MBG4234234 PDF
MBG4234234 PDF
MBG4234234 PDF
Edited by
Justin Sauer
Maudsley Hospital, London, UK
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Index 495
Preface
The importance of unhurried, comprehensive assessments of real patients in psy-
chiatric training is key in terms of skill acquisition and development, something that
is quite distinct from the time-limited scenarios with role-players as part of the CASC
or Clinical Assessment of Skills and Competencies. However, this examination is
now a firmly established component of the Royal College membership examinations,
and there are decent arguments that underpin its inclusion, despite the
limitations.
Learning the mechanics of the process and the CASC tricks of the trade are key to
success. Passing an examination of this type can never be guaranteed, but as with
everything, the more you practice, the luckier you will be.
We hope the examination guidance and breadth of scenarios in this updated edition
will help you in your examination success and future careers.
Speech
Should be clear, confident and unrushed many of us have a tendency to speak
faster when anxious
Verbal habits again ask colleagues or record your interview addressing your
ums or similar utterances can make a huge difference in how you come across
Where possible start with an open question
Avoid swing questions
Exam guidance xxi
Interview technique
Read the scenario carefully
Answer the tasks that have been set for you and not what you want to talk about
(a common error)
Clarification is important if you are unsure there will be a copy of the scenario in
the examination cubicle if you need to refer to this (but hopefully this will not be
necessary)
Introduce yourself to the patient
Ask if it would be alright to talk to them/ask some questions etc.
Reassure/empathise where appropriate
Use normalisation where appropriate
Learn stock phrases in case you run dry e.g. Do you have any questions for me at
this point? So to summarise
Dont end the station until you are told to end if you get the timing wrong it can
feel very awkward
If running short on time, explain this to the patient/relative
Better to say you dont know, than to get it very wrong
Always be polite and courteous throughout even if youve had a hard time and
thank the actor at the end
Dont take the actors behaviour personally
Smiling can put everyone at ease
Know the ICD-10 or DSM 5 diagnostic criteria for the main conditions as these will
instruct your assessments
Do not ignore non-verbal cues e.g. EPSE, agitation
Listen to what the patient or relative is saying. It is a common mistake to ignore
valuable information and to talk at people rather than enter into a dialogue
Always consider risk
Practise with a stopwatch and Dictaphone
Chapter 1
Old age psychiatry Oliver Bashford
LINKED STATIONS
INSTRUCTION TO CANDIDATE
Mr Jones is a 74-year-old depressed patient. He has not responded to
therapeutic doses of lofepramine and sertraline and, more recently, a
combination of venlafaxine and mirtazapine. A worsening of mood and the
emergence of psychotic features led to a compulsory admission to hospital
under the Mental Health Act. He has been seen by the ward psychologist but
is too depressed currently to engage with cognitive behavioural therapy (CBT).
The nursing staff are concerned with his dietary intake, which has declined
since his admission. Over the last week, fluid intake has reduced and blood
tests show abnormal urea and electrolytes consistent with dehydration. His
wife wonders if he should be transferred to a medical ward. In the absence of
the consultant, you see this gentleman on the ward.
Explain to Mr Jones how you wish to manage him further and what this is
likely to involve.
DO NOT INCLUDE A RISK ASSESSMENT.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introducing yourself. Acknowledge
his current circumstances and explain the purpose of your meeting: Hello Mr Jones, I am
Dr______, a psychiatrist. I am sorry that things have been difficult for you lately; I under-
stand your depression hasnt improved despite treatment with several antidepressants
2 Chapter 1: Old age psychiatry
Allow the patient to respond to your introduction and maintain a flow in your
conversation.
Then explain your concerns: I can see that you havent been able to eat and drink well
lately; is something stopping you from eating or drinking? Do you remember you had
some recent blood tests? Well, the results are concerning because they are abnormal,
probably because you arent drinking very much.
Explain the purpose of your discussion and offer him any clarifications: I would like to
discuss with you the various treatment options available to help you recover from this
depression. Please do interrupt me if you want to ask me anything in-between.
Medical treatment
Here, you have to explain your concerns about his physical health and how you are
planning to manage this: Mr Jones, it is very important that we talk about your physi-
cal health. Your recent blood tests were abnormal (deranged kidney function and salt
levels in the blood), indicating that you are dehydrated. We will need to closely monitor
this as, unless you are drinking, we might need to transfer you to the general hospital
so they can rehydrate you with fluids. So we will be keeping a very close eye on your
daily food and fluid intake over the next 24 hours to make sure your general health is
satisfactory. We will need to take further blood tests and check your blood pressure
and pulse rate frequently on the ward and I will be asking the nursing staff to encour-
age you to eat and drink at frequent intervals. Though all of this may seem like we are
disturbing you quite often, these are important measures to support your general
wellbeing.
Psychological treatment
Here, you can briefly explore the outcome of the psychological assessment: I understand
that you met with the psychologist to work out ways of overcoming your depression.
Can you tell me how it went? Then you can briefly explain the rationale of CBT and
why it may not be suitable for him right now: Cognitive behavioural therapy aims at
modifying your thoughts and behaviours which contribute to depression. However, it
may take up to several weeks to achieve this, and given the severe nature of your depres-
sion, we may have to leave it for the future and not consider it as an option right now.
Pharmacological treatment
Here, briefly explain the options available for treatment-resistant depression.
Youwillhaveto familiarise yourself with the literature evidence for the various drugs
(see Further Reading).
You should explain that changes to medication will depend on him being physically well
and appropriately hydrated. If the patient is somewhat unresponsive, it might seem
inappropriate to discuss the detail of particular drugs; but you can talk in broad terms:
Mr Jones, there are further changes to your medication that might help you. Adding
medication can have a positive effect on mood; however, this often takes some time to
see a positive effect.
Possibilities here for discussion include lithium, tri-iodothyronine or quetiapine.
ECT
ECT should be considered as an option when the effects of depression are potentially life
threatening, such as through poor fluid or dietary intake. It will be important to demon-
strate to the examiner that you recognise the severity of the depression and the risks faced
Station 1(a): Treatment-resistant depression 3
by the patient and that ECT may be an appropriate treatment option. You should be
familiar with the mental health law surrounding the administration of ECT in a consent-
ing/non-consenting patient in principle, but are unlikely to be asked specifics in relation
to the Mental Health Act law in a CASC station.
Mr Jones, unfortunately, you remain very depressed despite treatment and it is seriously
affecting your general health now. We are concerned that your physical health will dete-
riorate further without appropriate treatment. Taking all of this into consideration, one
option that we need to discuss is ECT. At this point, you should ask if he has heard about
ECT or knows anyone who has been treated with ECT. This will help to address any pre-
conceptions that he may have about ECT.
Conclusion
Here, you can summarise what you have discussed, any further information you wanttogive
and what the next steps will be: Mr Jones, we have had a discussion about your depression
and how we can help you get better. I know theres been a lot of information for you to
4 Chapter 1: Old age psychiatry
take in, but I am going to leave a written summary with your key nurse about what weve
discussed. We can then meet again tomorrow, after you have had a chance to discuss this
with your family. Does that sound OK? Its been very nice talking toyou.
FURTHER READING
Cleare, A., Pariante, C.M., Young, A.H. et al. (2015) Evidence-based guidelines for treating
depressive disorders with antidepressants: A revision of the 2008 British Association for
Psychopharmacology guidelines. Journal of Psychopharmacology, 29(5), 459525.
Depression in adults: Recognition and Management. Clinical Guideline 90 (CG90) by
National Institute for Health and Clinical Excellence. Published in October 2009 and
updated in April 2016.
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edition, London: Wiley-Blackwell.
www.nice.org.uk/guidance/ta59 National Institute for Health and Care Excellence (NICE)
guidance on the use of electroconvulsive therapy.
www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/ect.aspx
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You meet with his wife, Mrs Jones, who is concerned about her husbands further
deterioration since admission to hospital. You inform her that the team believe
that ECT should now be considered in view of his worsening condition.
Mrs Jones has heard only negative things about ECT. Discuss the ECT with
Mrs Jones and answer any questions.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain your reason for wanting to speak with her: Hello, Mrs
Jones, my name is Dr_____, a psychiatrist. Thank you for meeting with me today. I would
like to discuss your husbands treatment with you and answer any questions you may
have. Mention that you have just met with her husband and have discussed the treatment
options, which include ECT. Acknowledge that ECT does have bad press, but that it is
extremely effective in depression and that you would be happy to discuss any concerns
she may have. It is useful to start by asking what she already knows about ECT.
Rationale
It is important to explain why ECT is being suggested, and to convey to Mrs Jones the
seriousness of the situation and why alternative treatment options are less suitable.
Mrs Jones, your husband has been treated with several different antidepressants and is
6 Chapter 1: Old age psychiatry
Procedure
An explanation of the procedure, if pitched at the appropriate level, can allay patients and
relatives anxieties. Remember to invite questions and check that you have been
understood.
Would it help if I explain what happens during the treatment? Please feel free to interrupt
and ask questions at any time. ECT involves the use of electricity to induce a very brief
fit or seizure that usually lasts no more than 30 seconds. It takes place in a special
treatment room. An anaesthetist gives a general anaesthetic, so that the person is asleep
during the procedure, and a muscle relaxant to reduce the body movements that happen
during a fit. The patient is not aware of what is happening and it is not painful. A brief
electric current is given by the psychiatrist using two pads that are placed on the head
for just a few moments. At all times, the anaesthetist, psychiatrist and ECT nurses will be
present. After the fit has finished, the patient wakes up a short while later and then remains
in a recovery area supervised by staff until ready to return to the ward.
A usual course of treatment is between 6 and 12 sessions and given twice a week.
How it works
A detailed account is unlikely to be required here. It is sufficient to describe in lay terms
an alteration to the brains chemistry: We are not sure exactly how ECT works, but believe
that the treatment causes a release of neurotransmitters or natural brain chemicals,
whose imbalance is thought to underlie depression. This artificially induced release of
feel-good chemicals may be how it works.
Risk
It is important to emphasise that whilst ECT is associated with some risks, there are also
risks of not having treatment, which include further delay in recovery from depression
and deterioration in physical health, which could lead to death if not eating or drinking
Station 1(b): ECT 7
sufficiently. Mention that the risk of death following ECT is approximately 1 in 100,000
treatments, due to the anaesthetic risk.
Conclusion
As the interview is nearing its end, you should summarise the content of the discussion
and comment on anything else that you might like to do. This can provide a neat ending
to the station: Mrs Jones, just to summarise what we have discussed: I have tried to explain
the rationale for recommending ECT for your husband and hopefully have given you
some idea of what it involves and what the main side effects are. I am happy to provide
you with written information to have a read through and if you have any further ques-
tions or concerns, please dont hesitate to ask.
ADDITIONAL POINTS
1. Some of the neurochemical changes following ECT include increased
noradrenaline, dopamine and serotonin and reduced acetylcholine.
2. ECT can also be used in prolonged mania and catatonia, and has been used
in Parkinsons disease and neuroleptic malignant syndrome.
3. Medical investigations are routinely checked beforehand including full blood
count, urea and electrolytes, ECG and chest x-ray when indicated and sickle-
cell screening is important for Afro-Caribbean and Mediterranean people.
FURTHER READING
https://www.nice.org.uk/guidance/ta59 NICE guidance on the use of ECT.
http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/ect.aspx information from
the Royal College of Psychiatrists.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are about to see a patient in your clinic. Below is the referral letter.
Dear Doctor,
Re: Prof. Michael Baugh 15.06.32. Weston Hill Rise, Southwark, London
Thank you for seeing this retired sociologist who lives alone. He has reported
worsening of his memory and I wonder if he has a dementing illness. He has
a history of hypertension. No major surgical procedures. I have given him an
antibiotic for a recent UTI.
Current medication: Trimethoprim 200mg b.d.
Simvastatin 20mg
Aspirin 75mg
Enalapril 20mg
He has one daughter, Mrs Carol Davies. She works but is happy to speak to you.
Sincerely,
Dr Byron Moore
SUGGESTED APPROACH
Setting the scene
Hello, Professor Baugh. My name is Dr_____, and I am a psychiatrist. I have received a
letter from your GP saying that you have been concerned about your memory. Is this
correct? Can you tell me whats been happening?
Start with open questions and then move on to closed questions as appropriate.
The interview will involve taking the patient through the development of the memory
impairment, any associated features and how this impairment has affected different facets
of his life. The impact on social and occupational functioning is very important in
the assessment of the severity and in making a diagnosis. The medical history is
alsoessential.
Differential
Dementia in Alzheimers disease has a slow, insidious course and usually affects recent
memory first and the learning of new information, with relative preservation of longer-
term memory.
Vascular dementia may have a sudden onset or a stepwise decline, may be associated with
a known stroke and there may be relative preservation of insight. The pattern of cognitive
deficits depends upon the extent and location of cerebrovascular disease.
Dementia with Lewy bodies (DLB) may present with marked fluctuations in cognition
and level of alertness, visual hallucinations, rapid eye movement (REM) sleep behaviour
disorder or spontaneous features of Parkinsonism.
Personality changes with early loss of insight may indicate a fronto-temporal dementia.
10 Chapter 1: Old age psychiatry
Delirium usually has a rapid onset, presents with fluctuating consciousness and marked
inattention, there may be visual hallucinations or other psychotic features and is
associated with acute physical illness. There may be an increase or decrease in motor
activity.
Depression can present with poor attention, concentration and bradyphrenia and may
occur following life events and physical ill health. Often there are subjective complaints
of memory loss in depression, unlike in dementia, where people will frequently hide or
compensate for deficits.
It is important to differentiate isolated memory impairment from multiple or global
cognitive deficits. Enquire about aphasia (e.g. nominal), agnosia, apraxia (e.g. dressing)
and executive functioning (planning, organising, sequencing and abstract ability). In
amnestic disorders, there is memory impairment rather than global cognitive decline.
Also consider alcohol and substance misuse, schizophrenia and malingering.
Medical history
Currently, he has a UTI. Has this caused an acute confusional state?
Ask broadly about his medical history, and specifically enquire about cardiovascular risk
factors: I see that you are on treatment for cholesterol and high blood pressure. How long
have you been on treatment for these? Do you know why you are prescribed aspirin? Do
you smoke? Have you ever had a heart attack, angina or an irregular heart beat? Do you
have diabetes?
Also ask about neurological conditions: Have you ever had a stroke or a mini-stroke, or
a head injury that knocked you unconscious? Have you had a tremor?
Ask about alcohol consumption: How much alcohol do you typically drink in a week?
(and enquire about harmful use and dependence if appropriate).
Ask if he has ever had a brain scan and whether the GP has arranged blood tests or an
ECG. If these have not been done, they should be included in your management plan.
Social functioning
It is essential to establish how the symptoms affect his day-to-day functioning. Remember
that functional impairment is needed in order to make a clinical diagnosis of dementia.
Mild memory impairment without significant functional decline is termed mild cognitive
impairment and does not always lead to dementia.
Domains to ask about include basic self-care, domestic tasks around the home and more
complex tasks like driving, finances, shopping and using public transport: How are these
problems affecting your day to day life? Do you get any help from family or friends, or
have professional carers visiting? (If so, ask what tasks they perform.) Do you have any
difficulties with washing, getting dressed or eating dinner? How are you with tasks around
the house, like cooking, cleaning and washing up? How do you manage your finances?
Are you still driving? Do you do your own shopping or does someone help you with that?
Risk
Have you ever forgotten to turn off the gas, left the taps running by accident or left your
keys in the door when youve gone out? How often does this happen? Have you found
any ways to manage this? Are you still driving (and if so, have you had any problems with
this)? Have you got lost at all? Establish whether he has gotten into any risky or vulner-
able situations and how often this has happened.
Station 2(a): Memory loss 11
Management
This will depend on the diagnosis, which is based on your clinical assessment, physical
examination and investigations that include memory tests, blood tests and brain
imaging.
The actor may ask you what you think is wrong with him and what you will do should
he have dementia. You should explain that further investigations/test results are required,
but you believe there is a memory problem.
Most likely diagnoses in this scenario are Alzheimers or vascular dementia, and recent
worsening due to a delirium, secondary to urinary tract infection.
Consider management under biological, psychological and social headings. Management
will depend on the degree of cognitive and functional impairment, so not all of the sug-
gestions below will be relevant in every case.
Biological
Optimising vascular risk factors (e.g. hypertension, dyslipidaemia, diabetes, atrial fibril-
lation and smoking cessation [if present])
Additional medication for untreated physical risk factors; ensure current UTI is treated
adequately
Possible role for acetylcholinesterase inhibitors or memantine in Alzheimers disease
(AD) be aware of recent NICE guidelines
Treat any psychiatric comorbidity (e.g. antidepressants)
Advice about alcohol if drinking heavily
Encourage exercise for its wide range of physical and psychological benefits
Psychological
Cognitive stimulation, memory groups and CBT for depression
Reality orientation, validation therapy and reminiscence therapy
Social
Ensuring adequate social support (e.g. carer/home help/meals-on-wheels/day centres)
Compliance aids for medication (if still self-medicating; e.g. pill-box or blister pack)
Occupational therapy (OT) assessment and adaptations for the home environment (e.g.
memory prompts, Telecare devices and Keysafe)
Alzheimers Society information resources, support groups and carers assessment
Support for daughter (e.g. carers group)
Advice about finances and lasting power of attorney
Conclusion
A good way to finish the station is to thank the patient and comment on further action
you will take: Thank you for coming today, Professor Baugh. If you would like, I will
write to you to summarise our discussion and send you some information leaflets that
will be of interest. Also, if you are in agreement, I would like to speak to your daughter
about the matters we have discussed today. Is that OK? I look forward to seeing you again
next time.
12 Chapter 1: Old age psychiatry
ADDITIONAL POINTS
1. When considering anti-dementia treatment, remember to take into account
the NICE guidelines, any arrhythmias and a history of dyspepsia or gastric
ulceration. It is important to explain that the drugs are not a cure and that
benefits are modest, but they can help with cognitive symptoms for some
people.
2. Three acetylcholinesterase inhibitors (donepezil, galantamine and
rivastigmine) are currently recommended by NICE for Alzheimers disease.
They are all similar in their clinical effect on memory and improved attention
and motivation. Common side effects include headache, nausea, vomiting,
anorexia, weight loss and diarrhoea.
3. Memantine is now recommended for managing severe Alzheimers disease
and for moderately severe disease if acetylcholinesterase inhibitors cannot be
taken. Memantine is an N-methyl- d -aspartate (NMDA) receptor antagonist that
affects glutamate transmission. The dose is reduced in renal impairment.
FURTHER READING
http://pathways.nice.org.uk/pathways/dementia NICE guidance on dementia.
http://www.alzheimers.org.uk/ Alzheimers Society website.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You meet with Prof. Baugh again in your clinic. Following a full
initial assessment and the results of investigations, you diagnosed
this gentleman with Alzheimers type dementia and initiated
acetylcholinesterase inhibitor treatment. A letter from his daughter tells
you in confidence that his personality has changed significantly. She
finds him to be difficult, embarrassing and on several occasions he has
exposed himself. This is completely out of character and predates the new
medication.
Assess his frontal, temporal and parietal lobe function.
SUGGESTED APPROACH
Setting the scene
Hello, Professor Baugh, its very nice to see you again. Do you remember our last meet-
ing? Asking him how he has been getting on with the new medication would be a good
way to lead in to the station. Explain that you would like to do some more tests to see how
the different parts of his brain are working. Inform him that you ask these questions of
many people you see and not to worry if he makes a few mistakes, as some of the questions
are more difficult than others.
Managing your time is important in this station, and you will lose marks if you do not
cover all three sections. The examiners will not expect to see every single test for each
lobe squeezed into 10 minutes, but rather a sensible, broad selection of tests that are
performed properly.
14 Chapter 1: Old age psychiatry
Frontal lobes
Personality Have you changed in yourself in any way? In what
way?
Motor sequencing (Lurias test) Demonstrate the hand sequence fist, edge, palm
five times, and then ask the patient to repeat with
both hands. Perform for 30seconds on each side.
Verbal fluency Ask the patient to generate as many words as
possible (not names or places) for the letters F, A or
S. Perform for 1 minute and record all responses
(there will not be sufficient time to test all three
letters).
Category fluency Ask the patient to name, for example, as many
animals with four legs as they can in 1 minute.
Record all responses.
Abstract reasoning (proverb Ask the patient to interpret what a proverb might
interpretation) mean: too many cooks spoil the broth (or similar;
bear in mind cultural differences here).
Cognitive estimates How many camels are there in Holland? How
tall is the Post Office Tower?
Abstract similarities Ask the patient in what way the following are
similar: an apple and a banana; a table and chair;
and/or a wall and a fence.
Primitive reflexes Grasp reflex/rooting reflex/palmomental reflex.
Temporal lobes
Dominant lobe
Receptive dysphasia
Alexia Ask to read something
Agraphia Ask to write something
Non-dominant lobe
Visuospatial difficulties
Anomia Ask to name a wrist watch, strap and buckle
Prosopagnosia Ask if he recognises the Queen on a 5 note
Hemisomatopagnosia Belief that a limb is absent when it is not
Bilateral lesions
Amnesic syndromes (Korsakoffs amnesia and KluverBucy syndrome): assess short- and
long-term memories.
Station 2(b): Frontal/temporal/parietal lobes 15
Parietal lobes
Function Task
Dominant lobe
Dysphasia Receptive dysphasia Obvious from
conversation
Gerstmanns syndrome Finger agnosia Point to left ring finger
with right index finger
Dyscalculia Simple arithmetic
Rightleft disorientation Touch left ear with
right hand
Agraphia Ask to draw something
Non-dominant lobe
ADDITIONAL POINTS
Features of frontal lobe dysfunction
Disinhibition, distractibility
Lack of drive
Errors of judgement
Failure to anticipate
Perseveration
Poor adaptation to change
Overfamiliarity
Sexual indiscretion
Consequences of neurological damage to temporal lobe structures
Changes in behaviour/personality
Increased aggression, agitation or instability (limbic system)
Contralateral homonymous upper quadrantanopia (assess visual fields)
Depersonalisation
Disturbance of sexual function
Epileptic phenomena
Psychotic disturbances akin to schizophrenia
Potential neurological consequences of parietal lobe damage
Homonymous lower quadrantanopia (optic radiation)
Astereognosis, reduced discrimination (sensory cortex)
FURTHER READING
Hodges, J.R. (2007) Cognitive Assessment for Clinicians, 2nd edn. New York, NY: Oxford
University Press.
Lishman, W.A. (1998) Organic Psychiatry, 3rd edn. Oxford: Blackwell Science.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
STATION 3: WANDERING
INSTRUCTION TO CANDIDATE
This elderly woman with vascular dementia was taken to hospital by the
police after she was found wandering the streets in the early hours of the
morning barefoot and dressed only in her nightclothes. She was confused
and afraid.
She has been assessed in accident and emergency (A&E) and they have ruled
out a physical aetiology. The casualty doctor informs you that she was seen
in hospital a year ago by the neurologists after she had a transient ischaemic
attack. She denies drinking alcohol, but is a smoker. She scored 7 out of 10
on an abbreviated mental test score today and is now asking to return home.
Assess if this patient is safe to go home. Do not carry out a cognitive
assessment.
SUGGESTED APPROACH
This woman has put herself in an extremely vulnerable situation and management will
involve an assessment of risk and of her current mental state. It will also depend on her
current social circumstances and whether there are any family members or close friends
who will be able to provide support should she return home today.
Taking a history
Can she remember what happened?
Why did she leave the property?
Can she remember her home address?
Has anything like this happened before? (You would want to corroborate this from
A&E, police and a family doctor.)
Does she live alone? (You would want to speak to anyone living at home with her,
her neighbours or her warden. If in a supported accommodation, how has she been
managing?)
Does she have any next of kin or friends who you would be able to talk to?
Are there any healthcare professionals (or allied professionals) involved? (community
mental health team [CMHT] for older adults, community psychiatric nurse [CPN],
social worker, occupational therapist or day centre.)
It is important to find out about her living conditions (food, hygiene and gas/
electricity).
Is she looking after herself appropriately?
It is important to note her current level of personal care (unkempt/
undernourished).
History of alcohol or substance misuse?
History of falling?
Likelihood of repeating episodes? (Any old medical records in A&E.)
History of harming self or others?
History of behavioural disturbances? (Public or at home.)
Is she prescribed any regular medication? (Psychotropic medication; is she taking
them appropriately?)
Has she been started on any new medication (e.g. diuretics or digoxin)?
Risk assessment
Consider the following:
In the household: gas, appliance use, smoking, fire, flooding or poor heating in
winter
Financial: managing bills, access to money and pension
Diet: doing the shopping, preparing meals and malnutrition
Falls: at home and outside. What adaptations might be needed?
Abuse: financial (family, friends, tradesmen and opportunists) and emotional
Security: wandering and locking up (theft and burglary)
Capacity
Demonstrating capacity with regards to the event and associated risks would be somewhat
reassuring if considering a return home. Capacity is defined as follows: the person must
be able to understand and retain information long enough to make a judgement. They
should be able to weigh up the pros and cons of his or her choice. The person should be
able to communicate the decision made.
Further management
Respite or hospital admission
Admitting the patient would depend upon the information gathered during the interview.
Even if cognitively impaired, the patient should be part of the process and continually
updated. Admitting an elderly patient with dementia can be extremely distressing and
you would want to provide them with appropriate reassurance. Rather than hospital
admission, it might be that a period of respite in a residential or nursing home would be
more appropriate.
CMHT follow-up
If not already known to mental health services, she would benefit from an assessment
and follow-up. The multi-disciplinary team (MDT) will almost certainly play a role in
looking at her medication, considering her cardiovascular risk factors, nursing input to
monitor her mental state and OT to look at her accommodation and any modifications,
particularly in view of her wandering behaviour.
Care package
She might benefit from more support depending on her social circumstances and ability
to care for herself and her home environment. The social worker or care manager will be
able to advise on financial matters and moving to more supported accommodation where
appropriate.
ADDITIONAL POINTS
1. Assistive technology: devices can be installed in the home that alert a
centre to an individuals activities. These can, for example, alert one to
the fact that the front door has been opened at night. Similarly, the use of
mobile phones or other devices attached to coats can allow people to be
tracked if they put themselves at risk from wandering.
2. Further medical assessment: she has been cleared medically and for the
purposes of the exam you would assume that to be the case. However,
20 Chapter 1: Old age psychiatry
in reality, you want to know the details of what examinations and tests
have been performed. Is there any evidence of a fall or head injury? She
should have had a full neurological assessment, and if not, you would want
to do this. What were the results of blood tests and urinalysis? Does her
presentation represent an acute confusional state (delirium)? Ideally, she
should have had brain imaging (computed tomography/magnetic resonance
imaging) in view of the history of transient ischemic attack (TIA).
FURTHER READING
ales, H.C., Gitlin, L.N. & Lyketsos, C.G. (2015) Assessment and management of
K
behavioural and psychological symptoms of dementia. BMJ, 350, h369.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 4: Testamentary capacity 21
INSTRUCTION TO CANDIDATE
You have been asked by a solicitor to assess this elderly woman. Her son has
concerns that his mother has suddenly changed her will. He believes that his
sister is plotting to exclude him from any inheritance.
Assess this woman to see if she has testamentary capacity (TC).
SUGGESTED APPROACH
Setting the scene
Hello, my name is Dr_____, a psychiatrist. I have been contacted by a solicitor, on behalf
of your son, to talk to you about your will. As Im sure you understand, it is very important
when we make a will that we fully understand what it means and what the consequences
are. When we have finished today, I will write a report to the solicitor based upon our
meeting today. Is that OK? Do you have any questions?
3. The person must know the legal heirs those included and excluded and how the
will distributes the property.
4. The person has no mental disorder affecting 13 above. If a mental disorder is present,
any legal challenge will depend upon demonstrating its impact on the ability to com-
plete a will as set out in the criteria for TC as shown above.
5. The person must not be subject to undue influence by one or more third parties.
In assessing TC, it should be determined:
Whether there is/was a major psychiatric disorder
Whether this psychiatric disorder impairs the ability to know she was making a will
Whether delusions are present that involve the estate or heirs
Whether this disorder impairs her ability to know the nature and value of the estate
Whether this disorder impairs her ability to identify the heirs that would usually be
considered
Whether the individual is vulnerable to undue influence
Clinical assessment is very important, as a number of conditions can interfere with valid
will completion. Major psychiatric illnesses such as schizophrenia and organic diseases
such as dementia are common examples. Their presence, however, does not always mean
that the individual lacks TC. Someone with a psychotic illness who believes the FBI has
bugged their apartment, for example, may know very well the size of their estate, their
children and how it should be divided between them. Psychosis/delusions that would
invalidate a persons capacity to make a will often involve their heirs in a negative way. If
dementia is suspected, you would need to perform a test of cognitive function (e.g. mini-
mental state examination [MMSE]).
Risk
As in all scenarios in the exam, where there is an opportunity to demonstrate that you
are a safe trainee, do so. A screening question as part of your mental state examination
(MSE) on suicide/self-harm would do.
ADDITIONAL POINTS
1. Elderly people are often advised by lawyers to have an evaluation of
testamentary capacity at the time a will is executed. Videotaping is
increasingly used at the time of will execution, which can later be used in
court.
2. Ordinarily, all relevant medical and psychiatric records would be available, as
well as an estimate of the value and nature of the estate. This information
would be sent to you by the solicitor. The criteria for testamentary capacity
(TC) date back to 1870 and the case of Banks v. Goodfellow.
FURTHER READING
Banks v. Goodfellow (1870) LR 5 QB 549.
Station 5: Cognitive assessment 23
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
This 67-year-old civil engineer has noticed that his memory has deteriorated.
He has felt less sharp at work and, although he has no concerns about his
ability to do the job, has found grasping new information quite difficult. He
has a history of dyslipidaemia and hypertension, for which he is prescribed
medication. He has seen his GP and the clinical examination is reported as
unremarkable. There is no past psychiatric history. The GP has concerns that
the presentation represents a likely dementing process, although this has not
been discussed with the patient.
Carry out a cognitive assessment.
You are required to do some memory tests and you struggle to recall information but
otherwise fine.
Your mother had Alzheimers disease and so does your sister. You are worried if you may
have developed it too, and express your concerns to the doctor.
SUGGESTED APPROACH
Setting the scene
Hello, Im Dr_____. Ive had a letter from your GP who says youve had some concerns
about your memory. Is that correct? Would you tell me whats been happening? Take a
very brief history of the symptoms before moving on to the cognitive assessment.
Id like to run through some questions with you to test your memory. Some you may find
very easy, others more difficult, but the most important thing is not to worry, just try
your best. Is that OK? Try to put him at ease.
The examination
You will be expected to use a brief memory test such as the mini-mental state examination
or The Montreal Cognitive Assessment and should memorise it. You should be able to
complete this assessment with time to spare. We are unable to reproduce the MMSE here
due to copyright.
You should produce a score at the end. Writing the results down as you go along is therefore
important. You will then be able to explain any areas of concern and what these mean.
Giving feedback to the patient is important, as is reassurance.
If appropriate and if time allows, other cognitive tests may be used in addition to the
MMSE. Clock-drawing is a quick and simple general test of cognition. In some cases,
frontal lobe assessment is needed. It is also useful to ask questions relating to remote
memory, both personal (wedding date and childrens birthdays although you will not
be able to validate this) and impersonal (historical events).
Conclusion
A neat way to end can be to state any further action you would take: Thank you for com-
pleting these tests. I think it would be helpful for us to gather more information. If you
are in agreement, I would like to arrange for you to have a brain scan and for you to meet
a psychologist to do more detailed testing. Is that OK?
Station 5: Cognitive assessment 25
ADDITIONAL POINTS
Clock-drawing is increasingly used in cognitive assessment. It is easy to do
and is a useful way of demonstrating disease progression with time. This is a
clock face. Please fill the numbers and then set the time to 10 past 11.
a. Sensitive to deterioration
b. Repeat three to six monthly
It assesses:
a. Comprehension
b. Abstract thinking
c. Planning
d. Visual memory
e. Visuospatial abilities
f. Motivation
g. Concentration
FURTHER READING
F olstein, M.F., Folstein, S.E. & McHugh, P.R. (1975) Mini-mental state: A practical method
for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research,
12, 18998.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
26 Chapter 1: Old age psychiatry
INSTRUCTION TO CANDIDATE
This is Mr Shaw. Your team have been seeing his mother at a nursing home
since her admission there 2 months ago. She has Alzheimers disease and
had been irritable, aggressive and wandering whilst living in her own home. At
that time, she was assessed and prescribed olanzapine. She settled initially,
but has since become irritable again and the GP increased the dose.
Today, the son has asked to see you. He is angry and upset that his mother
has been prescribed an anti-psychotic and thinks she is over-sedated. He also
read an article about the dangers of these medications in dementia.
Manage this situation and advise him on alternative approaches to
behavioural changes in dementia.
SUGGESTED APPROACH
Setting the scene
Hello, my name is Dr______, Im one of the psychiatrists. Thanks for coming to see me
today. Weve been involved in your mothers care for the last few months and I understand
you have some questions about her treatment. Please tell me your concerns and Ill try
my best to help.
ADDITIONAL POINTS
BPSD include:
Motor behaviour: agitation, aggression and restlessness
Social interactions: withdrawal, inappropriateness and disinhibition
Speech: increased or reduced, mumbling and shouting
Mood/anxiety: anger, lability, anxiety and fear
Thoughts: delusions, paranoia and depression
Perceptions: visual and auditory hallucinations
Biological: sleep disturbance, incontinence and reduced appetite
FURTHER READING
Ballard C.G., Waite J. & Birks J. (2012) Atypical antipsychotics for aggression and psychosis
in Alzheimers disease. Cochrane Database of Systematic Reviews (1), CD003476.
http://pathways.nice.org.uk/pathways/dementia/dementia-interventions
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are about to meet Mrs Mary Evans, a 69-year-old lady who has been
brought into hospital after neighbours reported that she was behaving
strangely and was seen starting a bonfire in her front garden. When the
police arrived, she told them that she wanted to kill herself and asked to be
left alone.
Take a history to establish whether there are delusions, and if so whether
these are primary or secondary. Also perform a risk assessment.
SUGGESTED APPROACH
Setting the scene
Hello, Mrs Evans, my name is Dr_____, a psychiatrist. I understand youve been brought
to hospital today after people noticed you making a bonfire in your garden, could you
tell me whats been happening?
30 Chapter 1: Old age psychiatry
Risk
In addition to finding out exactly what she was doing in setting the bonfire, you will need
to ask some specific questions in order to form an impression of the level of risk that she
poses both to herself and others.
You were setting up a bonfire at home, could the fire have spread to the house or neigh-
bouring properties? Now that you are here and the fire has stopped, how do you feel about
that? Do you still want to burn your possessions? Do you think you would do the same
again? You mentioned earlier that you had thoughts about taking your own life, could
you tell me more about that? Have you thought about how you may end your life? Is there
anything you can tell yourself that stops you doing that? Have you found yourself having
thoughts about harming anyone else? Do you have any plans to do this?
If you think the patient is high risk, you could indicate this to the examiner by saying
something like: What you have told me is very concerning, and I think it is very important
that you get the right help and treatment to get you through this.
Conclusion
It can be helpful to summarise your conversation at the end in order to check that you
have understood what she has told you, and to thank her for talking to you. Before we
finish, let me check that I have understood. Is there anything Ive missed? Thank you for
being so open with me today.
FURTHER READING
Oyebode, F. (2008) Sims Symptoms in the Mind. An Introduction to Descriptive
Psychopathology, 4th edn. Philadelphia, PA: Saunders Elsevier.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are about to meet the daughter of Mrs Dorothy Groves. Mrs Groves is a
75-year-old lady with a history of progressive memory impairment, and more
recently has developed signs of Parkinsonism. You have just received the
report of the dopamine transporter (DAT) scan, which shows degeneration of
the dopaminergic system of the striatum. This confirms your suspicion of DLB.
Meet with Mrs Groves daughter to explain the diagnosis, prognosis and
management, and address her concerns.
SUGGESTED APPROACH
Setting the scene
Thank you for coming to speak to me today. Im Dr_____, a psychiatrist. Id like to
discuss with you your mothers diagnosis and care plan, and answer any questions you
may have. Is that alright? Can I start by asking how much you know already about her
diagnosis?
In the absence of two core features, the diagnosis of probable DLB can also be made if dementia
plus at least one suggestive feature is present with one core feature.
Supportive clinical features include repeated falls and syncope, transient loss of conscious-
ness, marked autonomic dysfunction, hallucinations in other modalities, depression and
systematised delusions.
Management
It is helpful to present discussions of management using the bio-psycho-social frame-
work. Treatment in DLB can be complex and it can be helpful to think about the dif-
ferent symptom clusters separately: cognitive, neuropsychiatric, motor, autonomic and
sleep.
There is no cure for Lewy body dementia, but we can help with some of the symptoms
and we can help your mother remain as independent as possible, for as long as possible.
Pharmacological
Rivastigmine and donepezil have both been shown to be effective for cognition and
psychiatric symptoms. Donepezil is well tolerated, but rivastigmine is licenced for the
treatment of Parkinsons disease dementia.
34 Chapter 1: Old age psychiatry
Social
Refer to OT for functional assessment and home adaptations, which may include Telecare
devices. Physiotherapy may be able to help with mobility. In some cases, it may be appro-
priate to think about moving into more supported housing, such as sheltered accommo-
dation. Refer to social services for assessment for a package of care to help with ADLs.
Suggest that attendance at a day centre may be beneficial in order to address social isolation
and boredom. Refer for assistance with finances and accessing benefits if appropriate. Give
advice regarding lasting power of attorney.
Psychological
Cognitive stimulation groups, memory groups and music and dance therapy are
recommended.
Do not forget to mention interventions for carers, which includes support groups and
access to respite services.
The Alzheimers Society can be a valuable support to people with all types of dementia,
so consider offering a referral to them.
Addressing concerns
DLB is not well recognised by the general public and it is unlikely that the patients
daughter will be familiar with it. She may, however, have concerns based upon reports in
the media about the care of people with dementia; she may be worried about her mother
ending up in a care home or putting herself at risk by wandering at night or leaving gas
hobs on. The way to approach this is to give a realistic impression of the kinds of problems
that may arise, but also to reassure her that there are a lot of things that can be done to
help her mother be as safe and independent as possible, and that there is support available
for carers as well.
Allow her to voice her concerns and repeatedly check her understanding of your
explanation.
Conclusion
Thank you for coming to see me today. I know it is a lot to take in, so before you go, Iwill
get some written information leaflets for you to take away. I also recommend the Alzheimers
Society website, as they have information about all types of dementia, not just Alzheimers,
and the website of the Lewy Body Dementia Association. Ill also give you our phone
number so you can call at any time if you have any questions or concerns.
Station 8: Lewy body dementia 35
FURTHER READING
McKeith, I.G., Dickson, D.W. & Lowe, J. etal. (2005) Diagnosis and management of
dementia with Lewy bodies: A third report of the DLB Consortium. Neurology, 65, 186372.
http://www.alzheimers.org.uk/ website of the Alzheimers Society.
http://www.lbda.org/ website of the Lewy Body Dementia Association.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 2
Anxiety disorders Priyadarshini Natarajan
LINKED STATIONS
INSTRUCTION TO CANDIDATE
Mrs Christine Ward is a 44-year-old woman and a mother of three children.
She has been referred to the Community Mental Health Team by her GP,
DrThomas, who had recently joined as a partner at the surgery. Dr Thomas
is wary of Mrs Ward presenting to his clinic again and again with various
physical symptoms, mainly pain, and requesting referrals to specialist clinics.
It seems that her old GP, retired Dr Jones, knew what to say to Mrs Ward to
reassure her. In her recent review with Dr Thomas, Mrs Ward is alleged to have
threatened to complain against him for negligence. He has now requested an
urgent psychiatric assessment.
You are a core trainee in the Community Mental Health Team. Take a history
from the patient, including a brief risk assessment.
You will be asked to discuss your findings and management plan with
a consultant psychiatrist in the next station (or) discuss diagnosis and
management with the patient in the next station.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introduce yourself. Acknowledge
that they might have had some reservation in attending this appointment and explain
the purpose of your assessment: Hello, Mrs Ward, I am Dr_____, a trainee psychiatrist.
It sounds like the past few months have been stressful for you. I am here to understand
your difficulties and see if we can help you manage them.
38 Chapter 2: Anxiety disorders
Allow the patient to respond. If they get angry, reassure them by making it clear that you
accept that their symptoms are real and that you will try and help as best as you can. You
may want to add that most people would be apprehensive of seeing a psychiatrist.
Then take a history of somatisation disorder, including the presenting complaints, dura-
tion of illness, differential diagnosis (which would include hypochondriasis), comorbid
condition such as depression and a brief risk assessment.
Conclusion
Here you can summarise what you have assessed, any information you may need and
what the next steps will be:
Mrs Ward, thank you for coming to see me today. We talked about your symptoms and
your fears. You told me that your pain instarted more than 2 years ago. You also men-
tioned that your pain started at around the same time you went back to work after a break.
You also said that your husband had to take on more work to bring in more money because
the expenses have gone up with a big family. There is a possibility that this combination
of stressful factors could have presented in the form of pain. I wonder if you ever thought
about the symptoms in that way. (Gill & Bass, 1997)
FURTHER READING
Gill, D. & Bass, C. (1997) Somatoform and dissociative disorders: Assessment and
treatment. Advances in Psychiatric Treatment, 3, 916.
ICD-10 (1992) Classification of Mental and Behavioral Disorders: Clinical Descriptions and
Diagnostic Guidelines. Geneva: WHO Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have just seen Mrs Ward in the previous station. Please discuss your
findings with the patient and formulate a management plan.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Mrs Ward, I am Dr_____, we met previously to discuss your
situation. Start with summarising the history that you have taken so far. Be clear and
non-judgemental in your approach. Clarify whether the patient continues to strongly
believe that her symptoms are due to undiagnosed physical disease.
Mrs Ward, thank you for coming to see us today. We talked about your symptoms and
your fears and worries. You told me that your painstarted more than 2 years ago. You
Station 1(b): Discuss diagnosis and management with the patient 41
have been to see your doctors and other specialists for a diagnosis; so far, they have not
been able to find an underlying disease to explain your symptoms. You also mentioned
that it started at around the same time that your husband had to take on more work to
bring in more money because the expenses had gone up with the growing family.
General advice
Help the patient to understand stress and identify the sources of stress in their life. Provide
advice on lifestyle changes, including a gradual increase in exercise-based activities and
relaxation.
Self-help
Self-help is one way of achieving control of a patients problems. It may enable the symp-
toms to become less of a problem and lead to a much improved quality of life.
Medical treatment
Comorbid depression or anxiety will need to be treated appropriately with medication,
if necessary.
Psychological treatment
Both individual and group cognitive behavioural therapy are useful for the treatment of
somatisation disorder of different types. The main focus is on changing the patients
cognitions and behaviour.
In some cases, brief psychodynamic psychotherapy has also been effective.
42 Chapter 2: Anxiety disorders
FURTHER READING
Burton, C. (2003) Beyond somatisation: A review of the understanding and treatment of
medically unexplained physical symptoms MUPS. British Journal of General Practice,
53(488), 2319.
Gill, D. & Bass, C. (1997) Somatoform and dissociative disorders: Assessment and
treatment. Advances in Psychiatric Treatment, 3, 916.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 2(a): Generalised anxiety disorder 43
INSTRUCTI0N TO CANDIDATE
This is Mrs Arnold, a 53-year-old married woman, who has been seeing a counsellor
in primary care as she is stressed and anxious most of the time. The patient does
not feel that the sessions have been helpful and the GP phones you and describes
her being persistently anxious with little let up in her symptoms. He has tried to
identify triggers without success and hopes you will be able to advise further. She
attends with her husband and you see them together with her consent.
Assess this woman and consider the differential diagnosis.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and thank the couple for coming to see you today. Direct your ques-
tioning to the patient, but keep the husband involved in the dynamics.
Id like to ask you whats been happening and Ive been told youre comfortable to talk
with your husband here. I understand that youve been feeling anxious, is that correct?
Could you tell me what things make you feel anxious? What does the anxiety feel like?
Start with open questions as usual and then become more focussed in your approach.
Normal worry
People with generalised anxiety disorder (GAD) tend to have more worries. There is also
little reprieve from their anxiety. Often they will report a history of long-standing worry
as reported here. The worry is all-consuming and it is difficult to focus on other issues. It
is ruminative and uncontrollable, with individuals unable to stop themselves worrying,
despite an acknowledgement that they worry too much. In GAD, there are also the mani-
festations of continuous tension (psychological [e.g. irritability and nervousness] and
physical [e.g. muscle tension and headache]). These features are often enough to cause
significant disruption to social and employment activities.
Medical illness
Ask about features of hyperthyroidism and other chronic physical ill health. Examples
include:
Mental illness
Consider and attempt to exclude anxiety related to psychosis, depression, dysthymia and
personality disorders (anxious and dependent). Try to differentiate between GAD, obses-
sive compulsive disorder (OCD), panic disorder, agoraphobia, social phobia, specific pho-
bia, post-traumatic stress disorder (PTSD) and adjustment disorder.
Mrs Arnold, you told us how your anxieties started with stress. Could I check if you were
ever low in mood before your anxieties started? Have you had any strange experiences
that you could not explain? Or was there something weighing on your mind all the time?
Do you avoid leaving home?
Medication
Take history of current medication use that is likely to mimic/exacerbate anxiety
symptoms:
Substance misuse
The use of amphetamines, cocaine, hallucinogens, alcohol and sedative hypnotics can
lead to anxiety.
Differential diagnosis
Differentiating GAD from dysthymia can be clinically challenging. Both are associated
with dysphoric mood, and patients with GAD often present initially with depression as
a consequence of their anxiety. Unlike PTSD and adjustment disorders, in GAD there is
Station 2(a): Generalised anxiety disorder 45
usually the absence of a significant life event or trauma. Unlike specific phobias, the
anxiety is broad and persistent.
GAD is a common form of anxiety, particularly in primary care. It affects women more
than men (2:1) and is commonly associated with other psychiatric morbidities. It is a
chronic condition and up to a quarter of sufferers will develop panic disorder. In Diagnostic
and Statistical Manual of Mental Disorders, Fourth edition (DSM IV), the distinction between
GAD and normal anxiety is explained by anxiety that is excessive and difficult to control
with significant impairment or distress.
Risk assessment
GAD is often associated with depression. These patients tend to be more treatment resis-
tant, and comorbid depression increases the suicide risk.
FURTHER READING
ICD-10 (1992) Classification of Mental and Behavioural Disorders: Clinical Descriptions and
Diagnostic Guidelines. Geneva: WHO Press.
Massion, A.O., Warshaw, M.G. & Keller, M.B. (1993) Quality of life and psychiatric morbidity in
panic disorder and generalised anxiety disorder. American Journal of Psychiatry, 150, 6007.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTI0N TO CANDIDATE
Mr Arnold asks if he can see you alone for a moment. His wife agrees and
is happy for you both to discuss her case. He explains that he has little
understanding of what it all means and wants to know what causes someone to
be like this. He acknowledges that she has always been a little cautious about
things, but that it had become so much worse over the last few years. He had
hoped she would be able to pull herself together, rather than having to see a
psychiatrist.
Explain to Mr Arnold what causes this condition.
SUGGESTED APPROACH
Setting the scene
The link here would not demand an introduction, but rather to pick up on the situation as
the wife exits the scenario: You asked to talk about how this could have happened to your
wife. Tell me what it is you would like to know and Ill do my best to answer your questions.
Was there a specific reason you didnt want Mrs Arnold to be here? Sometimes it is difficult
to discuss things openly with loved ones. Was there anything that you thought might
upset her?
widespread, but we are still not exactly sure what causes generalised anxiety disorder or
other anxiety disorders. Ill explain to you what the current thinking is on how these
conditions develop and if at any time you have questions or dont understand, please
interrupt me.
Biological
Genetic: there is little evidence for a genetic influence in GAD and it is unlikely to have
a specific genetic or familial basis. Studies have shown that children of GAD mothers were
no more likely to be anxious than counterparts with unaffected mothers. However, other
studies have shown higher rates of GAD in families, but this may reflect the influence of
a shared environment.
Pathophysiological: certain chemical systems in the brain called neurotransmitters have
been implicated as having a role in anxiety. There are various such compounds, such as
serotonin, noradrenaline, glutamate, gamma-aminobutyric acid (GABA) and cholecysto-
kinin. Currently, there is limited evidence for one neurotransmitter having a dominant
role in GAD. The benzodiazepine receptor has also been implicated.
Other: so far, there are no consistent neuroimaging findings in GAD. There is a circuit in
the brain which runs from our adrenal gland on top of our kidneys to certain brain regions,
and these auto-regulate each other by feedback mechanisms. There are some suggestions
that this hypothalamicpituitaryadrenal axis changes in functionality, which plays a
role in the stress response. Studies have suggested that the stress hormone cortisol may
be increased for prolonged periods of time in people with GAD.
Anxiety is like worry or fear that has become a problem because they are too strong,
making you uncomfortable and stopping you from doing things in your life. Some of us
seem to be born that way. Research seems to suggest that we can inherit anxiety from our
parents. Little is known about its precise aetiology. There may be a common vulnerability
shared with other anxiety and affective disorders.
Psycho-social factors
Cognitivebehavioural theory: according to this school of thinking, people with GAD
respond inappropriately to perceived dangers. They selectively attend to negative stimuli
around them and doubt their own ability to cope with them. Other cognitive models
include worry as a cognitive avoidance, beliefs about the benefits of worry (worrying leads
to avoidance of danger) and low self-efficacy (anxiety due to the belief that one is unable
to exercise control over events).
Psychodynamic: no specific model has been developed for GAD, and theorists believe that
anxiety in general is a symptom of unresolved conflicts from developmental stages.
Childhood: there is some evidence that early loss or separation from a parent is seen more
than would be expected in GAD cases. Individuals with GAD have described their rela-
tionships with their parents as overprotective, controlling, rejecting and dysfunctional.
However, these are not specific to GAD.
Life events: despite the usual gradual onset of GAD, increased stress and life events can
be precipitants.
Information on risk
As part of your assessment in the previous station, you will probably have enquired about
suicidal ideation. You could follow that up here with the husband, but could also discuss
the risks associated with comorbid depression, alcohol or substance misuse, if appropriate.
Similarly, risks associated with BZD dependence could come up if treatment issues are
raised by Mr Arnold.
Mr Arnold is looking for answers and the lack of definite causality might leave him feeling
disgruntled. You should explain that whilst the research evidence does not allow us to
48 Chapter 2: Anxiety disorders
be certain of what causes GAD, we have a good understanding of the condition itself and
how we should treat people. This might lead him to ask about management.
The earlier GAD is treated, the more effective therapy is likely to be. Unfortunately, most
people tolerate the anxiety for years before they come to see us. The treatment is a com-
bined psychological approach and medication.
FURTHER READING
Cowley, D.S. & Roy-Byrne, P.P. (1991) The biology of generalised anxiety disorder and chronic
anxiety. In Rapee, R.M. and Barlow, D.H. (eds), Chronic Anxiety. Generalised Anxiety Disorder
and Mixed Anxiety-Depression. New York, NY: Guildford, pp. 5275.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 3: Phobia 49
SINGLE STATIONS
STATION 3: PHOBIA
INSTRUCTION TO CANDIDATE
This 28-year-old taxi driver has a painful tooth but is refusing any dental
intervention. He has not been to a dentist for 15 years.
Meet him and explain how you intend to help him.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and acknowledge that the patient is in discomfort or in pain.
Im sorry to hear that youre in some discomfort with your tooth. Can you tell me what
happened? Why havent you seen a dentist for so long? What do you think would happen
if you saw a dentist?
misuse. Ask if he would allow you at some point in the future to speak with his partner/
family/friend for more information.
Management
You quickly identify that this gentleman has a specific dental phobia related to a fear of
needles. You need to explain in lay terms what you think is happening and how you sug-
gest he is treated.
Based on what you have told me today, I believe you have what we call a specific phobia.
This means that you are not usually anxious about things in your day-to-day life, but are
worried specifically about the needles dentists sometimes use. Some people are petrified
of spiders, and this is the same sort of thing. Because we dislike spiders or needles, well
do anything to avoid them. Even the thought of it can make people feel anxious and
panicky and sometimes, when confronted by the object, they can have panic attacks.
Specific phobias are not uncommon; some suggest that about one in ten of us are affected
at some point in our lives. The good news is that we can help and the most effective form
of treatment is a psychological approach.
Psychological treatment
Behavioural approaches are generally accepted as the most effective, although cognitive
therapy is also used on occasion.
Exposure-based treatment: usually involves gradual exposure in vivo. The patient is
exposed to various aspects and parts of the feared object or situation in an organised
hierarchy of increasing difficulty. Initially, the patient might be shown pictures of a
dentist and syringe and then videos with situations of increasing use of the object. The
next step might be to visit the dentist and once again to grade the exposure from the
waiting area until the patient is able to sit in the dentists chair. The anxiety response
should eventually habituate.
Systematic desensitisation: is seldom used today and involves using the imagination to
picture the feared object or scenario whilst undergoing progressive muscle relaxation.
This technique uses the mechanism of reciprocal inhibition.
Modelling: is employed by many therapists alongside exposure-based treatment, in which
they will demonstrate how to manage the exposure to the feared object or situation. They
might, for example, hold a syringe and then ask the patient to do the same.
Medical treatment
The role of medication is limited and no drug can be confidently recommended, particu-
larly for regular treatment. When psychology has failed or when patients have associated
anxiety disorders, selective serotonin reuptake inhibitors can play a role. BZDs should be
used with caution because of the high risk of dependence, but are given for time-limited
relief of severe and disabling anxiety. In flying phobia, for example, they can be used with
good effect for essential journeys.
FURTHER READING
ICD-10 (1992) Classification of Mental and Behavioural Disorders: Clinical Descriptions and
Diagnostic Guidelines. Geneva: WHO Press.
Strauss, C.C. & Last, C.G. (1993) Social and simple phobias in children. Journal of Anxiety
Disorders, 2, 14152.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTI0N TO CANDIDATE
You have just finished a discharge planning meeting for a patient with OCD.
There were a number of healthcare professionals present, including some
52 Chapter 2: Anxiety disorders
students. One of the student nurses asks if you have a moment to answer some
questions. Although you are busy, you agree to spend a few minutes teaching.
She asks you how you make a diagnosis of OCD and what the future holds
for this patient. Speak to her and answer her queries.
SUGGESTED APPROACH
Setting the scene
Keep the conversation informal and professional.
Hello, Im Dr_____, I didnt catch your name at the meeting. Id be delighted to talk to
you about obsessive compulsive disorder. Its great that youve shown an interest. You had
some specific questions which well talk about. Please feel free to interrupt or ask questions
as we go along. Tell me, do you know anything about OCD already?
ICD-10 criteria
According to the diagnostic guidelines, a definitive diagnosis of OCD requires the follow-
ing: obsessional symptoms or compulsive acts, or both, on most days for at least 2 weeks,
which must be distressing and interfere with activities.
Obsessional symptoms should have the following characteristics:
Must be recognised as the individuals own thoughts or impulses
At least one thought or act that is still resisted unsuccessfully
The thought of carrying out the act must not in itself be pleasurable
The thoughts, images or impulses must be unpleasantly repetitive
A fluctuating course with lifelong remissions (complete or partial) and relapses (reports
of 2%45%)
Constant, largely unchanging chronic course (15%60%)
Progressive, deteriorating course (5%15%)
Spontaneous and lasting remissions are rare. Some studies have shown that even after a
1020-year remission, people can still relapse. It follows that it is a condition that rarely
affords complete recovery, but lies dormant. Stressful life events are likely to contribute to
relapses.
Despite this, some longitudinal studies have shown improvement in the severity of OCD
in approximately two-thirds of cases; 70% of mild cases improve after 15 years; and
33% of severe (hospital-admitted) patients improve after 15 years.
Poor prognosis is associated with:
Risks of OCD
Often, patients with OCD are secretive about their symptoms and do not seek psychiatric
input for years, sometimes decades. Approximately a third of OCD patients have comorbid
depression, and severe depression is associated with a higher relapse rate. There is an
associated suicide risk with OCD.
Differential diagnosis
It is important to mention that in making the diagnosis of OCD, one has to exclude other
psychiatric illnesses in which OCD symptoms may be a feature:
Depression
Phobias
Personality disorder (anankastic)
Schizophrenia
Tourettes syndrome
FURTHER READING
Goodman, W.K. (1999) Obsessivecompulsive disorder: Diagnosis and treatment. Journal
of Clinical Psychiatry, 60(Suppl. 18), 2732.
ICD-10 (1992) Classification of Mental and Behavioural Disorders: Clinical Descriptions and
Diagnostic Guidelines. Geneva: WHO Press.
Veale, D. (2007) Cognitive behavioural therapy for obsessive compulsive disorder.
Advances in Psychiatric Treatment, 13, 43846.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 3 Matthew Fernando and Dennis Ougrin
LINKED STATIONS
INSTRUCTION TO CANDIDATE
Sacha Gurani is an 11-year-old girl who was referred by her GP to Child and
Adolescent Mental Health Services (CAMHS). Her mother is concerned about
persistent school refusal that started 3 months ago. Sacha previously refused
to attend school, but her mother was able to make her go using a variety of
coercive strategies that no longer work.
Take a history from Sachas mother and establish a differential diagnosis.
SUGGESTED APPROACH
Setting the scene
Begin by introducing yourself and explaining the purpose of the meeting: Hello, Im
Dr_____, a child psychiatrist. Ive been asked to see you as your GP was worried about
Sachas school attendance. Could you tell me about your concerns?
Reasons for refusal as perceived by the young person, if known (mothers view)
Associated distress in young person and important others
Impact of symptoms on school, friendships, family relationships and leisure
Ask specifically about symptoms of separation anxiety:
Worrying about: separation or being taken away, being alone or something unpleasant
happening to attachment figures
Refusing to: go to school, sleep alone or sleep in a strange place due to worries
Checking if attachment figures are OK at night
Reporting: nightmares about separation, aches, pains, feeling sick or signs of distress
on separation
Risk assessment
Screen for risk using the questions below. If a significant level of risk is suggested, this
should prompt further questioning:
Establish the nature of the coercive measures alluded to in the referral, but be careful
to do so sensitively to avoid the patients mother becoming defensive: Could you tell
me a bit more about the way Sacha is disciplined at home?
Station 1(a): School refusal 59
Explore any bullying at school: Have you ever been concerned about Sacha being bul-
lied or picked on at school?
Assess the nature of family relationships: How does Sacha get on with other family
members?
Assess the risk of self-harm and suicide: Has Sacha ever tried to hurt herself? Has she
ever tried to kill herself?
Assess the risk of violence to others: Does Sacha ever get into fights?
Establish if there is a need for child protection (is this child at risk of significant harm?)
FURTHER READING
Kearney, C.A. (2008) School absenteeism and school refusal behaviour in youth: A
contemporary review. Clinical Psychology Review, 28(3), 45171.
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
After completing your initial assessment of the young person, you reach a
working diagnosis of separation anxiety disorder of childhood (SAD).
Briefly explain SAD to Sachas father.
Propose investigations and management for a preliminary diagnosis of SAD
and explain the prognosis.
SUGGESTED APPROACH
Setting the scene
On the basis of our discussion so far, it appears that the most likely diagnosis is separation
anxiety disorder of childhood. This is a preliminary diagnosis and we need to do some
more investigations to make the final diagnosis. Before we continue, Id like to ask you if
you have heard of this condition before. What would you like to know about it by the
time we finish talking?
Station 1(b): Explaining a diagnosis 61
Explaining SAD
SAD is a condition in which the fear of separation from home or attachment figures causes
significantly more anxiety than expected in a typical child. There is anxiety about harm
coming to the child or to their attachment figures. It begins in early childhood and is
different from normal separation anxiety in being unusually severe or continuing beyond
the usual age period. It also causes significant problems in the childs daily activities
(e.g.going to school).
Refusal to go to school often occurs at the time of change of school and after a period of
legitimate absence from school (such as holidays or illness). SAD is common and affects
approximately 4% of children. It is more common in girls than boys (2:1).
Biological
Arrange information gathering and physical investigations.
Document headaches and abdominal complaints in order to establish the baseline and
differentiate from side effects of medication if used in the future.
Developmental conditions associated with SAD include dyspraxia, sensory impairment
and language disorders.
Consider the features of hyperthyroidism, migraine, asthma, seizures, lead intoxication
and excessive caffeine.
Consider non-prescription drugs with side effects that mimic anxiety, including diet
pills, antihistamines and cold medicines.
Prescription drugs with side effects that can mimic anxiety include asthma medication,
sympathomimetics, steroids, selective serotonin reuptake inhibitors (SSRIs) and anti-
psychotics (akathisia and neuroleptic-induced SAD).
Psychological
With parental consent, contact the mental health professionals that the young person
has previously seen.
Consider psychometric testing for global or specific learning problems.
Social
Contact school (teachers, special educational needs coordinators, educational psycholo-
gists, mentors and learning support workers as applicable) with parental consent.
Investigate learning profile (does she have an Education, Health and Care Plan?), quality
of interpersonal relationships (including bullying), specific relationship problems and
features of emotional or disruptive disorders in the school setting.
Contact social services with parental consent. Look for previous contact with the family
and evidence of child protection or child in need proceedings.
Establish the goals of the treatment. If the primary goal is dealing with school refusal,
then returning the child to school at the earliest opportunity should be the stated target.
In view of the relatively short duration of school refusal, a rapid reintroduction to school
should be the aim.
The two main therapeutic approaches used to treat school refusal underpinned by SAD
are cognitive therapy and operant behavioural therapy. Both draw on functional analysis
of the behaviour and make use of family resources. In practice, behavioural and cognitive
techniques are frequently combined. Cognitive behavioural therapy (CBT) has been shown
to be superior to waiting list controls.
Treatment components are:
Psycho-education for parents and teachers.
Helping Sacha to return to school as quickly as possible. A graded (albeit rapidly so)
rather than abrupt reintroduction is the method that is most commonly used.
Rewarding Sacha with praise and tangible rewards for achieving the goals. The rewards
used should be mutually agreed by parent and child in advance.
Pharmacological treatment
There have been small, random allocation studies of SSRIs and imipramine showing some
benefit, and their use may be considered if CBT fails.
Home education
This could be considered in a tiny minority of patients with school refusal with refrac-
tory SAD.
FURTHER READING
Ehrenreich, J.T., Santucci, L.C. & Weiner, C.L. (2008) Separation anxiety disorder in
youth: Phenomenology, assessment, and treatment. Psicologia Conductual, 16(3),
389412.
Station 2(a): Mood disturbance 63
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are assessing Richard Chip, a white British 17-year-old referred to a day patient
unit from a local community team. He presented with a period of deterioration
in school performance and increasingly uncharacteristic behaviour, with social
withdrawal, loss of usual interests and irritability. He reports feelings of people
laughing at him and sometimes has a horrible feeling as if he were a puppet.
Take a history of the presenting complaint and past psychiatric history.
Test any delusional beliefs.
64 Chapter 3: Child and adolescent psychiatry
SUGGESTED APPROACH
Setting the scene
Begin by introducing yourself and explaining the purpose of the meeting: Hello, Im
Dr_____, one of the psychiatrists. Ive been asked to see you today because your GP is
concerned about your mood. Could you tell me if theres anything youre worried about?
You should also explore the functional impairment caused by Richards symptoms:
Background history
Past psychiatric history
Age at which disturbance was first noted
Previous depressive symptoms
History of psychiatric symptoms (especially depressive, psychotic or [hypo]manic),
duration and treatment
Developmental history
Developmental delays
School attainment
Distress at separation from parents
Evidence of global or specific learning problems
Medical history
Medical differential: Hypothyroidism, mononucleosis, anaemia, malignancy, autoim-
mune diseases, head injury, hypoglycaemia and vitamin deficiency
Medication mimicking depression: Stimulants, corticosteroids, clonidine, beta-blockers,
diuretics and withdrawal of stimulants and benzodiazepines
Family history
Psychiatric disorders (depression, suicidal behaviour, anxiety, psychosis and bipolar
illness), criminality, substance misuse and medical illness
Perceived family relationship: discordant or supportive?
High expressed emotions
History of intrafamilial abuse
Social situation
Social adversity
Recent loss and other life events
Drugs and alcohol use
Interests and hopes
Criminality
Reciprocal social interactions, friendships and bullying
Romantic relationships and sexual orientation
Protective factors such as supportive family networks
Risk
Risk of self-harm and suicide
Risk of non-engagement
Risk of violence to others
66 Chapter 3: Child and adolescent psychiatry
Exploring comorbidities
Screening for anxiety disorders:
Are there symptoms of anxiety (biological, cognitive and behavioural)?
In what situations do they arise?
Are they distressing and impairing?
1. An idea of reference
2. An overvalued idea
3. A paranoid delusion
Richard also reports feeling like a puppet. It is important to determine if this indicates
the presence of:
1. Delusion of control
2. Derealisation/depersonalisation phenomena
Feeling of unreality
Unpleasant quality
Non-delusional (see above)
Loss of affective response
ADDITIONAL POINTS
See http://www.dawba.com for the Development and Well-Being Assessment
(Goodman etal., 2000), which includes useful questions on establishing the
presence of low mood.
FURTHER READING
Goodman, R., Ford, T., Richards, H. et al. (2000a) The development and
well-being assessment: Description and initial validation of an integrated
assessment of child and adolescent psychopathology. Journal of Child
Psychology and Psychiatry, 41, 645655.
Station 2(b): Explaining treatment and prognosis 67
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Following your assessment, you have diagnosed a severe depressive episode.
You have already discussed the diagnosis with Richard and his family.
68 Chapter 3: Child and adolescent psychiatry
SUGGESTED APPROACH
Setting the scene
Thank you for agreeing to see me today. You met the team recently to discuss Richards
diagnosis and I think its important to take a few minutes to discuss how we can treat his
depression and what the future holds. Does that sound OK to you?
It would be reasonable in an exam setting to assume that Richard has given consent to
speak to his mother, although you may like to explicitly state this (particularly as you are
disclosing information regarding the treatment plan and prognosis).
At the beginning of the interview, you should explore Mrs Chips hopes and expectations
and establish the overall goals and framework of the treatment. Emphasise the importance
of adopting a collaborative approach with other professionals and engaging the young
person and family (with the young persons consent) in all decision making.
the skills they have learnt and keep a diary of their progress. However, CBT does not always
work. In good studies, about 50% of young people who have CBT alone get better within
the first few weeks of treatment. I could also give you information about useful websites
and a leaflet explaining more about CBT.
IPT is similar to CBT and is also a talking treatment with several 1-hour weekly or
2-weekly sessions for at least 3 months. Unlike CBT, in IPT, the therapist and the young
person look mainly at the young persons relationships with other people. This is because
we know that most young people with depression could do with some help when it comes
to their relationships. We also know that young people tend to get depressed at the time
of relationship problems. In IPT, the young person and the therapist look at ways of
improving the young persons relationships and dealing with some of the bad things that
may have happened to the young person. Young people talk about their feelings and
learn how to manage them. They also discover ways of communicating more effectively,
solving problems and managing conflicts. During the treatment, other important people
in the young persons life can participate (with their consent). It is useful for young people
to practise some of the skills at home and at school and to do role-plays during the ses-
sions. I could also give you information about useful websites and a leaflet explaining
more about IPT.
Even better than this general approach is to use examples of specific social problems that
arose from the interview with Richard with relevant interventions.
Prognosis
In the short term, most young people will recover from depression. Between 60% and
90% of episodes of depression will get better within a year. There is, however, a high risk
of depression recurring, with 50%70% of young people who improve becoming unwell
again within 5 years. Young people are also at risk of mental health disorders and psycho-
social problems in adulthood, including anxiety and bipolar disorder, in addition to
depression. Because of this, greater understanding of depression and engagement with
the multidisciplinary team is extremely important.
FURTHER READING
Thapar, A., Collishaw, S., Pine, D.S., & Thapar, A.K. (2012) Depression in adolescence.
TheLancet, 379(9820), 105667.
5. Prognosis Evidence-based
20% of marks discussion of likely
outcomes
% SCORE _________ ___ OVERALL IMPRESSION
5 (CIRCLE ONE)
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Nadia Burrell is a 16-year-old young lady who presented to A&E at 2 a.m. this
morning following an overdose of 16 paracetamol tablets. She is accompanied
by her mother. Nadia was at a friends home when she took the overdose after
a fight. She was admitted overnight and is now medically fit for discharge.
Nadia was seen by a social worker, who expressed no immediate concerns.
Assess the risk of suicide and violence.
Conclude by making a brief risk summary and formulation to the examiner
in the station the examiner will listen but will not discuss the case
withyou.
YOU ARE NOT REQUIRED TO FORMULATE A MANAGEMENT PLAN
72 Chapter 3: Child and adolescent psychiatry
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain why you are meeting: Hello, Im Dr_____, one of the
psychiatrists. I was hoping we could talk a bit about whats been happening so we can
think about how best to help.
Previous self-harm
Previous suicidal attempts using violent methods
Use of prescribed medication (especially SSRIs and benzodiazepines)
Familial suicidal behaviour
Familial psychopathology/substance misuse
Family discord
Exposure to suicidal behaviour
History of antisocial behaviour
History of physical illness
Recent discharge from services
Family members expressing concern about suicide
Gay, lesbian or bisexual orientation
Station 3(a): Suicidality 73
Explore other factors associated with the risk of violence and suicide:
Substance misuse
History of emotional, physical or sexual abuse/exploitation
Exposure to violence
History of accidental injuries
Recent life events
History of self-neglect
History of impulsive behaviour
Social or cultural isolation
Social adversity
Poor daily living skills
History of psychiatric illness
Assess protective factors:
Good family relationships
Problem-solving ability
Peer support
Pro-social behaviour
Good social skills
Good self-esteem
Sense of control over life
Positive school experiences
Resilience to stress
Positive attitude to treatment
Positive attitude towards authority
In the past 6 months, has there been at least 1 week in which you had at least two
drinks?
Let me know if you have used any street drugs before, even if you have only tried
them once. Which ones have you used?
In the past 6 months, what is the most you have used? Every day or almost every
day for at least 1 week? Less? More? Was there a time when you used more?
FURTHER READING
http://www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/ksads-pl.pdf
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D. & Ryan, N.
(1997) Schedule for affective disorders and Schizophrenia for school-age children
Present and Lifetime Version (KSADS-PL): Initial reliability and validity data. Journal of the
American Academy of Child and Adolescent Psychiatry. 36, 980988.
Ougrin, D., Tranah, T., Leigh, E., Taylor, L. & Asarnow, J.R. (2012) Practitioner review:
Self-harm in adolescents. Journal of Child Psychology and Psychiatry, 53(4), 33750.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
76 Chapter 3: Child and adolescent psychiatry
INSTRUCTION TO CANDIDATE
You have now interviewed Nadia and the team decision is that she is fit for
discharge with urgent community follow-up. However, her mother indicates that
she is in two minds about the need for community follow-up, as things now
appear to be OK and the family want to move on. Nadia is also ambivalent
and stated she will only attend follow-up appointments if accompanied by her
mother.
Assess her mothers views and explore the importance of community
follow-up with her.
Nadia has consented for you to discuss her treatment plan with her mother.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain the purpose of the meeting. Ask about Mrs Burrells views
on her daughter and what she feels should happen. Gain a baseline understanding of her
beliefs and concerns.
Then move on to the pros. Explore the good things about attending community follow-
up. Common reasons for attending appointments include a wish to understand problem-
atic behaviour and reduce the risk of further self-harm, a desire to improve relationships
and a hope that the young person will learn new ways of dealing with problems.
Having obtained a summary score for the overall motivation you can develop this part
by exploring different elements of motivation.
How important is it that you and Nadia attend the follow-up appointments?
How come your score is not 0 tell me more about it. Why else? What would need
to happen for you to move up one point?
You could use the same principles to ask:
How confident are you that you can attend the follow-up appointments?
How ready are you to attend the follow-up appointments?
with the family members. You could also give Mrs Burrell written information about your
service and leave some time to answer questions.
Taking a cooperative stance:
Avoid direct confrontation and arguments
Express empathy
Emphasise self-efficacy
Instil hope
Use open questions
Affirm positives
Provide reflections
Use summaries
FURTHER READING
Rollnick, S. & Miller, W.R. (2002) Motivational Interviewing, 2nd edn. New York, NY: The
Guilford Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Salim Jahani is a 15-year-old boy who presented to A&E after self-harming by
cutting his arm with the blade from a pencil sharpener. He was brought in by
his teacher after they noticed the cuts. His parents have now arrived at the
hospital. Salim has received treatment for superficial cuts and can now be
discharged from a medical point of view.
Take a focussed history of the reasons for self-harm.
Assess Salims mental state.
Perform a brief risk assessment.
SUGGESTED APPROACH
Setting the scene
Begin by introducing yourself and explaining the purpose of your meeting: Hello, Im
Dr_____, one of the psychiatrists. I was hoping to find out what happened.
What did the patient use to cut themselves with and from where did they obtain it?
Where on themselves did they cut? Was it once or several times? How deep were
the cuts and what sort of medical attention, if any, did they need?
Was the self-harm impulsive or planned?
80 Chapter 3: Child and adolescent psychiatry
Where were they? Were they alone? How did they come to be in hospital?
What was the purpose behind the self-harm? Was it to relieve tension or to signal
distress, or was there suicidal intention?
Did the patient harm themselves in any other way (including simultaneous suicidal
acts such as an overdose)?
Explore possible precipitants by asking Salim about things that might have upset him
and that may have led to him wanting to hurt himself. Consider possible difficulties in
the following areas:
Explore life at home:
Who lives at home? What is the patients relationship like with their parents and
other family members? What about other intrafamilial relationships?
Are there fights at home? Is there any evidence of domestic (verbal, physical or
sexual) abuse that they might be witnessing or experiencing?
Are there problems with the home itself (e.g. overcrowding or problems with the
fabric of the home) that their family might be worried about?
Are there other stresses in the family (e.g. with money, ill health or
unemployment)?
Explore life at school this may be particularly relevant given that the patient was at
school when they harmed themselves:
Background history
Past psychiatric and medical history it is particularly important to include or exclude
illnesses that might be leading to self-harm.
Previous history of self-harm, including suicidal thoughts and acts
History of psychiatric symptoms, including depression and anxiety
Chronic illness causing pain or disability
Medications
Station 4(a): Self-harm 81
Family history
As above, plus family history of psychiatric disorders or other problems causing stress
to the patient (e.g. physical illness or substance misuse)
Developmental history
Evidence of developmental delay or learning problems
Evidence of difficulties with social communication or ADHD that may be contributing
to stress
Assessing risk
It is useful to consider risk in different domains (e.g. risk of self-harm and suicide, risk of
vulnerability and self-neglect, risk to other people, risk from others, etc.) and both imme-
diate and longer-term risks.
Risk to others
Does the patient pose any risk to others (e.g. through retaliating for being harmed
by them)?
and explain the limits of confidentiality in terms of sometimes having to tell other people
if someone might come to harm. Reassure Salim, however, that even if this does become
necessary, it is your role to help keep him safe.
FURTHER READING
National Institute for Health and Care Excellence Clinical Guideline 16 Self-harm in over
8s: Short-term management and prevention of recurrence: https://www.nice.org.uk/
guidance/cg16
Ougrin, D., Tranah, T., Stahl, D., Moran, P. & Rosenbaum Asarnow, J. (2015) Therapeutic
interventions for suicide attempts and self-harm in adolescents: Systematic review and
meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 54(2),
97107.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 4(b): Addressing bullying 83
INSTRUCTION TO CANDIDATE
After meeting with Salim, it has become apparent that he is being bullied at
school and this is one of the most significant triggers of his self-harm. With
Salims consent, you are now meeting with his father.
Explain your findings in relation to bullying and self-harm regarding Salims
finding.
Discuss how to address the bullying.
Respond to any concerns that Mr Jahani may have.
SUGGESTED APPROACH
Setting the scene
Begin by introducing yourself and explaining your role. Salims father did not bring him
to hospital, so first find out what he knows about what has happened. It will be useful to
start by checking his understanding of the situation and what might have led to Salims
presentation before explaining what you have found.
Addressing bullying
Check with the patients father what is already known about the bullying, whether it has
already been reported and what interventions are already in place.
Explain that while the school will need to get more information about what is happening,
it is important to listen to the patient and take him seriously, as he may be feeling fright-
ened, ashamed, embarrassed or guilty. There are many reasons as to why children are
bullied, and they often think it is their fault, so they should be reassured that this is not
the case.
84 Chapter 3: Child and adolescent psychiatry
It is necessary to have a good understanding of where and how the bullying is taking
place. Is it solely on school property or with peers from school, or are other people
involved? Bullying can take numerous different forms, including through the use
of text messages, online forums and social media, and all of these need to be addressed.
All schools are required to have an anti-bullying policy in place, and the first step will be
to contact them so that they can investigate what is happening. Simply bringing attention
to the bullying is enough to stop it in many cases. Talking to the young person about
ways to minimise bullying can also be useful; for example, how to react if they are called
names or places that they should avoid.
The patient may also need emotional support from the school nurse or counsellor. In
Salims case, the bullying has led to self-harm and he may need further help and treatment
from the CAMHS.
Responding to concerns
At the outset of the interview, it will be helpful to ask if the patients father has any
questions or concerns that need addressing. Some of the concerns that may arise could
include:
Why the patient harms himself:
If the patient has not given their own explanation, you might describe how
some young people find that self-harm helps to relieve stress and manage dif-
ficult emotions.
Whether there are any other treatments, such as medication or psychological thera-
pies, which may be helpful:
Treatments depend on the exact aetiology, but most importantly will include
intervening with bullying and other stressors.
Counselling may be helpful, and other psychological therapies and medications
may be indicated in cases of underlying diagnoses such as depression.
What to do if he continues to self-harm and how best to manage this safely:
You will be working with the patient to try to find alternatives to self-harm,
although in the short term, some young people who have been self-harming
for a while find it difficult to stop, and it can then be useful to try techniques
that reduce the dangerousness of self-harm.
What to do if self-harm escalates into suicidal thoughts or acts:
One aspect might be to use distraction techniques in order to avoid sustained
suicidal thoughts.
Acknowledge that it can be frightening and explain that if the parents are con-
cerned, they should always get in touch or, during out-of-hours time periods,
take the patient back to A&E.
FURTHER READING
Vreeman, R.C. & Carroll, A.E. (2007) A systematic review of school-based interventions to
prevent bullying. Archives of Paediatrics and Adolescent Medicine, 161(1), 7888.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
Philippa Abrahams is a 17-year-old woman who has been exposing herself
to young children at a local school. A number of the schools parents have
become concerned and have notified the police and the schools head teacher.
86 Chapter 3: Child and adolescent psychiatry
The young woman has a history of learning disability. She has shown sexually
inappropriate behaviour, which has improved somewhat over the years. Her
foster parents report ongoing challenging behaviour and have reported a
history of self-harm.
She attends a special school where she boards for 3 days a week and you
have been asked to assess her there by staff at the school. Parental consent
has been obtained. You first arrange an interview with a member of staff at the
young womans residential placement.
Take a history of her behaviour.
Establish the possible aetiology and perpetuating factors.
SUGGESTED APPROACH
Setting the scene
Introduce yourself to the member of staff. Establish how long the informant has known
Philippa and how often they have had contact with her. Explain that you have been
asked to find out a bit more about the nature of the difficult behaviours Philippa
displays.
Any possible positive (i.e. brings about something pleasant) or negative (i.e. takes
away something unpleasant) reinforcers?
Is Philippa ever unsupervised in such a way that she might be vulnerable to mal-
treatment by others?
Does it take a particular or stereotyped form which may indicate a specific syndrome
(e.g. LeschNyhan syndrome)?
To what extent are these behaviours threatening the tenability of current foster
and educational placements?
Does Philippa have functional expressive language? To what extent can Philippa
understand language?
What are Philippas abilities with regards to activities of daily living (e.g. toileting,
feeding, bathing and mobility)?
Is Philippa menstruating? When was her last menstrual period? Has she had a
pregnancy test?
Ask about withdrawal, altered sleep/appetite, tearfulness, activity levels and unchar-
acteristic behaviour
Risk assessment
Although not specifically requested, significant risks are evident in the candidate brief,
and this should prompt the need for some exploration of risk.
Risk of self-harm:
Is this self-injurious behaviour? This tends to be stereotyped and most commonly
skin picking, wrist biting, etc.
Is this better understood as purposeful, thought-out acts with the desire to end life
(not incompatible with milder LD)?
Are these behaviours planned and goal directed or, for example, is Philippa hitting
people unintentionally whilst resisting restraint?
Station 5: Learning disability 89
FURTHER READING
Oliver, C. & Richards, C. (2015) Practitioner review: Self-injurious behaviour in children with
developmental delay. Journal of Child Psychology and Psychiatry, 56(10), 104254.
Xenitidis, K., Russell, A. & Murphy, D. (2001) Management of people with challenging
behaviour. Advances in Psychiatric Treatment, 7, 10916.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
90 Chapter 3: Child and adolescent psychiatry
INSTRUCTION TO CANDIDATE
You are at work and have been approached by a receptionist who informs you
that a local journalist is at reception. They are writing a piece on a local child
with autism who has been excluded from one of the local schools. As part of
the article, they would like an expert opinion on autism.
Your consultant is not available, and having spoken with the Trusts public
relations department, you agree to meet the journalist briefly to make a
comment about autism.
The journalist knows not to ask you any political questions.
Talk to the journalist and give an overview of the condition. The journalist wants
general advice on what parents who are concerned about a child should do.
SUGGESTED APPROACH
Setting the scene
Begin by introducing yourself and explaining your role. Ask the journalist what in particu-
lar they would like to know about autism. Be clear that whilst you are not an expert in this
field, you are happy to cover key aspects, referring them to sources such as the National
Autistic Society if they need further information. Ask where the information will go and
state that you would like to see how you are being quoted before the article is printed.
Clinical characteristics
ASD is characterised by problems from early childhood with social interaction and com-
munication. These include verbal and non-verbal communication, such as eye contact and
body language, as well as developing and maintaining relationships with others. Repetitive
patterns of behaviour or movement, an insistence on sameness and inflexible adherence
to routines and highly fixated interests that are unusual in intensity or focus are also seen.
Some people with autism may be very sensitive to things like particular sounds or textures.
Symptoms are typically apparent from the second year of life and interfere with social
development and other areas of functioning.
that one or two in every 100 people has ASD. It is approximately four times more common
in males than females.
Contrary to some concerns that this increase may be due to an environmental factor (e.g.
the measles, mumps and rubella vaccination now clearly disproved as a cause of ASD),
the altered prevalence seems to reflect a change in how we diagnose the condition and
the fact that children who would have been diagnosed with other disorders (e.g. learning
disability or specific language problems) are now considered to have ASD.
The neurobiological basis of ASD is still not well understood, but there is some evidence
of early brain overgrowth and developing abnormalities in parts of the brain that are used
when we have to interact with others or to plan and control our behaviour.
In 10%15% of cases, ASD is seen in the context of a medical disorder that is thought to
be causal (e.g. tuberous sclerosis, phenylketonuria or SmithLemliOpitz syndrome). The
remaining 90% are considered idiopathic. Some non-specific risk factors have been
identified, however, including older parental age and lower birth weight.
Idiopathic autism has the highest heritability of all multifactorial psychiatric disorders,
with heritability estimates of up to 90% or more. ASD is familial and the recurrence risk
for ASD or related developmental conditions in siblings is 10%. Recent thinking regarding
genetic risk is that, in some instances, many small genetic factors act synergistically to
generate risk for the disorder, while in others, an abnormality within a single larger stretch
of DNA imparts risk.
Approximately 70% of those with ASD also have another psychiatric disorder (e.g. anxiety,
ADHD, obsessive compulsive disorder or psychosis). Approximately half have a learning
disability and 20% also suffer from epilepsy.
FURTHER READING
UK National Autism Plan: http://www.autism.org.uk/about/diagnosis/children/recently-
diagnosed/national-plan-children.aspx
Volkmar, F.R., Lord, C., Bailey, A, Schultz, R.T. & Klin, A. 2004. Autism and pervasive
developmental disorders. Journal of Child Psychology and Psychiatry, 45(1), 13570.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 7: Medically unexplained symptoms 93
INSTRUCTION TO CANDIDATE
Sarah Mason is a 9-year-old girl who was admitted via A&E complaining of a
sudden loss of sensation and movement in both of her legs.
She has been fully investigated over the past week by the paediatricians
and no clear medical cause for her symptoms could be identified. She was
discussed with your liaison psychiatry consultant, who wondered if she
might have a conversion disorder. A joint meeting has been arranged for 2
weeks time, when this would be discussed with Sarah, her family and the
paediatricians. Your consultant is currently on leave.
The receptionist informs you that Sarahs father is in the department. He is
very angry and is saying that his child is not mad or faking it.
Take a history from the father and answer his questions.
Discuss the next steps with him.
SUGGESTED APPROACH
Setting the scene
Do not interrupt the father, who may be angry at first; let him air his grievances. Thank
him for coming to see you and demonstrate an understanding attitude (I can see you are
very upsetof course this must be a concern for you). Contextualise your meeting.
Explain that your consultant is away, and that whilst you have not been directly involved
in Sarahs care, you are keen to help. You will try to address his questions and concerns
and plan the next steps in preparation for the consultants return.
Many thanks for clarifying things for me. In order to best help, I will need to ask you
quite a few questions. As time is limited, please forgive me if I appear to be rushing you.
We can always arrange to meet again in the near future. This is a generally helpful line
in CASC scenarios in which tempers are high and there is a lot to cover.
If fluctuating, are there any factors that seem to be associated with worsening/
improvement?
Has she ever had these symptoms before? What happened then?
Are their concerns shaped by specific prior experiences of illness (e.g. affecting
another relative)?
Has she been preoccupied with the possibility that she has a specific disease?
Has she ever expressed any bizarre/unusual beliefs in relation to them (e.g. nihilistic
beliefs/passivity experiences)?
How distressed is she by them? Is there evidence that she has la belle indiffrence
(a degree of distress that seems surprisingly low given the nature of the
symptoms)?
Has she ever witnessed similar symptoms in other people (e.g. father)?
What is the impact of Sarahs symptoms? What can/cannot she do? Is there any secondary
gain (e.g. cannot go to school where she is being bullied)?
Have the symptoms been preceded by any clear life event/stressor (e.g. family break-up,
exams, victimisation, etc.)? Does Sarah have any recognised physical health problems?
Does she take any prescribed medications?
Background history
Screen for:
Mood disorders
Anxiety disorders
Risk assessment:
Are there any factors that increase the risk of Sarah having experienced recent
abuse? Is there any past history of self-harm?
It is a good idea to make sure that you ask a few screening questions about risk in
any station. A good initial question might be: Do you have any concerns about
Sarahs safety? Sarahs symptoms could have been preceded by an adverse life
experience, which may include experiences of abuse.
Station 7: Medically unexplained symptoms 95
Addressing concerns
It is important to address the fathers concerns that you might think that Sarah is mad
or faking it. Useful things to say in response to these questions include:
Her experiences are clearly very real for her, and understandably worrying for her fam-
ily. It is highly unlikely that she is faking it.
However, physical investigations have not found a clear cause.
All of the physical illnesses that are usually considered to be causes of Sarahs symptoms
have been ruled out.
The important thing to recognise is that she is still impaired due to problems with
walking, so we need to think of what to do next.
It is impossible to be 100% sure that there is no physical contribution to her problems,
but we know that sometimes psychological factors are very important.
In the absence of an obvious physical cause (and treatment that any such diagnosis
might suggest), an alternative approach that can often be very useful is to think of how
these factors can influence the body.
Note: You may want to use somatic features of anxiety as an example. They are
common experiences and provide a concrete instance of how our emotional state
can affect our physical state.
For some people, without them knowing it, troubles and stress can influence their body
in such a way that things like altered sight, altered ability to move limbs and even fits
can occur.
FURTHER READING
Eminson, D.M. (2007) Medically unexplained symptoms in children and adolescents.
Clinical Psychology Review, 27(7), 85571.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 8: Attention deficit hyperactivity disorder 97
INSTRUCTION TO CANDIDATE
GP Referral Letter
Dear Doctor,
Re: Simon Harrington, 8 years old. 17 Evershaw Road, SE19, London
I would be grateful for your opinion on this child who has become increasingly
difficult for his mother to manage.
Past medical history: otitis media, gastroenteritis, right fibula fracture.
Medication: none.
His mother is asking for a psychiatric opinion. I have examined him today and
he appears a physically fit and healthy child. Of note, he smelt of cigarettes,
but denied smoking. I do not believe he has access to illicit substances such
as cannabis. Your advice would be appreciated.
Yours sincerely,
Dr Jane Michaels
Simon refused to come for his appointment today and has locked himself in
his bedroom.
Take a history from his mother.
Discuss the investigations you would like to perform.
Explain your likely diagnosis.
SUGGESTED APPROACH
Setting the scene
Thank Simons mother for coming and check her understanding of why you are meeting.
Tell her that you have received a letter from Simons GP mentioning that she wanted to
meet with Child Mental Health services about difficulties with Simons behaviour.
Explain that you would like to ask her a few questions in order to try and understand
things a bit better. What you discuss will be confidential. However, if your discussion
raises concerns about safety, you may have to share these with other agencies in discus-
sion with the family.
98 Chapter 3: Child and adolescent psychiatry
What is the nature of the difficulties as experienced by the mother? General questions
include:
What are the informants main concerns and how long have they been an issue?
Do problems occur across all settings (e.g. home and school)?
Are they associated with impairment (e.g. suspended from school or limiting what
the family can do)?
What has been tried in order to address the problems so far (include parental dis-
ciplinary methods, as well as formal support from within school or past CAMHS
involvement)?
Has the input received to date been of any benefit? If so, how? If not, any ideas
why not?
How does the family deal with Simons behavioural difficulties? Is physical chastise-
ment ever used? To what extent might his behaviours be reinforced by the responses
of others (e.g. outbursts reinforced by Simon eventually being given what he wants)?
Hyperkinesis:
High levels of physical activity
Fidgetiness
Inattentiveness:
How long can he stay on task?
Does he flit from one activity to another?
How easily is he distracted from a task?
If distracted, does he re-engage voluntarily or is prompting required?
Impulsivity:
Does he think before acting (e.g. running across the road if interested in
something)?
Can he wait his turn (e.g. queuing)?
Does he blurt out answers or interrupt others when they are talking?
Station 8: Attention deficit hyperactivity disorder 99
Are there problems with stress, slow development, substance use or ongoing contact
with mental health services in family members?
Developmental history:
Early milestones
Is there any evidence that Simon might have generalised learning difficulties/
specific learning disabilities?
Has he ever been granted an Education, Health and Care (EHC) Plan (previously a
Statement of Special Educational Needs)?
Many comorbidities of ADHD are also differential diagnoses. Consider and screen
for the following (refer to diagnostic criteria for details of what to ask about):
Oppositional defiant disorder/conduct disorder
Generalised learning disability
Specific developmental disorder
Substance misuse
Depression
Risk issues:
You will by this stage already have some clues (e.g. how parents deal with difficult
behaviour and whether Social Services have been involved), but ask more directly
about risk:
Gently enquire about Simons broken leg.
I can imagine things can get very stressful trying to control Simons behaviour.
Do things ever get physical?
100 Chapter 3: Child and adolescent psychiatry
Does Simon ever get so angry he hits out? Has anyone ever needed medical
attention as a result?
Is Simon at risk of harm due to his impulsivity (e.g. does he have good road
safety)?
Discussing investigations
Biological
You would want to arrange a meeting with the child so that you can carry out a
physical examination yourself.
Physical investigations might follow (baseline height/weight in case stimulant
medications are to be started, genetic investigations if dysmorphic, etc.).
Psychological
History and mental state examination are to be conducted with Simon himself.
If there is any suggestion that Simon may have a degree of unquantified
learning disability, cognitive testing would be indicated, as the inattention,
hyperactivityand impulsivity required for an ADHD diagnosis must be elevated
relative to the developmental stage of the child (i.e. mental rather than
chronologicalage).
If there is evidence that Simon has more specific learning problems (e.g. language
delay), psychometric testing would be indicated.
Social
Questionnaires such as the Conners rating scale are widely used for checking teacher
and parent observations of ADHD symptoms.
Mention that you might want to do direct school observations yourself at a later
stage.
You could mention to Simons mother that after further assessment has been car-
ried out, there may be helpful ways in which social services could get involved.
Some 40%60% of cases may carry on into adulthood, and it can be associated with
mental health and psycho-social difficulties in later life, but many young people learn
to manage their difficulties with appropriate support.
Ask if there are any questions.
FURTHER READING
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. London: Wiley Blackwell, p.384.
Taylor, E., Dpfner, M., Sergeant, J. etal. (2004) European clinical guidelines for hyperkinetic
disorder First upgrade. European Child and Adolescent Psychiatry, 13(Suppl. 1), i7i30.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
STATION 9: FIRE-SETTING/ABUSE
INSTRUCTION TO CANDIDATE
Rachel Connors is a 14-year-old girl who has been brought to A&E after setting
a fire in her bedroom. She has a history of previously setting fires and was
sexually abused by her stepfather. The staff in A&E are concerned that she
may have an underlying mental illness.
Assess for risk in relation to fire-setting.
Take a brief history to identify whether she has a mental illness.
SUGGESTED APPROACH
Setting the scene
Begin by introducing yourself and addressing the task: Hello, Im Dr_____, a psychiatrist.
I was told that you lit a fire and I would like to talk about why you might have done that.
Where was the fire lit, what materials and ignition source were used and was there an
accelerant?
What time was it, where were other people (and did they think about this?) and how
was the alarm raised?
Did they stay to watch the fire?
How were they feeling at the time (i.e. their emotional state)?
From here, you might start to ask about why they lit the fire:
Was it to destroy property or harm themselves or someone else?
Do they have a fascination with fire or emergency services?
Was it because they found something calming or tension relieving about the fire?
Were they persuaded or coerced by someone else?
Background history
Consider if there are current social stressors that might have acted as a trigger for Rachel
setting the fire (e.g. problems at school, with her family or with relationships). Find out
about existing links with social services and other agencies. Does Rachel live with her
family or is she in care? If the latter, find out more about her care history.
Explore particularly relevant elements of the history, some of which might be associated
with increased risk of fire-setting:
Past history of psychiatric disorder, neurological disorder or learning disability
Relevant past medical history or family history
Substance misuse
History of being bullied
History of neglect or physical, emotional or sexual abuse
Offending history, including type of offences and whether there was violence against
people or property
History of other violent behaviour, including cruelty to animals
Assessing risk
It is important to understand Rachels thoughts about what might have happened with the
fire, whether it might have spread and particularly whether it might have endangered anyone.
How much insight did she have into it and was she involved in calling for help? When
assessing risk, you will need to ask about previous fire-setting, as well as checking other areas
of forensic history. In terms of factors directly relating to fire, consider the following:
History of setting fires or playing with fire
Personal experience of fire and whether there is any symbolic significance
Remember to explore risk to self, particularly as the fire-setting may have been an act of
self-harm, as well as risk to others.
FURTHER READING
American Academy of Pediatrics; Stirling, J. Jr, Committee on Child Abuse and Neglect and
Section on Adoption and Foster Care, American Academy of Child and Adolescent
Psychiatry, Amaya-Jackson, L., National Center for Child Traumatic Stress (2008)
Understanding the behavioral and emotional consequences of child abuse. Pediatrics,
122(3), 66773.
Station 9: Fire-setting/abuse 105
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 4
Eating disorders Thomas Gilberthorpe
LINKED STATIONS
INSTRUCTION TO CANDIDATE
Miss Anderson is a 22-year-old woman with an established diagnosis of
anorexia nervosa who has been admitted to hospital with significant weight
loss and hypokalaemia.
You are seeing her on the medical ward and have been asked to:
Find out about her current and past episodes of anorexia nervosa
Ask about her physical symptoms
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name, introducing yourself and explaining
why you have been asked to see her.
Hello, my name is Dr_______, I am one of the psychiatrists. The nurses have told me that
you came into hospital because of your weight and blood results. Has somebody already
told you about your blood results? (If not, explain about her potassium being low.)
I would like to spend some time finding out about your recent eating habits and any
physical symptoms youve had. Id also like to go into your past history a little bit and ask
you about your eating and weight over the years. Would that be OK?
108 Chapter 4: Eating disorders
Past episodes
Enquire about time of first presentation and diagnosis. Do you remember when you were
first diagnosed and what the circumstances of you presenting to the doctor were? What
were the main symptoms you had at this time? When were you initially referred to mental
health services?
Ask about her highest and lowest ever weights.
Ask about the methods she usually uses to control her weight, including calorie restric-
tion, exercise, vomiting/purging and appetite suppressants.
Enquire about historical stressors precipitating relapse. What kinds of difficulties have
led to you becoming more unwell in the past?
Explore her history of treatment and engagement with services. How many relapses of
your eating disorder have you had over the years? Have you ever been admitted to an eat-
ing disorders unit? How long for? What treatment did you require? Have you ever needed
an enforced feeding regime? Have you previously been admitted to a medical ward like
this one for problems relating to your eating and weight? What previous psychological
treatment have you had? (Ask about family therapy, cognitive behavioural therapy (CBT)
and interpersonal therapy.) What previous medication (both psychiatric and physical)
have you taken?
Ask about comorbid psychiatric disorders and substance misuse. Have you ever been
diagnosed with mood or personality difficulties? Do you use recreational drugs? How
much alcohol do you drink?
Station 1(a): Anorexia nervosa History taking 109
Physical symptoms
You should ask about associated physical symptoms. Commonly, patients describe cold
intolerance, light-headedness, constipation and abdominal discomfort.
Given that this patient is hypokalaemic, she may also be feeling lethargic. Similarly, if
her cardiovascular function is impaired or she has comorbid depression, her energy levels
are likely to be reduced.
Ensure that you ask appropriate screening questions to cover cardiovascular, gastrointes-
tinal, neurological, endocrine, musculoskeletal, reproductive, dermatological and dental
problems.
Problem solving
The likeliest problems in this station would be a reluctance of the patient to disclose
information about her eating disorder. By being empathetic and patient, the actor will
tell you the information you require. You are not asked about management issues here,
so should not run into trouble with discussions about psychiatric admission and potential
use of the Mental Health Act, but this could arise in related stations.
ADDITIONAL POINTS
Anorexia nervosa (AN) has the highest mortality rate amongst psychiatric
illnesses. The mortality rate for women is 0.56% per year. There is also a high
associated suicide rate. Poorer prognosis is associated with low serum albumin,
poor social functioning, length of illness, purging and bingeing, substance misuse
and comorbid affective disorders.
AN usually presents in adolescence. It is often a chronic illness that is
characterised by relapses. The majority of sufferers actively binge or purge
and many will move diagnostically from the restricting type of AN to the binge/
purging type or to bulimia nervosa (BN) with the passage of time.
Fewer than 50% recover fully, 33% improve and 20% remain chronically unwell.
FURTHER READING
Birmingham, C.L. & Beumont, P.J.V. (2004) Medical Management of Eating Disorders.
London: Cambridge University Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
A Sister on the medical ward contacts you for advice as she has never managed
a patient with anorexia nervosa before. She wishes to know the following:
What should be done about feeding her?
How should staff engage with her?
How will her mental health difficulties be managed?
Station 1(b): Communication with a professional colleague 111
You feel stressed because a number of your nurses are complaining about their lack
of support from psychiatric staff.
You are very eager to have explicit instructions on how to manage the patients
feeding and psychological needs.
You welcome suggestions for additional support such as Registered Mental Health
Nurse (RMN), one-to-one observations and a visit from the psychiatrist to educate
the nursing staff in eating disorders management.
You feel relieved and reassured if the doctor has given clear advice and offered you
and your team support.
SUGGESTED APPROACH
Setting the scene
Begin the task by introducing yourself, clarifying the nurses name and position and
confirming the reasons you have been called.
Hello, my name is Dr_______, I am one of the psychiatrists. Can I ask your name and
confirm that you are the Sister on the medical ward looking after Miss Anderson? I have
just assessed Miss Anderson, the young lady admitted with hypokalaemia and weight loss
in the context of anorexia nervosa. Am I right in saying that you would like some advice
on how to manage her?
You should include the following key medical information and management advice:
You would like her to be transferred to an Eating Disorders Unit with a specialist multi-
disciplinary team, but this can only take place once she is medically stable.
You should confirm with the Sister that the hypokalaemia has been corrected and all
other relevant investigations have been done.
112 Chapter 4: Eating disorders
Approach to patient
Such patients often evoke mixed feelings amongst staff, who have limited experience of
managing them. Joined-up team-working is vital and should include effective commu-
nication between nursing staff in order to avoid splitting and ensure that consistent care
is provided.
You should offer to spend time with the staff, supporting and educating them about
anorexia nervosa.
Specific advice might include observing the patient for attempts to purge or vomit up to
2 hours after eating and ensuring that they do not have access to diuretics, laxatives or
stimulants.
Psychiatric management
You explain that she will require a full mental health and risk assessment whilst she is on
the ward.
Regular mental state examination for comorbidities including depression, obsessive com-
pulsive and anxious, dependent and perfectionistic personality traits is important.
Screening for drug and alcohol misuse should also be carried out.
Based on the initial assessment, it may be necessary to commence or reinstate anti-
depressant medication.
If risk of self-harm and/or suicide is felt to be high, then the patient may require continu-
ous one-to-one nursing observations either with a Healthcare Assistant (HCA) or registered
mental health nurse (RMN).
It may also help to mention that you will be asking the ED teams clinical psychologist
to assess the patient for individual therapy. This psychologist is likely to be a further
source of support and guidance to the ward staff.
A discussion about what to do if the patient refuses food may be required. Patients with AN
often refuse food, treatment and/or hospitalisation, and where there is significant risk of
medical deterioration as a consequence of malnutrition, use of the Mental Health Act becomes
necessary. If so detained, the patient can be treated without her consent, and this includes
tube feeding (as feeding is ancillary to the mainstay of treatment for mental disorder).
ADDITIONAL POINTS
Investigations should include full blood count (FBC), liver function tests
(LFT), serum creatinine, urea and electrolytes (U&E), calcium, magnesium,
phosphate, electrocardiogram (ECG) and bone density scan.
The following may necessitate a medical admission in AN:
Cardiovascular, hepatic or renal compromise
ECG changes a variety of ECG changes, including sinus bradycardia,
STdepression and a prolonged QT interval
Reduced pulse (<40bpm) or low blood pressure (<90/60) (<80/50 in children)
Low blood glucose, potassium, sodium, phosphate and magnesium
High sodium
Reduced body temperature
Dehydration, oedema, hypoproteinaemia and profound anaemia
Rapid weight loss, exhaustion and severe lack of energy
Station 1(b): Communication with a professional colleague 113
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
114 Chapter 4: Eating disorders
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You are working as the on-call psychiatry senior house officer (SHO) in a
general hospital.
Miss Jones is an 18-year-old dancer with a 3-year history of low weight and
amenorrhoea for the last 12 months. She has been admitted to hospital
overnight with gastritis and mild haematemesis. The medical team are
concerned about her low BMI and have asked you to assess her.
Your task is to take a weight and dietary history in order to reach a diagnosis.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name, introducing yourself and explaining
why you have been asked to see her.
Hello, my name is Dr_______, I am the on-call psychiatry doctor today. I understand that
you came into hospital last night because of stomach discomfort. How are you feeling now?
The medical doctors were concerned about your weight, which is why theyve asked me
to see you. Would it be OK for me to spend some time with you, finding out about your
weight and eating habits?
Dietary history
You should enquire about restrictive, avoidant and altered eating habits. When did these
begin? What are they specifically?
You need to find out about her current dietary practices. Is she vegan or vegetarian? What
does she actually eat? Ask about different food groups, amounts, restrictions and rituals
(cutting, separating and mashing). Does she chew food without swallowing it?
Take a typical 24-hour diet history, starting with breakfast and including lunch, dinner
and snacks. Include details such as the number of slices of toast, brown or white bread,
with or without butter. In addition, ask about milk with cereals and in drinks. Is this
skimmed? How much does she use?
Ask her about calorie-counting. Does she know the calorific content of each of her meals?
How many calories does she aim to consume each day?
Ask about meal times. Is she missing meals? Does she eat alone or with others? Does she
prepare meals for others but not eat with them?
ADDITIONAL POINTS
Cognitive distortions
You may elicit cognitive distortions during the course of the interview,
either in this or other ED stations. Where relevant, discussions about CBT
may follow. Examples of classic cognitive distortions in anorexia nervosa
include:
If I put on a pound, none of my clothes will fit me (magnification).
If I put on even a pound in weight, I will lose my friends as theyll think
Im ugly (catastrophizing).
116 Chapter 4: Eating disorders
Risk
Although not specifically asked, consider the risk component in all stations
where possible. Does she have insight into the effect her eating restriction
is having on her physical health? What does she believe will happen if she
continues to lose weight?
How does she explain the reasons for her admission to a medical ward?
If she appears low in mood, a few screening questions for low mood and
suicidality would be prudent.
Substance misuse
Some patients will use psychostimulants such as cocaine to help them lose
weight. It is important to ask about substance misuse in this station, including
alcohol. Dependence or intoxication may account for any behavioural change.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are a junior doctor working for the Community Eating Disorders team.
Mrs Tomkins, a 34-year-old woman, has been referred to you by her GP.
She has been concerned about her weight for many years and believes
that she is overweight. As a teenager, her school teacher told her parents
that he was concerned she may have anorexia nervosa, but she was never
formally diagnosed and did not receive any specialist treatment. She is now
a successful barrister working in a high-pressure job, and it appears that this
may have led to an abnormal eating pattern.
Her husband has asked to see you first, alone. He wishes to know the
following:
Does his wife have bulimia, and if so, what caused it?
What can be done to help her?
You should assume that the patient has given her consent for you to discuss
things with her husband.
SUGGESTED APPROACH
Setting the scene
Begin the task by introducing yourself, confirming the identity of Mr Tomkins (as the
husband of the patient) and clarifying why he wishes to see you.
Hello, my name is Dr_______, I am one of the psychiatrists working in the eating disorders
service. Thank you for coming to see me today. I understand that you would like to speak
to me about your wife, Mrs Tomkins, and have some specific questions that you would
like answering, is that correct?
Social factors: a cultural emphasis on slimness, media pressures, associations with par-
ticular professions and dieting fashions.
Station 3: Bulimia nervosa Communication and explanation to a relative 119
Family factors: genetic influences are important, such that first-degree relatives of indi-
viduals with BN have an increased risk of developing an eating disorder. Family envi-
ronment is also important, particularly where other members of the family have had
issues with food or have been critical of eating, weight or body shape.
Personality factors: the presence of certain personality traits or characteristics, includ-
ing perfectionism, impulsivity, mood lability, thrill-seeking and dysphoria associated
with rejection, have been linked to developing an eating disorder.
Life events: significant life events, such as relationship break-ups, can trigger the onset
of bulimia in up to 70% of cases. Childhood sexual abuse as well as parental neglect,
loss, indifference or separation have all been suggested as risk factors in BN.
Depressive symptoms: people often turn to food as a comfort when they feel depressed
or low in self-esteem. It is possible that bulimia starts off this way when people feel
unhappy with their lives and themselves. The guilt associated with bingeing then often
leads to vomiting or purging.
Psycho-education
This involves being given information on a number of important issues, such as the
physical consequences of repeated bingeing and vomiting and the inappropriate use of
prescribed and over-the-counter medicines, as well as the long-term effects of being under-
weight. It might also include advice on how to limit binges and the use of self-help materi-
als (e.g. books such as Getting Better Bit(e) by Bit(e)). NICE guidelines suggest an
evidence-based self-help programme as the first step in the treatment of BN. Healthcare
professionals have a role to play in providing direct encouragement and support to patients
undertaking this self-help programme, as this may improve outcomes. This may be suf-
ficient treatment for a limited subset of patients.
Psychological therapy
A number of psychological approaches have been used in the management of bulimia,
including:
Cognitive behavioural therapy: This is the most studied modality and is claimed to be
the treatment of choice for BN. You might want to explain the basic principles of this
therapy and the focus of challenging associated cognitive (thinking) distortions in
an attempt to modify behaviour. An experienced therapist or one specialising in eating
disorders is needed in such cases.
Interpersonal therapy: This is a short-term, focussed psychotherapy where the main
goal is to help patients identify and modify current interpersonal difficulties. It was
adapted from the treatment of depression by Fairburn (1997).
Family therapy: This is often less effective in bulimia than anorexia. It probably has a
greater role in patients of younger age, for whom family factors may be more
relevant.
Therapy might also be useful in addressing feelings of loneliness and boredom, anxiety
and depression and low self-esteem.
120 Chapter 4: Eating disorders
Pharmacological treatment
NICE guidelines (2004) state that adults with bulimia may be offered a trial of the selec-
tive serotonin reuptake inhibitor antidepressant, fluoxetine, as an alternative or addi-
tional first-line management strategy. Such medication can help to reduce the frequency
of binge eating and purging episodes, and these benefits are usually rapidly apparent.
Medication is not recommended in the treatment of adolescents with BN.
ADDITIONAL POINTS
Comorbidities
The incidence of borderline personality traits is higher in bulimia than
anorexia nervosa.
Half of patients with anorexia meet the criteria for bulimia.
A third of patients with bulimia have a history of anorexia and another
third have a history of obesity.
In 25% of bulimia cases, there is benign enlargement of the parotid gland.
Risk
Where there is a risk of self-harm or if community treatment has been
unsuccessful, a psychiatric admission can be arranged. This is not
without risk in itself, as patients can sometimes worsen. Therefore,
admissions are usually kept short.
It is also important to exclude comorbid substance misuse, particularly
when considering a treatment plan.
Oesophageal rupture (Boerhaaves syndrome) is a complication that is
associated with vomiting after eating.
REFERENCE
Fairburn, C.G. (1997) Interpersonal psychotherapy for bulimia nervosa. In D.M. Garner and
P. E. Garfinkel (Eds.), Handbook of Treatment for Eating Disorders. (pp. 278294). New York,
NY: Guilford Press.
FURTHER READING
Laird, B. C. & Treasure, J. (2010) Medical Management of Eating Disorders, 2ndedn,
Cambridge: Cambridge University Press.
NICE guidelines for eating disorders, January 2004. www.nice.org.uk/guidance/cg9
Schmidt, U. & Treasure, J. (1993) Getting Better Bit(e) by Bit(e). London: Lawrence Erlbaum
Associates.
Semple, D. & Smyth, R. (2013) Oxford Handbook of Psychiatry, 3rd edn, Oxford: Oxford
University Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 5
Addiction disorders Mark Parry
LINKED STATIONS
INSTRUCTION TO CANDIDATE
Mr Smith, a 22-year-old gentleman, has been referred to you by his probation
officer (PO) for help with his illicit drug use. You are assessing him in an out-
patient clinic.
Evaluate Mr Smith for illicit drug use. Please make notes if you wish as in
the next station you will be discussing Mr Smiths problems and treatment
with his probation officer.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and start the station by thanking the patient for coming to see you.
Enquire about reasons for seeking help, whether on his own accord or subject to a Drug
Treatment and Testing Order (DTTO) or a Drug Rehabilitation Requirement (DRR). Explain
that you will need to ask him details of his legal and illicit drug use and associated prob-
lems if any.
One should be familiar with the street names of illicit drugs (please refer to the
table below); however, street names for illicit drugs often change quite rapidly, so
if in doubt, ask the patient what drug the street name refers to.
C: We can discuss use of the alcohol and cannabis later on, shall we first look into your
heroin use? Please tell me how much heroin you use and how you use it.
Enquire into the details of the amount of heroin used, the frequency of use and the route
of administration (whether smoking, snorting or injecting). Some users may not be able
to quantify the amount; enquire into the amount of money spent; the street price and
the quality of heroin varies and is usually approximately 40 per gram. Many users may
smoke (chase) as well as injecting the drug. Ask about first use, pattern of use and any
periods of abstinence/treatment.
Some patients are vague when giving details. It is important to obtain the basic informa-
tion of their drug use. Ask what is the least amount they can get by on over a 24-hour
period. It is important to establish that they experience withdrawal symptoms, as it is
these that establish whether they are physically dependent; for example, by asking How
do you feel when you stop taking drugs, even briefly? It is not uncommon for patients
either to understate or overstate their use for whatever reason.
State that it will be necessary to obtain a sample of urine (or alternatively a sample of
saliva) for drug testing. This is extremely important to note that while a sample that is
positive for opioids does not prove opioid dependence, a negative sample disproves a
diagnosis of opioid dependence. Drug testing must never be omitted.
Explore the following:
Criteria for dependence: These are the same as for alcohol. The withdrawal symptoms
associated with heroin and other opioids are:
Aches and pains, anxiety, stomach cramps, nausea, hot/cold flushes, runny nose,
yawning, gooseflesh, sweating, tremors, dilated pupils, restlessness, tachycardia, diar-
rhoea, vomiting, muscle twitches
Use of other illicit drugs and alcohol.
Medical complications: any accidental overdoses, abscesses/infections, blood-borne
viral diseases (hepatitis B and C, HIV).
Psychiatric complications/comorbidities: anxiety, depression, post-traumatic stress dis-
order (PTSD), etc. When psychiatric symptoms are present, try to establish whether
they predate and/or persist during periods of abstinence. Do not go into details of
psychiatric history; remember the task of the station.
Psycho-social complications: relationships and social and occupational functioning.
Briefly explore what are the predisposing, precipitating and maintaining factors.
Forensic history: the fact that he has been referred by the probation officer indicates
involvement with the Criminal Justice System (CJS). Ask how he was funding his drug
habit. Often, drug users resort to crimes in order to fund their drug use. Briefly ask about
previous offending and criminal records.
Station 1(a): Opioid dependence 125
Problem solving
Individuals referred by the CJS may have been coerced into treatment; they may view the
health professionals as part of the CJS. It will be important to emphasise that you are not
part of the CJS, but will have to work closely with the CJS. If the individual is not moti-
vated, one may have to use the motivation enhancement techniques to improve motiva-
tion. Use of a non-confrontational approach is essential when dealing with these
individuals, who are often complex and difficult to engage.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
126 Chapter 5: Addiction disorders
INSTRUCTION TO CANDIDATE
You have seen Mr Smith in the previous station. You are now required to meet
his probation officer to discuss his treatment options. You have obtained
consent from Mr Smith regarding this discussion.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and state that you have the clients consent for sharing information.
Enquire whether the probation officer has any particular questions or information they
wish to obtain before you get into the details. The discussion would be shaped by your
earlier assessment and the information you gathered.
Pharmacological treatment
Regarding opioid detoxification or maintenance, explain the important factors, such as
patient choice, motivation and engagement, length and pattern of use and previous treat-
ments. Remember to avoid medical terms and explain in laymans language. Detoxification
is done over 24 weeks gradually by replacing with prescription medicines such as metha-
done or buprenorphine. This is then followed by a medication called naltrexone, which
in turn will block the effects of opioid drugs. Other medications such as lofexidine and
non-steroidal pain relief can be used to give relief from withdrawal symptoms such as
muscular pain.
If maintenance (substitute prescribing) is chosen, then patients are stabilised either on
methadone or buprenorphine and supervised prescription/administration is sometimes
continued for many years. Regular monitoring with drug testing through urine/salivary
analysis is mandatory in order to prevent misuse of the prescription and to detect on-top
use of illicit drugs. The idea behind substitute prescribing is stabilisation (the relief and
prevention of withdrawal symptoms, allowing the patient not to have to rely on street
heroin), prevention of the harm associated with injecting, reduction of criminal activity
and engagement in treatment.
Psycho-social intervention
Substitute prescribing or detoxification on their own do not have much value; these should
be part of a treatment plan which will include structured psycho-social interventions
such as individual/group therapy, provision of suitable accommodation, support from
family, friends and self-help organisations such as Narcotics Anonymous.
Station 1(b): Discussion with probation officer 127
FURTHER READING
Department of Health (England) and the Devolved Administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England),
the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.
Ghodse, H. (2010) Ghodses Drugs and Addictive Behaviour: A Guide to Treatment, 4th edn.
Cambridge: Cambridge University Press.
WEBSITES
http://www.talktofrank.com/
http://www.nta.nhs.uk/uploads/nta_care_planning_practice_guide_2006_cpg1.pdf
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mr Johnson, a 25-year-old gentleman, has been brought to the Section 136 Suite at
a Psychiatric Unit. The police who detained him report that he appeared confused
and was found wandering on the streets. He is unable to provide any sensible
information, but is settled enough to allow a physical examination. There are no
informants for obtaining a collateral history. Do not elicit a history from the patient.
Carry out a physical examination for signs and symptoms of drug
intoxication/withdrawal state.
Make notes if you wish as in the next station you will be discussing
MrJohnsons differential diagnosis and immediate management plan with
the Consultant Psychiatrist over the phone.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain to the patient that you need to carry out a physical exami-
nation on him. If the patient appears confused/does not understand your explanation,
try again; do not rush into the examination if he resists your examination.
Station 2(a): Physical examination ofdrugintoxication/withdrawal state 129
C: I am a doctor and I need to examine you. Is that OK? I would like to check your pulse,
blood pressure and temperature first. Ill explain what Im doing as I go along. You
shouldnt experience any discomfort at any time, but let me know if you are uncom-
fortable at any point. Do you understand me?
Be familiar with the features of various drug intoxication and withdrawal states; some of
these are summarised below.
Alcohol
Intoxication: tachycardia, hypertension, mydriasis (dilated pupils), skin flushing, slurred
speech, impaired coordination, nystagmus and gait disturbance.
Withdrawal: tremors, sweating, increased temperature, tachycardia, dilated pupils and
diaphoresis. Seizure and delirium tremens are not uncommon.
Look for consequences of long-term excessive alcohol use virtually any organ in the
body could be affected:
Gastrointestinal system: poor nutritional state, anaemia, hepatomegaly and liver failure
signs such as jaundice, oedema and spider naevi
Nervous system: peripheral neuropathy, Wernickes encephalopathy (WE; ataxia, nys-
tagmus and confusion) and Korsakoff syndrome (memory impairment)
Cardiovascular system: high blood pressure and alcoholic cardiomyopathy
Musculoskeletal system: proximal myopathy (proximal muscle weakness, shoulder
and hip).
Opioids
Intoxication: varying degrees of clouded consciousness, pinpoint pupils and respiratory
depression.
130 Chapter 5: Addiction disorders
Benzodiazepines
Intoxication: drowsiness, ataxia, dysarthria, nystagmus and hypothermia.
Withdrawal: irritability, anxiety, insomnia, hypersensitivity to stimuli, tremor, hypotonia
and hyporeflexia and seizures.
Cannabis
Intoxication: dry mouth, red eyes, impaired perception and motor skills, decreased short-
term memory, paranoia, mood swings and, rarely, hallucinations.
LSD
Intoxication: dilated pupils, high body temperature, increased heart rate and blood pres-
sure, sweating, loss of appetite, sleeplessness, dry mouth, tremors, flashbacks and percep-
tual abnormalities.
Look for factors associated with illicit drug use, such as needle track marks, thrombosed
veins and a perforated nasal septum.
Problem solving
This will be a challenging station. You will need to be selective in your assessment and
focus on the task. (If the patient is uncooperative, try to carry out as much of the exami-
nation as possible; try the Kirbys examination of an uncooperative patient.)
Form your opinion from the general reaction, attitude, posture, hygiene, dressing and
behaviour towards staff. Look out for symptoms and signs of resistance, evasiveness and
irritability/apathy. Look for any abnormal movements (retardation/overactivity), facial
expressions and conscious levels (alert, attentive, placid, vacant, aversive, perplexed and
distressed), emotional state and indication of mood fluctuations (tears/smiles). See if the
eyes are open or closed; if open, do they follow the examiners movements or are they
fixed in terms of eye contact, and if closed, does the patient resist attempts to open the
eyes? Observe the pattern and content of speech (mute, slow/retarded, over-talkative,
relevance and coherence) and reactions to what is said or done. Examine the muscular
reactions (rigidity and resistance).
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have examined a confused patient during your period on call. You have
noted that the patient has gait abnormalities; he is agitated, disorientated
and experiencing visual hallucinations. You are about to speak to the on-call
consultant psychiatrist over the phone.
Please discuss your findings with the consultant.
You will be asked about the differential diagnosis and immediate management.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: I am the doctor on-call, I wonder if I can discuss a patient who I have
assessed? The discussion will be shaped by your findings from the previously carried out
assessment.
FURTHER READING
Department of Health (England) and the Devolved Administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England),
the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.
NICE. CR184. When patients should be seen by a psychiatrist. Delirium: Prevention, diagnosis
and management. www.nice.org.uk/guidance/cg103
Royal College of Psychiatrists (2014) College Report 184. www.nice.org.uk/guidance/cg100/
ifp/chapter/acute-withdrawal-from-alcohol
Station 3(a): Cannabis and schizophrenia Discussion with family 133
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are the junior doctor working in an in-patient unit where Mr Mark Roberts,
a19-year-old man, was recently admitted and diagnosed with schizophrenia.
134 Chapter 5: Addiction disorders
You are exploring factors that were relevant to the onset of the illness and
suspect that illicit drug use may have contributed to it. Mr Roberts is reluctant
to talk about his illicit drug use. His mother is visiting the unit and wants to
speak to you. Mr Roberts has consented for you to meet his mother and share
information about him.
Gather information on Mr Robertss illicit drug use history from his mother.
Address her concerns if she has any.
Make notes as required as you will be meeting Mr Roberts in the next station.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and start the station by thanking the mother for coming to the ward
and speaking to you. Inform her that her son has consented to the meeting occurring.
Enquire about her views on his current state, treatment and the effects of the illness on
herself and other carers (family/friends).
C: This must be a difficult time for you. Have you been told about your sons diagnosis?
At this point, she may raise some queries about the diagnosis itself be prepared to address
those. If she has no knowledge of diagnosis, be prepared to explain this to her. Today I
want to find out more about the things that may have had a role in Mark becoming unwell.
There are a number of risk factors for the development of schizophrenia, and one such
risk factor is use of illicit drugs. Mark has been reluctant to talk about it, I wonder whether
you know anything about his drug use?
M: Well, doctor, as far as I know, Mark does not use drugs, except for cannabis.
C: Actually, cannabis is an illicit drug and can contribute to the development of mental
health problems. Please can you tell me about Marks use of cannabis?
M: I caught him smoking cannabis soon after his 14th birthday; I was not happy about
it, but didnt say much as many kids nowadays smoke the stuff.
C: We know that quite a few people use cannabis, but that does not make it any less harm-
ful. There is increasing evidence that it causes mental health problems. Do you know
when Mark started using cannabis and how often he used it?
Station 3(a): Cannabis and schizophrenia Discussion with family 135
Obtain illicit drug and alcohol consumption details as outlined in the Opioid
Dependence and Alcohol Dependence stations.
M: I didnt know that cannabis caused so many problems, if I only knew these things
before, I could have done something about it.
C: Please dont be hard on yourself, as you said you did not know these things and prob-
ably even Mark himself didnt know about it. The important thing is how we can help
Mark now to get better and remain well. It will be important for him to stay clear of
all illicit drugs. Now that I know that he regularly smoked cannabis from a young age,
I can talk to him about it.
M: I thought cannabis was just for fun and relaxing, can it damage ones health?
C: Although cannabis can produce relaxation, if higher amounts are consumed, it can have
the opposite effect by increasing anxiety. Some cannabis users may have unpleasant
experiences, including confusion, hallucinations, anxiety and paranoia, depending on
their mood and circumstances. Some users may experience psychotic symptoms with
hallucinations and delusions lasting a few hours, which can be very unpleasant. Even
though these unpleasant effects do not last long, since the drug can stay in the system
for some weeks, the effect can be more long-lasting than users realise. Long-term use
can have a depressant effect and reduce motivation. Some researchers also suggest that
long-term use can lead to irreversible, but minor cognitive deficits.
Problem solving
The carers may feel guilty about their role in the causation of the condition, be it the
genetics, family environment, lack of supervision, and so forth. It is important to acknowl-
edge these feelings and educate and empower them so that they contribute constructively
in the care and treatment of the affected individual.
ADDITIONAL POINTS
There can be similar scenarios involving the role of genetics (family history
of similar illness), compliance with medication and illicit drugs in relapse of
schizophrenia, and so forth. The key skills would relate to obtaining a collateral
history from carers and being sensitive to their needs.
FURTHER READING
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/cannabis.aspx
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You meet Mark Roberts, a 19-year-old man on the ward. You are familiar with
him and know that he has been diagnosed with schizophrenia. He is no longer
displaying any active symptoms of schizophrenia and you are working towards
a discharge plan. He had been reluctant to speak about his illicit drug use,
despite his urine drug screen being positive for cannabis. You have met his
mother and discussed his cannabis use.
Educate him about the effects of cannabis on schizophrenia.
Explain how he can be helped further by mental health services.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Mr Roberts, I am Dr_____, the psychiatrist, we have met a few
times in the last few days. It is good to see you doing well, I think you will soon be ready
for discharge. There are a few important things that we need to talk about today. We need
to discuss your cannabis use and be sure that you understand its effects.
If the patient denies use of cannabis, you may well have to mention the positive urine
drug screen and collateral history from the mother. However, it is important not to be
confrontational, and you may use the motivational interviewing (MI) techniques as out-
lined in the Motivational Interviewing station.
Problem solving
Many individuals may have a history of poly-substance misuse; be familiar with the role
of stimulants in the causation of schizophrenia/psychosis.
FURTHER READING
Cannabis and mental health leaflet (with references) published by the Royal College of
Psychiatrists: www.rcpsych.ac.uk
Castle, D., Murray, R.M. & DSouza, D.C. (eds) (2011) Marijuana and Madness. Cambridge:
Cambridge University Press.
DiClemente, C.C. (2006) Addiction and Change: How Addictions Develop and Addicted People
Recover. New York, NY: Guildford Press.
Moore, T.H.M., Zammit, S., Lingford-Hughes, A. etal. (2007) Cannabis use and the risk of psy-
chotic or affective mental health outcomes: A systematic review. Lancet, 370(9584), 31928.
Prochaska, J.O. & DiClemente, C.C. (2005) The transtheoretical approach. In: Norcross, JC;
Goldfried, MR. (eds.) Handbook of Psychotherapy Integration. 2nd ed. New York, NY: Oxford
University Press, pp. 147171.
WEBSITE
http://stepupprogram.org/docs/handouts/STEPUP_Stages_of_Change.pdf
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You have been asked to assess Mr Jones, a 35-year-old gentleman who was
admitted to an Acute Medical Assessment Unit for severe stomach pain 2
days ago. His stomach pain has subsided and he is feeling better. The physical
examination and routine investigations are essentially normal except for
slightly raised mean corpuscular volume and gamma-glutamyl transferase.
The medical team suspect alcoholic liver disease secondary to excessive
alcohol consumption and are suggesting that he undergoes further tests. He
is agitated, anxious, reluctant to have any more tests and is keen to leave the
unit. The medical staff are concerned and want you to assess him. He has
agreed to speak to you.
Evaluate Mr Jones for alcohol dependence.
Take an alcohol history.
You will then have to provide feedback to him.
140 Chapter 5: Addiction disorders
SUGGESTED APPROACH
Setting the scene
Introduce yourself, thank the patient for agreeing to speak to you and acknowledge his
anxiety and any distress. Ask if it would be OK to talk about what has been happening
(open question to start).
Do not get bogged down with numbers and percentages; you should get an idea of the
quantity of alcohol being consumed and demonstrate that to the examiner. So you are
telling me that in a week you consume about 2 litres of vodka and 10 pints of lager. Thats
approximately 100 units per week, which is far in excess of the recommended maximum
of 21 units per week for men.
Station 4: Alcohol dependence History taking 141
Elicit the alcohol consumption details, including the age of first drink, lifetime pattern
of drinking and any previous periods of abstinence/treatment, then focus on the
following:
Criteria for dependence: check for cravings, loss of control, tolerance, withdrawal symp-
toms, salience and excessive use despite knowledge of harmful physical or mental health
consequences (refer to Features of Alcohol Dependence Syndrome for specifics).
Medical complications: seizures, delirium tremens, head injury, liver damage, etc.
Psychiatric complications/comorbidities: anxiety, depression, PTSD, etc. When psychi-
atric symptoms are present, try to establish whether the psychiatric conditions are
primary by enquiring whether these symptoms predated and/or persisted during periods
of abstinence. Do not go into details of psychiatric history; remember the task of the
station.
Psycho-social complications: relationships, social and occupational functioning and
forensic history.
Time allowing, you could provide feedback of your assessment to the patient. You might
say: You have told me that on average you have been drinking 100 units of alcohol per
week for the last 2 years, you crave alcohol and experience shakes and sweats in the
morning. Without alcohol, you feel anxious to face people. You have been warned at
your workplace for being drunk on duty and your wife is threatening to leave you if
you dont stop drinking. It appears you are dependent on alcohol and it has caused you
a number of problems. Perhaps you need to do something about it.
Problem solving
Individuals who consume alcohol excessively can be defensive and minimise their alcohol
consumption. A gentle and non-confrontational approach often succeeds in building
rapport and eliciting details of alcohol consumption and the problems associated with
it. Be prepared to have a more detailed conversation about treatment options, including
in-patient detoxification.
ADDITIONAL POINTS
Focus on harm minimisation if the patient is not willing to stop drinking.
Identify predisposing, precipitating and maintaining factors for alcohol dependence.
Features of alcohol dependence syndrome: More information
1. Non-dependent drinkers drink in accordance with a variety of cues, whereas
the dependent drinker drinks to avoid symptoms of withdrawal. The drinking
repertoire is therefore narrowed.
2. The dependent drinker will continue to drink even though there are several
negative consequences such as financial, familial and physical.
3. The individual knows that taking a drink is irrational and the action is resisted
but, as in the case of compulsions in obsessive compulsive disorder, further
drink is taken.
4. There are physiological and neurochemical changes (more alcohol is
required to achieve the same effect). In the later stages, tolerance
develops, often with loss of control over alcohol intake.
5. Shaking, trembling, anxiety, physiological craving, vomiting and seizures may occur.
6. The individual may drink throughout the night and on waking in severe cases.
7. For severe dependents, following a period of abstinence, the previous high
levels of alcohol intake and tolerance can be achieved within a number of days.
FURTHER READING
Edwards, G. & Gross, M. (1976) Alcohol dependence: Provisional description of a clinical
syndrome. Br Med J, 1(6017): 105861.
Raistrick, D., Heather, N. & Godfrey, C. (2006) Review of the effectiveness of treatment for
alcohol problems. National Treatment Agency. Available at:
http://www.nta.nhs.uk/uploads/nta_review_of_the_effectiveness_of_treatment_for_alco-
hol_problems_fullreport_2006_alcohol2.pdf (A very useful rsum of basic techniques used
in alcohol treatment.)
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
A 45-year-old engineer has come to see you as he was found drunk on duty
and his employer wants feedback on this individual. You have obtained the
history, which reveals that he has been drinking over a bottle of spirits every
day for the last year, has been drinking during his lunch break for 6 months
and more recently started drinking in the mornings. He experiences withdrawal
symptoms if he does not drink, craves alcohol and has gradually increased his
alcohol consumption in the last 12 years. He blames difficult work conditions
and his relationship with his partner for his drinking. His employer has warned
him that unless he stops drinking, he will be dismissed from his job. He wants
to stop drinking and wants to know his treatment options. He does not have
obvious mental health or physical health problems.
Discuss the treatment of alcohol dependence and any other issues raised by
the patient.
144 Chapter 5: Addiction disorders
SUGGESTED APPROACH
Setting the scene
Introduce yourself and say, I am glad that you have come to see me today about your
drinking and that you want to address it. I think we should discuss the options for treat-
ment. How does this sound?
Short term
Explain the rationale and principles of medically assisted withdrawal from alcohol (detoxi-
fication programme): We can offer a medication regime that will help you during the
time when you are trying to stop drinking; let me explain this to you.
Management of withdrawal symptoms, most commonly with benzodiazepines (BZDs):
Chlordiazepoxide is the most widely used medication; the dose can vary considerably
depending on the severity of dependence, physical health, etc. The usual starting dose
is 2040mg four times a day (QDS) and is tapered down and stopped over 710 days.
Front-loading and symptom-triggered therapy are alternatives, but are not commonly
used. The aim is to minimise the discomfort of withdrawal symptoms and prevent
serious complications such as withdrawal seizures and/or delirium tremens. Lorazepam
or oxazepam are used in those with hepatic failure. Chlormethiazole and carbamazepine
are other options, but are not commonly used in the United Kingdom.
Vitamin supplements: Alcohol can affect the vitamin levels in your body and, over a
period of time, causes damage to nerves. We will offer you some important vitamin
preparations to protect your nervous system. This approach consists mainly of thiamine
and other vitamin B preparations, often by a parenteral route. Pabrinex, a preparation
with thiamine, riboflavin, pyridoxin, ascorbic acid and nicotinamide, is administered
by intramuscular route for 35 days; an intravenous preparation can be used in suspected
cases of Wernickes encephalopathy (WE). Vitamin supplements are administered in
order to replenish the bodys stores and to prevent WE and Korsakoff syndrome.
Management of comorbid medical and psychiatric conditions.
Psychological support prior to and during the detox.
Setting: Planned treatment always works better. We can discuss where you would like
to be treated, either in hospital or in your own home. A community setting is for those
with less severe dependence, no significant physical or psychiatric comorbidities and
good social support; an in-patient setting is recommended for complex patients or those
who failed community detox.
Station 5: Alcohol dependence Management 145
Long term
We should aim to maintain abstinence; in order to achieve this, psycho-social interven-
tions, including relapse prevention, motivational enhancement and cognitive behavioural
therapy in individual or group setting, are the mainstays of treatment.
Pharmacological treatments can supplement psycho-social interventions and these may
include drugs such as acamprosate, naltrexone and disulfiram. They act as deterrents
when one tends to consume alcohol. Self-help organisations such as Alcoholics Anonymous
can benefit you. If necessary, we offer advice on suitable accommodation, debt counsel-
ling, employment, etc. We will also consider family work, which is often necessary to
rehabilitate and integrate the individual with the family and society.
C: You seem to have been dependent on alcohol for about a year, but you do not have any
physical or mental health problems and have a supportive family, so I think you can
receive detoxification at home. I will explain and provide some leaflets about the treat-
ment process. Detox is only a small part in giving up alcohol; it will be important for you
to look into the reasons for your drinking and how to avoid drinking again, and this can
be achieved through psychological help.
C: What we have discussed is confidential; your employer may ask us for a report or an
opinion about your suitability to return to work, and we can only provide information to
your employer with your consent. If you were to object to information being shared with
your employer, we will not do so; however, that may adversely affect your employment.
Problem solving
As with other substances of addiction, relapse rates for alcohol dependence are high. Many
individuals are able to achieve abstinence only after several treatment episodes. Consider
residential rehabilitation for those who find it difficult to stop drinking. Consider harm
minimisation strategies, such as reduced drinking, improved nutrition, vitamin supple-
ments and social support, for those who do not want to stop drinking.
(Although management of delirium tremens or Wernickes encephalopathy might be an
unlikely CASC scenario, it would still be advisable to familiarise yourself with these topics.)
FURTHER READING
Lingford-Hughes, A.R., Welch. S. & Nutt, D.J. (2004) Evidence-based guidelines for the phar-
macological management of substance misuse, addiction and comorbidity: Recommendations
from the British Association for Psychopharmacology. Journal of Psychopharmacology, 18(3),
293335.
Scottish Intercollegiate Guideline Network (2003) The Management of Harmful Drinking and
Alcohol Dependence in Primary Care. Clinical Guideline No 74.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
A 35-year-old woman suffering from panic attacks and agoraphobia for several
years has been referred by her GP for advice regarding her prescription of
diazepam and temazepam. You are meeting her in the out-patient clinic.
Elicit a history regarding the usage of benzodiazepines. Please discuss with
her the management of benzodiazepine use.
Do not take a psychiatric history.
You have read in the papers that these can be harmful but you cannot imagine life
without the medications.
Recently you have been buying extra tablets via Internet as you are using more
than prescribed.
You would like to hear more form the doctor as to how to reduce this excessive
consumption of benzodiazepines.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and say, Your GP has requested we discuss your medication, particu-
larly diazepam and temazepam. Would that be OK? Before I can make any suggestions,
Ineed to ask you about details of your use of these medications, please can you tell me
about this.
then be gradually reduced in small increments over a period of weeks or months until
you tolerate the smaller doses, eventually discontinuing all BZDs completely.
Outline the principles of medically assisted BZD withdrawal.
Transfer all BZD and Z drug (non-benzodiazepine hypnotics) prescriptions to a long-acting
preparation such as diazepam (refer to the table below for equivalent doses). It is very
rarely necessary to prescribe more than 3040mg of diazepam as an equivalent, whatever
the stated use. This is because the benzodiazepine receptors will be fully occupied at this
level of prescribing. Prescribing above this level does not convey any benefits and may
substantially increase risk. Additionally, it is not uncommon for patients to grossly exag-
gerate their use of benzodiazepines in the hope of getting a larger prescription. Prescribing
excessive amounts does not alleviate the problem, it merely exacerbates it by providing
extra supplies, which may be misused or diverted by selling or giving to others.
Problem solving
At times, it may be better to prescribe/stabilise some individuals on a small dose of diaz-
epam if they cannot be successfully withdrawn from BZD. The aim here would be to
stabilise the individuals life and prevent their dealing in the illicit drug market.
Station 6: Benzodiazepine misuse 149
FURTHER READING
Department of Health (England) and the Devolved Administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England),
the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.
Lingford-Hughes, A.R., Welch. S. & Nutt, D.J. (2004) Evidence-based guidelines for the phar-
macological management of substance misuse, addiction and comorbidity: Recommendations
from the British Association for Psychopharmacology. Journal of Psychopharmacology, 18(3),
293335.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
150 Chapter 5: Addiction disorders
INSTRUCTION TO CANDIDATE
A 30-year-old woman was admitted to the acute medical ward following an
overdose of prescribed antidepressant medication. At the time of admission,
she was under the influence of alcohol, but 12 hours later, she has become
sober and has been referred for a psychiatric assessment. You have completed
your assessment and found that this patient suffers from depression and has
been drinking excessively in order to cope with stress. You have found out that
being under the influence of alcohol was an important factor in the overdose.
Using motivational interviewing techniques, try to motivate this patient to
abstain from alcohol. You are not required to discuss the management of
depression.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and say, We have talked about what happened and how you got to be
here, and part of that seems to be due to alcohol. I guess what Id like to know is, what are
the things you like about alcohol? Whats really good about drinking for you?
1. Pre-contemplation: Raise doubt. Do you think you may be drinking in excess? Has
does not consider the it occurred to you that your alcohol consumption may be related
possibility for change to some of your problems? Increase patients perception of
risks and problems with current behaviour. (Excessive alcohol
consumption worsening the depression.)
Station 7: Motivational interviewing 151
In the current scenario, the patient is likely to be in one of the first three stages.
C: Do you think the overdose might have happened even if you hadnt been drinking, or
do you think that it really had to do with the alcohol?
Pt: I think I just lost control for a minute, I wouldnt have lost that control if I was sober.
The principles of motivational interviewing are outlined below.
Express empathy
Expression of empathy is critical to the MI approach. When patients feel that they are under-
stood, they are more able to open up to their own experiences and share those experiences
with others.Importantly, when patients perceive empathy, they become more open to gentle
challenges by the interviewer about lifestyle issues and beliefs regarding substance use.
Support self-efficacy
A patients belief that change is possible is an important motivator to succeeding in mak-
ing a change. Patients are responsible for choosing and carrying out actions for change
in the MI approach, and the interviewer focusses his/her efforts on helping the patient
stay motivated; supporting their sense of self-efficacy is a great way to do that.
solutions to the problems that they themselves have defined; the interviewer should not
impose his/her ideas.
Develop discrepancy
Motivation for change occurs when people perceive a discrepancy between where they
are and where they want to be. When individuals perceive that their current behaviours
are not leading toward some important future goal, they become more motivated to make
important life changes.
C: We have talked about your alcohol consumption and how it adversely affects your
mood and makes you impulsive, but you feel it helps you cope with stress.
Pt: I know I shouldnt be drinking, especially when I am on an antidepressant. My key
worker and my family have been telling me not to drink, but I was ignoring them.
Iguess this overdose changes that. I will have to stop drinking and look for other ways
of handling the stress in my life.
C: What do you think you can do?
Pt: I will discuss with my key worker about a group programme she was talking about.
She was telling me that it helps people stop drinking, I think I will attend that group,
I will also attend the sessions about handling stress so that I am less likely to drink.
C: These seem to be good ideas. You have been managing your home, looking after kids
and supporting your mother. You have been under a lot of stress and turned to drink.
I think you are a capable person and you will be able to stop drinking, which might
help improve your depression.
A useful concept is the cycle of change, first described by Prochaska and DiClemente
(1992). Motivational interviewing is applicable when a patient is in the contemplative
stage. When a patient is in the pre-contemplation stage, then it is not useful.
Problem solving
If the patient was to deny problems and did not wish to change anything, do not become
despondent; try to provide information and educate them about the link between worsen-
ing depression and alcohol consumption. Use open-ended questions and MI principles.
FURTHER READING
Miller, R.W. & Rollnick, S. (2012) Motivational Interviewing: Helping People Change (Applications
of Motivational Interviewing). New York, NY: Guildford Press.
Sciacca, K. (1997) Removing barriers: Dual diagnosis and motivational interviewing.
Professional Counselor, 12(1), 416.
http://stepupprogram.org/docs/handouts/STEPUP_Stages_of_Change.pdf
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
A 25-year-old woman with a 10-week pregnancy has been referred by the
antenatal services for assessment and management of her substance misuse.
Assess her substance misuse history.
Give her advice about substance use in pregnancy.
Discuss relevant treatment options with her.
(if the doctor mentions social services, appear shocked). You also are worried about the
effects that the drugs may have on the unborn baby.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and thank the patient for coming to see you. Enquire about her under-
standing of the referral. Hello, Ms_____, I am Dr_____, a psychiatrist. I gather you are
expecting a baby. The antenatal clinic has advised a psychiatric review. I gather from their
referral that you are using drugs, and I wonder if we can discuss this further. If the patient
looks uncomfortable or reluctant, you may add, I understand this is a sensitive topic to
talk about, but this will be a confidential consultation. It is important because we want
the best outcome for you and your baby.
C: Alcohol and drugs can affect the baby throughout the pregnancy; the sooner you stop,
the less will be the effect on the baby. Continuing use of alcohol or drugs increases the
risks of complications to you as well.
Treatment principles
These are broadly similar to non-pregnant drug users. Some of the additional and specific
requirements are:
Substance misuse treatment is to be fast tracked.
Close coordination of treatment between various agencies including antenatal, sub-
stance misuse, paediatric, social services and the family.
Station 8: Substance misuse Management in pregnancy 155
Problem solving
Some women worry that their baby may be taken into care because they use drugs.
Substance misuse in itself is not a reason to involve the Social Services or to assume that
these individuals cannot care for their baby. However, if there is concern about the safety
or welfare of the child, their involvement will be necessary. This is true for everyone,
whether they use substances or not.
Many women are very ashamed of their substance misuse. It is important to convey an
empathic and non-judgemental approach or you may well find the patient difficult to
engage.
FURTHER READING
Department of Health (England) and the Devolved Administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England),
the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.
http://www.rcgp.org.uk/learning/~/media/Files/SMAH/RCGP-Guidance-for-the-use-of
substitute-prescribing-in-the-treatment-of-opioid-dependence-in-primary-care-2011.ashx
Lingford-Hughes, A.R., Welch. S. & Nutt, D.J. (2004) Evidence-based guidelines for the phar-
macological management of substance misuse, addiction and comorbidity: Recommendations
from the British Association for Psychopharmacology. Journal of Psychopharmacology, 18(3),
293335.
156 Chapter 5: Addiction disorders
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
A 20-year-old man is admitted to hospital at 10p.m. on Saturday evening. He
states he is depressed and suicidal. He also says he is prescribed 50mL of
methadone as a maintenance dose daily and is experiencing opioid withdrawal
symptoms. He asks that his methadone be prescribed.
Station 9: Substance misuse history and managing withdrawal 157
Take a history of illicit drug use from the patient and details of the treatment
he is receiving. Explain to him your plan of management. You need not
discuss the symptoms of depression or suicidality.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and thank the patient for coming to see you. Enquire about his current
difficulties. Hello, Mr_____, I am Dr_____, a psychiatrist. I gather you are not feeling
very well. Can you tell me what is going on? The patient may immediately start talking
about having methadone prescribed; listen to his concerns and probe more into the drug-
seeking behaviour.
Increased sweating
Joint pain
Lacrimation
Muscle spasm leading to headaches
Nausea and vomiting
Rhinorrhoea
Twitching
Urinary frequency
You will have to attempt to do a brief physical examination in order to check for tremors,
pulse rate and blood pressure (if equipment is available). You may want to demonstrate
to the examiner that you are observing such symptoms, You seem very shaky today. I can
see you are sweating a lot; this sometimes happens when someone experiences withdrawal
effects. Is it possible you are going through that?
It is very important to tell the patient about drug testing of either urine or saliva. You
would expect to find a positive test for methadone. If the test is negative for methadone,
then this is incompatible with a history of being on methadone; this is an important
point, as it would be dangerous to prescribe methadone in these circumstances as overdose
and death could ensue.
If the test is positive for methadone, it does not confirm either that the patient is being
prescribed methadone or that they are receiving the dose they say they are. During normal
working hours, it is possible to confirm a prescription with the prescribing service or
pharmacy; you may say to the patient, I would like to get in touch with your GP/metha-
done clinic to check the right amount of prescription for you.
The safest management plan in this circumstance is to use when necessary (PRN) dihy-
drocodeine in order to relieve symptoms of opioid withdrawal: 3060mg every 6 hours
PRN will help relieve symptoms of withdrawal without running the risk of causing opioid
overdose. Stress to the patient that this is not a life-threatening situation, but can be
uncomfortable. Explain that you will be looking at supportive measures to alleviate his
discomfort. Nursing staff should observe for objective symptoms of opioid withdrawal
using a chart such as the Clinical Opiate Withdrawal Scale (COWS). When possible, contact
the service that the patient attends in order to confirm the information the patient has
given.
Problem solving
This station may test the candidates ability to elicit a drug history from a reluctant his-
torian. The patient may be insisting upon getting more methadone, and the candidate
has to make sure that the patient is reassured that the uncomfortable symptoms of the
opioids will be addressed. It is important to demonstrate to the examiner that withdrawal
symptoms of opioid are considered and adequate checks such as urine/saliva drug screen-
ing and communication with GP/pharmacy about the accuracy of prescriptions will be
done as part of the management.
FURTHER READING
American Psychiatric Association (2006) Practice Guideline for the Treatment of
Patients with Substance Use Disorders, 2nd edn. http://www.psychiatryonline.org
Drug Misuse in Over 16s: Opioid Detoxification. NICE Guidelines [CG52]. (2007).
Station 9: Substance misuse history and managing withdrawal 159
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 6
Forensic psychiatry Marc Lyall
LINKED STATIONS
INSTRUCTION TO CANDIDATE
As a psychiatry trainee, you have been called to assess a young woman who is
in police custody charged with shoplifting. She has a history of deliberate self-
harm. While in the police station, she has made superficial cuts to her forearm
with a disposable razor that she had hidden.
Take a history of her self-harming behaviour and assess the risk of suicide
and of further self-harm in the short term.
SUGGESTED APPROACH
Display appropriate empathy
Set the scene start with general open questions, perhaps about the patients experience
in police custody. The woman is likely to be angry, anxious and distressed establishing
trust and empathy will be necessary before an accurate assessment can be
undertaken.
the woman that you will not divulge what is said to the police unless you have her
agreement, although there might well be pressure from the police to report what the
woman said.
ADDITIONAL POINTS
Good candidates might suggest to the woman that they will gather background
information from her GP and any mental health professionals who have been
involved in her care to date.
Approximately a third of deaths in police custody are due to self-harm or
suicide. The most common form of self-harm/suicide in custody is through the
tying of ligatures.
FURTHER READING
Bouch, J. & Marshall, J.J. (2005) Suicide risk: Structured professional judgement. Advances
in Psychiatric Treatment, 11(2), 8491.
Station 1(a): Self-harm in custody 163
INSTRUCTION TO CANDIDATE
The woman has given her consent for you to explain her situation to the
custody sergeant. Explain to the police officer your risk assessment and
advise him on how to manage the situation.
SUGGESTED APPROACH
Communicate with a non-medically trained professional appropriately
The difficulty in this station is to communicate the womans future risk of self-harm and
suicide in a way that is understandable to the police officer and avoids discussing unnec-
essary details of the womans history. The police officers understanding of mental health
issues is likely to be limited. However, they will be concerned with avoiding the woman
self-harming again or attempting suicide.
Introduce yourself: Hello. Im Dr_____, Im the on-call psychiatrist and Ive just been to
see Ms_____. Can I speak to you somewhere privately where we wont be disturbed? Is
this a good place?
Do not use medical jargon and check the understanding of the police officer.
Explain that the purpose of your assessment was to assess the womans risk of suicide and
self-harm in order to ensure that she receives proper medical care and explain doctor
patient confidentiality.
Ask if the patients injuries have been assessed by the police doctor (Forensic Medical
Examiner [FME]). If not, you should request that this happens.
Taking a brief account of the events surrounding her arrest and self-harm from the police
officer would be useful, not least to see if this concurs with the patients description.
Station 1(b): Discussion with police officer 165
Suggest avenues through which the police officer can access further help
The police are likely to want to know whether the woman has a mental illness. If in
your opinion she does, detention under mental health legislation will need to be
considered.
FURTHER READING
Kent, J. & Gunasekaran, S. (2010) Mental disordered detainees in the police station: The
role of the psychiatrist. Advances in Psychiatric Treatment, 16(2), 11523.
INSTRUCTION TO CANDIDATE
This woman became depressed after her husband left her. She was extremely
distressed and presented herself to accident and emergency (A&E), where she
was seen by the liaison nurse.
She agreed to an informal psychiatric admission to the ward and settled
extremely quickly. It was recommended that she start lofepramine (an
antidepressant) at night and she has cooperated with this.
She would now like to leave hospital and return home. There are no grounds
currently to detain her under the Mental Health Act.
During her admission, she disclosed detailed plans to another patient about
how she intends to kill her husband.
She has a history of violence towards her husband.
Take a relevant history and mental state, assessing the risk she poses to her
husband.
You have thought about killing your husband in the past but have not tried to do
this.
You believe that God is controlling your body and commanding you to kill your
husband.
You do not want to tell the doctor what your plans are, but if the doctor is tactful
and empathetic, you reveal what you are thinking.
SUGGESTED APPROACH
Communicate appropriately, displaying empathy
Hello, Im Dr_____, I work here on the ward. I wanted to speak to you about your plans
for when you leave hospital.
The course of the interview will be largely determined by the patients attitude to being
questioned. The discussion could initially be framed as a way of planning the care package
for her discharge, before later moving on to the specifics of the risk that she poses to
others.
The patient might well be guarded about her plans with regard to her husband. An open
and empathetic style of interviewing will be important. If the patient refuses to talk about
her threats, she will need to be informed tactfully and in a way that does not put others
at risk that she has been overheard describing what she might do to her husband. She
will need to be challenged directly about these ideas.
What is her level of insight? Will she comply with treatment in the community, including
with medication?
FURTHER READING
Adshead, G. (1999) Duties of psychiatrists: Treat the patient or protect the public?
Advances in Psychiatric Treatment, 5(5), 32128.
INSTRUCTION TO CANDIDATE
Following your interview in the previous station, you have arranged to meet
with her husband, who has been asking to see you.
Discuss how you intend to manage his wife. He wants to know if he is at
risk.
SUGGESTED APPROACH
Introduce self appropriately and display empathetic style
Introduce yourself: Hello, Im Dr_____. Im your wifes doctor.
The man is anxious and will be looking to you for support and assistance. He is likely to
be shocked and upset by his wifes threats.
ADDITIONAL POINTS
If the patient has capacity but refuses to consent to disclosure, the grounds
for breaking confidentiality are a matter of judgement and involve weighing
the risk of disclosing information against the risk of non-disclosure. If the
matter is of overriding public interest (e.g. if there is a risk of violence), then
there is a right to disclose (as described in the Royal College of Psychiatrists
guidance, Good Psychiatric Practice: Confidentiality and Information Sharing);
arguably, if the risk is considered significant and is focussed on a particular
individual, there is a duty to disclose information which safeguards that
individual. In essence, the question is: what would be supported by a Bolam/
Bolitho test (i.e. by a reasonable body of medical practitioners based on
logical evidence)?
If in doubt, the clinician should discuss with a senior colleague, their medical
defence organisation or their Trusts solicitors. Whatever decision is taken will
need to be justified in writing in the clinical notes.
FURTHER READING
Royal College of Psychiatrists (2012) Good Psychiatric Practice: Confidentiality and
Information Sharing. 2nd edn. http://www.rcpsych.ac.uk/usefulresources/publications/
collegereports/cr/cr160.aspx
Station 3(a): Prison assessment 171
INSTRUCTION TO CANDIDATE
You have been asked by the prison doctor to assess a 45-year-old man in
prison. He is charged with attempted murder. He has assaulted other inmates
while in prison. The man has spoken to a number of prison officers about
hearing the voice of God commanding him to attack others.
Assess the risk of the man acting violently to others in prison.
172 Chapter 6: Forensic psychiatry
SUGGESTED APPROACH
Communicate appropriately and with empathy
Hello. Im Dr_____. I work at the hospital. Im not a prison officer. Ive been asked to see
you today to see how you are. Could you tell me a little bit about what its been like in
prison? I understand that there have been some fights with other inmates can you tell
me about them?
It is important to be empathetic and non-judgemental.
FURTHER READING
Buchanan, A. (1999) Risk and dangerousness. Psychological Medicine, 29, 46573.
Maden, A. (2007) Treating Violence. Oxford: Oxford University Press.
Mullen, P. (1997) Assessing the risk of interpersonal violence in the mentally ill. Advances
in Psychiatric Treatment, 3, 16673.
INSTRUCTION TO CANDIDATE
You have made your assessment of the man in the previous station.
Summarise your findings to your supervising consultant and discuss your
proposed management plan.
The examiner in this station will take part in the role-play.
SUGGESTED APPROACH
Communicate appropriately
Use language that is appropriate when discussing with a professional colleague. Avoid jargon.
Be precise and accurate. Respond to questions that are asked appropriately and fully.
Station 3(b): Discussion with consultant 175
Explain to the consultant the circumstances of you visiting the prison and that you have
assessed the patient only briefly but that you are worried about the risk that he might
pose to other inmates.
ADDITIONAL POINTS
The prison environment is an unusual one and, for candidates who have not
visited a prison, such an environment might be hard to imagine. However,
the basics of risk assessment are transferable to any environment. The
management of the risk of violence, whether in prison or in hospital, has
common features, notably enhanced observation and limitation of access to
weapons and potential victims.
INSTRUCTION TO CANDIDATE
Mr Dillon is a 23-year-old man who has recently been admitted to an in-patient
psychiatric ward. He has presented with symptoms of psychosis. This morning,
without any warning, he approached a nurse on the ward, Mr Griffiths, from
behind and punched him repeatedly to the floor.
Assess Mr Dillon and his short-term risk of violence.
Before being admitted to hospital yesterday, you were taking cocaine regularly.
You have not previously been violent.
You are puzzled by your own actions, which you regret. You are agitated and worry
you will be violent again. You are happy to take medication, but worry that this
will cause tiredness and you will be unable to defend yourself.
SUGGESTED APPROACH
Rapport and communication
You need to gain Mr Dillons confidence, being non-judgemental and calm. Give him the
space to talk, but also control the interview so that you can elicit the necessary details of
Mr Dillons history and mental state.
FURTHER READING
Baird, J. & Stocks, R. (2013) Risk assessment and management: Forensic methods,
human results. Advances in Psychiatric Treatment, 19(5), 35865.
178 Chapter 6: Forensic psychiatry
INSTRUCTION TO CANDIDATE
Having assessed the patient, now speak to the nurse who is coordinating
the shift about your short-term management plan and your suggestions for
managing the risk in the medium to long term.
SUGGESTED APPROACH
Rapport and communication
You are discussing the situation with an experienced colleague. There is a need to use
appropriate professional language and to show the ability to listen attentively, take on
board the nurses concerns and negotiate and agree on a management plan.
Use of medication
Your management plan should consider the use of additional medication. You need to be
clear why medication is being prescribed; for example, is it for extra sedation? There should
be a discussion with the nurse about the type of medication, how long it will be prescribed
for and what route it should be administered by. You should consider what approach to
take if the patient refuses to take medication. Consider potential side effects and physical
health monitoring.
FURTHER READING
Davison, S.E. (2005) The management of violence in general psychiatry. Advances in
Psychiatric Treatment, 11(5), 36270.
INSTRUCTION TO CANDIDATE
You have been asked to see Mr Cowan, a 45-year-old in-patient on a general
psychiatric ward. Mr Cowan is thought to suffer from paranoid schizophrenia. He
has unescorted leave from the ward once a day. A nurse on a neighbouring ward,
Ms Williams, has told you that she has noticed Mr Cowan outside of her house
when he is on leave. He has not approached her, but she has seen him several
times in the last week and is concerned about her own safety. A number of
love letters have been left for her in the dining area of the ward. These are
crudely written and unsigned, but Ms Williams suspects that Mr Cowan might
be the author.
Examine relevant aspects of Mr Cowans history and mental state and
conduct a focussed risk assessment.
SUGGESTED APPROACH
Rapport and communication
The patient is likely to resent the suggestion that his belief is mistaken. He might become
agitated and aroused, challenging the doctor about the basis of their comments. You need
to remain calm and focussed, acknowledging what the patient believes, but also gently
seeking to challenge.
182 Chapter 6: Forensic psychiatry
Risk assessment
This has several parts: current intention, wider history and current mental state.
Patients who hold delusional beliefs often do not act directly on them; however, some
do. You should conduct a risk assessment to try and determine if and how the patients
behaviour has been influenced by their belief and what their plans are for the future.
Riskfactors, such as general antisocial behaviour and having multiple delusional objects,
and protective factors, such as a lack of substance misuse, should be elicited. Have you
tried to contact her? What was her response? How do you make sense of her response?
Or: Why havent you made contact with Ms Williams?
What is your intention now given your belief about Ms Williams?
Test out whether the patient has any thoughts of violence towards Ms Williams. If Ms
Williams doesnt want to see you, what will you do? Have you any thoughts of being
violent towards her? What thoughts have you had?
Explore the patients wider history, including their social circumstances patients without
social support who are actively misusing substances, with a forensic history and who are
impulsive are likely to be at particularly high risk of acting on their delusional beliefs.
Past behaviour is the best guide to future conduct. Hence, you should take a brief rela-
tionship history from the patient. How long have relationships lasted? Why have they
ended? How has the patient met partners in the past? Has there been any violence or
police involvement? How have relationships ended? Has the patient cohabited with a
partner?
Erotomanic beliefs can arise as a part of a delusional disorder, mania or paranoid schizo-
phrenia. There should be an attempt to explore the patients mental state, in particular
trying to establish symptoms of mania, other delusional beliefs and abnormal perceptions.
Feelings of anger and rejection that are so strong that they can lead to suicidal ideas can
be present and need to be elicited if present.
FURTHER READING
Mullen, P.E., Path, M. & Purcell, R. (2001) The management of stalkers. Advances in
Psychiatric Treatment, 7(5), 33542.
Station 5(b): Discussion with colleague 183
INSTRUCTION TO CANDIDATE
Having assessed Mr Cowan, you meet with Ms Williams (the nurse in
question). You need to judge what to say, bearing in mind that Ms Williams is
not directly involved in Mr Cowans clinical care and your duty of confidentiality
to Mr Cowan.
Inform the nurse of the situation. Provide advice in relation to support and
risk management.
You want to know how he found out where you live and what he wants from you.
You ask the doctor about Mr Cowans history, including his previous relationships.
If the doctor does not tell you what you believe you need to know, you become
upset and try to persuade the doctor to say more.
SUGGESTED APPROACH
Rapport and communication
Ms Williams is likely to be nervous and worried about her safety. You need to be reassur-
ing, professional and honest, while explaining the limits of what you can say about your
interview with Mr Cowan. You need to tell Ms Williams enough for her to be able to keep
safe, but not details that are not directly related to any threat she might face.
Explore support
Explore with Ms Williams what support she has. Does she have a partner or friends she
can talk to about this stressful situation? Can her manager at work help?
FURTHER READING
Path, M., Mullen, P.E., & Purcell, R. etal. (2001) Management of victims of stalking.
Advances in Psychiatric Treatment, 7(6), 399406.
SINGLE STATIONS
STATION 6: ARSON
INSTRUCTION TO CANDIDATE
You have been called to the Emergency Department of a local hospital to
see a young man who is under arrest for an alleged offence of arson. He has
suffered burns but is now physically well.
Take a forensic history with particular reference to fire-setting.
SUGGESTED APPROACH
Communicate appropriately and with empathy
An important aspect of the task is to be empathetic and non-judgemental. The patient
will need to be informed about the general confidentiality of the interview and reassured
186 Chapter 6: Forensic psychiatry
that information will not be disclosed to the police unless there appears to be a significant
risk to a named individual.
Time might run short in this station, as the candidate needs to take a comprehensive
history and the patient is likely to be a somewhat reluctant interviewee. Having a good
structure in approaching the task is important: concentrate first on the present incident,
and then consider past episodes.
FURTHER READING
Burton, P.R., McNiel, D.E. & Binder, R.L. (2012) Firesetting, arson, pyromania and the
forensic mental health expert. J Am Acad Psychiatry Law, 40(3), 35565.
Jackson, H. (1994) Assessment of fire-setters. In: McMurran, M. & Hodge, J. (eds) The
Assessment of Criminal Behaviours in Secure Settings. London: Jessica Kingsley, pp.94126.
Puri, B.K., Baxter, R. & Cordess, C. (1995) Characteristics of fire-setters. A study and
proposed multiaxial psychiatric classification. British Journal of Psychiatry, 166, 3936.
INSTRUCTION TO CANDIDATE
This patient, aged in her 20s, has attended the emergency clinic complaining of low
mood. She claims a long-standing history of feeling depressed since adolescence.
You discover that she has had a row with a neighbour who complained that she
was playing music loudly. This led to a physical fight.
You uncover a history of previous damage to property and violence. She
admits to having been extremely aggressive towards her ex-partner.
She wants to know what you can do to help her with her regular angry
outbursts.
Take a relevant history to determine the diagnosis.
Explain how you intend to assist her.
SUGGESTED APPROACH
Communicate with empathy
The patient has come seeking help, which is a major step, and is likely to need reassurance
regarding issues of confidentiality and the types of assistance that mental health services
can offer.
Remember to be aware of your own safety during the interview where are the alarms situ-
ated? Are colleagues aware that you are seeing the patient? Is the room set up adequately?
Station 7: Dissocial personality disorder 189
Try to establish firm boundaries and begin to draw up a treatment contract with the
patient, perhaps by suggesting: Its often useful if we establish right at the start how we
can help you and what you need to do.
190 Chapter 6: Forensic psychiatry
Other options for treatment might include attendance at a day hospital or admission to
a therapeutic community.
FURTHER READING
Banerjee, P.J.M., Gibbon, S. & Huband, N. (2009) Assessment of personality disorder.
Advances in Psychiatric Treatment, 15(5), 38997.
Fagin, L. (2004) Management of personality disorders in acute in-patient settings. Part 2:
Less common personality disorders. Advances in Psychiatric Treatment, 10, 1006.
Tyrer, P. & Bateman, A. (2004) Drug treatment of personality disorder. Advances in
Psychiatric Treatment, 10, 38998.
INSTRUCTION TO CANDIDATE
You have been asked to see this 30-year-old police officer in your clinic. She
was referred by the GP as she had attended A&E on at least six occasions
over the last few months with minor injuries. These had included injuries to
her hands from punching walls andalaceration to her face from an argument
with someone at her partners place of work.
The police have also been to her home address following calls from the
neighbours who were concerned about domestic violence, which she found
completely humiliating.
The letter from the GP includes details of a conversation with her brother,
setting out her belief that her husband is having an affair and the brothers
opinion that this is absolutely not the case.
She has also apparently been misusing both her work time and police
information to track her husbands activities.
Elicit the main features of what you believe is the likely diagnosis.
Assess the risk to others and of self-harm/suicide.
SUGGESTED APPROACH
Introduce self appropriately and establish rapport
One of the key problems with this station is engaging the patient in the assessment; the
patient is upset and firmly believes that her husband is committing adultery. The candidate
will need to show good communication skills and attempt to show the patient that her
own behaviour is causing her distress. Showing empathy without colluding or unfairly
supporting the patients belief about her husband is important.
Establishing how the patient views her attendance at the appointment will be important
early on in the interview. In her mind, her husband is to blame for her difficulties, and
she is likely to be resistant to the idea that mental health treatment could assist her.
The patient in this case is a police officer, which might increase the risk she poses to oth-
ers. Does she have access to weapons or otherwise confidential information about others,
especially her husbands alleged partner?
The risk to others in cases of a delusional disorder can be significant. A good candidate, as
well as assessing risk, will make some attempt to consider risk management. Options include
detention under mental health legislation or arranging an informal admission to hospital.
Treatment with anti-psychotic medication, at the same doses as in s chizophrenia, either
as an out-patient or in-patient will need to be considered. Psychological treatment in the
form of cognitive behavioural therapy, if the patient will allow this, might be useful, as
might work in ensuring that the patients partner does not provoke further conflict with
their reaction to the allegations. If the risk to the partners husband is great, geographically
separating the patient from her husband might be necessary.
ADDITIONAL POINTS
One cannot guarantee full confidentiality, particularly if other individuals are at
risk, and this will need to be established early in the assessment.
FURTHER READING
Fear, C. (2013) Recent developments in the management of delusional disorders.
Advances in Psychiatric Treatment, 19(3), 21220.
Kingham, M. & Gordon, H. (2004) Aspects of morbid jealousy. Advances in Psychiatric
Treatment, 10, 20715.
INSTRUCTION TO CANDIDATE
You are a psychiatry trainee working with out-patients. You are asked to see a
63-year-old man with a history of bipolar affective disorder. The man lives in a
housing association flat. His GP has been informed by his housing officer that,
whenever she has visited over the past 2 months, the patient has answered
the door with his trousers underdone, exposing his penis. He has corrected
his attire when told and has appeared embarrassed. The housing officer has
noticed pornographic magazines spread openly around the mans living room.
Take a history of the mans behaviour and any other sexually abnormal
behaviour and carry out a focussed mental state examination.
Station 9: Indecent exposure 195
SUGGESTED APPROACH
Demonstrate appropriate communication skills
The patient might well be embarrassed and distressed at coming to the appointment. This
should be quickly acknowledged and the overall structure of the assessment should be
explained, as should the duty of confidentiality.
Fantasy beliefs, particularly if they concern paraphilic activities, might be difficult to
elicit: normalising the issue of sex and being clear with the patient that everyone has
sexual ideas could assist with this.
Notwithstanding the difficulty, the situation is potentially serious and a clear assessment
of risk needs to be undertaken.
What did the patient do? What effect did he believe his actions would have, and what
was the effect that he wanted to have (e.g. to make the housing officer fearful, to be caught
or as the start of a sexual encounter)? Was the housing officer the intended victim and if
so why?
Was exposing himself sexually arousing? Was his penis erect or flaccid? Did he masturbate
afterwards?
How much planning was involved? Was the patient intoxicated at the time? What was
his mental state: any evidence of mania/hypomania such as an elevated mood, increased
energy, quick thoughts, insomnia, lack of fatigue, elevated self-regard, loss of concentra-
tion, grandiose ideation, and so forth? Was the man anxious and did exposing himself
make him feel less so?
Is there any evidence that the man was confused? Was he taking any disinhibiting
medications at the time (e.g. benzodiazepines)? Does he suffer from any physical illnesses,
such as diabetes, or a recent head injury that have might have affected his psychological
state?
What is his current attitude to what he did: embarrassment, entitlement or pleasure? Does
he want treatment?
196 Chapter 6: Forensic psychiatry
FURTHER READING
Darjee, R. & Russell, K. (2012) What clinicians need to know before assessing risk in
sexual offenders. Advances in Psychiatric Treatment, 18(6), 46778.
Russell, K. & Darjee, R. (2013) Practical assessment and management of risk in sexual
offenders. Advances in Psychiatric Treatment, 19(1), 5666.
LINKED STATIONS
INSTRUCTION TO CANDIDATE
You are about to see James, a member of staff from a local care home, who
is here with Sam, one of the residents with a moderate learning disability
who has displayed a marked change in his behaviour recently. He has been
withdrawn and banging his head against a wall repeatedly.
Please take a history from James to assist you in coming to a conclusion
around the possible explanation for this presentation. You might wish to
take notes, since you would be expected to explain your assessment and
management at the next station.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, I am one of the psychiatrists. How would you
like to be addressed? Greet James and Sam: I understand that you have some concerns around
a change in Sams presentation recently. Are you able to explain these in detail for me?
Risks
A risk assessment, including risk to self (suicidal ideation, self-harm and self-injury), risk
of harm to others (physical aggression and hurting others), self-neglect, risk of exploita-
tion (ask whether he is frightened of someone and whether he has experienced inappro-
priate behaviour) and risk of placement breaking down, is to be completed.
Aetiology
Consider:
Social/environmental changes/changes to routine.
Physical health.
Psychiatric: rule out depression. Are biological symptoms of depression elicited (e.g.
changes in appetite, sleep, anhedonia, withdrawal, tearfulness and diurnal variation
in symptoms)?
Risk: ask about death wishes, suicidal thoughts/active plans for suicide and self-harming,
as well as clarifying risk of self-neglect and risk to others.
Station 1(a): Behavioural change History taking 201
Points to consider
Rapport with carer and being sensitive.
Establishing baseline functioning of patient.
Obtaining a past and family psychiatry history of psychiatric disorder.
Demonstrating precipitating factor.
Ruling out physical/environmental and social causes systematically before consid-
ering a psychiatric explanation.
Thorough risk assessment. Psychiatric illness is four times more common in indi-
viduals with learning disability (LD) compared to the general population.
FURTHER READING
Challenging behaviour and learning disabilities: NICE Guidance. http://www.nice.org.uk/
guidance/ng11
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have just spoken to care worker James, who looks after Sam, in the
previous station. The care home manager is worried about Sam and asks what
is going on with him. He is anxious how to manage Sam in his care home and
would appreciate some help.
Please explain the findings of your assessment and the management plan to
the manager. Address any concerns that he might have.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, I am one of the psychiatrists. How would
you like to be addressed? I gather you are concerned about Sam. I have spoken to James
and I shall be explaining to you my understanding of the recent change in Sams behaviour.
We shall then discuss ways to manage it. I shall also address any concerns that you may
have.
complete your assessment. Mr_____, I am sure you are worried about Sam and his
recent change in behaviour. I have spoken to James at length and, from what I gathered,
I think Sam is probably experiencing depression. This is probably because he is missing
his mum.
M: Doctor, are you sure? Why do you think so?
C: It seems in the past few weeks Sam has seemed withdrawn, experiencing poor sleep
and appetite, not being his usual happy self and banging his head these could be his
way of expressing his psychological distress.
Give the diagnosis of depression and its comorbidity with learning disability.
Explain the diagnosis.
Check understanding and explain the reasons behind your conclusion.
M: Is there anything you can do to help Sam?
C: I shall first come and see him and complete my assessment. There are various treatment
options to address the depressive symptoms. Medical management will be to consider
antidepressants and, for acutely disturbed behaviour, some anxiety-alleviating
medication.
M: Is there anything the care home can do?
C: Certainly. We know that depressive symptoms improve by incorporating activities
that brings pleasure and a sense of achievement in daily life. We need to think about
what Sam usually enjoys and what gives him a sense of achievement. This could be
watching his favourite movies, listening to music or playing his favourite sport. In
the meantime, it may help to arrange for him to visit his mother in the hospital too,
if possible.
Ask if there are any questions before moving on to discuss treatment options.
Management options bio-psycho-social approach.
Address the carers concerns and provide reassurance.
Points to consider
Do not forget to mention regular cardiovascular exercise, activity scheduling and sleep
hygiene.
Cognitive behavioural therapy: this is an evidence-based psychological therapy, but
one would need to ascertain Sams level of learning disability to engage in this.
Antidepressant medication.
Mention patient choice and capacity.
Risk management and safety advice: ask about keeping Sam safe and allocating more
one-to-one time with his care worker in order to prevent him from head banging and
to respond quickly if he does so.
FURTHER READING
http://www.mentalhealth.org.uk/publications/learning-disabilities-iapt-positive-practice-guide
Hurley, A.D. (2008) Depression in adults with intellectual disability: Symptoms and
challenging behaviour. Journal of Intellectual Disability Research, 52(11), 90516.
Jennings, C. & Hewitt, O. (2015) The use of cognitive behaviour therapy to treat depression
in people with learning disabilities: A systematic review. Tizard Learning Disability Review,
20(2), 5464.
204 Chapter 7: Learning disability psychiatry
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You are about to meet Jen, a woman with learning disabilities who lives in
supported accommodation and has been brought to accident and emergency
Station 2: Learning disability and capacity toconsent 205
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, one of the psychiatrists. How would you
like to be called? Explain your role to the patient and the staff. Explore the patients under-
standing of the situation: I gather you have been unwell. Can you tell me what
happened?
Points to consider
Clarify the extent of learning disability.
Clarify dementia/delirium/other factors which could impact on the decision-making
process.
Awareness of the impact of current mental health and belief decisions on decision
making.
Making an unwise decision does not by itself imply a lack of capacity.
Facilitate information giving/support for making decisions.
ADDITIONAL POINTS
Remember that treatment is in the patients best interests.
Advance directives.
Independent Mental Capacity Advocate.
FURTHER READING
Making Decisions The Independent Mental Capacity (IMCA) Service (2009)
Department of Health and Office of the Public Guardian. https://www.gov.uk/govern-
ment/uploads/system/uploads/attachment_data/file/365629/making-decisions-
opg606-1207.pdf
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to
improve
INSTRUCTION TO CANDIDATE
This is Michael Stern. He is 18 years old, has a learning disability and lives at
home with his parents. His mother is his main carer. He also attends a special
school. Over the last few weeks, he has become significantly more aggressive.
This is mainly focussed towards himself. He will bang his head repeatedly
against the wall at home and he has been picking at his arms so that he has
multiple skin lesions.
Assess this man and consider the important aetiological factors.
SUGGESTED APPROACH
Setting the scene
Introduce yourself normally do not treat the patient like a child. Hello, I am Dr_____,
nice to meet you. I have come to talk to you in order to understand if I can be of any help.
Do not appear patronising or be over-familiar with him. Treat him with respect and, if
communication is difficult, adjust your style accordingly. Explain the assessment and inform
him that his parents are worried about him. Allow him to speak and build a rapport.
Psychological
Look for evidence of emotional stress. Ask about familial relationships and recent stressors.
Have there been arguments at home or school? Consider any behavioural component to
the self-harm and any positive gain. This should not be assumed to be attention-seeking
behaviour, but rather a way of communicating distress or unpleasant feelings. More
appropriate ways of communicating are aspects that a psychologist could assist with.
What about the work or school setting: is he being bullied or is he having any relationship
difficulties?
Social
Enquire about close relationships. Has anyone close to the family or friend/staff member
from school moved away? Has the daily routine changed? Has the patient recently moved
home or has something changed at home?
Station 3: Behavioural disturbance in LD 209
Problem solving
This is a challenging station as you are attempting to take a history in a short period of
time from someone who might not be forthcoming or who will be disturbed. The actor
may be instructed to have slow or delayed answers to your questions, so patience is key,
despite time pressures.
To help with communication, you should:
ADDITIONAL POINTS
Risk assessment: always consider the possibility of physical, emotional or sexual
abuse in vulnerable individuals. Ask about the self-harm and head banging.
Although such behaviours are likely to be related to frustration or distress, you
need to enquire about suicidality and homicidal thoughts. Psychiatric illness is
four-times as common in LD compared to the general population.
FURTHER READING
Emerson, E. (2001) Challenging Behaviour: Analysis and Intervention in People with Severe
Intellectual Disabilities. 2nd edn. Cambridge: Cambridge University Press.
http://www.challengingbehaviour.org.uk
The Challenging Behaviour Foundation provides information and support to parents and
carers of individuals with severe learning disabilities.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mr Roberts and his wife have come to see you. They have noticed that their
son, now 4, had been slow to speak compared to his peers. He seems
to be clumsy and slower to learn in new situations. He was seen by the
paediatricians and diagnosed with fragile X syndrome (FXS) following genetic
testing. The parents have been referred to your unit for advice regarding
his recent change in behaviour. They also want to know the risks of further
children being born with this condition.
Meet them and address their queries.
SUGGESTED APPROACH
Set the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the psychiatrists. Thank you
for coming to see me today about your son. Can I ask his name? Establish the purpose of
this meeting: I understand that youve seen the paediatric doctors recently. Is that cor-
rect? Did they talk to you about his diagnosis? Empathise with their difficult situation:
It must be a worrying time for you since you found out about the diagnosis. Can I ask
what you already know about fragile X syndrome?
Station 4: Fragile X syndrome 211
Behaviour
The parents will be worried about his behavioural disturbances. Ask about his current
behaviour. Take a history of what is happening, frequency, triggers, how long it lasts and
what seems to settle him, if anything. Behaviour is often the presenting feature prior to
a formal diagnosis. Enquire about the following:
Speech disturbance (FXS speech has been described as jocular or cluttered): Have
you noticed anything unusual with his way of speaking?
Attentional deficit: Is he able to concentrate on tasks for prolonged periods?
Mannerisms (commonly involving the hands and flapping): Does he engage in
any actions or mannerisms repeatedly?
Autistic-like behaviour (accounts for perhaps 2%3% of autism): Does he seem to
be lost in his own world quite often? How does he interact with other children?
What would you say about his social skills?
Sensory defensiveness (avoids loud noises, bright lighting, touch and strong smells):
Is he overly sensitive to loud noise, touch, brightness or strong smells?
Emotional instability: Are there sudden periods of crying or emotional
outbursts?
Anxiety: How does he cope in unfamiliar situations?
Management advice
A multidisciplinary approach (mental health services, school, social workers and voluntary
agencies) is advised, and engagement with LD services is recommended.
Occupational therapy
This can help to adjust tasks and conditions to match his needs and abilities. It can also
help with sensory defensiveness by using appropriate stimulatory or calming activities
in order to alter his responses to sensations.
Physiotherapy
This can help to improve motor control, posture and balance. At school, it can help a
child who is easily overstimulated or who avoids body contact to take part in sports.
212 Chapter 7: Learning disability psychiatry
Psychology
Psychologists can assist by teaching parents or teachers to identify why a child acts in
certain ways and how to prevent distressing situations, as well as teaching the child to
cope with the distress.
Education
Psycho-education is for both the child and family. It is also important that the school
understands that the child may have problems with auditory processing, concentration
and abstract concepts.
Medication
Medication is used for behaviour when other interventions have been ineffective.
Medication is not without risk of side effects and should be used cautiously. A proportion
of children will need anticonvulsants for epilepsy, and these drugs can also help with
behavioural and mood instability. Sometimes, different doses or combinations of medica-
tions are needed for maximum benefit. Stimulants such as methylphenidate can be of
benefit where attention deficit or hyperactivity is pronounced. Similarly, aggression can
be treated with mood stabilisers or antidepressants.
Problem solving
It is important to consider the timescale of behavioural change. Enquire about other
causes of this; for example, an underlying physical illness (UTI/pain), organic disorder
(e.g. epilepsy) or concurrent mental illness.
Testing eyesight and hearing is essential. FXS is associated with short- and long-sighted-
ness, squints and glue ear. These can aggravate speech and language problems and cause
frustration.
ADDITIONAL POINTS
Follow-up and engagement with services is important in order to help the child
as they develop. Epilepsy (20%), challenging behaviour and mood disorders
occur more frequently after puberty.
FXS usually occurs with an expansion of the FMR1 gene on the X chromosome
through CGG trinucleotide repeats. In the full mutation, there are more than
200 repeats (normal <54).
Station 4: Fragile X syndrome 213
FURTHER READING
Hagerman, R.J. & Hagerman, P.J. (eds) (2002) Fragile X Syndrome Diagnosis, Treatment
and Research. 3rd edn. Baltimore, MD: John Hopkins University Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 8
Liaison psychiatry Babu Mani
LINKED STATIONS
INSTRUCTIONS TO CANDIDATE
You are a liaison psychiatrist. The rheumatologist has asked you to see a
lady who has been diagnosed with Systemic Lupus Erythematosus (SLE)
and antiphospholipid syndrome. Recent investigations including a magnetic
resonance imaging (MRI) scan have indicated secondary small vessel disease.
She has been referred to you as she has become increasingly forgetful and
reports that she frequently forgets where she was meant to be going when out
driving her car.
Assess this ladys difficulties, carrying out any relevant brief cognitive
testing.
SUGGESTED APPROACH
Setting the scene
Begin the station by introducing yourself to the patient: Hello, Mrs_____, I am Dr_____,
the psychiatrist. I have been asked by my colleagues to have a brief discussion with you
about your difficulties. What is your understanding of this assessment?
The candidate should make it clear that they are a psychiatrist and that the rheumatolo-
gists have asked for a second opinion. The candidate can begin the interview by informing
the patient that they would like to ask her a few questions around her difficulties, includ-
ing a few questions specifically testing her memory.
216 Chapter 8: Liaison psychiatry
ADDITIONAL POINTS
1. This station should be handled in the same way as assessing memory problems in
any other context (e.g. old age psychiatry). It is important to ensure that a functional
psychiatric illness, such as depression, is not masquerading as memory disturbance.
Underlying vascular disease in the brain may also predispose to secondary mood and
psychotic disorders.
2. The Driver and Vehicle Licensing Agency (DVLA) has issued fairly clear guidelines on
driving for a number of conditions. https://www.gov.uk/guidance/
assessing-fitness-to-drive-a-guide-for-medical-professionals
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have spoken to Mrs Jones in a previous task. The rheumatologist is
interested to know your thoughts following your assessment.
Discuss this case with the referring practitioner and discuss how you think
this lady should be managed from a psychiatric point of view.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Dr_____, I am Dr_____, the psychiatrist. I have seen your
patient Mrs Jones; as you know, she has been worried about her memory. Shall we discuss
about how we proceed?
Biological investigations: urine drug screen (if not already carried out by referrer),
dementia screen-B12/folate/ thyroid function tests (TFTs), other vascular risk factors
and relevant neuroimaging.
Psychological investigations: formal neuropsychological assessment/testing.
Objective rating scales for mood (e.g. Becks Depressive Inventory both pre- and
post-treatment with an antidepressant).
Social investigations: collateral history from a family member or friend would be
extremely important to obtain. Consider occupational therapy assessment.
Objective rating scales (e.g. Global Assessment of Functioning) might also be used.
Management:
Rh: What do you suggest as further course of action?
C: The history and examination suggest that this lady may be suffering from comor-
bid depression. I would like to treat the depression, and suggest that she should
have her memory and mood reassessed at a suitable time point (e.g. 23 months).
I would like to follow this patient up frequently in the initial stages of treatment.
Suitable treatment might include a selective serotonin reuptake inhibitor (SSRI;
although note contraindications with increased risk of gastrointestinal bleed if pre-
scribed aspirin for pro-thrombotic tendencies) or other antidepressants such as mir-
tazapine or venlafaxine. Other possibilities might include psychological interventions
(cognitive behavioural therapy [CBT]), although underlying cognitive impairment
may limit how far the patient is able to take part in this therapy. She may benefit from
supportive counselling if she is finding it difficult to adjust to the diagnosis. Simple
aids could be suggested to help with her memory problems (e.g. dosette box for medi-
cations, a diary and wall clock with date for appointments, calendars and alarms).
As this is a liaison psychiatry station, how the candidate discusses these possibilities
with the referrer will be assessed.
Rh: What about her driving?
C: I am concerned about this lady continuing to drive at this point in time, as
she appears to have greatly impaired recent memory, and this could impact on
her judgement. I would suggest that she stops driving for now, and that she could
be referred for further neuropsychological testing, which may inform medical
recommendations to the DVLA. She should also inform her insurers. The issue
of driving could be revisited after her depressive illness has been adequately
treated and her memory problems have been reassessed. If she can demonstrate
Station 1(b): SLE Discussion with rheumatologist 219
that her skills are sufficiently retained and that the progression of the underlying
brain impairment is slow, she may be able to drive subject to annual review/a
formal driving assessment.
FURTHER READING
DVLA (2007) For medical practitioners: At a glance guide to the current medical standards
of fitness to drive. http://www.dvla.gov.uk/media/pdf/medical/aagv1.pdf
Taylor, D., Paton, C. & Kerwin, R. (2007) The Maudsley Prescribing Guidelines, 9th edn.
London: Informa Health Care.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
220 Chapter 8: Liaison psychiatry
INSTRUCTION TO CANDIDATE
You are asked to urgently see a young man who has stabbed himself and is
refusing surgical treatment. The wound has been bandaged; however, the
surgeons wish to take him to theatre and perform life-saving surgery, without
which they feel he might die. His mother reports that over the last year he has
become more reclusive and withdrawn. In accident and emergency (A&E), he is
mute and does not answer any of your questions.
Take a history from this gentlemans mother and assess his capacity
regarding consent to medical treatment.
You may wish to take notes as you will be asked to discuss his likely
differential diagnosis and management with his brother at the next station.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain the purpose of your visit: Hello, Mrs_____, I am Dr_____,
the psychiatrist. I can imagine how difficult this situation is for you. I have seen your son
and he is mute. I would appreciate it if I can gather some information from you about him.
This is a difficult situation, and you can say so as part of your opening introduction. Make
attempts to establish rapport with the patient and the mother. Despite the gravity of the
situation, you should assume that the patient has capacity unless you are able to prove
otherwise.
Onset and nature of any mental health difficulties preceding the attempt by the
patient to stab himself: Was there a clear change in his mental state or routine func-
tioning noted over the preceding days/months?
Is there a preceding history of potential prodromal features to a psychotic episode (e.g.
social withdrawal, decline in functioning, apathy/loss of drive or odd behaviour)?
Is there a possible preceding history of a mood disorder (stressful life events or history
of affective symptoms/biological features of depression) noted by mother?
History of previous bizarre behaviour or bizarre beliefs expressed to/noted by mother:
is there a possible prior history of auditory hallucinations?
Is there a previous psychiatric history, including previous attempts to harm self?
Concerns by family member as to his self-harm/suicide risk?
Is there a family history of psychosis, suicide or depression?
Is there a history of illicit substance misuse/dependency (cannabis, cocaine, etc.) or
alcohol misuse or dependency?
Is there any forensic history of note?
2 . Assess the patients mental state and capacity to accept or decline treatment.
Mental state examination in this station will be merely an observation as you will
not be able to communicate with the patient. It may be worth noting if he appears
to be responding to internal stimuli (e.g. auditory or visual hallucinations) and you
may wish to examine him, if appropriate, for associated catatonic features.
In this station, the patient is mute and will not be able to communicate with you either
verbally or otherwise; however, you must show that you have made attempts to adequately
communicate with the patient, and you may wish to check this with his relative.
You may wish to check with his mother if her son has any pre-existing religious or
cultural beliefs which might have affected his decision (e.g. Jehovahs witness/blood
products, etc.).
3. Turn to the patients mother and summarise your findings and likely diagnosis.
Given the history and the patients presentation (which represents a clear change in
mental state indicative of an underlying mental disorder, which you will elaborate
upon in the next station), it is likely that on balance of probabilities, this patient lacks
the capacity to consent to treatment for his injury.
You should explain to his mother that, given the urgency of the situation (life threat-
ening), the medical team should be advised to act in his best interests; however, his
capacity will need to be reassessed once his medical condition has been adequately
managed.
ADDITIONAL POINTS
1. Candidate should explain that as this is a life-threatening situation,
measures should be taken to act in the patients best interests; however,
his capacity for any further interventions should be reassessed when he has
had treatment for the injury.
2. The history and clinical presentation noted in this station should allow you
to summarise the likely differential diagnosis and likely management to the
examiner in the next station. The marks awarded in this station are mostly
for history taking, brief risk assessment, difficult communication and brief
case discussion (with the patients mother).
3. The general principles regarding the assessment of capacity still
apply.1 Based on the history, it seems likely that the gentleman has
an impairment or disturbance of the mind which, at present, makes
him unable to make a decision regarding surgical treatment and may
222 Chapter 8: Liaison psychiatry
REFERENCE
1. Booklets on all aspects of the Mental Capacity Act can be downloaded from http://
www.dca.gov.uk/legal-policy/mental-capacity/publications.htm#mental
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 2(b): Discussion with relative 223
INSTRUCTION TO CANDIDATE
The patient, Adam Smith, whom you assessed, has been admitted to the
surgical ward. His brother has come from Spain and would like to talk to you
about Adams likely psychiatric diagnosis and treatment. He is worried about
the risk to him if he were to go home from the surgical ward.
Assume that the gentleman is happy for you to communicate with his brother.
You do not need to assess his capacity to consent to psychiatric treatment.
Speak to patients brother and address his concerns.
SUGGESTED APPROACH
Setting the scene
Introduce yourself again to the patients brother: Hello, I am Dr_____, glad we could
meet. Hopefully I can be of help regarding your brother. The actor playing the role of the
mother may initiate the discussion by explaining her concerns. You may therefore wish
to start this station with a fairly open statement.
ADDITIONAL POINTS
1. The vignette indicates that risk assessment is an important part of this
station and will influence your subsequent management plan.
2. Biological, psychological and social approaches should be considered when
thinking about the investigation and management of this patient.
REFERENCES
1. NICE (2008) Structural neuro-imaging in first episode psychosis. http://www.nice.nhs.
uk/nicemedia/pdf/TA136Guidance.pdf
2. NICE (2002) Schizophrenia: Core interventions in the treatment and management of
schizophrenia in primary and secondary care. Clinical guideline 1. http://www.nice.
nhs.uk/nicemedia/pdf/CG1NICEguideline.pdf
Station 3(a): Conversion disorder History taking 225
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are asked to provide an opinion on 25-year-old Jane Smith, referred by the
neurologists as she has become wheelchair bound and is no longer able to
walk over the last 6 months. All neurological investigations, including detailed
neuroimaging, have been reported as normal. She was the passenger in a
tragic car accident 6 months previously in which her mother, who was the
passenger, was killed.
226 Chapter 8: Liaison psychiatry
Take a history from this lady. Conduct a mental state examination of this
lady, eliciting any abnormal psychopathology.
You may wish to take notes as you will be asked to discuss this case in the
next station.
SUGGESTED APPROACH
Setting the scene
Begin the station by explaining that you have been asked by your neurology colleagues
to provide an opinion on this ladys difficulties. Introduce yourself: Hello, Ms_____, I
am Dr_____, the psychiatrist. I am here to see you at the request of neurologists to see if
I can be of any help. Start off by asking her what her difficulties are and why she believes
she has been referred to see you.
The candidate should make it clear that they are a psychiatrist and that the neurologists
have asked for a second opinion. The candidate can begin the interview by informing the
patient that they would like to ask her a few questions around her difficulties.
ADDITIONAL POINTS
Dissociative motor disorders are classically associated with traumatic events,
insoluble and intolerable problems, or disturbed relationships, and have a
psychogenic origin.1 Patients may show a striking denial of obvious problems or
difficulties, despite these being fairly apparent to observers, and may attribute
distress to the resulting disability instead.1 Calm acceptance of disability
(la belle indifference) may also be apparent,1 although is not necessary for
diagnosis and may be present in only 6%41% of patients.2 For a diagnosis of a
dissociative motor disorder, it should be possible to make a clear psychological
formulation of why the patient is presenting in this way at this time.1
Dissociative disorders frequently present with other comorbid psychiatric
conditions, with comorbid mood and anxiety disorders reported in up to 80%
and comorbid personality disorders also frequently reported.3 Candidates
should ensure that they have screened for other functional comorbidities, as
the presence of these will influence management decisions, as discussed in
the next station.
Explaining your thoughts to the patient and her father may on the surface
appear difficult. However, a collaborative and flexible approach (suggested by
Bass & May, 2002) when assessing patients with multiple functional somatic
symptoms may also be relevant here4; for example, interview cues such as I
wonder if youve thought of it like this?4 or making tentative reframing links
between the trauma and the onset/temporal sequence of the symptoms may
be helpful to the patient.4
In an ideal situation, you would have at least an hour (and possibly further
interviews) when seeing a patient like this, so you may also wish to conclude the
interview by indicating that you would like to see them again, with more time in
hand to explore some of the difficult issues touched upon in this very brief review.
228 Chapter 8: Liaison psychiatry
REFERENCES
1. WHO (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines. Geneva: WHO Press.
2. Brown, R.J. (2006) Dissociation and conversion in psychogenic illness. In: Hallett, M.,
Fahn, S., Jankovic, J., Lang, A.E., Cloninger, C.R. & Yudofsky, S.C. (eds) Psychogenic
Movement Disorders: Neurology and Neuropsychiatry. Philadelphia, PA: AAN Press.
3. Ovsiew, F. (2006) An overview of the psychiatric approach to conversions disorder.
In: Hallett, M., Fahn, S., Jankovic, J., Lang, A.E., Cloninger, C.R. & Yudofsky, S.C.
(eds) Psychogenic Movement Disorders: Neurology and Neuropsychiatry. Philadelphia,
PA: AAN Press.
4. Bass, C. & May, S. (2002) Clinical review: ABC of psychological medicine. Chronic
multiple functional somatic symptoms. BMJ, 325, 3236.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 3(b): Conversion disorder Explanation 229
INSTRUCTION TO CANDIDATE
You are going to see Mr Edward Smith, father of Jane Smith. He would like to
know what is going on with his daughter. He would like to discuss possible
treatment and future prognosis with you.
Discuss your findings with him and outline the investigations, treatments
and prognosis for this lady.
SUGGESTED APPROACH
Setting the scene
Begin this station by introducing yourself to the father. You may want to acknowledge
the difficulties that Jane and her father have been going through in the last 6 months.
Hello, Mr_____, I am Dr_____, I gather you would like to discuss your daughters health
problems with me.
You should discuss management with him in the same way as for other stations:
Biological investigations: obtain confirmation that there is no comorbid history of
illicit substance misuse, possibly by obtaining a urine drug screen, and check routine
blood tests, including vitamin levels, and ensure that these are normal. You may want
to specify thyroid function tests to exclude underlying endocrine abnormalities.
Psychological investigations: psychological rating scales such as the BDI 2 or the
Hospital Anxiety and Depression Rating Scale3 are useful for objective measures of
depression or anxiety. If she is clinically depressed, the BDI can also be used to moni-
tor response to treatment.
Social investigations: suggest that you would like to obtain further collateral medical
and social history from this ladys GP. You may want to explore this ladys social
network and premorbid role/social functioning in further detail at the next review
(this may provide clues of other unconscious motives).
Management: The management of this condition is a combination of medications
and psychological help. Psychotropic medications are indicated if Jane is depressed
or anxious. Psychological therapies will address any unhelpful thinking patterns
that Jane may have regarding her situation, and will help her to modify some of
this thinking and these behavioural patterns. We will try to help her social situa-
tion, and if she wishes, we shall liaise with her employer.
Medical: treat a depressive/anxiety disorder if there is evidence of this on mental
status examination and suggest an SSRI as appropriate. She may need a referral to
physiotherapy if there is evidence of atrophy of leg muscles, and input from the
physiotherapist may also include a programme of graded exercise.4
Psychological: cognitive behavioural therapy may be appropriate if she can demon-
strate the ability to fruitfully use this approach and is keen to consider this.
Bereavement counselling may be appropriate if there are unresolved grief issues related
to the accident. You may also want to suggest suitable literature or self-help books,
and suggest patient/user groups for added support.4 It may be important to involve
the patients father/social network in any programme of psychological therapy, espe-
cially if secondary gain has become prominent (e.g. in supporting the family to allow
the patient to become independent of maintaining a passive/dependent role).4
Social: this should be tailored to her social circumstances. If at all possible, return
to work/education, which may play an important part in longer-term rehabilitation,
although in some cases work may be another form of stress to the patient and could
impede rehabilitation.4
3. Give an indication of longer-term follow-up and prognosis.
Usually, dissociative disorders can be difficult to manage, although positive factors
relating to her prognosis include clear onset following a psychological stressor, good
premorbid functioning and family/social support networks, as well as a recent onset
with short associated history.4
ADDITIONAL POINTS
As this section focusses on management, it may be fruitful to divide up
aetiology into predisposing, precipitating and maintaining factors and
suggest strategies to deal with each using a bio-psycho-social framework.
REFERENCES
1. Bass, C. & May, S. (2002) Clinical review: ABC of psychological medicine. Chronic
multiple functional somatic symptoms. BMJ, 325, 3236.
Station 4(a): Alcohol withdrawal Collateral history 231
2. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. & Erbaugh, J. (1961) An inventory for
measuring depression. Archives of General Psychiatry, 4(6), 561571.
3. Zigmond, A.S. & Snaith, R.P. (1983) The Hospital Anxiety and Depression Rating
Scale. Acta Psychiatrica Scandinavica, 67, 36170.
4. Gill, D. & Bass, C. (1997) Somatoform and dissociative disorders: Assessment and
treatment. Advances in Psychiatric Treatment, 3, 916.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are a liaison psychiatrist. The surgical team asks you to come and see an
elderly gentleman who was admitted 2 days ago with a fractured right femur.
He underwent an emergency surgery. Post-operatively, he has presented
232 Chapter 8: Liaison psychiatry
SUGGESTED APPROACH
Setting the scene
Introduce yourself to the patients wife. Begin by explaining that you have been asked by
the surgical team to provide an opinion on her husbands confusion. Hello, Mrs_____, I
am Dr_____, the psychiatrist. I have been asked to see your husband. I gather he had an
unfortunate fall and underwent surgery.
History taking
1. Take a corroborative history from the gentlemans wife.
When did she first notice that he was more confused? Was his confusional state fairly
sudden/acute in onset (onset pre- or post-operative)?
Clarify from his wife in what way is he confused (e.g. disorientated, paranoid, not
recognising her, memory difficulties or confabulation). Is there evidence of night-
time confusion or of agitation? Is there evidence of clouding of consciousness/sen-
sorium? Are there tactile disturbances?1
Station 4(a): Alcohol withdrawal Collateral history 233
Alcohol history
When was his last drink (NB signs of alcohol withdrawal peak within 2448hours)?2
Current (pre-admission) alcohol use (drinks every day or days off from alcohol use?);
what is his current pattern of use, what time does he usually have his first drink and
how much is his average daily intake (units)? Has there been evidence of narrowing of
drinking repertoire?3
Does she think he has problems controlling onset, levels and termination of use? Does
he crave alcohol? Does he ever drink to blackout? At home, is he secretive with respect
to his alcohol use? Does he drink to the detriment of other interests/activities? Have
there been any medical, psychological or social consequences to him from alcohol use?
Does he continue to drink despite this? Is there evidence of tolerance? Has his wife ever
noted features of alcohol withdrawal?
Does she know how old he was when he first started to drink and when his alcohol use
first started to escalate? Has he had any periods of abstinence or input from Alcoholics
Anonymous?
ADDITIONAL POINTS
1. The primary diagnosis should be severe alcohol withdrawal or alcohol
withdrawal-associated confusional state (delirium tremens) on a
background of alcohol dependence.2 This is a life-threatening condition
associated with convulsions.1 Delirium tremens is characterised by clouding
of sensorium or acute confusional state, tactile disturbances, auditory and
visual hallucinations, agitation and severe tremor.1 Also be vigilant for a
possible diagnosis of Wernickes encephalopathy, characterised by a classic
triad of confusion, ataxia and ophthalmoplegia.4 It is more common than
is usually thought and is frequently missed or undertreated.4 All patients
presenting with severe alcohol withdrawal should always be treated with
parenteral thiamine.1,2
2. For a diagnosis of alcohol dependence (F10.2) according to ICD-10, there
should be evidence of the presence of a cluster of behavioural, cognitive,
and physiological phenomena that develop after repeated substance use
and that typically include a strong desire to take the drug, difficulties in
controlling its use, persisting in its use despite harmful consequences, a
higher priority given to drug use than to other activities and obligations,
increased tolerance, and sometimes a physical withdrawal state.2
234 Chapter 8: Liaison psychiatry
REFERENCES
1. Kosten, T.R. & OConnor, P.G. (2003) Management of drug and alcohol withdrawal.
New England Journal of Medicine, 348, 178695.
2. Taylor, D., Paton, C. & Kerwin, R. (2007) The Maudsley Prescribing Guidelines, 9th edn.
London: Informa Healthcare, p.465.
3. WHO (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines. Geneva: WHO Press.
4. Thomson, A.D., Cook, C.H.C., Touquet, R. & Henry. J.A. (2002) Invited special article:
The Royal College of Physicians Report on Alcohol: Guidelines for managing
Wernickes encephalopathy in the accident and emergency department. Alcohol and
Alcoholism, 37(6), 51321.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 4(b): Alcohol withdrawal Management 235
INSTRUCTION TO CANDIDATE
You have met with Mrs Stuart and later seen the patient. Now, discuss your
findings with the surgical registrar.
You should discuss the likely differential diagnosis and advise them of
further management.
SUGGESTED APPROACH
Setting the scene
Introduce yourself to the surgical registrar: Hello, Dr_____, I am Dr_____, the psychiatrist.
I have seen Mr Stuart he seems confused, as you are aware. Hopefully we can discuss
what is going on and formulate a management plan.
ADDITIONAL POINTS
1. As this is a diagnosis and management station, a helpful structure would be:
Present the likely differential diagnosis (suggest most likely diagnosis
first). Support the differential diagnoses by salient findings gleaned from
the history which you gathered in the first station.
List any further investigations or assessments that had not been done
yet. Discuss the management: acute management should be followed by
Station 4(b): Alcohol withdrawal Management 237
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You are a liaison psychiatrist. The medical team call you to review 86-year-old
Mr Arthur Williams on a medical ward, who is being managed for an infective
exacerbation of chronic obstructive pulmonary disease (COPD). The medical
house officer reports that he has become acutely paranoid and confused,
frequently not knowing where he is. He believes that staff are trying to poison
him and he refuses to eat or drink. The house officer has spoken to the
daughter of Mr Williams and has gathered collateral information.
See Mr Williams and also speak to the house officer and take a relevant
history to arrive at a diagnosis.
You have spoken to his daughter, who has reported that Mr Williams did not have
any memory problems or paranoid symptoms prior to this admission.
Mr Williams is compliant with his medication and his COPD is getting better.
SUGGESTED APPROACH
Setting the scene
Introduce yourself to the patient and to the medical house officer. Begin by explaining
to the patient that you have been asked by the medical team to provide an opinion regard-
ing current difficulties. Given the vignette, you should already be considering possible
organic causes of the presentation, so you may wish to make apparent at this stage that
you will want to ask the patient questions regarding his orientation, as well as review the
history and recent medical management/medications with the house officer. Hello,
Mr_____, I am Dr_____, a psychiatrist. I am here to talk to you and understand your situ-
ation to see if I can be of any help. I will be assessing your memory as well, if that is OK?
ADDITIONAL POINTS
1. ICD-10 defines delirium as an etiologically non-specific syndrome
characterised by concurrent disturbances of consciousness and
attention, perception, thinking, memory, psychomotor behaviour, emotion
240 Chapter 8: Liaison psychiatry
REFERENCES
1. WHO (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines. Geneva: WHO Press.
2. Burns, A., Gallagley, A. & Byrne, J. (2004) Delirium. Journal of Neurology Neurosurgery
and Psychiatry, 75, 3627.
3. Fick, D.M., Agostini, J.V. & Inouye, S. (2002) Delirium superimposed on dementia:
Asystematic review. Journal of the American Geriatrics Society, 50(10), 172332.
4. Taylor, D., Paton, C. & Kerwin. R. (2007) The Maudsley Prescribing Guidelines, 9th edn.
London: Informa Healthcare, p. 465.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are asked to see 30-year-old Mr Andrew Jones, who has become
increasingly anxious and depressed. He recently discovered that his partner
is HIV positive. The man is accompanied by his sister; assume that he has
consented to you discussing his health with her.
Assess the gentleman and finish by explaining to him what you think the
problem is and how you might go about managing it.
SUGGESTED APPROACH
Setting the scene
Introduce yourself to the gentleman and to his sister. Hello, Mr_____, I am Dr_____, a
psychiatrist. I gather that you are going through a tough time right now. Hopefully we
can discuss your difficulties and see how we can help you. Explain that you wanted to
ask him a few questions regarding his health; it may be worth checking again if he is
happy to discuss all matters in front of his sister, given the sensitive nature of the
difficulties.
ADDITIONAL POINTS
Note the difference between an adjustment disorder and an acute stress
reaction, as described in ICD-10.1 To meet the criteria for an acute stress
reaction (F43.0), there should be evidence of exposure to an exceptional
mental or physical stressor, and symptoms should come on within 1 hour
of the stressor.1 Conversely, to meet the criteria for an adjustment disorder
Station 6: Adjustment disorder 243
REFERENCE
1. WHO (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines. Geneva: WHO Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
244 Chapter 8: Liaison psychiatry
INSTRUCTION TO CANDIDATE
Mr John Wright is a 66-year-old man who has been admitted with confusion to
the medical ward. He had been drinking 2L of cider every day and he required
alcohol detoxification. He continues to remain confused, is confabulating
and has ataxia. He has been requesting to take his own discharge. You are
a specialist trainee 6 (ST6) in the liaison psychiatry service and you have
assessed Mr Wright. You have made a diagnosis of Korsakoff syndrome. The
nurse in charge of the ward wants to speak to you about him.
Explain your findings. Address the nurses views, concerns and expectations.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and offer to address any questions the nurse may have. Hello, I am
Dr_____, the psychiatrist. Nice to meet you. I am aware that Mr Wright in your ward is
quite disturbed. I hope we can discuss and think about how to go about managing him.
Be mindful that the nurse could be quite frustrated and may start asking questions or
expressing her anger. Allow her to talk and listen, then address her queries.
ADDITIONAL POINTS
An individual with WernickeKorsakoff syndrome (WKS) is often mentally
confused. This can make patientdoctor communication difficult. A doctor
may overlook the possibility of a physical disorder when dealing with a
confused patient.
Check for signs of alcoholism and conduct a liver function test to check
for liver damage, which is a common sign of alcoholism.
The individual may also appear to be malnourished.
Nutritional tests may include:
Serum albumin test: a blood test that measures the levels of albumin (a
protein) in the blood. Low levels may signal nutritional deficiencies, as
well as kidney or liver problems.
Serum vitamin B1 test: a blood test to check vitamin B1 levels in the
blood.
Transketolase (enzyme) activity in the red blood cells: low enzyme activity
signals a vitamin B1 deficiency.
Diagnostic imaging tests for WKS include:
Electrocardiograph, which looks for abnormalities before and after giving
vitamin B1.
Computed tomography scan to check for brain lesions related
toWernicke's disease (WD).
MRI scan to look for brain changes.
Physicians may also use neuropsychological tests to judge the severity of
mental deficiencies.
FURTHER READING
Alzheimers Society (2007) Dementia UK: A Report into the Prevalence and Cost of Dementia
Prepared by the Personal Social Services Research Unit (PSSRU) at the London School of
Economics and the Institute of Psychiatry at Kings College London, for the Alzheimers
Society.
Kopelman, M.D., Thomson, A.D., Guerrini, I. & Marshall, E.J. (2009) The Korsakoff
syndrome: Clinical aspects, psychology and treatment. Alcohol and Alcoholism, 44,
14854.
Victor, M. & Yakolev, P.I. (1955) S.S. Korsakoffs psychic disorhic disorder in conjunction
with peripheral neuritis; a translation of Korsakoffs original article with comments on the
author and his contribution to clinical medicine. Neurology, 5, 394406.
WHO (2007) WHO Expert Committee on Problems Related to Alcohol Consumption. Geneva:
WHO Press.
Station 7: Korsakoff syndrome Explanation 247
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
248 Chapter 8: Liaison psychiatry
INSTRUCTION TO CANDIDATE
Mr John Smith is a 35-year-old patient known to services with a diagnosis
of schizoaffective disorder for 10 years. He was on a prescription of lithium
1000mg nocte and olanzapine 15mg nocte and had been stable for 2 years.
He showed symptoms of relapse and olanzapine was increased to 20mg
nocte 2 weeks ago. His mental state did not improve and he was admitted to
an acute psychiatric ward 4 days ago. He had been agitated and aggressive on
the ward and had been administered a few doses of haloperidol. Last evening,
he developed a high temperature and became increasingly confused. He was
noted to be stiff and his blood pressure was high. He was seen by the on-call
senior house officer (SHO) and transferred to a medical unit.
The next day, the liaison psychiatry team has received a referral. You are a
specialist trainee 5 (ST5) with the liaison team and you visit the medical ward
to review John. Johns father is waiting to speak to a psychiatrist about his son.
Talk to his father to clarify the situation. Address his concerns, views and
expectations. You are not expected to take a history.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Mr_____, I am Dr_____, the psychiatrist. I am aware of what
is happening with your sons situation. Hopefully I can address your concerns. It is
important to acknowledge the concerns of the angry relative and approach the issue
sensitively.
Why did you use a drug that could cause this condition?
This condition can occur with any anti-psychotic medication that we prescribe and it is
unfortunate that your son had developed this rare side effect.
Conclusion
Assure the relative that you are doing everything you can to ensure the safety of the
patient. Assure them that you can give them details of the trust complaints procedure
should they wish to complain.
ADDITIONAL POINTS
Cardinal features of neuroleptic malignant syndrome are as follows:
Severe muscular rigidity
Hyperthermia (temperature >38C)
Autonomic instability
Changes in the level of consciousness
Clinical features of neuroleptic malignant syndrome include:
Muscular rigidity (typically lead pipe rigidity)
Hyperthermia (temperature >38C)
Diaphoresis
Pallor
Dysphagia
Dyspnoea
Tremor
Incontinence
Shuffling gait
Psychomotor agitation
Delirium progressing to lethargy, stupor or coma
Station 8: Neuroleptic malignant syndrome 251
Risk factors
Risk factors that may predispose patients to developing NMS include male
sex, learning disability, iron deficiency, high ambient temperature, depot
anti-psychotic injections, alcoholism, exhaustion and dehydration. Any recent
changes to anti-psychotic medication (including abrupt increases or decreases
in dose) can precipitate NMS.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 9 David Okai
LINKED STATIONS
INSTRUCTION TO CANDIDATE
A 21-year-old university student, Miss Lara Tracey, has been referred to your service
with bouts of depression lasting a few weeks at a time. She takes mirtazapine and has
reported no change in her depressive symptoms. You have inherited this patient from
your predecessors out-patient clinic.
Take a history of her mood and find out more about her symptoms.
DO NOT PERFORM A PHYSICAL EXAMINATION.
SUGGESTED APPROACH
Setting the scene
Begin by addressing the patient by name and introducing yourself. Explain your under-
standing of the current problem from reading the notes.
Hello, Ms Tracey, I am Dr_____, the psychiatrist who has taken over from Dr_____. I
understand that things have been difficult for you for some time, that you have had
problems with low mood and that the antidepressants appear to have had little effect. Is
that correct?
254 Chapter 9: General adult psychiatry
Given that we have not met before, and as part of the process of getting to know you/
understand what you have been through, would you mind if we covered some aspects of
the history again?
Depression history
The core features of depression (low mood, anergia and anhedonia) along with additional
symptoms that indicate the level of severity (ICD-10 DCR) should be explored. Given that
the patient has been unresponsive to therapy, it is important to explore medication his-
tory and medical history and briefly look for the presence of comorbidities. In particular,
ask about anxiety disorders, alcohol, suicidal ideation and personality difficulties.
Please tell me the problems you have been having with your mood and when it all started.
What symptoms trouble you most? How have your energy levels been? What sort of things
do you enjoy?
Hypomania history
The candidate may gain marks for delineating a clear history with an exploration of
potential triggers. Additionally, the shifts in mood should be explored. They should ask
about physical health contributions, including thyroid disease, antidepressant-induced
switching and erratic sleep patterns.
Sometime people who suffer from low mood can also notice that they have periods
where they feel the opposite, an improvement in their mood, with increased levels of
energy, so they feel like they could do almost anything. Tell me more about those
periods.
FURTHER READING
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental
Disorders, 5th edn. Washington, DC: American Psychiatric Association.
Cooper, J.E. (1994) Pocket Guide to the ICD-10 Classification of Mental and Behavioural
Disorders: With Glossary and Diagnostic Criteria for Research: ICD-10/DCR-10. London:
Churchill Livingstone.
National Institute for Health and Clinical Excellence (2006) Bipolar Disorder: The
Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and
Secondary Care. NICE Clinical Guideline 38 (Update Clinical Guideline 185, 2014). http://
www.nice.org.uk/guidance/cg185?unlid=373313324201622816295
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
256 Chapter 9: General adult psychiatry
INSTRUCTION TO CANDIDATE
You decide from your history that the patient has bipolar II and is a rapid cycler
with several cases of depression each year. She has previously unobserved
episodes of hypomania and is currently hypomanic. The duration and the
severity of each hypomanic phase are increasing with each relapse, but she
does not yet fulfil the criteria for mania.
The patient says she would be willing to try any medications to stop the
frequency of her depressive episodes.
As you are new to the job, your consultant reviews the case with you, asks
what examination you did in clinic and asks how you are going to manage
the condition.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Dr_____, I am Dr_____. I have assessed Ms Tracey and wonder
if I can briefly discuss with you. You should be mindful that you are discussing with a
senior colleague, so you can use technical terms and psychiatric terminology to explain
your findings. Be systematic in presentation and summarise at the end.
Investigations
I would like to take some time to review the notes and perform a full history and physical
examination. I also need to perform a full blood screen (including thyroid function) and
urine drug screen. I would consider some form of brain imaging (computed tomography
or magnetic resonance imaging) if this has not been done already. I would also seek col-
lateral/informant history.
I would consider a rating scale (such as the Young Mania Rating Scale) given the variation
of her symptoms, allowing for a more accurate recording of fluctuation and perhaps
identifying a pattern (including any potential triggers).
Treatment
I would want to withdraw the antidepressant in the first instance. It may be appropriate
to observe for a period as this in itself may restore the balance in mood, but I would want
to see her again in out-patient or follow up by phone in 12 weeks to see if there was any
evidence of her symptoms worsening. My preferred setting would be regular out-patient
reviews, although this may change if she starts to present with any risks as a result of her
mental state, alongside other factors such as home environment and any others risks
brought up by the collateral.
If this period of watchful waiting/observation showed no improvement or a potential
worsening of symptoms, I would want to initiate an anti-psychotic with proven efficacy
in mania such as olanzapine or quetiapine that also have an evidence base for relapse
prevention.
Medium and long term, I would also consider a mood stabiliser, if necessary. I would put
to her the option of lithium or valproate. I would want to discuss the implications of both
choices with her, especially as she is of childbearing age. I would want to emphasise the
risk of relapse if she is poorly compliant with her medication.
Psychological therapies
Psychological work might include psycho-education, stressing the need to maintain
adherence to medication (especially in rapid cycling). She warrants a referral for cognitive
behavioural therapy, although NICE outlines a range of psycho-social interventions which
have a range of benefits in the form of medication adherence, help with the identification
of triggers, treatment of mood symptoms (in particular her depression) and help with
stress and lifestyle management.
As part of her care agreement, I would want her characteristic symptoms of depression
or hypomania documented alongside the early intervention strategies the patient and
our treatment should implement when faced by these symptoms.
From the social point of view, I would check whether she is driving, given her mood
symptoms and the likely start of further psychotropics. It would be useful to contact the
university, which can often provide some psychological support and help if she has prob-
lems with exams.
ADDITIONAL POINTS
Whilst rapid cycling has been a topic of debate over the years, there is
insufficient evidence to suggest that the treatment strategy should be
any different from any other form of bipolar, at least in the earlier stages.
258 Chapter 9: General adult psychiatry
FURTHER READING
BALANCE Investigators (2010) Lithium plus valproate combination therapy versus
monotherapy for relapse prevention in bipolar I disorder (BALANCE): A randomised
open-label trial. The Lancet, 375(9712), 38595.
Fountoulakis, K.N. (2010) The BALANCE trial. The Lancet, 375(9723), 13434.
Macritchie, K., Geddes, J., Scott, J., Haslam, D.R. & Goodwin, G. (2001) Valproic acid,
valproate and divalproex in the maintenance treatment of bipolar disorder. The Cochrane
Database of Systematic Reviews (3), CD003196.
National Institute for Health and Clinical Excellence (2006) Bipolar Disorder: The
Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and
Secondary Care. NICE Clinical Guideline 38 (Update Clinical Guideline 185, 2014). http://
www.nice.org.uk/guidance/cg185?unlid=373313324201622816295
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn, London: Wiley-Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are asked to see a patient, Mrs Johnston, for a second opinion by a more
junior colleague. She has a long-standing history of low mood and several
admissions with suicidal thoughts and plans. She is currently prescribed
amitriptyline.
Take a history of her mood symptoms and explore her previous psychiatric
history.
SUGGESTED APPROACH
Setting the scene
Begin the task by introducing yourself and explaining the purpose of the assessment.
Hello Ms. Johnston, I am Dr_____, I am a colleague of your usual psychiatrist who asked
for a review given your depressive symptoms. On some occasions when a patient is not
260 Chapter 9: General adult psychiatry
getting better with the usual treatments, it is not uncommon to ask for a second opinion
by another member of the team to see if there is more that can be done.
Risks
Have you thought about harming yourself recently? Have you gone so far as to think
about how you might do that? What thoughts have stopped you so far?
Problem solving
Some candidates may fail to identify this as a case of atypical depression. It is a somewhat
controversial diagnosis with some suggesting that it is associated with increased distress,
suicidal ideation and disability compared with typical depression. Despite this, they
should be able to highlight the psycho-social stressors that are having an impact on her
mood. The differential includes dysthymia and mixed anxiety and depressive disorder.
One should make an effort to exclude these as possibilities.
ADDITIONAL POINTS
A common failing in this situation is that candidates are unclear of the
symptoms for differentiating moderate from major depression. For a clear
Station 2(a): Depression 261
understanding of this, refer to the ICD-10 diagnostic criteria. Suicidal acts are
almost always associated with severe depression.
The candidate will gain extra marks for taking the history in a structured
way. However, they should not be afraid to further explore the information
provided by the patient, as a simple tick-list approach to symptoms will not be
rewarded.
FURTHER READING
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental
Disorders. 5th edn. Washington, DC: American Psychiatric Association.
Brown, G.W. & Harris, T.O. (eds.) (1978) Social origins of depression. In: A Study of
Psychiatric Disorder in Women, 5th edn. London: Routledge.
Brown, G.W., Harris, T.O. & Hepworth, C. (1995) Loss, humiliation and entrapment among
women developing depression: A patient and non-patient comparison. Psychological
Medicine, 25, 721.
Kendler, K.S., Hettema, J.M., Butera, F., Gardner, C.O. & Prescott, C.A. (2003) Life
event dimensions of loss, humiliation, entrapment, and danger in the prediction of
onsets of major depression and generalized anxiety. Archives of General Psychiatry, 60,
78996.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
The lady you have just seen is depressed with an atypical depression. She has
symptoms of variability of mood, tension, overeating, oversleeping and fatigue.
She has also expressed further recent thoughts of self-harm. She lost her job
as due to depression she was struggling to cope. She has a partner who is
not supportive and drinks heavily. He has been both verbally and physically
abusive in the past.
She has had recent thoughts of self-harm, but no clear plans as to how she
might do this.
You meet with your junior colleague. Give your advice on managing Mrs
Johnstons condition. Try to gather more appropriate information.
SUGGESTED APPROACH
Setting the scene
Introduce yourself; remember this can be informal as he is your colleague. Hello, glad
we can catch up, let us discuss this patient Mrs Johnston and think about how we can go
ahead.
Station 2(b): Depression Discussion with colleague 263
Treatment
I note this lady is on amitriptyline. I would want to know the reasons for such a choice.
I would then want to explore if it had been of benefit. It does have sedative properties and
may not be the treatment of choice as she is sleeping more than usual and has ideas of
self-harm, which might include overdosing.
The social interventions in this individual will be of particular importance. I would want
to contact childrens social services to clarify the risk to the children and discuss the need
for a safeguarded alert if this had not already been done. I would refer her to an adult
social worker within our team to look into her current financial situation and ensure her
basic needs are being met (e.g. is she on benefits? Does she have any money?). She may
need a review of her housing. She may also need a referral to other services such as
RELATE if she requires support for her marriage.
ADDITIONAL POINTS
Making reference to Barbui and Hotopfs (2001) meta-analysis indicating
the possibility of increased effectiveness of amitriptyline in comparison
to alternative antidepressants, despite its lower level of tolerability, is
impressive.
NICE suggests a selective serotonin reuptake inhibitor (SSRI) should be used
for all types of depression in the first instance. That said, whilst monoamine
oxidase inhibitors have largely fallen out of favour, the candidate may wish to
indicate their knowledge of the literature by suggesting that they may have
some efficacy in atypical depression.
The diagnosis of atypical depression, however, remains controversial. There
should be a balanced approach as she has symptoms that are consistent with
atypical depression and there should be awareness that understanding of this
condition and treatment implications are works in progress.
264 Chapter 9: General adult psychiatry
FURTHER READING
Barbui, C. & Hotopf, M. (2001) Amitriptyline vs the rest: Still the leading antidepressant
after 40 years of randomised controlled trials. British Journal of Psychiatry, 178, 12944.
Stewart, J.W., Tricamo, E., McGrath, P.J. & Quitkin, F.M. (1997) Prophylactic efficacy of
phenelzine and imipramine in chronic atypical depression: Likelihood of recurrence on
discontinuation after 6 months remission. American Journal of Psychiatry, 154, 316.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
An 18-year-old university student is referred for assessment by his GP. The
patient is perplexed, frightened and expresses ideas of persecution. He is
keen to be admitted to hospital. He has no previous psychiatric history.
Station 3(a): First onset psychosis 265
Your consultant catches you before you see the patient. She wants to
discuss your thoughts on the differential diagnosis and how you intend to
proceed over the next 48 hours.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Dr_____, glad we can meet beforehand to discuss this referral.
I gather from the GP letter I am about to see an 18-year-old student who is paranoid.
Differential diagnosis
Consultant: I just wanted to brainstorm with you what sort of differentials you have in
mind for this patient.
C: In terms of Foulds hierarchy, I would consider:
Drug-induced psychosis he could be in a state of intoxication or withdrawal.
Organic illness, including neurological disorders; this includes brain tumour, temporal
lobe epilepsy and autoimmune conditions causing vasculitis in the brain.
A pre-psychotic state or prodrome of psychosis, a full-blown psychotic episode or a
transient psychotic experience.
Schizoaffective state if there are affective symptoms alongside.
Manic episode with psychotic symptoms.
A depressive episode with psychotic features.
An anxiety disorder due to the clear high levels of distress.
Personality disorder (e.g. schizotypal or paranoid).
Investigations
I would want to investigate for important comorbidities such as substance misuse. Physical
investigations would include a full blood screen including glucose, liver, thyroid function
and lipids. I would also want baseline physical observations. There is an increasing trend
to consider screening for NMDA auto-antibodies if there is anything atypical about the
266 Chapter 9: General adult psychiatry
presentation e.g. movement disorders, evidence of seizures etc In line with NICE guid-
ance, I would arrange brain imaging such as a CT head or MRI.
Treatment
If however, he has clear-cut first rank symptoms and these psychotic experiences have been
present for some time, or he is significantly distressed, I would start an anti-psychotic imme-
diately. I would also bear in mind (although this would not delay instigation of treatment)
that both ICD-10 and DSM-IV require a 4-week history of symptoms to diagnose schizo-
phrenia (this is important regarding what we tell him of his diagnosis). I would consider the
prescription of a benzodiazepine to alleviate any significant distress or anxiety.
Consultant: Would you consider admitting him to hospital if he wants to?
C: From the brief description outlined by the GP, there is nothing that would indicate to
me a need for an admission currently, so I would want to explore the reasons for why he
is asking for a hospital bed. The types of risks I would bear in mind would be:
Those that pose a risk to self or others, including challenging or unpredictable behaviour
Risks associated with his high level of distress
Wider risks such as:
Lack of engagement at this important first stage
Damage to his social network and reputation, which may worsen with untreated
psychosis
Labelling as schizophrenic at too early a stage.
ADDITIONAL POINTS
It is good to have an awareness of the National Service Framework and its
suggestion of the need for early intervention and treatment to reduce levels of
morbidity.
The first point of contact with mental health services is important, as it
may influence engagement and counter the individuals and their relatives
prejudices and issues of stigma. This should be reflected throughout the
management of this scenario.
Essentially, the candidate should deal with two main issues in the acute
setting: treating the psychotic symptoms, treating factors associated with their
development (including consideration of treatment setting) and wider issues
relevant to their onset.
FURTHER READING
Department of Health (1999) A National Service Framework for Mental Health: Modern
Standards and Service Models. London: Department of Health.
Foulds, G.A. & Bedford, A. (1975) Hierarchy of classes of personal illness. Psychological
Medicine, 5(2), 18192.
Marshall, M. & Rathbone, J. 2006. Early intervention for psychosis. Cochrane Database of
Systematic Reviews (3), CD004718.
National Institute of Clinical Excellence (2002, updated 2010) Schizophrenia: Core
Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary
Care. London: NICE.
Station 3(b): First onset psychosis Discussion with relative 267
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have assessed the patient and you decide that the patient has symptoms
that are consistent with first onset psychosis. The patients mother, Mrs Giles,
turns up and asks what is going on. She saw a programme on bipolar disorder
the other day and wonders if this is what her son has. She wants to know what
the management plan is and if he will be able to go back to university (she
comments that he has been struggling for the last year he used to be top of
the class but has had no evidence of a frank psychosis until now). If not, she
wonders whether she should take him home. She has also heard of early-
onset services, and wonders whether this is a suitable service and what other
options may be available.
The patient has said he is happy for you to speak to his mother alone. Speak
to her and address her concerns.
268 Chapter 9: General adult psychiatry
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain the purpose of the meeting. Hello, Mrs Giles, I am
Dr_____, I have seen and spoken with your son, who has given permission to talk about
what we think is going on. How can I help you?
Try to clarify any concerns then address any negative stereotypes/fears of mental illness
(and services).
Explaining cause
Mother: Why has he got this illness?
C: We know one of the natural chemicals in the brain called dopamine is released in larger
quantities for those who suffer from this condition. This chemical is linked with
Station 3(b): First onset psychosis Discussion with relative 269
importance and learning. One theory behind the development of schizophrenia is that
too much of this chemical leads to too great an emphasis or meaning in relatively normal
events. The patient, like your son, starts off feeling the effects of dopamine, and starts to
suspect something is wrong. They may look preoccupied (or perplexed as we call it), just
like your son does. As the levels of this dopamine increase, they suddenly have a clearer
idea of what was so important. For example, an entirely random event such as someone
looking at them on the street may suddenly be taken to mean that the government has
sent that person (or MI5) to spy on them.
Explaining treatment
Anti-psychotics reduce the action of this natural chemical in the brain, and therefore
weaken the delusions and hallucination experience. It does not necessarily cure the con-
dition, but controls symptoms in the same way a blood pressure tablet controls hyperten-
sion. They work best when taken regularly.
Psychological therapies can also help, including cognitive behavioural therapy to identify
triggers to illness and ways of coping with them. Family therapy can also help your son
and yourselves cope better with the illness.
ADDITIONAL POINTS
Explore their viewpoint on what might have contributed to this current
state. Use predisposing, precipitating and maintaining factors rather
than discussion on a purely biological basis. A blame-free approach is
particularly important.
Address practical issues such as what home life is like and whether in
this situation it would be appropriate to send this patient home provide
an adequate exploration of the risks.
FURTHER READING
Kapur, S. & Mamo, D. (2003) Half a century of antipsychotics and still a central role for
dopamine D2 receptors. Progress in Neuro-Psychopharmacology and Biological Psychiatry,
27(7), 108190.
Reichenberg, A., Weiser, M., Rabinowitz, J. & Caspi, A. (2002) A population-based cohort
study of premorbid intellectual, language, and behavioral functioning in patients with
schizophrenia, schizoaffective disorder, and nonpsychotic bipolar disorder. The American
Journal of Psychiatry, 159(12), 202735.
270 Chapter 9: General adult psychiatry
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are on your lunch break when you are called to your general adult
psychiatry ward urgently. A new patient admission, Mr Clancy, has become
extremely agitated and has assaulted a member of staff. He is holding a
dinner fork in his hand and is shouting about the CIA coming to get him.
The patient has been escorted back to his bedroom. You enter the room with
the restraint team. Perform a mental state examination.
Station 4(a): Rapid tranquilisation 271
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Mr Clancy, I am Dr_____, the psychiatrist. The patient will be
agitated, rude and shouting; it is important to remain calm under pressure and be professional
at all times. Talk clearly and slowly and explain why you have come to see him. I hear that
things are not going very well for you right now, can you tell me what is bothering you?
still upset I would be inclined to suggest another tablet to help calm you down and
reduce the stress that the thoughts of the CIA are giving you. I hope you are not offended
by this, but it is a question I ask everyone: have you taken any illicit drugs prior to coming
on the ward? A final question: the nurse you hit is actually quite hurt currently. What are
your thoughts on that? Remind me, do you have any problems with your physical health?
Any problems with your heart or breathing problems? Have you had a particularly bad
reaction to any previous psychiatric medications?
ADDITIONAL POINTS
In the unlikely event that the patient becomes unmanageable, the candidate
should terminate the interview to allow for restraint and rapid tranquilisation.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 4(b): Rapid tranquilisation Discussion with nurse 273
INSTRUCTION TO CANDIDATE
The patient has now handed the fork over and has taken a single dose of
lorazepam 1mg orally.
He is still pacing the room restlessly, muttering to himself. He has punched
the wall on one occasion.
Speak to the nurse in charge about further management.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Sister, I am Dr_____, the psychiatrist. I know things have been
very difficult on the ward and you are concerned. Let us have a discussion on how to go
about this further. If the nurse interrupts with anger or asks questions, listen to and
acknowledge her. Try to address the worry that she expresses.
Medical treatment
We need to give some time for the lorazepam to take effect. If he is still agitated after 45
minutes, I think he should have a further dose of 12mg, depending on how successful
274 Chapter 9: General adult psychiatry
the current dose has been at reducing his agitation. Ideally, we would offer this to him
orally, but it should be given intramuscularly if there is no alternative. Can we check we
have stocks of flumazenil on the ward? We need to be careful that he hasnt taken other
illicit substances.
Is there a nurse who knows him well who might be able to encourage him to take some-
thing orally?
If he is still not settled and needs further treatment, I would prefer to use a single anti-
psychotic if possible. We are not sure that he has been taking his risperidone regularly in
the community, and he complained of some side effects as well.
I would be inclined to switch it to olanzapine, which has a reasonable proven efficacy in
disturbed patients. For the time being, shall we use the orodispersible Velotab to ensure he
is taking it, at a dose of 10mg if he is agitated. This can also be given intramuscularly if he
refuses oral medication to a maximum dose of 20mg in 24 hours. Remember, it cannot be
given within an hour of lorazepam, as it will increase the risk of respiratory distress.
He will need ongoing regular monitoring of levels of alertness (GCS), blood pressure,
pulse, temperature and respiratory rate if possible. If he is not cooperative, we will need
the nurse to document what observations she is able to carry out.
Psychological treatment
I think we need to allocate a regular time for interaction with his named nurse on the
ward say hourly in the first instance to build up a rapport, if possible, and to monitor
any levels or agitation or distress. If they have any concerns, they should contact me. We
will discuss his care regularly during the day.
Social treatment
I think we should give him a period of time out in his room until he calms down, and
he should currently be placed on within eyesight levels of observations. This needs to
be done carefully so as not to increase his levels of paranoia.
If he has a good relationship with his family, I think we might need to enlist their help
in calming him down. They certainly need to be told if we are using restraint and rapid
tranquilisation measures.
I will go back in and tell him the current plan. Can I take two nurses with me?
We will also need to tell the ward consultant that this has happened. They might want
to discuss the case with psychiatric intensive care, just so that they are aware that this
patient might potentially need a transfer.
I think we need to complete an incident form or Datix as well.
If all else fails, we may need to consider intravenous diazepam or a dose of zuclopenthixol
acetate (Acuphase) intramuscularly, or transfer to a psychiatric intensive care unit, but
lets see how he responds to the current treatment plan. I will discuss these with my
consultant if he is not improving.
The nurse who was assaulted should not return to the ward for the time being whilst the
patient remains an in-patient and a risk. I would speak to the ward manager about ensur-
ing that she goes to see occupational health. Additionally, we will need to think about
arranging a suitable time for a ward debrief with any of the nurses who wish to attend.
Finally, each of the patients should have some time with their key worker to see if they
were upset by the situation.
Station 4(b): Rapid tranquilisation Discussion with nurse 275
ADDITIONAL POINTS
There is some conflation in the literature of the studies of rapid tranquilisation
and how they relate to clinical practice. Most used a single psychotropic and
most patients were given their medications orally. Most relevant to the day-
to-day clinical scenario were the Tranquilizao Rpida-Ensaio Clnico (TREC
Rapid Tranquillisation-Clinical Trial) studies performed in Brazil and India, which
tested the effectiveness of parenteral treatments.
FURTHER READING
Alexander, J., Tharyan, P., Adams, C., John, T., Mol, C. & Philip, J. (2004) Rapid tranquillisa-
tion of violent or agitated patients in a psychiatric emergency setting. Pragmatic ran-
domised trial of intramuscular lorazepam v. haloperidol plus promethazine. The British
Journal of Psychiatry, 185(1), 639.
Huf, G., Coutinho, E.S. & Adams, C.E. (2002) TREC-Rio trial: A randomised controlled trial
for rapid tranquillisation for agitated patients in emergency psychiatric rooms. BMC
Psychiatry, 2(1), 11.
National Institute for Health and Care Excellence (NICE) (2015) NG10: Violence and
Aggression: Short Term Management in Mental Health, Health and Community Setting.
https://www.nice.org.uk/guidance/NG10
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. London: Wiley-Blackwell.
TREC Collaborative Group (2003) Rapid tranquillisation for agitated patients in emergency
psychiatric rooms: A randomised trial of midazolam versus haloperidol plus promethazine.
BMJ, 327(7417), 70813.
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SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You are seeing in your out-patient clinic a 50-year-old lady, Ms Gibson, who called
you 3 days after stopping her paroxetine. She thinks she is relapsing as she is
feeling increasingly anxious and nauseous. She wants to know if this is normal.
Assess her symptoms and explain how you are going to manage them.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain the purpose of the meeting: Hello, Ms_____, IamDr_____,
the psychiatrist. I understand you are feeling unwell after you stopped your psychiatric
medication. I hope we will be able to discuss this and find a solution to yourproblems.
Station 5: SSRI discontinuation syndrome 277
Management
Management should start with psycho-education, including a collaborative discussion
on a time frame for discontinuing a medication. It is worthwhile normalising the process
to an extent, indicating that paroxetine is one of the most well-known medications for
this condition and that, whilst these symptoms can happen while on any antidepressant
to some extent, her symptoms are significant enough that we would want to act on them.
There should be brief discussion about alternative therapies, such as cognitive behavioural
therapy, if she relapses and no longer wants tablets.
There should be some exploration of the differentials, including neuroleptic malignant
syndrome.
We normally recommend that you only stop your medication after discussion with our
team or your GP, ordinarily over a 4-week period.
I am not sure what you were told previously, as it is true that antidepressants are not
addictive; for instance, they are not like the benzodiazepine tablets that used to be used
so readily several years ago, and needed increased doses over time in order to have the
same effect. Paroxetine is generally maintained on the same dose.
Like all medications (even physical health medications like blood pressure tablets), one
should never stop them suddenly, as this can cause problems.
If you are happy with this, in order to manage these symptoms, I would be inclined to
restart you back onto your full dose, let you settle for about a week, then slowly taper off
the dose by 5mg per week until completely discontinued.
It is important to watch to see if thoughts of self-harm start to increase, and to let us
know immediately if this is the case.
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INSTRUCTION TO CANDIDATE
Mr Chan is a 30-year-old male with an established diagnosis of paranoid
schizophrenia who has tried two anti-psychotics for 6 months each. He is still
troubled by distressing persecutory delusions and auditory hallucinations.
Discuss ongoing management with him.
SUGGESTED APPROACH
Setting the scene
As always, begin the task by introducing yourself: Hello, Mr Chan, I am Dr_____, the
psychiatrist. Acknowledge your understanding of his current problem: I gather you are
troubled by hearing voices and are feeling unwell. Let us talk about this.
Patient requirements
There are a number of things we would need to do before starting treatment. The first
thing would be a blood test, including measurement of the cells that fight infection your
white blood cells and those that measure your blood sugar (glucose) and natural fat (or
lipid) levels. We would need to weigh you and also measure the function of your heart
using a heart trace machine called an electrocardiogram or ECG.
On the day that you start, you will need to come to the clinic in the morning and take a
tablet. We will observe you for a period to see if you tolerate it. On the second day, we
would repeat this, but give you a tablet to take home. We can then arrange for people to
come and visit you at home in order to monitor you physically as we increase the dose.
They will see you daily for the first 2 weeks.
We will wean you off the olanzapine that you are taking now. After 2 weeks, we would
start to decrease your olanzapine and would decrease this by 5mg every 2 weeks until
you were off it.
The one thing I would say is that if you are not confident that you will be able to take
these tablets regularly, we would need to think of another way to manage your illness.
Stopping the tablets suddenly puts you at high risk of a relapse.
FURTHER READING
Royal Pharmaceutical Society of Great Britain (2015) British National Formulary 70.
London: Royal Pharmaceutical Society.
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. London: Wiley-Blackwell.
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INSTRUCTIONS TO CANDIDATE
You are seeing Mark, a 32-year-old man who has been referred by his GP for
anxiety and lack of sleep. He has stopped working recently and is worried
about his future.
Speak to Mark and elicit the history of his symptoms with a diagnostic
approach.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introduce yourself. Acknowledge
that they may be anxious to see the psychiatrist and explain the purpose of your assess-
ment: Hello, Mark, I am Dr______, a trainee psychiatrist. I understand you have been
going through a tough time. I am here to understand your difficulties and see if we can
help you manage them.
Allow the patient to tell you what their understanding of this appointment is. As he is
experiencing anxiety already, he may be reluctant to freely explain the symptoms and
will need some encouragement.
282 Chapter 9: General adult psychiatry
Elaborate on history
Begin the interview using the information given by the GP: I see you have been experi-
encing anxiety/nervousness. Can you tell how this started? Ask about the chronology of
events: How long has this been affecting you? When did this begin? Have there been any
changes in your condition over these few months? How has this affected your life?
The most characteristic symptoms of PTSD are re-experiencing symptoms. PTSD sufferers
involuntarily re-experience aspects of the traumatic event in a very vivid and distressing
way. This includes flashbacks in which the person acts or feels as if the event were recur-
ring, nightmares and repetitive and distressing intrusive images or other sensory impres-
sions from the event. Reminders of the traumatic event arouse intense distress and/or
physiological reactions. Ask about such symptoms in a sensitive manner, as talking about
them can make the person uncomfortable. Have there been any instances where you felt
as if you were reliving that terrible moment again? When do you experience this? How
often does this happen? Can you describe how you feel during those times?
Avoidance of reminders of the trauma is another core symptom of PTSD. This includes
people, situations or circumstances resembling or associated with the event. PTSD sufferers
often try to push memories of the event out of their mind and avoid thinking or talking
about it in detail, particularly about its worst moments. On the other hand, many ruminate
excessively about questions that prevent them from coming to terms with the event; for
example, about why the event happened to them, how it could have been prevented or
how they could take revenge. Explore these symptoms in a gentle manner by asking, for
example, You have been through such traumatic events lately, I can imagine how difficult
it must have been for you. How do you cope in situations when you are reminded of that
accident? How has your life changed following this event?
People with PTSD experience symptoms of hyperarousal, including hypervigilance for threat,
exaggerated startle responses, irritability, difficulty concentrating and sleep problems. On
the other hand, PTSD sufferers also describe symptoms of emotional numbing. These include
an inability to have any feelings, feeling detached from other people, giving up previously
significant activities and amnesia for significant parts of the event. You can explore such
symptoms by asking questions like, Do you find yourself to be excessively sensitive to what
goes on around you? Are you getting startled by things that normally wouldnt surprise you
that much? Have your feelings/emotions towards others changed? Do you think your per-
sonality has changed in the recent months? If so, how have they changed?
Many PTSD sufferers experience other associated symptoms, including depression, gen-
eralised anxiety, shame, guilt and reduced libido, which contribute to their distress and
impact on their functioning, all of which need to be briefly explored. Ask about any
relationship difficulties or financial difficulties that may have ensued from his anxiety.
At the end, briefly rule out other anxiety disorders such as generalised anxiety disorder
(free-floating anxiety), panic disorder (frequent and regular panic attacks with no obvious
triggers) and depression. Do a risk assessment, mainly to consider any suicidal tendencies
and use of alcohol as a coping mechanism.
Station 7: Post-traumatic stress disorder 283
Conclusion
Here you can summarise what you have assessed, any information you may need and
what the next steps will be:
Mark, from what we talked about today, I gather you have been feeling increasingly
anxious since you met with an accident 8 months ago. You have been experiencing periods
where you are almost reliving the incident again and again. You therefore have been
avoiding the route, now you started to avoid driving and it looks like this has been sig-
nificantly affecting your activities of living and your emotions. I think you may be expe-
riencing post-traumatic stress disorder. Most people when faced with severe trauma get
over such experiences in time. In some people, though, traumatic experiences set off a
reaction that can last for many months or years. This is called post-traumatic stress dis-
order, or PTSD for short. We shall meet again to discuss the possible options to manage
your condition. This will include talking therapies and medications. In the meantime,
can I recommend to you some self-help books for you to consider?
FURTHER READING
American Psychiatric Association Steering Committee (2010) Practice guideline for the
treatment of patients with acute stress disorder and posttraumatic stress disorder. www.
psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutes
tressdisorderptsd.pdf
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstressdisorder.
aspx
Post-Traumatic Stress Disorder: Management. NICE Guidelines (CG26). Published date:
March 2005. https://www.nice.org.uk/guidance/cg26?unlid=388938798201641794355
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Chapter 10
Neuropsychiatry Derek Tracy
LINKED STATIONS
INSTRUCTION TO CANDIDATE
An orthopaedic specialty trainee, Dr Arun, wants to discuss one of his
in-patients who was admitted 10days ago following a serious road traffic
accident. The patient underwent external fixation of fractures in both femurs
and required suturing for multiple superficial injuries.
Over the past few days, this 40-year-old man has been behaving strangely
on the ward; for example, trying to climb out of his bed and walk despite his
leg injuries and nursing requests to remain in bed. Your colleague advises you
that all blood tests have been within normal limits for several days, though a
magnetic resonance imaging (MRI) scan of the patients head taken yesterday
shows frontal lobe contusions.
Dr Arun would like your opinion on what might, from a neuropsychiatric point of
view, be causing this behaviour, and advice on management.
Discuss the differential diagnoses you are considering and how you might
confirm or refute these. In general terms, discuss the treatment options
available.
SUGGESTED APPROACH
Setting the scene
Thank you for referring this very interesting patient, Dr Arun; Im Dr_____, the neuro-
psychiatry specialty doctor. Id like to clarify some issues you previously mentioned.
Considering management
Management will depend upon identifying the cause of the behaviour; for example,
rectifying electrolyte imbalances, treating alcohol withdrawal and reducing (where prac-
ticable) opiate analgesia.
Environmental management of a distressed or confused patient should not be under-
estimated and simple measures such as ensuring adequate lighting and provision of
location and time cues (e.g. a board with the ward name, day and date) can be
invaluable.
Station 1(a): Assessment of a head injury 287
Sedation could be considered, taking into account the fact that additional medications may
in fact worsen confusion. Options might include a benzodiazepine such as lorazepam. Of
course, should a mental illness be identified, this would need to be treated appropriately.
ADDITIONAL POINTS
1. An understanding of the potential for drugs (whether illicit, legal but
potentially harmful, such as alcohol, or prescribed) to cause confusion is
essential. It would look professional and structured to delineate drugs into
the categories above and to display awareness of how both initiation and
withdrawal from many substances can alter the mental state. Drugs to
specifically enquire about include alcohol, opiates and benzodiazepines.
2. Management of confused hospital in-patients is a common neuropsychiatric
problem. Medication is frequently less helpful than clear communication
with the patient and staff. The introduction of simple procedures, such as
ensuring staff always identify themselves to the patient and environmental
cues such as good lighting, can be hugely helpful.
FURTHER READING
David, A.S., Fleminger, S., Kopelman, M.D., Lovestone, S. & Mellers, J.D.C. (2012)
Lishmans Organic Psychiatry: A Textbook of Neuropsychiatry. 4th edn. Hoboken, NJ:
Wiley-Blackwell.
Fleminger, S., Greenwood, R.R.J. & Oliver, D.L. (2006) Prescription drug use for managing
agitation and aggression in people with acquired brain injury. Cochrane Database of
Systematic Reviews. http://www.cochrane.org/CD003299/INJ_prescription-drug
-use-for-managing-agitation-and-aggression-in-people-with-acquired-brain-injury
Levin, H.S. & Diaz-Arrastia, R.R. (2015) Diagnosis, prognosis, and clinical management of
mild traumatic brain injury. Lancet Neurology, 14(5), 50617.
Reis, C., Wang, Y., Akyol, O. etal. (2015) Whats new in traumatic brain injury: Update on
tracking, monitoring and treatment. International Journal of Molecular Sciences, 16, 1190365.
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INSTRUCTION TO CANDIDATE
The orthopaedic specialty trainee is grateful for your advice, although he
admits that he is not confident he has given an adequate history and requests
a review of this 40-year-old man. You are given the most recent set of blood
tests, which include FBC, U&Es and LFTs all of which are normal and a
copy of the radiologists report, noting frontal lobe contusions on his MRI scan.
The patient says that he cannot recall much about the accident but believes
his memory since his operations has been fine, which is corroborated by
the nursing staff. He felt well in himself in the preceding weeks: he denies
ever suffering from any mental health problems, describing himself as a
chirpy, happy sort of guy. He denies illicit drug use and says he rarely drinks
alcohol.
He admits that his mother has said he has been acting a bit weird since
the accident she complained that he cursed frequently and told sexually
explicit jokes in her presence, something she says he would never normally do.
The only change he has noticed is that he cannot operate his mobile phone
properly because there are too many buttons and controls to work out.
In light of the neuroimaging results and the patients comments, assess the
relevant cognitive domains. Explain your findings to the patient, Keith.
SUGGESTED APPROACH
Setting the scene
Thank you for seeing me, Keith. Im sorry to hear about the accident. It seems as if you
may be having some difficulties that you didnt have before; Id like to do a few tests
Station 1(b): Testing of a head injury 289
with you to check this in more detail if I may theyre not too difficult, and Ill explain
each one before we do it, but dont worry if you make mistakes.
Abstract reasoning
Neuropsychologists employ complex tests such as card-sorting tasks to assess abstract
reasoning, but at the bedside, either proverb interpretation or categorisation/conceptu-
alisation tasks can be utilised. Proverb interpretation involves getting the subject to
explain the metaphorical meaning of a well-known proverb such as people in glasshouses
shouldnt throw stones. Categorisation/conceptualisation tasks involve asking subjects
to state how two objects are similar to each other and how they differ from one another;
for example:
I know this might sound like an unusual thing to do, but Id like you to tell me, as best
you can, how you think a car is similar to a train. After allowing the patient time to
give their response, follow up with, Thank you, and now can you tell me how a car is
different to a train.
Frontal lobe dysfunction may lead to impaired abstract reasoning, with resulting concrete
interpretations of proverbs and categories; for example, Throwing stones will break the
glass, or Trains and cars are both red.
Mental flexibility
The subject is challenged to list as many words (barring the names of people and places)
beginning with a given letter (traditionally f, a or s) or by a given category (e.g. ani-
mals) in 1 minute. This tests the subjects ability to design a cognitive strategy: normal
functioning depends on the scale utilised, but a healthy individual should be able to name
more than 20 words or animals.
Now Im going to time you doing this next task. In 1 minute, Id like you to tell me as
many words as you can that begin with the letter f for Freddy. They can be any
words except the names of people or places. Is that clear? OK, well start the minute
now.
Motor sequencing
This involves copying and continuing a complex multistage motor sequence, such as the
Luria series of fist, palm, and edge. Frontal lobe impairment can lead to difficulty learn-
ing or executing the demonstrated sequence.
Interference resistance
The Stroop test involves subjects naming the colours of printed words whilst ignoring
what the word actually says. At the bedside, a finger tap test can be employed. When the
examiner taps their finger once, the subject should tap theirs twice; when the examiner
taps twice, the subject should tap once. This test explores the subjects ability to override
competing stimuli.
290 Chapter 10: Neuropsychiatry
Were going to do a tapping test next. When I tap my finger once, like this, Id like you
to tap your finger twice: lets try that. OK, and when I tap my finger twice, like this, Id like
you to tap your finger once: lets try that. Is that clear?
Inhibitory control
This is a go-no-go variation of the finger tap test above. In this version, the subject taps
twice when the examiner taps once, but does nothing when the examiner taps twice.
Impairment can lead to loss of inhibitory control, with subjects continuing to tap even
when they should not.
The next test is another tapping test, but the rules are slightly different. When I tap
my finger once, you tap your finger twice, like the last time: lets try that. Now when I tap
my finger twice, you do nothing dont tap at all: lets try that. Is that clear?
Autonomy
This is the subjects independence from environmental cues. It can be assessed by telling
the subject to do exactly what you command, then placing your hands on the subjects
palms telling them do not grab my hands. Lack of environmental independence will
result in the subject grabbing the examiners hands.
In this last test, Id like you to listen very carefully to what I say, and do what I tell you.
Could you place your hands on your lap with your palms facing upwards like Im doing?
Great, now do not grab my hands.
ADDITIONAL POINTS
1. Although test ordering is not important, once the major subdomains are
reviewed, candidates should have their own structured examination method:
this will allow them to appear more professional in testing, as well as
reducing the chance of omitting a test.
2. In the abstract reasoning task, categorisation/conceptualisation is
usually a preferable test to proverb interpretation. This is because proverb
interpretation is culturally, linguistically and educationally biased: many
subjects will not have heard a given proverb before. If this task is utilised,
one should ask the subject, Have you heard the phrase _____ before? and
only ask for its interpretation if the subject says yes.
3. Time is obviously short and precious in examinations: a single trial of
each test will probably suffice, although ambiguous performance on any
given test may warrant a second example. In a similar vein, it should prove
Station 1(b): Testing of a head injury 291
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292 Chapter 10: Neuropsychiatry
INSTRUCTION TO CANDIDATE
You are asked to see a 19-year-old college student, Karen, who has been
admitted by the neurologists for further assessment of seizures. She has been
having fits for over 2 years, and recalls having her first episode in school prior
to an examination. Anticonvulsants over the past 2 years have not been helpful
and video-telemetry during this admission has failed to show any epileptiform
activity on electroencephalography (EEG) during bouts of fitting.
In light of the telemetry findings, take a neuropsychiatric history from the
patient.
SUGGESTED APPROACH
Setting the scene
Hello, Karen, Im Dr_____, one of the psychiatrists in this hospital. My colleague has
asked me to have a chat with you about the seizures youve had to see if we can find whats
causing them and ways we might help.
ADDITIONAL POINTS
1. Candidates may find patient engagement and building a rapport a difficult
component of this station. This can be due both to potential patient hostility
to a psychiatric review and the doctors concern about offending the patient
or choosing the wrong term to explain whats happening. Openness and
honesty is essential. It has been the authors experience that it can be very
helpful to talk about how common seizures are and to note that some are
caused by abnormal firing of brain cells (epilepsy) but that some are not,
without giving weight or primacy to either.
2. Whilst the station is leading towards a diagnosis of dissociative seizures,
the possibility of an alternative undiagnosed psychiatric illness, whether
aetiological (panic attacks, in particular, may mimic the aura of a seizure)
or comorbid, must be considered.
294 Chapter 10: Neuropsychiatry
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SUGGESTED APPROACH
Setting the scene
Hello, Robyn, Im Dr_____, one of the psychiatrists in the hospital. As you know, I met
with your sister Karen recently and shed like me to explain to you what weve discussed
and where we might proceed from here. Of course, please feel free to interrupt me if I use
any terminology or phrases of which youre not sure. Before I start, are there any questions
youd like answered?
296 Chapter 10: Neuropsychiatry
ADDITIONAL POINTS
1. Dissociative seizures are more common in those who have had epilepsy in
the past, and approximately a fifth of those with dissociative seizures will
have current comorbid epilepsy. Given these facts and the frequent desire
for a medical cause, patients and relatives may challenge the diagnosis,
citing, for example, ambiguous EEGs (and remember that non-specific EEG
abnormalities are seen in approximately a sixth of healthy individuals) or
the concept that the EEG might have missed some fits. Such arguments
are impossible to refute, and usually best avoided. If directly challenged,
the clinician should not become defensive, accepting the raised points, but
trying to move the discussion past this. For example, in such a situation,
it would be correct to note that the seizures filmed were non-epileptic,
and therefore the treatments offered should reflect this. Symptoms and
investigations can always, and should be, revisited.
2. The issue of whether or not symptoms could be feigned for psychological
gain (a factitious disorder) or fraudulent gain (malingering) may be at the
back of the clinicians mind. Clearly, this is an extremely sensitive area to
explore, and guidelines on this topic cannot be prescriptive. Dissociative
seizures are, by definition, considered unconscious, and it is worth bearing
in mind that dissociative seizures are frequently quite dissimilar to epileptic
seizures, and most patients admitted for video-telemetry have a fit in an
environment where they know they are being closely scrutinised factors
that militate against intentional deception.
FURTHER READING
http://www.epilepsy.org.uk/info/nonep.html
http://www.patient.co.uk/showdoc/40026034/
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INSTRUCTION TO CANDIDATE
You have been referred to a 68-year-old woman, Katherine, with Parkinsons
disease who, during an admission for management of worsening tremor, has
been difficult to manage on the ward. She has appeared agitated at times and
has been frequently noted to lie naked and fully exposed on her bed.
Take a relevant history from the patient, with a particular focus on exploring
the behavioural change and possible causes of this.
SUGGESTED APPROACH
Setting the scene
Hello, Katherine, Im Dr_____, one of the psychiatrists in this hospital. Ive been asked
by my colleagues to have a chat with you about how youve been getting on in hospital.
Station 3(a): Unusual behaviour in Parkinsons disease 299
Some of what Im going to ask you may seem a little personal, but its important informa-
tion for me to obtain, so I hope youll bear with me.
ADDITIONAL POINTS
1. It is important not to be seduced by finding the diagnosis. Even if early
questioning heavily points to, for example, a depressive disorder, it is
essential to continue to screen for other causes and comorbidities; for
example, coexisting cognitive decline.
2. Time will likely militate against a full cognitive examination, so the candidate
needs to show awareness of the importance of this task and highlight that it
is an area to return to:
300 Chapter 10: Neuropsychiatry
You feel your memory isnt what it once was. When Ive more time, Id like
to examine this in some depth. For the moment, would you mind if I asked
you a few quick memory questions? Could you tell me:
What date it is today?
What your date of birth is?
Our whereabouts at the moment?
3. In practice, it is seldom possible to confidently state that low mood is
comorbid or psychologically reactive as opposed to a neuropsychiatric
complication of a Parkinsonian picture. However, the candidate should look
for a past psychiatric history, including prior to diagnosis with Parkinsons
disease, and get a sense from the patient regarding beliefs surrounding
any low mood. Even if the patient does not attribute any salience to the
Parkinsonian medication, it is helpful to establish what the patient is taking,
and in clinical practice, it is important to ask specific questions around
disinhibitory hypersexuality and gambling.
4. Parkinsons disease, like multiple sclerosis, has a higher-than-expected
rate of affective disorders when the overall disability of the disease is
taken into account, with typical figures showing an approximately 50%
prevalence for depression of at least mild severity. However, it is often
difficult to clearly determine whether a mood or anxiety disorder is directly
caused by Parkinsons pathology or is psychologically secondary or
independent of it, although some authors have argued that thoughts
of self-harm are less frequent when part of the neurological disease.
A diagnostic difficulty is the fact that several overlapping symptoms
with different causes may coexist. For example, apparent psychomotor
retardation may be part of a depressive disorder or simply part of the
Parkinsons disease. Similarly, apathy and mild cognitive impairment might
falsely suggest depression.
FURTHER READING
Averbeck, B.B., OSullivan, S.S. & Djamshidian, A. (2014) Impulsive and compulsive
behaviours in Parkinsons disease. Annual Review of Clinical Psychology, 10, 55380.
Weintraub, D., Simuni, T., Caspell-Garcia, C. etal. (2015) Cognitive performance and
neuropsychiatric symptoms in early, untreated Parkinsons disease. Movement Disorders,
30(7), 91927.
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INSTRUCTION TO CANDIDATE
Your assessment of Katherine shows that she has been suffering from
fleeting visual hallucinations of a ghost that distracts and irritates her, and
these hallucinations have led to much of her agitation on the ward. She was
somewhat disorientated, thinking she was at home with her husband Neil,
but besides intermittent agitation, her affect seemed generally euthymic. The
symptoms have been there for some time, although her husband feels they
have worsened since starting her new medication with this admission.
Her husband, Neil, wants to know what you can do to help his wife. Discuss
with him in lay terms what might be happening and how you might be able to
help.
SUGGESTED APPROACH
Setting the scene
Hello, Neil, my name is Dr_____, and Im a psychiatrist. I understand you wanted to talk
about what we can do to help your wife. I think its important to state at this point that
were not completely certain about the exact cause of her symptoms, as there are a number
of possibilities, and treatment options will depend on the cause.
by accepting that the problem could be iatrogenic without attributing blame, and by
discussing possible medication changes without promising something they cannot
necessarily deliver.
It is possible that the new medication, or indeed interactions with other medications,
could be causing some of these symptoms. However, the medications are obviously very
important, and well have to think carefully and perhaps consult expert colleagues in the
pharmacy department and the neurologists before making any changes, and any changes
will probably be done quite gradually.
ADDITIONAL POINTS
1. A temptation in a station such as this is to get caught up in pharmacological
management, whether by adding or removing medications; however,
good environmental management is just as important in delirium and
dementing processes. Simple examples in a hospital environment include
adequate lighting, cues such as clocks, calendars and photos from home
and assigning regular members of staff to look after the patient who can
repeat information in non-technical terms as required. Finally, do not forget
that psychotic symptoms are not necessarily caused by dopaminergic
treatments dyskinesias are more common as side effects of such drugs
and psychotic symptoms may be part of a progressive neurodegenerative
disease. Dementia and psychosis frequently coexist and the presence of
one increases the risk of developing the other.
304 Chapter 10: Neuropsychiatry
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Station 4: Assessment oftemporal lobe epilepsy 305
SINGLE STATIONS
STATION 4: ASSESSMENT
OFTEMPORAL LOBE EPILEPSY
INSTRUCTION TO CANDIDATE
On the advice of her neurologist, Dr Sean, a local GP refers to you a young
woman with established temporal lobe epilepsy (TLE). The neurologist
noted an increase in inter-ictal hallucinations following a recent increase in
her fluoxetine; the antidepressant had been commenced by her GP in the
management of a comorbid mild depressive episode.
Take a history of seizures from this patient, Sunita, focussing on the TLE and
key areas of mental state and discuss management options with her.
SUGGESTED APPROACH
Setting the scene
Thank you for coming to see me today. Can I call you Sunita? Im Dr_____, a specialty
doctor in psychiatry. I understand that youve been seeing your neurologist about your
epilepsy, but they thought it might be helpful to have a psychiatric review of your medica-
tion and difficulties.
It is important, as ever, to remain structured. There are several obvious lines of enquiry
opened through the vignette, and they will each need to be tackled: epilepsy, the novel
psychopathology, the depression and the therapeutic and/or side-effect aspects of
medication.
manifestation. Individuals are often unaware of the aspects of these, and the actor may
thus be primed to be a vague historian: direct probing will be important.
Temporal lobe epilepsy can manifest with a range of neuropsychiatric symptoms, and
candidates might feel uncertain about these and potential treatment options. It is easy
to confuse the concepts of partial and complex seizures, or to mistakenly only consider
the perhaps more widely conceptualised complex type. Some individuals will have both,
and TLE spreads to become a secondary generalised tonicclonic seizure for many; all of
these factors will need to be enquired into. Alcohol and illicit drug use are essential areas
for exploration in all psychiatric histories, and they have obvious potential as exacerbants
of epilepsy.
Partial seizures have preserved consciousness but altered autonomic, sensory, affective
and cognitive symptoms; complex seizures manifest with impaired consciousness and
usually a blank stare and idiosyncratic automatisms. A wide range of potential symptoms
is possible, which can be divided by time frame (before, during or after the seizure) and
symptom domain:
Autonomic: palpitations and nausea/abnormal gastric sensations.
Sensory: illusory disturbances or frank hallucinations. The modality may be atypical
to that usually seen in psychiatry (e.g. olfactory or gustatory).
Affective: sudden changes in mental state, including agitation, aggression, elation or
depression.
Cognitive: memory impairment is a signature feature of TLE, but can also affect other
cognitive processes, including IQ, executive functioning and language skills. Individuals
can suffer dj and jamais vu, derealisation and depersonalisation and oneiroid states.
Automatisms: repetitive movements of the face or hands; may be dystonias.
Seizures usually last for a few minutes, and are commonly followed by fatigue, headache
and confusion.
paroxetine are cytochrome P450 interacting, and might necessitate alteration of AED dos-
age. The psychopharmacology of AEDs is complex. Phenobarbital, vigabatrin, tiagabine
and clobazam can cause depression. Topiramate can cause word-finding difficulties, and
levetiracetam has had reports of agitation, aggression, depression and psychosis.
Carbamazepine, valproate, lamotrigine and pregabalin are established mood stabilisers.
ADDITIONAL POINTS
1. TLE is the most common focal epilepsy, with seizures originating in one
or both temporal lobes. However, its epidemiology is not well established,
in part due to its complex presentation, and also due to the fact that it
can spread to become a generalised seizure. It has been estimated that
approximately a quarter of those with a partial epilepsy have TLE; it is twice
as common on the medial aspect of the lobe as the lateral. Early-life febrile
seizures, central nervous system infections and traumatic brain injuries
are risk factors, as is a positive family history, although there can be a
considerable latent period of some years after any insult before seizures
become apparent. The illness burden can be quite considerable, heavily
impacting many sufferers in terms of their psycho-social functioning. Inter-
ictally, approximately a third will suffer depressive symptoms and one in
ten will suffer psychotic symptoms. Overall, the lifetime prevalence rates
of depression and generalised anxiety disorders are approximately double
those of the general population, with a fivefold increase in suicide. Seizures
can occur in sleep, some might not be witnessed and it can be difficult to
get an accurate sense of their frequency. Patients might downplay or deny
seizure frequency, particularly if there are concerns over their fitness to drive.
A collateral history is very helpful where possible, including to check on the
individuals responsiveness during a seizure.
2. Approximately half of patients are successfully treated on single-dose
AEDs, and approximately a third are refractory to pharmacological
intervention. The illness can be both progressive in symptomatology and
cause structural brain damage. Pathologically, there are hallmark temporal
lobe lesions, sclerosis or gliosis, particularly on the hippocampi, with
permanent cognitive impairment. However, damage can include areas
well outside of the temporal lobes. Neurosurgery is a therapeutic option
where pharmacotherapy has failed; it is a reasonably effective intervention,
particularly if any lesions have been demonstrated on neuroimaging.
Understandably, many are hesitant to undergo this, although decisions must
be balanced against the fact that the longer a refractory illness is untreated,
the greater the potential for permanent cognitive damage. Research has
shown that patients are typically referred for surgery after 20 years of
seizures, lessening the chance of positive outcomes. A randomised trial
has shown that amongst those with newly intractable TLE, surgery plus
medication had a better outcome over a 2-year follow-up than AEDs alone.
Actual rates of surgery-induced serious injuries, including verbal memory
impairment, are 15/100. Anterior temporal lobectomy was the classical
surgical approach, with removal of the mesial and lateral structures,
although there are more specific, area-sparing techniques such as selective
amygdalohippocampectomy and dominant mesial temporal lobe resection.
308 Chapter 10: Neuropsychiatry
NOTES/Areas to improve
Station 5: Explanation of the neuropsychiatry of a glioma 309
INSTRUCTION TO CANDIDATE
A core trainee in psychiatry, Dr Morgan, asks for advice about one of his
out-patients. The patient, Shri, is a 46-year-old man recently diagnosed with
a malignant glioma, with purported subsequent personality change. He is
undergoing radiotherapy combined with the oral chemotherapeutic agent
temozolomide, and is currently rather angry, wanting to know why he is seeing
a psychiatrist. The junior doctor admits to feeling out of his depth, and asks
that you speak with the patient.
Discuss the rationale for seeing a psychiatrist, elicit any relevant
psychopathology and discuss potential multidisciplinary care options.
SUGGESTED APPROACH
Setting the scene
Hello, Shri, Im Dr_____, one of the psychiatrists. I know you just saw Dr Morgan, and
he has requested, given the complexity and difficulty of all you have been through, that
a more senior doctor assists with some of your queries I hope thats alright. I appreciate
this must have been a hugely trying time for you and your family; would you like to
start by asking me any questions or identifying important issues you would like us to
cover?
Although the neuropsychiatry is complex, many of the principles of this vignette should
be second nature to a good candidate, irrespective of their knowledge of the gliomas.
Active listening to an upset individual, providing thoughtful and appropriate (but not
false) reassurance and considering the range of supports are core psychiatry skills.
310 Chapter 10: Neuropsychiatry
ADDITIONAL POINTS
1. The incidence of primary brain tumours is a little over 6/100,000 per
annum; unfortunately, early diagnosis and treatment do not improve
outcomes, and the prognosis is generally very poor. Their classification
can be confusing, and they are histologically quite disparate. Gliomas
tumours arising from the brains stromal or support glial cells (as opposed
to neurons, which are fascinatingly non-oncogenic despite their
proliferation through even adult life) can be classified by grade, by glial cell
type and by cortical location.
2. The World Health Organisation divides them into four categories (IIV) of
increasing aggressiveness, anaplasia (lack of morphological characteristics
of mature cells) and pleomorphism (increased variation in cellular
appearance). The most common type, accounting for over three-quarters of
all cases, are de novo grade III and IV anaplastic malignant gliomas that did
not arise from preceding lower-grade tumours.
3. Neurological/neurosurgical treatments include relief of pressure symptoms
arising from oedematous swelling via corticosteroids and antiepileptic
drugs if there are seizures, although there is no evidence to support
their prophylactic use. Surgical excision will debulk and allow histological
identification, although the tumour site may preclude this. Combination
radiotherapy and chemotherapy are usual, although the protocols vary
according to tumour factors such as type and location. Median 5-year
survival rates vary according to these factors and the individuals health,
from 85% for some well-differentiated low-grade tumours to less than 5% for
grade IV glioblastomas.
4. Whilst personality change, impairments of cognition and psychiatric
symptomatology are well recognised in the literature on gliomas, there are
no good data on their prevalence.
FURTHER READING
Boele, F.W., Rooney, A.G., Grant, R. & Klein, M. (2015) Psychiatric symptoms in glioma patients:
From diagnosis to management. Neuropsychiatric Disease and Treatment, 11, 141320.
Omuro, A. & DeAngelis, L.M. (2013) Glioblastoma and other malignant gliomas. A clinical
review. JAMA, 310(17), 184250.
Westphal, M. & Lamszus, K. (2011) The neurobiology of gliomas: From cell biology to the
development of therapeutic approaches. Nature Reviews Neuroscience, 12, 495509.
312 Chapter 10: Neuropsychiatry
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
The neurology team has admitted Radha, a 35-year-old woman, for a full
workup and investigations on the background of 15 years of full body pain
and generalised weakness, which have never been successfully managed.
This admission has included an MRI of the patients head, an EEG, an auto-
antibody screen including rheumatoid markers and routine bloods and physical
Station 6: Medically unexplained symptoms 313
SUGGESTED APPROACH
Setting the scene
Hello, Radha, my name is Dr_____, a psychiatrist. Id like to have a chat with you about
some of the problems youve been having. Would that be okay?
Sensitivity and tact are needed. In this station, the idea of somatoform or hypochondria-
cal illnesses can be raised, but the patient need not be directly challenged something
that is unlikely to occur on a first assessment in clinical practice. Ultimately, a time may
occur in treatment at which the patient will need to be confronted and told that further
investigations should not occur and that the diagnosis is a psychological one, but this
could be catastrophic at a first appointment. Rather, the candidates role is to introduce
the idea of bodymind interactions in order to explain the symptoms and how psycho-
logical theory can offer avenues for treatment.
in cold weather and how common this is to all of us. Given all of the negative find-
ings to date, I wonder if its possible that there could be a psychological component to
some of your symptoms? Could, for example, stress have made you pay more attention
to your bodys signals? I know these symptoms are real and uncomfortable when you
feel them.
A follow-up to this, considering treatment, avoids the need for direct confrontation at
this early stage of engagement:
Your doctors have mentioned how treatments to date have unfortunately been unsuc-
cessful. We commonly find that psychological help can be really valuable, regardless
of the cause of the illness; for example, managing pain in arthritis or helping people
manage illnesses we poorly understand, like IBS. I think this might be something that
would be really useful in helping you, and one of the great things about psychological
treatment is that it doesnt have side effects like medications can. How would you feel
about this?
ADDITIONAL POINTS
The term psychosomatic has become common parlance and should be
avoided lest it be misinterpreted as making it up. If asked for a diagnosis
directly, an honest and direct approach must be adhered to, no matter
how uncomfortable this may feel. Somatoform disorder is an overarching
diagnostic umbrella that might help explain how the mind and body can interact
in the first instance. Assessment of medically unexplained symptoms is a
common scenario in both liaison and neuropsychiatry.
FURTHER READING
Creed, F. & Barsky, A. (2004) A systematic review of the epidemiology of somatisation
disorder and hypochondriasis. Journal of Psychosomatic Research, 56, 391408.
Hatcher, S. & Arroll, B. (2008) Assessment and management of medically unexplained
symptoms. BMJ, 336, 11248.
Rhricht, F. & Elanjithara, T. (2014) Management of medically unexplained symptoms:
Outcomes of a specialist liaison clinic. Psychiatric Bulletin, 38(3), 1027.
van Dessel, N., den Boeft, M., van der Wouden, J.C. etal. (2014) Non-pharmacological
interventions for somatoform disorders and medically unexplained physical symptoms
(MUPS) in adults. Cochrane Database of Systematic Reviews, 11, CD011142.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
A consultant neurologist, Dr Byron, requests a ward review of Ms Kay, a
48-year-old woman with a 10-year history of MS. Whilst an in-patient for
assessment and management of a relapse of her MS, she has become quite
tearful and low in mood, saying that she does not wish to carry on anymore.
Assess her mental state and past psychiatric history and discuss treatment
options with her.
SUGGESTED APPROACH
Setting the scene
Hello, Ms Kay, Im Dr_____, a psychiatrist in this hospital. Dr Byron has asked me to have
a chat with you about how youve been feeling recently, is that okay?
ADDITIONAL POINTS
1. Remember to ask about current and past symptoms of elation. Pathological
laughter and crying is a syndrome that occurs in approximately one in
ten MS sufferers, particularly in late-stage disease. Psychotic symptoms
seldom if ever progress to a full schizophrenia-like picture: just because the
patient does not present as obviously psychotic, do not fail to ask about
hallucinations, which occur in approximately 20% of patients.
2. It is unlikely that there will be time to do a formal cognitive assessment; the
usual trick of asking about poor memory and concentration and mentioning
how one would like to revisit this domain for more formal and thorough
testing at a later time should suffice to demonstrate that the candidate is
aware of and understands the significance of these symptoms.
3. All chronic illnesses are associated with higher-than-average rates of
depression. Multiple sclerosis has a higher rate than expected for degree
of disability, suggesting at least a partial organic basis. Whilst there is
evidence for -interferon causing low mood, the significance of this may
have been overstated.
FURTHER READING
Feinstein, A., Magalhaes, S., Richard, J.F., Audet, B. & Moore, C. (2014) The link between
multiple sclerosis and depression. Nature Reviews Neurology, 10(9), 50717.
Fernie, B.A., Kollmann, J. & Brown, R.G. (2015) Cognitive behavioural interventions for
depression in chronic neurological conditions: A systematic review Journal of
Psychosomatic Research, 78(5), 4119.
Koch, M.W., Glazenborg, A., Uyttenboogaart, M., Mostert, J. & De Keyser, J. (2011)
Pharmacologic treatment of depression in multiple sclerosis. Cochrane Database of
Systematic Reviews, 16(2), CD007295.
Reder, A.T., Oger, J.F., Kappos, L., OConnor, P. & Rametta, M. (2014) Short-term and
long-term safety and tolerability of interferon -1b in multiple sclerosis. Multiple Sclerosis
and Related Disorders, 3(3), 294302.
www.mssociety.org.uk
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 11 Pranathi Ramachandra
Personality disorder
LINKED STATIONS
INSTRUCTION TO CANDIDATE
You receive a referral asking that you review a 24-year-old woman who initially
presented to accident and emergency (A&E) having taken an overdose of
ibuprofen and paracetamol. She is now physically fit and the charge nurse
has informed you that she is a right nuisance, taking up an acute bed
when it could have been used more appropriately. You are told of several
presentations to the same unit over the last 6 months.
You are also told that she has been known to mental health services for a
number of years since moving to this area. In that time, she has had a number
of different care coordinators and believes her team to be useless.
Gather relevant information that will help you in considering a diagnosis.
She has been told in the past that she has a personality disorder and wants
to know what this means.
SUGGESTED APPROACH
Setting the scene
Address the patient by name, introduce yourself and explain what you are there for: Hello,
my name is Dr_____, Im one of the psychiatrists. Ive been asked by the medical team to
see you. Would it be OK if we spoke about what led you to come into hospital? Or, Could
you tell me what happened?
Allow time for the patient to respond and explain what their concerns are.
322 Chapter 11: Personality disorder
emotional crises and excessive effort at avoiding feelings of abandonment in the form of
self-harm and suicide threats.
Unstable self-image How do you feel about yourself most of the time? Their self-image,
aims and sexual preferences are often unclear or disturbed.
Pt: The psychiatrist told me that I have a personality disorder. What does that mean? Am
I a bad person?
C: By the time we are young adults, we have usually developed our individual personali-
ties so that we think, feel and behave in our own ways. Most peoples personality remains
fairly constant throughout their lives, allowing them to get on fairly well with people
most of the time. For some of us, this doesnt happen and we develop personalities that
are less comfortable with others and sometimes ourselves. Often these differences in
personality have been present for a long time, usually from childhood. Were not exactly
sure why this happens. Some of it may be due to things like heredity and genes, and some
of it can be due to our experiences while growing up. This can mean that some people
have difficulties with personal relationships and friendships, dealing with feelings or
emotions and difficulty controlling their temper.
Risk
Self-harm and suicidal threats might lead to admission and this process can often be
counter-therapeutic for such people. However, a diagnosis of borderline personality dis-
order (BPD) should not compromise a thorough risk assessment and each presentation
should be considered in its own rights. A drug overdose as described could have been a
serious suicide attempt and requires an appropriate approach, especially in an acute A&E
setting. Although in this station you have not been asked to make such decisions, you
should always consider risk, and a few screening questions, including asking about illicit
substance misuse and alcohol, will let the examiner know that you are a sensible
psychiatrist.
Problem solving
Bear in mind that the patient is likely to be angry and dissatisfied with the help they have
received so far. While you might be the focus of their distress, it is important to remain
calm and in control.
Pharmacological treatment
Only indicated if specific target symptoms are present, such as antidepressants if depressed,
hypnotics for insomnia, anti-psychotics for psychotic symptoms, mood stabilisers, and
so forth. Be mindful of the potential for dependence and tolerance to hypnotics and
benzodiazepines, as well as the potential for overdoses, so there is a need to restrict the
supply of medications.
Psychological treatment
Various types of psychological treatment are available, usually longer term and community
based, with varying degrees of evidence.
324 Chapter 11: Personality disorder
Conclusion
Suggest the appropriate support and follow-up (crisis team/referral to CMHT/admission/
referral to personality disorder service) based on your assessment of the current mental
state and risk.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
The A&E consultant wants to speak to you after you have finished assessing
the patient. They are not happy with the repeated presentations of the patient,
which they feel take time away from caring for more deserving patients. They
ask why psychiatry services are not doing anything to prevent this patient
attending often in crises.
Talk to the A&E consultant about the management of patients with borderline
personality disorder.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, Dr_____, I am Dr_____, the psychiatrist. Can we have
a d iscussion about patient_____? Be mindful that although you are talking to
326 Chapter 11: Personality disorder
someonefrom the same professional background, this person is from a different spe-
cialty. He or she may come across impatient, but allow them to speak and listen to their
frustrations.
General
Good communication with all parties involved is essential.
Problem solving
You should offer to discuss concerns that the staff have and consider ways you might deal
with these. Suggesting a session with staff in which you could discuss the case and per-
sonality disorders in more detail would be useful. It is important to have a consistent
approach to the patient.
ADDITIONAL READING
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/personalitydisorder.aspx
NICE guidelines for treatment and management of borderline personality disorder. https://
www.nice.org.uk/guidance/cg78
The ICD-10 Classification of Mental and Behavioural Disorders (1992) Clinical Descriptions
and Diagnostic Guidelines. Geneva: WHO Press.
Gabbard, G.O. (2000) Psychodynamic Psychiatry in Clinical Practice. Washington, DC:
American Psychiatric Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You have been asked to assess this patient who has attended the clinic. He
has a diagnosis of paranoid personality disorder (PPD). He did not turn up for
his previous two appointments.
As part of your consultation, elicit the main features of PPD and discuss
management options with him.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the psychiatrists. Thank you
for coming to see me in the clinic today. We have not met before this time, how have you
been? The patient may seem guarded reassure them about confidentiality. Explain that
Station 2: Paranoid personality disorder 329
this appointment is to look at how he is coping with life generally and to identify whether
he may need any help. Inform him that this consultation is confidential and his consent
will be obtained before sharing information with other professionals.
You could also mention that he had missed several appointments: I notice that we havent
seen you for a while. Sometimes when people have a lot going on in their lives or theyre
stressed, they dont want to attend appointments. Has anything like that been happening
to you?
Psychotherapy
Psychological approaches are difficult, as building a trusting and intimate relationship
with a therapist is often unworkable, but they are the treatment of choice so long as the
patient demonstrates insight and is prepared to engage. Psychodynamic psychotherapy
may be too demanding, but if successfully initiated, the therapist should be aware that
ambitious interpretations may be met with resistance and breaking off of treatment. Group
psychotherapy can help reduce suspiciousness and improve socialisation, but frequently
such sessions are not tolerated.
330 Chapter 11: Personality disorder
Medication
The evidence base for effective pharmacotherapy is weak. Anti-psychotics can help with
agitation and hypervigilance. Antidepressants can help with affective and anxiety symp-
toms. Short periods of benzodiazepines have also been used for marked anxiety and agita-
tion, although there is the risk of dependence and they are generally out of favour.
Risk
Occasionally, the thoughts of these individuals can lead to violence against those they
suspect. If during the course of the interview they express anger towards others, explore
this further.
You can limit the likelihood of aggression towards yourself by not invading their space (i.e.
not getting too close), not embarrassing them and not using an accusational interview style.
Problem solving
You need to be aware of his likely sensitivity and suspiciousness. The use of normalisation
can be helpful here. Typically, these individuals do not do well with authority figures, such
as doctors. This is often an obstacle to engaging with services. Such individuals feel that
others are trying to get the better of them or to deceive or fool them. It is likely that during
the interview you will be subject to accusations and insults, and you need to remain polite
but not defensive. It is possible that any suggestions you make will be rejected or criticised.
ADDITIONAL POINTS
PDD patients are hypersensitive to potential slights, are suspicious and have
a hypervigilant view of the world. They persistently scan for signs of potential
danger and rarely relax their suspicions. These features make it difficult to form
enjoyable relationships and others often drift away. Acquaintances will view them
as secretive, prickly and devious. Unlike paranoid syndromes, in PPD, ideas or
themes are not of a delusional nature and there are no hallucinatory experiences.
FURTHER READING
Bateman, A.W. & Tyrer, P. (2004) Psychological treatment for personality disorder. Advances
in Psychiatric Treatment, 10, 37888.
Carroll, A. (2009) Are you looking at me? Understanding and managing paranoid personal-
ity disorder. Advances in Psychiatric Treatment, 15(1), 408.
The ICD-10 Classification of Mental and Behavioural Disorders (1992) Clinical Descriptions
and Diagnostic Guidelines. Geneva: WHO Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are seeing this 24year-old gentleman in your clinic. The GP has written to
you as he believes that this gentleman has an unusual personality. He gives
you little useful information as he is really not sure what to do. There is no
significant past psychiatric or medical history and no regular medication. He
hopes you are able to shed some light on what is going on.
Assess this patients personality.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the psychiatrists. Explain that
you have received a letter from his doctor and ask if he knows why the GP has referred
him. If he is unsure, then you could describe how his doctor felt that things did not seem
to be going so well for him in his personal life and relationships, which is why he had
asked that you see him. Did this seem correct to him? Ask if you could talk to him in order
to find out how things have been recently.
Character
Can you tell me what kind of person you are?
How would you describe your own personality?
If you were with other people, say at a party or at work, how do you behave?
Reserved/timid (anankastic)
Shy/self-conscious/anxious (avoidant)
Fussy/difficult/meticulous/punctual (anankastic)
Selfish/self-centred (paranoid)
Centre of attention (histrionic)
Sensitive/suspicious (paranoid)
Resentful/jealous (paranoid)
Attitudes of others How would people that know you describe your personality?
Attitudes to others What do you think of other people; for example, your friends or
people at work?
Habits
Risk-taking behaviour (with or without criminal behaviour) (dissocial) Would you
consider yourself as a risk taker? Can you give some examples of risky things you have
done? Have they got you into any trouble?
Food, smoking, alcohol and drugs Tell me about your dietary habits. What about alco-
hol? Do you smoke or take any street drugs?
Reactions to stress
How would you cope in an extremely stressful situation; for example, you lose your job
or have broken up with your partner?
Station 3: Personality assessment 333
Temperament
What are you like if you get angry? What is the worst thing you have done out of
anger?
Has your temper ever got you into trouble? (Dissocial)
Do you ever think you are irresponsible? (Dissocial)
Do you get into lots of arguments? (Impulsive)
How do you respond to criticism? (Anxious/paranoid)
Are you ever very emotional? (Histrionic/borderline)
Fantasy thinking
What do you dream of or wish for?
Do you ever daydream about things? Tell me more about this. (Schizoid)
Prevailing mood
What is your mood like for most of the time?
Are you predominantly cheery or gloomy?
Leisure
Asking about their free time and what they enjoy can provide information on whether
they prefer social or more solitary activities, as well as sedate or energetic activities.
Risk
When asking about mood and dissocial traits, this is an opportunity to screen for suicidal
and homicidal ideation.
Problem solving
It can be a tense moment in a scenario if the actor turns to you and asks, Do I have a
personality disorder? It would be prudent to say that it is difficult to make this diagnosis
after one meeting and without the benefit of more collateral information. However, do
mention if they have traits of a particular personality disorder (ICD-10).
334 Chapter 11: Personality disorder
It is challenging to form an accurate opinion on personality in such a short time and also
based entirely on the individuals opinion of himself. However, such is the nature of the
exam that one at least needs to attempt this.
It could be quite depressing to focus on entirely negative personality traits, and the person
might feel somewhat persecuted. Also enquire about their positive qualities. At the end
of the interview, conclude by saying that you would ideally like to speak to his parents,
partner and close friends for collateral information. If it turns out that he has features of
PD, inform him that based on the information gathered, there is a likelihood he may have
the features of a certain type of PD and give your rationale for this.
ADDITIONAL POINTS
A useful mnemonic for personality assessment is CHART FAME:
Character
HAbits
Reaction to stress
Temperament
FAntasy thinking
Mood (prevailing)
Enduring relationships
FURTHER READING
Leff, J.P. (1992) Psychiatric Examination in Clinical Practice. 3rd edn. Oxford: Wiley Blackwell.
The ICD-10 Classification of Mental and Behavioural Disorders (1992) Clinical Descriptions
and Diagnostic Guidelines. Geneva: WHO Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 12
Perinatal psychiatry Ruaidhri McCormack
LINKED STATIONS
INSTRUCTION TO CANDIDATE
Ms Rachel Carmichael has been referred to you by her general practitioner
(GP). She is a 27-year-old lady who has given birth to a baby boy 2 months ago.
Over the last 5 weeks, she has been feeling low. Her partner works in a very
busy city job and comes back late in the evenings. She has no other children.
Her parents live in Spain and she sees them perhaps once a year. Several of
her close friends do have children and live in the area, but she has preferred
not to socialise with them for several weeks now.
Elicit a psychiatric history from this woman.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introducing yourself. Acknowledge
her current circumstances and begin with an open question: Hello, Ms Carmichael, I am
Dr_____, a psychiatrist. I have a letter from your GP who is concerned about you. Can you
338 Chapter 12: Perinatal psychiatry
tell me a bit about what has been happening? Allow the patient to respond to your introduc-
tion and maintain a flow in your conversation. Supportive statements will demonstrate your
understanding of her situation and encourage good rapport; for example, The weeks after
delivery can be extremely stressful, and Its very common to feel this way after the baby is
born. Then proceed to hone in by using more closed questions where appropriate.
Stick to the task. The question about antidepressants is designed to distract you.
Acknowledge the question but immediately come back to the task: Antidepressants might
well have a role, but its important at this stage that I ask a few questions so I can best
understand how to help you.
Psychiatric history
Ask about past episodes of depression and other mental disorders. You need to know when
any episode occurred, how severe it was, what risks were associated (with their nature
and severity), what and how diagnoses were made and how episodes were treated (which
treatments did/did not work).
Station 1(a): Postnatal depression 339
Social circumstances
Ask about prevailing stressors and the network of social supports. Screen for relationship,
financial and employment-related pressures, and ask an open question about other
stressors.
Risk assessment
The best risk assessments always include the history of risk as well as current risk and best
impressions regarding future risk.
Intentional self-harm thoughts/plans/intent and history of self-harm.
Harm to baby where the baby is now, any fears/wishes to harm the baby and evidence
she has been unable to adequately care due to mental health symptoms or other
reasons.
Harm to others contact with other children and any wish to harm others.
Harm from others any ongoing contact between alleged sexual abuser and patient/
baby is relevant.
Other risks can be considered as appropriate risks of vulnerability, self-neglect or non-
engagement with treatment.
If there are concerns about the safety of the child or the mother, you will need to discuss
the case with her partner and social services.
Conclusion
If unclear about parts of the history, summarise back to the patient to confirm or
clarify.
FURTHER READING
Milgrom, J., Gemmill, A.W., Bilszta, J.L. etal. (2008) Antenatal risk factors for postnatal
depression: A large prospective study. Journal of Affective Disorders, 108, 14757.
Musters, C., McDonald, E. & Jones, I. (2008) Management of postnatal depression. BMJ,
337, a736.
340 Chapter 12: Perinatal psychiatry
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/cg192
World Health Organisation (1993) International Classification of Diseases (ICD). 10th edn.
www.who.int/classifications/icd/en/
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You meet with her partner (David), who has taken time off work to see you.
He explains that he is trying to be as supportive as he can, but that his job is
extremely demanding. He wants to know what is wrong with his girlfriend and
what he should do to help.
Answer his questions and address his concerns.
Station 1(b): Discussion with partner 341
SUGGESTED APPROACH
Setting the scene
Begin the task by introducing yourself, confirming Davids relationship to Rachel and mak-
ing reference to consent: Hello, David? My name is Dr_____, a psychiatrist, and Ive just
seen Rachel, who has given me consent to speak with you. I understand you are her partner?
Allow him to respond. He may simply confirm his identity, make some opening statements
or immediately start asking questions if questions are asked, say something like, I certainly
want to answer your questions, but in order to do that effectively, I need a bit more informa-
tion first. If you defer a question, make sure you return to it the actor may not ask again.
Other support
Association for Postnatal Illness provides support to mothers suffering from postnatal
illness.
PANDAS a support service for patients and families affected by antenatal or postnatal
illnesses.
CRY-SIS provides self-help and support for families with excessively crying and sleep-
less babies, 365 days a year.
National Childbirth Trust advice, support and counselling on all aspects of childbirth
and early parenthood.
The Samaritans provide confidential emotional support to any person who is suicidal
or despairing.
Risk management
Take time to confirm that your management plan as discussed has addressed the risks
identified in Station 1(a).
Station 1(b): Discussion with partner 343
Conclusion
It is sensible to summarise what you have discussed and where you go from here. Offer
written information about postnatal depression and charitable support. Offer a crisis leaflet
for his reference and ensure he knows who to contact or where to go if Rachel is in crisis.
FURTHER READING
British Association for Psychopharmacology (2008) Evidence based guidelines for treating
depressive disorders with antidepressants (revision). http://www.bap.org.uk/pdfs/
antidepressants.pdf
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn, London: Wiley-Blackwell.
Musters, C., McDonald, E. & Jones, I. (2008) Management of postnatal depression. BMJ,
337, a736.
National Institute for Health and Clinical Excellence (2009) Depression in adults: The
treatment and management of depression in adults. https://www.nice.org.uk/guidance/
cg90
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/
cg192
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Melanie Leighton is a 25-year-old lady with a 2-week-old baby girl. Her sister
has reported that Melanie is behaving quite strangely. You have been asked to
see her as a home visit.
Elicit the relevant features from the mental state examination and assess
the risks.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introducing yourself: Hi, Melanie.
My name is Dr_____, and Ive been asked to come and see how you are. I often see people
who might have concerns or worries after the birth of their babies. Identifying yourself
Station 2(a): Puerperal psychosis 345
immediately as a psychiatrist could be threatening for this patient who has not elected
to see you, although you must always be honest if directly asked. See how the patient
responds and try to develop a rapport by asking open questions: How have you been
since the baby was born? How is the baby?
Mood
Screen for the major and minor ICD criteria for depression (see Station 1[a]) and features
of (hypo)mania and suicidality. You can make an observational comment about affect:
You seem a bit flat.
Perception
You can start with open questions: Does your mind ever play tricks on you? Have you
had any experiences which youve found difficult to explain?
When asking about hallucinations, always screen for the five sensory modalities:
Do you ever hear voices or noises when nobody else is around? If voices, ask about their
nature and content where they come from, what they say and any commands.
Do you ever have any funny tastes or smells?
Do you ever feel things, like somebody touching you, when nobody else is around?
Do you ever see things, like visions, that cannot be explained or other people cannot see?
346 Chapter 12: Perinatal psychiatry
It is easiest to remember to screen for thought echo when asking about auditory hallucina-
tions: Do you ever hear your thoughts spoken out loud?
When asking about delusions, you can ask the following:
Do you ever feel under the control or influence of somebody or something? (Delusions
of control and influence)
Do you ever get messages from the environment especially for you, perhaps from the
TV, radio or newspapers? (Delusions of reference)
Do you feel safe? Is anybody or anything out to hurt or harm you or the baby in any
way? (Persecutory delusions)
Has anything of great significance to you happened recently, something very meaning-
ful to you? (Delusional perception; e.g. The traffic light turned red and I just knew then
that I was chosen to lead my people)
Other delusions to consider include delusions of misidentification (including Capgras and
Fregoli delusions), grandiose delusions and delusions of guilt. You should test (although not
argue about) any delusion, asking what evidence they have of such a belief. You can say
something like: That seems very unlikely to me, I dont understand what grounds MI5
would have for chasing you. Are you absolutely sure this is happening? If the patient gets
angry that you do not believe them, use a statement like, Of course I believe this is your
experience, Im just trying to really get a sense of what is happening.
Thought possession
Start with an open question: Are you able to think clearly? Is anything interfering with
your thoughts? Then ask about thought broadcasting (Do you ever feel that people can
read your mind?), thought insertion (Are thoughts ever put in your head that are not your
own?) and thought withdrawal (Are thoughts ever taken out of your mind by someone or
something?).
Risk assessment
This will be similar to the risk assessment performed in Station 1(a) covering harm to self
and others, including the baby and any other children. Do not forget alcohol and drugs,
stressors and supports and history of self-harm. The risk of non-engagement is very rel-
evant in this case; discern whether she has engaged with services during any prior episodes
and what her views on treatment are.
Conclusion
This station does not ask you to give the patient a diagnosis or discuss a management
plan. It may, however, be relevant as part of insight to evaluate views on treatment does
she think it is required and would she comply? You can summarise back to the patient if
you require clarification or more detail on a section of the mental state examination. It
may be appropriate to thank the patient at the end for talking to you and for being honest
about her experience.
FURTHER READING
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/cg192
Rule, A. (2005) Ordered thoughts on thought disorder. Psychiatric Bulletin, 29, 4624.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
348 Chapter 12: Perinatal psychiatry
INSTRUCTION TO CANDIDATE
You return to the community team base where you meet the team manager
Linda. She had been concerned about Ms Leighton following the referral. She
wants to know what your care plan is following assessment.
Tell her about your assessment and plans.
SUGGESTED APPROACH
Setting the scene
You know the team manager; a simple greeting is appropriate with a clear identification
of the patient to be discussed: Hi, Linda, how are you? Ive just been to see Melanie
Leighton. Do you have some time to discuss the case?
The assessment
Give a clear and succinct case summary. Present the main findings in terms of psychopa-
thology and the risk issues. Remember that this is also a management station. You can
refer to any notes you have taken in the first station. Pause at the end of this section to
see if the team manager has any comments, thoughts or questions at this stage. Do not
forget to present your diagnostic formulation or differential diagnosis.
Risk
Always consider the risk to the mother and the baby.
Conclusion
Summarise the plan and next steps.
350 Chapter 12: Perinatal psychiatry
FURTHER READING
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/
cg192
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. London: Wiley-Blackwell.
Royal College of Psychiatrists information leaflet: Postpartum psychosis: Severe mental
illness after childbirth. http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/
postpartumpsychosis.aspx
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 3: Bipolar disorder and pregnancy 351
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
Sarah Trimble is a 33-year-old lady with a history of bipolar illness. Her illness
has been well controlled over the last 8 years with lithium.
Today, she informs you that she has had a positive pregnancy test and thinks
she must be 68 weeks pregnant. She has been in a stable relationship with
her boyfriend for 4 years and has decided to keep the baby.
As you look through her records, you note that she also takes regular diazepam.
Her medications are: lithium (as Priadel) 600mg nocte and diazepam regular
10mg ter die sumendum (TDS three times a day).
You are asked to advise on medication management.
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introducing yourself as usual.
Acknowledge her current circumstances: I understand youre pregnant, is that something
youre pleased about? Well, congratulations. Its important that we have this time to talk
because we need to try to make sure that your baby stays healthy and, at the same time,
try to keep your mental health stable. Ask if she knows anything about lithium in
pregnancy.
Confirm current medications how long she has been on them, indication for benzo-
diazepine (BZD), compliance and what has happened during any drug-free periods.
Natural history of bipolar illness depressive versus (hypo)manic episodes (number of
relapses, when they occurred, triggers, duration, how severe, required Mental Health
Act (MHA) detention or not and how it was treated in the acute phase), history of medi-
cation and treatment interventions (ECT and psychotherapy) and history of self-harm
and/or harm to others when unwell.
Alcohol/illicit drugs/cigarettes.
Stressors and supports.
GP/midwife should provide regular support and monitoring of her mental state throughout
the pregnancy.
Breast feeding
Breast feeding is not recommended in mothers on lithium, as lithium can cause infant
toxicity. Any infants who are breast fed need to be closely monitored. BZDs can cause
sedation, lethargy and weight loss. Strategies to limit exposure include using the lowest
effective doses, using drugs with shorter half-lives or taking the drugs once daily before
the babys longest sleep (usually nocte) in order to avoid peak plasma levels. Small amounts
of carbamazepine, valproate and lamotrigine also pass into breast milk.
354 Chapter 12: Perinatal psychiatry
FURTHER READING
British Association for Psychopharmacology (2009) Evidence-based guidelines for treating
bipolar disorder. http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/
cg192
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. London: Wiley-Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 4: Baby blues 355
INSTRUCTION TO CANDIDATE
You are going to see Mrs Gray. She is a patient of yours and you have been
seeing her in the clinic for anxiety and concerns related to dying and ill health.
She has been physically well.
You started her on fluoxetine a year ago; this had a modest effect. She
later informed you that she was keen to start a family and had stopped the
antidepressant. Her anxiety worsened and you referred her for a course of
CBT. She responded well, although she required more sessions than was
anticipated and needed several top-up sessions.
She was able to conceive and handled the physical manifestations of
pregnancywell.
She had a healthy baby boy 5 days ago and has asked that she see you
urgently. Your secretary has squeezed her into your already overbooked clinic.
Take a brief history and mental state examination and formulate a
management plan.
SUGGESTED APPROACH
Setting the scene
You know the patient, so a simple recognition of seeing her again and greeting is all that is
required. Acknowledge her recent delivery and ask if the baby is well. If so, feel free to con-
gratulate her before moving to an open question that is relevant to the task: I understand
you wanted to see me urgently. Can you tell me a bit about what has been happening?
problems. Before you even see the patient, you should be considering if her request to see
you might have something to do with her prior anxiety issues or be related to baby blues
or postnatal depression/psychosis. Allow your history and mental state examination to
evolve based on the information she gives you and with this differential diagnosis in mind.
Enquire fully about her prior anxiety symptoms and whether she feels they have worsened
since the baby was born. If you identify an area of concern (e.g. anxiety), then probe
further (refer to anxiety stations). Take a history of recent events and, in particular, ask
how her anxiety and mood have been over the last 2 weeks. Enquire about the delivery
and any complications prenatally, perinatally or immediately postnatally is she still in
pain? Has there been any physical illness? Screen for depression and psychotic features if
positive for any, continue as for puerperal psychosis or postnatal depression.
From there, it is important to establish what medications she is taking (prescription or
over-the-counter), any alcohol or drug misuse and stressors and supports. Common stress-
ors are simply adjusting to the role of motherhood and breast feeding. Failure to breast
feed easily can be associated with guilty feelings and frustration.
Supports to consider are natural networks like family/partner/friends, a health visitor or
antenatal peers. The relationship between Mrs Gray and her baby is important.
Risk
Do not forget the risk assessment!
Diagnosis
In baby blues, it is useful to normalise. Acknowledge that many of her anxieties are
understandable and that many women experience similar feelings. The actor is primed to
give you a history and features of blues in this case tearfulness, emotional lability
(potentially with features of both low and elevated mood) and confusion a few days after
delivery. Postnatal depression is different from the blues, which is a brief period of low,
irritable and fluctuating mood (feeling a bit weepy) occurring approximately 35 days after
giving birth. It does vary in intensity and duration, but is transient and considered a normal
process. Baby blues should not involve hopelessness, worthlessness or suicidality.
Management
You can reassure her that the baby blues usually resolves in a few days and that up to 80%
of new mothers are affected. Bearing this in mind, (further) antidepressant treatment is
not immediately indicated unless something else is going on. If medications are discussed,
the benefits and risks will need to be considered if she is breast feeding.
The best psychological and social care at this stage is supportive with the following options
considered: a clinic review or a home visit from a community psychiatric nurse (CPN) or
health visitor. You might consider a few sessions with a psychologist, if available.
Make sure you have follow-up arrangements in place in order to make sure that this does
not develop into a more serious condition (e.g. postnatal depression). Discuss her natural
support networks (friends/family/partner) again and postnatal support groups. You can
provide written information on the baby blues and relevant charities.
FURTHER READING
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/
cg192
Station 5: Methadone in pregnancy 357
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to
improve
INSTRUCTION TO CANDIDATE
Carla London is a 22-year-old lady who has just found out a few days ago
that she is 68 weeks pregnant. She briefly considered an abortion but has
decided to keep the baby. She has been on methadone 40mg daily for a long
time. She comes to you as she is worried about the effect of methadone on
her baby.
Take a targeted history and discuss the options in terms of managing her
methadone treatment.
DO NOT PERFROM A MENTAL STATE EXAMINATION.
358 Chapter 12: Perinatal psychiatry
SUGGESTED APPROACH
Setting the scene
Begin the task by addressing the patient by name and introducing yourself. Acknowledge
her recent pregnancy and ask if she is happy about this news. If so, feel free to congratulate
her before specifying the purpose of your meeting: I understand you are on methadone
and want to find out more about what this means for your pregnancy. What do you know
about methadone and pregnancy? Allow her to respond. If she starts asking questions,
explain that you need some information first: Before you leave here today, we will have
agreed on a management plan with regards to the methadone. First, however, its impor-
tant that I ask a few questions so I can fully understand your situation. If you park a
question for later, make sure you return to it the actor may not ask again.
Social setup (stressors and supports and the patients lifestyle in terms of employment/
who is at home/other children/partner).
Risk assessment.
Methadone in pregnancy
Recommend that she books her pregnancy if she has not done so already with a local
obstetric service. You should also consider referrals to drug services and a specialist perinatal
mental health team as appropriate. In terms of investigations, you should consider blood
tests (HIV and hepatitis screens if not done recently and baseline renal and liver function)
and a baseline ECG (for QTc interval). You should advise that methadone levels in the
bloodstream may fall in the third trimester of pregnancy, so if she experiences craving or
withdrawal symptoms, she should seek advice on increasing the dose immediately.
Is methadone dangerous to the baby? Will the baby need it after birth?
There is no convincing evidence that methadone leads to congenital abnormalities.
Neonates may experience neonatal abstinence syndrome (with gastrointestinal, respira-
tory and autonomic symptoms), and the birth should take place in a centre with access
to paediatric services. The neonate may need methadone within 48hours, particularly if
they are not being breast fed.
come up with a management plan; to a significant extent, a lot will depend on the patients
informed choices based on the information you provide.
Conclusion
It is important to summarise a management plan as agreed. You can offer further written
information on methadone and pregnancy.
FURTHER READING
National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental
health: Clinical management and service guidance. http://www.nice.org.uk/guidance/
cg192
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. London: Wiley-Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 13
Psychotherapy Dinesh Sinha
LINKED STATIONS
INSTRUCTION TO CANDIDATE
You have been asked to see Ms Jones, a patient you have seen once since
joining the community mental health team (CMHT). She has a diagnosis of
anxiety and depression, but is known as a difficult patient by the team.
She has worked with several care co-coordinators, although you have not
previously met her. It is Friday at 4.45 p.m. and she is insisting on being seen
immediately by you and threatening self-harm if you are not available.
Using techniques learnt in psychotherapy, talk to her and see how you are
able to help.
SUGGESTED APPROACH
Setting the scene
Begin the interview by using as many open questions as you possibly can, which will
indicate a willingness to listen to your patient. Hello, Ms Jones, I was told that you were
really struggling at the moment. Please can you tell me about how things are at the
moment and how we could help? Allow the patient to speak her mind and perhaps begin
to tell you about what is causing her crisis and try to put her at ease by maintaining a flow
of conversation, such as by making it clear that you are hearing what she is saying and
trying to understand the issues.
You will need to find out why the patient has demanded to see you. The aim here is to
make a robust effort at building a therapeutic alliance and to move her away from a con-
frontation. If the patient is very angry/abusive, you may have to do some boundary setting,
suggesting that she needs to calm down or you need to meet again when she is able to
talk. Ms Jones, please do try not to shout, as we cannot continue the conversation in that
manner. It would be really helpful if we could try and work together, as if we cant talk
362 Chapter 13: Psychotherapy
calmly, then I wont be able to work out how to best help you. Addressing the patient
formally helps by reminding the patient of the setting. If she is anxious and wants to talk,
your being able to set the boundary and an enquiry with open questions will help her to
start talking to you, as it will indicate your availability. OK, Ms Jones, so what is worrying
you? Has something happened since you were last seen at the CMHT?
Treatment
You will need to hear her complaints and anxieties without feeling pushed to solve them
instantaneously. What may help is if you are able to hold in mind that a patient who has
only recently begun to see you and then finds it hard to let go (at the end of the week) has
issues regarding separation. This may then present in a manner with a number of griev-
ances, which will leave you feeling that you are doing something very wrong by leaving
her at the start of the weekend. Ms Jones, we have spent the last few minutes thinking
about how the week has gone and clearly you are feeling very distressed. It seems from
what you are saying that quite a significant part of the problem may be the impending
weekend, which is leaving you feeling very alone. Is it possible for us to think about this?
You need to talk to her about what is worrying her and point out that she will be meeting
her care coordinator early next week. Remaining calm when the patient is clearly in a
state of panic/anger will be important. You will have to take her self-harm threats seriously
while also coaxing out why she is presenting like that. How long has it been since you
have been thinking about harming yourself? Have you got any thoughts currently or
plans of self-harm? Have you done anything to harm yourself so far? You need to dem-
onstrate both robustness and openness. An attempt to connect emotionally with her
experience of loss will help more than simply providing her with a practical solution.
Patients are often thought about based on their existing diagnosis. The diagnosis may
undergo revision over time, but long-term patients who present in a needy way, such as
this patient, can be thought of as having prominent attachment difficulties that manifest
with separation issues. The interplay of functional symptoms overlying deeper personality
issues needs to be kept in mind for such patients.
The emphasis could remain on the patient being able to manage until you meet next time.
Ms Jones, can you tell me the things you could do over the weekend that could help you to
feel better? You have spoken about visiting family and friends and keeping yourself occupied
as helpful. Can you give me some idea of how you will manage if things get worse, and do
you think youll be able to keep yourself safe given the things weve already talked about?
However, this may well depend on the history of the patient and the level of risk that she
presents with. There is only so much you can offer in the time available. You must attempt
to have a discussion with her, which includes issues of risk. If she is not able to offer you an
assurance of her capacity to keep herself safe, then you must suggest to her other ways in
which she can seek help. However, if the sort of plans we are making for the weekend dont
work out or things get worse, then I suggest you try making contact with our crisis line to
talk things through or then visit the out-of-hours surgery or accident and emergency.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Ms Jones, we had a discussion about how you have
been feeling and have made a plan to get through the weekend and what to do if things
dont seem manageable. I will be able to see you next week and I suggest we keep that
appointment to review how things have gone.
FURTHER READING
Rosenfeld, H. (1987) Impasse and Interpretation. London: Tavistock.
Steiner, J. (1992) Patient-centered and analyst centered interpretations: Some implications
of containment and countertransference. Psychoanalytic Enquiry, 14, 40622.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
364 Chapter 13: Psychotherapy
INSTRUCTION TO CANDIDATE
The patient you have just spoken to is discussed in the team meeting. She
is very needy and rapidly engages with care workers. However, there can be
situations in which people are left feeling very anxious for her and provide a lot
of support for her. The patient will often use the intervention and be grateful,
but this does not result in any lasting change to her presentation. Her heavy
use of alcohol is assumed to account at least in part forthis.
The team manager has referred her to psychology for cognitive behavioural
therapy (CBT). She only attended some of those sessions, but was
appreciative of the help offered. The manager believes a deeper approach,
such as psychodynamic therapy, may help her.
Discuss a referral for psychotherapy with Laura, your team manager.
SUGGESTED APPROACH
Setting the scene
The discussion will be with the manager who has some knowledge of psychotherapy, but
perhaps not of its details. She wants to discuss the patient, who she believes requires a
psychodynamic intervention. Laura, can you tell me what you think about Ms Jones? I
know we have been worried about her contact with the team and the repeated crisis. The
information that is conveyed would guide the discussion and decision. I agree that the
CBT was useful, but it does not seem to have any lasting impact. I think we should consider
alternatives and look at the possibility of other psychological interventions, as well
as how we could manage the crisis better as a team including doing joint risk
assessments.
Treatment
The manager describes the young woman as being someone who has chronic drug and
alcohol difficulties. There is a sense of perpetual chaos evident from the description of
the patient, including in her use of services. You know, it does seem like she takes what
Station 1(b): Assessment for psychodynamic psychotherapy 365
we offer very much on her terms. I think she is really unable to make use of what has been
offered so far. She can make use of the support, but explorative psychotherapy is not an
intervention for providing support per se. Such information should alert you to the pos-
sibility that this may not be the best time for the patient to be engaging in a psychotherapy
intervention. Motivation is a key ingredient in the process of any psychological
intervention.
Further questioning of the manager would reveal ongoing and prolific use of substances,
including alcohol. The manager admits that the patient at times continues to use crack
cocaine, along with the methadone, which she gets from drug services. Laura, the problem
is that patients such as Ms Jones who are addicted to substances do poorly in therapy, and
the difficulty is that the relationship is with the substance rather than with the therapist.
Also, as painful issues will come up in the process of therapy, the patients capacity to
manage without drugs will be put increasingly under strain if it is not yet proven that she
can manage without them for a sustained period before commencing therapy.
As part of the discussion, it comes to light that Ms Jones has been resistant to discharge
from the team, even when things seem to be going well for her. You could discuss the
sense of an underlying narcissism and the patients apparent neediness. There is a feeling
that somehow everyone needs to be available to her and the engagement is often on her
terms only. She does not easily tolerate boundaries, and the anxiety that is felt and
responded to by professionals is evidence of the rampant projective identification at work.
Laura, I spoke with her care coordinator and her view was that Ms Jones disengaged
whenever their sessions begin to move towards more sensitive areas. Her difficulty with
being able to think of her emotional state bodes ill for any deeper explorative work.
Patients need to have some ego strength and curiosity about themselves to engage in
long-term work. This patient appears to be able to engage, although this does tend to be
as a helpless recipient.
Problem solving
Your colleague may be feeling pressure from the patient and the discussion of the referral
could represent a need for a third person to intervene in a stuck relationship. A formula-
tion could be the need for a firm paternal presence in thinking of this patient and to help
set the boundaries. In this way, thinking about the needs and motivations of the patient
would be beneficial in order to help the manager to separate herself from the projections
of the patient. Further risk evaluation (the patient is not currently self-harming or suicidal)
would help guide consideration of the alternatives. Ms Jones may currently only be able
to use supportive psychological interventions that help her reduce her addiction and
promote psychological thinking.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Laura, we both agree that Ms Jones needs a lot of
366 Chapter 13: Psychotherapy
thought and attention from the team in managing her contact with us better, as it does
not feel like she is currently using our help in the best possible way and is causing a lot of
anxiety. I agree that CBT was worth a try and it does seem to have been helpful during
this period, although there is possibly a need for deeper psychodynamic work. However,
I think that now is not the best time for it, and given her issues with motivation and the
use of illicit drugs, we will need to wait for some stability before referring her for longer
therapy.
FURTHER READING
Holmes, J. (1991) Textbook of Psychotherapy and Psychiatric Practice. Edinburgh: Churchill
Livingstone.
Storr, A. (1990) The Art of Psychotherapy. New York and London: Routledge.
NOTES/Areas to improve
Station 2(a): CBT first session 367
INSTRUCTION TO CANDIDATE
You are meeting Mr Jones for the first of 12 sessions of CBT.
Determine with the patient what will happen in the therapy and attempt to
answer any queries the patient may have.
SUGGESTED APPROACH
Setting the scene
The patient will be meeting you for the first time. Mr Jones, hello. My name is Dr_____.
I understand you have been on the waiting list to start CBT.
Start by asking what he knows about CBT already. The aim of CBT of enabling the patient
to acquire skills with which they can function better can be pursued from the beginning
of the meeting, as you could explain to them that you will not be someone who will be
simply instructing them on what to do to get better. You will be working alongside them
in discovering more about themselves and learning skills that they could then use both
inside and outside of the sessions.
You must demonstrate your knowledge of CBT and be empathically responsive to ques-
tions from the patient while putting him at ease by engaging him in dialogue about any
concerns. In this way, you will quickly begin to build a therapeutic alliance.
Treatment
Mr Jones, I suggest we agree to an agenda for the session and the things we would like to
discuss. I do want to set aside time for us to talk through any questions you may have. You
need to discuss the frame of the sessions, including the length, place, progress since last
seen (bridge), current difficulties, aims from therapy, knowledge of CBT, homework/work
outside the sessions and summary. Mr Jones may have further questions, which could
relate to the anxiety of starting therapy. An acknowledgement of his feelings along with
an enquiring and encouraging stance will help the patient feel more at ease with you.
How have things been since you went onto the waiting list? This can be followed up by
a discussion of how CBT may help him with understanding his difficulties. You should
introduce the central role of thoughts with the link to mood/feelings and behaviour. The
key is to allow the patient lots of room to ask questions while allowing new information
about the duration/structure and possible content of sessions to be introduced in the first
session. Drawing a simple diagram linking all of these together with a reinforcement loop
can help.
368 Chapter 13: Psychotherapy
Scenario Thoughts
Behaviour Feelings
Problem solving
Some patients could ask if there is any evidence that this therapy works. You could cite
NICE guidelines, which are based on systematic reviews of current relevant evidence and
make specific recommendations about the use of CBT. Avoid the use of technical jargon
and try to present the information to the patient in simple terms. Allowing thepatient
to express their doubts and reservations as the session progresses will help with setting
up a therapeutic alliance. Mr Jones, homework is about the work done in therapy con-
tinuing outside the sessions. Similarly, behavioural experiments are opportunities for
us to allow the skills which are being learnt here to be tested in the real world.
Conclusion
Here you can summarise what you have discussed, any further information you want
to give and what the next steps will be. Mr Jones, we have been talking about the period
in which you have been waiting to start CBT. We have discussed various concerns
aboutwhat therapy would bring up and if it would, in the end, be helpful. I think we
have covered a lot of ground of what to expect in CBT and discussed the structure of
sessions. I suggest now that we confirm that we will meet next week to start the
therapy.
FURTHER READING
Beck, A.T. (1987) Cognitive models of depression. Journal of Cognitive Psychotherapy,
1,537.
Greenberger, D. & Padesky, C. (1996) Mind over Mood. New York, NY: The Guildford Press.
Station 2(b): Behavioural experiment in CBT 369
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have now seen your patient for three sessions of CBT and he has
explained in some detail his difficulties in social situations. He can find
it difficult to function socially and spends much of his free time at home.
He feels that his career is also affected. He has often felt a failure when
describing past episodes of being in social situations.
Discuss a behavioural experiment with him.
with anxiety and your particular problems in social situations, which have been making you
feel so stressed that you have avoided social occasions. You have felt its impact on your career,
as you cannot interact well at work events and this makes you feel like a failure. Talking has
been difficult, but you are really not looking forward to an experiment in therapy.
SUGGESTED APPROACH
Setting the scene
The behavioural task is a useful tool in CBT and one of the important ways in which the
patient carries on the work outside of the sessions. It enables the patient to translate the
theory into practice and provides the therapy with an in vivo experiment to discuss and
base further work on. It can give the patient a real sense of picking up the skills being
discussed and a sense of mastery over the problems for which they have sought therapy.
It captures the need for collaborative work with the patient, and to do this, you need to
be able to explain the theory, explore anxieties and engage him in a dialogue. The thera-
peutic alliance and capacity to listen will help to put the patient at ease while using the
opportunity to impart knowledge of CBT as you seek to improve his skills.
Treatment
The rationale for the behavioural task needs to be explained to the patient. He will be
understandably anxious, as this is the first such task in the therapy. Allow enough space
for questions from the patient. The task for a patient with social anxiety has to be
carefully graded to be a step up from what they may be currently able to achieve and
yet not too much. I suggest that we start small, such as the Friday meeting that you
described at work, and see if we can set a small experiment around this situation, such
as talking over coffee with a colleague. Too much too soon can leave a patient feeling
more of a failure and ward off attempts at change. Thus, graded exposure to increas-
ingly more difficult tasks provides a sense of mastery over the problem. Later, there
may be more challenging tasks that could be set up, which could include different
settings and levels of tasks to be achieved. The setting of the task, the people involved,
the patients anxieties and fears and the actual task (talk for 5 minutes over coffee)
need to be considered and agreed upon. Making clear notes and encouraging the patient
to keep a record of the task also helps, as does imagining and discussing a situation
(cognitive rehearsal).
The patient could have catastrophic outcomes in mind and going through this following
the model of thoughts, behaviour and consequences in the setting will help him. Given
your concerns about things going wrong, lets have a think about various strategies you
could use to help you finish the task. This may include using distraction techniques
preceding the task to reduce anxiety or cue cards to help carry out the actual task. Role-
play (modelling) also helps by providing a taste of the experience in a contained setting
where the task can be rehearsed and misgivings addressed.
Problem solving
Adequate contingency planning to anticipate known reasons for avoidance and failure
to complete a task is important. After the task, there may be an opportunity to use a
feedback survey to properly evaluate task completion. This behavioural feedback can help
provide a more balanced report, which can be used to question black-and-white thinking.
Further work on automatic thoughts and clarification of rules, assumptions and beliefs
will help the patient understand his difficulties.
Station 2(b): Behavioural experiment in CBT 371
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Mr Jones, we have spent some time today discussing
the progress of therapy. We have been talking about the structure of CBT and exploring
the details of your problems that have brought you into therapy. That hasbrought us to
behavioural experiments and their crucial role in this kind of therapy. We have looked
at starting small and decided on a social behavioural experiment in asocial setting at
work to start things off, including how we will evaluate its success.Isuggest you do give
it a go in the next week and we review it in our session next week.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
372 Chapter 13: Psychotherapy
INSTRUCTION TO CANDIDATE
Ms Jones has presented to accident and emergency (A&E) having taken an
overdose. She has an unclear diagnosis, with several being mentioned in
records. She initially wanted help, but is now refusing treatment. A&E staff
are concerned about her physical state, but she does not allow them to
examine her.
Assess this patient and, in particular, the motivation for the overdose. In the
next station you will be asked to consider the case psychodynamically; this
will help focus your assessment.
You are not expected to complete a full history and mental state
examination in the available time.
SUGGESTED APPROACH
Setting the scene
Start by asking the patient, Ms Jones, I am one of the A&E doctors. Please can you tell me
what has brought you here today? The emphasis at the beginning needs to be on finding
out what has happened using open questions without creating an atmosphere of confron-
tation, which could be persecuting for the patient. Her responses will guide you into the
body of the task. Your interview technique needs to make use of open questions using
empathy and managing anxiety in a challenging situation. It seems things have felt really
hard after this falling out with your friend. Why did you take the overdose of paracetamol?
What were you hoping would happen?
In talking to the patient, you have to be able to try to find out what has happened, includ-
ing the reason for the overdose, in order to understand why she has presented (her moti-
vation to seek help) and what the problem is regarding accepting treatment, including a
risk assessment.
Treatment
Ms Jones, please can you tell me if this is the first time you have felt like this or have there
been difficulties with your mood in the past? She may report a lifetime of feeling low
and repeated self-harm. I notice that you did seek help after the overdose, but are now
refusing help when it is available. Please can you tell me what you would like to happen?
After this you could present her with options that are available, along with the risks and
benefits (in a concise way) of each.
Station 3(a): Overdose in accident andemergency 373
The actor might have instructions to engage with you fleetingly and then ask what you
think would help. If you mention the need for an in-patient assessment or community
follow-up, she will refuse and try to leave, as she is now in the midst of such intense anxiety
that the object quickly shifts from being good to bad. These are features of a paranoid
schizoid position, which is a persistent feature in borderline personality disorder, although
it can also affect other individuals in situations of stress. Ms Jones, it seems like something
of what I am suggesting does not meet your expectations. Can you tell me what you think
would be helpful at a time like this? This makes use of your counter-transference, such
as feelings of anxiety of how to deal with the situation, followed by a sense of being unsure
of what has gone wrong in your conversation with the patient, even feeling that you have
done something to provoke the patient to try to leave and being left with feelings of
rejection.
Problem solving
This could include having to deal with your own frustration when talking to such a
patient, as you need to be calm when the patient is agitated and anxious, without appear-
ing to be detached. While talking to the patient, you would also need to avoid being
authoritarian, and instead try to give her a sense of having options. Ms Jones, I know it
feels like we are struggling to agree on what would help, but actually, you have done
something very important by seeking help and we must not let that be forgotten. Parts
of her are acting in opposition. Appealing to the more adult part of her mind is one way
to engage with her limited awareness of needing help.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Ms Jones, we have been talking about the events
which led to your overdose with paracetamol earlier today. We have explored the problems
that led to the overdose and spent some time thinking about your risk to yourself at a
time like this. I think it is important that you have sought help from services at a stressful
time for you and agree that you do need further support. You continue to feel unsafe and
are unable to assure me of keeping yourself safe. We have agreed that it would help for
you to have support with a brief admission to our in-patient unit. I will now arrange your
transfer to the ward.
FURTHER READING
Gabbard, G. (2000) Psychodynamic Psychiatry in Clinical Practice. Washington, DC, and
London: American Psychiatric Press, Inc.
Steiner, J. (1987) The interplay between pathological organizations and the paranoidschiz-
oid and depressive positions. International Journal of Psycho-Analysis, 68, 6980.
374 Chapter 13: Psychotherapy
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
The patient you have just seen has been admitted to your ward. Her case
notes clarify her diagnosis as chronic depression with significant borderline
traits along with occasional possible psychotic symptoms, although opinion
has been divided regarding their nature (psychosis or pseudo-psychosis). The
patient now appears paranoid and talks about hearing voices. Some nursing
staff are unimpressed and feel that the bed could be better used. They feel
Station 3(b): Borderline personality disorder 375
angry towards her (and you for admitting her) and are suspicious that she is
here as her benefits are under threat.
Discuss a psychodynamic formulation and case management with the newly
appointed consultant, Dr James. He does not know the patient and wonders
if she could be discharged.
SUGGESTED APPROACH
Setting the scene
The consultant wants information about the patient and your opinion on what you think
may be going on. You need to start the discussion keeping in mind that there are already
strong opinions about her. You should summarise the circumstances surrounding her
admission and mention the need for more collateral information. Dr James, I have known
her for the relatively brief period since she has been on the ward, as there was no previous
knowledge of her prior to this admission. In your comments, you need to demonstrate
your understanding of transference and knowledge of counter-transference, making links
with her defensive manoeuvres. In this way, you would link the psychiatric presentation
with a psychodynamic formulation.
Treatment
The difficulty here will be keeping an open mind about the patient. Patients with border-
line presentations can arouse deep splits and conflict amongst clinicians involved in their
treatment. Indeed, they can often present with a combination of affective and psychotic
disturbances, which can coexist, causing additional difficulties in formulation. Along
with this, there may be comorbid alcohol and drugs misuse. Think about splitting fairly
early on in your discussion, in which the patient tries to manage opposing feelings by
lodging them in different members of staff. The good and bad split refers to the inability
to hold a whole object and the predominance of part objects in the internal world, while
the extreme reactions in the ward staff appear to mirror this problem. This can be linked
to in your discussion about the response to such feelings in staff (which includes yourself),
which can be understood by the defence of projective identification employed uncon-
sciously by the patient. Dr James, I do feel that the responses of the various staff members
are all part of the presentation of the patient. We need to try to hold these opposing feel-
ings together in order to deal with the patient in the most helpful way, which would
include evaluation and boundary setting.
You may then be asked about her possible discharge from the ward and whether you agree
with one or other staff members who have strong feelings about the patient being on the
376 Chapter 13: Psychotherapy
ward. I think the problem is that she does provoke extreme feelings in all of us. The risk
is that we may make an unhelpful decision about her care if we dont think about her
needs. It is known that long periods of in-patient treatment are not helpful for such
patients.
Problem solving
You should emphasise the need for risk assessment in managing the patient in the ward
and also the importance of the continuity of care into the community setting. If her
mental state is stable, discharge should be considered early, along with a clear plan on
how to manage crises in the community, preferably with the involvement of a limited
and small group of caseworkers. Discussion with care workers in the community helps
manage splits and provides the patient with some sense of being thought about, although
any sense of being discharged is likely to provoke persecutory responses.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Dr James, thanks, it has been helpful discussing the
care of Ms Jones. It seems likely that the strong reactions that have been evident in the
ward are connected to her issues and that as a group of clinicians we need to spend more
time thinking about our responses. I will speak to the nurses in charge ward manager
about this and we can also discuss our decision about boundaries and the period of in-
patient care in the ward round tomorrow.
FURTHER READING
Bateman, A. & Holmes, J. (2003) Introduction to Psychoanalysis. New York and London:
Routledge.
Hinshelwood, R.D. (1999) The difficult patient. British Journal of Psychiatry, 174, 18790.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
This patient, Ms Smith, has a diagnosis of post-traumatic stress disorder
(PTSD) and wants help. She has been started on antidepressant therapy by
her GP.
Discuss the possible psychotherapeutic options available.
SUGGESTED APPROACH
Setting the scene
The need is to reach a collaborative decision following an explanation of the theory and
choices. The patient could present in a helpless and anxious manner or she may confront
you with her research that she conducted on the Internet and want a particular type of
therapy. Ms Smith, please can you tell about the difficulties for which you have been
referred here today? It looks like the problems of nightmares, flashbacks and anxiety
around going outside and avoiding situations outside are becoming worse. Lets talk about
the various options that may be available. I note that your GP has already started you on
antidepressants which are likely to help with these problems. There are types of therapy
which could also be helpful. You have to be mindful of the need to discuss options and
try to help the patient arrive at a decision without pushing a decision onto the patient.
You need to explain best practice based on the NICE guidelines and explore her anxieties
while answering questions. This will help engage her in a dialogue and demonstrate
empathy.
Treatment
Ask what she knows about the talking therapies that have been recommended. Guidelines
need to be considered, but not necessarily adhered to rigidly. Ms Smith, there is a choice
of psychological treatments such as cognitive behavioural therapy or eye movement
desensitisation and reprocessing for the sort of difficulties that you are having. It is quite
common to consider a combination of medication and psychotherapy to help with PTSD.
The level and timing of intervention will depend on the period since the trauma. At the
beginning, we usually suggest that people wait and see if the problems resolve on their
own over time. However, in your case, there has already been a period of 4 weeks and so
this period of what we call watchful waiting is past. If the symptoms have lasted for over
3 months, then trauma-focussed psychological treatment should be carried out using
trauma-focussed CBT or eye movement desensitisation and reprocessing (EMDR), while
treatment beginning within 3 months of symptom onset can be briefer.
The treatment centres on psycho-education, exposure and cognitive restructuring. The
exposure can be invivo (previously avoided situations) or imaginal. The model for treat-
ment-focussed CBT therapy is somewhat along the lines of any anxiety disorder, incor-
porating feedback loops, anticipatory anxiety, avoidance behaviours and misperceptions/
misunderstandings of (physical and emotional) cues. Ms Smith, the therapy will try to
reduce anxiety by working to increase your confidence in situations that are currently
causing you to avoid going out, for instance. When the symptoms have lasted for a longer
duration, a much longer period of treatment may be required than the usual 812 sessions.
This is particularly important as CBT sessions will have to be focussed on over the longer
term in order not to forget the treatment aims. This restructuring aims to target unhelpful
thinking and uses thought records in order to identify automatic thoughts.
The patient is already using pharmacological therapy, which is not usually a first-line
treatment. The use of specific antidepressants (like paroxetine and mirtazapine) is advo-
cated and can also be given in combination or as adjuncts to the psychological interven-
tion. Presenting all of the available options and encouraging discussion will also help
soothe the patient.
Problem solving
Discussion of alternatives and weighing up the options can help with the patients engage-
ment with the eventual treatment, and the decision a patient may then reach should be
respected. Ms Smith, I know that you think the current issues are probably related to your
Station 4: Post-traumatic stress disorder Treatment options 379
early childhood and that you have researched psychodynamic therapy. However, there
are reasons why this treatment is not indicated for the sort of problems that you are having
at the moment. The need is for you to understand the basis of these difficulties in the here
and now and to work out ways to overcome your problems, such as not avoiding going out
altogether. You could speak of the evidence base (quality of evidence) used for the recom-
mendations (e.g. for CBT) whilst making it clear that there are options to choose from.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Ms Smith, we have spent some time in our meeting
today talking about the awful incident that led to your difficulties with post-traumatic
stress disorder. We have also considered your questions about the best mode of therapy
and your interest in psychodynamic psychotherapy. You have told me about the extent
of your ongoing problems and we have thought about how the CBT therapy could help
you gain some mastery over these issues and give you more of a sense of control and relief.
I think we are agreed that the treatment of choice for your problems currently would
beCBT.
FURTHER READING
Bisson, J. & Andrew, M. (2005) Psychological treatment of post-traumatic stress disorder
(PTSD). Cochrane Database of Systematic Reviews (2), CD003388.
National Institute for Health and Care Excellence (2005) Post-traumatic stress disorder:
Management of post-traumatic stress disorder in adults in primary, secondary and
community care. https://www.nice.org.uk/guidance/cg26
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are seeing Mr Jones for the first time. He has been on the waiting list for
psychotherapy for a year. He has a history of having been in multiple foster
placements. He seems hesitant and gives practical reasons for not being able
to commence therapy.
Conduct the business meeting to discuss the start of psychotherapy.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and acknowledge that the patient has been on the waiting list for some
time. You should explain that the meeting is not a therapy session, but instead aims to
agree to start therapy with you as the therapist (i.e. a business meeting). This will be
Station 5: Psychodynamic psychotherapy 381
particularly important for such a patient who has a history of being recurrently moved
on and thus experiencing possible difficulties regarding attachment and separation.
Mr Jones, I know that you have been waiting for a long time to begin therapy. As we
discussed in my letter, I now have a space for therapy and wanted to meet so we can agree
to the therapy. This is not the start of therapy, but more about agreeing on the plan and
structure for the sessions, such as times and the length of therapy. How have things been
since you were seen for your last review? Your interview technique must focus on the use
of open questions to elicit your patients current feelings of anxiety.
The patient tells you that he is not sure now is the best time for him to start, saying that
he is likely to be starting a new job. Your aim may be to understand his ambivalence
without being persecutory or dismissive. Mr Jones, I wonder if the possibility of therapy
starting has brought up some difficult feelings. Please can we talk about how this feels?
In opening up the possibility of talking openly about his concerns, you are helping the
patient with a difficult decision, as the final decision of commencing therapy remains
with him.
Treatment
The business meeting gives the therapist the opportunity to learn about the person, to
understand the current situation and to formulate ideas about treatment. Mr Jones, the
sessions will be once weekly at a fixed time and day and the length of the therapy will be
approximately 12 months. It is within this context that positive changes in the patients
outlook and behaviours are able to unfold. The therapist maintains a consistently neutral
and accepting stance and is trained to listen objectively without criticism.
The patient is likely to have had a prolonged assessment (usually two to three sessions)
with another therapist when he was entered onto the waiting list and there could be
feelings of resentment about having been moved again onto yet another person to actu-
ally commence therapy. He may insist that he does not need therapy any longer. He could
also say that he is now working or hoping to begin work and so can only do therapy if it
is offered to him in the evenings. We do sometimes have out-of-hours therapy available,
but as discussed at the assessment, most spaces are during working hours. I do think we
need to consider what else may be posing problems for you entering therapy when you
have been waiting for such a long time. The aim throughout is to encourage a dialogue
and acknowledge feelings of anxiety or anger. All of this needs to be done whilst not
converting the business meeting into a therapy session. The discussion needs to consider
the balance of claustrophobic anxiety (the patient feels trapped when therapy is avail-
able) and agoraphobic anxiety (he does not want to be left out, hence remaining on the
waiting list).
The patient may then tell you that he is afraid of what he will find out about himself in
the therapy. He may have feelings of anxiety about being picked up and then left by you.
As you continue to talk, the patient may then seem to become less dismissive.
Acknowledging the patients anxieties while at the same time pointing out that he has
been waiting for a long time for therapy and opening up further dialogue about this will
help him to make a decision. Be mindful that while you can help him to think about what
may be difficult, the decision of whether to start or not is his in the end.
very important to convey to the examiner, as well as that you are emotionally involved
with the patients dilemma while at the same time not being caught up in an
enactment.
Psychodynamic psychotherapy aims to help find relief from emotional pain. It is similar
to psychoanalysis in attributing emotional difficulties to unconscious motives and con-
flicts. Psychodynamic psychotherapy is employed for a variety of problems including
mood difficulties, relational issues, and so forth. Sessions can take place on 13 days per
week, with greater frequency allowing for more in-depth treatment, and they usually last
for 4550 minutes. Most NHS-based services will now offer no more than 1 year (approxi-
mately 40 sessions) of therapy.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Mr Jones, we have met to discuss the possibility of
you starting your treatment of psychodynamic therapy after the period you have spent
on the waiting list. However, you did have some serious concerns about any future work
interfering with you being able to attend therapy. I think in our discussion we worked
out that some of these concerns were also linked to the worry that therapy would be
disturbing and may make things worse. However, having thought about the possible
benefits, you have decided to give it a go, and so I suggest we meet next week at this time
for the first session of therapy.
FURTHER READING
Bateman, A. & Fonagy, P. (2004) Psychotherapy for Borderline Personality Disorder. Oxford:
Oxford University Press.
Hughes, P. (1999) Dynamic Psychotherapy Explained. London: Radcliffe Medical Press.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are seeing Ms Jones, a patient with bipolar affective disorder who
has been known to the team for several years. She is very angry with the
consultant who admitted her to the ward earlier that year under a section of
the Mental Health Act and is refusing to see him. She is seeing you in the
clinic for the first time as she is threatening to stop all of her medication and
to terminate contact with the team.
Speak to this patient and attempt engagement and discussion regarding the
future.
SUGGESTED APPROACH
Setting the scene
This is a potentially challenging station involving managing a patient who is very angry
and ready to have a fight with you regarding her medication and her recent treatment.
She believes that she should not have been admitted to hospital against her wishes. You
will need to demonstrate empathy and develop rapport while not reacting to provocation.
384 Chapter 13: Psychotherapy
Ms Jones, I know that you have been distressed and upset by your recent treatment and
I wonder if we can talk about your concerns.
Her insistence on and belief in her understanding of her illness have led to her anger. This
could become a point of disagreement involving her insistence that she comes off all of
her medication and your anxiety that this does not happen, as there is a history of relapse
on stopping treatment. It is important that you start with an open statement such as
acknowledging that she has a lot to talk about with you and allowing her to have her say
without seeming to be ready to disagree.
Treatment
She may launch into a provocative account of how she feels she was put into hospital
by the consultant who did not know her well. The actor would then tell you that she is
planning to start a family, how she feels completely well and that all your team has done
is to leave her in more difficulty. A lot of this is an evacuation of her resentment, which
you simply need to be able to bear and make some sense of. However, there is a lot in the
content and process of what is being said which could be helpful in this consultation.
She intends to stop her medications and withdraw from the team. She will not be coming
to any more of these useless clinic appointments. Ms Jones, I recognise that the last
few months have been difficult. I wonder how this leaves you feeling about your care
and the team.
The anger could also mask anxiety about what might happen with you and an attempt
to avoid mourning the effect of her illness. There may be an unconscious fantasy of a
successful union with you (unlike that with the consultant recently) and the birth of a
shared understanding. I do understand what you are saying about your knowledge
through experience and research of bipolar disorder. Good listening is key. Do not dismiss
her thoughts about wanting to start a family, which should be explored. In addition, this
discussion would feel more hopeful if it is led away from the point of contention (the
argument about the medication). This may help her begin to talk about plans and think
about her needs. Clearly, there is an aspect of the patient that does want to be thought
about (she has turned up for the appointment after all), and that is the aspect you need
to try to engage. When the patient begins to talk to you, you could begin to explore the
disruption that falling ill causes to her life and the need to be mindful of this given her
plans for the future.
Problem solving
Depending on your handling of the initial stages of the station, you may see a calmer
period in the conversation in which her ambivalence regarding accepting her illness and
the effects of this upon her can be talked about. On the other hand, she could well turn
back onto the grievance and demonstrate ambivalence in her interaction. The further
you can progress into the conversation and address the future while acknowledging her
grievance and also her wish for care, the better are the chances of engaging with her more
concerned aspect.
The mother and feeding baby dyad could be one way of thinking about this interaction
psychodynamically. The baby needs a feed in order to survive and at the same time experi-
ences fury at not having control of the breast. The rage is expressed in the initial biting
of the breast until a persistent and containing mother soothes the infant to feed.
medication due to her wish to have a baby (and if she is in a supportive relationship),
rather than getting caught up in any provocation or conflict. Ms Jones, its really great
that you are thinking about the future and have some clear ideas of what you would like.
Perhaps we could discuss what could be helpful for you to get there and how we could
best support you?
It will be helpful to consider your counter-transference. The rage from the patient and
your feeling trapped with her could be an experience of her difficulty with emotional
states in which she has to process a lot by herself, like a hungry infant that has to manage
hunger until the withholding breast returns.
Focus on the future so that the hopeful aspects of the patients interaction can begin to
be thought about, even if some of the plans may seem unrealistic.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Ms Jones, we have been talking about your concerns
about the care you previously received from the team. We spent some time thinking about
the impact of the recent admission and your wish to stop your medication. However, I
thought what really did seem important were your wishes and plans for the future. It is
really important that we do help you to get there and consider the support we can offer
you. We agreed that you will continue your medication for now, and we will continue to
meet in order to review your treatment.
FURTHER READING
Steiner, J. (2006) Seeing and being seen: Narcissistic pride and narcissistic humiliation,
international. Journal of Psychoanalysis, 87, 93951.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
This patient, Ms Patel, is a senior executive in an advertising firm. In the
records, you note that she has once-weekly private therapy. She tells you that
things have been well despite a hectic life. She has a diagnosis of depression
with a history of self-harm attempts a long time ago. She was brought up by her
father after her mother left when she was 6years old. She had no contact with
mental health services for a year, but the GP believes she is now less well.
Speak to this patient and use your experience of psychodynamic
psychotherapy to interpret her presentation.
SUGGESTED APPROACH
Setting the scene
Ms Patel, how have things been recently for you? She is likely to respond by giving you
a lot of detail of her busy life. She has been busy travelling abroad with her work. She goes
on to mention that she has been puzzled as to why she is not able to get out of bed on
some days. Ms Patel, it seems like on the one hand things are going rather well. Yet there
are problems that are harder to understand and seem to need some further thought. Have
you any idea of why your sleep has been disturbed? You need to highlight the discrepancy
and ask her more about this, otherwise she might continue to dazzle you with her func-
tioning aspects, which may present a false picture.
In conversing with the patient in a more general way with open questions, you demon-
strate the establishment of rapport. Ms Patel, it feels like its harder for us to stay with
what you are finding difficult at the moment, as I notice you keep moving back to talking
Station 7: Psychodynamic interpretation 387
about the busy events of your life, such as work. However, even here it seems from what
you said that there have been some problems. If she dismisses your attempt to understand
her difficulties, you may respond thoughtfully to it rather than being provoked into an
irritable response. In this way, you will explore current issues including risk and maintain
empathy for a defensive patient while exploring the need for the defence.
Treatment
It is important to make an emotional link with this patient who herself seems to function
in a cut-off way, making a manic flight away from her more depressive feelings. Ms Patel,
you say there have been days when you are unable to get out of bed. I wonder if you have
a sense of everything not being well. She says this has only happened now for the past 23
months. What have been the recent stresses? She mentions an incident 2weeks ago in
which she had gone into the shop to buy some medication for a cold and instead bought
several packets of paracetamol. She had never thought much about this and had certainly
not wanted to or planned an overdose. You might now feel anxious, a shift away from the
slightly cut-off and even irritated feeling at the beginning while she discussed her work.
Despite the task that has been set, you will need to consider a risk screen. Ms Patel, please
can you tell me about why you bought the paracetamol. What were you planning to do with
it? Have you thought of self-harm or attempting suicide? What stops you or prevents you?
Ask about what is coming up in therapy for her and if she has been going to her therapy
sessions. It transpires that she has been so busy in the past few months that she has missed
several sessions. This is another example of the scotomisation of her needs by moving
away from the space where her experience of loss could be considered. The patient is
struggling to process her loss, seeming to be stuck in a stage of denial about it. This is
acting out of her background in which she achieved a lot early on while seemingly man-
aging the loss of her mother, who left home when she was very young. The problem with
this is that her feelings of rage and hurt are ignored and instead turned inwards, as cap-
tured in her faltering motivation to work and the purchasing of tablets.
You could now have a discussion about her blocking out and highlight that there is a
process going on in which the frame that is available to help her think of her emotional
state is being left behind. Perhaps in leaving her therapist waiting, she is acting out how
left behind and messed about she feels, although this is only a fleeting triumph.
Problem solving
The patient might ask for more medication, as this is what has helped her in the past. She
thinks this is what will help her and she lapses back into telling you of all the meetings
which are coming up and the plans for travel which are a part of this.
You could feel very controlled by this patient, and when you try to direct to her therapy,
she seems to have shifted the discussion to something intellectual. She bristles when you
suggest her feelings of loss and her controlling you in the consultation are further examples
of her method of seeking to ensure distance from the object that makes her feel needy.
Ms Patel, I wonder if we need at the moment to stay with your need for the therapy that
you have been missing, rather than moving on to medication. You could also point out
that you are now also available for monitoring her in out-patient appointments.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Ms Patel, we have been talking about how you have
been doing more recently. We agreed that while things may appear fine with work and
so on, there may be some things that are becoming concerning, such as your sleep and
thoughts of suicide. We discussed the care you were receiving from your GP and in your
therapy. We agreed that it may be best for you to have some more support and this could
well be from regularly attending your therapy, instead of the number of sessions that have
recently been missed. I also think that the medication increases mentioned by your GP
will be helpful. I will speak with your GP, if thats OK, and see you in another 2 weeks to
see how things have progressed.
FURTHER READING
Rosenfeld, H. (1971) A clinical approach to the psychoanalytic theory of the life and death
instincts: An investigation into the aggressive aspects of narcissism. International Journal
of Psycho-Analysis, 52, 16978.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 8: Cognitive distortions 389
INSTRUCTION TO CANDIDATE
Mr Cole, a footballer, presents with depression. He underperformed in a
recent key match. He has various cognitive errors, including minimisation,
maximisation, selective abstraction and catastrophic thinking.
Assess him and identify these distortions.
Discuss psychological treatment options.
SUGGESTED APPROACH
Setting the scene
In conversing with the patient in a more general way with open questions, you demon-
strate the establishment of rapport. Mr Cole, please tell me what has brought you here
today. What are your concerns? You will need to engage a rather ambivalent patient who
is unsure about the benefits of talking. I understand you are a footballer and it seems like
there have been problems with your work. Please can you tell me some details of what
happened? In talking with such a patient, you may notice that he struggles to speak or
to describe his difficulties.
Treatment
You can help by reassuring him about the usefulness of the meeting. Mr Cole, it may be
useful to talk, as your coming here, even though you are unsure about how much use it
will be, suggests that there are things that need more thought. Its perfectly normal to
feel anxious or unsure about talking in the beginning, and perhaps we could start by
discussing what concerns you have about talking. He goes on to describe how the game
was lost due to him not scoring and that this means he has let everyone down.
Cognitive distortions describe flaws and errors in the cognitive processing of information
that lead to incorrect conclusions, which cause and maintain disturbances in feelings.
Mr Cole, please can you tell me about what was happening earlier that day in the lead
up to your match. He speaks about feeling unwell but is insistent that his poor game was
the problem. Mr Cole, I notice that you completed the game in spite of being unwell and
390 Chapter 13: Psychotherapy
prevented goals being scored against your team. Was this not important? Minimisation
is a cognitive distortion in which the patient minimises the importance of a success
incorrectly, while in maximisation, a minor issue is considered to hold importance out
of proportion as responsible for the event, often to the exclusion of other contributory
factors. In this scenario, the patient may present the sickness before the game as seemingly
of little importance, which increases his sense of guilt and responsibility for subsequent
events.
Losing the game may mean the end of everything, overshadowing all previous or future
achievements. The patient may show catastrophic thinking if he says that not scoring
and being picked by the talent scouts means the end of his career. I wonder if its inac-
curate that your not being at your best in a single game will mean that you will have no
chances of progressing your career in the future.
By challenging the evident cognitive distortions, you enter into a dialogue with the patient
about events, understand the errors in cognitive processing and determine whether they
are more widespread, affecting other areas of the patients life. Mr Cole, it seems to me
that you are underplaying the importance of being part of a team that held its place and
drew. Would you consider other players on the team as also not pulling their weight if
they were unwell?
Another distortion can be selective abstraction in which the patient takes an isolated
aspect of an event and makes conclusions based entirely on it while ignoring the broader
context. Mr Cole, it seems like not getting a goal in that one match, even if others in your
team praised your resilience, has come to define you as a player and as a person for every-
one who knows you.
The aim is to demonstrate the distortions and involve the patient in this discussion.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Mr Cole, we have been talking about the recent
episode in your game, which has left you very upset and distressed. In talking about this
experience, it is clear that this has set off painful feelings. As we discussed, I feel that the
sort of thoughts linked to these feelings are making things worse, and this is where CBT
could be of use. In CBT, we can explore and work on the thoughts being set off in situa-
tions such as what has happened to you and their links to feelings and behaviours. Hence,
you are likely to benefit from a course of CBT.
FURTHER READING
Beck, A. T. (1976) Cognitive Therapies and Emotional Disorders. New York, NY: New
American Library.
Station 9: Patient experiencing transference reaction in psychodynamic therapy 391
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mr Jones, a patient, is experiencing a transference reaction in
psychodynamic therapy and wishes to discontinue. You are not the regular
therapist, but the patient has asked to meet another doctor, as he is
considering ending treatment.
Explore his experience of therapy from a psychodynamic perspective that is
understandable to the patient.
392 Chapter 13: Psychotherapy
SUGGESTED APPROACH
Setting the scene
This situation is problematic, as the patient is not with you in therapy, but is meeting you
as he is unwilling to return to see his therapist. Mr Jones, I understand there have been
some issues with your treatment. Please can you tell me a little about them? He may speak
with some hesitation about his concerns with his therapist. He complains that she does
not greet him or say much during the sessions. He has found that the past 3 months have
achieved little, with her behaviour remaining unchanged.
Treatment
Mr Jones, it is concerning that things are not going as well as we would like, but it could
be useful for us to think further about these difficulties. Was the process of therapy
discussed with you at assessment and before it started? He may concur that it was, but
that the experience in therapy was still disturbing for him. Mr Jones, there can some-
times be problems between patient and therapists, but I noticed in the assessment notes
that some of these issue have appeared in other settings, such as work. He may agree
and talk about what brought him into therapy, including the difficulties with vari-
ousbosses and colleagues. He had previously left jobs after he felt badly treated by
employers and agrees that he may be sensitive to such experiences, although he still
insists that the issues in therapy would not be there if his therapist could just behave
differently.
You need to continue to link the past with his current issues. Mr Jones, given what you
have said so far about these problems happening repeatedly, I wonder if there could be a
connection with these coming up in therapy with your therapist. At this point, he may
become more open to thinking about this or continue to resist the idea of the problems
being connected to the past. It may be that the problems and feelings we are discussing
are what brought you into therapy and they need more space for exploration, rather than
stopping therapy early.
the task of sensitively helping someone recognise that the problems in therapy do not
mean that the therapy itself is at fault, but that it is bringing up issues which need further
exploration. This is a crucial interaction, as he is facing a decision of continuing or not
with the longer 1year commitment to the therapy.
Conclusion
Here you can summarise what you have discussed, any further information you want to
give and what the next steps will be. Mr Jones, we have been talking about the problems
that have come up in therapy, which you have attended over the past few months. Its
clear that your relationship with your therapist is under strain. You have helpfully spoken
about your experiences in therapy and we have explored these and other issues within
this and other relationships. We have explored the links between these issues and your
early experiences and there was some agreement that this could do with more analysis.
Hence, I suggest that you return to the therapy and bring up these issues with your thera-
pist so that you may both explore them.
FURTHER READING
Sandler, J.J. (1976) Countertransference and role-responsiveness. International Review of
Psycho-Analysis, 3, 437.
Seinfeld, J. (2002). A Primer for Handling the Negative Therapeutic Reaction. Lanham, MD:
Jason Aronson, Inc.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 14 Sangita Agarwal and Justin Sauer
Physical examinations
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, its nice to meet you. Im glad youve
decided to come and talk to me today about the drinking. First of all, would it be OK if I
examined you? Please feel free to ask me any questions you have as I go along.
396 Chapter 14: Physical examinations
Gastrointestinal
Abdominal examination is important, as gastritis and peptic ulcer disease are common.
Liver disease is common (fatty liver, alcoholic hepatitis, cirrhosis, portal hypertension
and carcinoma). Alcohol is also the most common cause of chronic pancreatitis.
Inspection:
Ask the patient if you can examine his/her stomach or tummy.
Tell the patient: If at any point you are uncomfortable or want me to stop, tell me.
Expose the abdomen (and chest if male).
Look for any obvious abnormalities/clinical signs (e.g. spider naevi, gynaecomastia,
tattoos, jaundice [sclera], pigmentation or abdominal distension [ascites]).
Examine the hands for clubbing, palmar erythema, Dupuytrens contracture or flapping
tremor.
Palpation:
Ask if the patient is comfortable lying flat. Ask that they put their arms by their side.
Feel the neck and supraclavicular fossae for enlarged lymph nodes (they may be enlarged
in carcinoma of the stomach, particularly on the left side).
Conduct light palpation in all four quadrants. Look at the patients face and ask if there
is any tenderness.
Deeper palpation: as above, and also in the midline for possible aortic aneurysm.
Then examine the main organs individually.
Liver (start in right lower quadrant and work upwards).
Spleen (start in right lower quadrant and move across to left upper quadrant).
Kidneys (bilateral palpation of lateral abdomen).
Percussion:
From the level of the nipple downwards, percuss out both the size of the liver and the
spleen.
The edges of both organs should become apparent.
Shifting dullness should be demonstrated if ascites is suspected.
Auscultation:
Bowel sounds
Renal artery bruits
Musculoskeletal
Chronic alcoholic myopathy affects proximal muscles more prominently. Look at muscle
bulk and for evidence of wasting (e.g. thigh muscles).
Neurological
Ask some screening questions for cognitive impairment and observe his gait.
WernickeKorsakoff syndrome (confusion, ataxia, ophthalmoplegia, nystagmus and
peripheral neuropathy)
Station 1: Alcohol examination 397
Alcoholic dementia
Cerebellar degeneration (cerebellar signs intention tremor, dysdiadochokinesis, nystag-
mus, dysarthria and broad-based gait)
Dermatological
There are a number of skin changes associated with alcohol:
Facial erythema (alcohol-induced vasodilation)
Psoriasis (mainly of the hands and feet)
Problem solving
As part of a comprehensive physical examination, one would also want to examine the
male external genitalia and rectum you could mention that, ordinarily, this should be
done and that his GP could do this.
ADDITIONAL POINTS
Alcohol-related changes occurring in the following areas consist of:
FURTHER READING
Kelleher, M. (2006) Drugs and alcohol: Physical complications. Psychiatry, 5(12), 4425.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Ms Gordon has been referred with concerns about her nutritional status. She
has been an out-of-work model for some time. As a teenager, she was told that
she was too fat to ever be successful.
She has had a difficult relationship with food for a number of years and heavily
restricts her calorific intake.
Her GP has an interest in mental health and believes she has anorexia
nervosa. She has been referred to your out-patient clinic.
Examine this patient for the physical manifestations of starvation.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, its nice to meet you. Ive had a letter
from your GP. Do you know why your doctor has referred you to see me today? As part of
my assessment, I would like to check you physically. This will include listening to your
heart and examining your tummy. Is that OK?
Mention a chaperone.
Cachexia
Examine for loss of body fat and reduced muscle mass (proximal myopathy ask about
difficulty climbing stairs). Ask the patient to squat and then rise again to an upright posi-
tion this will be difficult for her if present.
Examine for oedema this may be present as part of malnutrition, although it may also
be due to electrolyte imbalance.
Ask about cold intolerance.
Reproduction
Ask her about amenorrhoea and delayed sexual maturation. Absence of menses is a defin-
ing feature of AN.
Skin
Examine her for dry skin, Lanugo hair or hirsutism, calluses on her hands (from repeated
vomiting), bruising and purpura.
Problem solving
The patient is unlikely to complain of anorexia or weight loss. She may be uncooperative,
at least initially. Be supportive and clear as to why you are asking to examine her. Asking
about any problems she has been having (e.g. abdominal pain, bloating or constipation)
may be a good way to engage her in a dialogue.
400 Chapter 14: Physical examinations
ADDITIONAL POINTS
Investigations can be helpful as part of the assessment in anorexia nervosa.
Full blood count (FBC): a pancytopenia is common in severe AN. Leucopoenia is
present in up to two-thirds. Mild anaemia and thrombocytopenia can occur in up to
a third of patients.
Blood film: there can be morphological changes in red blood cells
acanthocytes (spur cells).
Urea and electrolytes (U&Es): hypokalaemic, hypochloraemic alkalosis and
hypomagnesaemia.
Thyroid: reduced thyroid metabolism (low T3 syndrome).
Sex hormones: low luteinizing hormone (LH) and follicle stimulating hormone (FSH).
Osteoporosis: bone density scan (dual energy x-ray absorptiometry [DEXA]).
FURTHER READING
Patrick, L. (2002) Eating disorders: A review of the literature with emphasis on medical
complications and clinical nutrition. Alternative Medicine Review, 7(3), 184202.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 3: Extrapyramidal side effects 401
INSTRUCTION TO CANDIDATE
This 28-year-old patient, Mr Brown, began hearing voices 2 months ago. He
was seen by the local community psychiatric service and diagnosed with
schizophrenia.
The consultant psychiatrist prefers prescribing the older traditional drugs. He
will often quote new research indicating that the atypical anti-psychotics have
no advantages and are much more expensive.
Having been given 100mg of chlorpromazine daily, Mr Brown stopped taking
it after complaining of uncomfortable legs, stiffness and a feeling of unease.
The community psychiatric nurse is concerned that the patient is refusing
further treatment and asks you to see him.
Assess this patient for extrapyramidal side effects.
Explain to the patient what has happened and how you will manage him.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the psychiatrists. Im sorry to
hear that youve been having some problems with your legs and some stiffness. Can you
tell me a little bit more about this? That sounds very uncomfortable. So that I can try to
help you, would you mind if examined you?
Mention a chaperone.
Global
Observe for restlessness, inability to sit/stand still and anxious/tense state.
402 Chapter 14: Physical examinations
Face
Inspect the following areas:
Expression: Movements of forehead, eyebrows, periorbital area, cheeks, frowning,
blinking and smiling or grimacing
Lips/peri-oral: Puckering, pouting and lip smacking
Jaw: Biting, clenching and lateral movements
Tongue: Increased movement in and out
Salivation: Look under tongue for increased/pooling of saliva
Glabellar tap: Tap forehead gently with index finger. Parkinsonian patients
continue to blink instead of accommodating after several taps
Upper limbs
Inspect for abnormal resting movements (choreic/athetoid movements):
Arm dropping: Ask the patient to stand and put arms out to the side, then let them
drop. You should demonstrate for the patient. In unaffected individuals, the arms fall
freely with a slap and rebound
Elbow rigidity: Place one hand on the forearm and the other at the elbow. Move back
and forth. Feel for stiffness and resistance (lead pipe rigidity)
Wrist rigidity: As above, except examine flexion, extension, lateral, medial and
rotational movements (cog wheeling if tremor is superimposed)
Legs: Observe the resting legs (e.g. restlessness). If possible, examine the patient on
a couch so that the feet do not touch the ground. Ask the patient to swing their
legs (demonstrate if necessary). Look to see if legs swing freely or if there is
resistance
Gait: Ask the patient to walk five to ten paces away and then back again. Is there reduced
arm swing, stiff gait or a stooped, shuffling gait (Parkinsonian features)?
Management
Further management depends on the type of side effect. It is important to discuss treat-
ment options with the patient.
Dystonic reactions
Unlikely here (usually in early stages of treatment)
Includes oculogyric crisis and torticollis
Anticholinergic treatment (per os/intramuscularly/intravenously)
Withdraw anti-psychotic
Station 3: Extrapyramidal side effects 403
Pseudo-Parkinsonism
Tremor, rigidity and bradykinesia
Can be treated with anticholinergics
Change to an atypical anti-psychotic
Akathisia
Reduce anti-psychotic or switch to an atypical such as olanzapine or quetiapine
Responds poorly to anticholinergics
Other treatment options might include propranolol, benzodiazepines, cyproheptadine
and clonidine
Seek senior advice if no improvement
Tardive dyskinesia
Think of risk factors (e.g. female or elderly)
Withdraw any antimuscarinic
Consider withdrawing anti-psychotic or changing to an atypical
Consider clozapine if appropriate
Vitamin E, clonazepam and propranolol
Problem solving
Have a discussion about alternative anti-psychotics.
It is important to discuss continued engagement with psychiatric services as the patient
will need monitoring.
Ask the patient how they feel about these symptoms and enquire about risk (to self/
others).
It is important that any agitation is not simply attributed to akathisia, but that psychosis
is considered. Ask how his thoughts have been since stopping the chlorpromazine and
whether the voices he used to hear have returned.
ADDITIONAL POINTS
Tardive dyskinesia is difficult to treat and its aetiology is more complex than
it appears. Anyone treated with anti-psychotics is at risk of developing this
condition, although greater risk may occur in those with an affective illness,
diabetes, learning disability (LD), females and the elderly.
FURTHER READING
Gervin, M. & Barnes, T.R.E. (2000) Assessment of drug-related movement disorders in
schizophrenia. Advances in Psychiatric Treatment, 6, 3324.
Taylor, D., Paton, C. & Kerwin, R. (eds) (2007) The Maudsley Prescribing Guidelines, 9th edn.
London: Informa.
404 Chapter 14: Physical examinations
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mrs Lloyd has been taking lithium for 12 years. She is an intensive care unit
charge nurse working in a busy teaching hospital. Her bipolar illness had
been poorly controlled prior to this and she was admitted to a psychiatric
ward where lithium was commenced. Mrs Lloyd is keen to continue with the
lithium treatment as she has been on various treatments which she could
not tolerate or were ineffective. Recently, she has noticed that her neck has
become more prominent and has questioned whether the lithium could be
causing this.
Station 4: Thyroid dysfunction 405
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, its nice to meet you, Im one of the
psychiatrists. I understand youve noticed that your neck has changed. When did you
first notice this? Would it be OK if I examine you and then we could talk about your blood
results?
Remember to mention a chaperone.
Palpation:
Ask the patient if you can feel her neck.
Stand behind her and to the right. This is less threatening than standing directly
behind.
With the fingers of both hands, feel the left and right lobes of the thyroid. Ensure
the neck is slightly flexed to ease palpation.
Attempt to locate the thyroid isthmus by palpating between the cricoid cartilage
and the suprasternal notch.
Move your hands laterally to try to feel under the sternocleidomastoids for the
fullness of the thyroid.
Assess hard or soft texture and the presence of any nodules.
Assess the extent of any enlargement.
Again, ask the patient to swallow some water whilst feeling a possible goitre move
beneath the examining fingers.
Examine local lymph nodes as the carcinoma (CA) thyroid can spread to local
lymphatics.
Percussion:
If able to, percuss the manubrium sterni to see if a goitre extends downwards (dull-
ness) into the chest.
Auscultation:
If a stethoscope is available, listen to both lobes of the thyroid for bruits.
Thyroid status:
Examine their hands for tremor (hyperthyroidism), sweaty palms, erythema and
thyroid acropachy.
Pulse: rate and rhythm (atrial fibrillation [AF] and sinus bradycardia).
Examine for brisk/slowly relaxing tendon reflexes (hyper/hypothyroid, respectively)
Examine their eyes specifically for lid retraction (sclera visible above cornea) and
lid lag, exophthalmos (sclera visible above the lower lid is a sign of Graves disease
and not related to thyroid status).
Comment on any hair loss, dry flaky skin, lateral loss of eyebrows, hoarse croaky
voice or carpel tunnel syndrome (hypothyroidism).
Enquire about intolerance to heat/cold, weight change and appetite.
Ask about increased agitation (hyperthyroid).
Problem solving
Interpretation of results
Feed back to the patient about your findings from the physical examination if you have
not already done so. Do not make up findings; if the thyroid feels normal, then say so.
You will need to explain to her that her thyroid function tests are all within the normal
range. However, her thyroid antibodies are high. As a professional colleague, ask her if
she has heard of Hashimotos thyroiditis. It is an autoimmune disease of the thyroid that
Station 4: Thyroid dysfunction 407
is often associated with normal or hypothyroid function. Suggest to her that she needs
to be seen by an endocrinologist as a first step. Certainly you would not be suggesting
that she discontinues the lithium at this point.
She may need thyroid medication, but you will be asking the endocrinologist to advise
on further management.
She might ask you about alternative treatments should the physician advise that lithium
is withdrawn. This would demand a discussion about the mood stabilisers, including the
anticonvulsants and also the anti-psychotics.
ADDITIONAL POINTS
You can talk to the patient in order to describe the physical examination as it
is being performed or summarise when the examination is completed. When
finished, thank the patient.
Note: an enlarged thyroid is referred to as a goitre. There is no direct
correlation between size and function a person with a goitre can be clinically
euthyroid or hypo- or hyper-thyroid.
A normal thyroid is estimated to be 10g with an upper limit of 20g or 24
teaspoons.
Thyroid nodules are common (prevalence 4%). Half of the thyroid glands
examined by ultrasound or direct visualisation (surgery or autopsy) have
nodules. Less than 5% of all nodules are cancerous.
FURTHER READING
Epstein, O., Solomons, N., Perkin, G.D., Cookson, J. & De Bono, D.P. (2003) Clinical
Examination, 3rd edn. London: Mosby Year Book Europe Ltd.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mr King is reporting having lost the ability to walk. There was a recent
incident and, since this time, he has been reporting a loss of function.
The GP made an urgent referral to the neurologist who saw him within 10
days. The neurologist reported that the patient showed no obvious course
for his functional loss. The pattern of paralysis was not typical and plantar
reflexes were present and down going. There is no evidence of muscular
atrophy. Of note, I believe that the muscles are capable of reacting when
the patients attention is directed elsewhere. Nerve conduction studies are
reported as normal.
Examine this gentlemans lower limbs.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the psychiatrists. Be prepared
for some hostility as it is clear that he is not keen on seeing a psychiatrist.
Thank you for seeing me today. I understand from your GP that youve had some dif-
ficulties with your legs. Could you tell me whats been happening? Could you tell me
about the incident which happened recently? Would it be OK if I examine your legs?
Mention that you would normally offer a chaperone, but ask whether he is happy to
proceed without this today.
Inspection
Look for any obvious abnormalities/deformities.
Skin colour/rashes.
Muscle bulk (wasting).
Muscle fasciculation (motor neuron disease).
Restlessness (extrapyramidal side effects; ask about any medication).
Tone
Im just going to move your legs; let them go all floppy.
Examine each leg by moving it passively at the hip and knee joints. Roll the leg sideways
and bend the knees backwards and forwards on the couch/bed. Lift the knee and let it
drop. With the legs hanging over the side of the bed, lift the leg and let it drop. Observe
natural swing at the knee.
Look in particular for increased/decreased tone and evidence of cog-wheeling or lead pipe
rigidity.
Power
Ask the subject to:
1. Lift your leg straight up, dont let me push it down (L1, L2)
2. With his knee bent, ask to push against my hand (L3, L4)
3. Bend your knee, dont let me straighten it (L5, S1, S2)
4. Point your toes up towards your face, dont let me push them down (L4, L5)
Coordination
Ask the subject to place his heel just below his knee and run it down his shin then back
up and down once more. Ask to repeat with the other foot.
410 Chapter 14: Physical examinations
Reflexes
Knee jerk (L3, L4)
Ankle jerk (L5, S1)
Plantar response (start at outer part of sole, move inwards towards big toe)
Sensation
Ideally, one should test light touch and pinprick in the following areas. Test the same
dermatomes on each leg:
Outer thigh (L2)
Inner thigh (L3)
Inner calf (L4)
Outer calf (L5)
Inner foot (L5)
Outer foot (S1)
Vibration sense can be tested in the medial malleoli (if tuning fork is present), as can joint
position sense (up and down).
Gait
Ask if the subject is OK to walk for you (he is likely to decline)
Observe his normal gait
Then ask him to walk heel to toe (ataxia)
Rombergs test
Ask the patient to put his feet together, stretch out his arms and close his eyes
Stand in front of the patient with your own arms outstretched to ensure they do not fall
Problem solving
For the purposes of the examination, you will probably not be expected to examine
pinprick sensation. Light touch using either cotton wool or asking the patient to close
their eyes and say yes when they feel you touching them with a finger should
suffice.
ADDITIONAL POINTS
Rombergs test is only positive if the subject is more unsteady with their eyes
closed.
A positive Rombergs test indicates a loss of proprioception (e.g. subacute
combined degeneration of the cord and tabes dorsalis).
FURTHER READING
Epstein, O., Solomons, N., Perkin, G.D., Cookson, J. & De Bono, D.P. (2003) Clinical
Examination, 3rd edn. London: Mosby Year Book Europe Ltd.
Station 6: Upper limbs 411
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to
improve
INSTRUCTION TO CANDIDATE
Mrs Kleiner was admitted to the clinical decisions unit at her local hospital.
She was brought in by her family, who have become concerned that she
is unable to move her left arm. The accident and emergency doctor has
examined her and performed routine blood tests and a computed tomography
brain scan, which are all within normal parameters. You are the psychiatrist on
call and have been asked to assess her. Although you are aware that she has
already been examined, you are keen to assess her yourself.
Perform a neurological examination of her upper limbs.
412 Chapter 14: Physical examinations
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the psychiatrists. I know that
youve already seen one of the doctors, but could I ask you to briefly tell me what has been
happening with your arm? Would it be OK if I examine you? Has anything stressful hap-
pened recently?
Mention a chaperone.
Inspection
Look for any obvious asymmetry/deformities in the arms and hands.
Skin colour.
Muscle bulk (wasting).
Muscle fasciculation (motor neuron disease).
Tremor (extrapyramidal side effects or Parkinsons disease).
Tone
Im just going to move your arms; let them go floppy.
Examine each arm by passively bending the elbow joint to and fro. Flex and extend the
hand at the wrist and rotate the hand to detect cog-wheel rigidity (Parkinsons disease).
Power
Demonstrate movements to make instructions easier.
Ask the patient to:
1. Put arms at right angles to their body, Dont let me push them down (deltoid, C5)
2. Bend elbow, Dont let me straighten it (biceps C5/6)
3. Push each arm out straight against your resistance (triceps C7)
4. Squeeze my fingers, offer two fingers (C8, T1)
5. Keep fingers straight, Dont let me bend them (motor C7/radial)
6. Spread your fingers out, Dont let me push them together (dorsal interossei ulnar)
7. Point your thumb to the ceiling, Dont let me push it down
8. Put your thumb and little finger together, Dont let me pull them apart
Coordination
1. Tap quickly on the back of your hand (demonstrate)
2. Touch my finger touch your nose (test)
Station 6: Upper limbs 413
Reflexes
Biceps jerk (C5, C6)
Triceps jerk (C7)
Supinator (C5, C6)
Sensation
Ideally, one should test light touch and pinprick in the following areas (although for the
purposes of the exam, a light touch using either cotton wool or a finger should be ade-
quate). Ask the patient to close their eyes and tell you when they feel something. Reassure
them that you will be gentle.
Shoulder (C4, C5)
Upper arm (C5, C6)
Forearm (C6, C7, T1)
Hand (C6, C7, C8)
Problem solving
Once the physical examination is complete, help the patient get dressed, thank her and
explain your findings. If your examination is normal and there is time, a conversation
about psychological contributory factors may ensue. Take care not to upset the patient if
possible, as this will be an unsatisfactory end to the station. Establish whether she believes
her presentation could have a psychological component. The use of normalisation here
is very helpful.
ADDITIONAL POINTS
A discussion related to management may follow and you should explain
that you have only had time to conduct a physical examination. You would
want to look at her health records, speak to the GP and invite her back for
a consultation where you would take a thorough history of recent and past
events that could account for her presentation.
FURTHER READING
Epstein, O., Solomons, N., Perkin, G.D., Cookson, J. & De Bono, D.P. (2003) Clinical
Examination, 3rd edn. Elsevier Health Sciences.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Whilst trying to get out of a chair on the ward, Michael, a 78-year-old
depressed gentleman, lost his footing and fell over. The fall was witnessed by
nursing staff who observed him hit his head. He was difficult to rouse at first
but soon became re-orientated. He has a haematoma to his left temple and is
complaining of a headache. The staff also report that he appears to be more
irritable following the fall.
Examine this gentlemans cranial nerves.
Do not examine:
Smell
Pinprick to face
Gag reflex
Corneal reflex
room and back to bed, but you allow an examination by the doctor. You do not have any
abnormal symptoms or signs.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, its nice to meet you. Can I ask your
name? I was told about your fall. Can you remember what happened? How is your head
now? Do you have any concerns at the moment? Do you feel confused, or sick at all? I
would like to examine you. This will involve looking at your eyes and testing your hear-
ing, would that be OK?
Gag reflex touch the back of throat on both sides with an orange stick*
(XII) Tongue
Ask to stick tongue out. Observe for deviation to left/right
Observe resting tongue for wasting and fasciculation
(XI) Accessory nerve
Shrug your shoulders and dont let me push them down
Turn your head to the right (feel left sternomastoid) And to the right (feel
right side)
(VIII) Hearing
How is your hearing?
Can they hear you rubbing your index finger against your thumb in
each ear?
(V) Trigeminal sensation
Can you feel me when I touch here? Use finger/cotton wool. Examine oph-
thalmic, maxillary and mandibular territories (corneal reflex*)
Problem solving
Should be able to assess all nerves within 7 minutes.
ADDITIONAL POINTS
Smell and taste (I, VII, IX)
Visual acuity (II)
Visual field (II)
Eye movements (II, IV, VI)
Nystagmus (VIII and cerebellum)
Ptosis (III, sympathetic)
Pupils (III)
Discs (II)
Facial movements (V, VII)
Palatal movements (IX, X)
Gag reflex (IX, X)
Tongue (XII)
Accessory (XI)
Hearing (VIII)
Facial sensation (V)
Corneal reflex (V)
FURTHER READING
Epstein, O., Solomons, N., Perkin, G.D., Cookson, J. & De Bono, D.P. (2003) Clinical
Examination, 3rd edn. London: Mosby Year Book Europe Ltd.
*Will often be asked to omit pinprick, corneal and gag testing, but be able to do them in
practice.
Station 8: Cardiovascular system 417
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are called to the psychiatric intensive care unit. This patient, detained
under the Mental Health Act, was restrained following aggressive and
threatening behaviour that was putting other patients and staff at risk. He
has subsequently settled somewhat with a time out and oral olanzapine and
clonazepam, but is now complaining of chest pain. You are called to see him.
Examine this patients cardiovascular system.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, Im one of the doctors. I understand
youve had some chest pain, when did it start? Can you tell me what it feels like? Where
is the pain now? Is the pain travelling anywhere or is it only in your chest? I need to
examine your heart, would that be OK?
Mention that you normally offer a chaperone, but ask whether it would be OK to proceed
without.
Problem solving
The patient may be anxious or distressed and need reassurance. A discussion about how
you intend to manage him is possible. Offer some analgesia/aspirin if appropriate. If you
believe the pain to be cardiogenic, explain the need for further investigations (bloods,
ECG and chest x-ray [CXR]). If you are concerned that he has had a myocardial infarct,
immediate management and emergency transfer will need to be organised.
ADDITIONAL POINTS
Remember to dress the patient and thank them when you have finished your
physical examination. Explain your findings.
FURTHER READING
Epstein, O., Solomons, N., Perkin, G.D., Cookson, J. & De Bono, D.P. (2003) Clinical
Examination, 3rd edn. London: Mosby Year Book Europe Ltd.
Station 9: Eye examination 419
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mr Khan has come back to see you in your out-patient clinic. She has bipolar
affective disorder and has been commenced on carbamazepine, as she has
a rapid cycling condition and could not tolerate lithium. She is anxious as she
has developed blurred vision and occasional diplopia.
Examine her eyes.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, nice to see you again. Im sorry to learn youve had some prob-
lems with your eyes. Could you tell me how your vision has been since we last met? I
would like to examine your eyes. Would that be OK? Part of the examination will involve
shining a light into your eyes, so let me know if it is uncomfortable at any point.
Mention the chaperone.
Visual acuity
Monocular (i.e. test each eye individually) finger count: How many fingers do you see?
Visual fields
Monocular: ask the patient to cover one eye; you cover your eye on the opposite side so
that you are comparing the patients visual fields to your own. Keep looking at my eye.
Test the patients upper and lower temporal quadrants by moving your wagging finger
from the periphery to the centre. Ask them to say yes when they see your finger moving.
To test their nasal fields, you need to swap hands. Any area of field defect will become
obvious by comparing the patients visual fields to your own. Do the same for the other
eye.
Reflexes
First accommodation convergence reflex: Look into the distance. Now look at my finger.
Place your index finger close to the patients nose; if normal, pupils will constrict.
Light reflex: pick up the ophthalmoscope, switch it on and check that it works. Shine the
light into each eye twice to check direct and consensual reflexes.
Fundoscopy
Hold on to the ophthalmoscope to examine the patients fundi. Im going to look at the
back of your eyes now. I will need to get quite close please let me know if it is too uncom-
fortable and I will stop. Tell the patient to fixate on a distant target. Examine the patients
right eye with your right eye and then his left eye with your left eye. Sit at arms length
opposite the patient. Aim to find the optic disc and comment on this and the appearance
of blood vessels around it. Come away from the fundus once you have had a good view.
Optic disc
Locate and bring it into focus. Look for size, blurred disc edge, cupping (glaucoma), new
vessels (diabetic retinopathy) and a pale disc (e.g. optic atrophy).
Blood vessels
Arteries are narrower and brighter and have a reflective, pale streak.
Start at the disc and follow the vessels out to look for hypertensive changes (A-V nipping)
and atherosclerotic changes.
Station 9: Eye examination 421
The fundus
Look for haemorrhages, exudates, cotton wool spots, new vessel formation and
micro-aneurysms.
Ask the subject to look straight at the light in order to examine the macula.
Be familiar with the basic appearance of:
Papilloedema: blurred disc edge, haemorrhages, hard exudates (late feature) and cotton
wool spots (due to retinal infarction)
Diabetic retinopathy: micro-aneurysms, small haemorrhages, exudates, cotton wool spots
and new vessel formation (proliferative diabetic retinopathy)
Hypertensive retinopathy: silver wiring, A-V nipping, haemorrhages, cotton wool spots
and disc swelling if malignant
Glaucoma: optic disc enlargement, undermining of the disc margins and blood vessel
bowing (advanced)
Photocoagulation (laser) scars
Optic atrophy
Problem solving
If faced with a mannequin in the examination, treat it as you would a real patient.
ADDITIONAL POINTS
Describe any features with reference to a clock face and optic disc size (i.e.
There are soft exudates at 3 oclock, two disc diameters away from the disc).
Explain that, ideally, you would like to examine the retinas in a dark room or
dilate the pupils to get a better view (1% cyclopentolate).
FURTHER READING
Epstein, O., Solomons, N., Perkin, G.D., Cookson, J. & De Bono, D.P. (2003) Clinical
Examination, 3rd edn. London: Mosby Year Book Europe Ltd.
4. Examination 3 Reflexes
25% of marks
5. Examination 4 Fundi
10% of marks
% SCORE_________ ___ OVERALL IMPRESSION
5 (CIRCLE ONE)
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are on call. A nurse bleeps you asking if you could attend to a patient
who has collapsed on the ward. When you arrive, you are told that he is
unconscious and does not appear to be breathing. There is no equipment/
defibrillator available.
Manage this situation.
SUGGESTED APPROACH
Setting the scene
The patient is unconscious and non-responsive. There is also a member of staff in this
scenario.
Hello, Im the on-call doctor, Dr_____, could you quickly tell me what happened and
how long hes been like this?
Problem solving
Ideally, you would want to protect yourself by using a reservoir bag and mask for ventila-
tion, rather than mouth to mouth. Ask the nurse whether the patient has any known
infectious diseases.
424 Chapter 14: Physical examinations
ADDITIONAL POINTS
Once you establish that the person is not breathing and is unresponsive, start
immediate resuscitation.
Get as much history from the nurse as possible; for example, is this a drug
overdose or suicide attempt? Can you initiate pharmacological treatment (e.g.
flumazenil in benzodiazepine overdose)? Ask about other vital signs.
Ask if the nurse has been trained in cardiopulmonary resuscitation, as this
could allow you to examine the patient more thoroughly whilst she continues
chest compressions.
If the cervical spine is damaged, as in a hanging attempt, care must be taken
to maintain the alignment of the head, neck and chest. Use minimal head tilt
when opening airway.
FURTHER READING
Resuscitation Council (UK) (2005) www.resus.org.uk. Check this website for more
information and any updates to guidelines.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 15 Russell Foster
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
You are the ward doctor on an acute adult in-patient ward. You have been asked
to see a 30-year-old university student who has a history of cannabis abuse, but
recently tried injecting himself with heroin. He was found collapsed in the street
and was transferred to the psychiatric ward after being stabilised medically.
He is worried about the risks of injecting and is seeking further advice. He is
anxious and has a number of questions for you.
Answer his questions and give him information on harm minimisation and
injection techniques should he continue to use.
SUGGESTED APPROACH
Setting the scene
Explain that you have been asked to see him. Try to get some background history of the
events leading up to his collapse. Explain that you have not been able to speak to the
nursing staff as yet or had access to his notes or other sources of information. Try to briefly
get an idea of his current and recent history of illicit drug use.
Systemic infections may result from direct transmission into the bloodstream of a number
of organisms, for example:
Note that atypical pathogens may be implicated, as can the effects of poly-infection with
a number of pathogens. Systemic infections may also affect the nervous system, produc-
ing cerebral abscess, infarction or meningitis.
Local infections may result from skin flora such as Staphylococcus species (e.g. S. aureus or
S. epidermidis) and include abscesses, cellulitis, necrotising fasciitis, thrombophlebitis or
tissue necrosis (gas gangrene). Infections may also result from foreign bodies such as
broken needles remaining in situ or following the use of contaminated drugs/water.
Infections of joints and bones have also been reported, and chronic use can lead to stig-
mata such as fibrosis, bruising, skin discolouration, granulomata and chronic
phlebitis.
What other medical conditions may be associated with intravenous heroin use?
These may be divided into drug-related and non-drug-related factors. Examples of the
former include sequelae of the drug itself (such as irritant effects leading to thrombophle-
bitis and thromboembolism), injection with adulterants added to the drug mixture (with
variable effects), drug overdose (such as heart failure, pulmonary embolism and respiratory
arrest) or drug withdrawal.
Station 1: Advising IVDU on injection technique and risk minimisation 429
Harm minimisation
Harm minimisation involves recognising that certain individuals cannot or will not stop
using drugs and therefore aiming to minimise the harmful sequelae of drug taking. A
number of interventions have been described, including:
Methadone maintenance programmes
Counselling
Supplying clean equipment (e.g. alcohol swabs, sterile containers or filters for
mixing drugs, sterile needles and sterile water)
Educating users in order to try to minimise risk of infection
Using non-injecting means of administration
Supervised injection (controversial)
Discouraging poly-substance use
Administering drug in the presence of others
Education regarding safer injecting techniques
Education regarding disposal of used equipment
Using low initial test dose to gauge strength of drug
After removing the needle, apply a clean tissue or cotton wool to puncture site to stop
bleeding.
Dispose of used needles and syringes carefully.
ADDITIONAL POINTS
Clinical features of opiate intoxication/complications
Mental effects: anorexia, decreased activity, diminished libido, drowsiness,
euphoria and personality change.
Physical effects: bradycardia, constipation, meiosis, nausea and pruritus.
Features of withdrawal
Abdominal cramps, agitation, craving, diarrhoea, diaphoresis, mydriasis,
piloerection, restlessness, tachycardia and yawning.
FURTHER READING
Foster, R. (2008) Clinical Laboratory Investigation and Psychiatry: A Practical Handbook.
London: Informa.
Hutin, Y., Hauri, A., Chiarello, L. etal. (2003) Best infection control practices for intrader-
mal, subcutaneous, and intramuscular needle injections. Bulletin of the World Health
Organization, 81(7), 491500.
Theodorou, S. & Haber, P.S. (2005) The medical complications of heroin use. Current
Opinion in Psychiatry, 18(3), 25763.
Zollner, C. & Stein, C. (2007) Opioids. Handbook of Experimental Pharmacology, 177, 3163.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
In your role as a liaison psychiatrist, you have been asked to see a man who
was admitted for treatment of delirium tremens. The 50-year-old homeless
man is thought to be mentally unwell and you have been asked to transfer him
to the local psychiatric hospital. During your initial review of the hospital notes,
you note the following blood results taken earlier today:
Albumin=21g/L (3550g/L)
Bilirubin=250mol/L (320mol/L)
GGT=600 IU/L (<60 IU/L)
ALP=300 IU/L (30130 IU/L)
ALT=55 IU/L (045 IU/L)
AST=170 IU/L (1050 IU/L)
MCV=150 fL (80100 fL)
You have an extremely inquisitive fourth-year medical student with you who
asks you a number of questions.
SUGGESTED APPROACH
Setting the scene
Introduce yourself. Ask if the medical student has ever seen anyone with delirium tre-
mens before. You could go on to explain that when seeing any patient in a liaison setting,
it is helpful to determine first what has been done to investigate and treat the patient,
given that delirium tremens is a medical emergency and often patients can be sedated
or be in receipt of ongoing medical treatment and thus may not be immediately ame-
nable to proper psychiatric assessment. You can explain that it is useful to check whether
the PLN has seen the patient and whether the patient is medically stable or requires
further input.
ADDITIONAL POINTS
The clinical associations of chronic alcohol use
These are numerous, including:
Cardiovascular: angina, arrhythmias and cardiomyopathy
Endocrine: pseudo-Cushings syndrome and hypogonadism
Gastrointestinal: alcoholic cirrhosis, hepatitis, gastritis and carcinoma pancreatitis
Haematological: anaemia (macrocytic, iron deficiency and sideroblastic)
Musculoskeletal: myopathy
Neurological: Korsakoffs syndrome and seizures
FURTHER READING
Foster, R. (2008) Clinical Laboratory Investigation and Psychiatry: A Practical Handbook.
London: Informa.
Mannelli, P. & Pae, C.U. (2007) Medical comorbidity and alcohol dependence. Current
Psychiatry Reports, 9(3), 21724.
Marshall, W.J. (1995) Clinical Chemistry, 3rd edn. London: Mosby.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are on call in the local accident and emergency (A&E) department and
are asked to see a difficult 18-year-old patient who was brought in by her
parents, whom she lives with. Her worried mother had informed the A&E doctor
that her daughter had not been eating for some time. The mother further
stated that her daughter, a ballet dancer, spends hours doing exercises and
appears to have stopped menstruating. You note from the A&E clerking that
no physical examination has been performed, as the patient is refusing both a
physical examination as well as blood tests.
You are about to meet her mother, a university lecturer, who believes her
daughter has anorexia nervosa and has a number of questions for you.
Explain anorexia nervosa to the mother and discuss the differential diagnosis.
SUGGESTED APPROACH
Setting the scene
Introduce yourself. Explain that you understand that she must be extremely concerned
about her daughter. Find out what she knows about eating disorders. Make sure that you
consider issues of patient confidentiality if you discuss issues relating to her daughter.
Has the daughter consented to her case being discussed with her mother?
What eating disorders are there and what are their features?
Although there is some disagreement, five major groupings of eating disorders may be
identified: obesity, anorexia nervosa, bulimia nervosa, pica and eating disorder not
otherwise specified.
Obesity:
Obesity may be defined as a body weight exceeding 120% of the accepted average for age,
gender and height in a given culture or setting. It may be further defined using the
Quetelets body mass index: weight (kg)/height (m)2.
Anorexia nervosa (ICD code F50.0):
The time frame of anorexia nervosa is non-specific.
Features:
1. Weight loss of at least 15% below the expected weight for height and age
2. Weight loss is self-induced
3. Perception/dread of being too fat, leading to a self-imposed desire for low weight
4. Multiple endocrine effects on hypothalamicpituitarygonadal axis, leading to altera-
tions in sexual potency and amenorrhoea
Bulimia nervosa (ICD code F50.2):
The time frame of bulimia nervosa consists of specific features (recurrent overeating) at
least twice a week for at least 3 months.
Features:
1. Recurrent episodes of overeating (large amounts of food eaten in short periods of time)
2. Preoccupation with eating, with compulsion/craving to eat
3. Manoeuvres are undertaken by the patient to counteract the effects of eating by at
least one of self-induced vomiting/purging, alternating episodes of fasting/starvation
and use of drugs such as appetite suppressants, thyroid preparation, diuretics and
insulin
4. Fear of and self-perception of being fat
Domain Condition
ADDITIONAL POINTS
Eating disorders, especially anorexia nervosa, are complex conditions that
require a multidisciplinary perspective due to the large number of associated
medical, metabolic and psychiatric complications.
438 Chapter 15: Investigations and procedures
FURTHER READING
Berkman, N.D., Bulik, C.M., Brownley, K.A. etal. (2006) Management of eating disorders.
Evidence Report/Technology Assessment (Full Report), 135, 1166.
Herzog, W., Deter, H.C., Fiehn, W. & Petzold, E. (1997) Medical findings and predictors of
long-term physical outcome in anorexia nervosa: A prospective, 12-year follow-up study.
Psychological Medicine, 27(2), 26979.
Van Binsbergen, C.J., Odink, J., Van den Berg, H., Koppeschaar, H. & Coelingh Bennink, H.J.
(1988) Nutritional status in anorexia nervosa: Clinical chemistry, vitamins, iron and zinc.
European Journal of Clinical Nutrition, 42(11), 92937.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
As part of the clerking of a newly admitted patient on the ward you are
covering on your week of nights, you have been asked to perform an
electrocardiogram (ECG) and report your findings to the notoriously pedantic
but supportive on-call consultant. You note that the patient, a 55-year-old
female, who has a history of anxiety in the context of a dependent personality
disorder, is cooperative, has a GCS of 15/15, appears slightly anxious and
sweaty but is otherwise unremarkable. The patient is not on any regular
medication. Unfortunately, the nurse on the ward has not done the ECG course
and is therefore unable to help you.
You manage to perform the ECG by following the instructions on the machine.
You note that the ECG print-out reports the following parameters:
Sinus rhythm but otherwise normal ECG.
HR 110
PR 150
QTc 429
Look at this ECG and prepare to report your findings back to the consultant.
4. What is the QTc interval? What psychotropics may be associated with prolongation
of the QTc interval?
5. If the patient were being treated on clozapine, what ECG changes might you see?
SUGGESTED APPROACH
Setting the scene
Introduce yourself. You can explain to the consultant why you decided to perform the
ECG and what your findings are.
The left lateral surface of the heart is looked at by leads VL, I and II.
The inferior surface of the heart is looked at by leads VF and III.
The right atrium is looked at by VR.
V leads:
How do you know that the electrodes have been correctly applied
to the patient and that the ECG trace is accurate?
Many machines now give real-time interpretations, but with older machines, the fol-
lowing rules of thumb are helpful for confirming correct lead placement in a normal
ECG:
If the patient were being treated on clozapine, what ECG changes might you see?
Clozapine may cause myocarditis or cardiomyopathy, which may be heralded by non-
specific symptoms such as chest pain, fever, shortness of breath, sweating and tachycardia.
In some cases there may be no changes, although the following may occur:
On ECG, myocarditis may cause a tachycardia and non-specific, transient ST waves. It
may also resemble an motivational interviewing (MI), with Q waves and a lack of R waves
in the anterior leads.
Cardiomyopathy may show non-specific ST and T wave changes in association with
arrhythmias, such as atrial fibrillation or ventricular tachycardia.
ADDITIONAL POINTS
If asked to report the ECG, it should be done systematically. You should have a
scheme in mind, such as the following:
This is the ECG from [name of patient], a 55-year-old [ethnicity] female who
was admitted with [brief history].
The ECG was taken on [date] and [time].
The rate is
The axis is [normal, shows right/let axis deviation].
The rhythm is [sinus rhythm, atrial fibrillation, atrial flutter, etc.].
The PR interval is [normal, shows first/second/third-degree heart block].
The QRS width is [normal, prolonged].
The QRS height is [normal, high].
There are/are no Q waves.
The QT interval is [normal, prolonged].
The ST segment is [normal, elevated/depressed in leads].
The T waves are [normal, peaked, flattened].
There are/are no U waves.
In summary, this is a 12-lead ECG of a 55-year-old which is normal/shows the
following abnormalities
Interpreting an ECG is often difficult, and if there is any doubt, the opinion of
an experienced physician should be sought. When performing an ECG, the
patient is instructed to remain still during the recording in order to minimise
any artefacts. Note that serial ECGs may be required, and that most modern
ECG machines will try to interpret the trace, often inaccurately.
442 Chapter 15: Investigations and procedures
FURTHER READING
Demangone, D. (2006) ECG manifestations: Noncoronary heart disease. Emergency
Medicine Clinics of North America, 24(1), 11331.
Goodnick, P.J., Jerry, J. & Parra, F. (2002) Psychotropic drugs and the ECG: Focus on the QTc
interval. Expert Opinion on Pharmacotherapy, 3(5), 47998.
Hampton, J.R. (1994) The ECG Made Easy, 4th edn. London: Churchill Livingstone.
Mackin, P. (2008) Cardiac side effects of psychiatric drugs. Human Psychopharmacology,
23(Suppl. 1), 314.
Merrill, D.B., Dec, G.W. & Goff, D.C. (2005) Adverse cardiac effects associated with
clozapine. Journal of Clinical Psychopharmacology, 25(1), 3241.
Taylor, D., Paton, C. & Kapur, S. (2015) Maudsley Prescribing Guidelines in Psychiatry, 12th
edn. Chichester: Wiley Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 5: Initiation and monitoring of clozapine 443
INSTRUCTION TO CANDIDATE
You are the junior doctor on a busy, general adult ward and have been asked
by the departing locum consultant to commence clozapine on a 29-year-
old patient with newly diagnosed schizophrenia. The patient has been on
olanzapine for 8 months, but this was changed to modecate (fluphenazine)
depot due to variable compliance, which the patient attributed to side effects.
A student nurse in the team wants to know more about clozapine.
SUGGESTED APPROACH
Setting the scene
Introduce yourself. Ask whether they have ever seen clozapine used before, and if so, what
they know about it. Explain that you will need to obtain appropriate background informa-
tion about the patient, including details of all previous treatments, how long the patient
was on them and why they were stopped. The views of the patient should also be
canvassed.
Myocarditis/ Risk variable (from 1 in 1300 up to 1 in 67,000) and may be more likely
cardiomyopathy in early stages of treatment (first 23 months)
Seizures Incidence approximately 3%, risk is dose-related and may require use of
prophylactic valproate
ADDITIONAL POINTS
The accepted reference range for clozapine is 350500 g/L. Blood should be
collected for trough levels (i.e. just before the dose) in a plain tube. It should
be noted that the time to steady state is approximately 3 days, and levels may
be lower in males, especially those who are younger and who smoke.
FURTHER READING
Foster, R. (2008) Clinical Laboratory Medicine and Psychiatry: A Practical Handbook.
London: Informa.
Raggi, M.A., Mandrioli, R., Sabbioni, C. & Pucci, V. (2004) Atypical antipsychotics:
Pharmacokinetics, therapeutic drug monitoring and pharmacological interactions. Current
Medicinal Chemistry, 11(3), 27996.
Rostami-Hodjegan, A., Amin, A.M., Spencer, E.P., Lennard, M.S., Tucker, G.T. & Flanagan, R.J.
(2004) Influence of dose, cigarette smoking, age, sex, and metabolic activity on plasma
clozapine concentrations: A predictive model and nomograms to aid clozapine dose
adjustment and to assess compliance in individual patients. Journal of Clinical
Psychopharmacology, 24(1), 708.
Taylor, D., Paton, C. & Kapur, S. (2015) Maudsley Prescribing Guidelines in Psychiatry, 12th
edn. Chichester: Wiley Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
446 Chapter 15: Investigations and procedures
INSTRUCTION TO CANDIDATE
You have been asked to review some blood results for a patient in her fifties
who was recently admitted after concerns from her husband that she had
become increasingly listless and odd. She has stopped going out for walks,
become increasingly forgetful and complained of feeling tired all of the time.
The ward doctor noted that she had no previous psychiatric or medical history
and had been gaining weight and complaining of constipation. He also noted
she had a hoarse voice and a slow heart rate.
Her husband is a psychologist and wants to understand her test results. He
asks:
1 . What blood tests are done and why?
2. You perform a number of tests and find that the serum TSH is 120 mU/L
(normal range approximately 0.30.4 mU/L) and the serum-free T4 is
4pmol/L (normal range approximately 926pmol/L). How do you explain
these results to the husband?
3. In general terms, how will she be managed?
4. What are the clinical signs and symptoms of hypothyroidism?
SUGGESTED APPROACH
Setting the scene
Introduce yourself to her husband. Remember to consider issues of patient confidentiality
and whether the patient has capacity and consents to your discussing her case. In order
to understand the blood results, further information about the patient is needed. This
can be obtained from ward staff and reading the hospital notes. You will be particularly
interested in the history of presenting complaints and medication history, further details
of which may be obtained from the husband or GP.
ADDITIONAL POINTS
Psychiatric manifestations of hyperthyroidism
Psychiatric symptoms include anxiety, cognitive decline, delirium, depression,
emotional lability, feeling of apprehension, irritability, nervousness and
psychosis (rare).
FURTHER READING
Costa, A.J. (1995) Interpreting thyroid tests. American Family Physician, 52(8), 232530.
Davis, D. & Tremont, G. (2007) Neuropsychiatric aspects of hypothyroidism and treatment
reversibility. Minerva Endocrinology, 32(1), 4965.
Foster, R. (2008) Clinical Laboratory Investigation and Psychiatry: A Practical Handbook.
London: Informa.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
One of the local GPs has referred a 32-year-old lawyer with a history of bipolar
affective disorder to your hospital out-patient clinic after recently commencing
him on lithium. The patient had previously been discharged from an out-of-area
psychiatric hospital and is reported to be intelligent, insightful and willing to
Station 7: Interpretation of lithium levels 449
comply with treatment so that he can get back to work. He is also said to be
interested in learning more about lithium, and has been told by the GP that you
are the expert on this! The GP has done blood levels and noted that the level
after 4 days was 0.2mmol/L. No other information has been supplied.
You are about to meet the patient, who has a number of questions in relation
to lithium treatment and monitoring. You are asked to address his concerns.
SUGGESTED APPROACH
Setting the scene
Introduce yourself to the patient. Briefly try to obtain some details about the patients
history. Ask what if anything he knows about lithium and how he has been in himself
since commencing this treatment.
What are the signs of toxicity and how do these relate to plasma levels?
Severe toxicity may occur at levels >1.5mmol/L and death may occur at higher levels
(>2.0mmol/L), although toxicity has also been reported at only mildly elevated serum
concentrations.
Lithium has a narrow therapeutic index and has a number of important adverse effects
in overdose, which may be fatal; these include neurological effects (tremor, ataxia, nys-
tagmus, convulsions, confusion, slurred speech and coma) as well as renal
impairment.
Are there any additional blood tests that should be done in a patient on lithium?
Prior to commencing lithium, the following baseline tests should be considered:
After 7 days Plasma lithium levels, then weekly until the required level is reached
(between 0.6 and 1.0mmol/L)
3-monthly U&Es, plasma lithium levels
612 monthly eGFR, U&Es, calcium, TFTs
Other CPK (if NMS suspected)
Calcium if hyperparathyroidism suspected
U&Es if patient is dehydrated/vomiting/having diarrhoea
Other parameters as based on clinical suspicion
Station 7: Interpretation of lithium levels 451
ADDITIONAL POINTS
NICE recommends the following laboratory monitoring for lithium:
3-monthly Lithium Lithium levels Three times over 6 weeks following initiation
of treatment and 3-monthly thereafter
U&E U&Es may be needed more frequently if the
patient deteriorates or is on ACE inhibitors,
diuretics or non-steroidal anti-inflammatory
drugs
TFTs Thyroid function for individuals with rapid-
cycling bipolar disorder; thyroid antibodies
may be measured if TFTs are abnormal
Glucose As based on clinical presentation
FURTHER READING
Foster, R. (2008) Clinical Laboratory Investigation and Psychiatry: A Practical Handbook.
London: Informa.
Bazaire, S. (2003) Psychotropic Drug Directory 2003/04. Salisbury: Fivepin Publishing Limited.
Taylor, D., Paton, C. & Kapur, S. (2015) Maudsley Prescribing Guidelines in Psychiatry, 12th
edn. Chichester: Wiley Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are phoned by a work colleague who is the on-call psychiatrist. He has
been called by the A&E registrar concerning an obese 44-year-old man who
has presented to A&E saying he feels unwell, though only describes vague
physical symptoms.
Although apparently stable from a mental state point of view, the registrar
wants a review as the patient is known to have a diagnosis of schizophrenia
and has been on olanzapine for some years. He also wants the patient
transferred to the local psychiatric hospital as soon as possible. He has not
performed any blood tests and has only done a brief physical examination as
the patient is psychiatric and bizarre. The registrar does not further define
this, but feels that the patient is acutely psychiatrically unwell and in urgent
need of sectioning.
A urine dipstick suggested microalbuminuria, but the registrar does not feel
that this was significant. There was also evidence of hypertension, but again
this was dismissed.
Your colleague calls for help as he thinks the patient might have metabolic
syndrome and wants your thoughts on the matter.
SUGGESTED APPROACH
Setting the scene
Introduce yourself. You will need to obtain any additional appropriate background infor-
mation about this patient, including details of all previous treatments, how long the
patient was on them and why they were stopped.
Problem solving
The first task is to try to find out any additional information about the patient. Advise
that your colleague obtains collateral information from the CMHT (if there is one) or the
GP. He will need to perform a proper history, mental state examination and physical
examination in order to determine whether this man is acutely psychiatrically unwell or
is in need of immediate medical attention. In his history, he will need to specifically ask
about any psychiatric history, medical history and medication history, as you are con-
cerned about the microalbuminuria, which you recall may be associated with the renal
toxicity of some medications.
454 Chapter 15: Investigations and procedures
He will need to ask the A&E team to perform a thorough physical examination and request
appropriate blood tests in order to rule out an organic cause of this mans presentation.
ADDITIONAL POINTS
Definition: metabolic syndrome, also called syndrome of insulin resistance,
syndrome X and Reavens syndrome, consists of the association of central
obesity with two or more of the four key features of the disorder (hypertension,
hypertriglyceridaemia, raised fasting plasma glucose and reduced high-density
lipoprotein). The World Health Organisation guidelines also include the feature
of microalbuminuria.
Incidence: controversial; in schizophrenic patients treated with anti-psychotics,
the published ranges vary between 22% and 54.2%.
Psychiatric associations: psychotic illnesses (especially schizophrenia)
treatment with anti-psychotic medication (especially atypicals); note that other
medications have been associated with the development of metabolic syndrome,
including some antiretroviral agents (stavudine and zidovudine) and steroids.
FURTHER READING
De Hert, M.A., van Winkel, R., Van Eyck, D. etal. (2006) Prevalence of the metabolic
syndrome in patients with schizophrenia treated with antipsychotic medication.
Schizophrenia Research, 83(1), 8793.
Grungy, S.M., Cleeman, J.I., Daniels, S.R. etal. (2005) Diagnosis and management of the
metabolic syndrome. Circulation, 112, 273552.
Haddad, P., Durson, S. & Deakin, B. (eds) (2004) Adverse Syndromes and Psychiatric Drugs
A Clinical Guide. Oxford: Oxford University Press.
Taylor, D., Paton, C. & Kapur, S. (2015) Maudsley Prescribing Guidelines in Psychiatry, 12th
edn. Chichester: Wiley Blackwell.
Station 9: Diagnosis and management of neuroleptic malignant syndrome 455
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
During a night on call, you are called to one of the wards to see a patient
whom the nurses are worried about. This is a 35-year-old man who was
recently recommenced on anti-psychotic treatment, with lithium having been
recently added due to an apparent history of bipolar affective disorder. The
nurses inform you that the patient looks unwell and is agitated and sweaty,
although not aggressive or hypomanic. He has a temperature, but is not
complaining of any pain.
They have done some basic observations and let you know that his pulse rate
is 120 per minute, his respiratory rate is 24 per minute and his blood pressure
is 160/110.
You are concerned and call the on-call medical team. They want to know
more about his presentation and likely diagnosis.
456 Chapter 15: Investigations and procedures
SUGGESTED APPROACH
Setting the scene
Introduce yourself. It is important to let the medics know that this is a possible case of
NMS, which is a medical emergency. Let them know that he needs transferring to a
medical setting for further management. Remember to talk in clear, calm and polite
terms and be prepared to explain how you intend to manage the situation acutely. If
your colleague refuses to accept the patient, you should explain that you will have to
call for an ambulance as there is a significant mortality associated with this
condition.
What is NMS?
NMS is a rare, idiosyncratic and life-threatening condition that is thought to be related
to the use of medications that block dopamine receptors and thereby induce sympathetic
hyperactivity.
Insert Venflon.
Ensure good communication with ward staff, on-call senior and receiving hospital.
Once patient is stabilised:
Ensure that appropriate documentation occurs
Problem solving
Remember that NMS and its differentials are potentially life-threatening conditions, and
prompt action is always required. Ensure that staff are aware of the urgency of intervention,
have appropriate equipment to hand and that the crash team has been alerted. There must
be no delay in seeing the patient, and it is advisable to ring for an ambulance at the earliest
opportunity, ensuring that the receiving hospital is also warned about the patient. A copy
of the current drug chart and psychiatric notes is always helpful, as is a transfer letter.
Prior to transfer to A&E, basic interventions (airways, breathing and circulation) and basic
observations should be performed, with additional input given where the doctor in charge
deems this appropriate.
ADDITIONAL POINTS
In normal practice, heroic interventions are not appropriate on the ward, and
although you have a duty of care towards your patient, performing interventions
that you are not adequately trained in or experienced with is never appropriate.
Management of medical emergencies is best performed in A&E.
FURTHER READING
National Institute for Health and Care Excellence (2006) Bipolar disorder: The manage-
ment of bipolar disorder in adults, children and adolescents, in primary and secondary
care. http://www.nice.org.uk/nicemedia/pdf/CG38fullguideline.pdf
Schweyen, D.H., Sporka, M.C. & Burnakis, T.G. (1991) Evaluation of serum lithium
concentration determinations. American Journal of Hospital Pharmacy, 48(7), 15367.
Taylor, D., Paton, C. & Kapur, S. (2015) Maudsley Prescribing Guidelines in Psychiatry, 12th
edn. Chichester: Wiley Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have been called to A&E to see Mr Richards, a 46-year-old man who has
been medically cleared. He was assessed by one of the PLNs, who noted that
he was confused and appeared sweaty. She is concerned that he might be
medically unwell and feels that a doctors opinion is needed. The patient had
apparently been taking a herbal medication, which the nurse thinks may be St
Johns wort. The helpful GP has confirmed that Mr Richards has a history of
amphetamine abuse and had been prescribed a selective serotonin reuptake
inhibitor (SSRI) due to depression, but appears to have been non-compliant.
When you see him, you note that he is confused, agitated and appears to be
shaking.
The PLN wonders whether he is suffering from a serotonin syndrome and
would like your opinion.
460 Chapter 15: Investigations and procedures
SUGGESTED APPROACH
Setting the scene
Introduce yourself. The current scenario should set alarm bells ringing as it implies a
medical emergency that requires immediate medical input. Try to get more of a handover
from the nurse and explain that you do not want to delay seeing the patient. Ask what
she knows about his history, physical examination and any investigations.
Neurological Akathisia
Hyperreflexia
Impaired coordination
Myoclonus
Tremor
ADDITIONAL POINTS
In normal practice, heroic interventions are not appropriate on the ward, and
although you have a duty of care towards your patient, performing interventions
that you are not adequately trained in or experienced with is never appropriate.
Management of medical emergencies is best performed in A&E.
Two separate sets of clinical features have been proposed to assist in the
diagnosis of serotonin syndrome.
The Hunter Serotonin Toxicity Criteria provide a series of decision rules, with
spontaneous clonus in the presence of a serotonergic agent confirming the
462 Chapter 15: Investigations and procedures
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Station 11: Diagnosis and management of hyperprolactinaemia 463
INSTRUCTION TO CANDIDATE
You are a new doctor in a Community Mental Health Team and have been
asked to see an anxious 62-year-old man with a history of schizophrenia who
is complaining of medication side effects. When you see him, he is distressed
and feels that he is turning into a woman. On closer questioning, he reveals
that he has been taking the same psycho medications for many years. He
also says that he has not been reviewed by a psychiatrist for many years. He
volunteers that the medications help his mental state and that he sometimes
takes one or two more of his pills on a stress day. After careful questioning,
he tells you that the name of the tablet is something like Haldone, which, on
clarification, you realise is haloperidol. He says that he thinks he should be
taking this at a dose of 5mg daily.
He says that he has recently been having increasing difficulties down below;
he feels he is starting to grow breasts, which, embarrassingly, seem to be
producing what he says is milk. He says that he never sees his GP and hates
having blood tests, but says that this is stressing him out and that he is
starting to get paranoid that people are paying him more attention. You see
from the notes that this is a known relapse indicator for the patient. You note
that he says that he has no medical problems, has never had any surgery and
is not on any other medications. He says that he thinks he has a brain tumour.
You receive the results of the routine blood tests and you see that his serum
prolactin level is 500 mIU/L. There are no other clinically significant results.
He has a number of questions for you:
1 . What is the likely cause of the symptoms that the patient is describing?
2. What is the physiological mechanism causing these?
3. What is your explanation for the prolactin level? How would you interpret
this?
4. How are you going to help him?
SUGGESTED APPROACH
Setting the scene
Introduce yourself and explain that you have been asked to see this patient. Explain that
some of your questions may be embarrassing, but that you will try to ask these
sensitively.
In females
Polycystic ovary syndrome
Pregnancy
Rarer causes
ArgonzDel Castillo syndrome (galactorrhoeaamenorrhoea in the absence of
pregnancy associated with oestrogen deficiency and decreased urinary
gonadotrophins).
ChiariFrommel syndrome (persistent galactorrhoea and amenorrhoea
postpartum).
Common symptoms in females include menstrual disturbances, galactorrhoea and
infertility, while in males these include impotence, infertility and
gynaecomastia.
Magnetic resonance imaging may also be helpful, and in some cases, osteoporosis may
be secondary to hypogonadism and may be noted on bone density scanning.
ADDITIONAL POINTS
Haloperidol is commonly associated with sexual side effects, as are all anti-
psychotics to varying degrees. Such potential side effects should always be
explained upon initiation of these medications, as may the finding that not
all individuals who are prescribed these medications complain of sexual side
466 Chapter 15: Investigations and procedures
effects. Taking a sexual history can be complex, and the use of a rating scale
such as the Arizona Sexual Experience Scale may be helpful here.
FURTHER READING
Ajmal, A., Joffe, H. & Nachtigall, L.B. (2014) Psychotropic-induced hyperprolactinemia: A
clinical review. Psychosomatics, 55(1), 2936.
Foster, R. (2008) Clinical Laboratory Investigation and Psychiatry: A Practical Handbook.
London: Informa.
Levy, A. (2014) Interpreting raised serum prolactin results. BMJ, 348, g3207.
Taylor, D., Paton, C. & Kapur, S. (2015) Maudsley Prescribing Guidelines in Psychiatry, 12th
edn. Chichester: Wiley Blackwell.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
Chapter 16 James Main
Miscellaneous disorders
SINGLE STATIONS
INSTRUCTION TO CANDIDATE
This is Michael Green, a 28-year-old who lives with both parents. Michael is
seeking comprehensive female gender reassignment and has been talking
about travelling to Thailand for surgery. Michaels family are not keen on the
idea and would prefer that the treatment is within the NHS.
Michael, having had feminising hormone treatment privately, is considering an
NHS transgender programme and hopes to discuss this with you today. The
referral notes that the patient wishes to be known as Charlotte.
Speak to the patient and clarify their eligibility for gender reassignment.
Explain what a treatment programme is likely to involve.
SUGGESTED APPROACH
Setting the scene
Introduce yourself and introduce the assessment. Hello, Charlotte, my name is Dr_____,
and I am a psychiatrist. I understand you are not happy living as a man.
Or:
I understand that you are interested in referral to a gender reassignment programme.
Can you tell me more about what led to this decision? Is it the case that you feel that the
gender you were assigned at birth does not fit? When did you first notice these
feelings?
468 Chapter 16: Miscellaneous disorders
Diagnosing transsexualism
The ICD-10 has three diagnostic criteria (F64.0):
1. History of gender dysphoria in which the person has been subjectively uncomfortable
with the gender allocated to them at birth, often accompanied by a desire to live in a
way and alter their body in order to align with their internal identity.
2 . They need to have a consistent and sustained desire to live as their preferred gender
for at least 2 years (although they can be referred for specialist assessment prior to
this).
3. Transsexualism can only be diagnosed where these beliefs and desires are not due to
any other psychiatric condition (e.g. schizophrenia or the differentials outlined below)
and where genitalia are unambiguous (e.g. a chromosomal disorder). Specialist assess-
ment is needed for possible gender identity disorder in a person with intersex
genitalia.
Differential diagnoses
The key differential diagnoses to exclude are dual-role transvestitism and fetishistic
transvestitism.
In dual-role transvestitism, the person temporarily adopts the clothing and behavioural
role of the other gender for enjoyment for a temporary period, not associated with sexual
arousal and with no desire for permanent change.
In fetishistic transvestitism, clothes of the other gender are worn for sexual excitement
and there is no desire to continue dressing as or any other aspect of the other gender
outside of periods of sexual arousal.
To make sure I understand your experience of your gender identity, can I ask how often
you wear feminine clothes? When you do this, is there any degree of sexual excitement or
is it purely an identity that you feel comfortable with? Is this something that you do or
would wish to do constantly? Are there times that you dont feel a need to live as a woman?
It is worth briefly excluding psychosis and affective disorder and enquiring into any past
psychiatric history.
Management
Referral to a specialist gender identity clinic for full assessment and guidance through
the process.
Psychological support: counselling or individual/group psychotherapy.
Hormone therapy: this is to effect changes in the body in order to bring it in line with
the persons gender identity. They can be taken indefinitely and require monitoring
and clear information about side effects. Oestrogens for male-to-female reassignment
require monitoring for lipids, liver function and hypertension. Give advice on the signs
of thromboembolism, as this could be of increased risk. Either of the hormone treat-
ments can reduce fertility, regardless of the birth gender, and gamete storage can be
considered before commencing treatment.
Speech and language therapy to assist with altering the voice to fit with the persons
gender identity. Note that hormone treatment for female-to-male reassignment will
deepen the voice, but hormone treatment for male-to-female reassignment will not
raise the pitch (the larynx does not reduce in size).
Peer support groups and support groups for the families of people going through gender
reassignment.
Hair removal treatments, particularly of facial hair in male-to-female reassignment.
Surgery
Gender reassignment surgery usually requires that the person has lived as their desired
future gender role for 2 years.
For male-to-female reassignment, surgery can include phonosurgery (for voice), breast
implants and the formation of a neo-vagina from existing genital tissue and autografts.
For female-to-male reassignment, surgery can include bilateral mastectomy, hysterectomy
and bilateral salpingo-oophorectomy, phalloplasty/metoidioplasty, scrotoplasty and tes-
ticular implants.
It is important to ask about the intention to seek surgery overseas and to highlight the
risks of not having sufficient support and preparation for surgery with major permanent
effects and potential complications. Reassure them that the NHS does have specialist care
for transgendered people and that they will be supported and have their rights respected
throughout.
470 Chapter 16: Miscellaneous disorders
Conclusion
Having demonstrated knowledge of the diagnosis, differentials and management, it is
helpful to recap the persons situation and goals. It is important to note that some hormone
treatment changes and gender reassignment surgeries are permanent and the management
process aims to ensure realistic expectations. Psychological and medical support continues
after medical and surgical treatment.
Thank you for talking to me today, Charlotte. From the information you have given, we
can refer you to a gender reassignment clinic in order to complete the assessment and
support you on the process of transitioning.
Key considerations
A person identifying as transsexual believes that they have always had an internal gender
that does not correspond to the gender they were assigned at birth on the basis of their
genitalia. It is important to use the name and gender pronouns (he/him/his or she/her/
hers) that they prefer.
A persons gender history prior to identifying as transsexual is confidential medical
information and should not be disclosed to third parties without consent.
Persons who have a subjective gender identity that does not correspond to their bodily
sex are transsexual or transgendered, and persons who have a gender identity that does
correspond to their bodily sex are often referred to as cissexual or cisgendered.
Patients considering gender reassignment may fear discrimination at work, from friends
and family or transphobic abuse from their community.
Transsexualism occurs in both directions (i.e. male-to-female or female-to-male). This
scenario concerns male-to-female reassignment, and corresponding but different hor-
monal treatments and surgical procedures are indicated for female-to-male
reassignment.
Gender reassignment (and so transsexualism) was made a protected characteristic in
Article 7 of the Equality Act 2010, making it illegal to discriminate on the basis of gender
identity.
FURTHER READING
World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural
Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO Press.
Helpful explanations and advice for professionals working with transsexual patients can be
found in the NHS Gender Dysphoria Guide. http://www.nhs.uk/Livewell/Transhealth/
Documents/gender-dysphoria-guide-for-gps-and-other-health-care-staff.pdf
NHS Choices. Gender dysphoria (contains useful information on treatment pathways).
http://www.nhs.uk/Conditions/Gender-dysphoria/Pages/Introduction.aspx
The Equality and Human Rights commission contains information on discrimination and the
rights of trans people: www.equalityhumanrights.com/
Station 2: Grief reaction 471
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Mrs Smith is a 39-year-old woman who lost her husband 8 months ago due
to cancer and has been attending the GP regularly with multiple non-specific
472 Chapter 16: Miscellaneous disorders
SUGGESTED APPROACH
Setting the scene
Hello, Mrs Smith, my name is Dr_____, and I am a psychiatrist. Your GP asked me to see
you as he was concerned about how you have been feeling since you lost your husband
some months ago. Id like to ask you a bit about how you were after the bereavement, how
things are now and briefly about your mental health more generally in the past. Would
that be alright?
Features of grief
The key here is whether the patient is having a normal grief reaction that may be somewhat
prolonged or whether she has developed a psychiatric condition following (or even prior
to) her husbands death. There are some unusual features noted by the GP for an otherwise
fit 39-year-old, such as requesting home visits and multiple health complaints.
Differentials to consider are an abnormal grief (adjustment) reaction that may have led
to depression with or without psychotic features, a psychotic illness, a somatoform disorder
such as hypochondriasis or an anxiety disorder.
Find out a little about her husband and then her daily life before and since the
bereavement.
Losing someone close to you is always painful and I wondered how long you had known
your husband for and how long you had been married. I understand from your GP that
Station 2: Grief reaction 473
he died from cancer. Was he unwell for a long period or did his death come suddenly?
Can I ask what has life been like since the loss? What do you tend to do day to day? Were
you working before he passed away? What has happened with your job and social life
since his death?
Exclude differentials
In normal grief, low mood and dysphoria may be intermittent and the individual is still
able to reflect on happy memories of the loved one. In depression, there is more pervasive
low mood and cognitive symptoms, such as feelings of worthlessness and hopelessness
or guilt, particularly in relation to the death.
Clarify whether she has the core and somatic symptoms of depression and enquire about
her concern over her health. Are there any nihilistic beliefs? Given her repeated calls to
the GP, consider differentials of health anxiety, hypochondriasis or depression with psy-
chotic symptoms (e.g. nihilistic delusions).
How would you describe your mood over the past 2 weeks? Do you find that you feel sad
or low all of the time or are there times when you feel better or more positive? What are
your energy levels like? Do you have enough energy to go about your routine or do you
feel tired most of the time? Are there things that you still enjoy doing or take your mind
off things? Your GP mentioned that you have seen him quite often with general health
worries. Are you concerned you may be ill? Is there anything in particular you are worried
about? How do you feel after you see your GP and he has told you that he believes you are
physically well? Does it reassure you?
Screen for other delusional beliefs such as persecutory ideas, thought interference and
delusions of reference.
It is normal for a bereaved person to experience brief illusions or hallucinations (whether
visual or auditory) of the deceased.
Sometimes when people have lost someone they were close to, they can seem to hear
their voice or might think that they see them from time to time. Is that something you
have experienced? How often does that happen? Do you ever find that you hear other
peoples voices talking when you are alone or that you hear anything else that others
cannot hear? Is it just your husbands voice you hear or anyone elses?
474 Chapter 16: Miscellaneous disorders
Aetiological factors
An estimated 6%15% of bereaved people develop a complicated grief reaction and this
is more likely following a sudden death or suicide, where the bereaved was dependent on
the deceased, where there is a past psychiatric history or there are pressures preventing
grief (e.g. dependents).
Enquire into any history of depression or other mental health problems. A history of
depression increases her vulnerability to developing another episode as a result of the
bereavement.
Enquire into how she has coped with any previous major losses or changes in her life.
Is there a family history of depression or other significant psychiatric disorder?
Risk
Be sure to enquire about any personal or family history of self-harm or suicide attempts.
As part of your assessment, enquire into any suicidal ideation resulting from the
bereavement.
Sometimes when people are going through a very difficult time, they think about not
being alive or wanting to end it all have thoughts like that come to you? Be careful to
distinguish any thoughts of ending her own life from a more passive wish to be with the
deceased that may be common in the early stages of grief.
You should enquire about substance use.
Conclusion
Explain that you think she is having an ongoing but normal grief reaction and that this
is partly being expressed as an anxiety regarding her own health, leading to repeated
reliance on the GP for reassurance.
Explain that antidepressant medication is not recommended in normal grieving, but that
she may benefit from bereavement counselling and that this may help with her anxiety
elsewhere.
Discussing practical support (e.g. others assisting her with things that her husband may
have taken a lead on in the past) and making use of her support network (e.g. her mother)
are important.
Signpost that she should see her GP should she develop clear symptoms of depression or
to seek urgent help if thoughts of harm to herself emerge.
FURTHER READING
Bonanno, G.A. & Kaltman, S. (2001) The varieties of grief experience. Clinical Psychology
Review, 21, 70534.
Hawton, K. (2007) Complicated grief after bereavement. BMJ, 334, 962.
Prigerson, H.G., Shear, M.K., Jacobs, S.C. etal. (1999) Consensus criteria for traumatic
grief A preliminary empirical test. British Journal of Psychiatry, 174, 6773.
World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural
Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO Press.
Station 3: Selective serotonin reuptake inhibitors and sexual dysfunction 475
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
This woman attends the community clinic wanting to speak to her husbands
psychiatrist. She is angry that their sex life has deteriorated as a result of him
taking a selective serotonin reuptake inhibitor (SSRI) antidepressant.
476 Chapter 16: Miscellaneous disorders
SUGGESTED APPROACH
Setting the scene
Introduce yourself by saying, Hello, my name is Dr_____, I am one of the psychiatrists.
I understand you have some worries about your husband?
She is clearly upset and may be bringing an important issue to your attention. Sexual side
effects can be distressing for both partners and can damage relationships. They are also
one of the main reasons for poor adherence to antidepressants in men.
Importantly, this is not your patient and you must not forget your duty of confidentiality.
She can provide you with information if she wishes and you can give general information
about conditions, medication effects and side effects, but you cannot give specific infor-
mation about her husbands treatment.
While I am happy to talk about general issues, I cannot give specific information about
your husbands care without his permission. Have you been able to talk to him about
coming here today? Please tell me about whats been happening.
happening with your partner? These kinds of side effects are seen with antidepressants
and this should have been explained to your husband when he started them Im sorry
if that wasnt the case.
It is crucial to clarify the timing of events in order to establish possible causation.
When did the symptoms of depression start?
When did the sexual problems first start?
When did the medication start and have there been any dose changes or switching?
What other medication is he on would any of those affect sexual performance, and if
so, when were they started?
Is he suffering from other side effects of SSRIs, such as dyspepsia, nausea, vomiting
or insomnia? Has anything been done to address these and the sexual side effects
sofar?
Talk through management options and also note that the aim of treatment is to remedy
his depression, which can also contribute to the sexual symptoms.
There are several things that we can do and Ill explain those now. I think it is important
to bear in mind that depression itself can affect sexual feelings and behaviour and the
aim of treating is to improve this in the longer term.
Drug holidays are an option; however, her husband should be informed about discontinu-
ation effects and the risk of a worsening of his depression or prolonging recovery.
The dose could be reduced, although this might mean less effective treatment.
Switching to another antidepressant that is less likely to cause side effects is another
option. Mirtazapine is commonly used and has a lower incidence of sexual dysfunction.
Bupropion (not licensed in the UK for depression) as an alternative or an adjunct and
agomelatine are least likely to cause problems, although neither are first-line treatments.
The uncertainty of another medications effectiveness should be weighed against any
benefit seen from sertraline.
Sex has an important psychological aspect that is relevant to sexual performance. Despite
limited evidence, cognitive behavioural therapy (CBT) to address sexual dysfunction may
be of benefit. Sex therapy is another option if interpersonal difficulties or performance
anxiety are significant factors.
Phosphodiesterase-5 inhibitors such as sildenafil have an evidence base for improving
erectile dysfunction in men and sexual dysfunction in women taking SSRIs.
Conclusion
Check whether you have addressed the problem and whether she has any questions.
Emphasise again that there are things that can be done and that you take her concerns
seriously, but that it is important that her husband is directly involved in anything that
affects his health. Ensure that she is aware that stopping the medication risks worsening/
prolonging his depression which, while impacting on sexual function independently,
carries significant risks.
FURTHER READING
Balon, R. (2006) SSRI-associated sexual dysfunction. Am J Psychiatry, 163, 15049.
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. Chichester: Wiley Blakwell, pp.3247.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
Assess this patient who feels that his eyes are too widely spaced apart and is
seeking corrective surgery.
Explain your diagnosis and how you plan to help.
You have avoided seeing friends over the same time period and they call you less
often you think this is because your eyes look weird.
For the past month, you have been feeling tired most of the time, anxious and low
and have stopped enjoying reading for your distance course.
SUGGESTED APPROACH
Setting the scene
Hello, Ms Smith, I am Dr_____ and I am one of the psychiatrists. Im glad that we can
meet to discuss some of your concerns. I understand you have had some concerns about
your appearance and were interested in having surgery?
Insight
Insight is of diagnostic importance (i.e. whether their perception and preoccupation
iswithin normal limits, whether it is an overvalued idea [with poor insight] or delu-
sional [with no insight]). A useful way to begin is with others perceptions of her
appearance.
Have you found other people comment on your eyes? Rather than criticise, do people
ever compliment your appearance? Do you think that others notice this less than you or
may have a less negative view of your appearance? Do you think there is something medi-
cally wrong with your eyes or do you think that this is normal variation and others have
similar features? Have you researched anything about this on the Internet?
Will they consider other explanations? It seems as though this has become an increasing
worry for you and I wonder whether all of the attention that you focus on your eyes may
exaggerate how badly you perceive it.
If they think there is a medical problem or that their features are progressively changing,
are they convinced by medical explanations that this is not the case?
Assess risk
What do they intend to do? A key risk issue is whether they have considered self-mutilating
or surgery from unsafe sources. If so, how far have they got with planning and implement-
ing this?
What would you want surgery for? Have you looked at ways of altering your appearance
online or thought about doing anything yourself? Do you think there could be risks
associated with this?
Is there any evidence of impulsivity or substance misuse that might impair their
judgement?
You will have explored symptoms of depression. Is there any evidence of suicidal ideation,
plans or intent or any history of deliberate self-harm or suicide attempts?
It is clear that this has been causing you a great deal of distress and worry. When people
are going through a difficult time, they sometimes have thoughts about wanting to harm
themselves or about dying. Have any thoughts like this come to you?
Management
Explain the diagnosis and what you would recommend as a management plan. NICE
recommends a choice of either CBT or SSRIs, and a combination if more severe.
I understand that you are worried about your eyes appearing too far apart, but my concern
is that this preoccupies you so much that it exaggerates the problem and leads you to take
dramatic steps that could make things worse. That could be avoiding other people who
are important to you or thinking about surgery. I believe you have developed a condition
called body dysmorphic disorder, which affects how you perceive a part of your body and
can be very distressing. We would recommend you consider two treatments that may be
helpful: cognitive behavioural therapy or medication. Cognitive behavioural therapy or
CBT is a talking therapy usually over ten or more weekly sessions that look at the way
you think about your appearance, your day-to-day behaviours relating to it and the emo-
tional states that come up with those thoughts and behaviours. You learn to recognise
how your emotions, behaviours and thoughts interact to compound the problem. You
then introduce different ways of thinking and acting that reduce the distress it causes
you; for example, training yourself to divert attention away from your appearance or how
you believe others will respond.
482 Chapter 16: Miscellaneous disorders
If their problems are more severe, you would offer them a SSRI alone or in combination
with CBT.
These medications are often used for depression and anxiety, but have been shown to
help in other conditions. Benefits in depression tend to appear within 2 weeks, but in
conditions such as BDD, this can take up to 12 weeks.
Describe the common side effects; explain that the SSRIs are not addictive, but that dis-
continuation effects can occur if stopped quickly. As for OCD, higher doses of SSRIs are
used.
Explain that there can be increased anxiety or agitation in the initiation period. It is
recommended to continue the medication for up to 12 months after any
improvement.
If there is time, you could go on to discuss a second medication, clomipramine, which
can be used if there is no benefit from one or more SSRIs.
There are also self-help materials and support groups available and it would be very useful
to involve a trusted friend or family member that they could confide in to support their
treatment.
FURTHER READING
NICE guidance for BDD is included in their guidance for OCD. https://www.nice.org.uk/
guidance/cg31
Veale, D. (2001) Cognitivebehavioural therapy for body dysmorphic disorder. Advances in
Psychiatric Treatment, 7, 12532.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You have been asked to assess this 32-year-old gentleman. He has been to
his GP on and off for 5 years complaining of changes in his sleeping pattern
and mood. Whilst working abroad for a year during the winter, he did not
complain of low mood.
The GP informs you that he is noticeably more depressed between October
and April, during which he will sleep excessively and put on weight. As spring
arrives, he can become mildly elated and irritable. His partner is finding his
unpredictability difficult to manage.
The GP referred him for psychotherapy, but this did not help. He wonders
whether excessive travelling is responsible for his unstable mental state.
What is the differential diagnosis? Explain your rationale for each.
Give him advice on what can be done to help.
484 Chapter 16: Miscellaneous disorders
SUGGESTED APPROACH
Setting the scene
Hello, my name is Dr_____, thank you for coming. I am a psychiatrist and your GP has
written to me explaining that you have problems with low mood and sleep and these
seem to happen at particular times of the year, is that right?
Differential diagnoses
You have considered recurrent depressive disorder in asking about non-seasonal episodes
of depression.
It is important to exclude adjustment reactions to stressors that might occur at particular
times in the year and confound the diagnosis (e.g. changes in work pattern).
Are there other changes in your life perhaps the nature of your job or things in your
personal life which change significantly because of the time of year? Are these things
that cause you a great deal of concern or worry?
Station 5: Seasonal affective disorder 485
As with any station involving depression, ask for a history of mania or hypomania that
may point to bipolar affective disorder.
Do you ever have periods lasting days to weeks or longer with unusually good mood
and increased energy or talkativeness? Does this ever become problematic, perhaps
leading to not completing tasks or being so talkative that others find it difficult to be
around you?
Ask about a lifelong history of prolonged cyclical changes in mood that may not have
adhered to a seasonal pattern. Another differential is cyclothymia, although in such a
case you would not expect these periods of low mood to last for the full duration of
winter.
Remember also to ask about substance use, particularly alcohol, which may explain the
mood symptoms. Think about whether this is prior to the onset of symptoms or whether
it may be a form of self-medication.
It is also important to mention physical health and to check their thyroid function.
Management strategy
Start by saying that there are various options you can consider, but it might be useful to
ask his partners perspective on his symptoms in winter and particularly the change dur-
ing spring if he is agreeable to your speaking to them.
The leading diagnosis is SAD. The NICE guidelines recommend approaching SAD in the
same manner as depression with CBT and/or SSRIs as the first line depending on the
severity and duration of symptoms and patient preference.
NICE advises against using bright light therapy as an alternative, but this can be used to
supplement the treatment, as there is some evidence of a benefit. The patient would need
to be exposed to 10,000 lux of white fluorescent light using a light box for at least 30
minutes every day during early morning or on rising. They need to stay awake during this
with their eyes open. They could read or do any other light activity that allows them to
stay by the light source. Benefit may be felt after several days, although it usually takes
up to 2 weeks to reach full effect. Ideally, treatment should be started in late summer or
early autumn.
Conclusion
The symptoms of irritability and becoming hyper in the summer may point towards
a bipolar affective disorder, but this requires a more in-depth interview and you can
suggest meeting for further assessment, as well as obtaining collateral from his partner.
Recurrent depressive disorder is another differential if there are episodes that do not fit
the SAD pattern. The clear leading diagnosis, however, is of seasonal affective
disorder.
Be sure to clarify time courses and confounders, summarise the symptoms reported in
order to make it clear that you have reached a diagnosis and always cover risk to self.
FURTHER READING
Eagles, J.M. (2003) Seasonal affective disorder. British Journal of Psychiatry, 182, 1746.
NICE Clinical Guidance CG90 1.6.1.2 (2009) Advises against using light therapy as an
alternative instead of antidepressants or CBT. https://www.nice.org.uk/guidance/cg90
486 Chapter 16: Miscellaneous disorders
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are the junior doctor on call and have been asked to see this 23-year-
old male patient who came back late from Section 17 leave and is behaving
Station 6: Urine drug screen 487
SUGGESTED APPROACH
Setting the scene
Introduce yourself as the doctor on call and explain why you have been asked to
seehim.
Hello, _____, my name is Dr_____, and the nurses asked me to see you because you came
back from leave late and we are concerned about what may have happened. Is it alright
if I talk to you for a while? The nurses also said that they asked for a urine sample for a
drugs test but you werent happy to do one, is that correct?
This station is largely about building rapport and trust so that you can take a history
regarding a sensitive issue from a vulnerable patient. You will need to explain to him/her
why you are concerned and the reasons for a urine sample and ascertain his expectations
and concerns.
Ascertain what happened during the leave, whether he/she used any illicit substances
and whether there was any risk of him/her coming to harm. This is a good opportunity
to reassure him/her and show an interest in his wellbeing.
How was your leave? Did you enjoy it? Did you see any friends or family? How did that
go? Sometimes when people have been unwell in hospital, others may try to take advantage
of them did you meet anyone that made you uncomfortable or did anything bad happen
to you? Did anybody try to attack you or try to take money from you?
488 Chapter 16: Miscellaneous disorders
Conclusion
Ask again whether they would allow a urine sample to be taken and offer to come back
and talk to them about it later. If there is time, you can ask whether they understand the
reason for their leave being stopped and the behavioural contract with the staff.
Acknowledge again that stopping recreational drug use is difficult and there can be great
pressure to buy and use substances in the community. Emphasise the expectation that
they will get better faster and get out of hospital sooner if they do not use drugs which
both affect their mental state and interact with their medication. The hope is to develop
a relationship of trust regarding leave and to enable staff to reduce restrictions on liberty
while being confident that the patients mental health will not suffer. Be mindful through-
out that the patient may well experience their leave being stopped as punitive and feel
mistrustful towards the team.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INSTRUCTION TO CANDIDATE
You are asked to see Mrs Oswald, a 77-year-old woman who presented to the
local police station in her nightie stating that she had committed a crime.
The police have brought her to accident and emergency (A&E), where you are
assessing her as the duty psychiatrist.
Take a history and perform a mental state examination in order to arrive at a
diagnosis.
You are convinced that this means you stole from the government and should be
punished. You cannot be convinced that you are not in serious trouble.
You were depressed 20 years ago after your son died in a car crash, but did not have
any treatment. You do not want any treatment now and would refuse to go into
hospital.
You are agitated and restless, with low mood, anxiety, reduced sleep and appetite for
6 months since your husband died. You have not slept for the past 3 nights at all.
You occasionally hear your husbands voice call your name, but have no other hal-
lucinations. You do not have any other psychotic symptoms.
You have thought about throwing yourself from your third floor balcony where
you live alone.
SUGGESTED APPROACH
Setting the scene
Introduce yourself: Hello, my name is Dr_____, and I am a psychiatrist. I understand that
you came to the police station because you are worried you have done something wrong.
You seem very distressed would you mind telling me what has happened?
This is a distressed and agitated patient remaining calm, speaking clearly and repeating
where needful will help to hold her attention.
Differentials
Late-onset schizophrenia-like psychoses, delirium and behavioural and psychological
symptoms in dementia are key differentials.
Delirium is a medical emergency and would require full medical assessment asking
about past medical history and any symptoms of urinary tract infection (UTI) or chest
infection indicates that you are thinking about this.
There is not enough time to conduct a complete cognitive screen, but asking about ori-
entation to time and place is useful and demonstrates that you are aware that this may
be a presentation related to cognitive impairment or confusion. A brief test of attention
is serial sevens or digit span test would be useful.
Given that she is presenting with delusional beliefs, other forms of psychosis should be
excluded. Screen for symptoms of schizophrenia (e.g. auditory hallucinations, persecutory
delusions, ideas of reference, passivity and thought interference). Is there any evidence
of racing thoughts, pressured speech or grandiosity?
Station 7: Psychotic depression in an older adult 491
You could also consider post-traumatic stress disorder by inquiring about traumatic
events (e.g. the two family bereavements) and intrusive imagery, nightmares or
avoidance.
Ask about past psychiatric history. Previous episodes of depression support a recurrent
episode in the present.
Risk
When people are going through a very distressing time, they sometimes think about
harming themselves or ending their lives. Have you had any thoughts like that? Have you
thought about any particular way that you would try to kill yourself?
Ask who is at home with her and what supports there may be.
Is she using alcohol and is there any evidence of impulsivity?
Has she every tried to end her life in the past?
Is there a family history of suicide?
Has she been eating and drinking? What is her hydration status?
Does this patient drive?
Does she ever look after any minors (e.g. grandchildren)?
Has she had any falls?
Immediate management
This lady is presenting with psychotic depression (delusional beliefs) in the context of a
recent bereavement and previous depressive episodes. Given her suicidal ideation in the
context of agitation and without supports at home, she is potentially high risk and needs
to be fully assessed in an in-patient setting.
Mrs Oswald, you seem to be very upset and worried and I am thinking about what may
be the best way to help you. In particular, I am concerned that you may be suffering from
a form of depression at the moment. How would you feel about coming into hospital for
a period of time where you would have people to support you and we could address what
treatment may help?
If the patient refuses to consider admission, with clear evidence of risks and mental dis-
order, you will need to discuss a Mental Health Act assessment.
From the things you have told me about how you have been feeling, I am concerned that
you may have developed a severe depression. I am quite concerned and I think it may be
important for your safety to come into hospital and to have a full assessment and treat-
ment, even if you are not happy to do so. Sometimes this happens under a part of the law
called the Mental Health Act if people are very unwell and their condition is putting them
at risk of harm. I will ask for two doctors and an approved mental health professional who
is not a doctor to meet with you in order to talk about your worries and why you came to
the police station. They will see you for a Mental Health Act assessment, which means
that they will consider whether you are unwell and require being in hospital under the
Mental Health Act. This is sometimes called being placed under a Section and would mean
that you go from A&E to a mental health hospital for a period of time in order to work
out what is wrong and try to get you better.
If there is time, you can explain Section 2 for assessment and treatment and that this lasts
for a maximum of 28 days.
492 Chapter 16: Miscellaneous disorders
A patient with severe depression and delusional beliefs is unlikely to be able to engage
with psychological therapies.
The first line will be antidepressants augmented with an anti-psychotic either at initiation
or if there is no response to antidepressant monotherapy. Doses should take into account
the patients age.
Tricyclic antidepressants may be more effective in psychotic depression, although they
are not tolerated as well as SSRIs.
If she does not respond to treatment at an appropriate dose, switching and augmenting
strategies should be used.
If she is not responsive to sufficient trials on pharmacotherapy or if rapid response is
needed (e.g. poor dietary intake), electro-convulsive therapy has a good evidence base in
psychotic depression.
Conclusion
This is severe depression with psychotic features and suicidal ideation, agitation, no carers
in the community and easy access to a potentially lethal method (jumping from her
balcony). Given the level of risk, she should be managed in hospital. Explaining that you
feel an admission is needed and discussing a Mental Health Act if she refuses demonstrates
your awareness of the severity of risk.
The hallucinations of her husbands voice may or may not be relevant to the diagnosis
these could be a normal experience in uncomplicated grief and may have predated the
depression. However, there is sufficient evidence for the diagnosis of severe depression
with psychotic features due to her nihilistic delusions of guilt.
FURTHER READING
Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry,
12th edn. Chichester: Wiley Blackwell, pp.2668.
Good Pass
Pass
Borderline
Fail
Clear Fail
NOTES/Areas to improve
INDEX