in the questions e Judgment
on the other hand is crucial .
In the form of the MCQs there are sixty system questions with five parts (i e.
a total of 300 questions)., Each must be answered by either true or False.

3. The response to one part of a stem does not .influer.ce or exclude possible
responses to any of
the others {I.e , -there may be -five true or five false answers in any stem or
any other combination).
Two hours are available to answer the papers. Answers are recorded onto a
computer niarking sheet with the soft lead pencil.
Pe11cil ,is provided.
It is important that all sixty systems are. Answered either 'True' or 'False ' in
each of the 300 spaces. ··
A sample answer sheet is sent out to all candidates 1,id it is important to be
familiar with~ this and the order of questions cm lt.
The computer marks the sheet by giving on mark for each correct answer.
The wording of MCQs may be difficult for those unused to this form of
examination in that it can appear ambiguous.
There is a consensus that the following term has these implied meanings:

4. Occurs -makes no statement on
Frequency {i.e. a recognized occurrence)
Recognized (feature OR association) reported on as a feature/association-it
has been

5. Characteristic OR Typical -feature which occur so often as to be of sum
diagnostic significance and if it were no present might lead to some doubt
being cast on the diagnosis.
Essential feature of -must occur to make a diagnosis.
Specific or pathognomic -features that occur in the named disease and no
other .
I Can be OR may be - that it is recognized (i.e. reported to occur)
Commonly/Frequently/is likely/ often - imply a rate of occurrence greater
than 50%
Always/Never -Suggests that there are no recognized exceptions.
Particularly/ associated - the association is significant in samples with
sufficient numbers.
Watch out for universal statements including only , never, exclusively ,
always , invariable - they are almost always false

6. Be wary of questions that appear to contain double negatives. Extra care is
needed in answering them. Even when the answer is clearly known
I.e. ... the following are not necessarily contra-indications to ECT:
. pregnancy during the first treatment {T)
. acute catatonic excitement (T)
. patient over the age of 80 years (T)
. anorexia nervosa (T)
. clinical picture of depression strongly colored (by Hysterical
symptoms) (T)
I some questions trap by virtue of names which sound
alike
e.g. catatonia, catalepsy , cataplexy .
others bring in names or terms from other Ares which sound right even
though they are wrong. e.g. the following are correctly paired with the
concepts they introduced :

7. . Jung : introversion (T)
. Adler : organ inferiority (T)
. Eugen Bleuler: dememtia (F)
. Freud: dissociation (F)
. Janet : conversion (F)
Technique and Timining:
Essentially , the aim of the candidate should be to score the highest mark
possible there are always rumors as to the number of questions that have to
be answered to pass,

8. Chapter “ II”
Clinical
Examination

9. Build up:
1 . Where is it
2. What cases they can possibly present.
3. Points you must not miss
3. What to wear.
The final count down :
. ignore intimidating candidates
. check examiner{name , nature ... )
. rehear your thoughts . introduce your self

10. Rehear your first sentence. (Basic introduction , name , age .. )
On The Exam:
A: Correct attitude Cues
-social
-Respectful + Confidence
8: Case Presentation (10 min)
Be -Confident -Concise
-Sympathetic
-Enthusiastic
DO NOT -Criticize (blame the
patient , blame the case or express
that the case is difficult)

11. -be hesitated
-take too long
-give too much detail
Do not say the patient is liying by saying he claimed , he denied , he is
promiscuous
Do not give the diagnosis alone say its differential Diagnosis ( I , II , Ill) If
they ask you what is your impression they mean The . formulation.
C . Questions:
-Look interested
-Answer to the point
- expect to be provoked
-stick to your opinion
-do not anger

12. Some example questions in clinical exams:
· Q : Tell about the case within few
minutes
· Q;What is the novel points about
the case
· Q : What is the crutial points about the case, this means: History,
mental state, diff. diagnosis,
,
ETIOLOGY.
· Q - What are the inquiry or investigations do you do
This means secure information

13. Q - What is your MANAGEMENT ? means investigation, in pateints

14. Chapter “ III”
In Oral

15. DON'T
- be evasive
be too Cautious
- Put your foot in it
- Worry if interrupted
- Worry if they change the topic quickly
- Anger
** Admit if you don't Know in some points Be great full for Criticism
Remember examiners are humans
ID
Example Oral questions
· What do you ask the staff nurse in case of suicide cases?
· What is your assessment(start your answers with short introductory
statement then details of the problems, history, mental state, diff. diagnosis
and etiology)

16. Psychiatric_Ob.iective Structural Ciinicai Examnination

17. Chapter “ IV”
OSCE

18. ·
)r . Ziad . N . Arandi
Assistant Professor ol I'sycchiatry An - Najaah Univrsity
D . P . L Psych - London B . C . L Psych - London J . B . C Psych ·· Amman

19. Objective Structured Clinical Examination <OSCE>
The OSCE was introduced for the first time in Spring 2003 and it replaced
the individual patient assessment (i.e. the long case). The OSCE consists of
12 stations that test the range of psychiatric knowledge and skills acquired
within first 12 months of basic specialist training (i.e. at the SHO level). The
examination may include one or two additional pilot stations, the results of
which do not count towards the overall result of the OSCE. The patient's role
is played by a role player (actor/actress).
There is ONE examiner at each station, who observes the candidate as they
perform their task. The examiner does not get involved except in exceptional
circumstances. Candidates have ONE minute before entering each station to
read the instructions. These include the purpose of the station and basic
information

20. About the pateints e.g. name, age, major

22. OSCE ADVICE
THE EXAM STRUCTURE
There are 12 7-minute stations.
There may be a rest station, but tbis depends on the examination centre. You
have l minute to read the scenario and tasks.
You will then hear a buzzer: walk into tbe station and perform the tasks. You
have 7 minutes to complete your tasks.
At 6 minutes, a buzzer will sound, reminding you that there is J minute left
to go At 7 minutes, a buzzer will sound: you must stop whatever you are
doing.
Move on to the next station.
Total examination time: I hour and 36 minutes (excluding any rest stations).
Instructions vary in length, and number of tasks will differ between stations.
If you finish early, remain in the station.
Practising OSCEs over will give you an inherent sense of the timings.

23. EXAMINATION CONTENT
Basic components of history-taking, examination skills (e.g. cranial nerves,
motor system, fundal examination), practical skills (e.g. application of ECG
leads), emergencies {e.g. resuscitation) and communication skills (e.g.
explaining treatment, consent to treatment, prognosis) are all likely to be
examined.
MAnKING
According to the Royal College of Psychiatrists, a minimum of grade C in at
least nine stations is required to pass. Failing any station witb grade E
(severe fail) means that tbe candidate fails the OSCE overall (see
www.rcpsych.ac.uk/traindev/exams/index.htm). A useful way of revising is
to think, at each station that you practise, about what tbe examiner might
have on his or her mark sheet. In our answers, we have included points that
we believe the examiner will be marking you on.
OSCE TECHNIQUE
Remember: IEP (I'm an Excellent Psychiatrist).
Introduce yourself to the patient (use their name if given): 'Hello Mrs Jones.
My name is Dr Smith:

24. Explain what it is you have been asked (or would like) to do and make sure
they are okay witb this (permission).

25. , oscr advice
DEALING WITH THE ACTORS
You are acting as much as they are: you must pretend that all the scenarios
are =I, otherwise you might underperfonn.
Always put the 'patient' at ease.
Try to develop rapport (supportive remarks).
Listen to what they are saying to you - don't ignore important cues. Actors
have been instructed to be difficult or to get upset at certain stations, so don't
take it personally; you can score highly if you handle it well.
EXAM DAY
There have been reports of confusion at the OSCE centres - he prepared for
this.
Be blinkered as you pass through your stations. Don't get distracted by
another candidate performing at their station.
Remember that the candidate before: you is direct competition. You must
'up' your performance on exam day.

26. Read each station and the set tasks ve,y carefully.
Most of us are anxious on exam day, but try to settle down quickly. If you
are too anxious, the examiner becomes anxious about you (practising will
reduce anxiety levels).
Never dwell on a previous station, even if it seems disastrous. You gave
your best shot, so now move on. Failure to do so is likely to damage your
concentration and performance in the next one or two stations.
Don't attempt to read what the examiner might be wrtting.
Always thank the patient at the end.
Talk to the examiner only if instructed to do so or if they speak directly to
you. You can acknowledge the examiner at the end of the station if you
wish, but don't overdo it
ISSUES THAT CANDIDATES HAVE RAISED WITH US BEFORE THE
EXAM
I'm shy, but I think I know enough to pass: what should I do? On the day,
you must appear confident and speal{ clearly, so both the examiner and
actor can bear you.. Practise as much as you can with seniors and colleagues.

27. Some people find it helpful to record their practice sessions using a small
cassette recorder and listening back to themselves.
I find it hard to keep to the seven minutes
By practising repeatedly, you will get a good feel for 7 minutes. If possible.
do not finish a station too early.

28. Sdting .the scene is a useful way to start and can give you some ttlinkmg
time should you RqDire iL For example, Tm sony to hear you've been
having side effieds from the medication. Would it be alright if you told me
how the medication bas been affecting you?'
GENERAL ADVICE
Try to impart infunnation to the patient dearly {this needs practice). Clear
speech rommunicares intdligence and competmce.
Speak in lay terms to patients.
• /Speak in professional terms in stations where the actor pmrnds to be a
colleague or the 1asks directly involve the examiner.
Start each interview with open qurstions and then become more fuemed. e.g.
'Can you tell me how you &av., been fttling nn:ntly?'
Avoid swing questions. e.g. 'Are you feeling high or low?' - not good. Avoid
leading questions. e.g. 'You're feeling low now. aren't you?'
. Don't ignore non-'ffiiial signs. e.g. tremoL
• / Pauses and moments of silence are acceptable. especially after emotional
responses. Be empathetic in such situations.

29. Exert control if you find the patient veering off the sul!iect. Bring them back
gently to the task you need to complete. 'We were just tailing about the
voices-.' 'fo come back to the voices you've been hearing._' 'Could you tell
me some more about the voices?'
It is bettez- to say you don't know something than to mate it up. Sommmes,
delaying an answer works well 'I will look into this and get back to yon'.
You must practise doing more than one station at a time so that you learn
how to overcame a poor performance in a previous station.
Although time will often be short; appearing umushed and calm looks
prolessional.
Know the ICD-10 diagnostic criteria fur the common conditions. Think safe
and consider the risk element in each station.
Have a general medical colleague run through physical examinations of the
main systems [cardiovascniar. etc.) with you so you will feel more
confident.
DEMEANOUR
Body language 'h vi:,y important. Do not slouch, fold your arms or cross
your legs. Rather, sit on the chah; with both reet on the ground, leaning

30. slightly towanls the actor, Your hands should be together or holding paper.
Be confulent and professional but not arrogant, ---Remaining calm
tbroughoot inspires confidence in the examine&
Smiling if appropriate shows that you are relaxed and demonstrates
confidence.
Be kttn and in~ in the patient

31. SKILLS TO BE TESTED IN OSCEs
· Communication skills: Then, will be a communication clement in
most stations. However. in some stations, this will be the principal skill
tested.
· lt!Slory taking.
· Clinical examination skills: The candidates are asked to examine a
partirular part of the body of simulared patients or perfunn the examination
on an anatomical modd. They should ONLY take a history OT perform the
examination according to instructions. They may be asked to explain their
actions to the patients and/or examiners,
· Practical skills/use of equipment This is to assess some of the
practical skills a senior house officer or equivalent trainee needs to possess.
The stations concerned will nonnally involve anatomical models rather than
patients.
· Emergency management These stations will test whether the
candidates know what to do in an emergency situation. The candidates may
be asked to explain what they are doing either to the patient or to the
examtner,

32. · ~ of matlal wsonlr:ts
· Classification of mental disorder.;
· Hislmy~g Mental state examination
· PhysicaJ/neuroJogical examination

33. · Assessing risk in patients with memory disorders,
· Eliciting feature; of chronic fatigue syndrome, morbid jealousy, sleep
disorders, depersonalization.
· Eliciting symptoms of post-natal depression, maternity blues,
puerperal psychosis,
· Risk assessment in the above patients.
· Eliciting collateral history from relatives/carers regarding
schizophrenia, depression, bipolar affective disorder, dementia, substance
misuse, etc.
· Eliciting history of seizure; in a patient on clozapine, phenothiazines
or tricyclic and other antidepressant drugs.
· Assessing compliance of patients suffering from long-term mental
illnesses.
· Assessing a patient's wellbeing in the clinical setting.
Clinical examination skills

34. The candidates are assessed on their ability to conduct a physical
examination of simulated patients. In certain circumstances, the examination
will be carried out on a manikin or model. They should only take a history or
make a diagnosis if instructions require them to do so. They may be asked to
explain their actions to the examiner and the patient as they go along.
Examples include:
o Cranial nerves
Motor and sensory nervous systems
· Extrapyramidal side effects
· Fundi
· Signs of alcohol and drug dependence
· Mini-Mental State Examination
Assessing cognitive functions in elderly persons, Wernicke-Korsakolf
syndrome
· Assessing nature, form and content of thought disorders Assessing
frontal lobe functions
Assessing dominant and non-dominant hemisphere functions

35. Performing cardiovascular examination, especially risk factors for vascular
dementia
· Examining patients with possible eating disorders and thyroid
dYsfunction
Practical skills and use of equipment
These stations assess some of the practical skills an SHO would have learnt
during the fust year of training. The stations concerned will usually involve
anatomical models rather than patients. The candidates must also be able to
use appropriate equipment when carrying out an examination.
Determination of correct settings on an ECT apparatus e Application of ECT
electrodes

36. Liaising with general hospital colleagues regarding disturbed patients.
Explaining driving regulations in relation to recent episodes of severe
depression and psychosis, drug and alcohol dependence, etc.
Explaining drug treatment in pregnancy, puerperium, children and elderly
persons.
History taking
Eliciting psychotic symptoms, including Schneider's first rank symptoms
from patients with schizophrenia, schizoaffective disorder, mania,
depression, persistent delusional disorder, etc.
Eliciting delusional beliefs.
· Eliciting hallucinatory experiences.
Eliciting salient features of mood disorders, e.g. depression, mania. Eliciting
negative cognitions in depression.
Eliciting features of normal, abnormal and prolonged grief reactions.

37. Eliciting salient features of anxiety disorders, e.g. panic disorder,
agoraphobia, social phobia, specific phobias, obsessive compulsive disorder,
generalized anxiety disorder.
Eliciting salient features of post-traumatic stress disorder, adjustment
disorders and stress reactions.
Eliciting features of anorexia and bulimia nervosa with or without co-
morbidity, such as type I diabetes mellitus (insulin-dependent diabetes
mellitus).
· Eliciting salient features of alcohol and drug misuse as well as
dependence.
Eliciting features of frontotemporal dementia, Alzheimer's disease,
multi¬infarct dementia, Lewy body dementia, Pick's disease, Creutzfeldt-
Jakob disease, Huntington's disease, Parkinson's disease and multiple
disseminated sclerosis.
Eliciting salient features of schizoid, schizotypal, antisocial (dissocial), and
borderline (emotionally unstable), histrionic and narcissistic personality
disorders.
Eliciting salient features of somatoform disorders, e.g, somatization,
hypochondria, persistent somatoform pain disorder.

38. Eliciting features of body dysmorphic disorder, transsexualism, dual-role
transvestism, fetishism, fetishistic transvestism, exhibitionism, premature
ejaculation, erectile impotence, etc.
Eliciting history of sexual dysfunction of a patient on psychotropic drugs
from his or her partner.
Assessing risk of deliberate self-harm and suicide in a variety of settings,
e.g. accident and emergency, general hospital wards, police station.
Assessing risk of aggression/violence in a variety of settings, e.g. accident
and emergency, out-patient clinic, reception area, general hospital wards,
police station.

39. PREPARING FOR OSCEs
Candidates should start thinking about OSCEs in the first six months of their
basic specialist training. The following lists should be useful for candidates
when preparing for OSCEs with the help of their colleagues. The lists are
not exhaustive but cover the commonly asked questions and exercises.
Communication skills
Active listening.
Involving patients/carers in decision making and checking their
understanding.
Communicating with other healthcare professionals, e.g. discussing a patient
with a senior medical colleague.
Breaking bad news, building rapport and showing empathy, respect and
sensitivity to others' emotions and coping with strong emotions of other
people.
Seeking informed consent for investigations, electroconvulsive therapy
(ECD, antimanic drugs, antipsychotic depot injections, clozapine.
Dealing with anxious or angry patients or carers.

40. Giving instructions on discharge from hospital
· Giving advice on lifestyle, health promotion or risk factors.
Dealing with complaints.
Explaining cognitive-behavioural therapy and other psychological
treatments for depression, anxiety disorders, psychotic symptoms, eating
disorders. Explaining counselling, psychodynamic therapy, cognitive
analytic therapy, interpersonal therapy, family therapy, group therapy.
Explaining diagnosis and prognosis of common mental disorders, e.g.
schizophrenia, depression, bipolar affective disorder, dementia, eating
disorders, anxiety disorders, substance misuse and dependence.
· Explaining investigations, e.g. tests for clozapine and lithium therapy,
preparation for ECT, brain imaging, etc.
Explaining treatment (acute, maintenance, i.e, to prevent relapse, and
prophylaxis, i.e, to prevent recurrence):
- Antidepressant drugs
- Antipsychotic drugs including depot injections and clozapine
- Antimanic (mood stabilizer) drugs

41. - Antidementia drugs in mild, moderate and severe dementias
- Drug treatment in special situations, e.g. antidepressants, antipsychotic and
antimanic drugs in pregnancy and puerperium.
Explaining detention and treatment under the Mental Health Act 1983.
Assessing a mute patient.
· Assessing the capacity to consent to psychiatric: treatment and
surgical/medical procedures or treatments.

42. Application of ECG leads
· Interpreting ECG, electroencephalogram (EEG), blood tests,
radiographs, computed tomography (CT) and magnetic resonance imaging
(MRI) scans
Emergency management
Cardiopulmonary resuscitation (CPR) Control and restraint
Rapid tranquillization .

43. ( stations and advice answers) STATION 1-
111c maln<rof a tt----ald man has aslml tD ,a, yon. Your mun has rettn1ly
diagnosal her .son with sdlizophn,nia am she has some questions for you.
Before his admission. he had been fiankly p,ytltulic and threalDling towaJd;
her. He thought that 11,115 was afb:r him and that bis life was in danger.
His mother iniliaRy old not bcliew: that he was mentally unwell and lhougltt
he was using illidt drugs and lazing around. Slit admits 1D having hem
bosl:iJe and aitical of him and that there were many arguments at home.
She asks you: What is sthimplua1ia? Is it a spit pe15111131ily?
What will ~ the t:ffttls of 111e illness m hd' son?
What are the diffaatc,es betwcai pasitM and ~ symptoms?
What beatmt:nts are available? - -
STATION 2
1hest, parenls have a 17-ycir-old dauglm,r Rllddly diagnosal lllilll anorexia
nenrusa. 1hq, had nom,ed for 5IIIUlle time thatshc would notmtwilh 11mn
at meal tinKS and was -.g weight. 1hq, have "'3nl of 1he illness but have a
number of questions lhatff,ey would th 1D ask.

44. What are the symptoms Qf aoomcia nm,vsa?
What is the diffaaltt belwtt!J bulimia and anorexia? What Clll2S anomda?
What do you adrise WC make htt cat?

45. STATION t-: SCHIZOPHRENIA
THE EXAMINER'S MARK SHEET
Cowrnunh.:atlon skills Schizophrenia explanation Effects on her son
Positive and negative symptoms Treatments available
Global rating
INTRODUC'..E. 'lQIJ.11SF,_1~'i
'Hello, nice to meet you. My name is Dr Smith.'
SET THE SCENE
'Thank you for coming to see me. I understand you have some questions
about schizophrenia. Is that rotTPr.t?'
'Would it be OK to ask you what you already know about schizophrenia?'
FIND OUT WHAT THEY ALREADY KNOW
Remember to speak in lay terms. Be empathetic.
INFORMATION ON SCHIZOPHRENIA
What is schizophrenia?

46. 'Schizophrenia is a serious mental illness. It affects about one in every 100
people and usually comes to light in the late teens or early adult life.
Thinking, emotions and behaviour are often affected. Unusual behaviour
may include delusions, hallucinations and/or a lack of insight:
Ask whether they know what these terms mean. If not, then explain them.
'Generally speaking, around one-quarter of affected people make a
reasonable recovery, but for others it can be a lifelong illness and can be
quite disabling:
Is it a split personality?
'Many people believe this from what they have heard in the media, but this is
a common misundeP.»tanding.'
What are the differences between positive and negative symptoms?
'The symptoms of schizophrenia can be divided into two groups for
convenience, called positive and negative symptoms. Not everyone affected
will experience all of the possible symptoms.'
Positive symptoms include delusions. thought disorder and hallucinations:
Delusions are strongly held beliefs that are unusual and raise. Often, no
amount of persuasion wilJ convince the person othemise .

47. Thought disorda is a disturbance of thought precesses, Sentences may make
little or no sense. wonls may be used inappropriately and new wonls may be
ma<kup.
Hallucinations are experiences of hearing, seeing, feeling or smelling things
that are not actually there. They feel very real and can be frightening to the
person experiencing them. They make some people feel vulnerable and
suspicious of others.
Negative symptoms usually occur in chronic schizophrenia after a number of
years. Individuals become quiet and withdrawn and appear unemotional
Loss of drive. lad of interest in things and lad of motivation are common
features; often there is also deterioration in the person's level of personal
care.
What will be the effects of this illness on my son?
'Of course, everyone is individual and some people do much better than
others. In our experience, people with schizophrenia often have difficulties
with .. :
Wori<. {often difficult to commit to the demands of employment}
Socialising, e.g. maintaining relationships

48. Depression (low mood and suicidal thoughts are common) Low self-esteem
What treabnents are available?
'Firstly, the earlier and quicker someone is diagnosed and treated, the better:
'Some people make a full recovery:
Discuss the importance of the following and their roles in management:
Medication
The multidisciplinary team Family
Day centres and work projects
Psychotherapy [targeted at abnormal perceptions or mood symptoms)
Organisations: Rethink, Mind, SANE
ASK WHETHER SHE HAS ANY OTHER QUESTIONS THANK HER

49. STATION 2: ANOREXIA NERVOSA
.1 THE EXAMINER'S MARK SHEET Communication skills
Symptoms of AN
Differences between AN and BN
Aetiology Dietary advice Global rating
INTRODUCE YOURSELF
'Hello, nice to meet you. My name is Dr Smith.
SET THE SCENE
'! understand your daughter bas recently been diagnosed witb anorexia
nervosa and you have a number of questions for me. Is that correct?'
FIND OUT WHAT THEY ALREADY KNOW
'Would it be OK to ask you what you already know about anorexia nervosa?'
INFORMATION ON ANOREXIA NERVOSA Symptoms
Fear of fatness
Undereating

50. Excessive loss of weight Increased exercise Monthly periods stop
'You may have noticed your daughter missing meals, eating little, avoiding
eating in public, believing she is too fat, exercising frequently, using the
bathroom after meals, vomiting or using laxatives.'
Differences between bulimia and anorexia Bulimia: Fear of fatness
Binge-eating
Vomiting/purging/use of laxatives
Normal weight (often also underweight) Irregular periods
Many young women want to be slimmer and more attractive, even if they
are not overweight. Sometimes, despite being of normal weight, the need to
be slimmer becomes an obsession, which can lead to problems. ln AN.
worries tend to be about weight, which leads to a dramatic restriction in
nutritional intake. Whilst someone witb BN also worries about their weight,
they switch between limiting their nutritional intake and eating to excess in
short periods of time

51. [bingeing), They commonly induce vomiting or use laxatives to limit weight
gain.
Aetiology
A number of important factors are thought to be involved:
Social: media, fashion, advertising, peers, popular diets.
Control: weight loss can lead to a sense of control when other areas of
the patient's life feel out of control.
Puberty: extreme weight loss can delay puberty and sexual development;
the demands of maturing and growing up therefore can be delayed.
Family: refusing food at meal times can exert control in family
interactions; eating disorders can run in families.
Life events: AN can be triggered by a traumatic episode such as a
bereavement or the divorce of one's parents.
Dietary advice
It is common for children with AN to resent their parents trying to interfere
with their eating, and such pressure may worsen the situation. The person

52. may respond better to the advice of someone outside the family, such as an
eating disorders specialist or the family doctor. If she has not already been
referred to a specialist, then this should be recommended.
The Royal College of Psychiatrists advises the following:
Eat regular meals, including breakfast, lunch and dinner. Eat a balanced diet.
Include carbohydrates with each meal. Don't skip meals.
Avoid sugary and high-fat snacks. Take regular exercise.
Try not to be influenced by other people skipping meals or commenting on
weight.
Offer the parents some information leaflets about the disorder.
ASK WHETHER THEY HAVE ANY OTHER QUESTIONS
THANK THEM

53. STATION 3: OBSESSIVE-COMPULSIVE DISORDER
THE EXAMINER'S MARK SHEET
Communication skills Empathy
Psychological treatment
Pharmacological treatment Answertng other questions Global rating
INTRODUCE YOURSELF
'Hello, nice to meet you. My name is Dr Smith.'
SET THE SCENE
Tve been asked to talk to you about the treatments available for obsessive-
compulsive disorder (OCDJ:
FIND OUT WHAT THEY ALREADY KNOW "Can I start by asking you
what you already know about OCD?'
'Do you know any of the treatments available and what they involve?' 'Have
you had treatment yourself in the past? What was this?'
INFORMATION ON OCD TREATMENT Management

54. A combination of psychological and pharmacological therapies is probably
the most effective approach. (It is appropriate to gauge the nature, e.g.
thoughts and/or acts, and the severity of the illness before discussing any
management with this patient)
Reassurance is a key component in the management of OCD. OCD is not a
condition that goes away overnight - it is usually chronic and fluctuating.
Exposure and response prevention
Performing rituals can relieve anxiety, but in general the more the rituals are
performed, the worse the patient gets. Therefore, it is important to reduce the
number of rituals performed.
E:rposure must occur for the patient to feel anxiety and want to perform the
ritual This is done by, for example, having the patient touch public handrails
or door-handles and then preventing them from washing their hands.
The response prevention is the tricky bit, and in reality anything that will
work in practice will be used. This may include verbal coaxing and
persuasion, distraction, and performing or engaging in alternative behaviour.
Family members and friends can be enlisted as therapeutic allies. However,
at all stages it is important to avoid conflict. This only causes setbacks.

55. 'Because lithium can interfere with thyroid function, we like to check the
thyroid before we start treatment, and then 6-monthly thereafter. We also
take a tracing of the heart to confirm that there are no pre-existing
abnormalities that may
worsen with lithium treatment:
A concentration of 0.5-1.0 mmol/L is usually sufficient for clinical effect.
Because the dose has to be kept within certain limits, the blood has to be
monitored initially after 5-7 days, and then weekly until the correct level has
been reached. Finally, levels should be monitored every 3-6 months when
stabilisation has occurred.
Lithium is prescribed as a single dose at night.
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Toe most common side effects are tremor, polynria, weight gain and nausea.
The tremor can sometimes be treated with a beta-blocker.

56. Toe nausea can be counteracted by taking the lithium with food; sometimes,
changing the preparation of lithium can make a difference.
Mention interactions with other drugs, e.g. diuretics, NSAIDs, haloperidol.
Offer a patient inforrnation leaflet.