Mastering Psychosis Assessment in PLAB 2: A High-Yield OSCE Guide

Practice a case with the AI patient 🤖

Assessing Psychosis in PLAB 2

In any PLAB 2 scenario where a patient presents with bizarre behaviour, hallucinations, delusions, or paranoia, you must screen for psychotic symptoms systematically.

🔍 Key Areas to Cover

1. Hallucinations

✅ Definition: Perception in the absence of external stimulus.

Ask:

• “Have you seen things that others cannot see?”

• “Have you heard voices when no one else is around?”

If yes:

• “Can you tell me more about these voices?”

• “What do they say to you?”

• “Do they speak directly to you or about you?”

• “Do you recognise the voice?”

• “Are they telling you to do anything?” (Command hallucinations – assess risk)

Other modalities:

• “Have you ever felt unusual sensations on your skin?” (tactile)

• “Have you smelled things that others cannot smell?” (olfactory)

2. Delusions

✅ Definition: Fixed false beliefs not in keeping with cultural norms.

Ask:

• “Do you feel people are talking about you or plotting against you?” (persecutory delusions)

• “Do you think you have special powers or abilities?” (grandiose delusions)

• “Do you feel that TV/radio messages are meant specifically for you?” (referential delusions)

• “Do you feel that your thoughts are being read or controlled by someone else?” (thought broadcasting/insertion/withdrawal)

3. Thought Disorders

✅ To assess disordered thinking:

• “Have you noticed your thoughts getting jumbled or racing?”

• “Do you find it difficult to keep track of what you are saying or thinking?”

Observe speech for derailment, tangentiality, neologisms, word salad during the consultation.

4. Insight

✅ Assess awareness of illness:

• “Do you believe these experiences are part of an illness, or do you feel they are real?”

5. Risk Assessment

Always assess risk to self and others:

• “Have you ever felt like harming yourself because of what the voices say?”

• “Have the voices told you to harm anyone else?”

• “Have you acted on what the voices told you to do?”

🌟 Mnemonic for Psychosis Assessment:

“HDT IR” ➔ Hallucinations, Delusions, Thought disorder, Insight, Risk

🔑 PLAB 2 Clinical Tips

✔️ Normalise questions: “These questions may sound unusual, but I ask them to everyone with similar experiences so I can understand how best to help you.”

✔️ Prioritise command hallucinations and risk for immediate safety concerns.

✔️ Document mental state examination findings clearly, including appearance, behaviour, speech, mood, thoughts, perception, cognition, and insight.

Rapid Psychosis Screening (2-3 mins)

If a patient presents with bizarre behaviour, confusion, or unusual beliefs, use these quick screening questions:

1. Hallucinations

• “Have you seen or heard things that others cannot?”

• If yes, ask:

  • “What do they say or do?”

  • “Do they talk directly to you or about you?”

  • “Do they tell you to do anything?” (command hallucinations → assess risk)

2. Delusions

• “Do you feel people are watching you, talking about you, or trying to harm you?”

• “Do you feel you have special powers or abilities?”

• “Do you think TV or radio messages are directed at you?”

3. Thought Disorder

• Observe speech flow, logic, coherence.

• Ask:

  • “Do your thoughts ever get mixed up or hard to follow?”

4. Insight

• “Do you feel these experiences are part of an illness or are they real for you?”

5. Risk

• “Have the voices ever told you to harm yourself or anyone else?”

• “Have you acted on these commands?”

📝 Mnemonic: "HDT IR"(Hallucinations, Delusions, Thought disorder, Insight, Risk)

Mini-Mental State Examination (MMSE): A Practical Guide for PLAB 2

The Mini-Mental State Examination (MMSE) is a quick, structured tool to assess cognitive function, widely used in memory clinics, general practice, and OSCE stations like PLAB 2.

🔍 Why is MMSE important in PLAB 2?

• Often tested in elderly patients with confusion, memory problems, or dementia screening scenarios.

• Assesses orientation, registration, attention, recall, language, and visuospatial ability.

• Marks are assigned to each section, with a maximum score of 30.

Quick MMSE – Short Version:

Use this when you have 2–4 mins only (like in PLAB 2).

👉 The key aim is to screen for significant cognitive impairment. You cannot give a precise severity stage, but you can decide if more testing is needed.

What to ask in Short MMSE

A) Orientation:

• “What is today’s date?”

• “What day of the week is it?”

• “Where are we now?” (hospital/home/clinic/town)

✅ → Covers Time & Place (4–5 marks)

B) Registration:

• “I’m going to say 3 words: Apple, Table, Penny. Please repeat them back to me.”

✅ → (3 marks)

C) Attention:

• “Please spell WORLD backwards.”(D–L–R–O–W) OR

• “Start from 100 and keep subtracting 7.”

✅ → (5 marks)

D) Recall:

• “Can you please repeat the 3 words I asked you to remember?”

✅ → (3 marks)

E) Basic Language Check (if time):

• “What is this?” (point to pen or watch) — naming (2 marks)

• “Please repeat: No ifs, ands, or buts.” — repetition (1 mark)

So your Quick MMSE covers about 15–20 marks out of 30.

How to interpret the Short MMSE

👉 Rule of thumb (not absolute):

• Normal: They get most right — e.g., only minor slips on date but good recall.

• Impaired: Struggling with orientation, cannot register or recall 3 words, poor attention → suggests moderate-severe cognitive impairment.

You can’t calculate an official staging with only part of the MMSE, but here’s a simple quick guide for your OSCE:

Mini version result	Likely meaning
Fully oriented, good recall	Likely normal cognition
Disoriented to time/place or unable to recall words	Mild to moderate impairment
Major disorientation, no recall, poor attention	Likely moderate-severe dementia

✅ REMEMBER:Always say — “A full MMSE or alternative cognitive test like ACE-R would be needed to confirm severity and monitor progression.”

What conditions you might pick up

• Mild Cognitive Impairment (MCI): Might only have mild recall problems.

• Dementia (Alzheimer’s, vascular): Orientation + recall + attention all affected.

• Delirium: May fluctuate — sudden confusion, worse at night, clouded attention.

• Depression (pseudo-dementia): May say “I don’t know” but answers improve with encouragement.

Takeaway for PLAB 2

Short MMSE:

• Covers Orientation, Registration, Attention, Recall.

• Screen only.

• If any area abnormal → explain you’ll arrange full MMSE, bloods, imaging, MDT referral.

🔑 KEY LINE:"I have done a brief cognitive screen. Findings suggest possible impairment. I would complete the full MMSE and appropriate investigations to rule out reversible causes and assess severity."