Clinical Vignettes and How to Ace Them

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tangled rope representing vignettes

What are clinical vignettes?

Clinical vignettes are a huge portion of most board exams. They present a scenario to the reader which includes key information they will need to answer a series of questions.

These questions may be syndrome related to identify a condition the case patient is being presented with; they may be symptom related to determine a symptom of a given condition based on the patient’s given history; or they may be treatment related to decide the best course of action for treatment of a given condition. Really, the sky is the limit when it comes to these tricky questions.

Vignettes are helpful learning tools. They hone in on your critical thinking, they test your attention to detail, and they provide a more realistic experience of how to discern information you’re given from a patient to make the best choices. Sometimes they can seem like a giant, tangled mess. Here’s how to untangle it and get started!

Where to start?

Let’s use an example (straight from our question banks!):

“Matt is a 13-year-old patient who is brought to see you because of behavioral problems. His parents report that in the last year Matt has had four separate occasions of intense aggression resulting in physical violence. The outbursts do not last long, typically abating within 20 minutes. The behavior is not in character for Matt and do not seem precipitated by a specifically intense trigger. In one instance he was unable to go to a friend’s house; he began screaming and hitting walls which lead to his hands becoming badly bruised. His outbursts are causing significant distress to his family, who are becoming more and more apprehensive of him harming them or himself. There have not been any major life events in the last year, and he is not diagnosed with any existing medical or mental conditions.“

Following this, you are presented with question such as: “What is the likely diagnosis?” or “What prognostic factors could have increased the likelihood of Matt developing this condition?”

Break it down

The first thing to do is look for key demographic and symptom information. In this vignette, we have an adolescent patient who is male. The vignette also tells us right away that he has behavioral issues. Knowing this narrows down the possibilities. Occam’s razor is true for most cases; you wouldn’t assume a 13-year-old is dealing with frontotemporal dementia for his behavior problems!

Next, look for symptoms ranges. This vignette tells us he’s been experiencing issues for the last year. This is important to know if the symptoms are a new, acute experience or something that has been persisting. It also helps as most diagnoses have requirements on how long symptoms must be present for.

Then, look for the 4 D’s: deviance, distress, dysfunction, and danger. Do the behaviors being presented fit into these criteria? Or is the patient experiencing sub-clinical symptoms with poor coping skills?

Process of Elimination, Vignettes style

Clinical vignettes are almost always multiple choice questions. You’ll be given five or more answer choices with each question and must choose the best option(s). Sometimes there’s more than one answer! Using our example above of “What is the likely diagnosis?“, you may be given answer options of:

A Oppositional defiant disorder
B Intermittent Explosive disorder
C Conduct disorder
D Disruptive Mood Dysregulation disorder
E Antisocial personality disorder

Least likely choices:

Now we need to look at each answer, and applying Occam’s razor, eliminate the least likely choices. Conduct disorder (choice C) does not match the presenting case as Matt does not show persistent disregard for other people or animals, deceitfulness or theft, or serious violation of rules. He does show intense aggression and destruction of property, but these are in brief occurrences and not a chronic issue.

Moving on to Disruptive mood dysregulation disorder (choice D), it also does not fit this scenario as it also requires the patient to have a persistent, irritable, negative mood most of the day every day; further, it cannot be diagnosed unless the behavior began before the age of 10. Matt’s parents have reported that this behavior has only been present for the last year in isolated incidents starting when Matt was 12.

Let’s look at Antisocial personality disorder (choice E). This condition cannot be diagnosed until the patient is 18, with specific disregard for the rights of others being present from the age of 15. Kick that one out.

And Oppositional defiant disorder (choice A). This is recognizable by persistent angry, irritable, vindictive, and argumentative behavior that is noticeable at least once a week for at least six months for Matt’s current age (attention to detail!).

Most likely choice:

Matt is presenting with symptoms that best match intermittent explosive disorder (choice B). His behavioral problems have only arisen in the last year with isolated incidents of intense, aggressive outbursts. The events are not precipitated by major life events or stressors, and the reaction is grossly disproportionate to the triggering incident.

Timing is Everything

The hardest part of mastering vignettes is being able to do them within time constraints. Generally, a board exam allows about 1 minute per question on the exam. 60 seconds is not a lot of time to gather all the information, discern what is valid or not, and eliminate the least likely options.

So what is the secret? The true key is practice, practice, practice. You know your DSM conditions, you know their criteria. You just have to practice the mechanics of gathering information and making critical choices from it. And what better way to do that than to give our clinical vignettes a try- totally FREE? – using our Free Trial!

We tailor each bank to the type of test you’re taking, whether that is Nurse Practitioner Mental Health Certification, ABPN, USMLE, or PRITE. You can take these practice exams over and over again until you get the hang of it. You can use a practice mode that doesn’t penalize for time, or you can use the timed mode that mimics the actual exam.

We want to help you MASTER clinical vignettes. They’re the part of exams most people do the worst on. Let’s tackle this and make it your strongest section! If you like what you see on the trial, check out our Question Banks and find the best option for you! Or, contact us with any questions you have so we can get you on the right path today!

Test Anxiety and How to Manage It!

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Test Anxiety and Performance

Most people know that chronic or acute anxiety has negative impacts on performance. This is particularly true for academic performance in the form of test anxiety. But, what is more stressful than going in to take an exam that will determine the rest of your career? Obviously this goes without saying that exams and anxiety go hand in hand.

However, some people are impacted by this more than others. There are a few factors that influence this, and if you fall into one of these categories, we hope we can offer some help to get you through your next exam with flying colors!

Glasses on notebook from test anxiety

Working memory can amplify the effects of test anxiety

Everyone feels the effects of anxiety. It makes it harder to concentrate, bring information to mind, and sucks your motivation. But there are some lucky individuals that feel these effects harder than others.

Working memory (WM) capacity, or the amount of information you’re able to hold in mind at a given time, differs across individuals. The more WM capacity you have, the more easily you can hold bits of information at the front of your mind and retrieve that information for a task at hand. The lower your WM capacity, the harder this is. This capacity varies from person to person.

People with low WM have increased effects of anxiety on test performance. The relationship seems to be: anxiety interrupts WM (which is already having a hard time), which in turn effects retrieval of additional information. Further, the anxiety the person is feeling diverts attention from the task at hand to worrying about their performance. This results in reduced performance which is not reflective of the person’s true ability!

Distress load

Another factor that can make test anxiety worse some compared to others is total distress their experiencing. Regardless of their working memory, if a person is experiencing high levels of distress, they will under perform on academic tests. High stress shuts down your prefrontal cortex which interrupts executive functioning and critical thinking. This leads to higher anxiety, reduced attention, and thus lower scores.

If you’re experiencing extraneous factors in your life that are causing you significant distress, this may have detrimental effects on your academic strivings.

So we know these different things hurt some people more than others, but what can we do about it?

Social Support

As we all know, people are social creatures. Studies have shown that increases in social support negatively predict test anxiety. So what does this mean? Stop studying for a hot minute and go chill with your friends! (What, a test prep site is telling me to NOT study??- yes!) The more we experience social support, the less likely we are to experience test anxiety. Does this mean it magically disappears? Unfortunately, no. But, it can help mitigate the amount you experience!

Self-Esteem

Self-concept, self-esteem, call it what you want. Individuals that have a greater capacity for self-esteem or self-care tend to have greater academic achievement, and this can reduce the effects of anxiety you experience. This isn’t a one size fits all concept. Some people come in knowing they’re the cat’s pajamas (and let’s be real, you really are 😉 ), but others need some help seeing the value they bring to the table just by being themselves.

Not to be repetitive, but if you fall into the second category, try getting around some people that help boost you up! If this isn’t a friend or other trusted person, sometimes seeing a counselor can help shift our perspectives on ourselves just a bit. And clearly the implications of doing this will reap reward!

Studying skills…what about those?

One last interesting thing about those of us that experience higher levels of test anxiety is we generally have GOOD study skills! So know that you have the tools to accomplish what you’re aiming for. You aren’t less intelligent even if your test scores come out lower than you know you can do. We know that, too.

At the end of the day, text anxiety can’t be totally dispersed as much as we’d like it to be. But, if you know you’re someone prone to experiencing it, we hope we dropped a few tidbits to help you get through your next round of exams with a little less stress! Want some extra practice? Try our question banks – FREE- using our Free Trial! Or if you’re ready to take the plunge, check out our Question Banks and find the best option for you! Or, contact us with any questions you have so we can get you on the right path today!

REFERENCES: Hyseni Duraku, Z., & Hoxha, L. (2018). Self-esteem, study skills, self-concept, social support, psychological distress, and coping mechanism effects on test anxiety and academic performance. Health psychology open, 5(2), 2055102918799963.

Matthews, G., Wohleber, R. W., & Lin, J. (2020). Stress, skilled performance, and expertise: Overload and beyond.

Syndrome Series: Illness Anxiety Disorder

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artistic design man holding his face due to illness anxiety

What is Illness Anxiety?

Illness Anxiety Disorder is a fairly new condition that was added to the DSM-V under the section of somatic symptom and related disorders. It is the preoccupation with having or acquiring a serious illness, generally in the absence of somatic symptoms. This is accompanied by a high level of anxiety about health, and individuals who have this condition perform excessive health-related behaviors such as checking for abnormalities on the body. . This condition can be care-seeking (where the individual is seeking physician visits, tests, and procedures at an unnecessary rate) or care-avoidant (where the individual avoids physician visits, tests, or procedures in fear of discovering an illness).

Illness Anxiety and Hypochondriasis

Prior to somatic symptom and related disorders being acquired, people fitting these criteria were generally referred to as hypochondriacs. Now, about 75% of those individuals have a somatic symptom disorder diagnosis. The other 25% are diagnosed with illness anxiety. Hypochondriasis is not considered an anxiety disorder and may have somatic symptoms present; illness anxiety is considered an anxiety disorder related to somatic symptom disorders due to the physical checking and specified anxiety related to ones health.

Illness Anxiety Comorbidities

As a newer condition, comorbidities to illness anxiety are not well understood. Currently it is expected that two-thirds of individuals with illness anxiety also are likely to have at least one other major mental health issue. Hypochondriasis is commonly seen to co-occur with anxiety disorders such as generalized anxiety, panic disorder, OCD, as well as depression. Since these conditions share similarities, these could be reasonable comorbidities to be aware of.

First Line Treatments

Treatment options for this condition focus on the ability to manage anxiety symptoms. This can include both psychotherapy and pharmaceutical therapy. The most common psychotherapy used is cognitive behavioral therapy (CBT). Mayo Clinic outlines the following as the goals of CBT in regard to illness anxiety disorder.

Psychotherapy Objectives

  • Identify your fears and beliefs about having a serious medical disease
  • Learn alternate ways to view your body sensations by working to change unhelpful thoughts
  • Become more aware of how your worries affect you and your behavior
  • Change the way you respond to your body sensations and symptoms
  • Learn skills to cope with and tolerate anxiety and stress
  • Reduce avoidance of situations and activities due to physical sensations
  • Reduce behaviors of frequently checking your body for signs of illness and repeatedly seeking reassurance
  • Improve daily functioning at home, at work, in relationships and in social situations
  • Address other mental health disorders, such as depression

Pharmaceuticals

The next option for treatment is selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications work well for anxiety disorders as well as depressive disorders, and have shown efficacy in the treatment of illness anxiety. They also have lower rates of side effects and higher rates of tolerability. They offer safe options for a variety of patients, including patients that are pregnant.

Ready to learn more?

Give our question banks a try- FREE- using our Free Trial! Or if you’re ready to take the plunge, check out our Question Banks and find the perfect fit for you! Or, contact us with any questions you have so we can get you on the right path today!

REFERENCES:

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

French JH, Hameed S. Illness Anxiety Disorder. [Updated 2022 Apr 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554399/

Mayo Clinic:https://www.mayoclinic.org/diseases-conditions/illness-anxiety-disorder/diagnosis-treatment/drc-20373787

How does perfectionism affect your life?

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Are you a self-diagnosed perfectionist? Or maybe you know someone else who says they are. It may seem like people with a proclivity for perfectionism have a higher degree of finesse or accomplishment. This can be intimidating for those of us that don’t identify with this mindset. It can make you feel like your performance or abilities are less-than in comparison. But did you know the data doesn’t really support this idea?

Dart on a bullseye perfectionism

Perfection is Unattainable (And Unassociated with…)

Yep, you read that right. Try as we might, no one is perfect (duh!). This is obvious, and, particularly in the psychiatric field, it becomes a mantra of sorts that we share with clients and patients as a way to soothe their worries. What’s more, perfectionism isn’t actually associated with academic success of accomplishment.

But wait, you say, I know someone who says they’re a perfectionist and they’re so smart! Sure they are. But a study conducted (back in the 90’s!) on academically gifted students versus typical cohort students found that there was no association between self-perceived perfectionism and academic giftedness (Parker, 1996). Another study by the same author looked only at academically talented students and assessed perfectionism within that group and found a normal distribution of non-perfectionistic type (32.8%), healthy perfectionistic type (41.7%), and dysfunctional perfectionistic type (25.5%), further suggesting perfectionism is not highly associated with academic accomplishment (Parker, 1997).

What Perfectionism IS…

Perfectionism can actually hurt the people that feel this way. Perfectionism is strongly associated with negative symptoms of anxiety, depression, obsessive compulsive inclinations, and distress. This is due to the impossible task of trying to achieve something we – quite literally- cannot. It also can wreck havoc when taking a standardized test that penalizes for missing answers. Instead of taking a best guess and moving on when encountering a difficult question, a perfectionist tends to sit and agonize because they want to be sure. They want to know their answers are just right.

Does this mean those that live for attention to detail and dotting all the i‘s and crossing the t‘s are doomed? Of course not! Everyone has strengths and weaknesses that contribute to what makes them unique. The important thing to see here is that whether or not you like perfectionism, it does not predict your ability to be a competent physician, psychiatrist, student, or worker.

For the perfectionist and non-perfectionist alike, give our question banks a try- FREE- using our Free Trial! Or if you’re ready to take the plunge, check out our Question Banks and find the perfect 😉 fit for you! Or, contact us with any questions you have.

REF: Parker, W. D., & Mills, C. J. (1996). The incidence of perfectionism in gifted students. Gifted Child Quarterly, 40(4), 194-199.

Parker, W. D. (1997). An empirical typology of perfectionism in academically talented children. American Educational Research Journal, 34(3), 545-562.