1.

ELICIT DELUSIONS
CASC LESSON 1
ELICIT DELUSIONS
Whilst eliciting delusions, it is important to elicit first, and then explore further
(Onset, nature, type, content, seek explanation, and assess degree of conviction)
Areas to be covered whilst eliciting delusions

• Address the patient's main concerns and the reasons for the presentation.
• Elicit the main abnormal belief
• Assess the nature, type and the content of the delusional idea.
• Assess their onset (primary/secondary) and their fixity (partial/complete).
• Elaboration and seeking explanation of delusional beliefs
• Assess the degree of conviction
• Effects and coping.
• Screening the patient for the presence of other kinds of delusional beliefs than the
one
• described above.
• Risk assessment especially risk of harm to self or others secondary to the current
delusional ideas.

Open Question

• Have you experienced anything strange, bizarre or unusual? Or perhaps something

that has puzzled you?
• Do you have any particular worries preying on your mind at the moment? (OR)
• Do you have any upsetting thoughts or distressing thoughts on your mind at the
moment?

Listen to the patient. Pick up clues from what the patient says to you.

Delusions of persecution

• How well have you been getting on with people?

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 • Do you ever feel uncomfortable as if people are watching you? (Or) talking about
you
• behind your back? (Or) paying attention to what you are doing?
• Do you ever feel that people are trying to harm you in any way?
• Is anyone trying to interfere with you or make your life miserable?
• Is anyone deliberately trying to poison you (or) to kill you?
• Is there any organisation like the Mafia behind it?

Delusions of reference

• Do people seem to drop hints about you or say things with a special meaning?
• When you watch television, hear radio or read newspapers, do you ever feel that the
stories
• refer to you directly? (Or)
• Do you see any messages for yourself/reference to yourself on TV or radio or in the
newspapers?
• When you watch television, hear radio or read newspapers, do you ever feel that the
stories
• refer to things that you have been doing?

Delusions of control or passivity

• Is there anyone trying to control you?

• Do you feel that you are under the control of a person or force other than yourself?
• Do you feel as if you're a robot or zombie with no will of your own?
• Do they force you to think, say or do things?
• Do they change the way you feel in yourself?

Delusions of guilt

• Do you feel that you are to blame for anything and that you are responsible for
anything going wrong?
• Do you have any regrets?

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 • Do you have guilt feelings as if you have committed a crime or a sin?
• Do you feel you deserve punishment?

Delusions of grandiosity

• How do you see yourself compared to others?

• Is there something 'out of the ordinary' about you?
• Do you have any special power or abilities?
• Are you specially chosen in any way?
• Is there a special mission to your life?
• Are you a prominent person (or) related to someone prominent like royalty?
• Are you very rich (or) famous?
• What about special plans?

Nihilistic delusions

• How do you see the future?

• Do you feel something terrible has happened or will happen to you?
• So do you feel that you have died?
• Has part of your body died or been removed? Inquire about being doomed, being a
pauper, intestines being blocked etc.

Religious delusions

• Are you especially close to God or Christ?

• Can God communicate with you?

Hypochondriacal delusions

• How is your health?

• Do you worry that there is anything wrong with your body?
• Are you concerned that you might have a serious illness?

Delusions of jealousy

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 • Can you tell me about your relationship?
• Do you feel that your partner reciprocates your loyalty?
• If the patient says 'yes' to any of the delusions, then pick up the clues from what the
patient
• says to you.
• Invite the patient to elaborate further on a positive response. Always probe for
further
• elaboration of the beliefs and seek examples
• Always try to assess the degree of conviction, explanation, effects and coping.
• Also try to assess their onset (primary/secondary) and their fixity
(partial/complete).

Conviction, explanation, effects, coping

• What do you think is causing these experiences?

• Who do you think is causing them?
• Why do they do so? And how do they do that?
• How would you explain them?
• Ask how he/she copes with these thoughts, what he/she has done and what he/she
intends to do about them.

Always check whether the delusion is:

Primary or secondary
How did it come into your mind that this was the explanation?
Did it happen suddenly or out of the blue? How did it begin?
Degree of conviction:
Even when you seemed to be most convinced, do you really feel in the back of your mind that
it
might well not be true, that it might be your imagination? (Or)
Do you ever worry that all of this may be due to your mind playing tricks?
The patient may have one or more delusional beliefs. It is important to ask
about other delusional beliefs. For example, if a patient presents with persecutory
delusions, it is important to ask about other delusional types such as delusions of
reference, delusions of grandiosity, delusions of guilt etc, by using appropriate mix of
open and closed questions and picking up clues appropriately.

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Risk assessment:
1. Risk of harm to self
2. Risk of harm to others secondary to the current delusional ideas\
3. Risk of Aggression and violence
4. Risk of non-compliance, Absconsion
5. Risk of alcohol and substance misuse
Also try and rule out other psychotic symptoms (like hallucinations, thought alienation
symptoms etc), as part of your assessment.

Ref: Get through MRCPsych-preparation for the CASC- Sree Murthy

Oxford handbook of psychiatry
Present state examination

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2 ELICIT HALLUCINATIONS
CASC LESSON 1
ELICIT HALLUCINATIONS
Areas to cover

• Explore the hallucinatory experience and its modality (auditory hallucinations)

• To clarify whether these are elementary/complex hallucinations
• To identify if they are true/pseudo hallucinations (source)
• Content of hallucinations
• Timing of hallucinations
• Reality with which they are experienced
• Explore hallucinations in other modalities
• Duration, effects and coping
• If the hallucinations are auditory in nature, it is important to clarify whether they
are Second or third person hallucinations, command/running commentary in
nature.

Auditory hallucinations
I understand that recently you have been hearing voices when there is no one around you
and nothing else to explain it. Can you tell me more about it?
(OR)
I should like to ask you a routine question, which we ask of everybody.
Do you ever seem to hear voices (or) noises when there is no one about and nothing else to
explain it?
If the patient agrees, then this experience should be further clarified.

Second person auditory hallucinations

• Do you hear voices?

• Can you please give me some examples of the sort of things the voice said?
• Who is it you are talking to? Can you recognize those voices?
• If you recognize them, then whose voices are they?

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 • How many voices do you hear?
• Do the voices belong to men, women or children?
• Do they speak directly to you?
• Do you hear your name being called?
• Do they tell you what to do? Can you please give me an example?
• Do they give orders? Do you obey?
• Can you carry on two-way conversion with the voices?

Third person hallucinations

• Do you hear several voices talking about you? (or)

• Do they refer to you as 'he' or 'she' like a 3rd person?
• What do they say?
• Do you hear voices like a running commentary instructing you to do things?
• Do they seem to comment on what you are thinking, reading or doing?

Confirm whether they are true hallucinations

• Where do these voices appear to come from?

• Do you hear them in your mind or in you ears?
• Do the voices come from inside (or) outside your head?
• Do you hear them as clearly as you hear me?
• Can you start or stop them?
• Do you feel that they are real or do you feel that they are just voices?

Hypnagogic / hypnapompic hallucination

• When did this occur? Were you fully awake when you heard these voices?
• Do these voices disturb your sleep?

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 • Do you hear them more at any particular time like when you go to bed or when you
wake up?

Visual hallucination

• Have you seen things that other people can't see?

• What did you see? Can you please give me an example?
• When do you see them and how often?
• Was the vision seen with your eyes (or) in your mind?
• How do you explain it?
• Were you half asleep at that time?
• Has it occurred when you are fully awake?
• Did you realize that you are fully awake?

Olfactory hallucination

• Is there anything unusual about the way things feel or taste or smell? (Open
question)
• Do you ever notice strange smells that other people aren't bothered by?
• What did you smell? Can you please give me an example?
• How do you explain it?

Gustatory hallucination

• Have you noticed that food or drink seems to have an unusual taste recently?
• What did you taste? Can you please give me an example?
• How do you explain it?

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Tactile hallucination

• Have you had any strange or unusual feelings in your body?

• Do you ever feel that someone is touching you, but when you look there is nobody
there?
• Some people have funny sensations on the body, for example, insects crawling
or electricity passing or muscles being stretched or squeezed. Have you had any
such experiences?
• How do you explain it?

Duration, Course, Effects, Coping

• How long have you had these experiences for?

• How often do you have them?
• What do you think might have caused this?
• Why do you think they are happening to you?
• How is it affecting your life?
• How do you manage to cope?
• Do you get any help?

Rule out co-morbidity;

1.Contributing factors to illness and stressors
2.Anxiety
3.Depression
4.Mania/Hypomania
5. Coping strategies like alcohol and illicit drug use.

Risk assessment: Risk of harm to self and or others secondary to hallucinations

Ref:
Get through MRCPsych-preparation for the CASC- Sree Murthy
Oxford handbook of psychiatry
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 3. ELICIT FIRST RANK SYMPTOMS OF
SCHIZOPHRENIA

CASC LESSON 1
ELICIT FIRST RANK SYMPTOMS OF SCHIZOPHRENIA

• It is important to start with open questions and then proceed to closed questions
• Listen to what the patient/role player says as they have scripted instructions AND
TRY TO PICK UP THE CLUES.

Areas to be explored:

• Auditory Hallucinations- Third person auditory hallucinations, Running

commentary hallucinations
• Thought-Alienation Phenomena- Thought withdrawal, Thought
insertion and Thought broadcasting
• Passivity phenomena-Made feelings, made impulses and made volition or
acts, somatic passivity
• Delusional perception
• Clarification, Effects and coping

Open question: I gather that you had been through a lot of stress and strain recently.
When under stress sometimes people have certain unusual experiences. By unusual
experience,
I mean for example, hearing noises or voices when there was no one about to explain it?
Have you had any such experiences?

If the patient agrees, then this experience should be further clarified.

• Can you tell me more about the voices?
• Can you please give me some examples of the sort of things the voice said?

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Third person auditory hallucinations
• Do the voices discuss you between themselves?
• Do you hear several voices talking about you?
• Do they refer to you as 'he' (or) 'she” as a 3rd person?
• What do they say?

Running commentary hallucinations

• Do you hear voices commenting on what you are doing?
• Do the voices seem to comment on what you are thinking, reading or doing etc?
• Do you hear voices like a running commentary instructing you to do things?

Hearing thoughts spoken aloud

• Are the voices repeating your own thoughts back to you?
• Can you hear what you are thinking?
• Do you ever seem to hear your own thoughts echoed or repeated?
• What is it like?
• How do you explain it?
• Where does it come from?

Thought alienation phenomenon (open question)

• Are you able to think clearly? (OR)
• Have you experienced any difficulties in your thinking?
• Do you ever get the feeling that someone is interfering with your thoughts? If so, in what
way Could you please explain it?

Thought broadcasting
• Do you feel that your thoughts are private (or) are they accessible to others in any way?
• Can other people read your mind?
• Are your thoughts broadcast, so that other people know what you are thinking?
• How do you know?
• How do you explain it?

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Thought insertion
• Are thoughts put into your head which you know are not your own?
• How do you know they are not your own?
• Where do they come from?

Thought withdrawal
• Do your thoughts ever seem to be taken from you head, as though some external person
(or) forces were removing them? (Or)
• Do your thoughts disappear (or) seem to be taken out of your head?
• Could someone take your thoughts out of your head? Would that leave your mind empty
or blank?
• Can you give an example?
• How do you explain it?

Passivity of affect, impulses and volitions

• Are you always in control of what you feel and do? (Open question)
• Is there something or someone trying to control you? What is it?
• Do you feel in control of your thoughts, actions and will? (Or)
• Do you ever get the feeling that you are being controlled? That someone else is forcing
your thoughts, moods or actions on you?
• Do you feel under the control of some force or power other than yourself as though you
are a robot or a zombie without a will of your own?
• Does this force make your movements for you without you willing it?
• Does this force or power force its feelings on to you against you will?
• Does this force have any other influence on your body?

Somatic passivity
• Does any force possess you?
• What does that feel like?
• Do you feel that someone or some force plays on your body and produces strange
bodily sensations like special waves affecting your body?
• Does this force have any other influence on your body?
• Can you please give me an example and can you also describe it for me?

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Delusion perception:
• Did you at any time realize that things happening around you have a special meaning
for you? Can you give me an example?
• Can you explain that? What happened exactly?
• Has a sudden explanation occurred out of the blue to you?

Clarification, Effects and coping

• What do you think is causing these experiences?
• How long have you had these experiences?
• Who do you think is causing them?
• Why do they do so? And how do they do that?
• How would you explain them? Could it be your imagination?
• How do they affect you? How do they make you feel?
• How would you cope with them? What do you intent to do about them?

Ref:

Get through MRCPsych-preparation for the CASC- Sree Murthy

Oxford handbook of psychiatry
Present state examination

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 4. ELICIT SYMPTOMS OF DEPRESSION

CASC LESSON 1
ELICIT SYMPTOMS OF DEPRESSION
Areas to be covered;

• Core Symptoms of depression (low mood, anhedonia, fatigueability)

• Biological symptom
• Cognitive and emotional symptoms
• Ideas of guilt and unworthiness
• Depressive cognition (negative thoughts) and suicidal ideation
• Rule out co-morbidity

Eliciting core Symptoms of Depression

Low mood;
• How are you feeling in yourself?
• How has your mood been lately?
• How bad has it been? Have you cried at all?
• If I were to ask you to rate your mood, on a scale of '1' to '10' where 'ten is normal and
one
is as depressed as you have ever felt, how would you rate your mood now?

Anhedonia
• Can you still enjoy the things you used to enjoy? (Or)
• Have you lost enjoyment in things you used to enjoy?
• Is the level of enjoyment same as before?
• What are the things that you find enjoyable/interesting?

Reduced energy level and decreased activity

• How have you been in your energy levels these days?
• Have you been feeling drained of energy lately?

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• How do you spend your day?
• Have you wanted to stay away from other people?

Other symptoms of depression

Eliciting biological symptoms
• How has your sleep been recently?
• Do you need less sleep than usual?
• Have you had any trouble getting off to sleep?
• Do you wake early in the morning?
• Does you mood vary over the course of the day?
• Is your depression/mood worse at any particular time of day?
• What is the best time/worst time of the day for you?
• What has your appetite been like recently?
• Have you lost any weight lately?
• Has there been any change in your interest in sex?

Cognitive symptoms
• How has your concentration been lately?
• What is your memory like at the moment?

Emotional Symptoms
• How confident do you feel in yourself?
• How do you describe your self-esteem to be?

Ideas of guilt
• Do you feel that you've done something wrong?
• Do you feel guilty about anything at the moment?
• Do you tend to blame yourself at all?
• Do you tend to blame anyone else for you problems?
• Do you have any regrets?
• Do you feel that you've committed a crime, (or) sinned greatly (or) deserve punishment?

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Eliciting suicidal intent and negative thoughts
• Do you have any worries on your mind at the moment?
• Have you ever felt that life wasn't worth living?
• How do you see the future?
• Do you feel inferior to others (or) even worthless?
• Do you feel hopeless about yourself? (Or) Has life seemed quite hopeless?
• Do you feel helpless?
• Do you feel that life is a burden?
• Do you wish yourself dead? Why do you feel this way?
• Have you had thoughts of ending your life?
• Have you thought about how would you do it?
• Did you actually try?
• Would you do anything to harm yourself or to hurt yourself?
• Have you got any plans to end your life? What plans?

Duration, course, effects, coping

• How long have you been feeling this way?
• What do you think might have caused this?
• How is it affecting your life?
• How do you manage to cope?
• Do you get any help?

Rule out co-morbidity

1.Anxiety, obsessions
2. Psychosis/Hypomania or mania
3. Coping strategies like alcohol and illicit drug use.

Ref: Get through MRCPsych-preparation for the CASC- Sree Murthy

Oxford handbook of psychiatry
Present state examination

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 5. PSYCHOSIS-ASSESSMENT (BAR CODE)
CASC LESSON 1
TASK:

Mr Miller, a 35 year old man, has been referred to your clinic by his GP as he is concerned he is
experiencing psychotic symptoms. He had a blood test at the GP surgery and reportedly objected
to the bar code on the sample label as it included the numbers "666".He stated that this was an
evil sign according to the Bible.

Please perform a mental state examination. You are not required to assess his cognitive
functions.

Case synopsis:

You are Mr Miller, a 35-year-old man with no previous history of mental health
problems. You objected to your GP taking your blood at the surgery as you noticed that the
sample bottle had a barcode on it including the numbers "666". You felt that this was an
evil sign and the GP was attempting to replace your blood with the Devil's.

You felt that the GP was going to draw your blood, that it would be mixed the Devil's blood
in the sample tube and then injected back into you. You became aware that God was
communicating with you via barcodes around 2 months ago. You realised this when you
were shopping and picked up a bag of rice and noticed that part of the barcode was
"463463" which could correspond with "GodGod" on old style telephone keypads.

You are attempting to find a pattern that will reveal God's plan so you can tell the world
about it. You do not believe you are a messianic figure, but that you do have a special role.
You believe that you are being opposed by some evil force that is trying to stop you finding
a pattern. You realised this 2 weeks ago after having an intermittent headache and some
tiredness for a week and you then went to see your GP.

You realised that you must have had a microchip implanted in your head by this evil force
and that they are trying to stop your thoughts about the pattern in the barcodes. You know
this as you sometimes find your mind going blank or your thoughts being muddled. This
has started to be a problem at work. You are entirely convinced that these events are
occurring. You have been feeling somewhat out-of-sorts and tense for around 2 weeks. You
could not identify a problem and assumed you must have been stressed from work. This
feeling cleared once you realised about the barcodes.

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You have not heard any voices or strange noises, or had any odd visual experiences. You
feel fine in your mood generally. Your sleep and appetite are fine. You are avoiding food
because you feel it is labelled with negative barcodes but you are eating 3 meals a day.

You live with your wife and 2 children, aged 5 and 7 years, in a mortgaged house. You work
as an IT engineer. Your marriage and life has been stable up until now. You drink socially,
have never smoked and do not use recreational drugs.

• This station involves the assessment of a man with prominent delusional ideation. This
includes referential delusions about seeing messages for him in barcodes. These are also
grandiose and religious in nature. He also has persecutory delusions about the evil
force.

• These delusions started with a delusional perception.

• There is evidence of thought withdrawal and block and a degree of thought
disorder.
• Candidates should empathically explore the symptoms with the patient and should
identify the nature of the delusional ideation and that it includes both referential
and grandiose beliefs, and persecutory beliefs. They should challenge these to
determine how securely they are held and explore the patients reasoning.
• Candidates should identify that the delusions started with a delusional perception
and the presence of a delusional mood beforehand.
• Candidates should determine what actions the patients is taking in response to his
beliefs to determine whether they are potentially harmful.
• Candidates should ask directly about thoughts about harming himself or
others. Good candidates will identify that the thought disorder is impacting on his
driving and advise him to stop.
• Candidates should ask him about any perceptual disturbances, including somatic
sensations.
• Candidates should ask about thought insertion, thought broadcast and passivity
phenomena.

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 • Candidates should offer the patient some appropriate interventions, including, but not
limited to, antipsychotic medication, home treatment or inpatient admission. They should
discuss the possibility of a Mental Health Act assessment once it becomes clear that the
patient will not accept any treatment.

Topic:PSYCHOSIS ASSESSMENT (BARCODE)

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit the nature of the delusional ideation
and that it includes both referential and
grandiose beliefs
Assess persecutory beliefs and degree of
conviction
Identify that the delusions started with a
delusional perception and the presence of a
delusional mood beforehand.
Hallucinations, thought alienation
phenomenon & other psychotic symptoms
Response to his beliefs

Risk assessment
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased
questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

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 Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and understandable to
the patient

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 6. PSYCHOSIS- MENTAL STATE EXAMINATION
CASC LESSON 1
TASK

You have been asked to assess Mr. John Abraham who is an 18-year-old college student,
brought to A&E by the police referred as they felt that there is something wrong in his
mental health. He has had a cut to his right wrist stitched in casualty. Assess to look for
evidence of psychosis and arrive at a diagnosis.

CASE SYNOPSIS

You're an 18-year-old university student on vacation, now studying

telecommunication. You live with your mother, stepfather and half-brother aged 14 and a
younger sister. You've just had a cut to your left wrist stitched in A&E. You cut yourself
whilst trying to break through your brother's bedroom door. Over the last 3 months you've
become increasingly convinced your brother and stepfather are trying to brainwash
you. You think your brother and his father are trying to transplant your intelligence into
your brother.

You can't relax at home for fear that they'll "attack” you. You think they are extracting the
thoughts from your head. They do this using a computer that's in your brother's
bedroom. You think they are aware of all your thoughts. They seem to know what you are
doing and what you plan to do next. They talk about you and you've heard them say things
like "he's gone mad; needs locking up etc. You're not depressed and generally feel okay in
your mood. You drink socially and don't smoke. Your concentration is not good. There is no
past psychiatric history.

Reading notes: Please use the screening questions for psychosis in the beginning

Topic:PSYCHOSIS - MSE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

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 Competency Domains Very Poor Average Good Excellent
Poor
Paranoia and Persecutory delusions-
elicitation,

Exploration and clarification

Delusional mood and bizarre delusional
ideas- Elicitation, Exploration and
clarification
Evaluate the falseness of beliefs and assess
degree of conviction

Effects and coping

Thought alienation phenomenon (Thought
withdrawal, thought broadcasting and
thought insertion)
Auditory hallucination- 2nd and 3rd person
(source, content, timing, reality with which it
is experienced),
Rule out hallucinations in other modalities.

Rule out passivity phenomenon and other

psychotic symptoms
Other symptoms- difficulties with coping,
irritability, aggression, deterioration in
performance, social isolation, poor
concentration etc.
Illicit drug and alcohol history
Risk assessment (Self-harm, violence, non-
compliance)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased
questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

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 Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and understandable to
the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of current
best practice
Does not develop an adequate awareness of management of risk

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CASC LESSON 1
7. ELICIT PSYCHOPATHOLOGY
(AGITATED DEPRESSION)
TASK: You are about to see a 78 year old elderly woman referred to the clinic by her GP
with a three month history of believing she has committed a crime many years ago. Take a
history of her beliefs, associated symptoms of relevance and background factors.

CASE SYNOPSIS

AGITATED DEPRESSION IN AN OLDER WOMAN

You're a 68-year old retired married woman living with your retired husband. Your
daughter's marriage broke down about 4 months ago. You've been convinced that you were
guilty of a dreadful crime you committed many years ago. You got pregnant by a man with
whom you had a very short relationship. When told about this he couldn't cope and left
you. You felt disheartened at the time and did not put a fathers name in the birth certificate
of your daughter. You believe that this has led to your daughters' broken marriage. You're
not sleeping well. You've lost your appetite and your clothes are baggy.

You're low in mood and have little hope for the future. You've thought of ending things but
you couldn't bear to think about hurting your husband. You're hearing voices of your
husband telling that you are an evil person and calling you a bitch. You believe
your husband bought tablets from a shop to try to poison you. You are beginning to wonder
if crime related programmes on the TV are being directed towards you. You are not
watching TV anymore, which you used to enjoy.

Reading notes: Please use the screening questions for depression and psychosis
given in the beginning of this lesson.

Topic:AGITATED DEPRESSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

24 | P a g e
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Identify the patient's current and past mood
symptoms
Elicit depressive symptoms, their time scale
and impact on daily life

(low mood, anhedonia, lack of energy)

Other Symptoms of depression

(disturbance in biological functions, poor

concentration & memory, depressed negative
cognitions, guilt feelings, self blaming etc)
Delusions- Elicit, explore and clarify

Assess degree of conviction

Explore the delusional beliefs to establish
whether they are primary or secondary
Hallucinations-modality, source, content,
timing

Reality with which they are experienced

Risk assessment- self harm (suicidal thoughts,
plans etc),

Self neglect
Co-morbidity (alcohol abuse, anxiety etc)
Significant history (Personal and family
history)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased
questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour

25 | P a g e
 4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and understandable to
the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of current
best practice
Does not develop an adequate awareness of management of risk
Reading materials

Depressive disorder: ICD-10 criteria

• Duration of at least 2 weeks is usually required for diagnosis for depressive

episodes of all three grades of severity.
• Depressed mood
• Loss of interest and enjoyment,
• Reduced energy leading to increased fatigability and diminished activity

Other common symptoms are:

(1) Reduced concentration and attention

(2) Reduced self-esteem and self-confidence

(3) Ideas of guilt and unworthiness (even in mild type of episode)

26 | P a g e
(4) Bleak and pessimistic views of the future

(5) Ideas or acts of self-harm or suicide

(6) Disturbed sleep

(7) Diminished appetite

Depressive episode must be present at least for 2 weeks.

• In depression, weight loss is taken as positive if unintentional weight loss of

5% weight in one month has happened.
• For mild depressive episodes, 2 from criterion A - core symptoms + at least 2 from
criterion B - other symptoms - at least 4 must be present. For moderate the count
becomes 2 + 3 / 4 and for severe it becomes 3 + 4 / 5. 4 -6 -8 is an easy way to
remember this.

The psychotic symptoms such as delusions and hallucinations are common in severe
depression. These symptoms are usually mood congruent. Delusions include poverty,
personal inadequacy, and guilt over presumed misdeeds, deserving of punishment and
other nihilistic delusions

The hallucinations are usually auditory (defamatory or accusatory) in nature. Rarely visual
and olfactory hallucinations may also occur.

Mood incongruent psychotic symptoms like persecutory delusions, thought broadcasting

are also possible (not of a clearly depressive nature)

Prevalence:

• In the population aged over 65 the prevalence of clinically significant depression is

10%
• The overall prevalence of major depression is estimated at 2-3%. This figure is
increased in hospital subpopulations and higher still in residential homes
(Fountaulakis et al 2003)
• Depressive disorders are at least 2 to 3 times more common in hospitalized patients,
nursing home residents, or outpatients with chronic medical disorders. In
particular, the 3 C's--cardiovascular disease, central nervous system disorders (eg,

27 | P a g e
 strokes, dementia,Parkinson disease), and cancer--are medical
conditions associated with a high risk for depression.

Clinical features:

• Depressed mood may be less prominent in depression affecting patients in old age
(Gurland 1976) but elderly people with new or recurrent depression are
more hypochondriacal and more delusional than younger people (Gurland 1976).
• Older people report experiencing less negative emotions such as sadness, fear and
anger than younger adults and ageing is associated with an increased ability to
inhibit negative emotional states and maintain positive emotional states.

Altered symptoms in late-life depression

• Reduced complaint of 'feeling sad'

• Hypochondriasis and somatic concerns instead of sadness

• Poor subjective memory - a dementia like picture

• Late onset neurotic Sx (Marked anxiety, obsessive-compulsive or hysterical

symptoms)

• Apathy and poor motivation

Symptoms that may be hard to interpret because of physical disorder

• Anorexia

• Weight loss

• Reduced energy

(Koenig et al 1997)
• Late onset depression is associated more with

o Cognitive impairment: It has been detected in 70% of cases

o Anhedonia

o Psychomotor changes (Hickie et al 2001)-severe psychomotor retardation or

agitation seen in up to 30% of depressed elderly patients

28 | P a g e
 o Depressive delusions regarding poverty, physical illness or nihilistic in nature

o Paranoia is also common and auditory hallucinations may occur in severe

depression (Derogatory and Obscene)

o Weight loss (Janssen et al 2006)

o severe life stress (Vandenberg et al 2001): The frequency and severity of life
events (physical illness, loss of a spouse) may be greater in later life than in
the general population. (Hughes et al 1988).

o Lifetime depressive symptoms and somatic symptoms as preclinical markers

(Hein et al 2003).

Ref:

GS Alexopoulos, et al, The course of geriatric depression with "reversible dementia”: a

controlled study, Am J Psychiatry 150 (1993), pp. 1693-99.

Alexopoulos, GS. Depression in the elderly. Lancet2005; 365: 1961-70

A 75 year old man with depression. Case discussion in JAMA, March 27, 2002--Vol 287.

Green, RC et al. Depression as a risk factor in Alzheimer's disease. The MIRAGE

study. Arch Neurol. 2003;60:753-759

Gelder et al (Ed). Shorter Oxford textbook of psychiatry. 5th ed. Page 511-13

Subramaniam, H & Mitchell, A. Am J Psychiatry 162:1588-1601

Management of depression in later life (Robert Baldwin and Rebecca Wild) APT-March
2004

Get through MRCPsych; Preparation for Long case presentation (Dr. Sree Murthy)

29 | P a g e
CASC LESSON 1
8. PSYCHOTIC DEPRESSION- (BON FIRE)
TASK: Miss. Rosie Green is a 45 year old woman who been brought to A&E by her
friend.Apparently she has not been attending her work for last few days. She believes she is
dead. Her friend found her in the back garden where she had lit a bonfire. Examine the
patient to establish what abnormal belief she holds. Assess if the delusion is primary or
secondary and assess the risk.
CASE SYNOPSIS: You're a 45-year-old woman brought to A&E by your friend.

You believe you are dead. Because you are dead, you wanted to burn yourself in your
garden. Your friend found you in the back garden where you had lit a bonfire. The police
were called. You were detained under the mental health act and admitted last night. These
ideas did not occur spontaneously. About 3 days ago while sleeping you woke to find an
angel standing at the foot of the bed. The angel rose up and then you knew you were dead.

You think you are a pauper and have no money in the bank. You believe your husband
emptied your bank account and left you for another woman. You are very depressed, and
can't see any future. You have suffered depression in the past with suicide attempts (on 3
occasions) and were treated with ECT

Topic:PSYCHOTIC DEPRESSION- ELICIT PSYCHOPATHOLOGY

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit Nihilistic delusions- Explore and clarify

30 | P a g e
 Evaluate the falseness of beliefs and Assess
degree of conviction
Assess whether it is primary or secondary

(Check if it occurred Out of the blue or

secondary to hallucinatory experience)
Elicit Delusions of poverty- Explore and clarify

Evaluate the falseness of beliefs and Assess

degree of conviction
Assess effects and coping
Establish depressive psychopathology&

Screening questions to cover other areas of

psychopathology

(Anhedonia, low energy, disturbance in

biological functions etc)
Risk assessment
(Risk of suicide/self harm/self neglect &
Risk in the future by exploring current
intent)
Past behaviour & Previous suicide attempts
explored
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased
questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability

31 | P a g e
 7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and understandable to
the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed

32 | P a g e
CASC LESSON 1
9. ELICIT PSYCHOPATHOLOGY (MANIA
WITH PSYCHOTIC SYMPTOMS)
Task:
Perform mental state examination on this lady Miss Tracy Burrows, who had been to a rock
concert and was shouting very loudly and dancing around. She was brought to the A&E
department by the police. When she arrived at the hospital 45 minutes earlier, a casualty
doctor saw her briefly and gave her diazepam injection to calm her after she had refused
tablets. She is now a little calmer and willing to talk. Examine her mental state and establish
whether any abnormal psychopathology is present. Do not perform cognitive assessment.

Case synopsis

You are a 19 year-old woman living with her parents. Following a religious rock concert,
the police take you to the local hospital because after the concert you were shouting very
loudly, "I am the alpha and omega, I am saved (Keep repeating it), I am washed in the blood
of the lord”. You were very overactive and dancing around. You spoke very fast and
wouldn't sit still or for long. You appeared ecstatic, believing all your problems in life were
answered.

Your sleep/appetite were affected but you still have lots of energy and the world is a genial
place. After arriving at the hospital a casualty doctor gave you an injection, you now feel a
little calmer. You see "the flames of hell” in the cracks of the floor and hear Jesus speaking
to you. The police are acting against you, the doctors are agents of Satan trying to reclaim
your soul. "If they are fighting for my soul, they are trying to block my union with Jesus”

Topic:MANIA WITH PSYCHOTIC SYMPTOMS- MSE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

33 | P a g e
 Competency Domains Very Poor Average Good Excellent
Poor
Circumstances leading to current
presentation
Elevated mood (usually out of keeping with
circumstances)
Increased energy

(Overactivity, pressured speech, racing

thoughts, reduced need for sleep)
Increased self esteem

(Overoptimistic ideation, grandiosity,

Overfamiliarity, reduced social inhibitions)
Risk assessment & Engagement in behaviour
that could have serious consequences
(Preoccupation with extravagant schemes,
spending recklessly, inappropriate sexual
encounters)
Look for psychotic symptoms-Delusions of
grandiosity, paranoia

Evaluation of falseness of beliefs and degree

of conviction,

Effects and coping

Look for other psychotic symptoms (Any
other abnormal beliefs, other hallucinatory
Experiences, thought alienation etc)
Disruption of work, social activities and
family life
Past psychiatric history, medical history
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased
questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour

34 | P a g e
 4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and understandable to
the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of current
best practice
Does not develop an adequate awareness of management of risk

35 | P a g e
CASC LESSON 1
10. ELICIT SYMPTOMS OF HYPOMANIA
AND MANIA
Areas to be covered;

• Core Symptoms of Hypomania/mania

• Biological and Cognitive symptoms
• Overoptimistic ideation and grandiosity
• Exploring grandiose delusions and clarification
• Risk assessment-Tendency to engage in behaviour that could have serious
consequences
• Rule out co-morbidity
• Mode of onset, duration and progression of symptoms
• Impact on current life

Clinical features of Mania

• Elevated mood/irritable mood

• Increased energy, which may manifest as over activity, excitement, reduced need for
sleep, pressured speech, racing thoughts and flight of ideas
• Increased self-esteem, evident as overoptimistic ideation, over familiarity and
grandiosity
• Reduced attention and increased distractibility
• Tendency to engage in behaviour that could have serious consequences such as
spending recklessly, sexual disinhibition leading to possible exploitation and
reckless driving etc
• Marked disruption to family life, social activities and occupation.

Core features of Hypomania / Mania

• How are you feeling in yourself?
• Have you sometimes felt unusually/particularly cheerful and on top of the world, without
any reason?

36 | P a g e
• If I were to ask you to rate your mood, on a scale of '1' to '10', how would you rate your
mood now?
• Have you felt so irritable recently that you shouted at people or started fights or
arguments?
• How is your energy level?
• Do you find yourself extremely active but not getting tired?
• Have you felt particularly full of energy lately (or) full of exciting ideas?
• Have you felt that you were much more active or did many more things than usual?

Biological symptoms
• How are you sleeping?
• Do you need less sleep than usual and found you did not really miss it?
• How has your appetite been like recently?
• Have you lost /gained any weight?
• How is the sexual side of your relationship?
• Have you been more interested in sex recently than usual?

Cognitive symptoms
• How has your concentration been like recently?
• What is your thinking like at the moment?
• Are you able to think clearly?
• Do your thoughts drift off so that you do not take things in?
• Do you find that many thoughts race through your mind and you could not slow your
mind down?

Eliciting overoptimistic ideation, grandiose ideas & delusions of grandiosity

• How confident do you feel in yourself?
• Do you feel much more self-confident than usual?
• How do you describe your self-esteem to be?
• How do you see yourself compared to others?
• Are you specially chosen in any way?
• Do you have any special powers or abilities quite out of the ordinary? Do you have any
special gifts or talents? If so, what is it?
• Is there a special mission to your life?

37 | P a g e
• Are you a prominent person (or) related to someone prominent like the royalty?
• Are you very rich (or) famous?
• Have you felt especially healthy?
• Have you developed new interests lately?
• Have you been buying interesting things recently?
• Tell me about your plans for the future? Do you have any special plans?

Clarification, Effects and coping

• If the patient harbors grandiose delusions, then pick up the clues from what the
patient says to you.

• Invite the patient to elaborate further on a positive response. Always probe for
further elaboration of the beliefs and seek examples

• Always try to assess the degree of conviction, explanation, effects and coping.

Tendency to engage in behaviour that could have serious consequences

• Has there ever been a period of time when you were not your usual self and you did
things that were unusual for you like spending too much money that ot you into trouble?
• Has there ever been a period of time when you were not your usual self and that other
people might have thought were excessive, foolish or risky?
Explore in detail about the symptom history, mode of onset, duration, progress,
precipitating factor and associated problems.
Duration, course, effects, coping
• How long have you been feeling this way?
• What do you think might have caused this?
• How is it affecting your life?
• How do you manage to cope?
• Do you get any help?

Rule out co-morbidity such as:

• Depression
• Psychotic symptoms (hallucinations- please see previous chapters for questions)
38 | P a g e
• Coping mechanisms i.e. Drug and alcohol misuse.

Ref:
Get through MRCPsych-preparation for the CASC- Sree Murthy
Oxford handbook of psychiatry
Present state examination

39 | P a g e
CASC LESSON 2

TOPIC 1: DELIBERATE SELF HARM- ASSESSMENT

TOPIC 2: GENETICS OF SCHIZOPHRENIA

TOPIC 3: CAPACITY ASSESSMENT-FINANCES

TOPIC 4: TEMPORAL LOBE EPILEPSY

TOPIC 5: DELIRIUM TREMENS-MSE

TOPIC 6: INDECENT EXPOSURE-ASSESSMENT

TOPIC 7: FLUOXETINE & SUICIDAL IDEATION-DISCUSSION

TOPIC 8: ANTIDEMENTIA DRUGS- DISCUSSION

1|Page
 1. DELIBERATE SELF HARM-ASSESSMENT
Assess a young woman who was admitted to A and E after taking an overdose of some
Diazepam tablets. This is her third overdose in the last 6 weeks. She has been medically
cleared by the A and E staff and they are asking if she can go home. Take a history from her
in order to assess her risk and consider whether she needs hospital admission.

Case synopsis

You're a 20-year-old woman who came to A&E earlier in the day following an overdose of 4
tablets of diazepam 5 mg tablets. Prior to the overdose, you had a heated argument with
your boyfriend of 6 months. You think he met someone in the pub and wanted to start a
relationship with her. You're clearly upset about this and took an overdose in order to get
his attention. You describe this as an impulsive overdose. You didn't leave a suicide note.
You now regret the incident but don't know what to do. You've taken overdoses in the
past, when you felt very insecure about yourself. Your mood generally fluctuates. You feel
empty inside. You're an impulsive person. E.g. you deliberately burn yourself with a hair
straightener when angry. Your stepfather sexually abused you for 4 years from age 12 to
16. This is when you started cutting yourself superficially on your arms. You want to be
discharged home. You've contacted your mum and would go to stay with her tonight.

Topic:DELIBERATE SELF HARM- ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Assess circumstances leading to overdose

Careful history of events surrounding self

harm, Psychosocial stressors
Evaluate the degree of suicidal intent and the
seriousness of the attempt

2|Page
 (Premeditation-Planning, performance in
isolation,

Precautions to avoid discovery, Suicidal note

etc)
Mental state: Mood and ongoing suicidal
thoughts, and plans (Intent to self harm
again) Signs of mental illness (Depression,
psychosis etc)
Risk assessment- risk to self-including
neglect, risk to others,
Risk from others (Abuse and exploitation)
Past h/o DSH behaviour

(Overdose, self cutting, burning etc)

Previous mental health problems, family
history etc

Drug and alcohol history

Current Social Circumstances, Can family be
recruited to help?
Coping strategies, Relationships, impulsive
traits
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

3|Page
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk

What is expected?

• You are expected to demonstrate clear communication skills that you are able
to understand the patient and be understood fully by the patient
• You must show sufficient awareness of the importance of key historical identifiers
such
as past psychiatric history, premeditation and current mental state with depression
& ongoing suicidal thoughts
• You should enquire about risk to self-including neglect, risk to others, risk from
others

Assessment: In terms of assessment, items on Beck's suicide intention scale are a useful
guidelines and your questioning should be focussed on following areas;

Circumstances related to suicide intent

• Isolation
• Timing
• Precautions against discovery
• Acting to gain help during or after the attempt
• Final acts in anticipation of death

4|Page
 • Suicidal note

Self report
• Patients statement of lethality
• Stated intention
• Premeditation
• Reaction to the act

Actual risk

• Predictable outcome in terms of lethality of patient's act and circumstances known to

them
• Would death have occurred without medical intervention

Assessment of suicidal intent and risk of repetition

• Ask for depressive negative cognitions like hopelessness regarding the future
which increases risk of repetition
• Ask if life is worth living
• Check if suicidal ideas and plans are still present
• Ask about suicide plans for the future- both short and long term
• Wanted to die? (Check regret survival/expected to die)
• Previous attempts
• Psychiatric illness needing treatment
• Others- recent life events, ongoing stressors

The Royal College of psychiatrists recommend that the following patient information
should be obtained before a deliberate self-harm adult patient is discharged;

• Demographic data including ethnicity

• Consciousness level
• Psychiatric history
• Previous history of self harm
• Alcohol and drug misuse
• Social situations
• Mood
• Presence or absence of thoughts and plans of suicide

5|Page
 • Assessment of risk of further self harm or suicide
• Assessment of capacity to give informed consent
• Decisions taken
• Specific arrangements for any follow up if not referred on for specialist opinion

Suicide risk factors

Static and stable risk factors

• History of self-harm
• History of a mental disorder
• Family history of suicide
• Gender
• Age

Dynamic factors
• Suicidal ideation
• Hopelessness
• Psychiatric admission or discharge
• Psychological stress
• Poor adherence to treatment
• Poor ability to cope with problems

Future risk factors

• Access to a method of suicide
• Future interaction with psychiatric services in terms of general contact and
interventions
Ref: Advances s in psychiatric treatment; 2013; vol 19, 284-289,
Alys Cole king, Victoria parker, Helen Williams and Stephen Platt

Statistics for people with DSH

• 20% repeat in next year

• 1% die in next year
• 10% eventually complete suicide

Risk factors for completed suicide

6|Page
 • Male sex
• Elderly
• Single, divorced or widowed
• Living alone with poor social support
• Previous Para suicide or DSH
• Presence of mental illness/ recent history of inpatient psychiatric treatment
• Concurrent physical illness
• Social/life events- Recent bereavement, unemployment
• History of Alcohol and or drug dependence
• Serious attempt
• Violent method chosen
• Evidence of careful planning
• Active psychological symptoms
• Active suicidal ideation, communication and intent
• Feelings of guilt, hopelessness, worthlessness and depressive features
Ref: Royal college of psychiatrists (2004b). Assessment following self-harm in adults,
Council report CR122
Emergencies in psychiatry-pg 119, Beck's suicide intention
scale, www.londondeanery.ac.uk

7|Page
CASC LESSON 2
2. GENETICS OF SCHIZOPHRENIA
TASK: Mrs Hussain is a 27-year-old woman with a diagnosis of schizophrenia currently
under the care of the community mental health team. She is currently 12 weeks
pregnant. She came to talk to you, as she wants to terminate the pregnancy in fear that she
might pass the schizophrenia gene to the baby. Talk to her about the etiology of
schizophrenia. Allay her concerns

INSTRUCTIONS TO THE ROLE PLAYERS

You are Mrs. Tahira Hussain a 27-year-old Muslim woman with a diagnosis of
schizophrenia currently under the care of the Community Mental Health Team. You are
suffering from Schizophrenia for more than 6 years. You don't have any symptoms like
hearing voices now and you are off medication for the last 6 months. You are currently 12
weeks pregnant. You came to talk to the doctor as you wanted to terminate the pregnancy
in fear that you might pass the schizophrenia gene to the baby. The doctor should talk to
you about the etiology of schizophrenia. Allay your concerns. You are very anxious. You
should repeat that termination is against the religion). You got converted to Islam 15 years
ago and worried that you will be disowned if you were to undergo abortion.

Suggested prompts

• I have heard that Schizophrenia is an inherited illness and it runs in families? Is this
true?
• I am worried that I might pass the Schizophrenia gene to the baby?
• Do you think the risk of this baby developing Schizophrenia is higher than the
general population, if one parent is affected?
• What is the chance of my baby developing schizophrenia in the future?
• Are there any tests to find out in advance who would or wouldn't develop
schizophrenia in the future?
• What are the reasons for developing schizophrenia? (Other than hereditary factors)
• I wanted to terminate the pregnancy but I am worried that I might be disowned by
my family, if I underwent abortion as I am a Muslim (you should mention that
termination is against your religion). What should I do now?
Topic:Genetics of Schizophrenia

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS

8|Page
 JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Heritability of Schizophrenia
Future risk of developing Schizophrenia (if
one parent is affected)
Discussion- Genetic testing
Etiological factors for developing
Schizophrenia
Allay her anxiety- Termination of pregnancy
& implications
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport, Lack of eye contact/non verbal
responses, does not show appropriate attitudes or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
8 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
9 Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

Aetiology of Schizophrenia
9|Page
1. I have heard that schizophrenia is an inherited illness which runs in families. Is
this true?

Broadly speaking, the majority of illnesses, including mental illness, are partially inherited.
However, the way in which illnesses are inherited is complicated and dependent upon many
factors.

It would best be explained if there is a family history of Schizophrenia; an individual inherits

an increased vulnerability to developing the illness.

2. I am worried that I may pass on the Schizophrenia gene to the baby.

Schizophrenia is not caused by just 1 gene. Our understanding is that it is most likely caused
by a complex combination of many genes, influenced many other factors such as early life
experience and social factors including stress and substance misuse.

3. Do you think that the risk of this baby developing Schizophrenia is higher than the
general population, if one parent has Schizophrenia?

The risk of an individual developing Schizophrenia if 1 parent has Schizophrenia, is higher

than in the general population.

If both parents have Schizophrenia, the risk is even higher than if just 1 parent has the illness.

4. What is the chance of my baby developing Schizophrenia in the future?

Research has looked at this question specifically. It has been estimated that the risk of an
individual developing Schizophrenia if they have 1 affected parent is 13% this risk rises to
46% if both parents have the illness.

The above compares to a risk in the general populations of 1%.

Therefore, the risk is significantly higher than in the general population, but if only 1 parent
has the illness, remains quite low.

5. Are there tests to find out in advance who would or would not develop the illness in
the future?

At the current time, there are no tests which can either diagnose of predict Schizophrenia.
Studies have shown subtle differences in the brain scans of those with Schizophrenia
compared to healthy controls, but these scans are not currently clinically useful.

6. What are the reasons for developing Schizophrenia?

10 | P a g e
No one as yet knows for sure what causes it. There seem to be a number of different causes It is thought that
Schizophrenia is caused by an imbalance of chemicals in the brain, predominantly dopamine, which can affect
an individual's: mood, thoughts, perceptions, social functioning and behaviour.

Our current understanding of the illness is that an individual may inherit a vulnerability to
Schizophrenia, but this vulnerability may be lessened or increased by their early life
experience. These 2 factors, in combination with social factors, such as stressful life events,
or substance misuse, may trigger an episode of illness.

7. I want to terminate this pregnancy, but am worried that I might be disowned by my

family if they found out. I am a Muslim and abortions are against my religion. What
should I do now?

Firstly, this consultation is entirely confidential and nothing that you discuss with me will be
disclosed to anyone else.

This is a difficult and important decision, which is yours alone to make, so it is important that
you consider it carefully and fully understand all the potential risks and benefits or
continuing with the pregnancy versus deciding upon a termination.

There are specific, specialist services which can support you in making the right decision for
you and I would be happy to put you in touch with these services.

Under UK law (excluding Northern Ireland), an abortion can usually only be carried out
during the first 24 weeks of pregnancy as long as certain criteria are met. These include:

• It is necessary to save the woman's life

• To prevent grave permanent injury to the physical or mental health of the

pregnant woman

• There is substantial risk that the child would be born with serious physical or
mental disabilities.
Abortions can only be carried out in a hospital or specialist licensed clinic. In order for an
abortion to take place, 2 doctors must agree that an abortion would cause less damage to a
woman's physical or mental health than continuing with the pregnancy.

11 | P a g e
CASC LESSON 2
3. FINANCIAL CAPACITY ASSESSMENT
Financial capacity assessment
TASK: You have been asked to assess Mr George Kelly who has a past history of paranoid
schizophrenia and on Quetiapine medication for the last 2 years. He lives on his own in a
flat. He has not paid his rent for the last 6 months and the landlord made an allegation
against him. The police are asking for a financial capacity assessment. Assess the capacity
of this young man to make decisions about managing his own money and let him know the
outcome of your assessment.

Case synopsis
The doctor will try to assess your capacity to make decisions about managing your own
money. You are in arrears with your rent. You have a long-standing diagnosis of paranoid
schizophrenia and have good insight into your illness and have not had any delusions,
hallucinations or symptoms of mental illness that influenced your capacity. You know your
income and expenses. Your mother used to control your money and pay your rent on your
behalf. You are now managing your own money.You understand the disadvantages of
controlling your own money but you also understand the advantages, independence. You
have not been organised and did not get round to paying the rent. You know that if you do
not pay your rent you could be evicted.

TOPIC:CAPACITY ASSESSMENT-FINANCES

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Abnormal Mental state exam findings: Look
for delusional ideas, paranoid beliefs etc.
Ability to Understand information relevant
to the decision-(rent, arrears, income,
expenses etc)

12 | P a g e
 Ability to retain information for a sufficient
length of time to make decisions
Use or weigh the information (Pros and cons
of managing your money)
Consequences of not paying the rent

Communicate the decision and maintain

choices
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Aspects of capacity assessment domains are highlighted but not explored in
depth or appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk

13 | P a g e
Financial capacity assessment

How do you assess whether someone has capacity to manage their money?

In making an assessment of the person's capacity to manage their money, you will need to
consider whether they understand the information relevant to making the decision in
question. Relevant information could include:

• The person's income, savings and expenditure

• Their financial needs and responsibilities

• Whether there are likely to be any changes in the person's financial circumstances.

As well as looking at a person's understanding of the relevant information, a capacity

assessment should also consider whether the person can:

• Retain this information long enough to make a decision

• Discuss the pros and cons of this decision with you (in other words, can they use the
information you've given them?)

• Communicate their decision in a way which not only works for them, but which
others can understand

The questions below cover a range of abilities relevant to financial decision-making;

• Does the person have basic skills to manage money- identifying currency, adding
notes/coins by value?

• Can the person correctly state what change they would expect for one or more items
of differing value?

• Can they understand what a bank account, a chequebook, a cash card and a credit
card are?

• Can they understand the parts of a cheque and its stub and complete a dummy
transaction?

• Can they explain the parts of their bank statement?

• Can they identify solicitation by advert (post/email) for legitimate and bogus
(spam) financial trasactions?

Ref: Old age psychiatry- Bart Sneeham, Salman Karim, Alistair Burns- Pg 182

14 | P a g e
Guidance on money management for people who may lack capacity to make some decisions
about how their money is used by- Jane Livingstone

CAPACITY ASSESSMENT

MENTAL CAPACITY ACT

The Act defines capacity as follows;

An adult can be considered unable to make a particular decision if;

• He or she has an impairment of or disturbance in the functioning of the mind or

brain, whether temporary or permanent

AND

He or she is unable to undertake any of the following steps

• Understand the information relevant to the decision

• Retain that information

• Use or weigh that information as part of the decision making process

• Communicate that decision made (by talking, sign language or other means)

CAPACITY ASSESSMENTS

Step 1:

Check if the person has an impairment or disturbance in the functioning of mind or brain
(due to various conditions like dementia, brain injury, learning disability, confusional state
due to illness or treatment or drug/alcohol misuse, mental health problems,
unconsciousness)

Step 2:

Check for the following

a. Understand the information relating to decision required (broad terms, simple

language)

b. Retain information (only long enough to make a decision)

c. Use or weigh information (take into account/believe)

15 | P a g e
 d. Communicate the decision (in any form recognised by the assessor)

Step 3:

a. If the person passes the test of capacity and has made the right decision, then
his/her decision must be respected.

b. If the person passes the test of capacity but has not chosen the right decision,
express your concerns to the person and explain that the best possible decision
has not been made. Inform them that although the person is free to make the
decision, it is contrary to the advice of the professionals involved in their care. Give
them adequate time to re-think about it, encourage them to talk to other
professionals like medical colleagues, nurses and social workers etc. Agree to see
them again.

c. If a person fails the test of capacity, the best interests check list must be followed.
All the following points must be considered when making a health/social care
decision in the 'patient's best interests'.

Best interests check list

1. All relevant circumstances (diagnosis, care needs etc)

2. Person's beliefs & values

3. Person's past & present wishes and feelings

4. Consult others who is involved in the care of the person (next of kin, family members,
relatives, carers, attorneys and deputies)

5. Any other factor the person would consider if they could?

6. Will the person regain capacity? If so, can it wait?

7. Is there a least restrictive option available?

8. Encourage the person to participate in the decision making process as far as possible

9. The decision is not solely based on person's age, condition or behaviour

10. For life sustaining treatment- the decision must not be motivated by a desire to
bring about person's death

The person carrying out assessments only has to have a reasonable belief about what is in
the person's best interests at the end of checklist above.

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(Ref: www.matrixtraining associates.com)

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CASC LESSON 2
4. TEMPORAL LOBE EPILEPSY

TASK: Mr James Murray is a 45-year-old car mechanic who was recently started on
Dosulepin by his GP for a depressive episode. The dose was increased to 150mg daily two
weeks ago. Over the last 12 days he has had 5 episodes of staring vacantly into space for a
few minutes at a time. He has been referred to your clinic urgently as a result.Please take a
history from Mr Murray to determine the nature of these episodes. You are not required to
perform a mental state examination.
CASE SYNOPSIS
You are Mr James Murray, a 45-year man who works as a car mechanic. You started feeling
low in mood around 5 months ago due to being at risk of being made redundant at work.
You were diagnosed with a depressive episode of moderate severity and started on a
medication called Dosulepin. She increased the dose to 150mg in the morning at that
appointment and you have been taking this since. Around 2 days afterwards your wife
noticed you "go weird" when you were at the kitchen table. She said that you were staring
into space and not responding to her when she was talking to you and shaking your
shoulder. This episode lasted around 3 minutes and you felt tired afterwards and initially
did not know where you were. Since then, you have had 4 similar episodes. You have
noticed that you tend to have an odd sense of fullness in your abdomen before they
start. Your wife has said that you seem to just stare into the distance for around 3-5
minutes and do not respond to her. You have been able to remember some sensations from
during these episodes. You feel like you are re-experiencing previous events, although they
are new, and the world feels unreal, "like the Matrix". You can also see swirling colourful
lights and smell caramel. Afterwards you feel tired and generally sleep. You and your wife
have noticed that you tend to not be aware of your surroundings for around 15 minutes.
You do not appear to lose consciousness entirely and neither you, nor your wife, have
noticed any odd movements, tongue-biting, incontinence or eye-rolling. You have never
had similar episodes before. You have no history of epilepsy or any other medical
problems. No-one in your family has epilepsy. You are not taking any medication apart
from Dosulepin and do not use recreational drugs.
Topic:TEMPORAL LOBE EPILEPSY

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS

18 | P a g e
 JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Description of episodes (Nature, type,
frequency, duration),

H/o absence seizures

Pre-epileptic phase- History of Aura,

Absences (stare blankly and become

unresponsive to commands)
Automatisms (lip smacking, chewing,
swallowing movements, facial grimacing,
hand gestures etc)

Abnormal experiences (Illusions,

hallucinations, De'javu experiences,
depersonalisation, Others)
Ictal phase: Secondary generalization and
loss of consciousness,

Generalised tonic-clonic activity

Post ictal phase (confused, sleepy, headache,
amnesia, incontinence
etc)
Significant history: Past history (including
febrile seizures), head injury etc

Medical conditions, Medications,

recreational drugs, alcohol etc, Family
history of seizures
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,

19 | P a g e
 Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed

ASSESSMENT OF TEMPORAL LOBE SYMPTOMS

• This station involves the assessment of a man with likely temporal

lobe epileptiform symptoms and complex partial seizures after taking an increased
dose of Dosulepin.

• There is a clear temporal relationship between the increased dose and onset of
symptoms and candidates should identify this.

• Candidates should identify the pre-ictal symptoms of abdominal sensations.

• Candidates should identify the ictal reduction in consciousness, visual and

olfactory hallucinations, derealisation and déjà vu.

• Candidates should identify the post-ictal features of confusion, disorientation and

lethargy.

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 • Candidates should ask relevant questions around loss of consciousness, odd
movements, incontinence, tongue-biting and other associated features of
epilepsy. They should relevant questions about the patients past medical and family
history, as well as around medication.

• Candidates should attempt to establish if these episodes are posing any risks
around driving, work or social activities. If there are risks identified, candidates
should give appropriate advice around avoiding them.

• Candidates should inform the patient, using appropriate language, that they are
experiencing complex partial seizures and that these are occurring because of the
antidepressant, Dosulepin, which has reduced their seizure threshold.

• Candidates should recommend that the medication is changed to an

alternative. It is acceptable for candidates to not suggest a specific alternative and
to say that will seek advice, but good candidates will mention Mirtazapine,
Imipramine, Amitriptyline and Mono-amine Oxidase Inhibitors (MAOIs) as having a
lower risk of inducing seizure activity.

• Candidates should address the patient's concerns about work and desire to return
to normal duties. It is reasonable for them to seek advice or recommend
Occupational Health input. But good candidates will recommend that the patient
would likely have to be established on a new medication, on a stable dose, and
without any further episodes for a period of at least several weeks, if not months
before returning to driving or normal duties. The DVLA could be mentioned as a
source of advice.

TEMPORAL LOBE EPILEPSY

• It is a complex partial seizure which may begin with impairment of consciousness

or may be preceded by the features of a simple partial seizure

• Complex partial seizures arise from the temporal lobe in about 60% of cases and
the frontal lobe in about 30% of cases

• Complex partial seizures in their complete form have three components, aura,
altered consciousness and automatisms (3-As)

Auras: Auras are equivalent to simple partial seizures. The clinical form depends on the
part of the cortex involved in the seizure.
These therefore include
• 1) Motor manifestations

• 2) Somatosensory or special sensory manifestations (simple hallucinations): Altered

perceptual experiences include both distortions of real perceptions and

21 | P a g e
 spontaneous hallucinations. Auditory hallucinations-buzz ling sound, a voice or
voices or muffling sounds .Visual hallucinations may consist of the simple elements
and complex formed hallucinations of scenes, faces or visions of past experiences.
Gustatory or olfactory hallucinations. Paranoid delusions and hallucinations may
figure prominently during the course of attacks. Distorted shape, size and distance
of objects. Things may appear shrunken (Micropsia) or larger (Macropsia) than
usual and Tilting of structures.

• 3) Autonomic manifestations; Effects include epigastric rising sensation or nausea,

tachycardia, piloerection sweating, pallor and salivation

• 4)Psychic manifestations Feelings of Déjà vu or Jamais vu, a sense of familiarity or

unfamiliarity. Experience of depersonalization or Derealization Strong affective
experiences such as fear and intense anxiety. Presence of confusion and
disorientation

• 5)Dysphasic symptoms, dysmnestic symptoms, cognitive symptoms, affective

symptoms

Temporal lobe seizures produces the most varied and complex auras of all. A variety of
autonomic effects and visceral sensations occur prominently in temporal lobe auras and
the Epigastric aura is perhaps the most common of all.
Altered Consciousness. This may follow the aura or evolve simultaneously. The altered
consciousness takes the form of an absence and motor arrest, during which the patient is
motionless and inaccessible (the motionless stare). The patient stares blankly, becomes
wide eyed, motionless stare, dilated pupils with behavioral arrest and becomes
unresponsive to questions or commands.
Automatisms are defined as involuntary motor actions which occur during or in the
aftermath of epileptic seizures in a state of altered consciousness. There is total amnesia for
the events of an automatism. Automatisms can be of various types such as lip smacking,
chewing and swallowing movements, salivation, picking at the clothes, facial grimacing and
hand gestures with continuous movements of the hands. Certain complex acts such as
walking may continue. Some people may become violent and aggressive
• Auras, altered consciousness and automatisms vary considerably in duration.
They generally last for very short periods (1-2 minutes to a few minutes) although
longer seizures sometimes lasting hours are occasionally encountered.

• When the epileptic foci spread from temporal lobe to other areas of the brain, it
evolves to a secondary generalized seizure

• This is followed by a Post ictal period of confusion

• Post ictally, the patient is amnesic for the period of the seizure and may feel
sleepy and confused.

22 | P a g e
Elicit history
• Infections, Trauma, Tumors

• Medical history and medications

• Family history of seizures, Febrile seizures, Past history of seizures

• Psychiatric disorder- panic disorder, psychogenic seizures

Note: Absence epilepsy- no auras, lasts less than 30 seconds and no post ictal
phase. Isolated auras with prominent psychological content such as hallucinations,
depersonalization or other subjective experiences are sometimes referred to as 'psychic
seizures'
Symptom elicitations; (Depersonalization and Derealization)
• Have you yourself felt unreal that you were not a person, not in the living world
or that you were outside yourself, looking at yourself from outside?
(Depersonalization)
• Have you had the feeling that things around you were unreal? (Derealization)
• What was it like? How do you explain it?
Phenomenology of temporal lobe epilepsy

• Autonomic sensations are the most common of auras, causing epigastric aura,
salivation, sometimes vertigo etc.
• Forced thinking The individual has a compulsion to think on a certain restricted
topic.
• Evocation of thought: Intrusion of stereotyped words or thoughts.
• Sudden obstruction to thought flow similar to schizophrenic thought block is also
reported.
• Panoramic memory: Here the individual recalls expansive memories in incredible
detail, as if running a video show of past.
• Psychic seizures: Isolated auras with hallucinations, depersonalisations,
micropsia or macropsia, déjà vu or jamais vu (especially if right sided origin) can
occur.
• Uncinate crises: Hallucinations of taste and smell of uncinate origin associated
with dream like reminiscence and altered consciousness.
• Strong affective experiences are reported - fear and anxiety being very common.

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CASC LESSON 2
5. DELIRIUM TREMENS-MSE
TASK:
Mr Smith is a 70-year-old man who has been admitted to the orthopaedic ward following a
fall two days ago. There were no overt signs of head injury and a CT scan was normal. He
sustained a fracture to his forearm, but is recovering well from the surgery. He is awaiting
OT assessment prior to discharge from hospital. Overnight, the surgical team became
concerned over his behaviour - he appears scared and agitated. He has a tremor and is
shaking. Blood results from admission showed a normal WCC, mildly raised CRP and a
raised MCV. Biochemistry showed a raised GGT and ALP. Please take a brief history and
assess his mental state with a view to view to arriving at a diagnosis.

CASE SYNOPSIS:
You are 70-year-old Mr Smith, a retired postman who lives alone after your wife passed
away 10 years ago. You are currently very scared as you are seeing visual hallucinations.
You can see snakes on the floor, which make you jumpy, and you think the nurses are
whispering and plotting against you. You are confused to time and place, and appear
irritable. You are shaky and have a tremor. You occasionally scratch your arms, believing
that insects are scurrying across.

You are disoriented to where you are, and have difficulty formulating sentences and
remembering details. You were admitted to hospital in the afternoon the day before
yesterday, after you tripped over the kerb whilst going to the local supermarket. You didn't
lose consciousness at the time, and noted that you had injured your right arm. A couple of
passers-by attended to you, one called the ambulance and you were taken to hospital. Your
last drink was 48 hours ago. Since the morning, you have drunk 4-5 cans of cider before
leaving to go to the supermarket to get more. You did feel unsteady on your feet. Your wife
died when you were 60 and your drinking since became much worse. Your daughter lives 3
hours away and visits you once a week. She has repeatedly expressed concern about your
drinking, but you don't really see it as a problem.

You currently drink about 4-5 cans of strong cider during the day and half a bottle of spirits
in the evening to help you sleep. When you wake up in the morning, you need a drink and
become agitated and shaky without one.

You have no other medical problems and don't see your GP.

Topic:DELIRIUM TREMENS- MSE

Candidate Name: Candidate Number:

Examiner name/initials:

24 | P a g e
Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explore the perceptual abnormalities
Assess paranoid thoughts and delusions
Brief assessment of mood, cognition and

assess their insight of the situation

An adequate history of alcohol misuse
Explore any history of other substance
misuse or past psychiatric/medical history
Reflective comments based on observation

(tremors, anxiety etc)

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)

25 | P a g e
 8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
Delirium Tremens(Prepared by Dr Jemma Theivendran, Registrar in Psychiatry)

For this station it is important to cover the following in the history and mental state:

• Explore the perceptual abnormalities (this will inform the differential diagnosis)
and include thought disorder such as paranoid thoughts and delusions

• An adequate history of alcohol misuse (when was their last drink, how much did
they drink that day, how much do they usually drink a day, do they crave for a drink
in the morning, do they drink when they get shaky 'to take the edge off' [indicative
that they have experienced withdrawals] do they consider that they have a
problem)

• Previous history of delirium tremens - can be phrased as whether the patient has
ever experienced this current situation before, have they experienced seizures or
been in hospital for tremors/shakiness

• Brief assessment of cognition is extremely important to do.

• Assess their insight of the situation

• Explore any history of other substance misuse or past psychiatric history

• It is important to empathise with the patient who is in distress - although the

candidate has their agenda, it is important to be flexible in the interview

• The candidate should persist (gently) with questions even if the patient appears
confused or distracted, but ensuring that the patient is settled. If the patient
becomes extremely anxious, it is important to help the patient calm down.

Differential diagnosis

• Delirium tremens

• Delirium

• Alcoholic hallucinosis

26 | P a g e
 • Visual hallucinations in Parkinson's disease

• Psychosis (schizophrenia)

• Drug-induced psychosis

Delirium Tremens:

• Delirium tremens is a toxic confusional state that occurs when alcohol withdrawal
symptoms are severe.

• The symptoms typically peak between 72-96 hours after the last drink

• The classical symptoms include confusion & clouding of consciousness, vivid

hallucinations affecting every sensory modality and marked tremors.

• Clinical features also include paranoid delusions which are fleeting, agitation,
sleep disturbances, signs of autonomic hyperactivity such as fever, sweating,
tachycardia and hypertension

• Risk factors for DT and seizures (from Maudsley guidelines)

• Severe dependence

• Past DTs

• Older patient

• Acute physical illness

• 10% die if untreated.

• Even in cases of polysubstance withdrawal, one must treat alcohol withdrawal

DTs first.

• Benzodiazepines with a longer half-life were more effective in reducing the

incidence of delirium. Longer dose tapering is also required in those with history of
DT or having current DT.

• Clinically, withdrawal medication is often not given until blood alcohol levels have
reduced or withdrawal symptoms are manifest due to concerns of over-sedation
and increased confusion.

• Haloperidol has been shown in a meta-analysis to reduce signs and symptoms of

alcohol withdrawal but they do not reduce the risk of seizures or delirium, as

27 | P a g e
 effectively as benzodiazepines. In fact they may increase the likelihood of seizures
compared with placebo.

Management

• Treat the underling cause if any such as infection, dehydration etc

• Ensure adequate fluid and electrolyte balance, providing adequate nutrition

• Optimisation of environment- well lit quiet room with adequate lighting

• Nursing support-Consistent nursing support to offer reassurance, reorientation

and explanation. If possible, discuss about providing input from the psychiatric
nursing team

• Librium sliding scale (detoxification regime with Chlordiazepoxide (Librium) in a

reducing dose).

• Using parenteral benzodiazepines judiciously in order to achieve quick sedation

and make the situation safe.

• Instituting parenteral, high potency vitamins (thiamine supplementation or

multivitamins).

• Avoiding use of phenothiazine antipsychotics (Haloperidol) due to risk of

inducing seizures.

• Warn about the risk of withdrawal seizures and Wernicke's encephalopathy.

Competency: Patients with delirium are not usually competent to direct treatment. The
Mental health legislation in the UK allows assessment and treatment in their best
interests. It may include

a. Temporary physical restraint to administer drugs

b. Holding within a ward or hospital, if patient tries to leave

c. Covert administration of essential drugs etc

In such situations, it is important to offer clear explanations to staff and family members of
the need for such interventions and their ethical and legal justifications and it should be
documented clearly in the medical notes.

Where to treat: In many cases the patient should be admitted to an acute general hospital
where there are advanced diagnostic facilities such as CT brain scan and staff trained to

28 | P a g e
manage acute illness. The admission is usually for a brief period. With appropriate support
and monitoring, discharge home or transfer to a less acute environment can often be
achieved early.

29 | P a g e
CASC LESSON 2
6. INDECENT EXPOSURE-ASSESSMENT
You are about to see Mr. Alan Johnson in A&E who was brought in by the police after he
exposed himself to children. Assess etiological factors for his behaviour and perform risk
assessment

Case synopsis

You're a 59-year-old man brought by police to A&E. The incident occurred this afternoon at
home. You were feeling uneasy as you were inside the house and suddenly when you stood
by the bedroom window you had a sudden urge to undress and expose yourself. You undid
your trousers and lowered them to expose yourself. You did not have an erection, did not
masturbate and you were not sexually excited. You don't know why you did it. You did not
know that children were there. They reported to the teacher who involved the police. You
say that it wasn't pre-planned. You admit to it 'being wrong and daft'. Your wife died 3 weeks ago
of sudden cardiac arrest. You are really stressed about it and unable to cope. Past history
revealed similar behaviour after the loss of your mother when you were aged 17 and when
your child suffered from meningitis when you were aged 34. There is also a history
of inappropriate contact with a step-daughter in the past.

Topic:INDECENT EXPOSURE-RISK ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Circumstances leading to current
presentation/Index incident

Check if they were aroused/masturbated

Patients' explanation & reaction to the
incident (admit to being wrong, guilty
feelings, indifferent attitude and being

30 | P a g e
 passive attitude, lack of guilt, indifferent to
any consequences of such behaviour)
Past history of similar incidents/offences
Psychiatric history, drug & alcohol history
Forensic history (previous sexual offences,
juvenile sexual offences)
Psychosexual history (previous
Relationships,deviant sexual fantasies,
abnormal sexual practices, paraphilias,
sexual thoughts/fantasies about children)
Current mental health difficulties, if any

(Alcohol, stress or psychiatric disorder)

Future plans & attitude towards intervention
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation

31 | P a g e
 Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Indecent exposure

For people with any abnormal/inappropriate sexual behaviour, the format given below
could be followed.

It is important to cover the following areas;

• Clear account of sexually inappropriate behaviour

• Obtain a psychosexual history

• Past h/o of similar behaviour including forensic history

• Consider use of alcohol and or drugs

• Assess mental state including a brief cognitive examination

• Risk assessment

1. Clear account of sexually inappropriate behaviour (in this case exposing himself)
• What did the person do?

• What was the effect that he wanted to have?

• What effect did he believes his actions would have?

• 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?

32 | P a g e
 • Was the man anxious and did exposing himself make it make him feel less anxious?

• What is his current attitude to what he did-embarrassment, entitlement, pleasure,

Lack

of guilt, fantasies, lack of remorse, lack of empathy, lack of insight, denial/

minimisation

• Future plans and attitudes towards intervention. Does he want treatment?

(Ref: Adapted from Passing the CASC exam- Justin Sauer, Abnormal sexual behaviour, Pg
161)

2. Past h/o of similar behaviour- Check for evidence of past behaviour

Ask specifically for past history of sexual offences

• Exhibitionism

• Indecent assault

• Rape

• Paedophilia etc

3. Obtain a psychosexual history

• Check whether the person has been previously been married or had partners

• Ask for number of sexual partners

• Any evidence of hyper sexuality

• Is there any evidence of fantasy beliefs?

• Frequency of masturbation

• Description of uncontrollable urges

4. Consider use of alcohol and or drugs- On top of asking for drug and alcohol history, it is
important to check if they were intoxicated at the time

5. Mental state examination- Rule out mood/psychotic symptoms

33 | P a g e
In older subjects, brief assessment of cognition in particular will be useful and rule out
acute/chronic confusional state

• Orientation

• Short-term

• Long-term memory

It would be useful to check for any form of functional decline recently to rule out
dementias, especially fronto-temporal type.

6. Risk assessment- Risk to self, others, children, sexual behaviour, Recidivism

Relationship between mental disorder and sexual offending

• Most sex offenders do not have a major mental illness (Grubin & Gunn, 1991).

• Sexual offending may also be associated with organic brain damage (Hucker et al,
1988), learning disability (Walker & McCabe, 1973), substance misuse (Williams &
Finkelhor, 1990) and personality disorder (Reiss et al, 1996).

• People with schizophrenia or related psychoses may commit sex offences or show
abnormal sexual behaviour; this may be related to the psychosis itself, either
directly (Smith & Taylor, 1999) or indirectly owing to disinhibition secondary to the
psychosis (Craissati & Hodes, 1992), or it may be related to the presence of deviant
sexual fantasies (Smith, 1999).

• Affective disorder in itself is not usually associated with serious sexual offending,
although patients with hypomania may behave in a sexually disinhibited manner
leading to offences ranging from indecent exposure to indecent assault (Brockman
& Bluglass, 1996)

Ref: Harvey Gordon and Don Grubin, Psychiatric aspects of the assessment and treatment
of sex offenders, APT January 2004 10:73-80

The assessment process for sexually inappropriate behaviour should aim to elicit
the following;
• What form does the behavior take?

• In what context?

• How frequent is it?

• What factors contribute?

34 | P a g e
 • Is it a problem? To whom?

• What are the risks involved? To whom?

• Are the participants competent?

Ref: Hypersexuality in dementia, Hugh Series and Pilar Dégano- APT November 2005
11:424-431

Indecent exposure:

Classification

1. Exhibitionists- Inhibited men

• They often have previous unremarkable character

• They have sudden powerful urge to display genitals

• The offender may or may not masturbate after exhibiting

• They make little attempt to avoid capture

• They make no further erotic or obscene gestures/attempt any contact with victim

2. Disinhibited- secondary to alcohol, drug use, stress or psychiatric problems such as

dementia, hypomania.

3. Aggressive, impulsive and antisocial- a small minority

• Indecent exposure is the most common sexual offense

• The offender usually stops reoffending after a conviction; serious progressive crimes
are very rare.

• Nearly 20--30% reoffend and if such reoffence leads to conviction, prognosis is very
poor in terms of high recidivism.

35 | P a g e
CASC LESSON 2
7. FLUOXETINE & SUICIDAL IDEATION-DISCUSSION
TASK: Mr David Matthews is a 20-year-old man who is experiencing a severe depressive
episode and has been admitted as an inpatient. He is due to be started on Fluoxetine.

His mother, Julie Matthews, has asked to speak to one of the doctors as she is worried
about the side-effects of Fluoxetine. You are the registrar on the ward and your consultant
has asked you to meet with her.

Please elicit her concerns and answer her queries.

CASE SYNOPSIS:

You are Mrs Julie Matthews, a 45-year-old woman, and the mother of David Matthews, who
has been admitted to hospital for a severe depressive episode. Your son was studying
electrical engineering at Manchester University up until 3 weeks ago. Around this time you
received a call from his worried housemates stating that he had been isolating himself in
his room and barely eating. You and your husband came to get him and took him to the
GP. When you visited him yesterday evening he mentioned that the plan is to start him on
an antidepressant called Fluoxetine. You went home and looked at the side-effects on the
internet and found that suicidal thoughts were mentioned. You were very worried about
this as, despite your son's low mood, he has never had suicidal thoughts. You cannot bear
the thought of him ending his life and are terrified of this. You are particularly interested
in knowing about the potential side-effects, especially the risk of it inducing suicidal
thoughts.

Suggested prompt questions;

• What is this drug (Fluoxetine)intended to do?

• How does it work?

• How quickly it can help

• How long it should be continued.

• What are the potential side effects, especially the risk of it inducing suicidal
thoughts?

• What if he felt suicidal during treatment with fluoxetine?

36 | P a g e
 • Are there any alternative treatments, including talking therapies. If Cognitive
Behavioural Therapy is mentioned, you will have heard and of this and want a brief
explanation.

• I want to know about my son's prognosis and whether he will be able to return to
university and get on with his life

EXPLANATION OF ANTIDEPRESSANT MEDICATION

• This station involves eliciting the concerns of a worried relative around

medication and the potential side-effects.

• Candidates should calmly and sensitively elicit the relative's concerns without
being defensive.

• Candidates should be able to clearly, and using appropriate language, explain the
rationale for starting Fluoxetine.

• Candidates should explain that Fluoxetine would need to be trialled for at least 6
weeks at an adequate dose to determine effectiveness, and that it works, should be
continued for at least 6 months after remission.

• Candidates should give a clear explanation of side effects associated with

Fluoxetine, including initial gastrointestinal upset, nausea, headaches, increased
anxiety and agitation. They may wish to mention sexual side-effects.

• Candidates should directly address the relative's concerns about the risk of
increased suicidal thoughts with Fluoxetine. They should acknowledge this risk but
emphasise that it is a rare side-effect that will be actively monitored for. Good
candidates will mention that Fluoxetine is the antidepressant with the lowest risk of
inducing suicidal thoughts in young people.

• Candidates should assure the relative that if their son develops suicidal ideation,
this will be recognised and his medication changed.

• Candidates should be able to provide a brief description of alternative

medications that could be used, including common side-effects.

• Candidates should be able to briefly describe the theory and practice of Cognitive
Behavioural Therapy.

• Candidates should be able to give a realistic idea of prognosis. The patient in this
scenario should recover and be able to return to normal activities.

Topic:SSRI-FLUOXETINE & SUICIDAL IDEATION

37 | P a g e
Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Mode of action
Duration of treatment
Side effects- CNS, Gastric and sexual side
effects
Concerns about suicidal risk with SSRIs
Alternative treatments
Prognosis
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Poor explanation of concepts
Specific Comments and suggestions

38 | P a g e
CASC LESSON 2
8. ANTIDEMENTIA DRUGS-DISCUSSION
TASK: Mr. Paul Smith was assessed in the memory clinic and has been diagnosed with
Alzheimer's disease. You are seeing him in the memory clinic and decided to start him on
Galantamine (Reminyl). His son Mr. Tony Smith wants to discuss more about the
drug. Talk to him about effects and side- effects of this drug. Address his concerns. Do not
take history.

CASE SYNOPSIS

ANTIDEMENTIA DRUGS

Your elder brother was diagnosed with Alzheimer's disease. The doctor has decided to
start him on Galantamine (Reminyl).

You're his main carer and you wish to discuss more about the drug. Suggested prompt
questions;

• How does it work?

• Does it cure dementia?

• How effective are these drugs?

• What sort of side effects might he get?

• I gather from the Internet that it could affect the liver. Is that true?

• It still sounds a bit worrying to me. Does it affect the heart?

• Is it addictive?

• I have heard that the treatment is expensive. Do we have to pay for it?

• Will you see him in the clinic again?

• How long should he stay on this drug for?

Topic:ANTIDEMENTIA DRUGS- DISCUSSION

39 | P a g e
Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain the nature of the drug & Mechanisms
of action
Offer balanced, factual information-

Drugs are not curative, slows down further

decline
Explain Duration (Long term)

Efficacy of treatment (40- 50%)

Describe side effects

(GI upsets, nausea, vomiting, headache,

dizziness, bradycardia etc)
Monitoring and follow-up

(Memory clinic, MMSE, CPN support)

Address Concerns

Hepatic impairment- less likely

Address Concerns-

Expensive

Addictive potential
No evidence for Daffodil oils
Administration-Long acting preparations
available for once a day
Sources of information- Leaflets, web sites
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

40 | P a g e
 (Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Reading notes

Summary of NICE guidance on acetylcholinesterase inhibitors.

• Acetyl cholinesterase inhibitors such as Donepezil, Rivastigmine and Galantamine

may be prescribed for those with Alzheimer's disease with a mild-moderate levels of
dementia

41 | P a g e
 • Diagnosis must be made in specialist clinic and only specialists should initiate
treatment.

• Assessment of cognitive functioning and activities of daily living should be made

before starting drug treatment.

• Only those likely to comply with drug treatment should be considered.

• If MMSE scores indicated no deterioration or improvement and there is evidence

of global or functional improvement then treatment should continue.

• Those remaining on drug treatment should be assessed at 6 monthly intervals.

Anti-dementia drugs Starting dose Treatment dose

1. Donepezil 5 mg daily 10 mg daily

2. Rivastigmine 1.5 mg BD 6 mg BD

3. Galantamine 4 mg BD 12 mg BD

Common side effects reported: When adverse effects occur, they are largely predictable;
excess cholinergic stimulation leads to nausea, vomiting, dizziness, insomnia and
diarrhoea.

Use with caution: Acetyl cholinesterase inhibitors should be used with caution in patients
with sick sinus syndrome, or other supraventricular conduction abnormalities, those who
are susceptible to peptic ulcer disease and in asthma and chronic obstructive pulmonary
disease.

Memantine
It acts as an antagonist at N-methyl-D- asparate (NMDA) receptors, an action that, in
theory, may be neuroprotective and thus disease - modifying drug.

Lecture notes on anti-dementia drugs

• Donepezil (Aricept), rivastigmine (Exelon), Galantamine (Reminyl) are

cholinesterase inhibitors used to treat mild to moderate cognitive impairment in
Alzheimer's disease.

42 | P a g e
 • They reduce the inactivation of the neurotransmitter Acetylcholine and, thus,
potentiate the cholinergic neurotransmitter, which in turn produces a modest
improvement in memory and goal-directed thought.

• Donepezil is well tolerated and widely used. Rivastigmine and Galantamine

appear more likely to cause gastrointestinal (GI) and neuropsychiatric adverse
effects than does Donepezil. None of these medications prevents the progressive
neuronal degeneration of the disorder.

• Rivastigmine has been evaluated in the symptomatic treatment of patients with

mild-to-moderate dementia associated with idiopathic Parkinson's disease.
Although the evidence is preliminary, it is the best available evidence among the
other options for Parkinson's related dementia. Rivastigmine appears to improve
both cognition and activities of daily living in patients with PDD, resulting in a
clinically meaningful benefit in a large number of cases.

Emre M, Aarsland D, Albanese A et al. Rivastigmine for dementia associated with

Parkinson's disease. N Engl J Med 2004;351:2509-2518.

ANTIDEMENTIA DRUGS - EXPLAIN TO A CARER

• Recently some new drugs have been made available for the treatment of
Alzheimer's disease. These drugs are collectively called antidementia drugs. There
are no major differences between these drugs. Some of the examples include
Donepezil (Aricept), rivastigmine and Galantamine. More drugs are on the way.

• It will not cure the illness completely, but it may help to stabilise the illness or
improve it for a while. It may help his memory. He can also have general benefits
including improving alertness and motivation. More often carers see general
improvements in behaviour or mood.

• Efficacy: Research studies have shown that 40-50% of people who have taken
these drugs have shown some improvement or stabilisation of their condition over a
period of six months.

• Mechanism of action: In Alzheimer's disease, one of the chemicals in the brain

called acetylcholine, which is important for learning and memory, is in short supply.
So if you have less acetylcholine activity, then you may have less memory ability and
reduced learning. The drugs act by increasing the brain levels of acetylcholine and
help to stabilise or improve memory, learning and functioning.

• Initiation: First of all, the specialist will see the patient in the 'memory clinic'.
People are often given a screening memory test called the 'mini mental state
examination' also called as MMSE. But before that, we have to find out if the drug
suits the patient. We will take a history, including a detailed medical history to rule

43 | P a g e
 out severe heart, kidney or liver problems or breathing problems and do relevant
investigations necessary to rule out any treatable causes for his memory problems.
Then we will also do a formal assessment of his daily living skills and if all goes well
then we may start him on these drugs

• The patients are initially started on a low dose of these medications. These drugs
take at least 4 weeks to show their full effect at the starting dose. After 4 weeks, we
may increase his dose.

• Initially we usually prescribe these drugs for a trial period of 3 months to see, if at
the end of 3 months, your father has shown any benefits from this drug. If not we
may take him off the drug

• If he/she does show improvement, he will be on it for a long period of time, as

long as it is benefitting him. Then we will need to review him approximately every 6
months to see if it is worthwhile continuing the treatment.

• The 'mini mental state examination' also called as MMSE is repeated once every
six months and we suggest stopping these drugs when the MMSE score goes below
10 out of 30

• However, in some patients, if we stop the drug they may deteriorate rapidly and
we may have to consider reintroducing it.

• Adverse effects: All medicines have side-effects, yet some patients may
experience none of them. The most common problem is feeling nauseous or a bit
sick in the beginning. But it tends to disappear gradually as the body gets used to the
treatment and generally will not last more than a few days. Other common side
effects are loose stools, loss of appetite, headache, dizziness, tiredness, muscle
cramps and sometimes-poor sleep. The uncommon and rare side effects are urinary
retention and seizures.

• Donepezil, Rivastigmine and Galantamine-Common side effects would include

Nausea, vomiting, insomnia, and diarrhea

• Drowsiness is not a main side effect of these drugs but if you do feel drowsy, then
you should not drive or operate dangerous machinery. You should take extra care as
they may affect your reaction times.

• The combination of Donepezil and alcohol may cause drowsiness. However,

patients on Donepezil can have an occasional drink, if they wish.

• You should have no problems if you take other medications and does not affect
the liver

44 | P a g e
 • These drugs are not addictive. There is no evidence of withdrawal symptoms.

• These drugs are now available on the NHS and is free of cost

• Cardiac effects: May cause bradycardia and dizziness. It should be used with
caution in patients with history of heart block. Do an ECG and seek cardiac opinion,
if you are in doubt

Note: It is worth mentioning at the end about information leaflets, fact sheets and other
information available in books and on the Internet.

45 | P a g e
46 | P a g e
Lesson 3:

TOPIC 1: TRANSFERENCE REACTION-PSYCHOTHERAPY

TOPIC 2: EFFECT OF PSYCHOTROPICS ON ECG & QTc
PROLONGATION
TOPIC 3: UN-COPERATIVE PATIENT REFUSING URINE TEST
TOPIC 4: TRANSEXUALISM- ASSESSMENT
TOPIC 5: OLD AGE DEPRESSION-REFUSING CARE & RISK
ASSESSMENT
TOPIC 6: ALCOHOL DEPENDENCE & MOOD SYMPTOMS
TOPIC 7: LD WITH AUTISM & SCHIZOPHRENIA- ASSESSMENT
TOPIC 8: ANGRY MOTHER- UNHAPPY WITH CARE RECEIVED BY
HER SON
TOPIC 9: OBSESSIVE COMPULSIVE DISORDER-HISTORY
TOPIC 10: VIOLENCE RISK ASSESSMENT
TOPIC 11: AUTISM-HISTORY TAKING

1|Page
Topic 1
CASC LESSON 3
TRANSFERENCE REACTION-PSYCHOTHERAPY
Task: You are seeing Mr. Shepherd in your outpatient clinic. He is a redundant teacher
who has been receiving psychotherapy. He informs that he had cancelled his therapy
session last week and is willing to finish his therapy with the therapist. Listen to him and
address patient's concerns. Discuss to see if there any transference issues and discuss
management plan. Do not take history of depression.

CASE SYNOPSIS

TRANSFERENCE REACTION

You're a 34-year-old woman seeing the psychiatrist in outpatient clinic. You're a

redundant receptionist who has been receiving psychotherapy. You've seen your therapist
weekly on 5 occasions now and have cancelled therapy session last week. You want to stop
therapy and are thinking of not attending any more.You do not feel therapy is benefitting
you. You'll say that you feel that you are depressed because you're unemployed. When a
candidate probes further, you feel the therapist is judging you and this reminds you of your
partner whom you experience in a similar way. Your partner makes you feel inadequate
and that it's your fault that you have been made redundant. This is the same feeling you
experience with your therapist. Ask the doctor if you can stop treatment and not go back at
all. You would like to seek some explanation for the way you feel about the therapist.

Topic:PSYCHOTHERAPY-TRANSFERENCE REACTION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

2|Page
 Competency Domains Very Poor Average Good Excellent
Poor
Explore reasons for dropping out from
psychotherapy:

Patient related factors/ Service related-

accessibility of services
Explore reasons for dropping out from
psychotherapy:

Therapist related factors (Incompetent

therapist, lack of expertise, trust broken by
therapist, Therapist moving away/ changing
jobs)
Explore sensitivity, similar experience in the
past with anyone else

Identification and exploration of the

transference with the therapist
Transference- Explain

(People may have a strong emotional

attitude toward someone important in their
life and this attitude then gets transferred
onto other people later in life and that then
moulds the way that new relationship
develops)
Transference (Shows awareness and
sensitivity that the transference towards the
therapist may be repeated in the present
setting with the examining psychiatrist,
Shows awareness and is able to elicit that in
fact this is a situation which patient tends to
repeat)
Information which is helpful for the
psychiatrist to be able to make an informed
decision whether to recommend the patient
return to psychotherapy
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues

3|Page
 Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
TRANSFERENCE REACTION :

• This is the process, by which a patient displaces onto his therapist feelings, ideas
etc, which derive from previous, figures in his life.

• Loosely it is the patient's emotional attitude towards his therapist.

• In the early days of psychoanalysis transference was regarded as a regrettable

phenomenon, which interfered with the recovery of, repressed memories and
disturbed the patient's objectivity.

4|Page
 • However Freud revised this view. He came to see it as an essential part of the
therapeutic process. It is the therapist's detachment and refusal to play along with
the patient's preconceptions, which creates a novel situation in which it is possible
to interpret to the patient that she is behaving as though the therapist was the
father.

• One can then see that there is a case in this scenario to recommend that returning
to therapy will give her a good opportunity to do some psychological work on how
her internal relationship with her father affects her fundamentally in subsequent
relationships.

Reference: Rycroft C. A Critical Dictionary of Psychoanalysis. London: Penguin, 1995

Explaining transference in simple terms:

(Dr. Rinku Alam, consultant psychiatrist)

People may have a strong emotional attitude toward someone important in their life, like a
parent and this attitude then gets transferred onto other people later in life( like the
therapist, partner or father like new figures in their life) and that then moulds the way that
new relationship develops. It means that problems from the past are gets replayed in
current interaction with people

PSYCHOTHERAPY- REASONS FOR TERMINATING TREATMENT

Reasons for terminating treatment;

1. Making good progress in psychotherapy- You have come to understand your life and
its unconscious motivations to such an extent that you no longer need a
psychotherapist to guide you

2. Ambivalence and poorly motivated patient- may drop out quickly

3. Pragmatic reasons- Progress made in current life situations- Initially might come to
psychotherapy due to depression and unemployment. After a few sessions might
find a new job and quit psychotherapy

4. Move away- Received a job offer and decided to move.

5. Lack of time- Feeling more confident and wanting to get back to

school/university/job etc and no longer has the time for psychotherapy

6. Financial issues and lack of affordability may prevent the treatment from continuing

7. Unfortunate reasons- psychotherapist performing his or her job incompetently

5|Page
 8. Patient believes that the trust has been broken despite efforts to speak about the
problem within the treatment, than may be no other option than for the client to
terminate treatment for his or her own psychological safety

9. Therapist inducing strong transference reactions on to the patient.

10. Therapist changing his job or moving to a different place

11. A therapist may have counter transference issues that can interfere with the
treatment

12. Sometimes a psychotherapist will realize that the psychotherapy has moved into an
area that requires expertise he or she does not have, and trying to continue
psychotherapy without proper training or supervision would be an ethical
violation.

Reference: A guide to psychology and its practice; Termination of psychotherapy.

Reasons for dropping out of psychotherapy

These may be patient related or therapist/service related

Patient related

1. Psychodynamic factors e.g. Transference

2. Demographic. Although studies show different results, some do show that risk factors
for drop out are younger age group (eg 25-30 year olds), and minority ethnic status.
All studies show low SE status is a risk factor for drop out.

3. Patient's explanatory model for his 'illness' and also his view of treatment

4. Patient's motivation - again this may relate to psychodynamic factors

(particularly ambivalence), although lack of a social support is also a risk factor for
drop out.

5. Other patient characteristics: increased drop out if patient socially isolated,

passive aggressive, hostile and has a PD diagnosis

Therapist/service related

1. Accessibility of service

2. Therapist characteristics (i.e. there may be an objective reality to the therapist being
problematic, we cannot always explain encounters through an understanding of the
transference).

6|Page
References

Early withdrawal from mental health treatment: Implications for psychotherapy practice.

Barrett, Marna S.; Chua, Wee-Jhong; Crits-Christoph, Paul; Gibbons, Mary Beth; Thompson,
Don Psychotherapy: Theory, Research, Practice, Training, Vol 45(2), Jun 2008, 247-267

7|Page
Topic 2:

CASC LESSON 3
EFFECT OF PSYCHOTROPICS ON ECG & QTc PROLONGATION
TASK: Mr. James Stewart has a long history of schizophrenia and is on maintenance
treatment with Quetiapine 700 mg daily. He attends the rehabilitation physical health clinic
for routine check up. ECG was taken and he is waiting to be reviewed by the doctor. He
is worried about the heart recording and are anxious to be re-assured. Check his ECG to
look for any abnormalities. Explain the findings and discuss your plan accordingly. Take a
history of risk factors. Do not perform a physical examination

ANTIPSYCHOTICS & QTc PROLONGATION

You're a 50-year-old man who has had schizophrenia since the age of 21. For the past two
years you've been on Quetiapine 700 mg daily. You remain symptom free. You've been
attending the rehabilitation physical health clinic and had the ECG recording. Response to
discussion about the ECG:

• The candidate should inform you that there are ECG changes and show you what
these are on the recording.

• They may well ask if you have any physical symptoms - you have none. They may
ask about your physical health and your medications. You take gliclazide,
Furosemide and Loratadine for hay fever. You are an ex-smoker and occasionally
drink alcohol.

• The candidate may suggest changing your schizophrenia treatment - you are very
against this and want to know how much of a risk is there

• Ask them-"Why do you think it is that tablet and not the other ones”

Topic:ECG & ANTIPSYCHOTICS- DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

8|Page
 Competency Domains Very Poor Average Good Excellent
Poor
Acknowledge and Inform the patient that
ECG is abnormal
Show and explain your findings to the
patient
(QT prolongation and show what these are
on the recording, what they are referring to
on the ECG)
Check for any physical symptoms
(e.g. chest pain, breathlessness, dizzy spells,
episodes of collapse, previous history of
heart problems, family history of cardiac
problems etc)
Check for risk factors-
Diabetes, hypertension, smoking, obesity,
hypercholesterolemia
Implications of abnormal ECG findings-
Prolonged QT interval is highly dangerous,
may cause conduction defects in the heart
leading to sudden death. (High risk factor
for ventricular arrythmias and sudden
death)
Suggest the following- Stop medication
immediately (high dose of Quetiapine)
Inform other alternative medications are
available, cardiology opinion
Acknowledge that Other medications also
cause this problem (Diuretics and
antihistamines)
Insist high risk, if continued on same
medication and dose
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,Lack of eye contact/non verbal
responses, does not show appropriate attitudes or behaviour

9|Page
 4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
QT PROLONGATION & ECG INTERPRETATION

PS: In the college exam, the candidates were asked to discuss the findings of an ECG with
prolonged QT interval of 600 ms (already on the ECG strip) and devise a management plan.
The BNF is provided too.

Explaining in simple terms

(Written by Charles Shuttleworth, Consultant Psychiatrist)

Suggested advice is:

• As you know we have had an ECG, which is an electrical reading of your heart.

• I think it is important that I explain what it has shown but if there is anything that
you do not understand please ask me to go over again, is that ok?

10 | P a g e
 • As you may know the heart is a pump made out of muscle and an electrical
messages tell it how to work.

• Your ECG shows that the electrical message telling the heart to contract and relax
or pump is delayed and this is potentially serious and life threatening.

• The most likely cause is your psychiatric or antipsychotic medication and

therefore it is important that you stop this immediately.

• There is a possibilty that your other medications may also have affected the heart
but the psychiatric medication is most likely the cause.

• I will discuss your ECG with a heart specialist and it is likely we will need to
repeat the ECG again to check that the electrical message has gone back to normal.

• I understand that this may be frightening and you might have questions?

ECG INTERPRETATION

QT interval

• This is the interval between the beginning of the QRS complex and the end of the
T wave. It varies with heart rate, and so must be corrected - the QTc, or corrected QT
interval.

• To calculate the QTc, divide the QT interval by the square root of the preceding R-
R interval (the latter is the interval between the R waves of two successive QRS
complexes). It should be less than 0.42 seconds.

• Corrected QTc = QT/square root of RR interval in seconds.

• Corrected QTc should be approximately 2 large squares.

Please note: If the QT interval is more than 2 large squares or 10 small squares, you
should suspect QT prolongation (simple way of remembering for psychiatrists who don't
read ECG regularly)

11 | P a g e
QT prolongation: (Mechanism)

Prolongation of the QT interval is mediated by blockade of the rapid component of the

delayed rectifier potassium current (IKr) responsible for repolarisation of cardiac Purkinje
cells and myocardial cells.

Many drugs, including certain antipsychotics and antidepressants, bind to this potassium
channel and thereby decrease the outward movement of potassium.

Some antipsychotics - especially droperidol, pimozide, sertindole and thioridazine - have a

greater capacity than others to cause IKr blockade

Antipsychotics

• Most psychotropic drugs are associated with ECG changes, especially

antipsychotics

• Some antipsychotics block cardiac potassium channels and are linked to

prolongation of the QT interval, which is a high risk factor for ventricular
arrhythmias- torsarde de pointes, which can be fatal

• The cardiac QT interval (QT-c) is a useful indicator of risk of torsade de pointes

and increased cardiac mortality

• Drugs such as droperidol, thioridazine, sertindole and Pimozide are associated

with QTc prolongation and sudden cardiac deaths.

• Effects on QTc

12 | P a g e
 • High effect- Haloperidol, Pimozide, sertindole

• Moderate effect- Chlorpromazine, Quetiapine, Ziprasidone, Zotepine

• Low effect- Olanzapine, risperidone, amisulpride, sulpiride, Clozapine,

flupenthixol (depixol)

• No effect- Aripiprazole

QTc values

• Normal QTc for men is 440 ms and 470 ms for women

• There is a clearly increased risk of arrhythmias in QTc values over 500 ms.

Monitoring

• ECG monitoring is essential for all patients prescribed antipsychotics

• According to NICE Schizophrenia guidelines, ECG should be performed on

admission to in-patient units, on discharge and yearly thereafter.

Actions to be taken

1. If QTc is less than 440 ms in men or less than 470 ms in women

a. There is no action required.

b. The patient should continue with their antipsychotic medication.

c. Consider referral to a cardiologist if there are other risk factors or major concerns
about cardiac functions

2. If QTc is more than 440 ms in men and more than 470 ms in women but less than 500
ms

• Consider reducing the dose of antipsychotic medication

• It is safer to consider alternatives (switching to antipsychotic drug of lower

effect)

• Repeat ECG

• Seek Cardiology opinion

13 | P a g e
 3. If QTc is more than 500 ms

• Stop the offending antipsychotic medication immediately

• Seek cardiology opinion immediately

• Consider alternatives (switching to antipsychotic drug of lower effect)

Other important points worth knowing

1. Non psychotropics associated with QTc prolongation

a. Antibiotics (Ampicillin, erythromycin, co-trimazole)

b. Antimalarials (chloroquine, Quinine)

c. Antiarrhythmics (Quinidine, amiodarone, disopyramide)

d. Antihistamines

e. Antidepressants- tricyclic antidepressants

f. Others-Amantadine, diphenhydramine, hydroxyzine, cyclosporine, tamoxifen

etc

2. Physiological risk factors for QTc prolongation

a. Female gender

b. Children and elderly

c. Stress/shock

d. Severe exertion

e. Anorexia nervosa

f. Cardiac causes- Bradycardia, Ischemic heart disease, left ventricular

hypertrophy, myocardial infarction, myocarditis, long QT syndrome

g. Metabolic causes- hypokalemia, hypocalcemia and hypomagnesemia.

3. In terms of cardiovascular diseases, risk factors such as diabetes mellitus,

hypertension, hypercholesterolemia, obesity and smoking presents a much
greater risk to patient morbidity and mortality.

14 | P a g e
 Ref: The Maudsley prescribing guidelines

ECG interpretation
The abnormalities would usuallybe very evident, so think of common things.

(Eg QTc prolongation on treatment with antipsychotic medications)

15 | P a g e
Topic 3:

CASC LESSON 3
UN-COPERATIVE PATIENT REFUSING URINE TEST
Task : Mr David Barett has paranoid schizophrenia and a history of polysubstance misuse.
He is a detained inpatient who has just returned from section 17 leave. The nurses called
you, as they are concerned that he is acting strange, with odd motor movements and
responding to unseen stimuli. The nurses suspect he has taken drugs on leave but is
refusing a drug test. Talk to Mr Barett and persuade him to give a urine drug test. DO NOT
perform a mental state examination. Do NOT take a history.

CASE SYNOPSIS

UNCOOPERATIVE PATIENT REFUSING URINE TESTING

You're a 37-year-old man with paranoid schizophrenia and history of 12+ years
polysubstance misuse. You're a detained inpatient who came into hospital about a week
ago. You went on 8 hours leave and just returned from section 17 leave. The nurses suspect
you've taken drugs on leave. The doctor has asked to talk to you and persuade you into a
urine drug test. You're anxious, restless and responding to voices. You don't want to go
home. During your last admission, 6 months ago, the nurses did a drug screen, which was
positive for speed. You were sent home immediately. There's no electricity or heating and
you've money problems. You're anxious about it happening again and so now are refusing
to give a urine sample. You're very worried that nurses will call the police. If asked, on your
8 hours leave today you avoided going home and went to sit in the park instead. You met a
local drug dealer who pressured you into paying £40 for a spliff.

Topic:UN CO-OPERATIVE PATIENT REFUSING URINE DRUG TESTING

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Form a therapeutic rapport with a difficult
patient
16 | P a g e
 Explore the patient's understanding and
fears about giving a urine drug screen
Clarify the patient's concerns about going
home
Address the patients concerns and clearly
explain the appropriate criteria for patients
given leave whilst detained under section.
Explore what happened on leave and any
resulting issues arising from this
Picking up psychosis and
giving consideration that psychosis might be
directing them not to agree.
Explore risk issues- Important to pick up
that the patient might be exploited for
money and safeguarding
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation

17 | P a g e
 Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Reading material:

(Written by Dr. Adil Akram, Consultant psychiatrist, Springfield hospital and edited
by Dr. Sree Murthy, course organiser)

How to approach this scenario:

• To form a therapeutic rapport with a difficult patient -interview the patient using
non-judgemental approach.

• To start by properly introducing yourself and your role and the purpose of the
interview.

• Openly mention the concerns and observations the ward staff have raised and
highlight the impact of illicit drug use on mental state.

• To explore the patient's understanding and fears about giving a urine drug screen
(UDS).

• To enquire why they are refusing to give a UDS and explain that this is a normal
part of the agreement in granting Section 17 leave from the ward for patients
detained under section of the Mental Health Act. (This should have been explained
to the patient and ideally documented on the Section 17 leave form. To apologise if
this was not explained to him earlier)

• To explore what happened on leave and any resulting issues arising from this i.e
that they are vulnerable to financial exploitation from local drug dealers and a
possible safeguarding issue exists.

• To clarify the patient's concerns about going home i.e. the state of the flat and not
having any electricity, so avoiding going home and ending up in the park. To offer to
raise this with the Care Co-ordinator, if not already being dealt with.

• To address the patients concerns and clearly explain the appropriate course of
action for patients given leave whilst detained under section who refuse to comply

18 | P a g e
 with leave conditions e.g. to cancel further leave, to inform the treating team and
consider if further medication adjustment is required.

• If he agrees to the UDS and it is positive, it is likely his leave will be cancelled until
the next ward round/ team meeting to discuss when would be appropriate to
reinstate the leave with the patient.

• To offer referral for support around the illicit substance misuse e.g. to advise a
referral to the Dual Diagnosis team/Addictions Services.

• To reassure the patient that the result of the UDS if positive will not be forwarded
to the police and his right to patient confidentiality will be maintained.

Useful points:

A hospital is entitled to prohibit patients from misusing drugs or alcohol on the wards. But
what it is entitled to do to enforce this requirement is more difficult. This is especially so with
regard to detained patients. Informal patients can undertake to abide by the rules or,
ultimately, they can be asked to leave. Discharge in similar circumstances is not an option
with patients who have been detained.

While the Mental Health Act 1983 confers the power to detain and treat for mental disorder,
nowhere does it explicitly refer to controlling patients. For example, it contains no provision
that allows staff to search detained patients and, in the absence of lawful authority, searching
a patient or his or her possessions (including urine screening) without consent constitutes a
trespass to the person.

However, Richard Jones (1996), submits that, "A search would be lawful if there are
reasonable grounds for suspicion that the patient is in possession of a substance or articles
that could be used to harm himself or other people or was in possession of a controlled drug
in contravention of the Misuse of Drugs Act 1971”. By extension, the authors' opinion is that,
where it is suspected that a patient may be under the influence of illicit drugs, the evident
dangers, such as the possibility of these substances interacting with prescribed medication
or other deleterious consequences of drug use, would justify the responsible medical officer
acting under a common law duty of care to the patient by carrying out an investigation, such
as urine sampling.

Introduction of contracts is an imaginative approach that has been adopted in some units to
tackle the consumption of alcohol and illegal drugs by patients. Each patient is asked to sign
a treatment contract or declaration, thereby giving an undertaking not to use alcohol or
illegal drugs on the ward; consenting to staff searching possessions on suspicion that the
patient has brought alcohol or drugs onto the ward; and agreeing to provide blood, urine and
breath samples when asked by staff.

Successful implementation requires a range of options for consideration if there is evidence

of substance misuse. These include
19 | P a g e
 1. An increase in observation levels

2. Restrictions on leave

3. More frequent property searches

4. Limits on visits and discharge or, for detained patients, transfer to higher security
wards.

Where a treatment contract has been introduced, patients are reported to accept the policy
as part of the admission process and tend to adhere to it during their hospital stay. But
success depends on the patients' cooperation, which may not always be forthcoming and
staff willingness to implement the policies.

Ref: Substance use and misuse in psychiatric wards- A model task for clinical
governance? (Psychiatric Bulletin February 2000 24:43-46)

20 | P a g e
Topic 4:

CASC LESSON 3
TRANSEXUALISM-ASSESSMENT
TASK:

Simon Brown had been referred by his GP, as he wanted to start taking oestrogens. Take a
history to arrive at a diagnosis. Do not conduct a mental state examination

CASE SYNOPSIS:

You are a man in your 20s, referred by your GP, as you wanted to start taking oestrogens.
You prefer to be called Simone, which is a female derived version of your name Simon. You
feel like a woman trapped in a man's body. You have the persistent desire to live and be
treated as a woman. You want oestrogen for breast development, hip development,
softened skin and a female voice. You would like a sex change operation eventually and
become a woman. You have had gender identity problems since you were a child. You have
had cosmetic surgery to remove your chest and body hair. You have changed your name to
Simone Brown on your passport and other documentation. You are aware that sex change
surgery is permanent and irreversible. You are also aware that oestrogens can have
adverse effects.

Topic:TRANSSEXUALISM-HISTORY

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
History of presenting problems

(Mode of onset, duration, progression,

impact on current life)

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 Gender history and an exploration of the
patient's sexuality

(Sense of gender dysphoria)

Childhood history (Type of play, Preferred
dress, Gender identity as a child, adolescent
& adult), Experience of puberty
Cross-dressing history as a woman-duration
and whether this was associated with sexual
arousal (Evidence of transvestism rather
than transexualism), Fantasies about normal
vaginal intercourse etc
Feelings towards own gender -specific
features, sexual organs, Aspects of self that
are perceived to be masculine and those
perceived to be feminine
Tendency to behave as a member of the
opposite sex, Any progress towards adopting
the opposite gender role (Changing name,
hair removal etc)
Patient's goals- regarding making the
transition to the opposite gender & hopes for
their sexual life
Awareness of Risk-Adverse effects of
estrogens & Monitoring, Surgery- permanent
& irreversible
Rule out mental illness (depression,
psychosis, delusional disorder etc)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)

22 | P a g e
 Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
Specific Comments and suggestions

Transsexualism

Transsexualism is described in ICD-10 as 'a desire to live and be accepted as a member of

the opposite sex, usually accompanied by a sense of discomfort with [...] one's anatomic
sex' (WHO 1992). For the diagnosis to be made, transsexual identity should have been
present for at least 2 years, and must not be a symptom of another mental disorder (e.g.
schizophrenia) or associated with any endocrine or chromosome abnormality.

The core clinical feature of these patients is an enduring belief that they are 'really' of the
opposite sex. The aim of the assessment is to make the diagnosis, offer alternative
treatments, to provide supportive psychotherapy and to supervise the real life test.

Transsexualism has the following criteria:

• Persistent discomfort with his/her sex or sense of inappropriateness in the

gender role of the sex

• Strong and persistent cross-gender identification (not merely a desire for any
perceived cultural advantages of being the other sex). This may be associated with
wish to make one's body as congruent as possible with the preferred sex through
surgery and hormone treatment.

• The disturbance is not concurrent with a physical intersex condition and not due
to other functional psychiatric disorders

• The disturbance causes clinically significant distress or impairment in social,

occupational or other important areas of functioning

• The transsexual identity has been present persistently for at least two years.

23 | P a g e
 • Most adult transsexuals in fact have origins of symptoms in childhood itself.

Various degrees of gender dysphoria exist. One mild form is recognized in ICD and DSM
as dual role transvestism.

• The individual wears clothes of the opposite sex in order to experience temporary
membership in the opposite sex.

• The individual experiences a sense of appropriateness by wearing clothes of the

other gender.

• There is no sexual motivation for the cross-dressing.

• The individual has no desire for a permanent change to the opposite sex.

This must be differentiated from fetishistictransvestism where cross-dressing results in

sexual arousal often associated with masturbation or sexual activity. This is classified as a
paraphilia.

The gender history (Carroll 2007)

Taking a gender history is an essential tool in diagnosis and serves a second purpose by
helping the clinician to understand the gender dysphoria in the context of that person's life
and make recommendations towards appropriate treatment (Carroll 2007). An exploration
of the patient's sexuality is also undertaken. This gives the opportunity to identify those
whose cross-dressing behaviour is purely for fetishistic purposes, as well as helping the
clinician to understand the importance of sexuality to the individual patient, how treatment
might affect the patient's sexual relationships and what the patient's hopes are for their
sexual life, so that help may be given.

Record aspects of the patient's life that pertain to their gender feelings and
experiences:

• Type of play as a child (conforming to gender role or non-conforming)

• Preferred dress as a child

• Gender identity as a child, adolescent and adult

• Reactions of others regarding the patient's gender behaviour

• Experience of puberty

• Cross-dressing history and whether this was associated with sexual arousal

24 | P a g e
 • Cross-gender experiences such as going shopping or socialising in public as a
member of the opposite sex

• Any progress towards adopting the opposite gender role, such as changing name
or hair removal

• Contact with other transgender persons

• Aspects of self that are perceived to be masculine and those perceived to be

feminine

• What the patient's goals are regarding making the transition to the opposite
gender

Steps towards changing gender role

• Change in social gender role/real-life experience- Most centers require a
successful real life test of at least one year prior to consideration for surgery during
which time the person undertakes to live full time and attempt to find employment
in the new sex.

• Hormone therapy

• High-dose estrogens produces diminished libido, skin softening, some breast

and hip development; there is no effect on voice pitch and speech therapy may be
required to produce an acceptable female vocal pattern

• Androgen therapy produces muscle development, some lowering of vocal pitch,

male pattern of bodily hair development and amenorrhoea.

• Surgery

• Male to female transsexuals- Orchidectomy, Penectomy with Vaginoplasty using

penile skin

• Female to male transsexuals- Bilateral mastectomy, Hysterectomy, Bilateral

salphingo-oophorectomy.

• Psychological support throughout each step. It is aimed at altering the core beliefs
but generally ineffective in the majority of cases and are not welcomed by the
patient.

Risk:

25 | P a g e
 • Gender reassignment surgery is permanent and irreversible. Sometimes if the
results are unsatisfactory, patients may become depressed and have been known to
harm themselves or attempt suicide

• People who take Oestrogen should be monitored of adverse effects like deranged
LFTs, Hypertension, hyperglycemia and thrombo-embolic events and should be
monitored for the same.

Ref: Disorders of gender identity- James Barrett- APT, 17: 381-388

Gender dysphoria: recognition and assessment-Kate Eden, Kevan Wylieand Emily

Watson Advances in Psychiatric Treatment (2012), 18: 2-11

Oxford handbook of psychiatry- pg 758

MRCPsych-Passing the CASC exam- Justin Sauer-317

26 | P a g e
Topic 5:

CASC LESSON 3
OLD AGE DEPRESSION-REFUSING CARE & RISK ASSESSMENT
TASK:

Mr. Clive Richards is an 83-year-old gentleman who has refused home help and the GP
asked you to see him. Assess him to arrive at a diagnosis and Perform appropriate risk
assessment

CASE SYNOPSIS:

You are an 83-year-old gentleman who has refused home help. You are severely depressed,
self-neglecting and not bothered about your life and future. You feel worthless at the
moment and can't see your future. Your wife died of breast cancer a year ago. You suffered
a stroke around this time. You recovered partially with some weakness in your right arm
and legs. You can become unsteady on your feet. 'Home care was decided' by the hospital
team following this stroke. You are not taking your medications. You have leg ulcers and
you don't want the district nurses coming to your flat to take bloods or change dressing.
You have a poor appetite and you don't want to eat anything. You haven't washed for quite
some time. No thought of intentional self-harm or others. You are drinking 3-4 glass of
wine every night, which relaxes you and helps you to sleep. You have no psychotic
symptoms.

Topic:OLD AGE DEPRESSION-REFUSING CARE & RISK ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Assess reasons for refusing care

27 | P a g e
 Assess core symptoms of depression (Low
mood, anhedonia, lack of energy)
Other Symptoms of depression (disturbance
in biological functions, poor concentration &
memory, depressed negative cognitions, low
self-esteem etc)
Risk assessment- self harm (suicidal
thoughts, plans etc), self neglect
Risk assessment- falls, Non compliance to
medications & treatment plan,
Risk assessment- further deterioration in
physical/mental state, alcohol misuse
Rule out psychosis, anxiety and cognitive
impairment
Significant Psychiatric history (Personal and
family history)

Support from friends, family etc

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently

28 | P a g e
 Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

OLD AGE DEPRESSION

Prevalence:

• In the population aged over 65 the prevalence of clinically significant

depression is 10%

• Depressivedisorders are at least 2 to 3 times more common in

hospitalizedpatients, nursing home residents, or outpatients with
chronicmedical disorders. In particular, the 3 C's--cardiovasculardisease, central
nervous system disorders (eg, strokes, dementia,Parkinson disease), and cancer-
-are medical conditionsassociated with a high risk fordepression.

Clinical features:

• Depressed mood may be less prominent in depression affecting patients in old

age (Gurland 1976) but elderly people with new or recurrent depression are more
hypochondriacal and more delusional than younger people (Gurland 1976).

• Older people report experiencing less negative emotions such as sadness, fear and
anger than younger adults and ageing is associated with an increased ability to
inhibit negative emotional states and maintain positive emotional states.

Altered symptoms in late-life depression

Reduced complaint of 'feeling sad'

Hypochondriasis and somatic concerns instead of sadness

29 | P a g e
 Poor subjective memory - a dementia like picture

Late onset neurotic Sx (Marked anxiety, obsessive-compulsive or hysterical

symptoms)

Apathy and poor motivation

Symptoms that may be hard to interpret because of physical disorder

• Anorexia

• Weight loss

• Reduced energy

(Koenig et al 1997)
• Late onset depression is associated more with

• Cognitive impairment: It has been detected in 70% of cases

• Anhedonia

• Psychomotor changes (Hickie et al 2001)-severe psychomotor retardation or

agitation seen in up to 30% of depressed elderly patients

• Depressive delusions regarding poverty, physical illness or nihilistic in nature

• Paranoia is also common and auditory hallucinations may occur in severe

depression (Derogatory and Obscene)

• Weight loss (Janssen et al 2006)

• severe life stress (Vandenberg et al 2001): The frequency and severity of life
events (physical illness, loss of a spouse) may be greater in later life than in the
general population. (Hughes et al 1988).

• Lifetime depressive symptoms and somatic symptoms as preclinical markers

(Hein et al 2003).

ELICIT SYMPTOMS OF DEPRESSION

Areas to be covered;

• Core Symptoms of depression (low mood, anhedonia, fatigueability)

• Biological symptoms

30 | P a g e
 • Cognitive and emotional symptoms

• Ideas of guilt and unworthiness

• Depressive cognition (negative thoughts) and suicidal ideation

• Rule out co-morbidity

Eliciting core Symptoms of Depression

Low mood;
• How are you feeling in yourself?
• How has your mood been lately?
• If I were to ask you to rate your mood, on a scale of '1' to '10' where 'ten is normal and one
is as depressed as you have ever felt, how would you rate your mood now?

Anhedonia
• Can you still enjoy the things you used to enjoy? (Or)
• Have you lost enjoyment in things you used to enjoy?

Reduced energy level and decreased activity

• How have you been in your energy levels these days?
• Have you been feeling drained of energy lately?
• How do you spend your day?
• Have you wanted to stay away from other people?

Other symptoms of depression

Eliciting biological symptoms
• How has your sleep been recently?
• Do you need less sleep than usual?
• Have you had any trouble getting off to sleep?
• Do you wake early in the morning?
• Does you mood vary over the course of the day?
• Is your depression/mood worse at any particular time of day?
• What is the best time/worst time of the day for you?
• What has your appetite been like recently?
• Have you lost any weight lately?
31 | P a g e
• Has there been any change in your interest in sex?

Cognitive symptoms
• How has your concentration been lately?
• What is your memory like at the moment?

Emotional Symptoms
• How confident do you feel in yourself?
• How do you describe your self-esteem to be?

Ideas of guilt
• Do you feel that you've done something wrong?
• Do you feel guilty about anything at the moment?

Eliciting suicidal intent and negative thoughts

• Do you have any worries on your mind at the moment?
• Have you ever felt that life wasn't worth living?
• How do you see the future?
• Do you feel inferior to others (or) even worthless?
• Do you feel hopeless about yourself? (Or) Has life seemed quite hopeless?
• Do you feel helpless?
• Do you feel that life is a burden?
• Do you wish yourself dead? Why do you feel this way?
• Have you had thoughts of ending your life?
• Have you thought about how would you do it?
• Did you actually try?
• Would you do anything to harm yourself or to hurt yourself?
• Have you got any plans to end your life? What plans?

Duration, course, effects, coping

• How long have you been feeling this way?
• What do you think might have caused this?

32 | P a g e
• How is it affecting your life?
• How do you manage to cope?
• Do you get any help?
Risk Assessment

• Self harm

• Self neglect

• Falls

• Non compliance

• Deterioration in physical/mental state

• Alcohol misuse

33 | P a g e
Topic 6:

CASC LESSON 3
ALCOHOL DEPENDENCE & MOOD SYMPTOMS
TASK
Mrs. Jill Patricks was referred to your outpatient clinic by her GP as she was worried about
her excessive alcohol consumption. Routine blood tests taken at GP surgery showed
evidence of abnormal liver function tests including raised GGT.
Obtain history to establish her pattern of drinking and its effect upon her mood.
CASE SYNOPSIS

You're a 35-year-old businesswoman. You've a stressful job that involves international

travel. You've had some blood tests, which showed that you're drinking too much and your
liver is under strain. You admitted you'd increased your alcohol consumption over the last
year. You drink in the morning to steady your nerves at 8am (2-3 home measures of
vodka), Pub, usually alone, at lunchtime (3-4 double vodkas), pub straight after work (2-4
pints of normal strength beer/lager) and continued drinking at home, until bedtime. You
keep the same pattern of drinking every day, including weekends. Drinking takes priority
over everything. You feel shaky and sweaty when you stop drinking. You suffer from
depression and describe low mood, poor sleep, appetite and concentration. You do not
have suicidal thoughts/plans. You live alone and broke up with your boy friend 3 months
ago due to drinking.

Topic:ALCOHOL DEPENDENCE & MOOD SYMPTOMS

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit core symptoms of depression (low
mood, anhedonia, lack of energy)
Elicit other Symptoms of depression
(disturbance in biological functions, poor

34 | P a g e
 concentration & memory, depressed
negative cognitions, low self-esteem etc)
Current alcohol history and pattern of
drinking
Establish features of alcohol dependence

(Tolerance, withdrawal symptoms,

compulsion, primacy, reinstatement etc)
Risk assessment- self harm, self neglect,
deterioration in physical and mental health
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Inaccurate or misleading information discussed
Specific Comments and suggestions

35 | P a g e
ELICITING ALCOHOL HISTORY

Explore the following:

1.Current usage

2.Longitudinal history

3.CAGE questionnaire

4. Edwards and Gross criteria for alcohol dependence

5.Risk factors

6.Complications-physical, psychological, social and legal

7.Insight and motivation

8.Rule out mood, psychotic symptoms and or illicit drug abuse.

Questions

A. Current usage in a typical day/week

1.Do you drink alcohol at all?

2.What do you usually drink?

3.How often do you have a drink?

4.How many drinks do you have on a typical day of drinking?

5. Describe a typical day for me. Could you describe any pattern?

6. What sort of effect does alcohol have on you?

B. Longitudinal history

1.When did it all start?

2.What was the first drink?

36 | P a g e
3.With whom did you have the first drink?

4.Was it out of your own will (or) peer pressure?

5.How did you progress to the current level?

a.Started drinking occasionally (social drink)

b.Regular weekend drinking

6. How much would you drink at the weekend?

a. Regular evening drinking

b. Regular lunchtime drinking

c. Early morning drinking (progressive)

7. What did you used to drink in the past? And what do you drink now?

C. CAGE questions
• Do you feel that you have to cut down on your drinking?

• Do people annoy by criticising your drinking?

• Do you feel guilty about your drinking?

• Do you have to drink first thing in the morning to steady your nerves?

D. Edwards and Gross criteria for dependence syndrome

Compulsion

• Do you sometimes crave for a drink? (Or)

• Do you have a compulsive urge to drink?

• Do you find it hard to stop drinking once you start?

Tolerance

37 | P a g e
• How much can you drink without feeling drunk? Nowadays, do you need more alcohol to
get drunk than you needed before? (Or)

• Does a drink have less of an effect on you than before?

Withdrawal symptoms

• What happens if you miss your drink? (Or)

• What would happen if you go without a drink for a day or two? (Or)

• If you don't drink for a day (or) two, do you experience any withdrawal
symptoms such as sweating, shaking, feeling sick, headaches and pounding in
your heart?

Treatment and rapid re-instatement

• Ask about details of treatment and details of any period of abstinence?

• What helped you keep off drink?

• Have you ever had an extended period of time when you did not drink?

• What happened to make you start drinking again?

• Have you ever gone to anyone for help with your drink problem?

• Have you ever been in hospital because of your drinking?

• Have you ever been involved in any detoxification programme? Was it

completed or not?

• If not, what are the reasons for the failure?

Primacy

• How important is drink compared with other activities for you?

• How often do you miss family and social commitments because of drinking? (Or)

• Have you been giving primary importance to alcohol and have you been
neglecting other alternative pleasures (or) interests?

Relief drinking

38 | P a g e
 • Do you need a drink first thing in the morning to steady your nerves?

• Do you have to gulp the first few drinks of the day?

Stereotyped pattern

• Do you always drink in the same pub?

• Do you always drink with the same company?

E. Risk factors for alcohol abuse

Ask about:

• Occupation

• Psychiatric history

• Family history of alcoholism

• Premorbid personality

39 | P a g e
Topic 7:

CASC LESSON 3
LD WITH AUTISM & SCHIZOPHRENIA-ASSESSMENT
TASK

You are the psychiatric trainee working in the community intellectual disability team. You
have been asked to see Joshua Lane. He has a mild intellectual disability and autism. He has
been referred due to a change in behaviour and concerns about his mental health.

Please take a relevant history to explore the nature of the current presentation including
causal factors. You are not required to formulate a management plan.

CASE SYNOPSIS

You are Joshua Lane, a 27 year old who lives alone in a one bedroom flat. You have a mild
learning disability, autism and schizophrenia. You are generally independent and are able
to do most things for yourself. You receive support from staff three times a week and they
help you with things like weekly food shopping, bills and appointments. You attend college
twice a week. You are a loner and don't have many friends. You have been brought to
hospital today by one of your support workers due to concerns about your behaviour and
thoughts. You believe that you are an undercover special agent, working for the
government. Earlier today, you shouted at a woman in the street. You firmly believe that
this woman was sent by the 'opposition' to hamper your mission and expose you as a
secret agent. You are sent on 'special missions' and these missions are sent to you via the
television. You believe that the people on television are talking to you and instruct you on
your next move. You've been missing college in the last few weeks because you've been
pre-occupied with watching and reading about secret agents. You are worried as you think
there could be other people who can 'read your mind' and will realise that you're an
undercover agent. This will jeopardise your mission of keeping the country safe and
protected. You were diagnosed with schizophrenia aged 20 but you don't believe that you
have a mental illness. You will admit that you often 'don't bother' to take your olanzapine
medication. It interferes with your thinking and 'slows it down'. You don't drink alcohol but
you admit to using cannabis on and off for several years. You gain access to cannabis from
someone at college. You think the cannabis helps you to carry out your special missions.

Topic:LD WITH AUTISM & SCHIZOPHRENIA- ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

40 | P a g e
 * OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT
FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Concerns and history of presenting
problems
Explore delusional ideas and assess the
degree of conviction
Assess other psychotic symptoms, mood and
insight
Additional background information
Risk assessment

Drug and alcohol history

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently

41 | P a g e
 Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
Neurodevelopmental Station (Prepared by Dr Rupal Patel, Consultant Psychiatrist)

Tips from the Examiner

This is a complex station requiring candidates to demonstrate effective communication in

order to take a focused, relevant history from a patient with a mild intellectual disability,
autism and schizophrenia with associated challenging behaviour.

Good candidates will gently probe for information and build rapport. Care should be taken
to use appropriate language, which is simple and clear. This patient has a mild intellectual
disability and is able to understand questions when they are asked in this manner. Avoid
asking more than one question at a time, as this can be confusing for people with
intellectual disability.

Remember that people with autism tend to be very concrete and literal thinkers so you
should avoid using language that could be misinterpreted. When speaking to a person with
more severe levels of intellectual disability, it is useful to obtain collateral information from
family/support staff.

The candidate should enquire about possible reasons for the relapse in mental health
including medication non-compliance, changes in routines and activities and substance
misuse.

Although you are not required to formulate a management plan in this task, it is important
to recognise that this patient presents with active psychosis which is most probably due to
medication non-compliance and complicated by lack of insight and concurrent use of
cannabis. Good candidates will perform a risk assessment in order to explore details of the
psychosis and to help inform the development of an appropriate management plan.

In this case, the management plan should involve re-starting psychotropic medication and
regular psychiatry review to monitor progress. This could be done in the community if the
patient is agreeable and adequate support systems are in place, e.g. support with
medication administration. Failing this, a brief admission to hospital could be considered
in order to re-establish medication.

Intellectual disability and challenging behaviour

42 | P a g e
Intellectual disability also known as 'learning disability' has 3 core criteria:

•IQ < 70

•significant impairment of social or adaptive functioning

•Onset before the age of 18

Approximately 1% of the population have an intellectual disability. People with intellectual

disability have higher rates of associated mental illness compared to the general
population. People with intellectual disability can have atypical presentations, often
presenting with a complex mix of mental illness, neurodevelopmental conditions such as
autism, substance misuse and physical disorders such as epilepsy. They can also present
with challenging behaviour.

Challenging behaviour is a socially constructed and descriptive concept rather than a

diagnosis. It can be used by a person to communicate a need, express their frustration or
boredom, avoid demands and can also be related to concurrent psychiatric illness (as in
this station). Challenging behaviour can present in many ways, for example, self-injury,
aggression and smearing.

Management of challenging behaviour involves gaining an understanding of the root cause

of the behaviour in question. Input from psychology, particularly behaviour analysis, is
useful to help understand the behaviour and bring about behaviour modification.
Medication, particularly anti-psychotics, can be considered in the management of
challenging behaviour in certain instances:

• If psychological or other interventions have failed to produce a change

• Treatment for any coexisting mental or physical health problem has not led to a
reduction in behaviour

• Risk to the person or those supporting them is very severe (e.g. violence, aggression
or self-injury)

For further information on challenging behaviour and intellectual disability, please refer to
NICE guidance on the management of challenging behaviour in people with intellectual
disabilities (published May 2015).

Autism

Autism and autism spectrum disorder (ASD) are both terms used to describe a lifelong
developmental disorder affecting social interaction, communication (both verbal and non-
verbal) and associated stereotyped or repetitive behaviours. ASD has an incidence of
approximately 1% in the UK and is much more common in men compared to women (ratio

43 | P a g e
of 4:1). ASD can affect people both with and without intellectual disability and
impairments in each of the areas relevant to ASD can occur on a continuum, affecting
people with varying degrees of severity.

Associated medical problems;

• Epilepsy. Around 25-30% of children with ASD also have seizures

• Visual and hearing impairments

• Mental health problems

o Evidence from studies suggests that up to 84% of people with ASD have some
form of mental illness. People with ASD have higher rates of anxiety
compared to the general population.

o ADHD is associated with ASD

o Rates of mental illness are increased in people with severe intellectual

disability and co morbid ASD

• Sleep disorders

Schizophrenia

Schizophrenia is a chronic mental illness, which affects the way a person, thinks, feels and
behaves. It can develop at any age although most commonly, it presents in adolescence and
the early 20s. There are many etiological factors associated with schizophrenia including
genetics, environment and social factors. Cannabis use has also been linked to the
development of psychotic symptoms and schizophrenia.

'First rank' or so called positive symptoms of schizophrenia include the following:

• Auditory hallucinations

Thought echo and running commentary, e.g. 'now, he's making a cup of
tea'

Thought broadcasting

• Thought insertion, withdrawal and interruption

• Delusional perception where abnormal significance is given to a normal event

• Somatic hallucinations

44 | P a g e
 • Somatic passivity where thoughts, sensations and actions are under external control

Negative symptoms of schizophrenia have been shown to be less responsive to

antipsychotic medication. They include blunting of affect, lack of motivation, poverty of
speech and thought, anhedonia and lack of social interest. Please note that these may be
difficult to tease out in a person with autism who may also present with flattened affect and
limited communication.

Management of schizophrenia involves a combination of antipsychotic medication and

psychological therapy, most commonly CBT. Please note that psychological treatment
options can be modified for people with intellectual disability and autism.

45 | P a g e
Topic 8:

CASC LESSON 3
ANGRY MOTHER- UNHAPPY WITH CARE RECEIVED BY HER SON
TASK: Talk to this angry mother of a male schizophrenic patient Mr. Gary Wilson, who
wants to take her son home. He has been an inpatient for last 3 months. He has been
treated on Clozapine for treatment resistant schizophrenia. Prior to admission he had been
living with his brother who was an alcoholic in squalid circumstances and likely exploited
him financially. He has had deranged Liver function tests at the time of admission. His
blood tests have been fine since 3 months. She is angry because she had looked up on the
Internet and saw that clozapine suppressed bone marrow. His response to treatment is
slow. He still needs prompting with personal care. She is not happy about the care he
receives and would like to take him home. She lives 30 miles from hospital with husband
who is also an alcoholic.Address her concerns.

CASE SYNOPSIS

You're a 47-year-old woman. Your 2nd son was diagnosed with schizophrenia 5 years ago
and has been in a mental health unit for 3 months. You and your husband, who is an
alcoholic, live 30 miles from the hospital.

Your son has been on Clozapine for 3 months with little improvement. You are unhappy
with treatment given and concerned as he looks very thin and unwell. You believe the
consultant is experimenting on him after an internet search revealed Clozapine affects
bone marrow. Prior to this admission, he lived with his brother, who neglected him and
likely exploited him financially. You're adamant you want to take your son home, believing
your care will be superior to the ward nurses/doctors. Check how long he should stay in
hospital. Your son has had blood test abnormalities. Ask what has happened to those blood
tests. You remain unconvinced throughout and say that you want to make a complaint

Topic:ANGRY MOTHER- UNHAPPY WITH CARE RECEIVED BY HER SON

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

46 | P a g e
 Competency Domains Very Poor Average Good Excellent
Poor
Calm them down, acknowledge distress
Reflective listening, use verbal and non
verbal techniques
Dealing the situation assertively than
becoming agitated

Taking control of the interview

Explain rationale behind starting him on
Clozapine
Discuss regular monitoring

Explain delay in onset of action, reason for

hospitalization
Reassurance regarding deranged LFTs
(possible alcohol misuse)
Discharge against medical advice-not helpful

Express concerns about husband/partner

being an alcoholic
Discuss about different channels

Hospital Complaints procedure, PALS etc

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability

47 | P a g e
 7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
DEALING WITH ANGRY RELATIVES
The candidate is expected to deal with such situations commonly in real life and in exams.
How to deal with it?
• There is clearly no one solution or one way to handle this situation

• It is also important to accept that you won't be in complete control at any point
during the station

• Make sure you remain calm and relaxed.

• Do not reflect the hostile body language of the other person

• Use verbal acknowledgements such as okay.......mmm........uh uh etc

• It is important to build rapport using reflective techniques- Reflective listening

(the interviewer tries to clarify and reinstate the other person is saying, which can
reassure the other person that someone is wiling to attend to his or her point of
view and is willing to help)

• It will be helpful to reflect back the other person's apparent emotions to

demonstrate that you recognize their concerns-

• Eg- 'I can see you are really angry and upset'. I understand why you are angry,
things have not happened the way we hoped but all I can do is to find a way forward
from where we are

48 | P a g e
 • Adapt to the situation and be prepared to go with the flow. (Be prepared to roll
with punches)

• Apologize for previous lack of communication (if any) and be supportive

(Ref: www.trickcyclists.co.uk)

49 | P a g e
Topic 9:

CASC LESSON 3
OBSESSIVE COMPULSIVE DISORDER-HISTORY
TASK: You have been asked by the GP to see this 35-year-old woman with a long history of
obsessions, which has worsened recently. Take a history of her obsessions and
compulsions as well as its impact on her functioning

OCD IN POSTNATAL WOMAN

You're a 35-year-old lady. You had a baby 6 weeks ago, a boy called Jacob. You aren't
breastfeeding as you are on meds called 'Sertraline”. Since childbirth, you are worried
about contamination, causing infections to your baby. You have had this recurring
thought and keep sterilising your baby's bottles. You recognize that the thought is
ridiculous but cannot get rid of it. As a result of this you repeatedly wash the feeding bottle
6 times. You recognize the lack of logic in this but if you try to resist the thoughts you get
increasingly anxious. In the past few weeks you've begun checking locks, switches etc. 6
times. You aren't depressed. You've had OCD since the age of 29. You've had CBT (talking
treatments) in the past. You were on a drug called clomipramine for few years, which was
then changed to sertraline 3 years ago due to side effects like sedation.

Topic:OCD IN POSTNATAL WOMAN

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Obtain History of presenting problems

(Mode of onset, duration and progression)

Establishing the connection drawn between
birth of baby and OCD relapse
Nature and quality of obsessions

50 | P a g e
 (Thoughts, ideas, images, ruminations,
doubts)
Phenomenology of obsessions-own
thought,

Unpleasurable, repetitive, resistance &

response
Elicitation of compulsive behaviours and
associated rituals,

The anxiety symptoms associated with it.

Other behaviours-washing, checking,

Counting etc
Avoidance and anticipatory anxiety
Risk of self neglect

Risky behaviour- Wash baby & change

nappies too frequently or neglect baby due
to rituals)
Impact on quality of life

(Social, occupational and

family)
Co-morbidity

(Mood Symptoms, anxiety symptoms,

alcohol abuse etc)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)

51 | P a g e
 Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
ELICIT SYMPTOMS OF OBSESSIVE-COMPULSIVE DISORDER

Areas to cover;
• Obsessional thoughts-ideas, images or impulses
• Compulsive acts/rituals-washing, cleaning, checking, counting
• Resistance and avoidance
• Duration, effects and coping
• Rule out co-morbidity-depression, anxiety

Obsessional thoughts
• Do any unpleasant thoughts / ideas keep coming back to your mind, even though you try
hard not to have them? (Or)
• Do you have any recurring thoughts, ideas, or images that you cannot get rid of your mind?
• How often do you have these thoughts?
• Are these thoughts your own or are they put into your mind by some external force?
• Where do they come from?
• What is it like? How do you explain it?
• What do you do when you get these thoughts?
• Are they distressing and if so in what way?
• Is there anything you try to do to stop these thoughts?
• What happens when you try to stop them?

52 | P a g e
Compulsive acts
• Do you ever find yourself spending a lot of time doing the same thing over and over
again even though you have already done it well enough? For example
• Do you spend a lot of time on personal cleanliness, like washing over and over even
though you know that you're clean?
• Does contamination with germs worry you?
• Do you find that you have to keep on checking things that you know that you have
already done? Like gas taps, doors, and switches?
• What happens when you try to stop them?
• Do you have to touch (or) count things many times?
• Do you have any other rituals?
• Do you find it difficult to make decisions even for simple trivial things? (Obsessional
ruminations)
• Do you have any impulses to do unwise things?
• What kind and do you ever give in to these impulses?
Explore in detail about the symptom history, mode of onset, duration, precipitating factors
and associated problems.

Duration, Effects and coping

• How long have you been feeling this way?
• What do you think might have caused this?
• How is it affecting your life?
• How do you manage to cope?
• Do you get any help?

Co-morbidity: Ask about associated symptoms, such as:

• Depression, Generalized anxiety, Phobias
• Anankastic personality traits - Do you tend to do things / keep things in an organized way?
Ref: Adapted from Get through MRCPsych; Preparation for CASC (Dr. Sree Murthy)

53 | P a g e
Topic 10:

CASC LESSON 3
VIOLENCE RISK ASSESSMENT
TASK:

Darren is a patient on your ward. He is known to have schizophrenia and has had several
admissions. This admission occurred after the police were called following an argument
with his girlfriend. He is now back on medication and wants to be discharged. Perform a
risk assessment and ask him relevant questions to identify risk of future violent
offending. You do not have to do a mental state examination.

CASE SYNOPSIS:

You are Mr Darren Williams, a 37-year-old man, who is an inpatient on the ward.

You are currently on medication (Olanzapine) and would like to be discharged home. This
admission occurred after the police were called to an argument with your girlfriend where
you were holding a knife. You thought that your girlfriend was putting thoughts into your
head which are 'dirty' and sexual in nature such as them having threesomes etc. You have
no remorse for the knife incident but you will threaten her again if she does it again. In the
past, the police arrested and cautioned when you had an issue with your ex-girlfriend and
threwed a chair at her. You don't think you have problems with your mental health. You
don't think you have any anger issues. You drink alcohol occasionally. You smoke 140
ounces of cannabis every week. You have suffered from mental illness since the age of 19.
You have had three previous admissions and treated with Risperidone tablets. You stopped
taking them 3 months ago.

TOPIC- RISK ASSESSMENT FOR FUTURE VIOLENCE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor

54 | P a g e
 Assess Circumstances leading to Index
offence and the symptoms associated with it
Assess Patients' view about it; Anger, lack of
remorse, lack of guilt

Insight and Attitudes (denial, minimisation

etc)
Current thoughts of violence/suicide,

Ongoing thoughts of violence

Threats towards particular victims,

Plans- Access to weapons, access to victims

History of mental illness

Medications? Defaulted from supervision or

follow up before?
Historical factors-h/o Previous violence,

Forensic history (Convicted and non-

convicted, nature, motivation, victims and
context)
Personality disorder, Cope with stress

(Paranoid, anti-social, impulsive traits etc)

Relationships (lack of relationships, unstable
relationships)

Employment- unemployment, poor

employment record
Childhood problems (Behavioural problems,
maltreatment)

Relevant Destabilisers-alcohol, drugs,

homelessness, victimization
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee

55 | P a g e
 3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport, Lack of eye contact/non verbal
responses, does not show appropriate attitudes or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment,
Does not develop an adequate awareness of management of risk
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Aspects of history highlighted but not explored in depth or appropriate manner
Violence risk assessment- Factors to consider

Historical factors

• Previous history of violence (convicted and non convicted, context and motivation)

• History of mental illness

• History of substance misuse

• Personality disorder

• Childhood problems (maltreatment, behavioural problems)

• Relationships (unstable relationships)

• Poor employment record

• Past history of difficulties with supervision (history of absconding, history of non-

compliance)

Current factors

Internal

• Active symptoms (delusions, hallucinations)

56 | P a g e
 • Threats (towards particular victim)

• Plans (realistic)

• Insight into illness, into previous violence etc

• Attitudes (minimisation, denial)

• Response to treatment

External factors

• Access to weapons

• Access to victims

• Lack of Support

• Relationship difficulties

• Stressors and life events

How to proceed?

• When assessing dangerousness, the candidates are expected to think about static and
dynamic risk factors.

• When talking to the patient, the candidates are expected to be empathic and offer
support/ validation for his distress.

• They should approach him in a non-confrontational and non-judgmental manner.

They should ask very open questions initially and try to build rapport.

• It would be good start by asking him how he is and show some empathy/ validation
about his response to being in hospital and the beliefs he has about his girl friend.

Useful questions

• Why does he feel angry and agitated?

• What are his thoughts about threatening his partner?

• Does he care about the potential consequences?

• Would he try to do this again?

57 | P a g e
 • Would he become suicidal?

• Are there any thoughts of violence or threat /over-ride control symptoms?

• Is he paranoid? Has he made threats of violence? Is there any violent intent?

1. Static risk factors

• Any forensic history and history of violence?

• When did he first get into trouble with the police?

• Is he mentally ill?

• Does he use alcohol or drugs?

• What is his personality like?

• Is he impulsive or short tempered?

• Does he have antisocial/ procriminal attitudes?

2. Dynamic risk factors

• Does he have symptoms of mental illness now? Paranoia?

• Is he taking his medications?

• Has he defaulted from supervision or follow up before?

• What is his future plan?

• What are the relevant destabilisers?

• How does he usually cope with stress?

• Does he have access to weapons?

• Does he have current thoughts of violence- or suicide?

Ref: Webster CD, Douglas KS, Eaves D, Hart SD (1997) HCR-20 Assessing risk
for violence (version 2). Vancouver: Simon Fraser University.

Oxford handbook of psychiatry- Pg 634

58 | P a g e
Topic 11:

CASC LESSON 3
AUTISM-HISTORY TAKING
You are Core Trainee in the CAMHS out patient clinic. You are about to see Mrs Young who
is the mother of a 3-year-old boy, Paul. She has expressed some concerns to the health
visitor, that there is something wrong with the child and that he is very different from his
brother.

Take a history from her in order to consider the nature of his problems. Obtain a
chronological history of symptoms especially around his development.

CASE SYNOPSIS
You are the mother of a 3-year-old boy, Paul. You have expressed some concerns to the
health visitor that there is something wrong with him. You also notice that he is not
developing as well as his elder brother Christopher, who is 5 years old. Paul did not start
walking till he was 2 years old. He does not really speak, and if he does he just says a few
words. His speech consists of a few words and at the age of 2 years, Paul was babbling and
used appropriately only 6 to 8 words. The first word he said was 'car'. Your paediatrician
initially reassured both of you that he might be a slow talker. He does not maintain good
eye contact. He does not play with other children and has no friends at all. He always plays
alone. When people talk to him, he doesn't reciprocate and seems to be in his own world.
You do note however that he did go through a phase of stroking a jumper you had, he was
obsessed with this jumper. He needs order and routine. He has tantrums if things are not
kept to routine. Paul often seems fixated on circular motions of the washing machine as
well as the wheels of his toy cars.

Topic:AUTISM- HISTORY & ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor

59 | P a g e
 Gross impairment in reciprocal social
interaction

(Poor Eye contact, failure to develop peer

relationships, Reduced interest in shared
enjoyment, lack of social reciprocity &
empathy, lack of symbolic play etc)
Qualitative impairments in communication

(Delay or lack of spoken language, Lack of

verbal or facial responses to sounds or
voices, Odd voice, monotonous with little
awareness of your response, Difficulty in
catching any meaning other than the literal)
Restricted, repetitive and stereotyped
interests or activities/ rigidity (Resistance to
change, obsessive preoccupations with
routine, timetable, objects; stereotyped body
movements like hand flapping, Body
rocking)
History of problems & difficulties

Level of distress and impairment in all

aspects of life
Birth history, Developmental History -
milestones

(Motor, language, cognitive and social skills)

Rule out co morbidity

(Learning disability, seizures, ADHD,

dyspraxia etc)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour

60 | P a g e
 4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
AUTISTIC CHILD

Autism is a pervasive developmental disorder involving deficits in language and non-verbal

communication, marked impairment in reciprocal social and interpersonal interaction and
abnormal behavioural characteristics such as repetitive or stereotypical behaviour. All of
these should be present before the age of 36 months. A triad of symptoms characterizes it:

• Qualitative impairment in social interaction

• Impairment in communication [language delay is most common cause for initial

referral]

• Restricted repetitive and stereotyped patterns of behaviour or interests.

In addition, 70% have mild to moderate LD.

By definition, the onset of autistic disorder is before the age of 3 years, although in some
cases, it is not recognized until a child is much older.

Autistic disorder is four to five times more frequent in boys than in girls. There has been an
apparent increase in prevalence rates over the years.

61 | P a g e
Some people have autistic traits and normal IQ. They are classified as either high-
functioning autism (with language difficulties) or Asperger's syndrome (with normal
language).

Asperger's syndrome represents mild case of autism without any significant delay in
language or cognitive development including intelligence

Clinical features

Difficulties with social relationships

• Absent social smile

• Lack of eye-to-eye contact

• Lack of attachment to parents

• Absence of separation anxiety

• Persistent aloofness or awkward interaction with peers

• No or abnormal social play; prefers solitary games

• Difficulty in making friends, few or no sustained relationships

• Limited empathy or sensitivity

• Usually egocentric with little concern for others; treats people as furniture

Problems in communication

• Absent or delayed speech

• Absence of communicative sounds like babbling

• Lack of verbal or facial responses to sounds or voices (might be thought as deaf

initially)

• Language is superficially good but too formal, stilted or pedantic

• Odd voice, monotonous and perhaps at an unusual volume talking at you with
little awareness of your response

62 | P a g e
 • Difficulty in catching any meaning other than the literal

• Awkward or odd posture and body language

Absorbing and narrowed interests

• A set approach to everyday life that may include unusual routines or rituals;
change is often upsetting

• Resistance to even the slightest change in environment

• Obsessively pursued and unusually circumscribed interests

• Attachment may develop to inanimate objects

• Stereotyped behaviours like head banging, body spinning, rocking, lining up

objects etc.

Comorbidity; Depression, anxiety, learning disability, OCD, ADHD, tic disorders,

dyspraxia, psychosis, depression etc

Investigation:

1. Psychologist to be involved to perform psychometric assessment to determine IQ

assessment and rule out Learning disability

2. Educational psychologist assessment

3. ADI with trained assessor, ADI - R (autism diagnostic interview - revised)

4. ADOS assessment (trained assessor), (ADOS-G Autism diagnostic observation schedule -
generic)

5. Speech and language assessment

Treatment:

• Educate the parents about diagnosis, treatment options and prognosis.

• Behavioural management-functional analysis of target behaviour and the

formulated plan should focus on promoting desired behaviour and reduce
unwanted ones. If the child is behaving inappropriately view this as needing to be
clearer about the rules and state the rules of expected behaviour very clearly.

63 | P a g e
 • Adequate effort should be taken to educate the child in a mainstream
school setting with more intensive support.

• If his functioning is very low, Special schooling of

appropriate educationalplacement should be considered having obtained report
from educational psychologist, SENCO (school educational needs coordinator),
obtaining medical report and involvement from social worker

• Social services to be involved -comprehensive assessment of social care needs

for the child and the family, Attend special day schools - and encourage living at
home.

• SS to arrange Special care, childcare assistance and residential schooling.

• Vocational training - older adolescents.

• Increased support to the family

• Join a voluntary organization and autistic society- meet other parents of

autistic children and discuss common problems.

Medical management:

• Medication - very little role may be helpful in addressing specific problems.

• Antidepressants such as SSRIs may be effective in ameliorating repetitive and

aggressive behaviors.

• Psychostimulant medication for co-morbid ADHD.

• Antipsychotics such as Risperidone are probably effective in the treatment of

hyperactivity, aggression, and repetitive behaviour and possibly effective in the
treatment of depression and irritability.

Ref: Oxford handbook of psychiatry pg 572-573

A short textbook of psychiatry-Niraj Ahuja- 152

64 | P a g e
Lesson 4:

TOPIC 1: FIRE SETTING BEHAVIOUR (ASSESSMENT)

TOPIC 2: INTELLECTUAL DISABILITY-DEPRESSED
PATIENT REFUSING BLOOD TESTS
TOPIC 3: OCD- EXPOSURE AND RESPONSE PREVENTION
TOPIC 4: POST TRAUMATIC STRESS DISORDER- HISTORY
& ELICIT SYMPTOMS
TOPIC 5: ALCOHOLIC HALLUCINOSIS
TOPIC 6: ABUSE IN INTELLECTUALLY DISABLED
PERSON- HISTORY TAKING
TOPIC 7: INTERPERSONAL THERAPY- ASSESS
SUITABILITY

1|Page
Topic 1:

CASC LESSON 4
FIRE SETTING BEHAVIOUR (ASSESSMENT)
TASK:

You are asked to assess an 18-year-old woman brought in by police after setting fire in her
hostel. The Police are concerned that she has some form of mental illness. Take history
pertaining to fire setting leading to diagnosis.

Case synopsis
You're an 18-year-old woman brought in by police after setting fire in your hostel. You
watched a programme on children in need prior to setting fire in your room. It brought
back old (and bad) memories as you were in foster care since early teens. You had a
difficult childhood. Your parents separated when you were 6. You were in foster care and
describe 'being abandoned' by your parents. There was history of emotional and physical
abuse by foster parents. There is previous history of fire setting on numerous occasions
with no regard for safety of others, damage to buildings. You did it as a cry for help, as
foster care traumatised you. There is a lack of empathy or remorse. You describe your life
as empty. You have no close relationships. You've no boyfriends/friends in general. You
don't have any goals in life.

Topic: FIRE SETTING BEHAVIOUR - ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Assess circumstances leading to fire setting
behaviour- ABC analysis

(Antecedents-Behaviour-Consequences)

2|Page
 Feelings associated with it (lack of empathy,
blaming others, not willing to take
responsibility)
Reasons behind fire setting behaviour

(curiosity, experimentation, cry for help)

Explore psychosocial conflicts & current
stressors- not addressed/unmet needs
Explore previous history of fire setting &
reasons
Obtain relevant childhood history

(traumatic experiences and adverse life

experience)
Rule out abnormal personality traits

(Impulsive, poor relationships, compulsive

behaviour etc)
Rule out symptoms suggestive of mental
illness

(depression, psychosis, alcohol. Substance

misuse)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

3|Page
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk

Fire setting behaviour

Juvenile fire setters usually fall into three general groups:

1. Under 7 years of age, usually boys. Generally, fires started by these children are the
result of accidents or curiosity.
2. Children ranging in age from 8 to 12. Usually motivated by curiosity or
experimentation, could also represent underlying psychosocial conflicts. They will
continue to set fires until their issues are addressed and their needs are met.
3. Adolescents between the ages of 13 and 18. These youth tend to have a long history
of undetected fire-play and fire starting behaviour. Their current fire setting
episodes are usually either the result of psychosocial conflict and turmoil or
intentional criminal behaviour. They have a history of school failure and behaviour
problems, and are easily influenced by their peers.

Possible reasons for fire setting behaviour

• Curiosity with fire

• Lack of understanding fire's danger

• History of behavioural problems as a child (truancy, bullying, cruelty to animals

etc)

• History of abuse (physical, emotional, sexual abuse) and or neglect

4|Page
 • History of parental alcoholism or drug abuse

• Attachment problems as a child

• Recent change in family life (seperation, death, divorce etc)

• Social isolation and poor peer relationships

• Blaming others and/or unwilling to accept responsibility for one's own actions

• Lack of empathy

• Could be secondary to a psychiatric disorder (Barnett & Spitzer, 1994). Common

diagnosis schizophrenia, alcoholism, affective disturbances, intermittent explosive
disorder and personality disorders- Geller (1992)

• Pyromania- compulsive fire setting behaviour

Ref: Focus adolescent services

5|Page
Topic 2:

CASC LESSON 4
INTELLECTUAL DISABILITY-DEPRESSED PATIENT REFUSING BLOOD TESTS
TASK: You are seeing a 19-year-old man with mild degree of learning disability in the
outpatients' clinic. Your consultant had diagnosed depression and wanted to start the
patient on Citalopram 10mg daily. He wanted to do a range of blood tests including FBC,
U&Es, TFTs and LFTs. Explain the diagnosis of depression, blood tests and treatment
with citalopram in simple terms.

Case Synopsis

You're a 19-year-old man with mild degree of learning disability, that broadly equates to
that expected in a normally developing 10-year-old child. Your consultant diagnosed you
with depression and wanted to start you on a medication called as Citalopram 10mg daily.
He wanted to do a range of blood tests. You can understand simple every day vocabulary
but you do not understand complex words or any medical jargon. You prefer to see some
pictures, which can improve your understanding.

• What is a blood test?

• Are you going to prick my skin and take blood?

• Needles are scary? Aren't they? They are painful

• Can I take Bobby with me (support worker), as I am scared?

• What is depression?

• What is this new tablet?

• Why do you want me to take it?

• Is it a big or small one?

• What does it do to me?

Topic:EXPLAIN BLOOD TEST AND ANTIDEPRESSANT MEDICATION

Candidate Name: Candidate Number:

Examiner name/initials:

6|Page
Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Use broad terms, simple language
Avoid complex sentences and medical
jargons
Explain diagnosis of depression
Explain blood test- what it involves (using
pictures)
Explain role of medications- using pictures
Pick up verbal and non-verbal cues
Check on patient's understanding and elicit
concerns generated by questioning
Demonstrate empathy with patient's
concerns
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

7|Page
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Reading materials

Explaining the procedure and treatment in simple terms

Blood test - Simple jargon free language

• You will go to the hospital/surgery for a blood test

• You will sit comfortably in a chair with arm rested.

• The blood taker will put a band around your arm

• The blood taker will feel your arm and look for a vein

• The blood taker tells you before she puts needle into your arm

• You will feel a scratch

• The blood taker will take some blood

• The blood taker removes the needle from your arm

• The blood taker removes the band from your arm

• They will put a plaster on your arm

• The blood test is finished

8|Page
Depression

Depression is a type of mental illness.

What can happen in depression?

• Feeling low, Crying without any reason

• Less interested in activities,

• Feeling tired all the time

• Eating too little or too much, Losing weight

• Difficulty in sleeping Waking up too early in the morning

• Feeling guilty without any reason

• Feeling that life is not worth living

Treatment

• Medications known as antidepressants (E.g. like Citalopram) can help in

treatment of depression.

• Doctors can prescribe Antidepressants for depression (moderate to severe).

• They can take up to 4-6 weeks to work for an acute episode of depression.

• A popular theory is that antidepressants may work by restoring the balance of

various chemicals within the brain.

• Take your medication as directed by your doctor. It is usually prescribed once a

day. If you are told to take your dose once a day this will usually be better in the
morning.

• If you feel sick when first taking it, this should only last for a few days, but taking
the medication with or after food can relieve the nausea.

• They are not sleeping tablets. However, these drugs may make you feel drowsy

What sort of side effects might occur?

9|Page
Like other drugs, these drugs may cause adverse effects. Some are relatively mild and can
happen in the first few weeks after starting the treatment. They can be unpleasant but
often disappear or get better with time.

Some of the common side effects are:

Side effectWhat happens

Common

Nausea and vomitingFeeling sick and being sick

InsomniaNot being able to fall asleep at night

Restlessness or anxietyTense and nervous, and you may sweat more

HeadacheYour head is pounding and painful

Loss of appetiteNot feeling hungry. You may lose weight

DiarrhoeaPassing loose, watery stools

Sexual dysfunction Finding it hard to have an orgasm. No desire for sex

10 | P a g e
Topic 3:

CASC LESSON 4
OCD - EXPOSURE AND RESPONSE PREVENTION
TASK: Mr. Michael Wright is a 30-year-old man who has been referred by his GP for
excessive hand washing and has been recently diagnosed with obsessive-compulsive
disorder in your clinic.He has been referred to psychology for CBT by your consultant.He
knows nothing about the therapy and wants an overview of this treatment. Speak to him
about CBT for the treatment of OCD and address his concerns.

CASE SYNOPSIS: You are Mr. Michael Wright, a 30-year-old man and have been recently
diagnosed with obsessive-compulsive disorder with predominant compulsive behaviour.
These are essentially washing and cleaning rituals and you spend several hours a day
washing and cleaning. You had an assessment by psychology team and suggested exposure
and response prevention. You are keen to know more about this treatment. You should try
to become anxious when the candidate talks of psychological treatments, which require
putting yourself in situations where you could become very anxious

Suggested prompt questions

• What is exposure and response prevention? Could you explain more?

• I don't think that I could actually deal with not cleaning and the anxiety would be too
much. What do I do then?

• How long do the sessions last for?

• Who will offer the treatments?

• Should I need to go into hospital for treatment?

• Do you think it is going to work for me?

• How well do these treatments work?

TOPIC: EXPOSURE AND RESPONSE PREVENTION

Examiner please circle one of the boxes

11 | P a g e
 * OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT
FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Mention CBT as the main form of
psychological treatment

Explain the nature of therapy ('here and

now' principles, Behaviour-mood-cognition
link)
Behavioural aspects- Exposure and response
prevention

(Clear explanation)

Exposure techniques for obsessions, and

response prevention useful in ritualistic
behaviour
Relaxation and breathing exercises

Focusing On anxiety management first

before behaviour therapy
Structure of Psychological sessions (Time-
limited, regular sessions, Behavioural
experiments, Goal settings, Home-work
assignments)
Discuss efficacy and relapse prevention
Social treatments (Support-family and
friends, self-help groups)

Sources of information (leaflets)

Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour

12 | P a g e
 3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Poor range of Symptomatology/psychopathology explored
Does not explain signs and symptoms competently
8 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
9 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
OCD- EXPOSURE AND RESPONSE PREVENTION

OCD can be treated through drug treatment, psychological or talking treatment - or by a

combination of both. The antidepressant medications have been shown to be helpful in
treating OCD.

The most common side effects found with antidepressant medicines are nausea, headaches,
dry mouth, blurred vision, dizziness and feeling sleepy. However it is important to
remember that they are not addictive. They will not cause withdrawal symptoms when you
stop taking them.

If you are given drug treatment for OCD, you may have to stay on treatment on a higher
dosage for a long time. This is to make sure there's no chance of symptoms returning.

Different forms of psychological treatments and the most commonly used treatments are
Exposure and response prevention, Cognitive behavioural therapy.

Exposure and Response prevention: The treatment strategy involves exposing the
individual to stimuli that trigger anxiety or discomfort, and then having the individual
voluntarily refrain from performing his or her ritual or compulsion. For each ritual the

13 | P a g e
individual will be required to list a range of situations that cause anxiety and The individual
would then rate each of these situations according to the amount of anxiety or distress that
would arise if he or she did not perform the particular ritual.

These are then arranged in order according to those that generate the least anxiety or
discomfort to those that generate the most anxiety or discomfort. The first task in the list
would be an activity that is mildly discomforting but not too difficult, while the last task in
the list would be the most difficult task that the individual can imagine.

Before starting theses exercises, it is important to provide training for slow breathing
exercises and relaxation. These exercises can be used prior to commencing each step of the
graded exposure hierarchy to ensure that the individual is calm and relatively relaxed at
the beginning of each graded exposure session.

It is worth mentioning the following points:

• This is a simple but highly effective technique

• It is usually done in graded steps

• The active participation of clients is necessary

• The situation can be real or imagined (a real-life situation will be more effective)

• It can be practised regularly with self-exposure tasks.

• It is used particularly in treatment of phobias and OCD

Obsessive compulsive disorder

Non-Drug treatments of OCD

Counselling and psycho education of the patient and the family - This involves explanation
of the symptoms and providing reassurance that these symptoms are not an early sign of
insanity. Also counsel relatives and spouse as often they may involve other family members
in their rituals, and encourage them to adopt a firm but sympathetic attitude to the patient.
Involve the family and educate about the illness, provide emotional support and
encouragement

CBT- Cognitive - behavioural Therapy: -

The Cognitive component of CBT involves identify and modify maladaptivecognitions and
seeks to reduce to suppress and avoid Obsessional thoughts.

14 | P a g e
The Behavioural component involves Behavioural techniques such as exposure and
response prevention which would be exposing the individual to those situations that
triggers anxiety (or) discomfort and refrain the individual voluntarily from performing his
(or) her ritual.

The therapist works with the patient and helps the individual plan a graded programme of
exposure tasks. These anxiety provoking situations are then arranged in order according to
those that generate the most anxiety (or) discomfort (hierarchy of tasks) the patient is also
provided training for relaxation and taught one step to the next until the person can mange
the last step with minimal anxiety without getting anxious.

The situation can be real (or) imagined (a real life situation will be more effective), usually
done in graded steps and can be practiced regularly with self-exposure tasks.

15 | P a g e
Topic 4:

CASC LESSON 4
POST TRAUMATIC STRESS DISORDER-HISTORY & ELICIT SYMPTOMS
TASK:

You are seeing Mr. Howard, a 37-year-old man in your outpatient clinic, who was referred
by his GP. He has had some difficulties at work, as he is very stressed. The GP started him
on paroxetine 4 weeks ago and there has been no response at all. Obtain history to arrive
at a diagnosis and rule out co-morbidity

CASE SYNOPSIS

You're a 37-year-old office assistant. You're unable to concentrate at work and become
irritable easily. You suffer frequent headaches due to work related stress. About 3 months
ago, on your way from work, you went to a shop to buy some groceries. While you were in
the store, a gun battle ensued between two rival drug dealers. Two men appeared out of
the blue, inside of the store firing weapons at each other. You witnessed a middle-aged man
shot in the head who died within a few seconds. You ran home. You're so traumatized and
distressed that you didn't want to talk about it at all for first few weeks. You have
subsequently avoided your old route to work and avoided conversations about crime,
murder etc as it brings back horrible memories. Subsequently, you've
had nightmares about it most nights and during the day are troubled
by flashbacks witnessing the murder.

Topic:POST TRAUMATIC STRESS DISORDER- HISTORY & ELICIT SYMPTOMS

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Obtain details of the catastrophic incident-

Nature and extent of the problem,

16 | P a g e
 Severity of symptoms and impairment on
current functioning
Hyper arousal Symptoms (Persistent
Anxiety, irritability,

Poor concentration, insomnia, enhanced

startled response etc)
Intrusions (flashbacks, nightmares,
Recurrent distressing Day dreams)
Avoidance of reminders of the events

(Place, person and activities), emotional

detachment, numbness
Rule out co-morbidity, coping strategies

(Depression, anxiety, alcohol and substance

misuse etc)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently

17 | P a g e
 Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
ELICITING PTSD HISTORY
Explore the following:

1.Details of the traumatic incident itself

2. Look for core features of post-traumatic stress disorder (PTSD) that includes
hyperarousal, intrusions and avoidance

3. Assess the mode of onset, duration, progression of current symptoms and impairment in
different areas of functioning (Social and occupational functioning)

4. Rule out co-morbidity.

PTSD- It may begin very soon after the stressful event or after an interval usually of days
but occasionally of months, though rarely more than 6 months.

Principal symptoms

Hyperarousal

1. Persistent anxiety and Irritability or outbursts of anger

2. Insomnia

3. Poor concentration and exaggerated startle response

Intrusions

1. Intensive intrusive imagery (flashbacks)

2. Vivid memories

3. Recurrent distressing dreams and nightmares

Avoidance

18 | P a g e
 1. Actual or preferred avoidance of circumstances resembling or associated with the
stressor

2. Emotional detachment and inability to feel emotions

3. Diminished interest in activities.

Others

Inability to recall either partially or completely, some important aspects associated with
the stressful event.

A. Traumatic incident

Explore the details of the accident, in particular the perceived severity and establish the
level of distress and fear at the time of the event.

• Could you describe the accident please? (Here approach the patient empathetically as
it is difficult to talk about traumatic incidents, and acknowledge the patients distress.)

• Find out about when it happened, how (terrifying) it was?

• Ask about any injuries in particular head injury, loss of consciousness, whether any
other person was injured etc.

• Inquire about any blame, litigation, court cases and their outcome.

B. Core features of PTSD

Intrusions

• How often do you think about the accident?

• Do you sometimes feel as if the accident is happening again?

• Do you get flashbacks?

• Have you revisited the scene?

• Do you get any distressing dreams/nightmares of the event?

• What would happen if you hear about an accident?

19 | P a g e
 • Do you have any difficulties remembering parts of the accident?

Hyper arousal

• Have you had the feeling that you are always on the edge?

• Do you tend to worry a lot about things going wrong? (Feeling anxious)

• Do you startle easily? (Enhanced startle response)

• Tell me about your sleep please. (Explore for sleep disturbance)

• Are you sometimes afraid to go to sleep?

• How has your concentration been recently?

• How has your memory been lately?

• Do you loose your temper more often that you used to? (Irritability)

Avoidance

• How hard is it for you to talk about the accident?

• Do you deliberately try to avoid thinking about accidents?

• Have you been to the place where the accident happened?

• Do you make any effort to avoid the thoughts or conversations associated with the
trauma? How would you do that?

• Do you make any effort to avoid activities, places or people that arouse recollection of
the trauma?

Emotional detachment and numbness

• How do you feel in yourself generally?

• Have there been any changes in your feelings generally? (Emotional detachment).

• How do you see the future?

20 | P a g e
C. Assess the duration, progress, severity, frequency of current symptom and impairment of
normal functioning

I would like to know how your problems have been affecting you, your family and social life
(Open question)

• How do you feel in yourself generally?

• How has all this been affecting you?

• How do you spend your time these days?

• Enquire about effect on family, social life and work

4. Rule out Co-morbidity

a.Mood symptoms, especially depression

b.Other anxiety symptoms

c. Current coping mechanisms including drugs and alcohol

Explore premorbid personality, past history

• Before all this happened, what sort of a person were you?

• How did you cope with stress?

• Have you had any mental health problems before the accident?

MANAGEMENT OF PTSD

• Trauma-focused CBT (psychological treatment) should be offered to those with

severe posttraumatic symptoms lasting 1 month or longer after a traumatic event.

21 | P a g e
 • It can prevent the emergence of chronic PTSD in individuals with post-traumatic
symptoms, and it should be provided on an individual outpatient basis.

• The treatment should be regular and continuous, usually at least once a week, and the
same person should deliver it.

• The duration of trauma-focused CBT should normally be 8 to 12 sessions but if

initiated earlier within the first month, fewer sessions may be sufficient (NICE, 2005)

Pharmacological treatment
Drug treatment should not be considered as a routine first line treatment.

• Selective serotonin reuptake inhibitors--paroxetine hydrochloride, sertraline

hydrochloride, fluoxetine hydrochloride

• Tricyclic antidepressents--amitriptyline, imipramine

• Venlafaxine, mirtazapine

• Phenelzine sulphate, lamotrigine

Higher doses of SSRIs are generally not recommended but individual patients may benefit
from higher doses.

In the acute phase of PTSD for the management of sleep disturbance--

use a hypnotic medication for short-term use but, if longer-term drug treatment is
required, consideration should be given to the use of suitable antidepressants.

Treatment periods of up to 12 weeks are needed to assess efficacy.

Psychological treatment
Trauma-focused individual cognitive behavioural therapy

The therapist aims to explain the traumatic event from the patient's perspective providing
information about the normal response to severe stress.

This involves:

• Recall of images of the traumatic events and exposure to situations that are being
avoided

• Self-monitoring of symptoms

• Cognitive restructuring through the discussion of evidence for and against the
patient's belief systems

22 | P a g e
 • Interpretation of the event and attributions following the event

• Anger management for those who feel angry about the traumatic events and their
causes

• Anxiety management and relaxation training.

Other psychological interventions

• Eye movement and desensitization reprocessing (EMDR)

• Supportive therapy/non-directive therapy

• Hypnotherapy

• Psychodynamic therapy.

Eye movement desensitization and reprocessing:

This is one of the new interventions used for the treatment of PTSD.

The therapist waves his or her fingers back and forth in front of the patient's eyes, and the
patient is asked to track theses movements while focusing on a traumatic event. The act of
tracking while concentrating seems to allow a different level of processing to occur. The
patient is able to review the event more calmly or more completely than before.

It also involves a cognitive behavioural component, where the negative belief about
themselves that resulted from the trauma is explored and the patient rates their level of
emotions and the extent to which they believe this new belief.

Longer-term treatment
• Continue drug treatment for a further 12 months in patients who are responding at 12
weeks

• Monitor the efficacy and tolerability regularly during long-term treatment--the best
evidence is for SSRIs.

NICE guidelines for PTSD - summary

23 | P a g e
 • Encourages primary care diagnosis and screening - it is probably
underdiagnosed.

• Up to 30% of people exposed to trauma may develop PTSD.

• PTSD can also develop in children.

• Watchful waiting if symptoms are mild and present for less than 4
weeks after trauma.

• Trauma-focussed CBT - individual basis as outpatients to be

offered to all with severe symptoms present for less than 3 months

• If present for more than 3 months (chronic) offer trauma focussed

CBT or EMDR.

• If no improvement consider pharmacological treatment.

• Paroxetine, mirtazapine for general use; amitriptyline or

phenelzine for specialist use.

24 | P a g e
Topic 5:

CASC LESSON 4
ALCOHOLIC HALLUCINOSIS
TASK:

Mr. Simon Cole is a 43-year-old man who came to A&E with his wife as he was hearing a
voice (that of his neighbour). He became anxious when he went to the supermarket with
his wife for grocery shopping. Assess psychopathology and obtain etiology.

CASE SYNOPSIS

You are a man in your 40s who came to the A&E with your wife as you are hearing a voice
(that of your neighbor). You became very anxious when you went to the supermarket. You
can't believe your neighbour Paul called you an idiot whilst grocery shopping this morning.
You have had many arguments with Paul about his children in the past, as they play music
very loudly in their flat. You hear him clearly through your ears, which is distressing. If
probed further, you admit to drinking 50 pints of alcohol per week, which you stopped
suddenly yesterday. You drink 5-6 pints of beer every day, at night for last 6-7 years. This
helps you sleep and relax. But your wife threatened to leave if you don't quit drinking and
so you decided not to drink anything yesterday. You do not have any other abnormal
experiences. You have no past psychiatric history. You do not take drugs.

TOPIC:ALCOHOLIC HALLUCINOSIS

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explore hallucinations (Modality, source-
True/pseudo hallucinations)
Type & Content of hallucinations -
2nd/3rd person, command/running
commentary

25 | P a g e
 Frequency & duration, Reality with which
they are experienced
Onset & precipitating factors
Effect on patient's life, Coping mechanism,
Patients explanation for them (degree of
insight, likelihood to act on any command
hallucinations)
Rule out other psychotic symptoms (visual
hallucinations, delusions etc)
Establish amount and duration of drinking
Any associated with medical and
psychosocial complications
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient

26 | P a g e
 10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

ALCOHOLIC HALLUCINOSIS

(Prepared by Dr Jemma Theivendran, Registrar in Psychiatry)

Alcoholic hallucinosis is a feature of chronic alcohol misuse. It can occur whilst under the
influence or in withdrawal, within 24 hours of the last drink. It can occur with or without
the presence of delirium tremens.

The pathophysiology of the condition is unclear as different neurotransmitter pathways are

involved in acute intoxication and withdrawal yet psychosis can occur in both. It is
hypothesised that dopamine activity in the limbic system may result in psychotic
symptoms, but this hypothesis is limited to hallucinations whilst intoxicated.

The hallucinations experienced are usually visual, tactile or auditory. They are often
distressing to the patient, who is disorientated to time and place. The patient can also
experience delusions and paranoia.

The history of alcohol misuse is extremely significant and should be elicited in the history
taking:

• When was the patient's last drink?

• How often does the patient drink?

• How much does the patient drink?

• Is the patient currently intoxicated?

• Is the patient in withdrawal?

• Has the patient ever gone through withdrawal?

• Has the patient ever had withdrawal seizures?

• Has the patient ever suffered delirium tremens?

27 | P a g e
It is also important to exclude other causes such as a history of recurrent non-substance-
related psychotic episodes or that the symptoms occur exclusively during an episode of
delirium.

During physical examination, it is important to observe for physical manifestations of

chronic alcohol misuse e.g. ataxia and peripheral neuropathy.

Differential Diagnosis

• Delirium Tremens

• Schizophrenia

• Other substance induced psychosis e.g. cannabis, cocaine

• Delirium

Investigations should be used to rule out other causes and confirm a history of alcohol
misuse:

• Full blood count: infection, anaemia

• LFTs: suggest alcohol misuse

• Urinalysis: urinary tract infection

• Urine/serum drug screen

• CXR: infection

• CT head: head injury

Management

• Treatment should be supportive

o Benzodiazepines should be used to manage the symptoms of withdrawal

o Lorazepam and chlordiazepoxide within the context of CIWA (Clinical

Institute Withdrawal Assessment)

o B12 and thiamine supplementation

• Antipsychotics lower the seizure threshold and should not be used

28 | P a g e
Complications

There is an increased risk for psychosocial impairment, depression and suicide

Prognosis

10-20% experience persistent psychotic symptoms. If the alcoholic hallucinosis accompany

symptoms of Korsakoff's syndrome, then the symptoms are more resistant to treatment
due to the irreversible neurological damage.

Reading notes

• Alcoholic hallucinosis (or alcohol-related psychosis) is a complication of alcohol

withdrawal in alcoholics.

• It refers to perceptual changes, including visual, tactile, or auditory hallucinations

that occur infrequently during alcohol withdrawal.

• Alcohol hallucinosis typically begins about 12 to 24 hours after the last drink and
resolves in another 24 to 48 hours. Patients are not delirious or disoriented.

• This involves auditory and visual hallucinations, most commonly accusatory or

threatening voices. This condition is distinct from delirium tremens since it
develops and resolves rapidly, involves a limited set of hallucinations and has no
other physical symptoms.

• The risk of developing alcoholic hallucinosis is increased by long-term heavy

alcohol abuse and the use of other, illicit drugs.

• Alcohol-related psychosis is often an indication of chronic alcoholism; thus, it is

associated with medical, neurological, and psychosocial complications.

• Alcohol-related psychosis spontaneously clears with discontinuation of alcohol

use and may resume during repeated alcohol exposure

• Distinguishing alcohol-related psychosis from schizophrenia or other primary

psychotic disorders through clinical presentation often is difficult. It is generally
accepted that alcohol-related psychosis remits with abstinence, unlike
schizophrenia. If persistent psychosis develops, diagnostic confusion can result.

• Comorbid psychotic disorders (e.g., schizophrenia spectrum and other psychotic

disorders) and severe mood disorder with psychosis may exist, resulting in the
psychosis being attributed to the wrong etiology.

29 | P a g e
 • Some characteristics that may help differentiate alcohol-induced psychosis from
schizophrenia are that alcohol-induced psychosis shows later onset of psychosis,
higher levels of depressive and anxiety symptoms, fewer negative and disorganized
symptoms, better insight and judgment, and less functional impairment

• Less frequently, hallucinosis can persist for extended periods and become chronic

• The risk for alcohol hallucinosis may be related to genetic factors and/or
decreased thiamine absorption.

Ref: http://emedicine.medscape.com/article/289848-overview

Alcoholic Hallucinosis: a psychiatric enigma--1, The Development of an Idea, ILANA B.

GLASS

Addiction Research Unit, 101 Denmark Hill, London SE5 8AF, United Kingdom,

British Joumal of Addiction (1989) 84, 29-41

www.uptodate.com/contents/medically-supervised-alcohol-withdrawal-in-the-
ambulatory-setting

30 | P a g e
Topic 6:
CASC LESSON 4
ABUSE IN INTELLECTUALLY DISABLED PERSON-HISTORY TAKING
TASK: You have been asked to speak to the key worker of a 26-year-old man with
moderate to severe degree of learning disability who attends the day centre. The key
worker is concerned that Paul has been withdrawn and tearful.Obtain more history from
the key worker to identify causes for his presentation and arrive at a diagnosis.

CASE SYNOPSIS: You're key worker for a 27-year-old man with a moderate degree of
learning disability who attends the day centre you work at. You contacted the mental
health team because of concerns about him. A couple of days ago you noticed bruises on the
left side of his face and neck, they are grey/purple in colour. He hasn't been his usual self
for the past few days/weeks. He is easily upset, and it is often difficult to ascertain why,
although he sometimes signs 'home' when distressed. He has been agitated prior to going
home in the evening. You have tried contacting his parents but there has been no reply to
phone calls. He has had epilepsy most of his life, however, in recent weeks, he has been
having fits more frequently, almost every day. He is currently on (tablets) Valproate and a
new medication. He has limited speech, mostly communicating in single words and basic
Makaton signs to communicate basic requests

Topic:ABUSE IN LEARNING DISABLED PATIENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Exploration of Presenting Problems- mode of
onset, duration and severity

31 | P a g e
 Elicit features of physical injuries and
physical symptoms

(Bruises- nature, colour, size, distribution

etc)
Check for evidence of neglect

(Poor self care, poor hygiene, weight loss

etc)
Elicit psychological symptoms (social
withdrawal, irritability, aggressive
behaviour, sexualised behaviour, anxiety
etc)
Medical problems (epilepsy, mobility
problems, vision and hearing problems, and
adverse effects from medication resulting in
falls, bumping into things)
Exploration of patients social circumstances
- residence, support from family and carers
and recreational activities
Evidence of inconsistencies in their
explanation and observed presenting
symptoms.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

32 | P a g e
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or Incomplete management plan
Specific Comments and suggestions

ABUSE IN LEARNING DISABILITY

(Prepared by Dr. Edward da costa, consultant in Learning disabilities)

What is Abuse?

Abuse is a violation of an individual's human and civil rights by any other person or
persons.

"Abuse may consist of a single act or repeated acts. It may be physical, verbal or
psychological, it may be an act of neglect or an omission to act or it may occur when a
vulnerable person is persuaded to enter into a financial or sexual transaction to which he
or she has not consented, or cannot consent. Abuse can occur in any relationship and may
result in significant harm to, or exploitation of, the person subjected to it.” (No Secrets,
Department of Health 2000)

People with learning disability have an increased vulnerability to abuse (Brown & Craft,
1992) because of dependence on other people for personal care; an 'imbalance of power'
between the carer and the person being cared for; difficulties in communicating; lack of
sexual knowledge and assertiveness; and guilt and shame at being disabled (Sinason,
1993a,b)

Legislation has been passed and there is a legal framework to ensure that all vulnerable
adults have safeguards to protect them from abuse. Legislation gives the local authority a
range of powers, including the ability to enter and inspect premises where a vulnerable
person is believed to be at risk, and to remove such a person for assessment or protection.
Every local authority (County Council) must ensure that they have the requisite policies
and operational procedures for adult safeguarding which needs to be multi-agency in
nature with the lead role resting with Social Services. All professionals within health and

33 | P a g e
social care services should be adequately trained so that they know how to act when they
encounter abuse.

A study by Cooke found that the average prevalence of definite experience of abuse was
found to be 4 - 5 % of individuals with learning disability.

Presentation of abuse: The presentation of abuse depends on the kind of abuse

perpetrated, and the psychological impact, which it had. Physical and sexual abuse and
neglect may be diagnosed from physical signs and symptoms in the same way as would
happen with children, but if there are not present, diagnosis can be much more difficult
where the victims are non-verbal. It is therefore necessary to be aware of possible
psychological manifestations of abuse, such as a change in personality or behaviour.

The person with learning disability may demonstrate

1. An increase in sexual preoccupation

2. Sexually inappropriate behaviour, and/or avoidant behaviour.

3. They may be aggressive towards themselves or others

4. Can become withdrawn

5. Suffer sleep disturbances

6. Lose previous skills and have a reduced level of functioning.

Abuse must therefore always be considered as a possible differential diagnosis in someone

with learning disability who presents with psychiatric symptoms.

Individual and group psychoanalytic psychotherapy within the National Health Service for
children and adults with learning disabilities who were emotionally disturbed or hurt by
abuse and other trauma was pioneered by the Yorkshire Association for Psychodynamic
Psychologists, by St Georges Hospital Medical School Psychiatry of Disability Department
and by the Tavistock Clinic in London in the 1980s. As such treatment depends on
'emotional' rather than cognitive intelligence (Stokes & Sinason, 1992), the severely and
profoundly learning - disabled are also able to benefit and show a reduction in symptoms
(Sinason, 1993a).

Indeed there is no level of disability which makes someone ineligible for psychoanalytic
treatment (Hollins et al, 1994). The only difference is the technique used with people with
little or no verbal or sign language (Makaton signs). In there circumstances adults are
provided with drawing equipment, anatomical dolls and other items so that concerns can
be communicated by non-verbal means. Sinason (1993a) found large home-shopping
catalogues particularly useful.

34 | P a g e
More recent additions to a 'psychotherapy kit' for adults with limited language abilities are
the adult picture books of male and female abuse (Hollins et al, 1993a,b) produced by St
George's Hospital Medical School in the 'Books Beyond Words' series.

The stages and themes that have to be explored and worked through with learning -
disabled abuse victims share similarities with other victims.

There is often a sense of betrayal of trust, shame, self-disgust, fear of telling a secret, guilt at
sexual excitement or involuntary responses. Where the abuse was not perpetrated by a
stranger but by a trusted worker, family member or friend, there are the issues of poor
family attachment, low self-esteem and little or poor sex education (Brown & Craft, 1992)
prior to the abuse.

It may be necessary and desirable to use several different therapeutic approaches

simultaneously, e.g. an antidepressant + art therapy + self - assertiveness training.

Defects in cognitive functioning and limited maturation may make it impossible to process
the memories and emotions induced by the abuse, leading to chronic psychological
dysfunction.

What is expected of me?

• Ignoring abuse is not an option - if at anytime you think that a vulnerable person
is being abused or is at risk of abuse you must report your concerns so that they can
be looked into.

• If you come across a situation where you think a vulnerable person is at risk of
abuse you must not ignore the information. Do not assume that others know what
you know. You must tell so that others can help.

• Remember that vulnerable adults have human rights. You have a duty of care to
ensure the rights and needs of the vulnerable person is your main consideration.

• If at any time you feel the person needs urgent medical assistance call for an
ambulance or arrange for the appropriate medical professional/service to see the
person at the earliest opportunity.

• If at the time you have reason to believe the vulnerable person is in immediate
and serious risk of harm or that a crime has been committed call the police.

• If you see something that concerns you or you are given information that causes
you to be concerned about a vulnerable person then:

o Keep calm; this will help the vulnerable person

35 | P a g e
 o Make sure that the person is safe

o Listen carefully to what is said

o Observe what you see around you, if possible

o Reassure and take care of the person

o Get help as soon as possible.

• Remember you will need to record everything that you saw, heard and
did. Record the facts of what happened.

• Remember it is expected that you pass on any concerns immediately to the Adult
Safeguarding Service or contact your consultant psychiatrist supervisor in this
context.

Signs of possible physical abuse

• Unexplained injuries, bruises or burns, especially if recurrent

• Improbable excuses given for injuries
• Refusal to discuss injuries
• Untreated injuries or delay in reporting them
• Excessive physical punishment
Signs of possible physical neglect

• Constant hunger
• Poor personal hygiene
• Constant tiredness
• Poor state of clothing
• Frequent lateness or non-attendance at school
• Untreated medical problems
Signs of possible emotional abuse

• Low self-esteem, continual self-deprecation

• Sudden speech disorder
• Rocking, head-banging, or other neurotic behaviour
• Self-mutilation
Signs of possible sexual abuse

36 | P a g e
 Behavioural

• Lack of trust in adults or over-familiarity with adults

• Fear of a particular individual
• Social isolation, withdrawal, and introversion
• Sleep disturbances (nightmares, irrational fears, bed wetting, fear of
sleeping alone, needing a nightlight)
• Running away from home
• Girls taking over the mothering role
• Unusual interest in genitals of adults, children, or animals
• Expressing affection in inappropriate ways
• Developmental regression
• Over-sexualised behaviour
Physical/medical

• Bruises, scratches, or other marks to the thighs or genital area

• Itch, soreness, discharge, unexplained bleeding from the rectum, vagina,
or penis
• Pain on passing urine or recurrent urinary tract infection
• Recurrent vaginal infection
• Venereal disease
• Stained underwear
•Discomfort/difficulty walking or sitting (Adapted from; Oxford
Handbook of Psychiatry, 1st Edition)
References:

SETSAF: Southend, Essex and Thurrock Adult Safeguarding Policy.

Abuse of people with learning disabilities and other vulnerable adults, Advances in
Psychiatric Treatment (1998), vol. 4, pp, 119-125, L.B.Cooke & V.Sinason.

Abuse of people with Learning Disabilities;

Areas to be targeted in history taking

1. Exploration of Presenting Problems- mode of onset, duration and

severity

37 | P a g e
 2. Exploration of patients social circumstances - residence, support
from family and carers, educational, community, occupational
and recreational activities
3. Elicit features of physical injuries and physical symptoms which
could be suggestive of physical abuse and neglect (such as
bruising of any part of the body, cigarette burns, finger-mark
bruising, linear whip marks, dehydration, dishevelled
appearance etc)
4. Elicit psychiatric symptoms and features of psychiatric disorder
that could be manifestations of physical or sexual abuse (recent
onset of social withdrawal, irritability, aggressive or other
disturbed behaviour, sexualised behaviour, anxiety and
autonomic arousal, etc)
5. Explore whether key- worker has information about patient's
level of communication, intellectual functioning and skills, and
social interaction in different settings e.g., college, day hospital,
community facilities, when in the presence of family members,
6. Explore other causes for patients presenting symptoms such as
epilepsy, ataxia, mobility problems, vision and hearing problems,
and adverse effects from medication resulting in falls, bumping
into things. Whether involved in any violent incidents due to
conflicts or incompatibility with other patients, chronic history of
self -injurious behaviour
7. Ascertain whether manager has made attempts to contact family
to obtain their account of reason for patient's presenting
symptoms, whether there is evidence of inconsistencies in their
explanation and observed presenting symptoms.

38 | P a g e
Topic 7:

CASC LESSON 4
INTERPERSONAL THERAPY-ASSESS SUITABILITY
TASK:
You are seeing Mrs. Pauline Smith in the outpatient clinic who suffers from depression. She is keen
to have some form of talking treatments. Explore her depressive symptoms and assess suitability
for IPT (Inter Personal Therapy).

CASE SYNOPSIS: You're a 48-year-old woman. You work part time in admin but have been
sick from work for 6 weeks. You're feeling low in mood and depressed. Your husband is a
psychiatrist with a very good private practice. He's busy with his practice and you don't see
him much. He can be very demanding and critical of you. Your relationship is under
strain. Your supportive mother, with whom you were very close, died from a heart attack 3
years ago. 2 years ago your son left home moving to Edinburgh and you haven't heard
from him much. Your daughter left home 6 months ago, moving stateside after marrying an
IT technician. Above all, you were diagnosed with breast cancer a year ago and treated with
radiotherapy. You are interested in receiving some form of verbal treatment. You are
having difficulties in adjusting to these changes in life. You have motivation to participate in
talking treatments and willingness to get better eventually.

Topic:INTERPERSONAL THERAPY

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Assess depressive features- Core symptoms,
emotional and biological symptoms etc
Assess for Selection criteria- outpatient,
Establishing mild to moderate depressive

39 | P a g e
 illness. Non-psychotic depressive illness,
non-bipolar illness
Identify interpersonal problem areas- Grief
(complicated bereavement after the death of
a loved one)
Identify interpersonal problem areas-
Interpersonal deficits (History of social
impoverishment, inadequate or unsustaining
interpersonal relationships)
Identify interpersonal problem areas-
Interpersonal role disputes (conflicts with a
significant other- a partner, other family
member, close friend etc)
Identify interpersonal problem - Role
transitions (Economic or family change- the
beginning or end of a relationship or career,
a move, a promotion, retirement, graduation,
diagnosis of a medical illness)
Assess motivation and willingness to comply

Route to recovery- Resolving interpersonal

issues
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

40 | P a g e
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
INTERPERSONAL THERAPY

Interpersonal therapy (IPT) is mainly used for the treatment of depressive illness (mild-
moderate) and bulimia nervosa. It is a time-limited and disorder-focused therapy which
deals with symptoms in the 'here and now'

Principle:

• The focuses of treatment are the current interpersonal relationships and their
relationship to the development of illness.

• Emotional problems are best understood by studying the interpersonal context in

which they arise.

• It does not make any assumptions about the causation of the illness, but aims to
use the connection between the onset of depressive symptoms and the current
interpersonal problems as a focus of treatment

• Resolving the interpersonal problem is seen as a route to recovery.

• The four interpersonal areas related to illness development include:

a. Grief (loss of a loved object/relation)

b. Interpersonal disputes e.g. Conflict with family members, colleague or a

friend

c. Change of role (e.g. graduation, new mother, retirement, job loss, medical
ill health)

d. Interpersonal deficits.(inadequate interpersonal relationships)

41 | P a g e
Structure:

• It is time-limited

• Treatment lasts for 12-16 hour long weekly sessions, offered by trained therapist

• The therapist starts with a diagnostic phase, in which the disorder is identified
and explained. Inventory of all close relationships is created in early part of therapy.

• The therapist will now try to link the depressive symptoms with one of the four
interpersonal areas and will pursue strategies specific to one of these problem
areas.

• The therapist is directive and takes an active & supportive stance.

• The patient is encouraged to identify and carry through change in interpersonal

relationships and to test the possibility of consequent improvement in their
symptoms.

• The final phase involves assessment of improvement and develops ways of

identifying and countering depressive symptoms, should they recur in the future
and plan for termination of therapy.

Explain interpersonal therapy

• Interpersonal Psychotherapy (IPT) is a form of structured psychotherapy

• It is time-limited that is normally delivered over 12-16 weekly sessions.

• IPT focuses primarily on relationship problems. It helps people recognise the

problems they face with other people and to make changes in their relationships.

• IPT looks at the ways in which a person's current difficulties in relationships

contribute to their psychological stress, and in turn looks at the ways
psychological problems affect relationships.

• When an individual can deal with relationship problems more effectively, their
psychological symptoms often improve.

• The relationship issues usually fall into one of the following areas:

1) Interpersonal disputes - disagreements or arguments with others,

and unmet expectations

42 | P a g e
 2) Role transitions - circumstances in which your life changes, such as
retiring or starting a new job

3) Grief and loss - an emotional reaction to a major loss through

bereavement

4) Interpersonal sensitivity - difficulty initiating or maintaining

relationships

Early phase: During the first few sessions, the therapist will be talking with your
about your depression and current important relationships to see how they
are linked

You will work with your therapist to complete an InterpersonalInventory, which

is basically a review of your key relationships, looking at their strengths and
problems and how other might be able to assist you in your recovery. This will help
you to identify those relationships, which it would be most useful to focus on during
therapy.

You will agree a contract with your therapist, outlining the focus of the work for the
remaining sessions.

Middle phase: During the middle sessions of treatment, you and your therapist will
discuss your agreed main area of interpersonal difficulties and work on making
positive changes.

There are several tasks assigned during these sessions. This will include a)
monitoring current relationship triggers for depression b) working on improving
communication, and c) discussing your emotional reactions to your relationship
problems.

You might decide to invite someone who is important in your life to one of these
sessions to help them to understand and support you in the work you are starting to
do.

Final phase: In the last few sessions, you and your therapist will discuss feelings
about therapy ending and the progress you have made during the treatment.

The therapist willspend some time with you planning ahead for any other problems
you anticipate in the future and how to use the new skills and supports you have
developed.

• It is common to use talking treatments such as IPT alongside medications such as

anti-depressants, and for some people this may be better than receiving either
treatment alone. It is important to inform your therapist about the medications and
any changes to them.
43 | P a g e
 (Ref: Produced by psychology & psychological therapies-June 2008, publication
number 1)

44 | P a g e
Lesson 5:

TOPIC 1: OPIOID MISUSE

TOPIC 2: ANGRY MOTHER-SCHIZOPHRENIA (DIAGNOSIS)
TOPIC 3: BODY DYSMORPHIC DISORDER
TOPIC 4: GHB DEPENDENCE
TOPIC 5: WEIGHT GAIN PSYCHOSOCIAL HISTORY AND
MOTIVATION TO CHANGE
TOPIC 6: DISSOCIATIVE STUPOR-HX & DIAGNOSIS

1|Page
Topic 1:

CASC LESSON 5
OPIOID MISUSE
TASK: Mr. Tony Gordon, a 32-year-old gentleman was seen in the drug and alcohol
outpatient clinic following referral from his GP, as he has a history of multiple drug use.
Take a history of drug misuse and establish features of drug dependence syndrome.

CASE SYNOPSIS:

You're a 32-year-old man with a history of heroin useon a regular basis, beginning from age
14. Initially it was due to peer pressure but later you willingly started using. This habit
escalated and your intake increased. You buy and smoke about 1 gram of street
heroin daily. You get it from a local drug dealer (£30 worth on the street). You really enjoy
the highs you get. You are also injecting but your veins have become very difficult to use
and have recently given out too. You've not shared needles but you've shared syringes
once. You had HIV and Hepatitis C screen 3 years ago but you are scared to be re-tested.
You've had periods when you were abstinent for short periods of time. During those
periods you experienced nausea, abdominal cramps, shivering, goose bumps, and a strong
desire to take heroin. These periods were 'awful'. You know that you have problem with
drugs but can't modify your habit

Topic :OPIOID MISUSE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit type & Quality of drug use
Duration of abuse and cost
Obtain Longitudinal history

2|Page
 Mode of administration & needle sharing
Withdrawal symptoms
Social impact of drug use- relationship,
employment, financial and legal
Psychiatric symptoms- depression, mood
change or psychosis or hallucinations
Physical problems
Patient's reflection on his drug taking
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Inaccurate or misleading information discussed
Specific Comments and suggestions

OPIOD MISUSE- ELICIT ILLICIT DRUG HISTORY

The areas to be explored are:

3|Page
1. Current usage

2. Longitudinal history

3. Look for features of drug dependence

4. Complications-physical, mental, social and legal

5. Assess Insight and motivation

6. Risk assessment-sharing needles, unsafe sex etc

7. Rule out co-morbidity

Open questions
• Are there any tablets (or) medicines that you take apart from those you get from your
doctor?
• Is there anything that you buy from the chemists (or) getting from friends?
• Have you ever used any recreational drugs such as cannabis, cocaine/ crack,
amphetamines, speed, ecstasy, LSD (or) acid?
(Ask about individual drugs by naming them).
• What about tablets to settle your nerves (or) help you sleep?

Current usage
• What drugs are you using now?
• What is the frequency of use?
• What is the pattern of typical drug using?
• What is the amount of drug taken? (In appropriate measures)
• What effect is the patient seeking when using the drug?
• Ask if more than one drug is used at a time.
• How much money do you spend in a day/week for getting these drugs?
• What is the route of use? (Oral, smoked, snorted, injected)
If injected, the following questions are useful to ask.
a. Are needles used?
b. Where are they obtained?
c. Are needles shared?
d. What sites are used for injection?

4|Page
• What risky behaviour does the patient engage in?
e. Injecting and sharing needles
f. Involving in Unsafe sex
g. Sex for drugs
• How is he/she financing the drug use?

Longitudinal history
Ask about the patient's age of first use of drugs, and when the patient started to use the
drug regularly
• When did it start?
• What was the first drug taken?
• Was it by your own will (or) peer pressure?
• How did you progress to the current level?
• When did you start taking them regularly?

Features of 'Dependence syndrome'

Compulsion
• Do you sometimes crave for drugs?
• Do you have a compulsive urge to take drugs?

Tolerance
Do you have to increase the amount of drugs that you take to get the same effect (or) same
amount has given you less effect than earlier?

Withdrawal symptoms
• If you don't take drugs for a day (or) two, do you experience any withdrawal symptoms?
For example, if the patient takes
heroin, ask about symptoms such as sweating, gooseflesh, running nose, watery eyes etc.
• Ask the patient to describe them in their own words?

Treatment & re-instatement: Enquire about the patient's past experience of treatment
for a drug problem
• Have you ever gone to anyone for help to come out of this?

5|Page
• Have you ever been in hospital for a drug problem?
• Have there been any periods of abstinence when you were not using any drugs and if so,
what has helped the patient to
achieve this?
• What triggers have brought on this habit again?

Complications
Have you experienced any complication? (Ask about physical, mental and social
complications?
Have you ever worried about?
• Hepatitis B, C and HIV,
• Complications of injecting like infections, abscesses, sepsis
• Accidents, head injury, falls, fits
• Anxiety, depression, hearing voices, seeing things
• Financial problems
• Row or arguments with friends or family members or working place

Insight
• Do you feel you have a problem with drugs?

• Do you think that the difficulties that you experience currently are related in any way to
your drug problems?

Motivation
• What would you like to do?

• Have you ever thought of giving it up completely?

• What do you think will happen if you give up completely?

6|Page
Topic 2:

CASC LESSON 5
ANGRY RELATIVE-SCHIZOPHRENIA
TASK: Mr. Peter Hill is a 19-year-old university student, who is currently an in-patient on
your ward and was admitted few days ago with bizarre behaviour, auditory hallucinations
and odd beliefs of lizards taking over the world for more than 6 weeks. Blood and urine
tests are normal. His mother is angry to know from the nurses that he has been diagnosed
as having schizophrenia. Ms. Linda Hill wants to seek clarification of her son's diagnosis.
Address her concerns and allay her anxiety.

CASE SYNOPSIS:

Your only son was admitted to the psychiatric ward a few days ago with bizarre behaviour
and auditory hallucinations.You've heard from a nurse that he has been diagnosed with
schizophrenia. You went home, looked it up on the internet and read that the condition is
caused by 'bad mothering'. You return very angry and ready for a showdown. You deny the
diagnosis. You feel that he has been hearing voices because he might be on drugs. You
should seek explanation for diagnosis, keen to know the possible causes for schizophrenia
and check whether his future has the possibility of being successful. Your son now has this
stigma attached to him, which is concerning you

Topic:ANGRY MOTHER

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Calm her down

Get her to sit down

Apologise for previous lack of
communication

7|Page
 Alleviate guilt

(She is not to blame and no one is blaming

her)
Explain reasons for diagnosis and nature of
the illness

(Rationale behind his diagnosis)

Causal explanation

(Multifactorial-Chemical imbalance, Genetic

factors,

Stress, ? Sparked off by illicit drugs etc)

Prognosis

(Discuss her son's future has the possibility

of being successful)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion),
significant omissions
Disorganised/unstructured consultation, Poor management of interview
5 Does not explained signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
6 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
7 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
8 Limited or Incomplete management plan,

8|Page
 Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

DEALING WITH ANGRY RELATIVES

The candidate is expected to deal with such situations commonly in real life and in
exams. One of the frequently asked stations is
a. To deal with a mother whose son has been recently diagnosed with schizophrenia?
b. To deal with a father whose son has been recently diagnosed with Neuroleptic
malignant syndrome
Suggested approach in such situations include
1. Calm the relative down
2. Hopefully to get them to sit down
3. Apologize for previous lack of communication
4. Explain that he/she is not to blame and no one is blaming him/her
5. Explain all the possible causes for this presentation
6. Explain reasons for the diagnosis
7. Explain his/her future has the possibility of being successful
How to deal with it?
• There is clearly no one solution or one way to handle this situation
• It is also important to accept that you won't be in complete control at any point during
the station
• Make sure you remain calm and relaxed.
• Do not reflect the hostile body language of the other person
• Use verbal acknowledgements such as okay.......mmm........uh uh etc
• It is important to build rapport using reflective techniques- Reflective listening (the
interviewer tries to clarify and reinstate the other person is saying, which can reassure
the other person that someone is wiling to attend to his or her point of view and is willing
to help)
• It will be helpful to reflect back the other person's apparent emotions to demonstrate that
you recognize their concerns-
• Eg- 'I can see you are really angry and upset'. I understand why you are angry, things have
not happened the way we hoped but all I can do is to find a way forward from where we
are
• Adapt to the situation and be prepared to go with the flow. (Be prepared to roll with
punches)

9|Page
• Apologize for previous lack of communication (if any) and be
supportive (Ref: www.trickcyclists.co.uk)

10 | P a g e
Topic 3:

CASC LESSON 5
BODY DYSMORPHIC DISORDER
TASK: You are seeing Miss. Sarah White, a 27-year-old lady who has seen her GP
complaining that her eyes are wide apart.Obtain history to explore the nature and extent of
her problems. Assess her to clarify her diagnosis.

CASE SYNOPSIS:

You're a 27-year-old lady referred by your GP. You believe that your eyes are widely set,
too large, bent upwards and misshapen. The eyelashes are ugly, disfigured and not straight.
You're convinced there is a defect although you accept some people might not see it as you
do. You've had these concerns since aged 13. Your classmates bullied you at school. You
check your eyes constantly in the mirror. When you go out, you use some light make up to
reduce the appearance of the eyes and wear dark glasses to hide them. You chose to do
night shifts as you won't be noticed much. You check several times before you leave. You're
really anxious in social situations and have stopped going to parties/functions. You went to
Harley Street twice to see a cosmetic specialist but couldn't afford it. You've been
researching eye surgeries on the internet and if you can't get it done through the NHS then
you may do it yourself.

Topic:BODY DYSMORPHIC DISORDER

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Nature and description of presenting
problems

(Onset, duration, and severity), and impact

on normal functioning

(Personal, social and occupation)

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 Assess the strength of Beliefs and degree of
conviction (overvalued ideas/ delusional),

Look for any other abnormal beliefs

Avoidance Behaviour-Social situations,
social withdrawal,

Lack of self confidence etc

Compulsive habits & behaviour- Mirror

gazing, Repeated checking and elaborated
Grooming rituals
Risk assessment:

1. Suicidal ideation

2. Risk of actually performing surgery

themselves

3. Risk of unwanted tests and investigations

Past psychiatric history

Rule out co-morbidity-Depression, social

phobia, schizophrenia
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability

12 | P a g e
 7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
Specific Comments and suggestions

BODY DYSMORPHIC DISORDER

• Body dysmorphic disorder also called as Dysmorphophobia, is described as a

'subjective description of ugliness and physical defect which the patient feels is
noticeable to others'
• It is characterized by a preoccupation with an imagined defect in appearance, or if there
is a slight physical anomaly and the concern is out of proportion to the anomaly
• It is an excessive concern (overvalued idea) about trivial or non-existent physical
abnormalities, which are perceived to be deformities. Here the patient is constantly pre-
occupied, convinced and tormented by abnormal belief that some part oh his/her body
is too large, too small or misshapen, which to other people, the appearance is normal or
there is a trivial abnormality
• There is a spectrum of patients with overvalued ideas to those whose beliefs are held
with delusional conviction. Beliefs about deformity that are of delusional intensity are
classified under delusional disorders
• The common complaints are about the nose, ears, eyes, eyelids, mouth, jaw, chin,
buttocks, penis, breasts, skin, hair but any part of the body may be involved. The
preoccupation is frequently focussed on several body parts simultaneously.
• The assessment should involve exploring the nature of the pre-occupations with
appearance and of the ways in which this has interfered with personal, social life and
occupational or other important areas of functioning.
• The affected person might think that other people notice and talk about his deformity
and therefore involve in elaborated grooming rituals to hide the perceived defect
• They would get involved in time consuming behaviours such as re-examining, repeated
checking, mirror-gazing, excessive camouflage, comparison of features, skin-pricking,
reassurance seeking, avoidance of social situation. etc

13 | P a g e
 • BDD affects 1-2% of population. This condition usually begins in late adolescence and is
chronic with some fluctuations over time.
• The prevalence is significantly higher (11.9%) among people who receive
dermatological care than those who don't.
• It has a high degree of co-morbidity with mood disorders, OCD and social phobia. can
occur as part of other psychiatric disorders such as depression or schizophrenia, or may
be associated with social phobia or personality disorders
Screening questions for the diagnosis of body dysmorphic disorder

• Do you currently think a lot about your appearance?

• What features are you happy with?
• Do you feel your features are ugly or unattractive?
• How abnormal or noticeable do you think your features are?
• On an average day, how many hours do you spend thinking about your abnormal
features?
• Please add up all the time that your feature is on your mind and make the best estimate?
• Does your feature currently cause you a lot of distress?
• How many times a day do you usually check your features?
• How often do you feel anxious about your feature in social situations?
• Does it lead to you avoiding social situations?
• Has your feature had an effect on dating or existing relationship?
• Has your feature interfered with your ability to work or study?
(Adapted from psychiatry Journal March 06; pg 94)

Management;

• The treatment of this condition is often difficult, as most patients lack insight and will
not accept psychiatric treatment or referral
• Surgery is usually contraindicated and it is important to explain the lack of success of
this approach and suggest there are other effective treatments. Patients may seek plastic
surgery but the outcome is not good
• Some patients will mutilate themselves in attempt to do their own surgery. Assess
patients for suicidal ideation, as the risk is high.
• If there is co-morbid depression or psychosis, it should be treated in the usual way.
• Good liaison with GP and cosmetic surgeons is extremely important to avoid un-
necessary and unhelpful surgery. Joint appointments may be extremely helpful to ensure
consistent advice. The help seeking behaviour of patients also need to be contained as

14 | P a g e
 they may repeatedly try to consult other plastic surgeons, dermatologists and
psychiatrists etc.
• Some patients are helped by reassurance and practical support
• Serotonergic antidepressants may be effective in high doses and for long periods.
• SSRIs are often helpful in patients with depressive symptoms. Drugs may be helpful
particularly when there are clear symptoms of depressive/ delusional beliefs
• The NICE guidelines on BDD recommend Cognitive behavioural therapy (CBT) or SSRIs
as evidence based treatments.

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Topic 4:

CASC LESSON 5
GHB DEPENDENCE
TASK:

You are on call over the weekend covering A&E and the medical wards. You have been
asked to see 27-year-old Mr Aleksander Nowak who was brought to hospital by ambulance
after he collapsed at a party. The medical team gave him supportive treatment with
oxygenation and IV fluids but he did not require airway management. His blood gas
showed a mild acidosis but normal electrolytes. His urine tested positive for GBL (Gamma
butyrolactone) but was free of any other substances. The medical team feel he is ready for
discharge now that he is alert.

Reviewing his notes on the A&E system he has been seen once with a similar collapse after
taking GHB around 1 year ago, but left the department once awake, without having any
further assessment. He is not known at all on the mental health system and has no known
physical health issues.

His friends who initially were with him in A&E have now left, but reported to A&E staff that
he had been taking GHB at the party and they did not report any concerns about his mental
state. However they did say they were worried about how much GHB he is using. It is
reported in the medical notes that he is Polish but speaks excellent English and has been
living in the UK since he was a teenager.

You have been asked to take a history related to his collapse, assess the degree and impact
of his substance misuse, and assess for any comorbidities. You do not need to discuss
management.

CASE SYNOPSIS:

You are Aleksander Nowak, a 27-year-old painter and decorator, originally from Poland but
you have been living in the UK since the age of 13 when your parents moved here. You are
slightly restless and starting to crave GHB. Currently you feel your heart is beating quite
quickly, you feel a little sweaty and you would like to take some more GHB. You feel a little
tremulous. You went to the party with your friends, as you do most Saturday nights but
you do recall feeling more anxious than usual, as you've recently been to see your boss
about your work performance. You normally take sips of GHB liquid throughout the day,
every few hours. However, at the party you didn't want to be having to do this so you
injected around 4mL in a room on your own before going to hang out with friend. You
remember feeling pretty out of it and the nothing after that, before waking up in A&E. You
might inject before a party sometimes and then sip to top up through the night but
normally you'd just inject 2mL. You didn't want to harm yourself and it wasn't a suicide
attempt. You did want to feel nothing for a while and forget about the work issues. You

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started using GHB when you were 16, when an older friend introduced you to it. Prior to
that you'd smoked a lot of weed, sometimes using bongs since the age of 14. You preferred
GHB and it was easier to hide from your parents. It started off just as something you'd take
at the weekends, at parties, but in recent years you've been using it multiple times a day -
taking a small sip of liquid at least 3-4 times a day. You take a bit extra at night to help you
sleep. There is less effect now and you've noticed you need to take more to have the same
effect. If you need to take some you have noticed you feel restless, have palpitations, feel
sweaty. You have had a period when you were abstinent for short period of time (around 2
days). You haven't been abstinent for more than a day in the last few months. You don't
share needles, but shared a syringe once, and were last tested for HIV and Hep C about 3
years ago when you went to your local drug and alcohol service. You haven't ever used
GHB in the context of chemsex. You spend around £30 per day on it and are consequently
in debt. You buy pre-mixed GHB and don't mix your own. You have never dealt drugs. You
have debts of around £500. In a previous decorating job you stole some cash from a
property to fund your habit. You were convicted and served 6 months in prison. Your
current job is with a boss who has also served time but is reformed and wants to give
former offenders a chance. You've never had any mental health problems. You are
heterosexual but not in a relationship. Your last girlfriend broke up with you some months
ago because she felt you were a bad influence. You want help as you are very shaken up by
what has happened. You don't want to be admitted to hospital. You have work tomorrow
and want to turn up on time and make sure you don't get fired. You would be open to
seeing a drug and alcohol worker in the coming days and getting some support with
reducing your use or a detox.

Topic: GHB Dependence

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history of collapse yesterday
(including dose, route of drug taken, and
intention) and current state (symptoms of
withdrawal including nausea, tremor,
sweatiness, palpitations, anxiety, cravings,
signs of delirium).

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 Elicit history of drug use including age of
onset, routes of administration, assess for
tolerance and increased dose, amount spent,
frequency of use, any previous attempts to
reduce or stop and success of these attempts.

Previous contact with any drug services.

Elicits impact on life including: debts, effect
on employment, housing, relationships,
crime to finance drug use, violent crime or
acts whilst under the influence, current
employment, driving offences, history of
unintentional overdoses.
Assess for other substance use and ask about
other drug history including marijuana/THC,
street benzos, heroin, ecstasy, cocaine,
crystal meth, cigarettes, alcohol, ketamine
Risk assessment - sharing needles, blood
born virus screening, involvement in
chemsex, polysubstance use, risk of
withdrawal, suicidality, history of violent,
risky or impulsive behaviour when
intoxicated, unintentional overdoses.
Assess insight into dependence and
willingness to address drug use.
Non-judgemental and open approach to
asking about substance use.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview

18 | P a g e
 6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
Lecture Notes

GHB Dependence

• This station tests the candidate's ability to thoroughly take a history of substance
misuse (with dependence), the impact on the patient's life, and screen for
comorbidities.

• Candidates should be able to ask about the extent of GHB use, as well as other
substances in a non-judgemental way.

• They should be able to elicit that the patient has GHB dependence, with significant
impact on his life.

• They should also be able to identify that his taking extra GHB on this occasion
(causing collapse) was not a suicide attempt, however is certainly a risky behaviour.

• Excellent candidates will screen for comorbid mood disorders, consequences of the
drug dependence. ensure they ask about other substances, ask about routes of taking
drugs, harm minimisation and risk associated with injecting.

GHB

General information:

GHB is a short-chain fatty acid endogenously produced in the CNS which acts as a precursor
and metabolite of gamma aminobutyric acid (GABA) (inhibitory neurotransmitter). GHB
(Gamma hydroxyl butyrate) was first synthesized in the late 1800s as a general anesthetic,
hypnotic and treatment of depression. It has recently become more popular in the rave
scene, due to its euphoric effects. It is also known as G, Gina, Liquid E and Liquid ecstasy,
and is frequently used alone or in combination with other drugs for chemsex parties. It has
also been used as a date rape drug as it is colourless, tasteless and odorless. It was
classified as a Class C drug in the UK in 2003. The precursor of GHB, gammabutyrolactone
(GBL) has similar properties as GHB and is increasingly being misused. GBL is commonly
sold as an organic solvent for industrial cleaning use.

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Actions:

GHB is rapidly absorbed from the GI tract reaching peak plasma concentration in 20-90
minutes after ingestion. GBL is more lipophilic and more rapidly absorbed resulting in
faster action, compared to GHB. Effects of the drug can occur within 15-30 minutes and last
1-6 hours depending on the dose. Small increases in dose can result in large changes in
behavioural effects and toxicity.

GHB has effects on glutamate and dopamine. It has biphasic clinical effects which can result
in a mixture of sedation and stimulant like effects.

Dependence syndrome:

Users who consume the drug at regular intervals are at high risk of dependence. Tolerance
to the drug can start quickly (within 1 week to 6 months) in those who use regularly.
Patients who are GHB dependent usually use between 10-58g/day in divided doses (often
once every 1-3 hours). Recreational users tend to take exact measurements in mL, those
who are dependent will just take a sip from a bottle when they need their next dose.

Factors associated with dependence are: sleep disorders, psychiatric disorders (especially
anxiety and depression), borderline personality disorder.

Acute intoxication:

At low doses GHB cause reduced inhibitions, feelings of euphoria, and increased libido.
Higher doses can cause sedation, vomiting, dizziness and seizures.

Comatose state can occur with irregular and depressed respiration. If in an A&E setting
generally supportive therapy only is needed, although sometimes airway support can be
required, with ITU admission. Sometimes patients will develop withdrawal symptoms after
waking up from the coma.

It is important to be aware that HIV medications such as ritonavir can potentiate the
mechanism of GHB. Use of other CNS depressants such as alcohol also increases the risk of
sedation.

Withdrawal syndrome:

Abrupt cessation can result in severe withdrawal. Patients who dose at shorter intervals
(eg: every 2-3 hours) are at the highest risk. Withdrawal usually starts a few hours after the
last dose.

Symptoms include: tachycardia, irritability, restlessness, diaphoresis initially followed by

the later development of hallucinations, tremors, insomnia, confusion, nausea,
hypertension after 3-6 hours. After 12-48 hours seizures, confusion, hypervigilance can

20 | P a g e
occur. The life threatening complications are those of acute renal failure, rhabdomyolysis,
excited delirium, catatonic stupor and seizure.

Differentiating such presentations in A&E can be extremely challenging. Differential

diagnoses can include alcohol or benzodiazepine withdrawal, delirium (from other causes),
serotonin syndrome, neuroleptic malignant syndrome, or cocaine induced delirium. More
complicated still is that coma, confusion, psychosis and aggression can occur in both
intoxication and withdrawal, making diagnosis and management challenging.

Treatment of Withdrawal:

The mainstay of treatment is high dose benzodiazepines. This generally requires admission
to medical ward, intensive care or specialised addiction are setting. Doses of up to 300mg
diazepam total daily have been required.

Guidance for assessing patients who use GHB/GBL:

Ask about age at first consumption, current consumption (quantity, frequency, duration of
current levels, history of accidental overdose, setting of use, eg: chemsex), periods of
abstinence and how this was achieved.

Ask about previous withdrawal - tremors, anxiety, hallucinations, seizures, confusion,

whether hospital admission was required. Ask about other drugs, current social
circumstances.

High risk factors (suggesting need for monitoring in hospital):

Using more than 6g/day, history of severe withdrawal, co-dependence on other drugs.

References:

Kamal RM, van Noorden MS, Wannet W, Beurmanjer H, Dijkstra BA, Schellekens A.
Pharmacological treatment in γ-hydroxybutyrate (GHB) and γ-butyrolactone (GBL)
dependence: detoxification and relapse prevention. CNS drugs. 2017 Jan 1;31(1):51-
64.GHB/GBL Information Pack [Internet]. Dualdiagnosis.co.uk. 2019 [cited 17 March 2019].
Available
from:http://www.dualdiagnosis.co.uk/uploads/documents/originals/Manchester%20GHB
%20information%20pack%20(Final).pdf

21 | P a g e
Topic 5:

CASC LESSON 5
WEIGHT GAIN PSYCHOSOCIAL HISTORY AND MOTIVATION TO CHANGE
TASK: You are in your outpatient clinic. Your next patient is Mr. Robert Jones. Robert is a
46-year-old gentleman with a history of bipolar affective disorder. His key worker,
Stephen, who was concerned about Robert's weight, referred him to your clinic. You have
received results of blood tests from Robert's GP which show elevated triglycerides and
cholesterol. His blood pressure was 140/95. Robert's BMI places him in the obese range.
Take a psychosocial history to explore the factors surrounding Robert's weight gain and
assess his motivation to lose weight. Do not take a medical history.

CASE SYNOPSIS: You are Robert Jones. You are 46 years old and work in HR at a general
hospital. Your key worker, Stephen, referred you to the psychiatric outpatient clinic, as he
was concerned about your weight. You accept that you have put on weight and understand
Stephen's concerns. You will mention that you have gained 6kg in the last two months.
Around two months ago, you went to your GP because of your low mood. Your GP prescribed
mirtazapine 15mg (to take at night time) and this was increased to 30mg by your GP two
weeks ago as your symptoms hadn't really improved. For most of your life, you have been a
healthy weight (80kg). You now weigh 120kg. You used to play rugby up until two years ago
but sustained a knee injury, which meant you couldn't play anymore. At the moment, you do
not exercise. You have a history of bipolar affective disorder. You were diagnosed at the age
of 24. You are currently taking sodium valproate (1g twice a day) and have been for over
twenty years. Your mood was stable up until two months ago. Your self-esteem is low; you
feel unattractive because of your weight and shape, and this gets you down. As a result, you
comfort-eat junk food and watch TV box sets, which make you feel better in the short-term.
You are aware that your GP performed some blood tests recently and found your cholesterol
and lipid levels to be high. You are aware that this is likely due to your poor diet. Your blood
pressure was 140/95. You were told by your GP that your body mass index ('BMI') falls in
the obese range and you accept this. You have a family history of cardiovascular problems.
Your father died from an MI (myocardial infarction / 'heart attack') at the age of 61, when
you were 30 years old. Your paternal grandfather died aged 74 from a stroke. Your older
sister, Caroline, aged 53, suffers from angina. You smoke four cigarettes a day. Following
advice from your GP you were referred to a smoking cessation service and cut down about
two months ago. You had previously smoked 10 cigarettes a day for 2 years. You admit that
your diet is not great. You eat a lot of unhealthy food, including sweets, fizzy drinks,
chocolate, take-away meals (burgers, pizza, curries). You drink alcohol on a daily basis.
Before your most recent episode of depression, you would go to the pub with friends and
drink two to three pints of lager. At present, you have stopped going out and only drink at
home (two or three cans of lager on most nights). You do not and have never used
recreational drugs.

You accept you do not follow a healthy lifestyle. You work in an office and spend most of the
day sitting at your computer. A colleague of yours went off sick about three months ago. Your

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workload has increased as you have taken on their work. You are open to advice given to
you by the doctor, to include smoking cessation, cutting down alcohol, a referral to the
dietician, exercise and for your GP to review you medically. He or she may mention that your
GP may wish to prescribe a medication to manage your high cholesterol (statin).

Topic: WEIGHT GAIN HISTORY WITH PSYCHOSOCIAL FACTORS AND MOTIVATION TO

CHANGE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicits timeline of weight gain

Elicits relevant recent history

(commencement of mirtazapine
following depressive episode). Elicit
biological and psychological symptoms
of depression

Elicits other causative factors of weight

gain and unhealthy lifestyle (lack of
exercise, poor diet, sedentary lifestyle,
smoking, alcohol).

Elicits impact of weight gain on life and

vice-versa (work, relationships and
friendships)
Elicits family history (including
cardiovascular illness, diabetes)

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 Ascertains patient's understanding of
risk factors for cardiovascular disease
and diabetes and the consequences for
not managing these
Assesses patient's motivation to
change. Elicits patient's recognition of
the problem and desire to change.
Communicates management options to
patient and assesses whether patient is
agreeable to this.

(Smoking cessation, cutting down

alcohol consumption, diet modification,
exercise

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
8 Limited or Incomplete management plan, Does not develop an adequate
awareness of management of risk

24 | P a g e
WEIGHT GAIN- PSYCHOSOCIAL HISTORY AND MOTIVATION TO CHANGE:

• This station assesses a candidate's ability to conduct a psychosocial history of a

patient (with bipolar affective disorder) who has gained weight and to assess the
patient's motivation to change

• Candidates should explain the purpose of the interview and be able to engage the
patient.

• Candidates should elicit the patient's weight gain history, and identify that weight
gain has been a problem for two years.

• Candidates should identify that the patient has had a relapse of depression

• Candidates should elicit that the patient was treated for his depression by his GP
two months ago. Good candidates will elicit that the patient was prescribed
mirtazapine, which can contribute to weight gain through increased food cravings.

• Candidate should elicit the following; the patient's mental state had been stable
for years (on sodium valproate); he was previously very active (played rugby avidly
for a hobby) however due to a knee-injury, he no longer plays; this led to a
worsening of his mood during which he comfort-ate; in the last two months his
depressive symptoms (low mood, loss of pleasure, feeling tired, poor sleep, difficulty
concentrating at work and low self-confidence) became worse likely exacerbated by
the stress he has experienced at work.

• Symptoms of depression (ICD 10) include the following:

o Persistent sadness or low mood and/or loss of interest or pleasure, fatigue or

low energy (at least one of these, most days, most of the time for 2 weeks)

• Associated symptoms of depression (ICD 10):

o Disturbed sleep, poor concentration or indecisiveness, low self-confidence,

poor or increased appetite, suicidal thoughts or acts, agitation or slowing of
movements, guilt or self blame

• Candidates should elicit that the patient has low self-confidence. Eating junk food
and watching TV box sets make him feel good in the short-term. Ultimately,
however, he feels unattractive and down about his appearance.

• Good candidates will enquire into whether the patient is displaying any risks.
They will ask whether the patient has felt worthless and / or had thoughts of
hurting themselves or ending their lives. Good candidates will also briefly screen for
psychotic symptoms (e.g. delusional beliefs, hallucinations).

25 | P a g e
 • Good candidates will ask the patient whether they understand the risks that
weight gain and other risk factors stated, have on their health (increased risk of
cardiovascular diseases, diabetes) and whether they are aware of the consequences
if risk factors go unmanaged.

• Good candidates will ascertain whether the patient is willing to lose weight and
address other risk factors (smoking cessation, cutting down alcohol consumption,
diet modification, exercise). Good candidates will discuss possible options of
management for these risk factors and check whether patient is agreeable to engage
in these interventions.

26 | P a g e
Topic 6:

CASC LESSON 5
DISSOCIATIVE STUPOR
TASK: Mrs Emma Graves is a 45-year-old woman whose 18-year-old daughter, Annie, has
been admitted to her local hospital after collapsing in the street yesterday afternoon. Annie
has been admitted to the acute medical unit for assessment and has been fully investigated
but no organic cause has been found. She is presenting as entirely unresponsive and not
accepting any food or drink. Please take a brief history from Mrs Graves and explain her
daughter's likely diagnosis.

CASE SYNOPSIS: You are Mrs Emma Graves and have come to your local hospital after
your daughter, Annie, collapsed in the street yesterday. Your first concern is for Annie's
wellbeing and you want to know what has happened to her and how she can get
better. You are worried by the fact she is still not responding to anything despite all the
investigations coming back as showing no physical cause. You saw Annie in the morning
yesterday as she headed off to college as usual. You were alerted to her being in hospital by
one of her friends who was walking home with her after college. She reported that they
were in a group and talking together with Annie joining in most of the way. She then
abruptly collapsed on the pavement and fell onto a grassy area next to it and then just lay
there. You came to the hospital as soon as you could and found her in the medical
assessment unit. She has had an urgent MRI and EEG with no problems being found. Her
blood tests are also fine. You have stayed with her all night and she has not moved or
accepted any food or drink, despite you trying to get her to take them. She doesn't seem to
respond to anything anyone else does or says. You will volunteer that Annie has seemed
unsettled recently as your brother-in-law, Annie's uncle, whose name is Mark, has recently
been arrested for possession of child pornography and is under investigation for other
offences, although you do not know what these are. The family all found out a week ago
after your sister, Jane, phoned you in a panic as the police had unexpectedly raided their
property and confiscated various electronic devices. Mark has gone to stay with his
parents as he and Jane have 13 and 16-year-old daughters together and he is not permitted
in the same house as them while the investigation is ongoing. No-one in the family is sure
of what to think about the situation but Annie has seemed more affected by it than the rest
of the family. Annie has seemed more withdrawn and has shown less interest in her
college courses since the news broke. You want to know the answers to the following
questions, asking at appropriate times:
• What is wrong with Annie?
• What does it mean that the investigations do not show anything?
• If it is psychological, can she snap out of it?
• Does this mean that Mark did something to her?
• How can I help her get better?

27 | P a g e
 • What treatment does she need?
• What needs to happen now?
Topic: DISSOCIATIVE STUPOR

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit brief collateral history around the
circumstances of the collapse and
investigations since

Elicit history around patient's previous

history and recent stresses around her
uncle's arrest, including her response to it
Communicate likely diagnosis of a
dissociative stupor and explain its meaning
Explain that her presentation is likely linked
to the recent news around her uncle's arrest
Respond sensitively to the relative's
questions

(Handle the inevitable question of whether

the patient was abused by her uncle. They
may choose to acknowledge this possibility
or state that this will have to be explored in
future but it may well not have occurred)
Explain likely prognosis and treatment -
Good outcome, treatment of underlying
illness, addressing stress

28 | P a g e
 Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate awareness of management of risk

DISSOCIATIVE STUPOR
• This station tests a candidate's ability to identify a likely dissociative stupor, a
potential precipitating stressor and examine the diagnosis to a worried relative.
• Candidates should elicit a history of the collapse and any associated
symptoms. They should ask about any odd movements, incontinence or injuries
arising from or after the collapse and any symptoms since. They should elicit that
the patient continues to be unresponsive following the collapse.

29 | P a g e
 • Candidates should determine which investigations the patient has had and that
they showed no physical cause for the symptoms.
• Candidates should elicit a history of the recent stressor in terms of the arrest of
the patient's uncle and the allegations of child pornography. Candidates should gain
an understanding of how the patient responded to this event prior to the collapse.
• Good candidates may elicit information about the patient's contact with her uncle
during childhood and how close their relationship was.
• Candidates should elicit a history of the patient's previous mental health
difficulties and any relevant family history.
• Candidates should sensitively explain the potential diagnosis of dissociative
stupor and the factors leading to this conclusion, such as: lack of physical
explanation for such a collapse, investigations showing no abnormalities, recent
acute stressor, evidence of recent stress, ongoing symptoms of stupor.
• Candidates should explain that the symptoms should gradually remit over days to
weeks although it is unclear how long this will take. Any underlying mental illness
can then be addressed. The causative stressor of her uncle's arrest will have to be
discussed with the patient in due course and she may benefit from some
psychological intervention.
• Candidates should sensitively handle the inevitable question of whether the
patient was abused by her uncle. They may choose to acknowledge this possibility
or state that this will have to be explored in future but it may well not have
occurred. Poor candidates will not answer directly or try to avoid the question.
• Candidates should explain that general support from the family would be most
beneficial. Good candidates will caveat this by advising the relative not to collude
with the dissociative symptoms and treat the patient as normally as possible under
the circumstances.
• Candidates should explain that the patient may need to be cared for in a physical
health hospital if she cannot accept any oral fluid or nutrition as it may not be
possible to deliver intravenous fluid in a psychiatric hospital. Depending on how
she progresses, she could need admission to a psychiatric unit. She will remain
under review for the time being.
• Good candidates will advise that they will keep the family updated regarding
plans.

30 | P a g e
Lesson 6:

TOPIC 1: NEUROLEPTIC MALIGNANT SYNDROME

TOPIC 2: HYPERPROLACTINAEMIA
TOPIC 3: LITHIUM AUGMENTATION
(ANTIDEPRESSANTS)-DISCUSSION
TOPIC 4: ELECTROCONVULSIVE THERAPY- DISCUSSION
TOPIC 5: SODIUM VALPROATE & EFFECTS ON
PREGNANCY
TOPIC 6: ADHD- MANAGEMENT

1|Page
Topic 1:

CASC LESSON 6
NEUROLEPTIC MALIGNANT SYNDROME
TASK:

Mr Francis Green is an 18-year-old man who was admitted to the ward six days ago with a
diagnosis of first episode psychosis. He was stared on Haloperidol 5 mg thrice a day 3 days
ago. He became agitated on the ward, wanting to leave. He was given 10 mg of Haloperidol
intramuscularly on two occasions, as part of rapid tranquillisation. Blood taken on
admission were normal. The nursing staffs have noticed he has become unwell.

Vital Signs are given below;

• Temperature- 41 C

• Pulse rate- 104/ mt

• Blood pressure- 140/90

• Respiration- 22 per minute

Blood investigations were sent again

• WCC- 14000

• CK-1024 IU/L (38-174 IU/L)

• AST- 44 (14-20 U/L)

• ALT- 82 (10-40 U/L)

Other blood parameters are normal. Urinalysis- normal. On examination, there is also some
muscle stiffness. Talk to the father of this patient to explain the cause of this presentation
and devise a management plan. Address his concerns, ideas and expectations. Do not take
history.

2|Page
Case Synopsis:

Your son was admitted to the ward six days ago with a diagnosis of first episode psychosis.
He was started on Haloperidol, 3 days ago. The nursing staff has noticed he has become
physically unwell. The doctor has come to talk to you about why she is presenting this way.
Suggested prompt questions;

• Is this an allergic reaction to her medication?

• Does it show up anything on blood tests?

• Is it dangerous? How dangerous is it?

• What will happen to her now?

• How are you going to treat it?

• Can she get it back again after treatment?

• How are you going to treat her psychosis in the future?

NEUROLEPTIC MALIGNANT SYNDROME

A rare, life-threatening, idiosyncratic reaction to antipsychotic medication

Signs and symptoms

• Symptoms: Fever, diaphoresis, rigidity, confusion, fluctuating consciousness, fluctuating

blood pressure, tachycardia

• Signs: Elevated creatinine kinase, leucocytosis, and altered liver function tests.

Course May last 7-10 days after stopping oral antipsychotics and up to 21 days after depot
antipsychotics (e.g. fluphenazine).

3|Page
Risk factors

• High potency typical antipsychotic drugs

• Recent or rapid dose increase of antipsychotics

• Rapid dose reduction

• Abrupt withdrawal of anticholinergic drugs

• Psychosis, organic brain disease, alcoholism, Parkinson's disease

• Hyperthyroidism

• Agitation

• Dehydration.

Morbidity: Rhabdomyolysis, renal failure, aspiration pneumonia, , seizures, respiratory

failure, arrhythmias, DIC, worsening of primary psychiatric disorder (due to withdrawal of
antipsychotics).

Investigations

• Blood tests include: FBC, Blood cultures, LFTs, U&Es, calcium and phosphate levels,
serum CK, ABGs, coagulation studies

a.Creatinine phosphokinase (CK) - elevated

b.Arterial blood gases (looking for metabolic acidosis)

c.Coagulation screen

d.Serum iron (has been reported to be low)

4|Page
• EEG: Non-focal generalised slowing on electroencephalography, consistent with
encephalopathy, has been reported in over half of NMS cases

• CTscan

• Lumbarpuncture.

Cerebrospinal fluid examinations, sepsis evaluation, brain-imaging studies are negative in

NMS, and allow for the exclusion of other causes of fever and neurological deterioration.

Management

N.B. If diagnosed in a psychiatric setting, transfer patient to acute medical services where
intensive monitoring and treatment are available

In the psychiatric unit:

a.Withdraw antipsychotics (offending drug)

b.Monitor temperature, pulse, BP.

c. Possible transfer to the medical unit if patient shows evidence of further deterioration in
his/her physical health status.

In themedical unit:

• Rehydration.

• Supportive measures-Oxygen, correct volume depletion and hypotension with IV fluids,

reduce the temperature using cooling blankets, antipyretics

• Sedation with benzodiazepines which are useful in reversing catatonia, are easy to
administer, and can be tried initially in most cases.

• 1st line pharmacotherapy to reduce rigidity: Dantrolenesodium appears to be

beneficial in cases of NMS involving significant rigidity and hyperthermia. It has been
beneficial in rapidly reducing extreme temperature elevations in many cases.

5|Page
• 2ndline pharmacotherapy to reduce rigidity: Trials
of bromocriptine, amantadine, or other dopamine agonists may be tried in patients
with moderate symptoms of NMS. L-dopa and carbamazepine have also been used.

• 3rd line-ECT, Consider ECT for treatment after other interventions have failed.

• Rhabdomyolysis: vigorous hydration and alkalisation of the urine suing IV sodium

bicarbonate to prevent renal failure.

• Artificialventilation if required.

Restarting

• Antipsychotic treatment will be required in most instances and 'antipsychotics

rechallenge' is associated with acceptable risk.

• Stop antipsychotics for at least 5-7 days, preferably longer.

• Allow time for symptoms and signs to resolve completely.

• Begin with very small dose and increase very slowly with close monitoring of
temperature, pulse and blood pressure.

• CK monitoring may be useful.

• Consider using an antipsychotic structurally unrelated to that associated with NMS or

a drug with low dopamine affinity (quetiapine or clozapine).

• Avoid depots and high potency conventional antipsychotics for the future.

ECT may be preferred

a.If NMS symptoms are refractory to other measures

b.In patients with prominent catatonic features

c.In patients who develop a residual catatonic state or remain psychotic after NMS has
resolved.

6|Page
Mortality: 5-20% and death is usually due to respiratory failure, cardiovascular failure,
renal failure, myoglobinuria, arrthymias and disseminated intravascular coagulation.
However with good supportive care, prognosis is good.

Differential diagnosis:

• Malignant hyperthermia

• Lethal catatonia

• Meningitis/encephalitis

• Serotonergic syndrome

• Toxicity due to other drugs (amphetamines, cocaine etc)

• Septic shock

NMS vs. serotonin syndrome

NMS Serotonin syndrome

Dopamine antagonism and suspected Excess serotonin availability
hypothalamic mediated sympathetic
overdrive.
Onset subacute - days to weeks Sudden minutes to hours onset

Resolves in 2 weeks - depending on Resolves as soon as excess serotonin is

t1/2 of offending drug reduced - in 24 hours generally

No myoclonus Myoclonus prominent

Hypomania, not a feature Hypomania may be seen
Reflexes normal or absent Hyperreflexia seen
Rhabdomyolysis, resultant renal failure Muscle breakdown not common
and acidosis occur commonly

CPK elevation common; WBC also These laboratory abnormalities are less
elevated frequent in serotonin syndrome

7|Page
Topic:NEUROLEPTIC MALIGNANT SYNDROME- DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain Nature and causation of NMS

(Antipsychotic induced-Standard treatment

but unpredictable)
NMS-Extremely rare but serious effect of
medication
Explain clinical features of NMS
Discuss Investigations

Arrange urgent medical tests

Discuss treatment options

(Stop the offending drug, Transfer to a

medical unit)
Discuss Implications for future
management and

Antipsychotic rechallenge,

Involve patient in decision-making process.

Address concerns- Mortality rate

Discuss complications
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

8|Page
 Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Poor range of Symptomatology/psychopathology explained
Does not explained signs and symptoms competently
8 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
9 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

9|Page
Topic 2:

CASC LESSON 6
HYPERPROLACTINAEMIA
TASK: You are seeing Mrs. Sarah Green, a 34-year-old woman with a long-standing mental
illness of Schizophrenia for the last 4 years. She was on a drug called as 'Haloperidol depot
', which was given in the form of an injection for 2-3 years. She developed some stiffness in
her body and felt uncomfortable. The injection was stopped and she was started on oral
tables called as Risperidone, a year ago. She is feeling reasonably well on this medication.
The auditory hallucinations, which she had before have quietened in both frequency and
intensity. She doesn't have any abnormal beliefs. She felt dizzy in the mornings when she
first started taking the drug 'Risperidone' but not any more. She has noticed some breast
enlargement. She is concerned whether she is having a tumour in the breast or something,
which is not the case. She has noticed milk coming from both nipples, which is quite
embarrassing. This has happened quite a few times. She has very little libido or none at all.
She is not interested in sex any more these days. Her ex-boy friend was unhappy and he left
her 6 months ago. The doctor reviewed her mental state in his clinic. She had no menstrual
periods for last 8 months. She informed the doctor in the clinic appointment and he did
some blood tests. She had the coil inserted, a year ago. if Marina coil inserted could lead to
disturbance in menstrual cycles. The doctor arranged for blood test. Her serum prolactin
levels was 770 mIU/L. (Normal value is 0-530 mIU/l). Explain her results and address her
concerns.

Discuss management. Do not perform a mental state examination.

CASE SYNOPSIS: You're a 34-year-old woman diagnosed with Schizophrenia almost 4

years ago. You're on oral tables called as Risperidone for the last 12 months, which is
helping you. You have had no menstrual periods for 8 months You had the coil inserted, a
year ago (Marina coil). You've noticed some breast enlargement. You have noticed milk
coming from both nipples, which is quite embarrassing. You have very little libido or none
at all. The doctor is expected to discuss blood test results and explain the short and long
term side effects of raised prolactin levels. Check with the doctor for any long-term
complications of raised prolactin levels and also if Marina coil inserted could lead to
disturbance in menstrual cycles.

Topic:HYPERPROLACTINAEMIA- Discussion & Management

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

10 | P a g e
 * OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT
FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain the findings of blood test results
Prolactin- hormone made in the body
Inform that it is antipsychotic associated
Elicit clinical features of
hyperprolactinaemia
Discuss long-term side effects
Discuss Options-

Reducing dose/switch to other

antipsychotics
Allay anxiety and offer positive reassurance
Address concerns

Amenorrhoea- ? Possible with marina coil

inserted
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

11 | P a g e
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

Reading notes

Here are some good points from guidelines, worth bearing in mind when devising a
management plan

• Patients should have a baseline measure of prolactin when they take antipsychotics,
especially those antipsychotics known to be associated with raised prolactin such as
Riperidone and Amisulpride.

• At 3 months, patients should be checked for prolactin related symptoms like

amenorrhea and sexual dysfunction.

• If prolactin is high and patient is symptomatic, then switch to antipsychotic which are
less likely to cause raised prolactin like Aripiprazole , olanzapine, quetiapine etc

• If prolactin level is high and patient is Asymptomatic, there are 2 options

• Option A. Continue on it with a joint decision made with the patient and perform
annual monitoring of prolactin levels.

• Option B. Switch to another antipsychotic with less propensity to cause

hyperprolactinaemia.

• Hyperprolactinaemia and related symptoms are reported to improve fairly promptly

following the addition of Aripiprazole.

12 | P a g e
 • Finally, it is good to bear in mind that long term use of prolactin elevating drugs in
young women is known to increase the risk of decreased bone mineral density leading
to osteoporosis and increased risk of breast cancer.

Mechanism: Antipsychotic are dopamine antagonists. Dopamine inhibits prolactin release

and so antipsychotics can increase prolactin levels. Hyperprolactinemia is caused by
blocking of D2 receptors on anterior-pituitary mammotrophic cells that normally are
tonically inhibited by dopamine produced in the hypothalamic arcuate nucleus.

PET studies have indicated that 60%-80% occupation of D2 receptors is associated with
antipsychotic efficacy. Higher occupancy levels are associated with an increased risk
of hyperprolactinemia from the blocking of D2 receptors on anterior pituitary
mammotrophic cells that normally are tonically inhibited by dopamine produced in the
hypothalamic arcuate nucleus

Elevation of prolactin and their adverse consequences

• Menstrual disturbances leading to amenorrhoea

• Breast growth and galactorrohoea

• Loss of libido and sexual dysfunction

Hyperprolactinaemia can result in loss of sexual arousal and erectile dysfunction in men;
amenorrhoea, reduced sexual desire and hirsutism in women. Antipsychotics reduce sexual
performance both directly by reducing dopaminergic transmission and indirectly through
inducing hyperprolactinaemia. 43% of those taking antipsychotics report sexual
dysfunction at some point, not all of this attributable to the drug.

Long-term adverse consequences

• Reductions in bone mineral density leading to osteoporosis

• Possible increase in the risk of breast cancer

Serum prolactin levels Suggested

Management
1 Men 0-20 ng/ml Normal Continue medication if
within this range
(0-424 mIU/l) Normal
Continue medication if
Women 0-25 ng/ml (0- within this range
530 mIU/l)

13 | P a g e
 2 25-100 ng/ml Need for retest Switch to non prolactin
elevating drug
(530-2120 mIU/l)
Monitor levels every 6
months.
3 > 150 ng/ml Rule out Need referral to neuro-
prolactinoma surgeon
(> 3180 mIU/l)

(Ref: The Maudlsey prescribing guidelines-10th edition; pg 83-85)

Treatment Options

1. Switchto non-prolactin elevating drug. The antipsychotics, which are usually not
associated with hyperprolactinaemia includes Aripiprazole, Olanzapine, Quetiapine
and Clozapine. When switching, symptoms tend to resolve slowly. (This is the
preferred option for most clinicians)

2. AddAripiprazole to existing treatment. Symptoms are reported to improve fairly

following the addition of Aripiprazole. (Shim et al, Lorenz RA et al, Lu ML et al)

3. Addition of dopamine agonists like dopamine and bromocriptine could be tried but
they have the potential to worsen psychosis.

PS: Please note that insertion of coil could lead to disturbance in menstrual cycles including
amenorrhoea after few months. However, serum prolactin levels won't be raised and
patient may not have other symptoms, suggestive of hyperprolactinaemia.

14 | P a g e
Topic 3:

CASC LESSON 6
LITHIUM AUGMENTATION-DISCUSSION
TASK:You are seeing a 34-year-old woman suffering from recurrent depressive disorder.
Her case was discussed at the ward round and it was decided to commence her on Lithium
carbonate for augmentation of her antidepressant. She is already taking amitriptyline 150
mg/day for last 6 weeks with minimal improvement. Discuss commencing Lithium with
her. Explain rationale, practicalities, side effects and answer any questions she has. Do not
take history.
CASE SYNOPSIS

LITHIUM AUGMENTATION & DISCUSSION

You're a 34-year-old woman, currently an inpatient suffering depression. This is the third
episode of depression you've had in the past 3 years. Your case was discussed at the ward
round and it was decided to recommend a further tablet be added to your prescription -
lithium (you are already taking amitriptyline with minimal improvement). Suggested
prompt questions;

• I have heard it is used for manic-depressives? Why is it given to me?

• What are the side effects of this drug?

• Should I have any tests before starting lithium treatment?

• I am worried as my father died of renal failure.

• Well I am not getting younger and I wanted to start a family. Can I take lithium when I
am pregnant?

• Is it true that Lithium can damage the growing baby in the womb?

• I heard it could cause toxic reactions in your body?

Topic: LITHIUM AUGMENTATION-DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

15 | P a g e
Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain the rationale behind Augmentation
Initial screening tests prior to commencing
treatment

Describe the monitoring process

Discuss Short term side effects (GI effects-
nausea, diarrhoea

(Polyuria, polydipsia, fine tremors, bad

metallic taste)
Discuss Long term side effects

(Weight gain, Hypothyroidism and renal

impairment)
Explain Warning Signs of Lithium toxicity

When and how to stop it?

Address concerns about Renal impairment
Address concerns regarding
suicidality- suicide prevention effect
Discuss effect of Lithium on pregnancy and
baby

(Congenital anomalies, miscarriages,

Ebsteins
anomaly)

Warn- Breast-feeding not indicated

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

16 | P a g e
 (Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk

LITHIUM TREATMENT

• Lithium is a mood stabiliser. It is used in treating and controlling mood disorders like
depression and mania, especially when they keep coming back. It is also used to increase
the effect of antidepressant drugs when these are not working enough on their own.
Lithium tends to lead to fewer manic and depressive episodes or to their disappearance.

17 | P a g e
 • Lithium is a substance, which occurs naturally in food and water. Small amounts can
therefore be found in the body.

• Initiation: Before beginning lithium therapy, your doctor will need some information
that includes your medical history including heart disease, thyroid disease, kidney
disease, psoriasis or epilepsy or any history of mental health problems in your family,
especially mania or depression. Also tell your doctor about any medications you are
taking, especially diuretic medications (water pills used to treat high blood pressure),
drugs used for asthma, painkillers, steroids and antidepressants.

• It may be necessary for you to undergo a number of tests to ensure that the medication
can be used safely, and these include Kidney function test, thyroid function test and ECG

• Blood tests: Once you have begun treatment, it will also be necessary to have regular
blood tests (sometimes called 'a lithium level', a 'serum lithium level' or a 'plasma
lithium level'). This test is important because it enables the doctor to monitor the
amount of lithium in the bloodstream, and therefore ensures that your dosage is both
effective and safe. Doses are adjusted to keep the blood level within the range of 0.4 and
1.0 m mol per litre, which is considered to be the appropriate therapeutic range to
maximise benefits and minimise side effects.

• Monitoring: Blood tests are needed more often in the early stages of treatment or
when your dosage is adjusted. In these circumstances, they may be needed at least once
a week. Once serum levels have stabilised, they will be needed only once a month and
even less frequently later. As a rough guide, blood tests should be done at least every
three months once serum levels have stabilised.

• Caution: It is important to make sure that the body is provided with proper amounts of
salt and water is a very important part of lithium therapy. It is important to maintain salt
and water balance and also to avoid excessive loss of both water and salt.

• Side-effects: Like other drugs, lithium may cause adverse effects. Some are relatively
mild and occur during the initial adjustment period. These can happen in the first few
weeks after starting lithium treatment. Some of the early adverse effects may include
Feeling thirsty, Passing more urine than usual, Blurred vision, Dry mouth, Bad metallic
taste in the mouth, Slight muscle weakness, Occasional loose stools and Fine trembling
of the hands

• Some of the long-term side effects are excessive weight gain, Changes in kidney
functioning, which may lead to damage, Reduced thyroid activity, shaky hands and skin
rash.

• If the level of lithium in your blood is too high, you will experience Persistent
diarrhoea, severe nausea/vomiting, severe hand tremors, Blurred vision, Slurred speech,
Lack of co-ordination, Confusion and Frequent muscle twitching. In such conditions, it

18 | P a g e
 may be necessary to stop taking lithium temporarily until your physical health has
returned to normal.

• Response: This will vary from person to person. Depending on the course of your
condition lithium may prove necessary to prevent episodes of mania or depression for
the rest of your life.

• It doesn't always work. Some people do not respond to lithium therapy and others
cannot tolerate it. Some may respond only partially, and may experience reduced or less
severe episodes of depression and mania. It may take six months to a year to achieve a
full effect as a preventive treatment.

• What should I do if I forget to take a dose?: Start again as soon as you remember unless
it is almost time for your next dose, then go on as before. Do not try to catch up by taking
two or more doses at once, as you may experience more side-effects and toxicity. If you
have problems remembering your doses (as many people do) ask your pharmacist,
doctor, or nurse about this. There are special packs, boxes, and devices available that can
be used to help you remember.

Lithium

• Detailed physical and neurological examination and arrange for appropriate

investigation: - (Pre - lithium treatment work up)-FBC, U&E, TFT, ECG, Renal
function tests.

• Discuss with the patient about the therapeutic effects, side effect profile and
discontinuation effects & also involve the family.

Monitoring -

• Start at 400 mg once daily, check plasma level after 5-7 days, 12 hours after dose,
then check plasma level every week until the required therapeutic level is reached
(0.4- 0.6 m mol/L for recurrent depression).

• Once stable, check, level once every 3-6 months, check renal function test & thyroid
function test and ECG every 6 months.

• Provide the patient with lithium card, which should be, carried the entire time and
also provide patients information leaflet. (Basic information about lithium and how
to minimize the risk of toxicity).

Side - effects: - Nausea, Metallic taste, diarrhoea, polyuria, polydipsia, Tremor, muscular
weakness.

19 | P a g e
Long Term side effects: Weight gain, hypothyroidism, impaired kidney function & rarely
renal failure, exacerbation of acne, ECG changes, diabetes insipidus (SIADH)

Lithium Toxicity: - Levels >1.5 m mol/L,

Vomiting, Diarrhoea, muscles weakness, drowsiness, coarse tremor, dysarthria ataxia,

restlessness, muscle twitching, seizures and death.

Prevention of lithium toxicity:

• Ensure the importance of maintaining an adequate fluid balance.

• Stop lithium immediately if toxicity suspected and need to contact the GP if there
is Vomiting, Diarrhoea, Fever, and infection

• Avoid over exercise, sunbathing, and salt free diet & avoid dietary changes).

Interactions - Diuretics, NSAIDS, Haloperidol, ACE inhibitors, SSRIS, Carbamazepine and

alcohol.

Women of childbearing age - should be advised to use reliable contraception.

Maintenance treatment - 2-3 years (minimum) to be reviewed regularly, and the risk of
relapse may be reduced by decreasing the dose of lithium very gradually (over a period of
one month).

Adverse effects of Lithium therapy

Renal

Thirst, polyuria, polydipsia

Impaired renal tubular function

Impaired glomerular filtration rate

Gastrointestinal symptoms

Nausea

Diarrhoea
Weight gain
Nervous system

Mild impairment of attention & memory

20 | P a g e
 Tremor
Skin

Precipitates or worsens disorder (eczema, psoriasis)

Cardiac

T-wave flattening/inversion of ECG in 30% of patients

Thyroid

Hypothyroidism and non-toxic goitre (5%)

Transient hyperthyroidism
Haematological

Leucocytosis

Ref: Fundamentals of clinical psychopharmacology/3rd edition- Pg 84-85

What is a mood stabiliser?

There is no clear definition for a mood stabiliser. Antiepileptics and lithium are commonly
called as mood stabilisers. Bauer et al proposed thatan agent be considered a mood
stabilizer if it has efficacyin each of four distinct uses: 1) treatment of acute manic
symptoms,2) treatment of acute depressive symptoms, 3) prevention ofmanic symptoms,
and 4) prevention of depressive symptoms. According to their analysis only lithium was
eligible to be called a mood stabiliser.

Suicide prevention:

For hospital admitted patients, the suicide risk is around 10% over long-term follow-up.
Based on naturalistic comparison of patient cohorts, the findings from different centres

Consistently report that lithium could have a suicide prevention effect. The treatment effect
is very large for this finding. (Geddes 2003).

Lithium and pregnancy

1. 1 in 10 chance of having a malformation if lithium is continued through first

trimester.

2. The UK National Teratology InformationService have concluded that lithium

increases the risk of alltypes of malformation of approximately three-fold and witha

21 | P a g e
 weighting towards cardiac malformations of around eight-fold (Williams & Oke,
2000)

3. Ebstein's anomaly-Relative risk compared to general population-10-20times higher,

but the absolute risk is low at 1:1000. (Absolute spontaneous risk of Ebstein's is 1 in
20,000. Cohen et al., JAMA 1994;271:146-150) (9.5 is the closest answer for the
question that appeared in March 2008)

4. Maximum risk is at 2-6 weeks after conception when many pregnancies are still
undiscovered.

5. Foetal toxicity-Hypotonia,
lethargy, poor reflexes, respiratory difficulties & Cardiac
arrhythmias. ( Note- these are reversible and do not cause later complication)

6. Important- Risk to mother andchild of lithium withdrawal might have been

underestimated and risk to foetus of lithium exposure might have been
overestimated.

7. Risk of relapse-up to 70% within 6 months, faster the discontinuation- higher the
risk of relapse.

8. The risk of relapse on discontinuation during pregnancy is same for

pregnant and
non-pregnant women. But among women with bipolar disorder who elect to
discontinuelithium therapy in the puerperium, the estimated risk of relapseis
threefold higher than for nonpregnant, nonpuerperal women.

22 | P a g e
Topic 4:

CASC LESSON 6
ELECTROCONVULSIVE THERAPY-DISCUSSION
TASK:

Mr. Smith has been treated with fluoxetine 40 mg daily for 6 weeks and then Venlafaxine
150 mg for 6 weeks, but has not improved. He is a 65-year-old inpatient suffering from
major depression. Medically he has a history of hypertension controlled by Ramipril and a
history of mild renal impairment. He appeared to comply with thesetreatments. Your
consultant has proposed that he be treated with ECT. He has very little knowledge about
ECT and is worried that it might make his memory worse.You are asked to give the patient
information about ECT with a view of assisting him in deciding whether he is willing to
agree to have the procedure. Address patient's beliefs, concerns and expectations about
treatment. You are not required to assess his capacity to consent treatment. You are not
required to obtain the patient's consent.

Case synopsis

You're a 65 year-old man suffering from a severe depressive illness and are an inpatient.
You were tried on fluoxetine and then venlafaxine. You have mild hypertension and are on
Lisinopril. You also have mild renal impairment. You are worried about ECT. Suggested
prompt questions to ask the doctor;

• Why do you think this treatment will work for me when the others haven't?

• How does it work?

• How many treatments will be necessary?

• What side effects are there?

• Does it cause memory problems

• Can anything be done to reduce memory problems?

• Are there other side effects- can it cause epilepsy and do people bite their tongue?

• Does it affect blood pressure?

23 | P a g e
TOPIC : ECT DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Basic description of ECT/

Cover the rationale of ECT in refractory

depression
Discuss the potential likelihood of treatment
being successful

Discuss Potential benefits, efficacy (8 out of

10 get better)
Discuss what the procedure of ECT entails
Number and duration of treatments (8-12
treatments/twice a week)
Discuss common Side-effects- immediate
and short term (Post-ECT)

(headache, vomiting, dizziness, slight

confusion, Muscle aches, memory loss)
Risk of death and major injuries- very low
Concerns

Memory loss-transient side effect, No long

term effect on memory

Unilateral ECT will be considered.

Check on physical health issues including
patients concern regarding hypertension
Give them adequate time to decide

Discuss Sources of information (Leaflets,

websites, talk to nurses etc)

24 | P a g e
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed

ECT COUNSELLING

• ECT stands for electro convulsive therapy. ECT is most commonly used to treat
severe depression not responding to drug treatment. In severe cases of depression,
ECT may be the best treatment and it can be life saving.

25 | P a g e
 • It is not a barbaric treatment. Due to the advances in the field of anaesthesia and
with modern equipment, ECT has become more sophisticated and you may not
experience any pain or suffering.

• The exact mechanism of how it works is not known. During ECT, a small amount
of electric current is passed across your brain. This current produces a fit/seizure,
which affects the entire brain including centres that control thinking, mood, appetite
and sleep. Repeated treatments alter the chemical imbalance in the brain and bring
them back to normal. This helps you begin to recover from your illness.

• An ECT treatment involves having an anaesthetic. The anaesthetist will ask you to
hold out your hands so you can be given an anaesthetic injection. It will make you go
to sleep and cause your muscles to relax completely. You will be given some oxygen
to breathe as you go off to sleep. Once you are fast asleep, a small amount of electric
current is passed across your head and this causes a mild fit/seizure in the brain.
There are little movements of your body because of the relaxant injection that the
anaesthetist gives.

• Over 8 out of 10 depressed patients who receive ECT respond well, making ECT
the most effective treatment for severe depression.

• A course of ECT involves 8 to 10 treatment sessions on an average and is usually

given twice a week.

• Some patients may be confused and get headaches just after they awaken from
the treatment, and this generally clears up within an hour or so. Sometimes your
memory of recent events may be upset and this memory loss goes away within a few
days or weeks. But ECT does not have any long-term effects on your memory or
your intelligence.

• ECT is amongst the safest medical treatments given under general anaesthesia;
the risk of death or serious injury with ECT is rare and occurs in about one in 50,000
treatments. This is much lower than that reported for childbirth. Very rarely deaths
do occur and these are usually because of heart problems.

• ECT consent form: At some stage before the treatments, we will ask you to sign a
consent form for ECT. If you sign the form it means that you are agreeing to have up
to a certain number of treatments (usually 6). You can refuse to have ECT and you
may withdraw your consent at any time, even before the first treatment has been
given. The consent form is not a legal document and does not commit you to have
the treatment. It is a record that an explanation has been given to you and that you
understand to your satisfaction what is going to happen to you. Withdrawal of your
consent to ECT will not in any way alter your right to continue treatment with the
best alternative methods available.

26 | P a g e
 • ECT usually works more quickly than medication. But with regard to medication,
we could try yet another antidepressant drug. However, you may have to wait for up
to 6 to 8 weeks to know whether the new drug is effective, and there is the
possibility of new side effects. Drug therapy also has risks and complications and
drug treatment is not necessarily safer than ECT.

• Concerns about memory loss; If there are serious concerns about memory
problems, instead of giving the electrical stimulus bilaterally across both temples,
we can give it unilaterally to just one side of the head.

ECT:Summary of the UK ECT review group meta-analysis:

• Real ECT was significantly more effective than simulated ECT.

• Treatment with ECT (both B/L and U/L) was significantly more effective than
pharmacotherapy (various drugs)

• Bilateral ECT was more effective than unipolar ECT. But greater cognitive
impairment was seen among patients treated with bilateral ECT.

• High electrical dose led to a larger effect especially in bilateral ECT, but the effect
was not significant.But patients treated with high-dose unilateral ECT took longer to
regain orientation.

• No significant difference in efficacy was seen between brief pulse and sinewave
ECT.

• Rose (2003; BMJ) analysed 35 studies of patient views about ECT; she reported
that nearly 1/3rd had significant memory loss. The British Journal of
Psychiatry (2008) 192: 476.

27 | P a g e
Topic 5:

CASC LESSON 6
SODIUM VALPROATE & EFFECTS ON PREGNANCY
TASK:

Mrs Donovan is a 32-year-old woman with a diagnosis of bipolar affective disorder. She is
currently well in her mental state. She has been referred to an outpatient clinic by her GP
as she has recently become pregnant and is currently taking Sodium Valproate at a dose of
1g at night. She is currently 7 weeks pregnant. She has been informed by her GP that the
medication may cause problems for the developing foetus, but she is not aware of what
these may be.

Please address her concerns, explain the relevant risks and discuss possible management
options. You do not need to perform a mental state examination.

CASE SYNOPSIS:

You are Mrs Donovan, a 32-year-old woman with a diagnosis of bipolar affective
disorder. You are currently mentally well. You have had two severe episodes of mania due
to the bipolar affective disorder. The first was 7 years ago and the second 5 years ago. You
have had to come into hospital under section on both occasions and had to remain there for
around 4 months each time. You were started on Sodium Valproate, a mood stabiliser,
during your second admission and this was effective and has kept you well since, without
significant side effects or breakthrough symptoms. This has enabled you to start a
successful career in advertising and find a long-term partner. You have recently
discovered that you are pregnant. However, your GP has informed you that your regular
medication, Sodium Valproate 1g at night, could cause development problems in your
baby. You remember something being mentioned when it was started 5 years ago but
cannot recall what it was. You are now very worried about this and want to find out about
the possible risks and what can be done. You want some particular questions answered,
including:

• What are the possible effects of Sodium Valproate on the baby? Are they physical
or mental as well?

• At what stage in pregnancy will the effects occur? You are aware from school that
different parts of the body develop at different times in the womb.

• What can be done to prevent these problems?

• Can we find out in advance if the baby is likely to have these problems?

• If not, when will we know?

28 | P a g e
The doctor may talk through the benefits and risks of staying on the Sodium Valproate or
stopping it in detail. The doctor may offer you options including remaining on Sodium
Valproate, changing to an alternative medication or having no medication. You do not have
to make a decision at this appointment

TOPIC: SODIUM VALPROATE & EFFECTS ON PREGNANCY

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Discuss risks of taking the medication
Discuss benefits of taking the medication
Possible effects of sodium valproate on the
baby

Physical & mental effects

Discuss prevention aspects

Folate supplementation
Identify teratogenic effects in early
pregnancy

Discuss Prenatal monitoring

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,

29 | P a g e
 Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
8 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
9 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
VALPROATE AND PREGNANCY

(Prepared by Dr Michael Rutherford, Consultant Psychiatrist)

• Sodium Valproate is an anticonvulsant medication that also works as a mood

stabiliser.

• Sodium Valproate is associated with a 1.5% risk of neural tube defects. This may
be attributed in part to its effect in reducing serum folate, itself thought to be
protective against neural tube defects.

• Other abnormalities include: hypospadias, heart defects, craniofacial and skeletal

anomalies. The reported rates of malformations, especially neural tube defects,
skeletal defects, hypospadias and heart defects, are higher in children of mothers
who took Sodium Valproate during pregnancy, especially at high doses, than in the
general population (5.7% vs. 1.5%, RR 4.1,95% CI 1.9-8.8).

• Exposure to Valproate in utero can have adverse effects on mental and physical
development of the exposed children. The risk seems to be dose-dependent but a
threshold dose below, which no risk exists, cannot be established based on available
data. The exact gestational period of risk for these effects is uncertain and the
possibility of a risk throughout the entire pregnancy cannot be excluded.

30 | P a g e
 • Studies in preschool children exposed in utero to Valproate show that up to 30-
40% experience delays in their early development such as talking and walking later,
lower intellectual abilities, poor language skills (speaking and understanding) and
memory problems.

• Valproate should not be prescribed to female children, female adolescents,

women of childbearing potential or pregnant women unless other treatments are
ineffective or not tolerated.

• Valproate treatment must be started and supervised by a doctor experienced in

managing epilepsy or bipolar disorder.

• The benefits of Valproate treatment must be carefully balanced against the risks
when prescribing for the first time, at routine treatment reviews, when a female
child reaches puberty and when a woman plans a pregnancy or becomes pregnant

• All female patients must be informed of and understand: the risks associated with
valproate during pregnancy; the need to use effective contraception; the need for
regular review of treatment; and the need to rapidly consult if she is planning a
pregnancy or becomes pregnant.

• If sodium valproate is to be used during pregnancy, the lowest effective dose is

recommended divided over the day or controlled-release tablets to avoid rapid
peaks in plasma level. NICE (Guideline CG192) suggests doses should be limited to a
maximum of 1 gram per day, administered in divided doses and in the slow release
form, with 5mg/day folic acid. However, it is not clear how the serum level of
valproate affects the risk of abnormalities.

• Folate supplementation should be started before pregnancy as appropriate. This

should be at a dose of 5mg daily if a woman is taking Valproate.

• Specialist prenatal monitoring should be instigated to detect possible occurrence

of neural tube defects or other malformations when Valproate has been used. This
will generally be organised by the obstetric services and involve frequent
ultrasound scans.

• Candidates should elicit the ideas and concerns of the patient regarding Valproate
therapy and respond to their queries in a sensitive and accurate manner.

• They should elicit sufficient information about her previous history to enable
them to discuss the options of future management with the patient.

• Candidates should clearly explain the risks and benefits of continuing Valproate,
stopping it or changing to an alternative medication.

31 | P a g e
 • They should offer the patient additional information, a further appointment or
referral to a Perinatal service if the patient is unsure about how to proceed.

32 | P a g e
Topic 6:

CASC LESSON 6
ADHD-MANAGEMENT
TASK:Abraham is a 6-year-old boy attending the CAMHS Clinic. His mother Mrs. Young is a
32-year-old lady attending the clinic with her son. The GP referred her son to the clinic, as
he remains hyperactive all the time and she is finding it difficult now to cope with him. She
works as a part-time medical secretary and have some medical background knowledge.

He's overactive constantly and this behaviour has escalated over the last year. At home,
he's fidgety and moving about all the time. She describes him to be 'overactive' and very
difficult to manage. He's unable to play quietly and continually interrupts. He doesn't listen
to your instructions and loses things for tasks. He can't sustain attention and is easily
distracted. Bedtime is especially difficult, as he stays up till midnight wanting to jump on
his bed. Teachers report that he gets up and runs about all the time, climbing desks and
disrupting other children. His task completion is poor, cannot organise and makes
mistakes with tasks that require attention. He has difficulty finishing school assignments on
time. His academic performance is poor. He appeared to be below most of his classmates in
his ability to recognize letters, numbers and shapes. Teachers are annoyed at him they
might expel him from the school.

He's the 2nd child with a younger sister Kate aged 4.. He had a normal birth and achieved
normal developmental milestones. Mrs young is 8 weeks pregnant now. She lives with her
husband and 2 children. You have taken history from the mother already and his diagnosis
is confirmed. Mr. Young is curious to know about the diagnosis and drugs available for the
treatment of her son's condition. She is worried about other siblings. Address her concerns
and allay her anxiety

CASE SYNOPSIS

Your child is very hyperactive and was seen by child psychiatrist. You wanted to discuss his
diagnosis with the doctor, who will explain that your child could be suffering from ADHD
(Attention deficit hyperactivity disorder). He has problems at home, school and with peers.

• I want to know what is wrong with my son. Please clarify his diagnosis?

• Is it not normal for a 6-year-old boy to be active?

• What causes ADHD in children?

• Are there any blood tests to confirm this condition?

• Is there any special diet that could help with his hyperactivity?

33 | P a g e
 • Do you give a stimulant?

• Does this medication make his sleep worse?

• What are the side effects of this medication?

• Can it affect his growth?

• Can it affect the liver?

• Is this hereditary? (Dad's brother had ADHD)

• I am 8 weeks pregnant now. Is my next child is going to be affected?

Topic: ADHD-DISCUSSION
Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain diagnosis of ADHD in simple terms
Explain nature of the condition and
aetiology
Methylphenidate- Mode of action and
efficacy, (Activates some parts of the brain
which is not working well)
Side effects (Short-term and long-term)

Duration of treatment,
Concerns- Blood tests to confirm diagnosis
Need for special diet

Avoid caffeinated, sweetened products

Concerns
Stimulant and its effect on sleep

Growth suppression
34 | P a g e
 Concerns -(Heritability- 2-3 times higher
risk in siblings)

? Affect unborn child

Concerns- ? Same as autism
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Poor range of Symptomatology/psychopathology explained
Does not explain signs and symptoms competently
7 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
8 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
9 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

ADHD- COUNSELLING & METHYLPHENIDATE TREATMENT

Explaining ADHD in simple terms

35 | P a g e
 • The term attention deficit hyperactivity disorder is used mainly in the USA. In UK,
the official term is hyperkinetic disorder.

• ADHD is a medical condition that is increasingly being recognized in the UK as a

cause of severe behavioural problems.

How can I tell if my child has ADHD?

• These children usually under 5-s are overactive, restless and excitable. They have
difficulty concentrating and have problems with attention control. They are easily
distracted and do not finish things. They are impulsive, suddenly doing things
without thinking first.

• Although this type of behaviour is not uncommon in children, it becomes a

problem when these characteristics are exaggerated, when compared to other
children of the same age.

• To make the diagnosis, significant symptoms from each category described below
have to be present in the child from a young age and must cause real and significant
problems affecting the quality of the child's life.

They include:

• Hyperactivity/over-activity

• Poor concentration/distractibility

• Impulsivity

What causes ADHD?

• We do not know the exact cause of this disorder

• The condition is due to a problem in the brain's regulation of attention,

concentration and activity levels. Its exact nature is unknown, though the part of the
brain affected seems to be the frontal lobes, involving a brain chemical called
dopamine.

• The condition also tends to run in families and genetic factors seem to play a part.
Boys are generally affected more than girls.

Other possible causative theories

• Brain trauma may be another cause, either following a difficult labour and birth
or through direct trauma to the brain tissue - for example following a head injury or
exposure to alcohol as a foetus.

36 | P a g e
 • Extreme deprivation or abuse in infants may also lead to irreversible
developmental changes that do not respond to being well cared for in later life.
How is ADHD diagnosed?

• This is no clear test for ADHD. There is no specific blood test or other
investigations for ADHD.

• A child psychiatrist or specialist paediatrician usually does the assessment and a

full diagnosis can be made.

Effect of diet on children

• There is some evidence about the effect of diet on children as some children may
be sensitive to certain foods and can become hyperactive on them. If parents notice
such changes with specific foods, it is best to avoid them.

• Some foods, such as those containing preservatives and additives, can make
ADHD worse or can cause similar symptoms in some children, and eliminating these
may be helpful. However, there is no evidence that these are the actual cause of
ADHD.
How serious is ADHD?

ADHD can have a devastating effect on a child's life if it is not diagnosed and treated. The
child is often in trouble and has difficulties at school, at home and with friendships. This all
undermines his self-esteem and motivation to succeed in life, and sometimes it can lead to
school failure, delinquency and criminality.

The secondary complications of ADHD, such as delinquency, criminality, school failure, low
self--esteem and associated mood problems, as well as poor peer relationships, are the
aspects of the condition that are most likely to determine a child's future

Treatment: Some medications such as methylphenidate may reduce hyperactivity and

improve concentration as well. It possibly could help children to think more clearly, to
understand things better and feel more in control of themselves.

How does it work?

The exact mechanism of action of stimulant medications is not clearly known and it
possibly seem to affect parts of the brain involved with paying attention and organising our
behaviour

The effect begins within 30-60 minutes of taking them. Longer acting preparations are also
available. However, the exact amount of dose will be adjusted by the specialist

37 | P a g e
Side effects:

• Common side effects would include reduced appetite and staying awake later
than usual.

• Less common side effects would include tics or twitches, drowsiness or dizziness,
headache, tummy aches and or feeling sick.

• For most children, medications may need to be continued for several years and
some may need medication as adults

• Specialist will monitor treatment regularly. Your GP should perform regular

health checkups and repeat prescriptions.

Other treatments

• However medications are used as one part of the treatment for ADHD.

• Effective treatment will include advice and support for the parents

• Practical ways of helping child to improve behaviour include praising good

behaviour, rewards for good behaviour, praising for efforts and achievements and
brief periods of time away from other when presenting with challenging behaviour.

• Parenting groups are very helpful in providing support between parents in a

similar situation; in educating parents about the condition and how to manage it;
and in giving those who do not have consistent parenting skills the necessary
techniques to make this possible.

• It is also important that the child has adequate help with learning in the
classroom from teachers and with controlling difficult behaviour

What is the long-term outcome?

Although ADHD may never entirely go away, the underlying symptoms do improve with
age. Currently a third of sufferers seem to outgrow the need for medication, a third don't
and a third are somewhere in between - using lower doses, for example, or taking it only
for particular situations such as exams.

If these are prevented early on with active treatment, the outcome can be very good.

Ref: www.rcpsych.ac.uk

The young mind- Prof Sue Bailey and Dr. Mike Shooter

38 | P a g e
39 | P a g e
Lesson 7:

TOPIC 1: ADULT ADHD- DISCUSSION

TOPIC 2: MANIA DISCUSSION AND MANAGEMENT
TOPIC 3: POSTNATAL ILLNESS-MANAGEMENT
TOPIC 4: CAPACITY ASSESSMENT & DISCUSSION-(REFUSING
TREATMENT) SUPPORT WORKER
TOPIC 5: INTELLECTUAL DISABILITY- STERILISATION AND CRY
FOR HELP
TOPIC 6: PRISONER WITH A HISTORY OF ASSAULT-DISCUSSION

1|Page
Topic 1:

CASC LESSON 7
ADULT ADHD- DISCUSSION
TASK :You are seeing Mr. Brian Cox, a 45-year-old man. He is a judo coach and he is
coaching Mr. Tom Foster, a 19-year-old man. Tom came to see the psychiatrist in the
outpatient clinic today, as he is in a difficult situation in terms of his career progression. He
has participated in many regional competitions, managed to win some good titles and he is
progressing well, under your coaching which you are proud to say. He is taking a drug
called as 'Ritalin' (generic name: Methylphenidate) as he has a diagnosis of ADHD since
aged 7. He has been on it for many years. Recently the Judo association told that he should
not participate in Judo competition because the drug Ritalin is considered as energy
enhancing under anti-doping rule stuff. Mr Cox want him to stop taking Ritalin and change
something it to something else. He ia aware that he was tried on a non-stimulant drug
called as Strattera (Generic name: Atomoxetine) when he was aged 16 and unfortunately
his symptoms became worse, had some problems in his liver and was put back on Ritalin.
Mr Cox is aware that he still has some residual symptoms of ADHD. He still tends to make
careless mistakes and do not follow instructions from coach properly. He has some
problems with concentration. He has trouble paying attention to tasks and could be easily
distracted. His mates say that he talks too much, interrupts while they talk and he doesn't
seem to have many friends. Sometimes, he still has trouble sitting still and has to do some
form of psysical activity. He can't remember much about his childhood. At School, he found
it very difficult to settle in class and teachers would complain that his behaviour was
disruptive. At home, Mum described him to be a live -wire. He was considered as accident
prone, as he was always jumping, running and climbing. He has a bad temper and is getting
into fights with other players. He becomes irritable for silly reasons. He was caught by the
police in M25 for reckless and dangerous driving. He Used cannabis frequently during
night-outs and parties. The doctor took some history to support his diagnosis of ADHD,
establish current problems and progress on treatment. In this station, you talk to his
manager and answer all his questions. Do not take collateral history.

CASE SYNOPSIS: You're a judo coach coaching this 19-year-old man who has participated
in many regional competitions and he's progressing well, under your guidance. He is taking
a drug called 'Ritalin' as he has a ADHD diagnosis since aged 7. Recently the Judo
association said he should not participate in Judo competition because the drug Ritalin is
considered as energy enhancing under anti-doping rules. Suggested prompt questions;

• Why do you think he has ADHD?

• What will happen if we stop Ritalin now?

• How about trying some non-stimulant drug for his ADHD?

2|Page
 • You would like him to start on Chinese medicine called Ricazoid, which has
proven to help calm one with too much energy.

You insist that Ritalin should be stopped with immediate effect, as it is a banned drug in
Judo. You should ask the doctor if he knew he takes ecstasy. In the end, you insist a
certificate issued to his player

Topic: ADULT ADHD- DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Discuss the findings of your assessment to
justify Adult ADHD

(Presence of residual symptoms- inattention,

hyperactivity and impulsivity)
Explain implications of stopping the
medication
Emphasise strongly- It is not advisable to
stop the drug
Address concerns- Complimentary
treatments (Not evidence based)
Discuss other medications and explain why
there are not appropriate
Acknowledge that the drug is banned but
could be used in people with ADHD
Role of methylphenidate in adult ADHD-
Gives them focus, not performance
enhancing, No specific advantage
Suggest to apply for a Medical Dispensation,
which can be granted by the individual
Governing Body
Supportive statements- Lot of people with
ADHD excel at sport it is essential to find out

3|Page
 all we can to ensure that the person is able to
continue to enjoy Sport and be able to
continue in something they are good at.
Risk of taking illicit drugs-Inform the
relevant person that they are not allowed to
take illicit drugs before any competitions
due to risk of eviction.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice

4|Page
 Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

Reading notes

Adult ADHD
Adult ADHD is a clinical diagnosis, and the clinician-administered interview remains the
cornerstone of diagnostic evaluation (Adler 2004).

Diagnostic assessment

• Assessment of adults is similar to that of children.

• The clinician must assess current (in the past 6 months) and childhood (before 7
years of age) symptoms in accordance with standard diagnostic criteria

Clinical manifestations of ADHD in adults

Some symptoms of childhood ADHD persist more than others into the adult form. Research
suggests that up to 66% of children will continue to have clinically significant symptoms in
adulthood (Barkley 2002).

Hyperactivity

If hyperactivity continues into adult life, its form differs from that in childhood.

• Fidgets with hands or feet- The symptom of 'nervousness' is often reported

(Miller 2002)

• Has trouble sitting still- Individuals may describe feelings of discomfort that are
relieved only with physical activity. There may be physical or verbal overactivity

• Feels restless and jittery- Individuals may find it very difficult to rest, moving
about excessively, squirming or fidgeting

• Often talk excessively

• Has trouble doing things quietly, either interrupting others

• Is a person who is 'on the go'

Their disruptive behaviour often creates great problems in social, family and occupational
situations.

Impulsivity

5|Page
 • Gets frustrated when having to wait for things

• Interrupts other people's conversations and not letting others express their views
which often undermines the quality of social interactions

• Acts before thinking things through- Problems may arise as a result of aggressive
driving, impulsive and injudicious spending, or starting multiple projects without
carrying them through to completion.

The inability to control frustration and poor academic performance despite average or above
average IQ is found in adult ADHD (Elliott 2002). A pattern of pleasure-seeking behaviours
and limited capacity to plan or assess their consequences is noted. Often their actions result
in forensic sequelae

Inattention

• Does not pay close attention to what he or she is doing and makes careless
mistakes

• Has trouble paying attention to tasks

• Has trouble following verbal instructions

• Starts things but does not finish them

• Has trouble getting organized

• Tries to avoid doing things that require a lot of concentration-watching TV or

reading

• Misplaces things

• Is easily distracted by other things going on

• Is forgetful

This often results in significant educational, occupational and interpersonal problems.

Comorbidity:

• Comorbidity is common, with estimates as high as 80%.

• The comorbidity for alcohol misuse is 32-52%; for other types of substance
misuse, including marijuana and cocaine, it is 8-32% (Goldstein 2002: p. 47).

6|Page
 • Dysthymia in particular is common in adults with ADHD.

• The National Comorbidity Survey Replication Study found that among individuals
diagnosed with depression, bipolar disorder or anxiety disorders, the rates of ADHD
were 32%, 21.2% and 9.5% respectively (Kessler 2006).

Ref: Raguraman Janakiraman and Tony Benning( Attention-deficit hyperactivity

disorder in adults; APT March 2010 16:96-104)

Helen Crimlisk (Developing integrated mental health services for adults with ADHD-
APT November 2011 17:461-469)

Steps in the diagnosis of ADHD in adults;

• Clinical interview to assess current ADHD symptoms (within the past 6 months)
Assess functional impairments at work, home and in relationships

• Developmental history and childhood history of ADHD symptoms- Adults may

have difficulty in accurately recalling childhood symptoms, therefore obtaining a
childhood history is an essential component of the assessment: self-report rating
scales and gathering information from school records/reports as objective evidence
of childhood onset is necessary.

• Rule out other psychiatric disorders or establish comorbid conditions

• Family history of mental health problems (e.g. ADHD, obsessive-compulsive

disorder, tics, learning difficulties, attention/concentration difficulties)- As ADHD is
highly familial, it is essential to look for a family psychiatric history of the disorder:
first-degree relatives might have difficulty with tics, drug use and criminal
behaviours.

• Complete physical examination (rule out head trauma, seizures, substance misuse,
hormonal problems)- A complete physical examination to rule out neurological and
hormonal problems is also an important part of the assessment.

• Rule out ongoing social stressors as generators of symptoms that mimic ADHD

• Neuropsychological assessments (e.g. attention, memory, intellectual functioning

and academic achievement). (Adapted from Weiss 2003)

• It is useful to obtain information from parents or siblings, aided by the use of

standardised rating scales. Cultural factors should be borne in mind when
diagnosing the disorder.

Rating scales for current behaviour and retrospective symptoms

7|Page
 • Wender Utah Rating Scale - retrospective and current symptoms

• Conners Adult ADHD Rating Scale

• Barkley's Current Symptoms Scale

Pharmacological interventions for ADHD

Pharmacological treatments proven to be efficacious in children appear to benefit adults.

First-line treatment

• The first line of treatment is with stimulant agents such as methylphenidate or

amfetamine salts.

• Methylphenidate dosing requires careful titration from lowest possible dose to

achieve best control of symptoms.

• Dexamfetamine can be started at a dose of 10 mg/day, and increased by 10

mg/day weekly up to a maximum of 45 mg/day.

• Atomoxetine was the first non-stimulant medication approved by the US Food

and Drug Administration (FDA) for the treatment of ADHD in both adults and
children. It is a highly specific nor-adrenaline reuptake inhibitor with minimal
affinity for serotonin and dopamine transporters and neuronal receptors.

About two-thirds of adults with ADHD who are given these medications show significant
improvement in their symptoms (Gadow 2001). Randomised placebo-controlled studies
have showed atomoxetine to be effective in the treatment of adult ADHD (Michelson 2003).

Second-line treatment

Second-line treatment includes imipramine, clonidine and, occasionally,

moclobemide. Supervision, behaviour modification, family intervention and support
possibly help to alleviate the symptoms of impulsivity and hyperactivity.

Drug regimens in adult ADHD

Generic name Dose range in adults (unlicensed) Precautions

Methylphenidate 5mg three times a day, increased to Monitor weight loss and
maximum of 100mg/day growth retardation

Monitor heart rate and

blood pressure

8|Page
 Monitor for tics
Atomoxetine 40mg once a day for 7 days, increased Liver function tests before
to 80-100mg once a day to a initiation of treatment if risk
maximum of 120mg/day under factors or alcohol misuse
supervision of specialist
Caution in those with
depression or liver
dysfunction
Dexamphetamine 5mg twice a day, increased to Monitor for weight loss and
maximum of 60mg/day growth retardation

Monitor heart rate and

blood pressure

Monitor for tics

METHYLPHENIDATE IN SPORTS

• Methylphenidate is on the list for Banned Substances in Sport and will show up on
any random drug test either during a competition or other random test during non-
competition time. This is according to the list available from the International Sports
and Olympics Sports Governing Bodies. These lists are used for all competitive
Sports and are taken as guidelines for all other Sports Governing Bodies.

• However any person who is prescribed Methylphenidate can apply for a Medical
Dispensation, which can be granted by the individual Governing Body. This means
that the person have to contact the Governing Body for the Sport in question and ask
their advice as to how to apply for a Medical Dispensation. This has to be applied for
before every competition and has to have medical evidence of need for use signed
by a consultant each time. The certificate of dispensation has to be taken to every
meeting and shown to the organisers before the start of any competition.

• In the UK the Governing Bodies for Sport are all individual at the present time but
there are moves to make this a more combined service in the near future and
therefore this should make things easier when applying for Medical Dispensations.
The main government body is aware of the concerns regarding this medication and
young people in sport who may have ADHD may be prevented from taking part in
Competitions due to the lack of awareness to the Banned Drug Lists.

• UK Sport is working with the Governing Bodies to bring them all together under
one roof so to speak and therefore make applying for Dispensations easier for all.
Currently in UK Medical Dispensation has to be sought before every competition.
Also be aware that Dispensation is not always granted and can take a while to sort
out so make sure it is applied for in enough time and always make sure that you
have signed evidence from a consultant which is also kept with the Dispensation
Certificate/Letter and taken to each competition.

9|Page
 • With regard to school competitions it is best to speak to the local School Sports
Officer at the Local Education Authority to confirm if they need any form of Medical
evidence within Sport in their Authority as it would be very upsetting for any child
to take part in an event only to be disqualified when someone found out they were
taking medication. Although most times there is no actual drug testing for school
events it only takes someone to inform the competition organisers that this child
takes this medication, which is on the Banned Drug List for things to turn very
difficult for the child.

• As a lot of children with ADD/ADHD excel at sport it is essential to find out all we
can to ensure that the child is able to continue to enjoy Sport and to be able to
continue in something they are good at.

Reference:Adapted from 'Developing integrated mental health service for adults with ADHD'
- Helen Crimlisk

www.adders.org

10 | P a g e
Topic 2:

CASC LESSON 8
MANIA-DISCUSSION & MANAGEMENT
TASK: Mr Elliott Bethany is a 28-year-old man who was diagnosed with an episode of
mania 2 years ago. He was presenting as elated and with grandiose delusions at this time
and required inpatient care under mental health legislation. He was started on Lithium
during his admission and he responded well to this and made a full recovery. He has been
referred urgently to your clinic by his GP after being taken there by his family. He stopped
taking Lithium around 2 months ago and his parents are worried.He has been feeling very
happy like he can do anything. He has far more energy than usual. He sleeps for about 2
hours a night. He is going to the gym twice a day. He is working late on projects at work and
developing his own film ideas at home. He had spent a great deal of money on some high-
end equipment, including a camera and very excited about this. He has an idea about
producing a film using actors and he has been approaching people to talk about this
idea. His family and colleagues have expressed concerns about his behaviour. He has not
been using any alcohol or drugs. Please speak to him about the likely diagnosis and
formulate a management plan.

CASE SYNOPSIS: You are Elliott Bethany, a 28-year-old man, who was diagnosed with an
episode of mania around 2 years ago. You don't remember much of this but you were then
admitted to hospital and were there for around 6 weeks where you were started on
Lithium. You were well after discharge and were seen regularly in a psychiatry clinic before
being discharged about 6 months ago. You felt unsure about whether you should continue
to be on Lithium as you were no longer seeing a psychiatrist and didn't have a diagnosis of
anything long-term as far as you were aware. You decided to stop taking your Lithium
about 2 months ago to see what happened. You were also finding the slight tremor and
regular blood tests irritating. Now you have been feeling very happy and like you can do
anything. You've found that you have far more energy than usual and do not need as much
sleep. You have so much energy and are working late on projects at work and developing
your own film ideas at home. You've recently spent a great deal of money on some high-
end equipment, including a camera, sound-mixing deck and PC with professional video
graphics hardware and software. You've been putting forward numerous ideas at work.
You feel that you're becoming too able for your current company and are planning to
branch out by yourself. You have an idea about producing a film using actors that you find
on the street and you've been frequently approaching people to talk about this idea. You
are confident that you'll get a cast together soon. You would be willing to accept that you
may be experiencing another episode of mania. You are willing to entertain the possibility
of a diagnosis of bipolar affective disorder if the candidate explains it clearly. You don't
want to take Lithium again as you disliked the tremor and blood tests. You are willing to
talk about alternative medications if the candidate can explain them clearly. You want to go
back to work but are willing to have some time off if the candidate advises, and stay with
family. You can be upset if they insist on you going to hospital and will suggest ways to
avoid this.

11 | P a g e
Topic: MANIA-DISCUSSION AND MANAGEMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Able to maintain control of the consultation
when caring for a disinhibited patient and

Able to maintain appropriate boundaries

Identify explicitly that the patient is
experiencing an episode of mania and
explain the reasons for it
Give some information about the diagnosis
of Bipolar disorder (due to second episode of
mania)
Reasonable to offer Lithium again
Open to discussing alternative treatments
with the patient (antipsychotic or mood
stabilizer) and be able to describe benefits
and potential side-effects
Discuss other inputs- local Crisis team or
some other intensive community support

Reasonable to discuss admission as an

option if community treatment is
unsuccessful.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)

12 | P a g e
 2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan
Specific Comments and suggestions

MANAGEMENT OF A PATIENT WITH MANIA

• This station assesses a candidate's ability to recognise a patient with an episode of mania
and to formulate an initial management plan.

• It assesses a candidate's ability to maintain control of the consultation when caring for a
disinhibited patient with significant symptoms of mania.

• The patient is this case is clearly experiencing an episode of mania with symptoms and
signs of elation, over-optimism, grandiosity, increased energy, diminished need for sleep,
disinhibition and overspending.

• Candidates should identify explicitly that the patient is experiencing an episode of mania.
Good candidates will explain why they feel that the patient is presently manic and do so in a
fluent and sensitive manner.

13 | P a g e
 • Candidates should identify that a second episode of mania would indicate that the patient
has an underlying diagnosis of bipolar affective disorder. Good candidates may explain why
they have reached this conclusion and give some information about the diagnosis.

• Candidates should offer the patient some effective medication. As he has responded to
Lithium previously, it would be reasonable to offer this again.

• Candidates should be open to discussing alternative treatments with the patient and be
able to describe benefits and potential side-effects in a clear manner. It would be
reasonable for them to offer an antipsychotic or a mood stabiliser. They may also offer
some short-term sedative medication.

• Candidates should explore where the patient should be cared for until they recover. It is
reasonable to explore inpatient admission but this should not be insisted upon once it
becomes clear that the patient is willing to take medication and would have support in the
community. Candidates could offer input from the local Crisis team or some other intensive
community support. It is reasonable to discuss admission as an option if community
treatment is unsuccessful.

• Candidates should not allow the patient to dominate the interview and should maintain
appropriate boundaries. Candidates will have to interrupt the patient in order to
adequately discuss diagnosis and management.

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Topic 3:

CASC LESSON 7
POSTNATAL ILLNESS-MANAGEMENT
TASK: Mrs. Rachel Smith is a 35-year-old lady who was referred to the psychiatrist by her
GP because of low mood. She is suffering from low mood with frequent episodes of
tearfulness, poor sleep, poor appetite and anxious about the well being of your baby. She is
now 10 weeks pregnant, and cannot feel positive about it. She has another child; a 7 month
old boy. Her 1st child was born through caesarean section following which she spent 24
hours in the special care baby unit but there were no ongoing problems with the baby.

She was not suicidal and had no thoughts of harming the baby. She felt increasingly guilty
and that she was a bad mother. She felt hopeless and unable to change what is happening.
She did not have hallucinations or psychotic symptoms. You're the husband of a 35-year-
old pregnant woman suffering from low mood.

You are anxious about your wife's condition. You want to know what is wrong with her
and what can be done about it. Check whether she could be treated at home rather than
admitting her to hospital? Seek clarification about the effect of any treatment on the
unborn baby. He wanted to clarify the effects of the illness on your other child. Check if she
could breastfeed when she is on medication. Clarify if mothers with postnatal illness might
harm the baby.

You also wanted to find out how you could help her? Address his concerns and allay his
fears.

Topic: POSTNATAL ILLNESS- MANAGEMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Communicate their findings of their
examination in jargon free language

15 | P a g e
 Explain diagnosis & clinical presentation
(Offer Clarification and justification)

Post partum illness (affective presentation)-

Severe depression
Management- Admission to hospital-mother
& baby unit,

Use of antidepressants and antipsychotics

Effect on psychotropics on unborn baby
(Explain risks of medicine to foetus and
balance it to benefit to mother's health)
Effect of illness on patient, unborn baby &
existing child (If untreated)

(Impact on Mother-infant relationship,

Emotional and cognitive problems in

children in later years,

Lack of obstetric care, neglect)

Addressing concerns

Breast feeding whilst on psycho tropics

Addressing concerns -

Self harm, Fear of harming the baby etc

Support from husband & family,

Counselling, Psychotherapy etc

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

16 | P a g e
 Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

PUERPERAL DISORDER - RISK ASSESSMENT AND MANAGEMENT

Areas to be concentrated upon

1. Explore the risk factors for post natal illness

2. Bonding and assess relationship with the baby

3. Assess the mother's mental state

• Look for depressive symptoms and negative thoughts such as worthlessness

• Look for psychotic symptoms

• Thoughts of harming herself and the baby

• Assess cognitive state and insight

4. Relevant history including past psychiatric history, family history and social support.

17 | P a g e
1. Risk factors

Ask briefly about 4Ps:

P-Parity

P-Planned/unplanned pregnancy

P-Partner

• Are you currently in a relationship?

• How are things between you and your partner/husband?

• Have there been any difficulties since the baby was born?

P-Problems during pregnancy and or during labour

• How did you get on generally during the pregnancy?

• Tell me about how the delivery went.

2. Relationship with the baby

• Please tell me about your baby

• How do you feel about your baby?

• How are you coping with the baby?

• Does he sleep well?

• Does he cry too much?

• Have you been losing your temper with the baby?

• Does he have any problems?

18 | P a g e
3. Mental state examination

• How do you feel in yourself?

• How do you feel as a mother?

• Do you feel useless or worthless as a mother?

• Do you feel trapped as a mother?

• Do you blame yourself for something you have done or thought?

Ask questions regarding her anxiety about the well being of the baby and any abnormal
ideas about the baby

• Are you worried/concerned about the baby?

• Do you have any particular worrying thoughts about the baby? Tell me more about it?

• Do you think there is something wrong with the baby? If so what do you think is wrong
with the baby and why do you think so?

• Are you worried that someone might take the baby away? Who do you think might take
the baby away and why would they do so?

Enquire about depressive symptoms and psychotic symptoms

• Weepiness, Low mood, Tiredness, exhaustion

• Anxiety, Irritability, Insomnia

• Paranoid thoughts, hearing voices or seeing things

Risk assessment - explore any thoughts of harming herself or the baby

• Have you thought of doing something to yourself? If so, what would you do?

• Do you have any thoughts of harming yourself?

19 | P a g e
• What did you think you might do to yourself?

• Do you feel that you need to do something to the baby?

• Can you explain that please?

• Have you heard voices that tell you to harm the baby?

4. Relevant history

• Past psychiatric history of depression, bipolar disorder, psychosis, anxiety disorder etc

• Family history of mental illness, family history of postnatal illness

• Social support-support from friends and family

• Recent significant life stressors

• Any misfortunes like bereavement, the partner's losing his job, housing, financial
problems, etc.

Also assess the cognitive functions and insight at the end of your assessment

• Cognitive functions - look for disorientation to time and place

• Insight- what do you think is the problem?

• Do you think you might be unwell?

POST NATAL DEPRESSION- COUNSELLING

• Postnatal depression means becoming depressed after having a baby and it is one
of the common complications following childbirth. It is like other kinds of
depression except that 'it is brought on by having a baby'.

• It is quite common, yet often unrecognised. One out of every ten women suffers
from PND.

• It usually starts within a month of the delivery but can start up to six months
later. It can go on for months, or even years, if untreated.

20 | P a g e
 • Symptoms include Depressed mood feeling low, unhappy and tearful, Exhaustion
and loss of energy, Sleep and appetite disturbance, Feelings of
guilt/incompetence/hopelessness, Suicidal thoughts, plans, or actions, anxiety and
exaggerated fears concerning the self, the baby or the partner.

• The exact cause of PND is unknown. Probably there isn't a single cause, but a
number of different stresses may have the same consequence, or may act together.

• The risk factors are Previous history of depression (especially PND), Lack of
support from the partner and family, Recent stressful life events, An accumulation of
misfortunes such as bereavement, the partner losing his job, housing and money
problems, etc

• It seems likely that huge hormone changes take place at the time of giving birth,
but this evidence is still lacking and women who do, and who do not, get PND have
similar hormone changes.

• Mothers with PND often worry if they might harm their babies, but they never do.

• The treatment is similar to depression. Usually, the mother may need only
reassurance, practical support and supportive counselling. If depression is
associated with marital problems, they will have to be tackled through marital
counselling. One of the most important aspects of treatment is educating new
fathers. Educate the partner about postnatal depression, the demands of being a
mother and practical and emotional support that she needed.It is also very
important to address her social difficulties, her needs and provide adequate social
support.

• For some, antidepressant drugs will be needed. In very severe cases, other drugs
and even ECT may be needed.

• There is no need to necessarily stop breastfeeding. Antidepressants that does not

get into your mother's milk and affect baby in any way are available and could be
used.

• The chance of someone without a history of depression getting a PND is 10-15%

and someone who already had one episode of PND getting a second one is higher
which is around 20-40%.

• Some of the common strategies of prevention and early intervention include:

Prenatal education, Encourage the mother to keep in touch with the GP, to attend
antenatal classes, take your partner with you and also to keep in touch with the
health visitor, Encourage the importance of regular exercise, rest, sleep, nutritious
food; maintaining good relationships with your partner and family is
important.Techniques such as relaxation training, confidence building courses and

21 | P a g e
 assertiveness training may be useful for preventing the escalation of stress and help
them to cope with difficult situations.

• Research evidence shows that PND adversely affects mothering, bonding mother-
infant relationship and the emotional development of the infant.

POST-NATAL ILLNESS- GENERAL MANAGEMENT

Your management plan should be formulated according to the nature and severity of the
postpartum illness and all the following options should be considered in your management
plan, which should be tailored according to the needs of individual patient.

• Early identification of the presence of postnatal illness

• Education and Explanation about the disorder to the patient and the family

• Organise Extra Support and practical help for the mother either through friends,
family or professional help

• Close Monitoring of 'those at risk'

• Provide or refer for specific treatments such as individual counselling, marital

counselling, and Psychotherapy especially cognitive behavioural therapy.

• Depressive episode-appropriate pharmacological intervention with

antidepressants

• If depression is severe or associated with thoughts of self-harm or harm to the

baby, may require hospital admission (specialist mother and baby unit if possible)

• Psychotic symptoms should be treated with antipsychotic medications and should

follow the treatment protocol for treatment of psychotic illness.

• For major affective disorders there is also good evidence for ECT and mood
stabilisers

• Prevention of future episodes through pre-natal education, enhancing coping and

stress management techniques such as relaxation training and assertiveness
training should be also considered.

Postnatal depression

• Most women can be treated effectively in primary care by brief, supportive (on)
problem solving treatments together with practical support.

22 | P a g e
 • Few of them may benefit from antidepressant medication.

• Few may require referral to specialist psychiatric services.

• Postnatal depression adversely affects the mother - infant relationship and also
the cognitive and emotional development of the child.

Risk factors for postnatal depression

1. Older Age

2. Single mother

3. Unplanned pregnancy

4. Personal history of depression

5. Family history of depression

6. Poor social support

7. Significant other psychosocial stressors

Prognosis:

a) The recurrence rate of depressive illness in the puerperium after subsequent childbirth
would be 20 - 30%.

b) 50% women who have suffered a puerperal depressive illness will later suffer a
depressive illness that is not puerperal.

POSTPARTUM PSYCHOSIS

Risk factors for postpartum psychosis

1. Personal history of major psychiatric disorder

2. Previous postpartum psychosis (30% risk of developing psychosis in the subsequent

pregnancies)

3. Family history of major psychiatric disorder

4. Single parenthood

5. Lack of adequate social support

23 | P a g e
Postpartum psychosis

• An acute psychotic episode, occurring following 1.5/1000 live births

• Peak occurrence at 2 wks postpartum.

• Aetiology is unknown

• 3 common clinical presentations: prominent affective symptoms (80%) -mania or

depression with psychotic symptoms; schizophreniform disorder (15%); acute
organic psychosis (5%). (Ref: Oxford handbook- pg no: 756)

• Common features include: lability of symptoms; insomnia; perplexity,

bewilderment, and disorientation; thoughts of suicide or infanticide.

Treatment:

Make sure that appropriate investigations including all blood investigations were done to
rule out any organic cause for this presentation. CT/MRI scan to exclude any intracranial
pathology

Admission to the psychiatric unit depends on:

Risk to mother and baby

Social support available

Severity of the condition.

Admission to hospital - informal but if patient refuses, I may have to consider use of mental
health legislation for possible detention.

Mother and baby unit- ideal place to treat postnatal illnesses to minimize any adverse
effects on maternal bounding, and all contact between mother & baby should initially be
supervised by nursing staff and reviewed according to the progress.

If the mother has serious thoughts of harming the baby, I would advise staff to separate the
baby from its mother immediately. Once when she is recovering, then the baby should be
introduced to the mother gradually.

Psychosocial interventions

Education, supportive counselling and Reassurance to the patient, partner and the family

Counselling or marital therapy

24 | P a g e
Behaviour therapy - release mothering skills and improve confidence

Involve the CPN Input, social worker to be involved

Liaise & work in close liaison with the GP, health visitor, community psychiatric nurse and
obstetrician.

Offer health education, support to the patient, partner and the family and also Advice
adequate rest

Attending a postnatal support groups

Information and advice on planning subsequent pregnancies

Would you consider Breast-feeding: -

Most psychotropic medication are not indicated during lactation period, Therefore
discontinue and change it to bottle-feeding preferably, it gives the mother some rest
especially during the acute phase of the illness.

If the mother still decided to breastfeed, then the benefits would have to be weighed
against the risk of exposure in the infant. In which case I would use low dose lowest
optimum dose of antipsychotics preferably Sulpiride or olanzapine (recommended by the
Maudsley guidelines 2007)

I would tend to avoid drugs with long half life and the time feeds as to avoid peak plasma
drug levels in the milk

When will you consider ECT treatment: -

Disorders of moderate (or) marked severity (Depressive (or) manic disorders)

Acute onset and no definite improvement within a short period.

If there is high degree of risk involved - (Suicidal risk, risk of neglect and infanticide risk)

Good Prognostic factors

Acute onset

Affective illness

Good social support.

First episode

Well adjusted pre morbid functioning

25 | P a g e
Lack of social adversities.

Risk of psychosis during pregnancy and labour

General population-0.1-0.25%

The risk of perinatal psychosis is about 50% in women with a history of bipolar disorder

The risk of postpartum psychosis in patient with a history of postpartum psychosis is 50-
90%

General Principles during pregnancy and lactation

Continue the same medication given during pregnancy.

Use the lowest effective dose.

Avoid poly pharmacy.

Avoid drugs with a long half-life.

Time the feeds to avoid peak drug levels in the milk.

Recommendations during Breast-feeding (Extracted from The Maudsley Prescribing

guidelines )
Antipsychotics -Sulpiride, olanzapine

Antidepressants-Paroxetine/ Sertraline

Mood Stabilizers-Avoid if possible; valproate if essential

Sedative-Lorazepam for anxiety, zolpidem for sleep

26 | P a g e
Topic 4:

CASC LESSON 7
CAPACITY ASSESSMENT & DISCUSSION-MEDICAL DECISION
TASK:Mr George Franklin is a 35-year-old man living in a supported housing project for
people with mild learning disabilities. He takes pills everyday called Risperidone. For the
past 6 months, he often gets tummy pain middle of your stomach. Today he suddenly had
severe pain, felt sick and threw up blood. The ambulance was called and he threw up more
blood. The A& E staff explained to him that he is probably bleeding from your tummy. They
are concerned he might bleed more and might die if this happened. The staff wanted to take
some blood tests and connect a drip, but he couldn't understand what they said. Staff also
told him they want to put a camera down his throat to look inside his tummy. He thinks the
police gave him an injection in his sleep and that's why he threw up the blood. He thinks
the doctors and nurses in the hospital are working for the police. He thinks that the blood
test is just an injection to get him to bleed more inside. He thinks the camera is to show the
Police how much they have damaged you inside. He doesn't want to have these tests, as he
thinks he might die if he had them. He is able to understand the information given to him
but doesn't trust anyone in the hospital. He is able to retain the information given but not
keen to have further tests. He has a mild learning disability that broadly equates to that
expected in a normally developing 10-year-old child. However he is able to communicate
well. He has been seeing a psychiatrist for several years now and is currently on
Risperidone. The staff are important people in his life, and he does have some friends at the
day centre. He has a social worker, but he doesn't see her much, just for annual
reviews. Regarding his family he only sees his mother every Christmas. She lives in
another town a long way away. You have done a capacity assessment on Mr. Franklin who
is on a medical ward. Now speak to his support worker, explain the findings of your
assessment and devise a plan of action for further management of this case. Address his
concerns. Do not take history.

CASE SYNOPSIS:

You're a support worker and have come today with a man that has a learning disability
who you work with in supported housing. You came with him in the ambulance after he
vomited a lot of blood at home earlier today. His mother lives 20 miles away. The doctors
have suggested blood tests, and a camera test. However he's refusing them and the doctor
has assessed his capacity. Suggested prompt questions:

Do you think he has capacity to refuse treatment? Why?

How do you make these assessments?

What do you mean by 'best interest'?

Shouldn't his mother decide what is best?

27 | P a g e
Can it wait till tomorrow?

Is it legal to go against his wishes?

Can I give consent for his treatment on his behalf?

Topic: CAPACITY ASSESSMENT- DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain the findings of capacity assessment
in order to refuse treatment
Explain how you assessed patients' decision
making ability (capacity) and

What conclusion they reached

Address concerns by carer

(If anything can be done to help him make

decisions, and if this would be likely to
work)
Emphasise - Decisions should be taken based
on best interests of the patient in
emergencies (If patient lacks capacity and
making unsafe decisions with lack of
awareness of risks involved)
Best interests- views of anyone involved in
the care of the person and consult others
who is involved in the care of the person
(next of kin, family members, relatives,
carers, attorneys and deputies)
Encourage the person to participate in the
decision making process as far as possible
and discuss least restrictive option available

28 | P a g e
 Address concerns-

1. Proxy consent- No one can give proxy

consent

2. Could it be post-poned until next day

(urgency)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
8 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
9 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Specific Comments and suggestions

CAPACITY ASSESSMENT

MENTAL CAPACITY ACT

29 | P a g e
The Act defines capacity as follows;

An adult can be considered unable to make a particular decision if;

• He or she has an impairment of or disturbance in the functioning of the mind or

brain, whether temporary or permanent

He or she is unable to undertake any of the following steps

• Understand the information relevant to the decision

• Retain that information

• Use or weigh that information as part of the decision making process

• Communicate that decision made (by talking, sign language or other means)

CAPACITY ASSESSMENT

Step 1: Check if the person has an impairment or disturbance in the functioning of mind or
brain (due to various conditions like dementia, brain injury, learning disability, confusional
state due to illness or treatment or drug/alcohol misuse, mental health problems,
unconsciousness)

Step 2: Check for the following

Understand the information relating to decision required (broad terms, simple language)

Retain information (only long enough to make a decision)

Use or weigh information (take into account/believe)

Communicate the decision (in any form recognised by the assessor)

Step 3:

If the person passes the test of capacity and has made the right decision, then his/her
decision must be respected.

If the person passes the test of capacity but has not chosen the right decision, express your
concerns to the person and explain that the best possible decision has not been made.
Inform them that although the person is free to make the decision, it is contrary to the
advice of the professionals involved in their care. Give them adequate time to re-think
about it, encourage them to talk to other professionals like medical colleagues, nurses and
social workers etc. Agree to see them again.

30 | P a g e
If a person fails the test of capacity, the best interests check list must be followed. All the
following points must be considered when making a decision in the 'patient's best
interests'.

Best interests check list

All relevant circumstances (diagnosis, care needs etc)

Person's beliefs & values

Person's past & present wishes and feelings

Consult others who is involved in the care of the person (next of kin, family members,
relatives, carers, attorneys and deputies)

Any other factor the person would consider if they could?

Will the person regain capacity? If so, can it wait?

Is there a least restrictive option available?

Encourage the person to participate in the decision making process as far as possible

The decision is not solely based on person's age, condition or behaviour

For life sustaining treatment- the decision must not be motivated by a desire to bring about
person's death. The person carrying out assessments only has to have a reasonable belief
about what is in the person's best interests at the end of checklist above.

(Ref: www.matrixtraining associates.com)

PATIENT REFUSING MEDICAL TREATMENT

If the adult patient does not have the capacity to give or refuses consent then no-one can
give proxy consent on behalf of the patient. The doctor should act in the patient's best
interests

If a patient refuses medical treatment the doctor needs to make 2 judgements before
accepting the patient has the right to refuse;

Is the patient competent (does he have the mental capacity) to refuse treatment

Has the patient been influenced by others to the extent that a refusal has been coerced is
not voluntary

31 | P a g e
The assessor should always keep in mind that refusal is often based on misapprehension
about the illness and treatment. He/she should always spend as much time as is needed
exploring the medical issues and try to understand the patient's beliefs and worries.

Full, calm discussion may eventually enable agreement about a treatment plan that is
medically appropriate and acceptable to the patient.

Where adult patients do not have the required capacity to consent and have not made an
advanced directive (also called as living wills), others have to decide whether treatment
should be given or withdrawn. This decision must be based on the basis of the patient's
best interests as determined by the responsible clinician on the basis of their clinical
judgement in accordance with general medical opinion.

It is wise to consult relatives (although they cannot give or withhold consent) and to
discuss the case with other professional staff.

Detailed notes should be kept of the reasons for the decision and the consultants that took
place (Ref: Shorter oxford of psychiatry: 79-81)

CAPACITY ASSESSMENT FOR MAKING SOCIAL DECISION

The legal position for social decisions for incompetent patients such as where a patient
should live is the same for medical decisions

Often patient with physical or cognitive difficulties who are at risk in their own
environment could express their wish to live alone in their own home, which could pose a
huge challenge for the treating team.

It is important that the treating team should consult with family to try and ensure that the
patient's best interests are met (unless a valid lasting power of attorney is in place).

In order to supervise welfare decisions, it may be necessary to apply to the court of

protection for a court appointed deputy

If a patient insists on returning home against advice, first assess whether the patient is
competent or incompetent to make this decision

It is important to assess competence in line with the principles described (under mental
capacity act) and document meticulously in the notes.

How to proceed further?

A. Competent patients

If a patient is competent then they should accept that they are at risk and reason that they
prefer to take the risk than accept other forms of accommodation

32 | P a g e
If the patient is deemed competent, then they cannot be forced to abandon their home or
accept outside help

We could try two things

1. In such situations, it is important that the treating team and family can continue to
negotiate and persuade. The patient may have some misconceptions which may be
the motive behind their insistence and if it can be corrected, then the patient might
agree

2. Some patients will agree to a trial period of residential/nursing home placement and
this often leads to long term agreement

• If the patient continues to refuse despite all these measures, then the
treating team should still try to accommodate the patient's wishes

• Express your concern that the patient had not made the best possible
decision

• Explain that although the patient is free to make the decision, it is contrary
to the advice of the treating team.

• Disconnecting or removing dangerous items, setting up alarm systems,

wearing a pendant alarm, regular carer visits may still allow a patient to
return home (could be done as part of risk minimisation plan)

• Arrange a multidisciplinary case conference involve patient, carers and all

professionals involved.

Note: Candidate should offer to come back and reassess the patient at a later time/date to
establish 'consistency of thinking and decision making'.

B. Incompetent patients

• When the patient is incompetent, then there is a duty of care to ensure that
the patient is not discharged to an environment where they will be at
unreasonable risk

• The treating team should consult next of kin/close relatives where

important decisions are made for incompetent patients

• Often relatives/next of kin might help doctors to decide what the patient
might have wanted under the circumstance.

33 | P a g e
 • If they do not have a relative or next of kin, then IMCA (Independent
mental capacity advocates) should be involved

• If there is a conflict between medical team and relatives about what is in

the best interests of the patient that cannot be resolved, the doctor involved
may wish to seek a second medical opinion or refer to the courts (Ref: Oxford
handbook of geriatric medicine- 720)

34 | P a g e
Topic 5

CASC LESSON 7
INTELLECTUAL DISABILITY-STERILISATION AND CRY FOR HELP
LEARNING DISABILITY
TASK: Mrs. Dorothy Lawrence is a middle-aged woman and mother of Mr. Robert
Lawrence, a 26-year-old gentleman who has mild form of intellectual disability. She is a
single mum who brought up her son alone with no support. She worked full time in a pub
and work mostly during antisocial hours. She has very few friends. She is emotionally and
financially stretched. At the time of her son's birth, he suffered from hypoxia and he was
delivered through emergency caesarean section. There was a delay in his speech. He
started talking and walking only at 5 years of age. The school psychologist assessed to
inform that he has a mild level of intellectual disability. He was sent to special school. He
can't read or write much. He can communicate and express his needs. He needs minimal
supervision with daily activities. He lives in a supported accommodation. She had a very
difficult time, raising him on her own with no support from family. He now lives with his
girl friend who also has mild intellectual disability. She is now 6 months pregnant.

In the past he got into trouble with the police as he exposed himself to a girl on the stairs
when he was stressed about money. This has happened again because he is stressed that
the unborn baby will be taken away from them at birth. She thinks he should be sterilized
as they 'clearly cannot cope with a family' and she is really concerned that the burden of
bringing up this new baby up will ultimately fall on her. She is extremely worried that the
baby may be disabled and dependent like your son. His mother Mrs. Dorothy Lawrence has
come to see you in your clinic today. Elicit her concerns and allay her anxiety. Discuss
strategies to manage this situation effectively.

CASE SYNOPSIS

You're a middle-aged mother of a 26-year-old man who has mild learning disability. You're
a single mum who brought her son up alone without support and had a very difficult time.
You were financially and emotionally stretched. He was sent to special school. He lives with
his girlfriend who also has mild learning disability. She is 6 months pregnant. In the past
he got into trouble with the police as he exposed himself to a girl when he was stressed
about money. This has happened again because he is stressed that the unborn baby will be
taken away from them at birth. You strongly think that he should be sterilized as they
'clearly cannot cope with a family'. You're really concerned the burden of bringing up the
baby up will ultimately fall on you. You are extremely worried that the baby may be
disabled and dependent like your son.

Topic: STERILISATION & CRY FOR HELP-INTELLECTUAL DISABILITY

Candidate Name: Candidate Number:

35 | P a g e
Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Sterilisation- not be considered as an option,
People with learning disabilities have same
rights as anyone else (forced sterilization is
against human rights principle/against the
law to enforce upon) whether the person has
LD or not.
Informed consent from the individual should
be obtained,

Others including family members could not

consent on his behalf.

Best interest- only for medical reasons

Discuss about support systems in place,
social services provide support around
parenting. (Parenting assessment & joint
support management plan)
Reassure mother that she would not be
expected or forced to support her son or to
look after the baby.
Heritability- not all cases of learning
disability are caused by genetic factors.

Explain that there are not always explainable

causes.
Heritability- Enquire son's developmental
history, family history, any scans done and
explain that any major anomalies could or
would have been picked up.
Stress and Exposing Himself- Acknowledge
Unhelpful way of managing stress

Managing stress or anxiety- mental health

learning disability team could help

36 | P a g e
 (Psychologist), further education around the
topic could be considered
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
7 Use of medical jargon without explanation
8 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
9 Limited or Incomplete management plan,
Specific Comments and suggestions

LEARNING DISABILITY- STERILISATION & CRY FOR HELP

(Written by Dr Sarah Maber, ID Registrar, St Georges NHS trust & Dr Sujeet

Jaydeokar, ID consultant)

1. Question of Sterilisation

• Sterilisation is classified as a surgical procedure and is a permanent (and

usually irreversible) way to reduce a person's fertility. Sterilisation, as a
procedure, would require informed consent.

• No-one can consent to a procedure on behalf of a competent adult.

• If an adult lacks capacity to consent to the procedure, a decision is taken by

the person proposing the treatment in the patient's best interests. Good
practice would also include consulting with and taking into account the views

37 | P a g e
 of anyone interested in the person's welfare or caring for them e.g. Robert's
mother. In the case of sterilisation the courts would also be involved to
consider whether it was in the medical or psychological best interests of the
person.

• In this case less invasive/restrictive options such as sex education and

alternative methods of contraception should be considered first.

How would you explain it?

Sterilization:

• With regards to sterilization I would gently explain that it would not be

considered as an option.

• People with Intellectual disabilities (ID) have same rights as anyone else.
Sterilization is an invasive procedure and forced sterilization is against
human rights principle whether the person has intellectual disability or not.

• Any procedure like sterilization required informed consent from the

individual and could not be performed without his consent.

• I would explain that others including family members could not consent on
his behalf.

• Where there is lack of capacity, such procedures could not be performed

without court interventions and only when it is in the person's best interest
i.e. only when it is for medical reasons.

• At this point I would also acknowledge / comment on her concerns or ask

about her real concerns; i.e. what is she worried/concerned about

Ethics & Law

The Human Rights Act 1998: Forcing anyone to have a medical procedure against their
will would be a breach of the Act. Article 8 protects the right to a private and family life and
Article 12 protects the right of people to marry and start a family.

The Equality Act 2010 (replacing the Disability Discrimination Act): A person with an
intellectual disability (ID) would have the same rights as anyone else. Treating a person
with ID less favourably than someone else because of their disability is a form of direct
discrimination.
The Mental Capacity Act (MCA) 2005: Sterilisation carries risks like any invasive
procedure. A principle of the MCA is that due regard is given to achieving the purpose (i.e.

38 | P a g e
preventing pregnancy) effectively in "a way that is less restrictive of the person's rights and
freedom of action”.

In a recent case (August 2013) a high court judge at the court of protection ruled in favour
of sterilisation as there was a risk of psychological harm to a 36 year old man with ID who
did not have capacity to consent to the procedure but who made clear he didn't want
further children.

2. Support Networks

Reassurance should be offered that it is normal to have some worries on becoming a parent
for the first time whether a person has ID or not. There would be no obligation or
expectation for Robert's mother to care for the child.

Establishing what support networks already exist for Robert e.g. type of living
arrangement, what agencies are involved.

All parents have a right to services in supporting them in the parenting of a child. This is
balanced against the parent's ability to meet the child's needs and the child's welfare being
of paramount importance bearing in mind the Children's Act 2004.

Interagency working between adult and children's services (and Community Learning
Disability Teams) to allow joint assessment and planning will work towards protecting the
child and supporting the parents. For example involving social services early on to assess
the parents' needs, involvement of children's social services for parenting assessment and
management plans.

Studies have looked at the level of IQ and competent parenting. They have not found a
correlation until the IQ reaches the lower end of mild ID (IQ<60). Even then, IQ alone is not
the sole determinant of 'good enough parenting' with many other factors contributing such
as "family size, family relationships, characteristics of the father of the child, and
the extended family including support networks”. Some people with ID (especially mild
ID) can become successful parents given the right support.

Support systems- I would explain it in the following way;

I would like to get more information. What are the current support systems, where is he
living, who else is there. What support structures are in place, are there any other
professionals involved etc.

I would explain that she should not be expected to look after or bringing up the baby.

I would explain how these things works. Now a days, social services provide support
around parenting. Philosophy is to support/help parents as much as possible to bring up
their children. This is irrespective of their learning disabilities.

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There will be an involvement from children's social services. It would be job of children's
social worker to do parenting assessment. Your son's social worker and other professionals
involved should work with children's services on this.

They would make a joint support management plan.

In those situations where it was felt that parents are not able to look after the child and
where the child is at risk - only then they would be looking at another arrangement.

Reassure her that she would not be expected or forced to support her son or to look after
the baby.

3. The Risk of a Child with Disabilities

There are certain risks or causes that we know of that make the chances of having a child
with a disability more likely. Establishing if Robert's cause of his ID is known to his mother
and whether she had any antenatal or postnatal complications will help establishing
further risks to his child. Also ask if there were any known conditions that ran in the family
to help establish any hereditable causes.

In general causes can be divided into the prenatal, perinatal and postnatal factors e.g.
infections: ToRCH (toxoplasmosis, rubella, cytomegalovirus, herpes), nutritional status of
the mother during pregnancy, maternal smoking/alcohol/drugs, infant prematurity or
obstetric complications during birth. Age of the parent may also increase certain
chromosomal abnormalities such as Down's Syndrome. Autosomal recessive disorders
would also be increased if there was consanguinity. Fragile X is the commonest inherited
causes of ID.

Heritability

I would briefly ask about her son's developmental history. What led to his ID? Whether
there is a family history.

I would explain that not all cases of intellectual disability are caused by genetic factors. It
could be due to other factors like hypoxia etc, which is clearly not hereditary.

I would ask whether his girlfriend had any scans done and explain that any major
anomalies could or would have been picked up. I would explain that there are not always
explainable causes.

Good antenatal care is important and has improved in the last 20-30 years since Robert's
mother's own experience, with ultrasound scanning and genetic testing early in pregnancy.
In any event of abnormalities being found, counselling support and advice are given. Co-
ordinated care with the obstetric team and the GP may also be offered.

4. Stress and Exposing Himself

40 | P a g e
We know that people react to stress in different ways. Some manage it in more helpful
ways than others.

Briefly assess the risk:

What were the consequences at the time e.g. Police involvement, a criminal record?

How old was the girl?

What was his reaction/how did it make him feel?

Did anything else happen?

Has it happened since?

Future plans?

Use of cognitive distortions?

If all the information could not be gathered from his mother, I would acknowledge that to
obtain a full understanding of the event, further information would be needed including
speaking with Robert. This would allow you to offer a more informed opinion on whether it
would be likely to happen again.
The incident could be classified as disinhibited indecent exposure e.g. due to alcohol, stress
or psychiatric disorder. Most do not reoffend (first time offenders rates are 20%, but if
there are previous sexual offences this increases to 60%). "Most sex offences committed by
people with LD are associated with lack of sexual knowledge, poor social skills and inability
to express a normal sex drive appropriately”.

Managing stress or anxiety may be something that the mental health learning disability
team could help Robert with, teaching him some more positive or less harmful ways in
managing stress. In particular, if Robert feels frustrated in his ability to communicate with
others in times of stress, the input of a Speech and Language therapist and/or
Psychologists may be useful in facilitating communication. Similarly if it is the case that
Robert does not fully understand about appropriate sexual behaviour, further education
around the topic could be considered

PEOPLE WITH LEARNING DISABILITY WHO BECOME PARENT THEMSELVES

Learning disability or intellectual limitation in itself is not an absolute bar to parenthood.

The fertility rate of learning disabled people appears to be generally low.

Sexuality and pregnancy is a common fear of many parents of learning disabled adolescents.

People with LD have 'normal sexual desires' which can be more of a problem for
families/carers than the individuals themselves. The argument against allowing people with

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learning disabilities to have sexual partners often involve judgements about whether
someone is deemed fit to be a parent.

Long term sexual relationships and parenting children are considered to be an integral part
of being an adult, including learning disabled people. Unfortunately people with learning
disabilities are seldom encouraged to develop sexual relationships.

One of the personal rights authorised in article 8 of the European Convention of Human
Rights is one of which guarantees respect for private life. An individual with learning
disabilities is entitled to be treated as normally as possible by the law, consistent with the
protection against harm or abuse.

In the U.K, research has demonstrated that some people with learning disabilities can
become successful parents provided they are given appropriate and effective support.
(Booth, TT. www.intellectualdisability.info). Many people, particularly with mild LD, are
capable of being successful parents and provide a stable environment for children with
appropriate support.

Problems usually arise with planning ahead and constant protection from danger that young
babies require. However, there are now techniques to help teach these skills. Undermining
the learning disabled mother or father should not be encouraged and the secret of success in
such teaching is a positive attitude of enhancing skills.

If a learning disabled woman has a partner who is both stable and more able many women
cope extremely well

It becomes difficult only when a young woman with learning difficulties finds a partner with
even more problems and has, for example, high risk of being hurt by a violent man and of
failing to protect children from similar abuse. It is problems such as these rather than the
learning disability itself that makes the safety of the children questionable

When the child grows older the problems increase as the balance between protection and
encouraging new skills becomes more difficult.

Therefore, specialist mental health teams for people with learning disabilities should include
organising services around patients' wishes and needs that includes sexual needs as well.

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Topic 6

CASC LESSON 7
PRISONER WITH A HISTORY OF ASSAULT-DISCUSSION
TASK:

Mr Daniel Griffiths is a 32-year-old man who is currently serving a custodial sentence for
assault. He has been in prison for 3 months. He had been demonstrating good behaviour
on the prison wing and had not raised any concerns among the staff. He witnessed another
prisoner being violent to one of their fellow inmates a few weeks ago and seemed shaken
immediately afterwards. Since this time he has been reporting that he can hear voices from
outside his head telling him that he is going to be harmed and that he needs to defend
himself. He has reported being worried by these. He has also been stating that he feels that
someone else may be influencing him and that he has been having impulses and thoughts
about harming others. He has not acted on these. He was brought to the hospital wing of
the prison for assessment 2 days ago. Concerns have been raised that he may have been
using illicit substances, particularly GHB. He had previously used various illicit substances
before being imprisoned.

You are the forensic psychiatry doctor covering the hospital. One of the psychiatric nurses
on the hospital wing has asked to speak to you about what may be happening and whether
Mr Griffiths can return to the prison wing.

Tasks

1) Please obtain a brief handover from the nurse about how Mr Griffiths has been since
his transfer.

2) Please discuss your initial management plan for Mr Griffiths' with the nurse.

CASE SYNOPSIS
You are Gary Harrison, one of the nurses on the hospital wing of the prison. You have been
part of the team looking after Mr Daniel Griffiths who was transferred into the hospital
wing 2 days ago after an assessment by one of the prison GPs. He was checked over
physically at the same time but has not had any investigations in terms of blood or urine
tests. You were informed that Mr Griffiths is serving a sentence for assault and had been
fine on the wing until a few weeks ago. He witnessed an assault around this time and
appeared to be shaken by it. You have been informed that he has been reporting that he
can hear voices from outside his head telling him that he is going to be harmed and that he

43 | P a g e
needs to defend himself. You were also told that he has been stating that he feels that
someone else may be influencing him and that he has been having impulses and thoughts
about harming others. You are aware that he has a long history of drug use before entering
prison and that there has been an increasing problem with GHB being used in the prison.
You and your colleagues feel that his recent difficulties are more likely to be due to use of
GHB or some other illicit substance and would want him to return to the prison wing
soon. You are under a significant amount of pressure to discharge patients at the moment
and you have been frustrated by the number of patients presenting with problems
primarily related to substance use.

You are keen to know from the doctor:

• What they think has been causing Mr Griffiths difficulties?

• What do they think that the risks are in his case? You will initially be of the
opinion that they are limited, as you have not seen anything to the contrary.

• If the doctor feels that the patient poses a risk to themselves or others, you should
ask them why they feel this is the case.

• What is their plan for how to look after Mr Griffiths for now?

• When can he return to the prison wing?

Topic: PRISONER WITH A HISTORY OF ASSAULT-DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Patient is likely to be experiencing an episode
of psychosis, ? Substance misuse could be a
factor.

44 | P a g e
 Potentially pose a significant risk to others
(Previous history of violent offending, active
psychotic symptoms- hallucinations and
passivity symptoms)
Acknowledge that the patient has not had an
adequate period of observation or MSE or
risk assessment being made.
Relevant blood tests/urine drug testing be
carried out
Insist longer period of observation and
treatment with antipsychotic medications

Agree to assess the patient

Risk management- potential risk to him and
others if he was returned to the wing
prematurely.
Justify their decisions clearly and not unduly
influenced by the nurses' opinion

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored

45 | P a g e
 Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate awareness of management of risk

PRISONER WITH A HISTORY OF ASSAULT

(Written by Dr Michael Rutherford)

• This station assesses a candidate's ability to consider the differential diagnosis for
this patient, formulate an initial assessment of risk based on limited information,
and decide on a plan to investigate and manage the patient.

• Candidates should identify that it appears that the patient is likely to be

experiencing an episode of psychosis, although they should acknowledge that
substance misuse could be a factor.

• Candidates should identify that the patient could potentially pose a significant
risk to others. They have a previous history of violent offending, are experiencing
hallucinatory voices stating that they are at risk and may need to defend themselves,
are having thoughts about harming others and are describing passivity
symptoms. The latter are particularly associated with significant risks in this
context. Candidates should be able to describe all or most of these factors when
asked. Good candidates may specifically identify passivity symptoms as a particular
concern. Good candidates should also identify that the patient would be at risk from
others if he was violent, due to the possibility of retaliation.

• Candidates should identify that this patient has not received a sufficient
assessment of their mental state so far. Good candidates may sensitively explain
that the patient has not had an adequate period of observation, nor has their inner
thoughts been explored. This prevents any definitive diagnosis or risk assessment
being made. There is also no evidence that the patient has had any investigations
beyond an initial examination by the prison GP.

• Candidates should insist that the patient receive a longer period of observation
and request to see the patient in the immediate future. Good candidates may
request that a urine drug screen or relevant blood tests be carried out. Good
candidates may state that they intend to gather a collateral history by speaking to
staff on the patient's previous wing in the prison, as well as his family
members. Candidates may discuss the possibility of starting antipsychotic

46 | P a g e
 medication in the future but should aim to delay this until after they have assessed
the patient.

• Candidates should insist that the patient remain on the hospital wing of the
prison until they have had an adequate assessment. They should be able to explain
that his diagnosis and risk assessment are not established and there would be a
potential risk to him and others if he was returned to the wing prematurely. They
should hold to this view in spite of the nurse's concerns about other people
potentially needing to come into the hospital wing. Good candidates may
empathetically acknowledge the nurse's frustration with the level of substance use
within the prison and how this impacts on them and their colleagues. Excellent
candidates may allay the nurse's concerns by offering to help triage the potential
patients.

• Candidates in this station are expected to communicate in a clear and professional

manner with a colleague. They should ensure that their initial assessment of risk
and the patient's potential diagnosis are not unduly influenced by the nurse's
opinion that his symptoms are the result of substance use. They should ensure that
their advice and initial plans for the patient take the uncertainty around their
formulation into account and are safe. Candidates should categorically not advise
that the patient leave the hospital wing. Candidates are expected to be able to
justify their decisions clearly.

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48 | P a g e
Lesson 8:

TOPIC 1: SCHIZOPHRENIA AND CANNABIS MISUSE-

MANAGEMENT
TOPIC 2: PUERPERAL PSYCHOSIS-DISCUSSION &
MANAGEMENT
TOPIC 3: TREATMENT RESISTANT DEPRESSION
TOPIC 4: MORBID JEALOUSY-DISCUSSION WITH
PARTNER
TOPIC 5: PAEDIATRIC OVERDOSE- ASSESSMENT
TOPIC 6: LEWY BODY DEMENTIA- MANAGEMENT

1|Page
Topic 1:

CASC LESSON 8
SCHIZOPHRENIA AND CANNABIS MISUSE-MANAGEMENT
TASK: Mr Martin Fawkes is a 25-year-old man with a previous diagnosis of paranoid
schizophrenia. He was prescribed Olanzapine after his last episode of illness and recovered
on this. He stopped taking his medication 6 weeks ago and has started to relapse and hear
voices again. He has been managing these by using cannabis. He was referred urgently to
clinic by his GP. Take a brief history from Mr Fawkes and formulate a short-term
management plan.

CASE SYNOPSIS:

You are Martin Fawkes, a 25-year-old man with a previous diagnosis of schizophrenia. You
were diagnosed with schizophrenia when you were 20 years of age at university and using
a significant amount of cannabis. You experienced persecutory and referential delusions
about your housemates sending you messages via their choices in food and TV
programmes with the aim of interfering with your university work. You had auditory
hallucinations of them whispering about you from their rooms, even when you thought
they weren't in. You were referred onto the local psychiatry team and treated successfully
with Risperidone but it caused you significant sexual side effects and you were changed to
Olanzapine, which worked well for you. You retook the year at university and completed
your degree. You have had one other episode of illness 3 years ago when you were
experiencing significant stress at work and started using cannabis again. You were started
back on Olanzapine in the community and recovered well. You stopped your Olanzapine 6
weeks ago as you started to experience some difficulties getting an erection. You were well
for around 2 weeks but then started to feel worried about people around you. You started
to feel that your co-workers are looking to sabotage the advertising campaign that you are
working on at the moment. You thought that your colleagues were influencing your
manager in some way. You started to think that the way people leave their cars in the car
park across the road is significant in some way and meant to communicate something to
you. You've been frightened by this and have been avoiding looking out of the window. In
the last 2 weeks you have been intermittently hearing a voice coming from somewhere
above your head. You have started smoking cannabis again. You are currently smoking 3-4
spliffs most evenings. You eventually decided to get help after your manager pulled you
aside and asked if you were OK. You do not have any thoughts about harming yourself or
anyone else. You would be willing to take Olanzapine as it has worked before but would
not want to take it long-term. You are willing to take an alternative antipsychotic, provided
that the candidate can explain the possible side-effects to you. You have never been to
hospital and would not wish to go now. You would be willing to see someone about your
cannabis use but would want to deal with your psychotic symptoms first.

TOPIC: SCHIZOPHRENIA & CANNABIS MISUSE- MANAGEMENT PLAN

2|Page
Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Clarify the patient's recent history of
symptoms, including the time course and the
temporal relationship to them discontinuing
medication.
Elicit history of cannabis misuse
Offer the patient appropriate anti-psychotic
medication- either Olanzapine or an
alternative antipsychotic
Discuss effects and side effects
Suggest abstinence from cannabis and

Offer input from drug services

Discuss other options and agree a
management plan- Input from crisis team,
community support
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion

3|Page
 5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Inaccurate or misleading information discussed
11 Limited or Incomplete management plan
Specific Comments and suggestions

SHORT-TERM MANAGEMENT OF A PATIENT WITH SCHIZOPHRENIA

• This station assesses a candidate's ability to formulate a short-term management

plan for a patient experiencing a relapse of schizophrenia.

• This patient is clearly experiencing a relapse of schizophrenia with referential and

persecutory ideation that does not yet meet the criteria for delusions but which are
clearly related to their previous psychotic phenomena. They are also experiencing
auditory hallucinations with insight into their nature but a significant degree of
distress.

• Candidates should clarify the patient's recent history of symptoms, including the
time course and the temporal relationship to them discontinuing medication.

• Candidates should elicit that the patient has been using cannabis.

• Candidates should offer the patient appropriate anti-psychotic medication.

• Good candidates will identify that the patient has stopped their Olanzapine due to
experiencing sexual side-effects. Good candidates may discuss that there may be
other causes of sexual symptoms which may need to be investigated in due course.

• Candidates may offer the patient Olanzapine as this has been effective for them in
the past. Candidates may offer Olanzapine even if they have identified that the
patient stopped it due to troubling sexual side-effects, provided that they
acknowledge them and have an intention to transfer the patient onto an alternative

4|Page
 medication once they have recovered as the medication is clearly not acceptable to
the patient in the long-term.

• Candidates may offer the patient an alternative antipsychotic.

• Candidates should be able to discuss side-effects with the patient for any
medication that they recommend.

• Candidates should advise that the patient stop using cannabis immediately. They
should be able to explain how it will be likely to increase his symptoms and impair
his recovery and the usefulness of antipsychotic medication. Good candidates may
mention some of the research linking cannabis with psychosis.

• Candidates may offer the patient input from drug services to help them stop using
cannabis.

• Candidates may wish to offer the patient some short-term medication to manage
their anxiety around the voices. Candidates may offer the patient input from the
Crisis team and should offer some frequent and regular community input. Good
candidates may ask the patient about what support they have in community so they
are not alone when away from work.

• Candidates may discuss admission as an option but should not insist upon it. The
patient clearly has insight and is willing to take medication and engage with mental
health services.

• Candidates should aim to develop and agree a management plan with the patient.

5|Page
Topic 2:

CASC LESSON 8
PUERPERAL PSYCHOSIS-DISCUSSION & MANAGEMENT
TASK:Mrs Joanne Barker is a 34-year-old woman who is currently 36 weeks pregnant. She
has a history of 2 previous episodes of puerperal psychosis. Her older children are now 4
and 7 years old. Her last episode was treated with Lithium and Quetiapine and she
recovered completely. She has been without any psychotropic medication for the last year
and she has been well over this time. She is now concerned that she may become unwell
again and is wondering about medication. Please address her concerns and expectations
and devise a management plan.

CASE SYNOPSIS: You are Mrs Joanne Barker, a 34-year-old woman with a history of
experiencing 2 previous episodes of puerperal psychosis following the births of your sons,
aged 4 and 7. You became ill within a few days of giving birth on both occasions after
having significant difficulties with sleep and had prominent and unshakeable fears about
people harming your children or kidnapping them. You also experienced voices, which you
felt were coming from the ceiling and told you that your husband and healthcare staffs
were going to take your children away from you and sell them to paedophiles or into
slavery. You were admitted for a few weeks under the mental health act. You found the
admission very distressing as you were separated from your child. You were prescribed
medicines including Olanzapine initially and then prescribed Quetiapine and Lithium
carbonate, which you took them until about a year ago when you told your GP that you
wanted to become pregnant again. You gradually stopped them with your GP's
assistance. You are now 36 weeks pregnant and have been referred to a psychiatric clinic
as you are concerned that you may become unwell again. You were aware that you might
become ill again but had 2 sons and wanted to have a daughter and were ignoring the
possibility of another episode. You have been getting increasingly worried about becoming
ill again and so requested a referral. You have been with your husband, Ben, for 10 years
and he is supportive of you. Your parents live around 45 minutes away and are also
helpful. Your in-laws live around 4 hours away and you have a good relationship, although
they are less able to practically help. Your housing and finances are stable. You do not
drink, smoke or use recreational drugs.

You are keen to get answers to the following questions:

• I am worried I might relapse. What do I do to avoid this?

• What is the risk of me having another episode of puerperal psychosis?

• What kind of treatment would you advise for me?

• Would it be sensible for me to take Lithium again?

6|Page
 • What are the effects of medication on the pregnancy?

• What kind of support do you think I should have over the rest of the pregnancy?

• Do I have to stay in hospital after giving birth or can I go home straight away?

• What support would I get after the pregnancy?

• What would happen if I became unwell again after giving birth?

• Can I breastfeed on medication? Please ask about Lithium specifically.

• What happens if I go into labour before my Caesarean section date?

Topic: PUERPERAL PSYCHOSIS- DISCUSSION AND MANAGEMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Future risk of puerperal Psychosis-30-80%,
more likely on the higher end due to 2
previous episodes
Elicit the patient's views on medication and
discuss their options
Highlight that the patient is sufficient late in
pregnancy that there is no risk of congenital
malformations.
Discuss the effects of Lithium on pregnancy
including the risk of congenital
malformations and the need to regularly

7|Page
 check Lithium serum levels during
pregnancy and after delivery.
Advise the patient that she could not
breastfeed if she takes Lithium.
Discuss the effects of antipsychotics at this
stage in pregnancy, timing of doses can be
adjusted around feeding times
Multi-disciplinary management plan with
input from psychiatry, midwifery and
obstetrics, post natally- health visitors

Referral to Perinatal mental health services.

Crisis team, mother and baby unit
Discussion about managing early labour
before expected date and plan for any future
pregnancies
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
8 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
9 Limited or Incomplete management plan
Specific Comments and suggestions
8|Page
MANAGEMENT OF PATIENT AT HIGH RISK OF PUERPERAL PSYCHOSIS

• This station assesses a candidate's ability to recognise a patient as being at high

risk of puerperal psychosis and to formulate an initial management plan.

• Candidates should identify that the patient is at high risk of experiencing a further
episode of puerperal psychosis and communicate this clearly to the patient. If asked
for a figure, candidates should be able to quote a risk of around 50% or, at the
minimum, state that the risk is high but that they will get back to the patient with an
exact figure after researching it. Good candidates will state that the risks vary
depending throughout studies from 30-80% but that the patient's risk will likely be
on the higher end of this in view of her having 2 previous episodes.

• Candidates should advise the patient that they would recommend that she takes
some form of medication to reduce the risk of relapse. Candidates should not advise
that she can continue without medication. If they do so, they cannot pass the
station.

• Candidates should elicit the patient's views on medication and discuss their
options. Good candidates will be able to discuss that no medication can be
considered to be entirely safe in pregnancy and breastfeeding due to the limitations
of the available evidence, although some medications are thought to be relatively
safe based on the numerous experiences of people who have had to take
medications at these times. Good candidates will highlight that the patient is
sufficient late in pregnancy that there is no risk of congenital malformations.

• Candidates should be able to discuss the effects of Lithium on pregnancy

including the potential increase in the risk of congenital malformations and the need
to regularly check Lithium serum levels and after delivery. Good candidates should
be able to describe that serum levels must be checked monthly during early
pregnancy and then weekly from 36 weeks. Good candidates should be able to
describe that increasing doses of Lithium may be necessary to keep the patient
within the therapeutic range as pregnancy progresses, with the required dose then
falling immediately after birth. Good candidates should identify that delivery must
be planned and that the patient's Lithium level should be checked within 24 hours,
the dose adjusted and then the level checked again 5 days later.

• All candidates should advise the patient that she could not breastfeed if she takes
Lithium. Candidates should advise that large doses of Lithium are present in
breastmilk and infants are unable to safely metabolise this placing them at risk of
toxicity. Good candidates will state that the levels in the mother's serum and in
breastmilk are very similar.

• Candidates should be able to discuss the effects of antipsychotics at this stage in

pregnancy and identify that they are felt to be relatively safe, although sedative

9|Page
 medications can lead to infant sedation. Good candidates will be able to discuss that
antipsychotics are thought to be relatively safe throughout pregnancy. Excellent
candidates may mention that only Risperidone has been associated with congenital
abnormalities.

• Candidates should mention that sedative antipsychotics may cause sedation in

breastfed infants. Good candidates may mention that the timing of doses can be
adjusted around feeding times. Good candidates may also mention that infants may
require a period of observation after delivery to ensure that they do not experience
any difficulties in adapting.

• Candidates should agree that the patient would benefit from a planned
delivery. They should identify that the patient would require a multi-disciplinary
management plan with input from psychiatry, midwifery and obstetrics, with all
professional groups being aware of her risk of experiencing a further episode of
puerperal psychosis and how this may present. Post-natally, they should identify
health visitors as a potential support. Good candidates should identify that the
patient may benefit from increased input from health visiting and midwives and that
it would be useful if the family could provide more support as well. Good candidates
may identify that it would be useful if family could support the patient with their
sleep.

• Candidates should identify that the patient will require regular reviews at home
from mental health services and that they and their family should have contact
details for services as well. Candidates should recommend a referral to Perinatal
mental health services.

• Good candidates may discuss the improvement of the patient having sufficient
sleep and discuss how this may be achieved via help from their partner or family.

• Candidates should advise that, if the patient started to become unwell, the
intention would be assess and treat them urgently, with the aim to keep them at
home if safe and appropriate. This would likely involve the assistance of the Crisis
team. They should identify that admission to a Mother and Baby unit may be
necessary. Good candidates should acknowledge the patient's concerns about this
and emphasise that this would only be pursued if it was needed.

• Candidates should identify that the patient would have to remain in hospital after
delivery until they and their baby had been checked and felt to be well enough to
return home. They would not have to remain in hospital for a prolonged period if
they were physically and mentally well as they would be followed up closely at
home.

• Candidates should advise that if the patient goes into labour before their Caesarean
date, the obstetricians will need to make a decision about her

10 | P a g e
 management. However, mental health services would need to be informed so she
can be followed up earlier.

• Candidates should advise the patient that they should plan any future pregnancies
and inform mental health services beforehand. They should discuss contraception
and advise that this would ideally be long-acting and reversible, such as the implant,
coil or intrauterine device. Good candidates would advise a preconception planning
referral to Perinatal services and that the patient should be followed up throughout
any future pregnancy and into the post-partum period by the Perinatal team.

• Candidates should communicate in a clear and open fashion with the patient and
be responsive to their questions and concerns. They should acknowledge that their
previous experiences have been difficult but ensure that they provide accurate
information.

11 | P a g e
Topic 3:

CASC LESSON 8
TREATMENT RESISTANT DEPRESSION
Task: You have been asked to see Mr. Jeremy Smith, who gives a history of 3 episodes of
depression in the past, which remitted with Fluoxetine 20 mg. About six months ago, he
started to experience symptoms of a relapse consisting of low mood and energy,
anhedonia, poor concentration and appetite. The GP saw him and fluoxetine 20mg was
reinstated. However after 6 weeks, the symptoms had not improved and the dose was
increased to 40 mg. After 6 weeks on this dose there was no response and the patient was
switched to venlafaxine 150 mg. Although there has been some improvement in mood,
other symptoms remain.

The diagnosis is confirmed. Given the patient's circumstances, explain the management
options.

CASE SYNOPSIS:

You're a young married teacher who has experienced 3 previous episodes of depression in
the last 5 years. You began experiencing relapse symptoms 5 months ago. The school
underwent an Ofsted inspection six months ago and gave an indifferent report despite your
hard work. Your weight has increased which is concerning you. You tried fluoxetine, which
was changed to venlafaxine after a few weeks. You're concerned you're not getting better
even after trying 2 different drugs. You're keen to know the next course of action. The
doctor may mention increasing the dose of Venlafaxine and check if you need more tests
done. The candidate should discuss other options for resistant depression. The candidate
may explain combination treatments with 2 drugs or combining talking treatments with
drugs. They may also mention ECT, as a last resort. Other physical symptoms feeling tired,
constipation, dry skin and unable to stand the cold.

Topic: RESISTANT DEPRESSION- DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

12 | P a g e
 Competency Domains Very Poor Average Good Excellent
Poor
Discuss the possibility of hypothyroidism-

(Constipation, weight gain, lethargy,

depression etc)
Check on physical health, past and family
medical history- particularly
hypothyroidism, hypertension, epilepsy and
coronary heart disease

H/o substance misuse

Cover standard treatment approaches to
refractory depression-

2 antidepressants (different classes) for

adequate dose and duration
Discussing the most appropriate treatment
strategy for the patient

And not deliver a list of every possible

treatment strategy

(Ideal course of action- To increase the dose

of Venlafaxine as the next step)
Emphasise need for more physical health
monitoring & blood tests-

BP, Pulse, Electrolytes, ECG etc

(NICE guidelines suggestion for patients on

high dose of Venlafaxine)
Discuss specific treatment strategies with
confidence

Augmentation treatments

Combined drug therapies

Emphasise that one of the best approach is
to combine Pharmacological

And Psychological therapies

ECT- should not be the highest priority and
should be tried only when all other
measures fail

13 | P a g e
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk

TREATMENT RESISTANT DEPRESSION

Management

14 | P a g e
 • Try to obtain a detailed comprehensive history, perform mental state
examination, physical examination, arrange for relevant laboratory investigation to
rule out any medical health problems such as hypothyroidism, multiple sclerosis etc.

• In the history, it is important to identify any ongoing psychosocialstressors, co

morbid psychiatric conditions such as anxiety, grief reaction, PTSD, Psychosis, drug
& alcohol abuse, possibly could be due to her prescribedmedications, (Cardiac drugs
or corticosteroids), lack of social support, premorbid personality.

Treatment algorithm for depression

• Titrate the new antidepressant to recognized therapeutic dose and assess the
efficacy over 4-6 weeks. Increase dose and assess over a further 2 weeks.

• If no desired response achieved, give an antidepressant from a different class.

Titrate to the therapeutic dose - assess over 4-6 weeks. Increase dose as necessary.

• If no effect, consider treatment of refractory depression. Augmentation of

antidepressants with Lithium, Tri-iodothyronine, high dose venlafaxine, L-
Tryptophan, Combination of SSRI with mirtazapine.

• Also try psychosocial interventions like CBT, family therapy, individual / group
psychotherapy.

• If no response, obtain a second opinion and ECT treatment (8-10 treatments)

should be tried, if all other measures fail (after obtaining informed consent)

• Consider combination of multiple drugs and review diagnosis.

Check reasons for treatment resistance- 4As

• Adequate dose

• Adherence

• Alcohol/drugs

• Axis II/III disorders

Is combining two antidepressants an effective strategy?

The evidence base for combination antidepressants is very sparse and is reviewed by
Palaniyappan et al. (APT 2008). There are no clear recommendations that could be made
from available evidence.

15 | P a g e
 • No single combination is found superior to others in head to head trials.

• Venlafaxine mirtazapine combination is called Californian rocket fuel

• Neuropharmacological rationale must be checked before combinations - for

e.g. combining two SSRIs may not give any pharmacodynamic advantage,
combining two different mechanisms of action must be aimed for.

•SSRI TCA combinations may work both by pharmacodynamic and kinetic

mechanism - SSRIs inhibiting TCA metabolism.

• Some combinations may be used for specific symptom relief e.g. trazodone
for insomnia in combination with other antidepressants.

• Serotonin syndrome is a risk with many combinations especially SSRI-MAOIs

Venlafaxine and NICE Guidance on Depression

• NICE states "venlafaxine should only be initiated by specialist mental health

practitioners, including GPs with a Special Interest in Mental Health

• NICE also states "venlafaxine should be considered for patients whose depression
has failed to respond to two adequate trials of other antidepressants.

• Consideration should be given to increasing the dose up to BNF limits if required,

provided patients can tolerate the side effects.”

• Before initiating venlafaxine an ECG, electrolytes and blood pressure

measurement should be undertaken and practitioners should take into account:
a)The increased likelihood of patients stopping treatment because of side effects,
compared with equally effective SSRIs. B) Venlafaxine's higher propensity for
discontinuation/withdrawal symptoms if stopped abruptly, its toxicity in overdose
and its higher cost

• The ECG should be undertaken to establish the corrected QT interval (QTc - see
below).

• The BNF states: Depression, initially 75mg daily in 2 divided doses increased if
necessary after at least 3- 4 weeks to 150mg daily in 2 divided doses; severely
depressed or hospitalised patients, increased further if necessary in steps of up to
75mg every 2-3 days to max. 375mg then gradually reduced.

Venlafaxine is contraindicated in:

1.Patients with heart disease e.g. cardiac failure, coronary artery disease, EGG

16 | P a g e
abnormalities (including pre-existing QT interval prolongation - prescribers should be
aware of other co-prescribed drugs that cause QT interval prolongation

2.Patients with electrolyte imbalance

3.Patients who are hypertensive.

Patients currently taking Venlafaxine

All patients already taking venlafaxine should have their treatment reviewed.

Patients should be reviewed at their next routine appointment for heart disease,
hypertension and electrolyte imbalance.

Risk factors for these (e.g. a family history of heart disease; those on very high doses of
venlafaxine; and those co-prescribed other drugs that prolong the QT interval) should also
be reviewed.

• If there are any clinical signs of heart disease venlafaxine should be discontinued
by gradually tapering the dose down over a period of several weeks or months,
according to the patient's needs.

• For those with cardiac risk factors an EGG should be carried out. If the corrected
QT interval (QTc) > 440msec (men) or > 470msec (women) alternative
antidepressant treatment should be considered.

• Patients currently prescribed venlafaxine benefiting from treatment and with no

contraindications can continue treatment with continued regular monitoring (and
due regard for NICE guidance on continuing treatment).

Once reviewed, patients continuing to be prescribed venlafaxine should have BP, and if
appropriate U&Es, checked 6 monthly and be regularly monitored for clinical signs of heart
disease (particularly those on higher doses). Reference: Venlafaxine and NICE Guidance on
Depression Advice for Gwent GPs

17 | P a g e
Topic 4:

CASC LESSON 8
MORBID JEALOUSY
TASK: Mr Harris Brown is a man in his 40's and has been with his current partner for
about 1 year. He is convinced that his partner is being unfaithful and believes that a
neighbour is possibly her secret lover. His sex life is infrequent. He blames her lack of
interest in him for this. He has checked her mobile phones, bed, and purse/ handbag for
evidence but found none. He is carrying a knife in case the evidence on this man is found.
Earlier today his partner saw him hitting the bed in a very agitated state, she persuaded
him to attend A&E to see a doctor.

About 4 years ago he had a previous partner, he believed that she was being unfaithful to
him. He attacked her impulsively with a knife in the kitchen. He stabbed her several times
but she escaped. He ended up in hospital under a section of the mental health act and
treated on risperidone 2mg.

Mr. Harris brown has now been assessed. Explain his diagnosis and further management
plan to his partner. Address her concerns.

CASE SYNOPSIS:

The doctor assessed your partner. You love your partner immensely and have no intention
of leaving him or of him being admitted to hospital. You are against any suggestion of this.
Suggested prompt questions;

• What is his diagnosis? Is he psychotic?

• Why don't you increase his medication and send him home?

• How are you going to treat him?

• How do you think admission would help him?

• Do you think I should get separated and stay away from him?

The doctor may discuss about use of mental health act and admission to hospital formally
for assessment. The doctor may warn you about his past history and you believe that the
past knife attack was due to stress.
Topic: MORBID JEALOUSY-DISCUSSION

Candidate Name: Candidate Number:

18 | P a g e
Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain the diagnosis-Morbid Jealousy
(Delusions of infidelity)
Emphasise risk involved to wife

(Past history of violence and dangerous

behaviour)
Emphasise risk to third party (Carrying
weapons, active threats etc)
Management

(Consider Admission to hospital -

compulsory detention if necessary,

Geographical separation of partners, risk

assessment and evaluation)
Treatment with antipsychotics

Treat co-morbidity (depression,

alcohol/substance misuse etc)
Gradual re-introduction into community,

Offer support to wife,

Multidisciplinary Team approach

Persistence in the candidate in saying- this
was a high risk situation given his history
and his deterioration in mental state
recently and that he would need to come
into hospital for further admission
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

19 | P a g e
 (Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Poor range of Symptomatology/psychopathology explored
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
8 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
9 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

MORBID JEALOUSY- ASSESSMENT

Areas to be covered:

• History of alleged assault and Circumstances leading to the act.

• Assessment of evidence for the Belief of Wife's infidelity & intense

seeking Behaviour (Searching in diaries, Handbags, Smells of perfumes, Aftershaves
etc)

• Assessment of strength of beliefs, degree of conviction and other abnormal beliefs

(The partner plotting against the patient, Trying to poison him etc)

20 | P a g e
 • Risk assessment- Risk to self, wife and third party, Risk to children, Hx of violent
behaviour or aggression, Recent/active threat, Stalking, harassing, carrying a
weapon

• Screening other psychotic Sx-other delusions &Hallucinations, mood

symptoms

• Co-morbidity: Alcohol & substance misuse, Sexual problems, marital problems and
paranoid personality traits

(Adapted from www. Trickcyclists.co.uk)

History:

Take a full psychiatric history including;

• Threatened and perpetrated violence-enquiries about arguments, confrontations,

threats and actual violence perpetrated by the jealous individual should be made)

• The quality of the relationships-marital relationship, sexual and domestic

violence history should be elicited.

• Family constitution

• Evidence of associated mental illness such as affective disorders, psychotic

disorders and substance misuse should be elicited.

It is also important to obtain collateral history from spouse. Both partners should be
interviewed separately and then together.

Mental state examination:

• The form of morbid jealousy (May take the form of a delusion, an obsession, or an
overvalued idea or combinations of these)

• Associated psychopathology

Risk assessment:

1. Suicide

2. History of domestic violence

3. Risk to children-The risk to children in the household should be considered and

protecting them is a paramount concern.

21 | P a g e
 4. History of interpersonal violence, including any third party

MANAGEMENT- MORBID JEALOUSY

Principles of management involve treating the mental disorder (psychosis, depression etc)
and risk management.

Admission to hospital
Aims:

1. For further assessment of mental state

2. To carry out a comprehensive risk assessment

3. Instigate clear management plan, both short term and long term

4. Arrange adequate follow up and support on discharge.

Inpatient treatment

• Reasons for Admission to hospital (compulsory detention if necessary)-When it

gives rise to appreciable distress, a significant risk of harm or if it is not managed
satisfactorily by outpatient treatment, admission to hospital may be necessary.

• If there appears to be a risk of violence, the concerned doctor should warn the
partner. Specific threats made to partner (or) to others - Disclose to the concerned
person/ police (duty of care- Issues of confidentiality/ Tarasoff case)

• Consider close monitoring, multidisciplinary team involvement, and periodic risk

assessments by more than one person

• Treatment with antipsychotic medication or with antidepressants. Adequate

treatment of any associated disorder such as schizophrenia, delusional disorder (or)
mood disorder with antipsychotic, antidepressants and mood stabilizers.

• Treatment of co-morbid condition such as substance misuse and alcoholism

• Psychological therapies-Couple therapy, CBT (If obsessions are prominent) and

dynamic psychotherapy (in whom personality disorders with borderline and
paranoid traits are present)

22 | P a g e
 • Child protection proceedings should be instituted if necessary-children in the
household may witness arguments between their parents, suffer from emotional
and physical abuse or even be injured accidentally during assaults.

• Geographical separation of the partners may be all is effective if morbid jealousy

is refractory to treatment (Shepherd 1961). In such cases, the Geographical
separation of the partner is recommended - to ensure safety. Consider Gradual
reintroduction into the community

Note: - Bear in mind that it is not uncommon for feelings of pathological jealousy to wane
once a relationship has ended. Sometimes, the problem re-emerges if the patient enters a
new relationship.

Prognosis:

• It depends on various factors such as underlying phenomenology, premorbid

personality, underlying psychiatric disorder, the existence of co-morbid mental
disorders and response to treatment.

• Those with a psychotic illness generally have a poorer prognosis but a third of
patients may show significant improvement (Langfeldt 1961 and Mooney 1965).

• The possibility that morbid jealousy will recur is significant and therefore careful
monitoring is warranted indefinitely

• Research evidence suggests that over half of them still had persistent (or)
recurrent jealousy. The prognosis is often poor.

Note: In order to pass this station, persistence in the candidate in saying- this was a high
risk situation given his history and his deterioration in mental state recently and that he
would need to come into hospital for further admission should be strongly advised.

23 | P a g e
Topic 5:

CASC LESSON 8
PAEDIATRIC OVERDOSE-ASSESSMENT
TASK: Take history from a 15-year-old girl who was admitted to the paediatric ward 2
days ago following an overdose of 30 tablets of paracetamol. She was treated for the
overdose and had treatments including an intravenous drip. She is medically fit and then
transferred to a paediatric ward. The nurses informed that she was holding a piece of paper
folded over in which she had written 'They are coming'. She also pleads the nurses not to
send her home.

Assess circumstances leading to her overdose and take history about self-harm risk.
Evaluate the seriousness of the overdose and look for presence of mental illness. Decide if
she is suitable for discharge.Do not discuss diagnosis.

CASE SYNOPSIS

You are a 15-year-old girl admitted to the accident and emergency department following an
overdose of 30 tablets of paracetamol. You do not want to go home. You feel safe in the
hospital because aliens are trying to attack you. You think you are impregnated with
aliens. You also believe that they have plans to do it to everybody on this planet and hence
taking over the human race. You are hearing voices of aliens making obscene comments
that you are a slut. They told you to take an overdose of tablets. You feel sad and miserable.
About 4 days ago, you went to school as usual. You decided to end it all. You went to the
local pharmacy and bought paracetamol tablets. You also wrote a note to your mother
saying sorry. You went to bed but your best friend telephoned. As you were sick, she called
the ambulance. You live with your mother and 45-year-old stepfather. Your mother
suffered another episode of depression a month ago and she is in hospital

Topic:PAEDIATRIC OVERDOSE & PSYCHOSIS - ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor

24 | P a g e
 Circumstances leading to self-harming
behaviour
Degree of suicidal intent at the time of
Deliberate self harm

Impulsivity or planned nature of the self-

harm episode
Intensity, frequency and duration of self-
harming thoughts

Behaviour at time of over dose/self harm,

Help seeking or help avoiding behaviour

Ongoing plans for further self-harm or
suicide
Previous history of self-harming behaviour
Establish abnormal psychopathology

(? Depression, psychosis-Delusions,
hallucinations etc)
Establish the current level of functioning
(peer relationships, significant events-
bullying and abuse, drug/alcohol abuse,
educational attainment)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability

25 | P a g e
 7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
Specific Comments and suggestions

Reading notes

Assessment

In addition to those cases where a disclosure of self-harm has been made, the possibility
that a child or adolescent has self-harmed should be considered in the following situations,
when they present with;

• Acute onset of hallucinations

• Acute confusional state

• Unexplained medical symptoms

• Injuries that could have been the result of self harm

The assessment process involves both physical and psychiatric.

The Physical assessment of a child or adolescent who has thought to have self-harmed
should identify Injuries from self-harm and likely/potential effects of ingestion of
substance. It is important to assess if the young person has the capacity to consent to or
refuse treatment and they should be provided with appropriate medical treatment

The Psychiatric assessment should focus on identifying;

· Presence or absence of mental illness

• Risk of further episodes of self harm

26 | P a g e
 1. History of act of self-harm

· Circumstances leading to self-harming behaviour

• Degree of suicidal intent at the time of Deliberate self harm

• Impulsivity or planned nature of the self-harm episode

• Intensity, frequency and duration of self-harming thoughts

• Behaviour at time of over dose/self harm

• Help seeking or help avoiding behaviour

• Ongoing plans for further self-harm or suicide

• Previous history of self-harming behaviour

2.It is important to establish the current level of functioning.

It will be useful to ask specific questions regarding peer relationships, significant events
including bullying and abuse, drug/alcohol abuse, educational ability & attainment and
evidence of other risk taking behaviour

3. A full mental state examination should be completed

4. Clinical interview with the parents

• It is important to obtain a corroborative history of events from parents

surrounding self-harm episode

• Explore parental response to the episode of self-harm

• An assessment of current family functioning & available support for the child or
adolescent

• Identification of a history or symptoms suggestive of a psychiatric disorder.

• Parents should be involved in the assessment and management planning as they

have a responsibility to ensure the safety of their child.

Management

The aim of initial intervention is to treat physical effects of the self-harm episode and then
to arrange a mental health assessment

27 | P a g e
Urgent psychiatric assessment should be undertaken for children and adolescents who
have

• Taken an overdose

• Ongoing suicidal ideation or risk of significant self harm

• Evidence of mental illness with significant psychiatric symptoms, which

contributed to an act of self-harm

Risk management

The safety of the child/young person is of paramount importance.

· Admission to an age appropriate service for medical treatment and perform a full
psychosocial assessment

• Make sure appropriate supervision is in place

• Consider access to medication and other means of self harm

• A specially trained member should do mental heath assessment including risk

assessment, with ready access to psychiatric opinion. Refer to the local CAMHS
(Child & adolescent mental health service) for a fuller assessment and ongoing
management

• Consider admission to an inpatient unit if there are significant concerns regarding

young person's ongoing suicide risk. The admission should be made in an age
appropriate unit.

• Treat psychosis with antipsychotic symptoms, consider treatment for moderate

to severe depression with antidepressants etc

• Co-morbid psychiatric disorders should be managed.

• If there are concerns about child protection or care issues, a referral should be
made to social work and it need to be tackled according to local procedure.

Helpful Interventions

The interventions should focus on 3 different areas- individual, family and school

The aim of individual intervention is to address self-esteem issues, improve interpersonal

skills, improve communication skills, address relationship difficulties, and learn more
positive ways/helpful ways to cope with stress.

28 | P a g e
The family work should include family support and counselling. Family therapy should be
considered in appropriate cases

The school-based interventions include entire school programmes focusing on self-esteem

peer relationships, peer support programmes, development and implementation of
antibullying policies in school.

The factors that are most likely to be associated with a higher risk of suicide among
adolescents who deliberately harm themselves include;

• Male gender

• Older age

• High suicidal intent

• Feelings of hopelessness

• Presence of depressive symptoms

• Presence of psychotic symptoms

• Having an unclear reason for the act of deliberate self harm

Management of Psychosis in children & adolescents

• Care should be offered in age appropriate setting. The aim of most CAMHS
services will be to deliver treatment in an outpatient basis, but it may occasionally
be necessary to consider inpatient treatment. The type of therapeutic setting
(inpatient/outpatient care) will depend on the following factors;

• Complexity of case

• Level of risk

• Likely engagement

• Likely effect on child of being away from family

Pharmacological management:

•·Although age specific evidence base is limited, current recommendations suggest

using atypical antipsychotics as first line treatment of psychosis.

29 | P a g e
 • Olanzapine, Risperidone and Aripiprazole have all been shown to be effective in
the treatment of psychosis but there is no evidence to support the superiority of any
one agent over another.

• The algorithm for treating psychosis in young people are the same as those for
adult patients except that metabolic adverse effects are more common and therefore
more intensive monitoring is required.

• Children and adolescents are particularly sensitive to antipsychotics and have an

increased risk of adverse effects (such as sedation, weight gain, metabolic effects,
raised prolactin levels and extra pyramidal symptoms) when compared with adult
subjects.

• Baseline physical (minimum should include height, weight, pulse, blood

pressure), blood tests, ECG with ongoing monitoring is recommended dependent on
the medication being used.

• First generation antipsychotics should be generally avoided in children

• Clozapine seems to be effective in treatment resistant cases, although this

population may be more prone to neutropenia and seizures than adults.

Psychosocial management

• Individual work involves Psycho education, CBT and social skills training

• Family work involves education and support to family. The family intervention
are aimed at reducing expressed emotion and building supportive relationship

• Educational/vocational input which mainly involve re-integration package to

school

• It is important to manage co-morbidity, perform ongoing risk assessment &

management

• Involve early intervention in psychosis services (EIS), often extending down into
the adolescent age group

• Thoughtful and measured transition to adult services

Ref: The Oxford handbook of psychiatry- 596-601

The Oxford handbook of child and adolescent psychiatry-267-279

The Maudsley prescribing guidelines- 10th edition-26

30 | P a g e
Topic 6:

CASC LESSON 8
LEWY BODY DEMENTIA-MANAGEMENT
TASK: Mr Mark Coleman is an 82-year-old man. Over the last 18 months he has had increasing
problems with his memory. Over the last 9 months he has had Parkinsonism symptoms and is
having frequent falls. He has also been complaining of visual hallucinations. He sees all dead
relatives especially his wife and your mother and tries to establish conversations with them as if
they are real. He also sees animals like cat and fox at home and faces of children. A DAT scan has
been carried out and confirms Lewy body dementia. He was started on Rivastigmine and is
currently on 3mg twice daily. His behaviour has deteriorated and his family are increasingly
concerned about him. Speak to the grandson about his behaviour and further management
options. Address his ideas, concerns and expectations

CASE SYNOPSIS

You are the older brother Mark Coleman, who is an 82 year old gentleman. In the last 18
months he has had increasing problems with his memory. Over the last 9 months he has had
Parkinsonism symptoms and is having frequent falls. He has also been complaining of visual
hallucinations seeing cats on the sofa set. A DAT scan has been carried out and confirms Lewy
body dementia.

Suggested prompt questions.

• What is his diagnosis, doctor?

• He has had a scan of his brain. Can you explain the findings for me please?

• Can you tell me why it is not Parkinson's disease dementia?

• Are you planning to start him on L-dopa?

• Is he going to get worse?

• How are you going to manage his condition?

• Can these drugs help to cure his dementia? Ask what side effects there are?

• How are you going to treat the hallucinations?

• I have heard that antipsychotic drugs may worsen his condition?

31 | P a g e
 • You are worried that he may not remember to take his medications?

Topic: LEWY BODY DEMENTIA- DISCUSSION AND MANAGEMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Clarification of diagnosis

Explain nature and causation

(neurodegenerative disorder and Lewy
bodies in brain)
Clinical presentations (Motor symptoms of
Parkinson's disease, fluctuating levels of
consciousness and cognitive decline, visual
hallucinations-well detailed, multiple &
Complex etc)
Prognosis- Progressively deteriorating
condition,

Not curative
DAT scan and its role in diagnosis- rule out
other forms of dementia.
Role of L-dopa- Treating parkinsonian
symptoms
Hallucinations- Psycho education,
reassurance and support to patient & family,
Role of antidementia drugs- Rivastigmine
Discuss neuroleptic sensitivity and
worsening of motor symptoms due to
antipsychotics

Minimal doses to be used when distressed

Role of MDT in management
Detailed feedback with areas of concern (tick/shade the box)

32 | P a g e
 1 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
8 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
9 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

DEMENTIA WITH LEWY BODIES (DLB)

• Dementia with Lewy bodies (DLB) is the third commonest dementia in the UK after
Alzheimer's disease (AD) and vascular dementia (VaD) and accounts for
approximately 10-20% of all dementia cases.

• Clinical features to aid the diagnosis of DLB include detailed and recurrent visual
hallucinations, fluctuating cognitive impairment, and symptoms of parkinsonism.
These three clinical symptoms are termed "core features”. The presence of two of
these three core features has traditionally constituted a diagnosis of "probable DLB”
whereas the presence of only one feature is termed "possible DLB”.
Revised criteria for the diagnosis of dementia with Lewy bodies

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Core features (Two features required for a diagnosis of probable DLB in a cognitively
impaired patient, one for possible DLB)

• Fluctuating cognition with pronounced variations in attention and alertness

• Recurrent visual hallucinations that are typically well formed and detailed

• Spontaneous features of parkinsonism

Suggestive features: (One core feature plus one or more suggestive features sufficient in a
cognitively impaired patient to make a diagnosis of probable DLB)

• Low dopamine transporter uptake in the basal ganglia demonstrated by SPECT or

PET imaging

• Severe neuroleptic sensitivity

• REM sleep behavioural disorder

Lewy body dementia: If both motor symptoms and cognitive symptoms develop within 12
months, then it is conventional to give a diagnosis of Lewy body dementia. In this condition,
cognitive and behavioural impairments precede motor phenomena and are more severe.

Note that several features are common to DLB and Delirium such as fluctuations, effects of
drugs, perceptual and psychotic phenomenon etc. But the following is true of DLB

• Onset is insidious

• Progression is gradual

• No precipitating illness is found (eg infections)

• Hallucinations are complex and not the result of misperception of stimuli

• Delusions are well formed and may be persistent

Parkinson's disease dementia:

• If the Parkinsonian symptoms have existed for more than 12 months before
dementia develops then a diagnosis of Parkinson's disease dementia is given.

• This applies even if the dementia syndrome is otherwise typical of LBD.

• Here the motor impairments precede conginitive impairments and are more
severe.

34 | P a g e
 • Many patients with Parkinson's' disease may have subtle impairments of
cognition, too mild to justify a diagnosis of dementia. Slowed thinking, deficits in
visuospatial, attention and executive function are commonly seen

Summary of recommendations by NICE for neuro-imaging in patients with suspected

dementia if the diagnosis is in doubt

MRI/CT -To detect structural abnormalities and subcortical vascular changes

HMPAO SPECT- To help differentiate Alzheimer's disease, vascular dementia and

frontotemporal dementia

FDG PET- To help differentiate Alzheimer's disease, vascular dementia and frontotemporal
if HMPAO SPECT is not available

123

I-FP-CIT- To establish the diagnosis of DLB

(Adapted from: Imaging in dementia with Lewy bodies; A review by Paul Kemp and
Clive holmes; Imaging the dopaminergic system in suspected Parkinsonism, drug
induced movement disorders, and Lewy body dementia (Paul Kemp)

Important points to remember

• The pathophysiology of DLB and idiopathic Parkinson's disease (IPD) are the
presence of cerebral Lewy bodies.

• It is arguable that DLB, IPD and Parkinson's disease dementia represent different
manifestations of a continuous disease spectrum.

• Lewy bodies are the basic pathology of both idiopathic PD and dementia with
Lewy bodies (DLB). In the former, the Lewy bodies are predominantly located in the
brain stem (and thereby disrupt the nigrostriatal fibres), and in the latter the Lewy
bodies are predominantly found in the limbic and and neocortical association areas.
It is estimated that 75% of DLB patients will develop parkinsonian features during
the course of their illness.

• Conversely, 40-50% of IPD patients will develop a clinical dementia and many
others will have cognitive problems of a lesser severity. Consequently, IPD and DLB
may represent two ends of a disease spectrum of underlying Lewy body pathology.

• The SPECT ligands 123I-FP-CIT (N-fluropropyl-2β-carbomethoxy-3β-4-[123I]

iodophenyl tropane), 123I-β-CIT, and the PET ligand 18F-dopa ([I18F] flurodopa)

35 | P a g e
 can be used to image the presynaptic dopaminergic terminals in the corpus
striatum.

• The 123I-FP-CIT agent is also known commercially as the 'DaTSCAN'.

• Following the intravenous administration of 123 I-FP-CIT, 123 I-β-CIT, or 18 F-

dopa to the individuals, the uptake in the corpus striatum will appear as two mirror
image commas

The importance of an accurate diagnosis

• It can be extremely important to the psychiatrist/neurologist to be aware as to

whether the cognitively impaired patient has DLB or a non-DLB form of dementia.
Most importantly there has to be a judicious use of antipsychotics (neuroleptics) in
patients with cerebral Lewy bodies.

• In a patient with Lewy body dementia, the presynaptic dopaminergic terminals

will be markedly reduced and therefore there will be less dopamine produced into
the synaptic cleft. The effects of antipsychotics are to blockade the D2 receptors.
This will therefore exacerbate the situation within the synapse in that the relatively
little dopamine being produced is not able to interact with the blockaded post-
synaptic D2 receptors. This can provoke a parkinsonian crisis in up to 80% of
patients with DLB who are administered antipsychotics, which can be fatal in
approximately 50% of these cases.

• Consequently, the first line of treatment for psychotic symptoms in DLB patients
are acetylcholinesterase inhibitors and when anti-psychotics are used as the second
line treatment they have to be introduced with extreme caution at a low dosage.

• Cholinergic therapy for the cognitive impairment is effective, and indeed maybe
more effective in DLB patients than in AD patients which is most probably as a
consequence of the greater cerebral cholinergic deficit in the former. Hence,
cholinergic therapy in DLB is the initial treatment of choice, both for the cognitive
and psychiatric manifestations.

• Awareness of the presence of cortical Lewy bodies by the clinician can increase
their confidence in the management of these complex DLB patients. As the disease
progresses there has to be a fine balance between preserving movement or
cognition, as the introduction of anti-psychotics as second line treatment for
psychosis will exacerbate the parkinsonian symptoms.

LEWY BODY DEMENTIA- EXPLANATION

36 | P a g e
• Dementia with Lewy bodies is a form of dementia that shares characteristics with
Alzheimer's and Parkinson's disease.

• It accounts for around 10% of all cases of dementia in older people and tends to be under-
diagnosed

• It is more prevalent in people over the age of 65

• It appears to affect men and women equally

Etiology: The cause of dementia with Lewy Body is still unknown. It is considered to be a
neuro-degenerative disorder associated with abnormal structures, which are called Lewy
Bodies, found in certain areas of the brain. These are spherical tiny protein deposits and the
presence of these structures in the brain disturbs the brains normal functioning, can
interrupt the action of some important chemical messengers in the brain, including acetyl
choline and dopamine. It is still not yet fully understood how they cause damage in the brain.

Clinical presentation: DLB can be difficult to diagnose and a specialist usually does this. In
addition to memory problems patients with DLB experience, hallucinations, motor
impairment due to Parkinson's disease and fluctuating alertness.

People with Dementia of Lewy Body will have the following:-

1. Motor symptoms such as tremor and rigidity with decreased muscle activity resulting
in muscle stiffness, which may fluctuate greatly, making some days more difficult than
others.

2. Frequent visual hallucinations which are well formed and detailed

3. Fluctuations in alertness and consciousness

4. Increased sensitivity to some drugs which act on the brain, especially antipsychotic
medication

The progression of this disorder occurs in a similar fashion to Alzheimer's disease and the
patients will experience a steady decline in their cognitive ability.

Investigation: There is no specific investigation to diagnose Lewy Body Dementia. The

diagnosis of Dementia with Lewy Body remains a clinical one. Blood tests and brain scans
are performed in these patients and they are aimed at excluding other causes for the
symptoms rather than confirm the diagnosis.

Treatment: At present there is no cure for Dementia with Lewy Body. Patients with Lewy
Body Dementia may require different types of medication:-

37 | P a g e
 a. Anti Parkinsonian medication which are used to treat the motor symptoms of
Parkinson's Disease

b. Although the cholinesterase inhibitor drugs are not licensed for treating Dementia
with Lewy Body recent research suggests that drugs like Rivastigmine may be useful
in treating Dementia with Lewy Body. Recent guidelines from the National Institute
of Clinical Excellence do suggest that these drugs should be considered, especially for
people who have non cognitive symptoms like apathy and hallucinations, causing
significant distress or leading to behaviour that challenges.

c. Anti psychotic medication should be used with extreme caution as these patients are
often very sensitive and it should be used carefully to avoid the increase in severity
of symptoms. It is preferable to find ways of dealing with a person's distress and
disturbance that do not involve medication. Under no circumstances should
antipsychotics be prescribed as a substitute for good quality care

d. If prescribed in exceptional circumstances like instances of extreme distress, high risk

of harming themselves or others, then they should be prescribed with utmost care
under constant supervision and should be monitored regularly.

e. A lot of these patients may also tend to develop depression and anti depressants may
be used to treat symptoms of depression.

The likely prognosis is generally poor as there is no specific treatment to reverse the
progression of the disease.

(Ref: www.alzheimers.org.uk, Dementia-Questions answered- Brown and Hillam)

38 | P a g e
Lesson 9:

TOPIC 1: CLOZAPINE - METABOLIC SYNDROME

TOPIC 2: PSYCHOSIS - MENTAL STATE EXAMINATION- DOMINIC-
FOOTBALLER
TOPIC 3: EROTOMANIA - ASSESS DANGEROUSNESS
TOPIC 4: SUBSTANCE MISUSE IN PREGNANCY - ASSESSMENT
TOPIC 5: REFEEDING SYNDROME
TOPIC 6: HYPOCHONDRIASIS - DISCUSSION

1|Page
Topic 1:

CASC LESSON 9
CLOZAPINE-METABOLIC SYNDROME
Mr. John Richards has a long history of schizophrenia and has been stable on Clozapine for
the past 5 years. He attends the rehabilitation physical health clinic on a clinic yearly
basis. He had his routine blood tests to monitor his physical heath status whilst he is on
medication.

Values

• Fasting blood sugar-6.1 m mol/L (Normal value- 35-5.0 m mol/L)

• Blood pressure- 146/90 mm Hg

• HDL-Cholesterol- 30 mg/dl (less than 40 mg/dl is associated with an increased risk

of heart disease)

• Fasting triglycerides- 2.7 mmol/L (Normal -- Less than 1.7 millimoles per liter
(mmol/L), Borderline high -- 1.8 to 2.2 mmol/L, High -- 2.3 to 5.6 mmol/L)

• Waist circumference- 108 cm (38 inches) (Waist circumference of more than 88 cm

in women and 102 cm in men is considered as obese)

He is doing really well on clozapine treatment. He has no unusual ideas and do not have
hallucinations. Explain the results, check for risk factors and discuss future management.Do
not take a history. Do not perform a physical or mental state examination.

CASE SYNOPSIS

You are a middle aged and overweight woman with a long history of schizophrenia. You've
been stable on Clozapine for the past 5 years and your mental health has been the best
ever. Your recent blood tests show that you have now developed high cholesterol and high
fasting blood glucose. The only issue is having put on weight, about 15 kgs over 2-3 years
and struggling walking due to the pressure on your knees. The doctor will explain that you
are suffering from metabolic side effects of clozapine featured by obesity, high cholesterol
and diabetes/raised blood sugar levels. This is a common side effect of clozapine and
occurs as a direct negative effect of this medication. You are anxious that the doctor may
stop clozapine. The doctor should discuss options, one of which is to stop clozapine. You
are adamant that you don't want to stop clozapine as you have been so well on it. Good
doctors will reassure and discuss other options.

Topic: CLOZAPINE INDUCED METABOLIC SYNDROME

2|Page
Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Check for features of metabolic syndrome

(Weight gain, impaired glucose tolerance,

hyperlipidemia)
Explain the results and educate it is a sign of
antipsychotic induced metabolic syndrome
(most likely)-(Frequency of metabolic
syndromewas 2-4 times higher for patients
on antipsychotics)
Refer patients with abnormal glucose or
lipid levels for medical opinion
Dyslipidemias-dietary advice & counselling,
life style changes, and or treatment with
statins
Weight gain- Encourage weight loss, Regular
exercise, Healthy diet,

controlled behavioral programs

Diabetes- Refer to GP for further testing,
OGTT

Controlling serum glucose levels with the

use of hypoglycaemic agents.
Switching- not generally recommended as a
strategy in patients with treatment resistant
illness
Be alert to the possibility of diabetic
ketoacidosis and Clozapine-induced
hyperglycaemia may be serious leading to
coma

3|Page
 Allay patients anxiety regarding stopping of
clozapine

Consider alternatives as last choice if all

measures fail
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
7 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
8 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

Reading notes

Metabolic syndrome in schizophrenia:

Metabolic syndrome is a cluster of disorders comprising

• Obesity (central and abdominal)

• Dyslipidaemias

4|Page
 • Glucose intolerance, insulin resistance (or hyperinsulinaemia) and

• Hypertension

World Health Organization criteria for metabolic syndrome:

Insulin resistance and/or impaired fasting glucose and/or impaired glucose tolerance AND
two or more of the following:

1. Waist - hip ratio >0.90 (men), >0.85 (women) OR body mass index >30 kg/m2;

2. Triglyceride level >1.7 mmol/l OR high-density lipoprotein <0.9 mml/l (men), <1.0
mmol/l (women);

3. Blood pressure >140/90 mmHg (or treated hypertension);

4. Microalbuminuria (this is not presented in some revised criteria for metabolic

syndrome)

Itis highly predictive of type 2 diabetes mellitus and cardiovasculardisease.

• Diabetes Mellitus is twice as prevalent among schizophrenia cohorts than in the

general population

• Both typicals and atypicals increase the risk of metabolic syndrome in

schizophrenia manifold. But antipsychotics cannot explain all the metabolic
dysfunctions noted in schizophrenia.

• There is a four-fold risk of metabolic syndrome in patients with schizophrenia

compared with the general population (Saari et al 2005)

• In Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia

Trial baseline data (n = 689), the metabolic syndrome prevalence was found to be
51.6% for females and 36.0% for males.

• Females with schizophrenia have higher risk than males with schizophrenia when
compared with reference population.

Second-generation antipsychotics and metabolic syndrome

Ranking on the basis of relative risk for development of metabolic syndrome:

• Clozapine (highest risk)

• Olanzapine

5|Page
 • Quetiapine

• Risperidone

• Aripiprazole

• Ziprasidone (lowest risk)

• Mean weight increases during the first year of therapy

• 12 to 14lb for clozapine (5 to 6 kg)

• 15 to 26lb for olanzapine (7 to 12kg)

• 6 to 12lb for quetiapine (2.5 to 5kg)

• to 5lb for risperidone (2 to 2.5kg)

• Less than 2lb for Ziprasidone and aripiprazole

• For patients with schizophrenia, the best-studied options for weight control include
diet and exercise. But controlled behavioral programs for weight reduction in
schizophrenia have high dropout rates and are not always accessible. Switch to
relatively weight neutral drugs can be considered in resistant cases.

• While the onset of weight gain, hyperglycemia, increased glucose levels, or diabetes
may be signs or symptoms of antipsychotic-induced metabolic syndrome, physicians
should nevertheless continue to treat a patient's mental disorder. Discontinuing the
antipsychotic is not generally recommended as a strategy in patients with treatment
resistant illness

• Careful monitoring of at-risk patients may aid in the prevention of metabolic

syndrome as well as the management of any potential symptoms should they occur.

Monitoring Tips for Metabolic Syndrome

• Physical examination: Weigh patients, check blood pressure, waist circumference

and track BMI at each visit

• Take a history and record whether known risk factors are present or absent at
baseline and monitor at regular intervals

6|Page
 • Perform baseline laboratory tests including fasting glucose, fasting lipids, total
cholesterol, Low density lipoproteins (LDL), high density lipoproteins (HDL),
triglycerides, alanine aminotransferase (ALT) and gamma glutamyl transferase (GGT)

• The choice of antipsychotic medication should be based on the cardio metabolic risk
profile of each medication

• Perform Physical examination and Repeat Laboratory tests at week 6, week 12, week
52. After 1 year if all the laboratory tests are within normal range, repeat tests
annually

General recommendations for managing metabolic syndrome

• Diet modification - advise the patient to:

• Avoid saturated fat (eg red meat, egg yolks, fried food)

• Eat food low in calories

• Eat fresh fruit and green vegetables

• Encourage moderate exercise (e.g. walking, swimming, cycling) for 30-40 minutes a
day, three or four times a week

• Set the patient the target of losing weight between each out-patient visit

• Control blood pressure using antihypertensives to achieve <140/80 mmHg

• Optimise lipid levels by diet modification or statins: aim to achieve fasting LDL
cholesterol <3 mmol/l; HDL cholesterol >1 mmol/l; triglycerides <20 mmol/l

• Refer patients with abnormal glucose or lipid levels for medical opinion

(Gurnell 2001)

Ref: Metabolic syndrome in psychiatry: advances in understanding and management

Cyrus S. H. Ho, Melvyn W. B. Zhang, Anselm Mak and Roger C. M. Ho

Clozapine and Diabetes

When GPs, diabetes specialists or diabetes outreach services are contacted by psychiatric
wards for advice on diabetes management in people being

treated with clozapine, the psychiatric team are generally advised that clozapine may be a
causative agent and to consider lowering the dose of clozapine or ideally changing to

7|Page
an alternative antipsychotic drug. In cases where clozapine is the only effective drug,
attempts to control the deranged blood glucose levels with oral antidiabetes drugs
and insulin could be attempted but only if reasonable stability of blood glucose levels can
be achieved. If this proves unsuccessful, there is likely to be no feasible option other than
discontinuing clozapine and managing the psychiatric complications using all alternative
measures.

Oral glucose tolerance test (OGTT) is considered as the most sensitive method of detection.
Fasting plasma tests (FPG) are less sensitive but recommended. HbA1C is increasingly
being recognized as a useful tool in detecting and monitoring diabetes.In addition, all
patients should be advised to report signs and symptoms of diabetes (fatigue, candida
infection, polyuria or increased thirst).

Recommended monitoring for diabetes in patients receiving antipsychotic drugs

Time Ideal test

Baseline OGTT or FPG, HbA1C if fasting not possible (+RPG)

Continuation All drugs: OGTT or FPG or HbA1C every 12 months

(+RPG)

For clozapine and Olanzapine or if other risk factors are present- OGTT or
FPG after 1 month, then every 4-6 months. RPG-Random plasma glucose,
FPG- Fasting plasma glucose, OGTT- Oral glucose tolerance tes

Monitor at-risk patients on initiation of clozapine

• In some cases continuation of clozapine is possible by controlling serum glucose

levels with the use of hypoglycaemic agents. This approach may be useful in
refractory schizophrenia responsive to clozapine.

• In some cases the condition has been of new onset, and in others exacerbation of
pre-existing diabetes mellitus has occurred.

• Hyperglycaemia appears to be of early onset (2 weeks to 3 months after initiation of

clozapine) and to occur without predisposing factors.

• In those with diabetes mellitus, glucose monitoring should be conducted in

conjunction with the obligatory haematological monitoring.

• Glycaemic control following initiation of clozapine should be monitored in diabetics

and should be considered in those with a family history of diabetes mellitus or a
personal history of hyperglycaemia (e.g. gestational or drug-induced)

8|Page
 • There are also pharmacologic options for preventing type 2 diabetes; recent studies
have shown that metformin can be added to a patient's drug regimen to not only
prevent metabolic changes, but also to treat atypical antipsychotic-induced type 2
diabetes.

• Clozapine-induced hyperglycaemia may be serious leading to coma, but it is

reversible on discontinuation of clozapine.

• Hyperglycemia, sometimes leading to ketoacidosis or glycosuria, has been reported

in association with clozapine

Ref: Thakore, J. H. (2005) Metabolic syndrome and schizophrenia. British Journal of

Psychiatry, 186, 455 -456

Clozapine and refractory diabetes treatment- Nuwan Galappathie, Rajendra Harsh

(www.thejournalofdiabetesnursing.co.uk/media/content/_master/3227/files/

http://www.medsafe.govt.nz/profs/puarticles/cloz.htm)

Stahl S. The metabolic syndrome: psychopharmacologists should weigh the evidence for
weighing the patient [BRAINSTORMS]. J Clin Psychiatry 2002;63:1094-1095

Hyperlipidemia and antipsychotics

Monitoring lipid concentrations in patients receiving antipsychotic drugs

Antipsychotic drug Suggested monitoring

Clozapine, Olanzapine Fasting lipids at baseline, then every 3

months for a year, then annually

Other antipsychotics Fasting lipids at baseline and at 3

months, then annually

Treatment

• If moderate to severe hyperlipidemia develops during the course of antipsychotic

treatment, a switch to another antipsychotic less likely to cause this problem should
be considered in the first instance.

• This is not generally recommended as a strategy in patients with treatment

resistant illness

• Aripiprazole seems at present to be the treatment of choice in those with prior

antipsychotic induced dyslipidemias.

9|Page
 • Patients with high cholesterol may benefit from dietary advice, life style changes,
and or treatment with statins

• When triglycerides alone are raised, diets low in saturated fats and the taking of
fish oil & fibrates are effective treatments

Adverse effect Suggested drugs Alternatives

Dyslipidaemia Amisulpride

Aripiprazole

Ziprasidone
Impaired glucose tolerance Amisulpride Risperidone

Aripiprazole

Ziprasidone
Weight gain Amisulpride Quetiapipne

Aripiprazole Risperidone

Haloperidol Ziprasidone

Trifluoperazine
Note: There is evidence that both switching and co-prescription of Aripiprazole are
effective in reducing weight, dyslipidemia and impaired glucose tolerance.

(Ref: The Maudsley prescribing guidelines- 11th edition-Pg 24-25, 130-139)

10 | P a g e
Topic 2:

CASC LESSON 9
PSYCHOSIS-MENTAL STATE EXAMINATION
TASK: You are seeing Mr Domink Andrzej, a 27-year-old professional football player in the
casualty department. His father took him to the GP surgery this morning, as he was
concerned about his mental state. His father has noticed that his son is displaying odd
symptoms. On several occasion his father observed him making false allegations against his
manager. He decided to seek professional help for his son and he was referred to see a
psychiatrist. The psychiatrist recommended seeing a counsellor. However he has refused to
see a counsellor because he thought that they won't believe what he was saying. Then he
was lost to follow up and his mental state has deteriorated significantly. So he took him to
the GP again, who referred him to the A&E department for an urgent psychiatric evaluation.
He plays for the national league team, Tottenham. He has played on a professional level
since the age of 16. He lives with his father. Sadly his mother died of breast cancer 7 years
ago. He gets on very well with his father. His father works as a bus driver and came from
Poland 30 years ago, after meeting his British mother.He had a few girl friends in the past
and the relationships usually lasted for 1-2 years. He doesn't drink alcohol and don't take
any recreational drugs. He has a few good friends and socialize well with people.

Perform mental state examination to come to a diagnosis at the end.

CASE SYNOPSIS

You are Mr Dominik Andrzej, a 27-year-old professional footballer. You play for the
national league team, Tottenham. You live with your father. Sadly your mother died of
breast cancer 6 years ago. Your father came from Poland 30 years ago, after meeting your
British mother.. Your father took you to the GP surgery this morning, as he was concerned
about your mental state. The GP referred to the A&E department for an urgent psychiatric
evaluation, as he thinks something is wrong in your mental state. About 8 weeks ago, whilst
you were playing in a football match, you heard the opposing crowd chanting racist abuse.
You heard them saying 'Go home pole', which upset you greatly. Then a week later, in
another match, you heard it again when you were playing in, from supporters of the
opposite team. You reported this incident to your manager but he ignored it. When you are
in the dressing room, you heard voices discussing at one point. There were 2 men who
were discussing about you and saying it was because you were polish. You don't know
these men at all and not sure why they have said this. You did not see them. It was so real
and you are sure you heard it.

You spoke to your close friend Tom who is your teammate and he dismissed your feelings.
You really think that racism is still alive, it is kicking in football and people are ignoring
your concerns. You heard a voice behind you, to your right. You think you are hearing the
voice of the devil. You heard it several times a day for the last month or so. It also talks to
you directly and always says you should go home. It is always behind you and on your right

11 | P a g e
side. You believe god is with you and so things are OK. You are unsure as to how you can
deal with this racism. You mentioned it to your father quite a few times lately.

Topic: PSYCHOSIS-MSE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit hallucinations-

Modality, source, timing, reality with which

it is experienced
2nd/3rd person hallucination

Command/running commentary etc

Elicit and explore other Psychotic symptoms

(Paranoia, ideas of reference etc)

Seek explanation for psychotic experiences

Assess degree of conviction

Effects and coping

Risk assessment

(Self-harm, self neglect, violence, drug and

alcohol misuse etc)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee

12 | P a g e
 3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
Specific Comments and suggestions

Reading materials_: Please read mental state examination in LESSON-1

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Topic 3:

CASC LESSON 9
EROTOMANIA-ASSESS DANGEROUSNESS
TASK: A young man has come to the hospital reception and demanded to speak to a staff
nurse, that he is in love with. The receptionist has asked you to see him.

Obtain a history to assess his thoughts and beliefs

Establish the level of dangerousness.

CASE SYNOPSIS

You're a 27-year old unemployed man living alone. You attended your local A&E dept. 3
months ago thinking you'd suffered a heart attack. Passed fit by the A&E doctor, you then
saw a psychiatric nurse, Emma White. She did relaxation exercises with you and was very
nice. You feel intense feelings of love for her; you find yourself thinking about her all the
time. You are convinced she's in love with you. There's no evidence to support this except
she smiled at you in a way no one has before. You've vivid thoughts about having sex with
her. You went to the mental health unit reception asking for her; the receptionist didn't co-
operate. You became verbally abusive/threatening towards the receptionist who called a
doctor to see you. Strongly deny any intention to harm her. Towards the end of the
interview you are determined to force people to take notice of you. You may even use
weapons. You don't have mental health symptoms.

Topic: EROTOMANIA- ASSESS DANGEROUSNESS

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor

14 | P a g e
 Begin by asking neutral questions to establish
rapport and keep control of the interview,
terminating it if necessary.
Explore the level of information known about
the other person (whom he is in love with)

Familiarity, closure, previous meetings,

email, mobile address, living address,
observations, Does he know if she has a
partner already? Etc
Delusions of love- elicit, explore and clarify,
effects and coping
Assess fixity and degree of conviction

Seek explanation for content of delusional

beliefs
Risk assessment- Aggression, violence,
stalking, threatening acts,

Self harm, thoughts of harming the

concerned person)
Past history, psychiatric history, drug and
alcohol history
Forensic history, Psychosexual history-
sexual fantasies and deviant sexual practices
Be able to take control of the interview and
demonstrate positive ability to deal with
angry patient
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)

15 | P a g e
 Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed

EROTOMANIC DELUSIONS- ASSESS DANGEROUSNESS

Part A: Erotomania - Assess

(Compiled by Dr. Mark Tarn & Dr. Sree Murthy)

A young man has come to the hospital reception and demanded to speak to a staff nurse, that
he is in love with. The receptionist has asked you to see him. Obtain a history to assess his
thoughts and beliefs. Establish the level of dangerousness.

•In a real life you would begin by deciding the appropriateness of the
receptionist's request.

• Background information would be needed, who is this man?

• Is he a current or ex-patient of the unit?

• Is the nurse in question aware of his visit?

• Does she understand why he has turned up unannounced?

• In the real situation you are likely to be involving the police from the start and they
will probably be in the best position to interview this man with the team's advice.

16 | P a g e
The CASC station does instruct you to interview him, how should you proceed?

Firstly, normally you would not interview him alone and you would be cautious regarding
him carrying any weapons (there may be a search facility).

An appropriate interview room would be selected, with the patient furthest from the door
and you having access to an alarm.

Explain to him the limits of confidentiality.

How to approach this situation;

• When assessing dangerousness, it is extremely important to consider about static

and dynamic risk factors.

• When talking to the patient, the examiner would expect candidates to be

empathic and offer support/ validation for his distress.

• They should approach him in a non-confrontational and non-judgmental manner.

They should ask very open questions initially and try to build rapport.

Areas to be targeted in the history

1. Beginning by asking neutral questions to establish rapport and keep control of the
interview, terminating it if necessary.

Where is the patient from?

Who does he live with? Is he employed and as what?

2. Ask him to tell you about the nurse.

• How did they meet?

• Was it through his mental health needs?

• What does he believe is the quality of their relationship?

• How does he know that? (ask for evidence)

• How much does he know about the nurse?

• Is this the first time he has sort her out?

• Does he know he know her mobile/email address?

17 | P a g e
 • Does he know where she lives?

• Has he been there?

• Has he been observing her?

• Does he know if she has a partner already?

• What will he do about that?

Check the conviction of his beliefs - could he have misinterpreted her actions/words? Was
she not just doing her job?

3. Enquire about his mental health history

• Is he a patient of mental health services?

• What is his diagnosis?

• What medication is he on?

• Does he have symptoms of mental illness now? Paranoia?

• Is he taking his meds?

• How does he usually cope with stress?

• Has he taken it as prescribed?

• Self harm in past? Current MSE.

4. Drug & Alcohol history, forensic history, personality- static factors

• Ask about drugs and alcohol- Does he use alcohol or drugs?

• His forensic history and history of violence? When did he first get into trouble with
the police?

• Ask about previous offending and any custodial sentences?

• Have similar episodes happened but they've not been brought to the attention of the
criminal justice system? Any offences against the person?

• What is his personality like? Is he impulsive or short tempered? Does he have

antisocial/ procriminal attitudes?

18 | P a g e
 1. Previous similar presentation and psychosexual history

• Has this happened with anyone else (unfrequented love)?

• What were the circumstances?

• Ask about psychosexual history (particularly fantasises and other partners).

6. Current thoughts and plans:

• What will he do with the nurse if they meet?

• What are his thoughts if his feelings are not reciprocated?

• Would he hurt the nurse? Would he become suicidal?

• Does he have current thoughts of violence- or suicide?

• Does he have access to weapons?

• Lastly, what will he do now if he can't see her and she has informed staff that she
never wants to see him?

Reasons for failing in this station:

1. If the candidate could not take control of the situation/ be empathic to his distress.
2. If the candidates did not perform a brief MSE looking at psychotic and mood
symptoms.
3. If the candidate did not ask about several static and dynamic risk factors- especially
about thoughts of violence/ homicide/ weapons/ substance misuse/ forensic
history.
Part B: Erotomania - Case discussion & risk management

You assessed this man earlier. Later staff told him that he can't see her. He became aggressive
and waved a knife. He was overpowered, arrested, taken to the police station, but was
released by mistake. He is now loose in the community. Discuss this situation with the nurse
and answer her questions.

Explain your Risk assessment and Risk management plan.

• Firstly, any planning (including the reduction of risk) can only be carried out with
close liaison with the police. The candidate is the best informed regarding the patient
and he/she will have already relayed that information to the police.

19 | P a g e
 • The nurse should be encouraged to seek the police's advice at the end of the
interview with appropriate support. The consultant is on his/her way in.

• The risk to the nurse has primacy over the confidentiality owed to the patient,
because of the immediacy of action required. This does not mean that the candidate
has to provide all information provided by the patient but it should be proportional
and relevant to the risk.

•The patient may know where the nurse lives, her mobile number and her normal
routines. You should explore with the nurse if it is feasible for her to stay with
friends/relatives and ensure advice is taken from the police.

• Useful questions

• Does she need to return to her accommodation to pick up items?

• Will the police escort her?

• Is there a member of staff that can escort her to her car/bus stop?

• Who can she call for support?

• How will her work commitments be affected?

The nurse may well ask as what will be the likely outcome of his inappropriate contact. An
honest answer should be given and avoid over reassurance if groundless.

20 | P a g e
Topic 4:

CASC LESSON 9
SUBSTANCE MISUSE IN PREGNANCY- ASSESSMENT
TASK:Miss Janet Atkinson is currently under the care of community drug treatment
services, currently on methadone prescription and she thinks that she might be pregnant
now. Take a history to clarify her current drug and alcohol use including prescribed
medication. Elicit the concerns that the woman has about the pregnancy and about her
social support. Do not carry out a full mental state examination. You may wish to take
notes, as in the next station you will speak to the patient's partner who will want to know
what the risks to the baby are.

CASE SYNOPSIS

SUBSTANCE MISUSE IN PREGNANCY- ASSESSMENT

You're a 25-year-old single woman who has been on treatment for heroin addiction for 6
months. Recently you've been taking methadone, 50 mg dispensed on a daily basis. You
think you may be pregnant. You have 1 other child; a boy aged 6 who live with your
mother. You were well during the pregnancy, giving up drugs and alcohol. You started
using drugs due to depression following childbirth. Your parents applied for a residency
order for your son. Social services were involved and you have access only if supervised by
your mother. You have recently begun a relationship with a patient in the drugs service. He
insists you stop taking drugs, as now you're pregnant. You've been injecting into your groin
veins. You aren't currently experiencing any withdrawal symptoms. You've recently tested
negative for blood borne viruses. You've never shared needles but have had unprotected
intercourse with other drug users. You've used cannabis and crack on and off since you
were 15.

Topic: SUBSTANCE MISUSE IN PREGNANCY- ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor

21 | P a g e
 Obtain a history that picks up the relevant
information about illicit drug and alcohol use
(heroin, methadone and crack/cocaine)
Explore the duration and extent of the
problem (including street costs)
Explore mode and practice of administration
(injection sites)
Engagement in risky behaviours (sharing
needles, unprotected intercourse etc)

Check where they buy needles/dispose

needles etc
Explore withdrawal effects/ abstinence,

Previous treatments (needle exchanging

programme)
Ask about how things have been going in
drug treatment
Explore circumstances of her pregnancy
including her feelings about the pregnancy
Elucidate mood symptomatology
Obtain relevant personal history, Past
psychiatric history & Engagement
Social history- current social circumstances
and explore her support network
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task

22 | P a g e
 Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
ELICIT ILLICIT DRUG HISTORY (OPIOD MISUSE)

The areas to be explored are:

1. Current usage

2. Longitudinal history

3. Look for features of drug dependence

4. Complications-physical, mental, social and legal

5. Assess Insight and motivation

6. Risk assessment-sharing needles, unsafe sex etc

7. Rule out alcohol and use of other substances

SUBSTANCE MISUSE IN PREGNANCY

Important points about heroin and methadone in pregnancy

• The candidate is expected to discuss all the risks associated with drug use in
pregnancy

• It is important that they explain that methadone and heroin are not teratogenic.

• Continued use of heroin might provoke miscarriage or intrauterine death

• The candidate should explain that drugs being used cross the placenta and after
birth the baby might experience neonatal abstinence syndrome

23 | P a g e
 • It is important to monitor baby for signs of opioid withdrawal as well as possibly
that the baby might need to be treated

• Also it is worth mentioning that babies born to mothers on heroin alone were
more likely to be premature and small for dates. These effects could be reduced
when the mother is stable on methadone

• Opiate withdrawal syndromes in babies include irritability, high pitched cry,

jitteriness, sneezing and colic.

Important points about use of cocaine/crack in pregnancy

• Also cocaine or crack is associated with some teratogenecity of genitourinary system

and bones of the skull

• Discuss risk of placental abruption with cocaine use

• Use of cocaine and crack do result in abstinence syndrome after birth

• There is a higher incidence of sudden infant death syndrome when using

cocaine/crack

Role of social services

• Social services: Some men and women worry that their baby may be taken away
by social services. Their baby may be 'taken into care' because they misuse drugs.
Opioid misuse in itself is not a reason to involve social services or to assume that
they can't be good parents and cannot care for their baby. However, if there are
significant concerns abut the safety and welfare of the child, the involvement of
social services will become absolutely necessary. But this rule is applicable for
people who don't use any drugs too.

• Social services would be involved if there are concerns about neglect or harm to
children or if the pattern of drug use would lead to risks to the children (involving
children in drug seeking activities).

PREGNANCY AND OPIOID USE

• Substitute prescribing can occur at any time in pregnancy and carries a lower risk
than continuing illicit use.

• The emphasis must therefore be on early engagement in treatment, and,

methadone maintenance treatment during pregnancy, in the context of a
multidisciplinary team (including obstetricians, neonatologists and addictions

24 | P a g e
 specialists) and detailed holistic package of care, (including comprehensive
psychosocial input); this is currently regarded as the gold standard.

• Stability on prescribed medication and attendance at antenatal clinics are the

main goals of treatment.

Principles of managing pregnant opioid user:

Therapeutic alliance

Aim to reduce risk-taking behaviours (sharing needles,

prostitution).

Stabilize on non-injectable alternatives such as methadone.

If considering detoxification, this should be done in the middle

trimester - avoid first trimester for the fear of abortion and last
trimester for the fear of premature birth.

Close liaison with obstetric, midwifery, and paediatric teams, and

with social services where appropriate.

HIV and hepatitis screening (vaccination where appropriate).

• Stabilization on an oral substitute drug should always be the initial aim.

• Ideally, the mother should be encouraged to become abstinent prior to delivery--

often this may not be possible.

• If detoxification is planned, it should be carried out with caution in the second

trimester of pregnancy

• If pregnancy begins while a woman is taking high doses of methadone, the dosage
should be reduced slowly (e.g., 1 mg every 3 days), and foetal monitoring must be
carried out closely.

• It is important to stabilize opioid misusers who are on methadone and the dose
may need to be increased in the third trimester due to increased metabolism

• Maternal metabolism of methadone may increase towards the third trimester of

pregnancy. At this time, an increased methadone dose may be required or
occasionally split dosing on the medication to prevent withdrawal.

• There is no clear relationship between maternal methadone dose and the

intensity of neonatal withdrawal but lower doses (15 mg) are advocated during
maintenance.

25 | P a g e
 • The main effects on unborn baby due to opioid misuse during pregnancy are low
birth weight and pre term delivery. It is important to explain that higher the doses
and duration of substance misuse and intake, the greater is the risk to the foetus

• Methadone is not a contraindication to breast feeding but local policies may vary.

• Less data are available for buprenorphine maintenance but it appears similar
benefits are seen for mother and foetus as for methadone

• The risks to the mother and baby are least on methadone.

• Psychosocial interventions: Consider family or couples therapy (as pregnant

women often have substance misusing partners)

• Social services: Some men and women worry that their baby may be taken away
by social services. Their baby may be 'taken into care' because they misuse drugs.
Opioid misuse in itself is not a reason to involve social services or to assume that
they can't be good parents and cannot care for their baby. However, if there are
significant concerns abut the safety and welfare of the child, the involvement of
social services will become absolutely necessary. But this rule is applicable for
people who don't use any drugs too.

Opiate withdrawal syndrome in babies;

• Usually begins 24-48 hours after birth, depending on the time of last dose.

• However, signs may not appear in the infant until 3-4 days after birth.

• Hyperirritability, gastrointestinal dysfunction, respiratory distress, and vague

autonomic symptoms (eg, yawning, sneezing, mottling, fever). Tremors and jittery
movements, high-pitched cries, increased muscle tone, and irritability are common.

• Normal reflexes may be exaggerated. Loose stools are common, leading to

possible electrolyte imbalances and diaper dermatitis.

• Methadone withdrawal symptoms typically appear within 48-72 hours but may
not start until the infant is aged 3 weeks. Milder with buprenorphine withdrawal.

• The majority of neonates born to methadone-maintained mothers will, however,

require treatment for neonatal abstinence syndrome (NAS).

Pregnancy and breast feeding - methadone:

26 | P a g e
 • Major risk is via injection to the baby - infection and the effects of drug itself
causing stillbirth, premature birth, antenatal complications, low birth weight,
microcephaly and neonatal withdrawal.

• Although the newborn may experience a withdrawal symptom, as described,

there is no evidence of an increase in congenital defects with methadone.

• Methadone is considered compatible with breast feeding, although other risk

factors, such as HIV, hepatitis C, use of benzodiazepines, cocaine and other drugs
need to be considered and may mean that breast feeding is contra-indicated.

• The Clinical Guidelines recommend that breast feeding should still be encouraged,
but that with regards to methadone and breast feeding "the dose is kept as low as
possible while maintaining stability, and the infant monitored to avoid sedation.”

Pregnancy and breast feeding - buprenorphine:

• Currently there is insufficient evidence, regarding the use of buprenorphine as an

opioid substitute treatment during pregnancy or breastfeeding to be able to define
its safety profile. More evidence is available on the safety of methadone, which, for
that reason, makes it the preferred choice.

• However, women well maintained on buprenorphine prior to pregnancy may

remain on buprenorphine following full informed consent and advice that safety of
buprenorphine in pregnancy has not been demonstrated.

• Please note buprenorphine is not licensed for use in pregnancy and should not be
initiated in this circumstance by a non-specialist.

Ref: The 10th Maudlsey prescribing guidelines- Pg 316-317

27 | P a g e
Topic 5:

CASC LESSON 9
REFEEDING SYNDROME
TASK: You are about to speak to a CAMHS CPN Ms. Jennifer Davies with regards to Jane (16
year old girl) who has a diagnosis of anorexia. The CPN has been seeing Jane at home in the
last 2 weeks to monitor her weight and diet. Last week, Jane's mum had pushed Jane to eat
a lot and as a result she has gained 3kg in 1 week. GP has done blood tests a week ago,
which are normal except she has slightly low phosphate levels. The CPN has asked to speak
to you as she is worried about Jane. Address her concerns.

Explain the cause of the symptoms she has noted and discuss management. Do not take
history.

CASE SYNOPSIS

RE-FEEDING SYNDROME

You're a new CPN and your patient is a 16-year-old girl who has anorexia nervosa. You've
known her for only 2 weeks. You are seeing her at home. Last week, her mum had pushed
her to eat a lot and as a result she has gained 3kg in 1 week. However, her hands and feet
have swollen up and she developed difficulty swallowing. You are concerned about her.
Suggested prompt questions;

• What do you think is wrong with her?

• What could have caused this?

• What should we do with her now?

• Why have her hands and feet become swollen?

• Why would she have trouble swallowing?"

• What could have been done to prevent this?

Topic :REFEEDING SYNDROME

Candidate Name: Candidate Number:

28 | P a g e
Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain diagnosis of Re-feeding syndrome

Reassurance and offer clear explanation for

current presentation

(Risks of re-feeding)
Discuss the possible causation of re-feeding
syndrome
Explain common Clinical presentations
Explain physiological mechanism

(Sudden shift from fat to carbohydrate

metabolism and a sudden increase
in insulin levels after refeeding)
Concerns- Swollen hands & feet (sudden salt
shift & cardiac decompensation)
Concerns- Swallowing difficulties (Low
phosphate causing muscular problems)
Discuss complications

(Respiratory failure, heart failure,

arrythmias, seizures, coma )
Discuss Management of the condition
(Correct electrolyte
imbalance, Prescribing thiamine, vitamin
B complex (strong) and a multivitamin and
mineral is recommend)
Discuss Prevention (very cautious approach
to nutrition and re-feeding, Gradual built up
of calorie intake)
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

29 | P a g e
 (Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Does not discuss signs and symptoms competently
9 Use of medical jargon without explanation
10 Inaccurate or misleading information discussed
11 Limited or Incomplete management plan

RE-FEEDING SYNDROME

• Refeeding syndrome is a high risk condition associated with cardiac

decompensation and sudden death

• It occurs when refeeding is undertaken too quickly without adequate attention

being paid to electrolye imbalance

• The risk is very high in the first 2 weeks.

•This syndrome can occur at the beginning of treatment for anorexia nervosa when
patients are reintroduced to a healthy diet

• Children and younger adults are at higher risk than adults and therfore re-feeding of
younger patients should take place in hispital

30 | P a g e
 • The characteristic symptoms include

1. Oedema

2. Excesive bloating

3. Features of congestive cardiac failure

• It is a syndrome consisting of metabolic disturbances that occur as a result of

reinstitution of nutrition to patients who are starved or severely malnourished

• Renourishment is the process of avoiding refeeding syndrome.

Mechanism:

• Refeeding syndrome usually occurs within four days of starting to feed.

• Patients can develop fluid and electrolyte disorders, especially hypophosphatemia,

along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic
complications.

• Most effects result from a sudden shift from fat to carbohydrate metabolism and a
sudden increase in insulin levels after refeeding which leads to increased cellular
uptake of phosphate.

• Refeeding increases the basal metabolic rate. Intracellular movement of electrolytes

occurs along with a fall in the serum electrolytes
including phosphate, potassium, magnesium, glucose, and thiamine. Significant risks
arising from refeeding syndrome include confusion, coma, convulsions, and death.

• The shifting of electrolytes and fluid balance increases cardiac workload and heart
rate. This can lead to acute heart failure. Oxygen consumption is also increased which
strains the respiratory system and can make weaning from ventilation more difficult.

• Treatment: Refeeding syndrome can be fatal if not recognized and treated properly.
If potassium, phosphate or magnesium are low then this should be corrected.
Prescribing thiamine, vitamin B complex (strong) and a multivitamin and mineral is
recommended. Biochemistry should be monitored regularly until it is stable.

Re-feeding syndrome (Explained in simple terms)

What is re-feeding syndrome?

It is a disorder of fluid and salt balance in the body brought on by a shift from fat and
protein metabolism to carbohydrate metabolism.

31 | P a g e
When does it occur?

It occurs when the body goes from starvation mode to having 'enough'.

Who are more likely to be affected?

The groups most at risk of refeeding syndrome is patients with anorexia nervosa, cancer
patients, chronic alcoholics, post operative patients and following patients suffering from
long term starvation (developing countries)

Why does it happen?

Human body is generally dependent on glucose to provide the energy for all its functions.
Glucose usually comes from carbohydrates. The breakdown of carbohydrates is controlled
by insulin. As a result of long term starvation, the body runs out of carbohydrate to process
and insulin secretion is reduced. Now the body allows the alternative energy source such as
proteins and fats to break down as a direct effect of reduced insulin secretion. This
provides some glucose as well as some unwanted products and most importantly allows
a shift of salts such as phosphate and potassium from within the cells into the blood
stream

However on re-feeding, there is sudden shift from fat to carbohydrate metabolism and
insulin secretion increases leading to shift of salts from the blood back into the cells.
This leads to low levels of those salts in the blood stream particularly phosphates and
potassium.

This sudden salt shift can cause swelling in hands and feet (edema). Low phosphate in
blood can cause muscular problems and in extreme cases lead to seizures and coma. Low
potassium levels can cause disturbance in heart rhythm called as arrhythmias and in
extreme cases can lead to even death. It could result in respiratory failure, heart failure, an
irregular heartbeat, seizures, coma and blood cell dysfunction

How do we manage these patients?

It can hopefully be avoided by a very cautious approach to nutrition and refeeding. The
calorie intake should be built up gradually over one week (start at 5 k cal/kg/day). It is
important to normalise salt levels first, restore circulating volumes and regular monitoring
of electrolytes with prompt correction as needed is the most appropriate way to approach.

If potassium, phosphate or magnesium are low then this should be corrected.

Prescribing thiamine, vitamin B complex (strong) and a multivitamin and mineral is
recommended.

Ref: www.bathnes.gov.uk/ Emma Bradley

Oxford handbbok of child and adolescent psychiatry- 345

32 | P a g e
Risks of re-feeding;

With re-feeding, cardiac decompensation may occur, especially during the first 2 wks
(when the myocardium cannot withstand the stress of an increased metabolic demand).
Symptoms include excessive bloating, oedema, and, rarely, congestive cardiac failure (CCF).

To limit these problems:

Measure U&Es and correct abnormalities before re-feeding.

Recheck U&Es every 3 days for the first 7 days and then weekly during re-feeding
period.
Attempt to increase daily caloric intake slowly by 200- 300 kcal every 3-5 days until
sustained weight gain of 1- 2 pounds per week is achieved.
Monitor patient regularly for development of tachycardia or oedema. (Adapted from
oxford handbook of Psychiatry; 383)

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Topic 6:

CASC LESSON 9
HYPOCHONDRIASIS-DISCUSSION
TASK:Mr. Mark Powell presents with headaches and believes he has brain cancer. A history
of pain and associated symptoms was taken and nothing abnormal was found.
Investigations by a neurologist including CT brain scan were normal. He is constantly
worried that he has a brain tumour and regularly asks for reassurance. It all started after a
watching a TV programme a year ago about brain tumours. Since then he constantly reads
health magazines and surfs on the Internet about brain tumours.

You have seen this man already and think he has a diagnosis of hypochondriasis. Now
speak to his girlfriend Miss. Jane Moore about his diagnosis and treatment with her.
Address her ideas & concerns and the impact of his illness on his life.

CASE SYNOPSIS

You are Miss Jane Moore. Your boy friend is diagnosed with a condition called
'Hypochondriasis' It is a form of health anxiety disorder. You are concerned about him. You
wanted to know of his diagnosis and ask the doctor to explain it. You wanted to know of the
problems faced by people with this diagnosis. Check if he he might need further tests and
ask what the treatment is for this illness. You are unsure as to how you can help him. If not
already covered by the doctor, ask whether counselling can help

Topic: HYPOCHONDRIASIS-DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain possible diagnosis
(Hypochondriasis- health anxiety disorder &
form of overvalued idea

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 Explain nature of the problem with clinical
presentation (featured by preoccupation &
rumination, constantly seeking reassurance
despite negative investigation)
Address Concerns- need for further tests and
investigation (not necessary)
Treatment options (medical, psychological,
social)

Emphasize aim to improve function.

CBT (principle and structure)- Identify
and challenge misinterpretations,
substitution of realistic
interpretation, graded exposure to
illness-related situations, and
modification of core illness-beliefs
Role of family members and
education- Break cycle of reassurance
and repeat presentation (family
education may help in this)

Reduction of psychosocial stressors,

advantages of sick role.
Reasons for seeking reassurance-Temporary
relief of anxiety
Detailed feedback with areas of concern (tick/shade the box)

1 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee
2 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
3 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
4 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
5 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
6 Does not demonstrate adequate skills in risk assessment

35 | P a g e
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
7 Poor range of Symptomatology/psychopathology discussed
8 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
9 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice
Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

HYPOCHONDRIASIS

• Hypochondriasis is the preoccupation with the fear of having a serious disease,

usually one which will lead to death or serious disability and this constant
preoccupation persists despite negative investigations.

• It is also sometimes called as a form of 'health anxiety disorder'.

• In this condition, minor ailments will be interpreted as signs of serious disease.

• As a result of this, the patient will consequently seek medical advice and
investigation but is unable to be reassured.

• There is a persistent refusal to accept the advice and reassurance of doctors that
no such physical illness exists.

• It could cause significant distress, impaired function and severe disability.

• The form of the belief is that of an over-valued idea. Here the patient may be able
to accept that his/her worries are groundless but nonetheless be unable to stop
dwelling or worrying and acting on them.

• It is seen equally in men and women, between the ages of 20 and 30 years.

• Co-morbidity: It is associated with generalized anxiety disorder in more than

50% of cases. It may also coexist with major depressive illness, panic disorder and
obsessive compulsive disorder

36 | P a g e
Etiology:

• Hypochondriasis is multifactorial in origin

• Past experience of true organic disease, especially in childhood in either oneself

or a family member may predispose to the development of this disorder. In many
cases, there may be a history of childhood illness, parental illness, or excess medical
attention seeking in the parents. (Medicalised families)

• Childhood motional abuse or neglect, childhood sexual abuse are associated.

• Psychological model: Individuals with combination of anxiety symptoms and

predisposition to misattribute psychical symptoms, seek medical advice. The
resulting medical reassurance provides temporary relief of anxiety, which acts as a
'reward' and makes further medical attention seeking more likely.

• Precipitating factors are usually significant psychosocial stressors. The condition

is often perpetuated by persistence of such stresses and advantages of sick role.

Management:

• Allow patient time to ventilate their illness anxieties.

• Organic disease should be excluded.

• Primary psychiatric disorder such as depression and anxiety should be treated

vigorously.

• Explain negative tests and avoid further unnecessary tests.

• Specific medical interventions should be kept to a minimum.

• It is important to establish continuing relationships and review patients regularly

and attention should be given to nay social and personal factors from which the
complaints are considered to arise.

• Emphasize aim to improve function.

Education: Education about the role of psychological factors in the development of

symptoms and how to cope with such symptoms is vital.

Brake cycle of reassurance and repeat presentation - family education and support would
be helpful in this regard.

Psychological: CBT is the most important specific treatment of choice.

37 | P a g e
The aim of CBT is to

1. Identify and challenge misinterpretations.

2. Substitution of realistic interpretation.

3. Graded exposure to illness-related situations with response prevention should be

undertaken.

4. Modification of core illness-beliefs.

An RCT concluded that a six-session CBT intervention modestly but significantly improved
a range of hypochondriacal symptoms, beliefs, and attitudes at 6 and 12 months.

Medical: Antidepressants are certainly the second line treatment of choice if CBT fails or if
there is significant co-morbidity. SSRI are recommended. Antidepressants like fluoxetine
20mg increasing to 60 mg is helpful, as most hypochondraical symptoms are secondary to
depression.

Prognosis:

• Prognosis of often poor, with indivuduals having chronic mild disbility for most of their
adult life.

• Hypochondriasis often is refractory to treatment and improvement involved better

coping methods rather than cure.

• Role functioning may improve as a functional outcome.

• Reduced distress associated with beliefs rather than eradication of beliefs is the primary
outcome expected (Barsky et al 2004).

References: 1 Warwick HM, Clark DM, Cobb AM, Salkovskis PM (1996) A

controlled trial of cognitive-behavioural treatment of
hypochondriasis. BJP169, 189- 95.

2. Oxford Handbook of psychiatry- Pg 748-749.

Hypochondriasis Somatisation

1. Preoccupied with diagnosis 1. Preoccupied with symptoms

2. 'One dreadful disease' 2. 'One wonderful cure'

3. GI most common 3. Musculo-skeletal MC

38 | P a g e
39 | P a g e
Lesson 10:

TOPIC 1: MANIA IN A 16 YEAR OLD GIRL

TOPIC 2: SEVERE DEPRESSION WITH PSYCHOTIC SYMPTOMS-HX
& MSE
TOPIC 3: POST MI DEPRESSION-DISCUSSION
TOPIC 4: ANOREXIA- PROGNOSTIC FACTORS
TOPIC 5: SYSTEMATIC DESENSITISATION-DISCUSSION
TOPIC 6: SOCIAL PHOBIA
TOPIC 6: FORENSIC NECK INJURY - CAPACITY ASSESSMENT

1|Page
Topic 1:

CASC LESSON 10
MANIA IN A 16 YEAR OLD GIRL
TASK: You are a trainee working with the Acute Hospital Liaison Team and you have been
asked to see a 16-year-old girl, Jennifer McLaughlan with a first presentation of a mental
illness. She has been brought to A&E by her parents, who both look tired and
strained. Since being in A&E, Jennifer has been agitated and interfering with other patient's
care, trying to help the nurses and has had to be confined to her side room to stop her
leaving the department. Complete a Mental State Examination on the patient including the
risks that the patient poses to herself and others.

CASE SYNOPSIS: You are a 16-year-old schoolgirl in you GCSE year and are expected to do
well in your exams. You are taking mainly science subjects and hope to become a doctor or
a nurse and look after older people in your career. The reason you have for this is that you
used to have you grandmother living with you and you were very close to her. When you
were 10 she went into a care home with dementia and you used to visit her there. She died
three months ago, you miss her very much and you were deeply sad about her death and still
miss her badly. When she first died you cried a lot. However over the past six weeks you
have realised that you have felt better and that you have the skills to help and care for elderly
people in your work. You are so excited about this that you are not sleeping at night and have
not slept more than 2 hours a night for the past 6 weeks. You are making plans to set up the
perfect nursing home and this took up most of your time until about a week ago, when you
started to find it difficult to settle to writing your plans down. Your bedroom is full of
drawings of how you would design the care home and timetables for staff rotas as well as
lists of things that the perfect care home needs to have. In fact, you don't think you need to
pass any exams, go to college or learn, as you know it all and really should be teaching other
people how to do it. You have lots of energy. You say that you are good at business and are
skilled at raising money. You claim that you could easily raise millions of pounds for charity
or for your business and have written to the Minister for Health asking for funding for your
project. You are spending all the money you had saved for university. You have tried to
borrow money from your parents and your friends, claiming this is an investment in your
business and that they will make great returns if they lend you money and invest in your
plans. If asked, you have no other psychotic symptoms such as hearing or seeing
hallucinations. You have no thoughts of suicide, but you have been quite irritable with your
family. You have thrown mugs and plates against the wall and onto the floor sometimes when
you feel that your mother and father have not been listening to you and don't
understand. This has happened about 4 times, but you have never thrown them at people,
or hurt anyone. You have lost your appetite a little and you have lost about 2 kilograms in
the past week.

You do not believe that you are mentally ill and it is everyone else who is too stupid to
understand when great good you can bring to the lives of old people.

2|Page
TOPIC: MANIA IN A 16-YEAR OLD GIRL

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Taking control of the interview without being
rude or over-assertive in the face of an over-
talkative patient.

Eliciting biological symptoms of mood

disorder, sleep, appetite, weight gain or loss.
Assessing the presence or absence of
psychotic symptoms, grandiose, persecutory,
thought disorder.
Assessing the current or recent use of drugs
and alcohol.
Determining how long this episode has
lasted, what the previous personality was
like and if there has been a dramatic change
in personality.
Eliciting any history of risk behaviour,
including as aggression, sexual vulnerability,
excessive spending, self neglect.
Assessing the patient's insight into her
presentation, if she feels she needs
psychiatric help and if so what kind of help
does she feel that she needs.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee

3|Page
 3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Inaccurate or misleading information discussed
10 Does not develop an adequate awareness of management of risk
Specific Comments and suggestions

READING NOTES FOR CANDIDATES AND WHAT IS EXPECTED TO PASS CLEARLY IN

THIS STATION- Dr Richard Hillier 2018

The object of this station is to demonstrate that you can assess someone presenting with
acute manic episode. The assessment includes the ability to determine how long the
current presentation has lasted, what risks are associated with the presentation and if it is
a change from the patient's normal personality. You need to demonstrate that you were
aware of what important features on mental state need to be recorded in the notes. You
will not be asked to present the mental state examination, but it is useful to have in your
head the headings of mental state examination so that you can use this as a checklist of
questions to ask, as if you were going to write up for mental state examination in the
patient's notes after the interview. Below are the kind of symptoms that someone with
manic illness may present with under the different headings of the mental state
examination.

Appearance and Behaviour

The patient may experience an increase in motor activity, an increase in interest in work or
pleasurable activities, increased time spent on one particular activity or not being able to
settle to activities at all. There may be irritability and impatience, especially if the patient

4|Page
feels that others don't follow their fast speech, doubt their grandiose plans or disbelieve
them. There may be increased sexual interest, and a manic patient may be vulnerable to
exploitation sexually by others. At interview they may be restless, distractible and over-
familiar. Patients with mania may dress in very bright or sexually provocative clothing, but
they may also appear quite neglected when they have been ill for some time.

Speech

A manic patient will normally have increased amounts of very pressured speech and may
be difficult to interrupt to ask questions. The doctor will need to be able to manage the
interview so that they can ask sufficient questions to obtain the information needed,
without frequently interrupting the patient or taking over them. It may be at time
necessary to say things such as ”That is very interesting, can we come to that later?”

The speech may be very telling of an underlying thought disorder. The characteristic
thought disorder of mania is "flight of ideas”. This is when the patient will start talking
about one subject, distract themselves by what they have been saying, and move onto
another subject entirely. The link between the two ideas is usually fairly obvious. There is
also loosening of associations, characterized by punning or "clang associations”. In this case
a word that the patient or someone else speaks will cause the patient to become distracted
and start talking about something that rhymes with the word that that has just been used.

E.g. "Yes that coat is mine. Actually I want to own a diamond mine, because that will make
me very rich and a stitch in time saves nine don't you think? Wink? You're very handsome!”

Rarely, in extreme cases of mania the patient maybe mute, this may be combined with very
little motor activity and is known as "manic stupor”.

Mood

Patients with mania are usually described as elated in their mood. They themselves may
however report that they feel depressed or frustrated, especially when others don't seem
to have followed their train of thought. Sometimes, often in older people, manic patients
present as intensely irritable rather than happy. They still have grandiosity and
overconfidence, but rather than being elated, they can appear angry and hostile. Usually
many patients will have biological symptoms of a mood disorder including the reduced
need to sleep and sometimes weight loss. This is often because they are too distracted to
prepare food or sit down to have meals.

Affect

Affect is an aspect of the mental state examination that is often forgotten. However in
describing an affect, the terms used are so laden with diagnostic meaning it is a shame to
omit this heading. In manic patients the affect is usually grandiose, overconfident, warm,
easily distracted and may be over-familiar. This is usually true of the elated type of manic

5|Page
patient. However, as described above, the irritable manic patient may present angry and
hostile.

An important feature of the affect in a manic patient that should not be missed is
"emotional lability”. This is when the patient, who has been chatting away happily about
one subject suddenly switches onto a sadder subject and bursts into tears. The tears
usually only last a few seconds to a minute or two before, but may be quite distressing to
the patient whilst they last. The patient then recovers spontaneously and returns to more
cheerful topics. The most important feature of emotional lability in mania is that it is mood
congruent and fits with the topic that the patient is discussing.

Thoughts

Patients with mania usually have ”racing thoughts” and may describe these thoughts either
as rational thoughts coming very quickly or, if there is a psychosis, then usually grandiose
psychotic beliefs are expressed in these thoughts. The form of thought characteristic of
mania is "flight of ideas”. As described above, this is where one thought cascades into
another thought, often without the first thought being completed. Usually the listener can
recognize the link between the thoughts. Generally the most frequent psychotic beliefs in
manic person are those of having special powers, being special themselves in some way,
having links or friendships with important or powerful people, or having a special
relationship with god or religious character.

Abnormal experiences

In mania auditory and visual hallucinations may be quite common. Visual hallucinations
are more common in mania than they are in schizophrenia. The content of hallucinations is
usually grandiose and a manic patient may describe the hallucinations as being the voice of
God or an important individual speaking to them directly. Usually auditory hallucinations
in mania are experienced in the second person. Visual hallucinations are often religious in
content.

Concentration

In mania, concentration is usually quite severely affected. Whilst the patient believes they
are able to complete multiple tasks at once, or that they have special skills, the reality is
that they usually cannot concentrate for long enough on one thing to complete a task. They
may have grand plans to set up a business, but are too busy designing a logo for the
company letterhead, rather than producing the product or service that they hoped to sell.
This lack of concentration usually presents during psychiatric interview in the form of
distractibility and not being able to stay on one subject very long.

Suicide / vulnerability, risk to self

Generally manic patients do not report themselves as feeling suicidal. However due to the
increased confidence they can put themselves at risk of harm and patience with a psychotic
6|Page
manicure have jumped from high places, believing they can survive jump because they are
special.

Patients with mania may also put themselves at risk by driving too fast, driving while
drunk, trying to jump the traffic lights, board trains, all cross the road in front of busy
traffic, thinking they are immune to harm. Patients who have become over sexualized may
put themselves at risk of sexually transmitted disease, unplanned pregnancy, or sexual
exploitation. This can be a particular risk in female patients with manic presentation.

Patients with mania may try to self medicate with alcohol to help them sleep and take
drugs such as benzodiazepines, cannabis or opiates. The use of drugs should always be
considered when someone is presenting as manic as stimulant drugs as well as medically
prescribed steroids, used for inflammatory disease can both facilitate manic episodes.

Risk to others

Patient with mania may pose a risk to others, especially if they are driving too fast or whilst
drunk or undertaking other risky activities in public such as running in front of the traffic.

Insight

It is rare for someone presenting with a manic episode to have any insight into their
condition.

7|Page
Topic 2:

CASC LESSON 10
SEVERE DEPRESSION WITH PSYCHOTIC SYMPTOMS
TASK: Mrs Jackson is a 27-year-old hairdresser who has been brought to A&E today by her
work colleagues. She has told her colleagues this morning that she believes her husband is
trying to kill her. Her colleagues report to nurse in triage that Mrs Jackson has been off sick
for most of the last month for unspecified mental health reasons. She turned up to work
today when she wasn't rostered and said she needed help. Prior to being off sick her
colleagues had noticed that Mrs Jackson's concentration was poor, she was withdrawn,
distracted and restless. She had often been found crying in the toilets and wouldn't be able
to explain why. She had never been aggressive to anyone and appeared frightened a lot of
the time. Mrs Jackson had informed her manager that she has been to see her GP who
prescribed her something but she isn't feeling any better. She came to work today saying
that she thought her husband was going to kill her when he came home from work and she
didn't know where else to go. She said to her colleagues in the taxi on the way to A&E that
she deserved to be killed because she was useless. On the summary care record you are
able to see that she has been prescribed citalopram 20mg for the last four weeks. There is a
note in her GP record to suggest that prior to moving to this area she had depression but no
further details are described. Please conduct an interview with Mrs Jackson with a view to
reaching a diagnosis. Your assessment should include Brief history of presenting complaint
and screening of past history and Mental State Examination with a view to reaching a
diagnosis and informing Mrs Jackson of your impressions. You do not have to provide an
extensive treatment plan.

CASE SYNOPSIS:

You are Louise Jackson, a 27-year-old married hairdresser. You used to work part time,
and enjoy this, as well as taking care of the flat. Your husband James is in construction and
works very long hours. You started to feel down about 2 months ago. First your sleep
started to deteriorate and you found you were waking in the early morning. You can't enjoy
anything, and can't concentrate on anything. You have been off work for a month and feel
embarrassed and useless. You have always felt good about keeping the house tidy and
preparing meals for your husband but you now have no energy for this. You can't get out of
bed and haven't bothered to wash for a week or so. Everything feels very difficult and
exhausting. You feel guilty and useless that you aren't working or doing anything at home.
Your husband is having to do everything and you are either lying in bed or pacing around
but not getting anything done. You have started to believe that your husband is poisoning
you because you are so useless. The food he has been cooking has tasted strange and bitter
in the last week or so, so you haven't been eating it. You had lost your appetite anyway and
have lost about 5kg in the last month. You are drinking enough water but haven't eaten for
a couple of days. Although you are frightened of dying you also feel that you deserve to die,
and understand why your husband would need to get rid of you. You do not have any plans
to harm yourself but you do feel you are worthless and don't have any right to be alive. You

8|Page
are not hearing any voices. You don't drink alcohol, use drugs or smoke. You do not have
any medical conditions. You had previously had depression and required admission to
hospital where you were given two medications though you can't remember the names of
them. You stopped taking them about 6 months ago because you felt better and had moved
to a new area with your husband. You weren't under any mental health services after you
moved so you didn't discuss the decision to stop medication with anyone. You have never
had a manic episode. You went to your GP 4 weeks ago when your work colleagues
encouraged you to. You started citalopram but it hasn't made any difference. Your GP has
referred you to the CMHT but you haven't had an appointment yet. In the end, you should
ask the doctor if they will let you go home, since there is nothing anyone can do to help.

Topic: SEVERE DEPRESSION WITH PSYCHOTIC SYMPTOMS

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit Relevant history- Past history of
depression and stopped taking medication
and that her current episode began with
mood symptoms and poor sleep

Elicits relevant recent history such as

commencement of SSRI with minimal
improvement, and history of depression
requiring hospital admission and multiple
drug treatments.
Elicit biological and psychological symptoms
of depression.
Elicit psychotic symptoms in depression -
guilt, worthlessness, that she deserves to die
and belief that husband will poison her.
Screen for hallucinations. Elicit possible
gustatory hallucinations related to taste of
food.
Risk assessment - self harm, self neglect

9|Page
 Communicate diagnosis of likely depression
with
psychotic symptoms to patient. Explain to the
patient briefly that it is likely she will require
inpatient treatment.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate awareness of management of risk
PSYCHOTIC DEPRESSION:

• This station assesses a candidate's ability to conduct a mental state examination

of a patient with psychotic depression and assess risk with a view to reaching a
diagnosis.

10 | P a g e
 • Candidates should explains purpose of interview and is able to gain trust and
rapport from anxious and distressed patient.

• Candidates should identify that the patient has a past history of depression and
stopped taking medication and that her current episode began with mood
symptoms and poor sleep.

• Candidates should elicit that the patient has had treatment for depression before
and good candidates will intuit that the fact that the patient was taking two
medications raises the possibility of either treatment resistant depression or
psychotic depression. The fact that the patient required treatment to hospital in the
past also suggest the depression was severe.

• Candidates should elicit that the patient has lost weight, low energy, poor sleep
with early morning wakening (biological symptoms of depression).

• Major symptoms of unipolar depression (ICD 10) include the following:

o Persistent sadness or low mood and/or loss of interest or pleasure, fatigue or

low energy (at least one of these, most days, most of the time for 2 weeks)

• Associated symptoms of depression (ICD 10):

o Disturbed sleep, poor concentration or indecisiveness, low self-confidence,

poor or increased appetite, suicidal thoughts or acts, agitation or slowing of
movements, guilt or self blame

• Candidates should elicit that the patient has delusions of worthlessness and
believes (to delusional extent) that her husband is going to poison her.

• Delusions in depression tend to be mood congruent, ie: consistent with

depressive themes of worthlessness, guilt, uselessness, deserving punishment,
nihilism, or there being no hope in treatment. Hallucinatory experiences also tend to
be mood congruent and often associated with the delusions. They can be derogatory
or persecutory in nature.

• Good candidates will also exclude relevant negatives such as nihilistic delusions,
Cotard's delusions or delusions of poverty. Good candidates will also briefly screen
for passivity phenomena such as thought insertion or withdrawal.

• Good candidates will also identify that she may have gustatory perceptual
abnormalities (in terms of the taste of the food her husband is making for her).

• In terms of risk assessment candidates should assess risk to the patient in terms
of self harm and self neglect (poor oral intake (food) (both due to lack of appetite

11 | P a g e
 and also fear of being poisoned), poor self care). She does not have suicidal ideation
but feels worthless and as if she deserves to die. Other risks to her would include the
risk of inadequately treated mental disorder. In terms of risks to others; she feels
her husband is trying to poison her but that she deserve this, even though she is
afraid. She has no thoughts to harm him, however such delusions (poisoning) are
obviously high risk even if the patient does not report thoughts to harm their
partner.

• Good candidates should demonstrate consideration and assessment of risk to self

in terms of both self-neglect, poor eating, and checking for thoughts of harm to self,
as well as inquiring about risk to others (particularly husband), given the nature of
the delusions.

• Candidates should correctly identify that the patient is depressed and has
psychotic features, rather than a primary psychotic illness. When the patient asks if
they can go home, the candidate should suggest that the patient requires admission
to hospital as her current presentation is not safe to manage in the community. They
are not required to discuss the use of the mental health act or treatment at this
point.

Suggested Reading:

Rothschild AJ. Unipolar major depression with psychotic features: Epidemiology, clinical
features, assessment, and diagnosis. Roy-Byrne PP & Solomon D, ed. UpToDate. Waltham,
MA: UpToDate Inc. http://www.uptodate.com (Accessed on October 29, 2018.)

12 | P a g e
Topic 3:

CASC LESSON 10
POST MI DEPRESSION-DISCUSSION
TASK:

Mr Patel is a 57-year-old man who was previously seeing you in clinic for moderate
depression. He has a history of depression for several years and was prescribed
antidepressants under your care. He was discharged back to the GP 9 months ago. Mr Patel
has presented to the GP with low mood, poor sleep and appetite following a recent MI. It
transpires that he had stopped his antidepressants several months ago as he was feeling well.
Mr Patel is not engaging in the cardiac rehabilitation programme including non-compliance
with cardiac medication. He is smoking despite advice against this. The GP has re-referred
Mr Patel back to your clinic for review of his mental state, and to formulate a plan to help
him re-engage with the cardiac rehabilitation programme.

A third year medical student attached to your team is due to review this patient in clinic next
week. She is gathering information about this patient to present to her supervising
consultant. Address her concerns and expectations.

CASE SYNOPSIS: DISCUSSION WITH MEDICAL STUDENT

You are Annabel Smith, a medical student in their third year and on psychiatry placement.
You are a diligent student, who has a keen interest in psychiatry and, therefore, would like
to engage well in this placement. You are aware that Mr Patel who has a history of
depression, is due to return to clinic following an MI (Myocardial infarction - heart attack)
and he has not been attending is cardiac rehabilitation because of his low mood.

Suggested prompt questions;

• What is Mr Patel's diagnosis?

• How common is it?

• What is the link between depression and MI? Did the patient's previous history of
depression cause the MI or did the MI cause the depression?

• What sort of management would be appropriate for Mr Patel?

• You can also ask if there are any medications that you would not prescribe.

• You can also ask, if the candidate does not mention, what other therapies or
interventions might be useful for Mr Patel.

13 | P a g e
 • You can probe further about what CBT is, if the candidate mentions it

• What sort of prognosis does Mr Patel have?

• Who else might be involved in this case? You can probe further, asking what
would be expected in the role of the allied health professionals (dietician,
occupational therapist)

• What implications might this diagnosis have for his future e.g. work?

Topic: POST MI DEPRESSION- DISCUSSION WITH NURSE

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Prevalence of post-MI depression-about 20%

Post-MI-associated with poorer quality of life

and independently associated with cardiac
risk.

Appropriate medication- sertraline

secondary to findings in the SADHART trial
CBT may work in conjunction with cardiac
rehabilitation e.g. tracking compliance with
cardiac medication or tracking physical
activity with the goal to build a healthy
lifestyle.
Role of MDT-referred to a dietician for
nutritional advice and occupational therapy,
as their current work may require
modification.

14 | P a g e
 Require smoking cessation advice or
alcohol/substance misuse services.
Patients with untreated depression have
poorer adherence to lifestyle modifications
and poorer compliance with cardiac
medication
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport, Lack of eye contact/non verbal
responses, does not show appropriate attitudes or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Inaccurate or misleading information discussed
9 Limited or Incomplete management plan, Does not develop an adequate
awareness of management of risk

STUDY MATERIALS

This station is looking at knowledge around post-myocardial infarction depression. Post-MI

depression is common, and overwhelming evidence suggests that there is an increased risk
in morbidity and mortality. In this station, the candidate would be expected to demonstrate
knowledge in the rationale behind management of post-MI depression and the
consequences. In addition, the candidate would be expected to demonstrate good
communication skills - clarity of language and explanation.

15 | P a g e
Prevalence:

Reported prevalence of post-MI depression during initial hospitalisation is about 20% or 1

in 5 patients, though the range varies between 10% and 47%. The literature suggests that
most of these patients continue to experience symptoms, which would meet the threshold
for depression following discharge and in the 1-3 months following.

Morbidity/Mortality:

Depression diagnosed during hospitalisation post-MI is associated with poorer quality of

life in the first year following depression and post-MI depression is independently
associated with cardiac risk.

Diagnosis:

Diagnosis of depression using clinical history and rating scales such as Beck's Depression
Inventory (sensitive to lower threshold depression) and Hamilton Rating Scale for
Depression (more sensitive for severe depression).

Management plan (medication):

The appropriate medication to suggest in post-MI depression is sertraline secondary to

findings in the SADHART trial (detailed below), however SSRIs in general would be
appropriate. Sertraline has a lower incidence of drug interaction. SSRIs are associated with
hyponatraemia in older adults. There are no specific NICE guidelines on post-MI
depression, however this is NICE guidance on 'Depression in adults with chronic physical
health problems'.

Major points to note about the SADHART Trial

• SADHART: 'Sertraline treatment of major depression in patients with acute MI or

unstable angina'. 2002 JAMA
• The study was evaluating whether sertraline was a safe and effective choice for
treatment of recurrent depression in patients who had been recently hospitalised
for MI/ACS.
• 50% of episodes of post-MI depression will spontaneously remit.
• TCAs are associated with orthostatic hypotension, arrhythmias and prolonged QT
interval
• SADHART randomised patients with depression into sertraline or placebo.
Cardiac safety was measured but not treatment of depression (therefore efficacy of
sertraline compared with placebo was not compared). Sertraline was not associated
with significant effects on cardiac measures and therefore deemed safe.

16 | P a g e
 • An incidental finding in a subgroup that had previously been diagnosed with
depression showed that an improvement in symptoms was associated with
sertraline use.
Management Plan (other)

Other areas of management with post-MI depression are psychological and physical.
Psychological management of post-MI depression would be the same as for depression in
healthy individuals and those with other chronic illness - CBT. CBT is a form of individual
work, short term (8-12 sessions) looking at thoughts, feelings and behaviours. It may
require specific tools such as mood diaries, and often requires some form of work to do
outside the session. In a case like post-MI depression, the CBT may work in conjunction
with cardiac rehabilitation e.g. tracking compliance with cardiac medication or tracking
physical activity with the goal to build a healthy lifestyle.

Other aspects of management would involve physical health care.

• Cardiac rehabilitation, often a nurse-led clinic, would be the forefront of

management.

• The patient may also be referred to a dietician for nutritional advice and
occupational therapy, as their current work may require modification.

• The patient may also require smoking cessation advice or alcohol/substance

misuse services.

The candidate should therefore mention the wider MDT in post-MI depression as part of
the management plan.

Prognosis

Patients with untreated depression have poorer adherence to lifestyle modifications and
poorer compliance with cardiac medication. The research is muddled as it suggests that
treating the depression may not improve outcomes in 8 years follow-up. (SADHART 8 year
follow up, ENRICHED Trial). The MIND-IT Trial also noted similar outcomes but noted that
depression severity was associated with cardiac risk severity and therefore poorer
outcomes suggesting that it was not the depression itself associated with poorer outcomes
but the severity of underlying disease.

Depression in itself is associated with increased risk of morbidity and mortality outside of
any other comorbid diagnosis. In addition, patients who are compliant with
antidepressants may also be compliant with other aspects of cardiac rehabilitation, and
therefore have better survival and lower morbidity rates.

17 | P a g e
Topic 4:

CASC LESSON 10
ANOREXIA-PROGNOSTIC FACTORS
TASK

Assess this young woman Miss. Kate Fitch, with anorexia nervosa for both good and bad
prognostic factors.

She is currently an inpatient in an eating disorders unit and is making good progress with
her treatment.

CASE SYNOPSIS:

You're a 28-year-old woman with a history of anorexia nervosa. You were admitted to
eating disorders unit about 2 months ago. You comply with treatment plan and are getting
better. Your anorexia was diagnosed 3 years ago but started at school when you were 14.
Your friends commented in school that you were 'fat with thick legs' and since then
increasingly restricted eating started. You were formally diagnosed aged 25. You've lost
significant amount of weight prior to admission about 2 stone in 2 months. You've had
menstrual periods this month after 9 months. You're trying to eat 3 meals plus snacks a day
and adhering to plan from your team. You try to avoid some types of higher calorie
foods. You're the only child. Your parents were disciplinarians but not harsh. There's no
family history of eating disorder. Your social life is poor. You don't have friends or long-
term relationships at all.

Topic: ANOREXIA- ASSESS GOOD AND POOR PROGNOSTIC FACTORS

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Late onset,

18 | P a g e
 Longer duration of disorder before
presentation

Chronic course of illness

Physical symptoms:

1. Excessive weight loss

2. Longer duration of amenorrhoea

Presence of Bulimic features (more binging
behaviours,

Vomiting and purging as part of the clinical

picture)
Social history: Good/Poor social adjustment

Family situation: Good/Poor parental

relation ships, Greater family hostility, High
expectations from parents etc
Psychiatric co-morbidity especially cluster C
personality disorders, depression, substance
misuse etc
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment

19 | P a g e
 Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of history explored, Aspects of history or mental state highlighted
but not explored in depth or appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Inaccurate or misleading information discussed
Specific Comments and suggestions

Anorexia Nervosa- Prognostic factors

Risk factors for poorer outcome

• Male sex

• Late onset

• Longer duration of disorder before presentation

• Chronic course of illness

• Excessive weight loss

• Longer duration of amenorrhoea

• Bulimic features (more bingeing behaviors, Vomiting and purging as part of the
clinical picture)

• Poor social adjustment

• Poor parental relation ships, Greater family hostility

• Psychiatric co-morbidity especially cluster C personality disorders, depression,

OCD, substance misuse and autistic spectrum disorders

• Anxiety when eating with others

Predictors for death in anorexia

• Weight below 35 kg at presentation

• More than one inpatient admission

20 | P a g e
 • History of psychiatric hospitalization for anorexia

• Substance misuse and alcohol misuse

• Longer duration of illness at start of treatment

• Poor social adjustment

• Hospitalization for an affective disorder

• Suicidality associated with co-morbid mental illness

Bulimia nervosa

Poor outcomes predictors

1. Old age at illness onset

2. Life time history of anorexia

3. Poor impulse control

4. Pre-morbid obesity

5. Poor social adjustment

6. Substance misuse

7. Co-morbid affective disorder

8. Low self esteem

Impulsive behaviors such as alcohol or substance misuse, recent suicide attempt, bingeing
or stealing were the strongest predictor of a poor prognosis for patients with anorexia and
bulimia for a 4 to 6 year follow up

(Ref: Puri and Hall-699/700,

Oxford handbook of child & adolescent psychiatry 335/351)

21 | P a g e
Topic 5:

CASC LESSON 10
SYSTEMATIC DESENSITISATION-DISCUSSION
TASK:Mrs. Catherine wood is a 40-year-old married housewife. She has been referred by
her GP to the outpatients' clinic due to her anxieties about going out of her house. You have
seen Mrs. Wood who has been diagnosed as suffering from agoraphobia. Discuss the
Psychological treatment options available for this condition. Address her concerns.
CASE SYNOPSIS

Your wife has a 4 -year history of agoraphobia and some anxiety symptoms, not wanting to
leave house and has become housebound. You want to discuss her diagnosis, the different
treatment options available for the treatment of her condition.

• What's wrong with my wife?

• What has caused this?

• What treatments are available for her condition?

• Why do you want to prescribe anti-depressants when she is not depressed?

• Can you please explain more about talking treatments or psychological

treatments? How long does this treatment last for?

• Does sensitisation mean 'you would be thrown in the thick end'?

• Who will give this treatment?

• Where will you give treatments?

• How can I help her?

TOPIC: SYSTEMATIC DESENSITISATION- DISCUSSION

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

22 | P a g e
 * OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT
FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Explain treatment options

Education about anxiety and phobic

avoidance
Psychological: CBT

(Systematic desensitisation- Graded

exposure to feared situations, Relaxation
training and breathing
exercises)
Structure of therapy (Weekly session, 40-50
minutes,

Therapist aided and homework tasks)

Family and social support- vital

Address concerns

Can't come out of the house- Therapist to do

home visits.
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)

23 | P a g e
 Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient
10 Limited or incomplete explanation of concepts/problem
Inaccurate or misleading information discussed
11 Limited or Incomplete management plan,
Does not develop an adequate management plan reflecting knowledge of
current best practice

AGORAPHOBIA- TREATMENT OPTIONS

• Agoraphobia is a common problem and it is definitely treatable.

• There are a number of different treatments available including education,

psychological treatments and medication.

• Education may sound simple, but patient and family need to know about the
nature of the illness, what keeps it going and how to deal with it.

• There are two main types of medication, benzodiazepines and antidepressants.

Benzodiazepines for example (Valium) start working very quickly and can be useful
in the short term but they are addictive, and people may become dependent on
them.

• Antidepressants would be a better option. They treat and modify the chemical
imbalance in the brain, which might be responsible for this condition. We start them
at a low dose and increase gradually. They may take up to 8 weeks to start working.
Once you feel better, you will have to continue the medication for about 6 months, if
not longer. Then we have to taper it off gradually and stop. They are not addictive.

24 | P a g e
 • The name of the psychological treatment offered is called as 'systematic
desensitisation'. This treatment is also called graded exposure with relaxation. In
this therapy, first the patient will be taught relaxation exercises to help them control
the anxiety and panic. Then we make a list of hierarchy of situations that you find
difficult to face. We arrange them from the least difficult to the most difficult and
you may find it easier to face situations if you move from the least to the most
difficult, Then you start by facing the easiest situation, whilst managing to relax.
When you feel comfortable with that situation, you then go onto the next one. You
will have to practice this daily. e.g. like going out of the front door of your house,
going out to your garden from your house, then going out to a nearby shop with a
family member/friend and then going out to a supermarket with a family
member/friend and so on.

• Practice the steps until it no longer causes anxiety. Once you feel confident with
one step, move on to a more difficult step and repeat the practice.

• If there are difficulties in getting out of the house, then we can arrange for the
therapist to come to your house to help you initially.

Your family members and or your partner have an important role in the treatment and it
will be very helpful if they can also be involved to improve confidence and support them

25 | P a g e
Topic 6:

CASC LESSON 10
SOCIAL PHOBIA
TASK:

You are seeing Mr. Cockfield in your outpatients' clinic. He is due to be married soon but
extremely worried about the occasion.

Obtain history to arrive at a diagnosis and identify possible aetiology.

CASE SYNOPSIS:

You are Mr. Stephen Cockfield, a 27-year old man who works as a teaching assistant in a
primary school. You are engaged to your girlfriend and due to be married in 6 weeks time
and you are extremely worried about facing many people at the wedding reception. You
have always avoided attending marriages or social gatherings as you experience similar
feelings that led you to either leave the gathering early or decline invitations to attend. You
find all these social gatherings as 'a form of threat'. You have experienced symptoms such
as dry mouth, excessive sweating, a racing heart and feel you are beginning to
panic. Sometimes you make up excuses to leave groups of friends because of your
anxieties. You report a long history of feeling uncomfortable in social situations since
childhood. This fear is interfering with your social life, personal life and job performance.
Your employers have made some concessions for you as a temporary arrangement; i.e.; you
do not have to do teaching at school in front of pupils.

TOPIC: SOCIAL PHOBIA- ASSESSMENT

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

26 | P a g e
 Competency Domains Very Poor Average Good Excellent
Poor
Symptoms of incapacitating anxiety
restricted to particular social situations,
leading to a desire for escape or
avoidance
Somatic symptoms- blushing, dry mouth,
trembling, perspiration when exposed to
feared situations
Elicit consequences of social phobia-

(Avoidance, social withdrawal, lack of

confidence, difficulty in maintaining
social relationships, vocational problems-
work in less demanding jobs, well below
their abilities etc)
Rule out co-morbidity- anxiety spells,
panic attacks and agoraphobia.

Alcohol and substance misuse

Etiology- Family history, negative
childhood experiences, shy & anxious
personality traits

(Genetic factors- predisposition towards

overly interpreting situation as
dangerous)
Etiology- Environmental factors-
Individual interpretations of social cues,
spontaneous

(the conditioned fear response may be

determined environmentally and
triggered by the social situation in which
anxiety first appeared
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,

27 | P a g e
 Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Use of medical jargon without explanation
Does not use language and or explanations that are relevant and
understandable to the patient

ELICIT SYMPTOMS OF SOCIAL PHOBIA

SOCIAL PHOBIA
• Symptoms of anxiety (all including psychological, behavioural and autonomic
symptoms) should be present and they are not secondary to other symptoms
delusions or obsessions

• Anxiety occurs particularly in social situations (restricted to eating in public,

public speaking, encounters with the opposite sex)

• Avoidance behaviour: avoidance of the phobic situation as a prominent feature.

There may be associated blushing, nausea, hand tremor and often leads to
avoidance behaviour and alcohol misuse.

Etiological factors (Social phobias)

• There is limited evidence of a genetic inherited predisposition to develop social

phobia

• The development of phobias can arise spontaneously

28 | P a g e
 • Predisposing factors- shy individuals, anxious and avoidant individuals with low
self esteem

• People who have experienced parental separation, over controlling maternal

upbringing and childhood sexual abuse

• In social phobias, the conditioned fear response may be determined

environmentally and triggered by the social situation in which anxiety first
appeared (Classical conditioning)

• Avoidance of a phobic situation would be associated with a reduction in anxiety,

which is rewarding and therefore reinforces the avoidance (maladaptive learning
response- which perpetuates the behaviour)

• Perpetuating factors may include drug and alcohol misuse

(Ref: Puri & Treaseden-pg654)

Areas to cover
• Symptoms of social phobia
• Psychological and physical symptoms of anxiety
• Enquire about panic attacks
• Avoidance mechanism
• Impact on personal, social and occupational life
• Rule out co morbidity-agoraphobias, other phobias, depression etc

Social Phobias
• Do any particular situations make you more anxious than others?
• Do you tend to get anxious when meeting people e.g. going into a crowded room and
making conversation?
• What about speaking to audience? What about eating or drinking in front of other
people?
• Please tell me more about it?

Duration, Effects and coping

• How long have you been feeling this way?
• What do you think might have caused this?
• How is it affecting your life?
• How does it interfere with your activities?
• How do you manage to cope? (Ask about drug and alcohol misuse)

29 | P a g e
 • Do you get any help?

Avoidance

• Do you tend to avoid any of these situations because you know that you'll get
anxious?
• Do you make any effort to avoid activities, places or people because you know that
you will feel more anxious and embarrassed?
• What would you do? How does that make you feel?

Eliciting anxiety symptoms

• Have there been times when you have been very anxious (or) frightened? What was
this like?
• Have you had the feeling that something terrible might happen?

Eliciting panic attacks

• Have you had times when you felt shaky, your heart pounded, you felt sweaty, dizzy
and you simply had to do something about it?
• What was it like?
• What was happening at the time? Could you please describe it for me?

Agoraphobia
• Do you tend to get anxious in certain situations such as traveling away from home (or)
being alone?

Special phobias
• Do you have any special fears like some people are scared of cats or spiders or birds?

Rule out co-morbidity:

a. Depression
b. Obsessional symptoms
Anxious personality- would you say you were an anxious person?

30 | P a g e
Topic 7:

CASC LESSON 10
FORENSIC NECK INJURY-CAPACITY ASSESSMENT
TASK: Mr Robert Peters is a 24-year-old man with a previous diagnosis of emotionally
unstable personality disorder. He has been admitted to hospital from prison where he was
serving a 2-year sentence for actual bodily harm. He has cut his neck relatively deeply but
without damage to underlying vessels and nerves, nor muscles. The plastic surgeons have
advised that this wound should be closed under anaesthetic but Mr Peters is declining this
and states he wants to return to prison again as soon as possible.Please assess his
capacity. You do not need to perform a mental state examination.

CASE SYNOPSIS:

You are Robert Peters, a 24-year-old man with a diagnosis of emotionally unstable
personality disorder. You are currently 1 year into a 2-year sentence for actual bodily
harm. You got into a fight with the brother of your girlfriend and broke his jaw.

You had been diagnosed with emotionally unstable personality disorder prior to being
imprisoned but had not managed to attend any psychology sessions as you kept forgetting
or were feeling angry with the team and so did not go. You have found the routine of
prison reassuring and have been able to see mental health staff more regularly than you
ever have before. You have been engaging well enough that there is a plan for you to move
to a different wing of the prison, which has more mental health input and where you can
see a psychologist regularly. You've been told that the therapy they offer is for people with
difficulties similar to yours and remember the letters "DBT” being mentioned. You have
been very keen to have this therapy and have been waiting for the past 4 weeks. You have
been finding this extremely frustrating, particularly as no-one has been able to give you a
date for when you will be transferred, and have found yourself getting agitated at
times. You cut your neck in this context. You used a piece of off-cut tin from the metal-
working class you have been taking in your current wing. You cut yourself after speaking
to the mental health nurse and they advised you that there was still not a definitive date for
your transfer, although it should be soon. You were frustrated that it had not happened as
it felt like it has been "soon” for weeks. You are feeling better since but acknowledge that it
was perhaps not the most sensible step to take. You have a history of self-cutting relatively
deeply when overwhelmed by emotions. You have sometimes required stitches but have
managed some wounds yourself with these sometimes scarring. You dislike staying
overnight in hospital as you feel distressed by the noise at night and the constant
activity. You deny any further thoughts about harming yourself although accept that it

31 | P a g e
could theoretically happen again in similar circumstances. You are not feeling low, nor are
you having any odd thoughts or experiences. You are not anxious apart from being keen to
have therapy.

You are aware that the plastic surgeons want to repair the cut under general anaesthetic
due to the depth of the cut and its position. They have told you that this approach would
likely mean that it would heal quickly and cleanly but that you would need to remain in
hospital, potentially for a few nights. They have told you that to not operate would mean it
may heal slowly, could be infected and you may be left with a substantial scar. It may also
not close. You want to return to prison as soon as possible. You are concerned that if you
remain away from prison too long, that you may miss your opportunity to be transferred to
the new wing and so receive effective treatment. You feel that this is the most important
thing for you. You do not believe that having cut your neck would block your transfer as
you see it as part of your condition. You feel that the cut can be adequately managed in
prison with dressings and antibiotics if it became infected. You acknowledge that it may
not heal as well but do not feel this is as important as receiving therapy. You are unfazed
by the prospect of a scar. You would be willing to return to hospital if there was some
major complication later on.

Topic: FORENSIC NECK INJURY - CAPACITY

Candidate Name: Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT
Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicits a brief relevant history -
Circumstances of the self-harm, previous
diagnosis, past history, circumstances of
imprisonment.

Capacity assessment - Understanding of

information, ability to retain information
and communicate decision

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 Capacity assessment - Weighing of relevant
information
Capacity assessment - Summarise result of
assessment and explain this to the patient
Screen for symptoms of depression or
psychosis
Performs a relevant risk assessment -
Particularly around the risk of further
serious self-harm.
Communicate decision around return to
prison or not to patient
Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately
phrased questions)
2 Poor active listening skills and use of cues
Failure to listen/identify/respond to concerns or cues from the interviewee
3 Lack of empathic response & missed opportunities in empathy, Poor body
language, Does not appear to develop rapport,
Lack of eye contact/non verbal responses, does not show appropriate attitudes
or behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,
Inappropriate avenues of enquiry or discussion
5 Lack of Fluency on the required task (Interview/examination/discussion)
Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task
Omissions related to lack of knowledge/ability
7 Does not demonstrate adequate skills in risk assessment
Inadequate or superficial risk assessment (just limited to presenting
complaint)
8 Poor range of Symptomatology/psychopathology explored
Does not explore signs and symptoms competently
Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,
Does not develop an adequate awareness of management of risk
FORENSIC NECK INJURY - CAPACITY

33 | P a g e
 • This station assesses a candidate's ability to perform a capacity assessment, with
particular regard to a patient's ability to adequately weigh information, and
communicate their decision.
• It requires that the candidate appreciate that a patient's priorities may be
different to that of medical staff and that individuals are entitled to make potentially
unwise decisions.
• The candidate should explain the purpose of the assessment and the concerns
from staff around the patient declining the treatment being offered. They should
explain the treatment offered and the possible negative outcomes of not having their
neck laceration closed under anaesthetic, including bleeding, infection, scarring and
failure to close.
• They should elicit a brief account from the patient of the circumstances of the self-
harm, its intention and precipitants. They should identify that this self-harm was
not suicidal in nature and related to frustration around delays in treatment.
• They should assess the patient's ongoing risk, particularly with regard to further
serious self-harm, but also suicide and risks to others. The risk of self-harm in this
case is ongoing and elevated due to the recent episode of self-cutting but it is not
immediately raised and there is no suicidality.
• They should elicit a brief but relevant past history of the patient, including their
previous diagnosis of EUPD and the circumstances of their current imprisonment.
• They should establish that the patient can understand and retain information. A
formal assessment of memory is unnecessary for this and the patient summarising
information given should be sufficient.
• They should establish the patient's ability to weigh up the relevant information to
reach a decision. This will require an understanding of the rationale for their
decision, particularly them prioritising receiving an effective treatment for their
mental health difficulties.
• Candidates should identify that, while the patient's decision is probably unwise as
a brief hospital admission is unlikely to impact on the timing of them receiving
psychotherapy, they do appear to have the ability to weigh the information.
• They should clearly communicate the outcome of the assessment, that the patient
has capacity and can accept or decline treatment. They should caution that this is
contrary to medical advice.
• Good candidates should strike a balance between making it clear what the
medical advice is and encouraging the patient to accept this, whilst not pressurising
them.

34 | P a g e
READING MATERIALS: MDU. Assessing capacity. [Internet]. C2018-19. [updated 2018
Jul 31; accessed 2019 Apr 10]. Available online at: https://www.themdu.com/guidance-
and-advice/guides/assessing-capacity

35 | P a g e
Lesson 11:

TOPIC 1: MANIA TREATMENT- DISCUSSION ABOUT OPTIONS &

MANAGEMENT PLAN
TOPIC 2: SECLUSION REVIEW OF DEHYDRATED PATIENT
TOPIC 3: OLANZAPINE WEIGHT GAIN AND MANAGEMENT
TOPIC 4: ASSESSMENT OF MOOD IN TERMINALLY ILL PATIENTS
TOPIC 5: UREMIA RELATED COGNITIVE IMPAIRMENT/DEMENTIA

1|Page
Topic 1:

CASC Lesson 11
MANIA TREATMENT - DISCUSSION ABOUT OPTIONS & MANAGEMENT
PLAN
TASK:

You have been asked to attend the local PICU (Psychiatric Intensive Care Unit), as the
registrar on-call for Sunday by Amanda, the nurse in charge, as one of their recently
admitted patients does not appear to be responding to treatment. He is Mr Josh Watkins, a
26-year-old man with a diagnosis of bipolar affective disorder, Type I.

Discuss treatment options and arrive at a plan with the nurse in charge. Address their
concerns and expectations. She is concerned about Mr. Watkins being at risk due to him
intruding on the personal space of other patients and would like to know about further
treatment options.

CASE SYNOPSIS:

You are Amanda, the nurse in charge for a PICU (Psychiatric Intensive Care Unit). You have
a relatively new admission to the ward, Mr. Josh Watkins, a 26-year-old man with a previous
diagnosis of bipolar affective disorder. You know that he has not taken medication
regularly outside of admissions and that he was admitted after being detained outside a
pub after causing a disturbance and breaking glasses. Mr. Watkins is very unwell and is
presenting as ‘elated and restless’. His speech is rapid and frequently difficult to follow. He
is barely sleeping and is reluctant to eat. He seems somewhat suspicious about the
motivations of the staff and has not had any blood tests done as he is worried about the
staff using his blood for experiments. He has also refused physical observations although
appears to be well.

He has been prescribed Olanzapine 10mg at night and has been taking this, although with
persuasion. During his ward rounds, Dr. Singh suggested that Mr. Watkins could be
changed to Lithium if he does not respond adequately to Olanzapine. You feel that Mr
Watkins has not improved at all over the last 3 days despite the Olanzapine. You are
concerned about him repeatedly intruding on the personal space of other patients and
potentially coming to harm as a result. You think that he should be changed onto Lithium
as soon as possible and have called the doctor to the ward so it can be done today. If they
talk about regular blood tests, you will mention Mr. Watkins' reluctance to have them done.
If the doctor decides against prescribing Lithium, you will challenge them and state that Dr.
Singh made it clear that Mr. Watkins should be changed onto it if Olanzapine is not
effective. If they can provide an adequate explanation, you will accept this. If they have no

2|Page
alternative suggestions, then you will be exasperated. You will accept their suggestions for
alternative interventions, provided that they can explain how they will help.

MARKING SHEET : MANIA TREATMENT - DISCUSSION ABOUT VARIOUS OPTIONS &

MANAGEMENT PLAN

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history: Circumstances of admission and
current presentation
Elicit relevant history: Treatment of patient so far and
their engagement with staff and willingness to accept
care
Elicit staff member's views on medication and the
rationale for them
Elicits relevant risk information - Intruding on other
patients and at risk from them, and not accepting care
from staff
Identify that initiating Lithium with this patient is
unwise at this stage and explains why (Monitoring
required)

(Blood tests if not done-sub-therapeutic levels or

toxicity)
Able to justify their clinical opinion to their colleague

(Trial of olanzapine on adequate dosage, adequate

duration)
Provide an alternative treatment strategy

3|Page
(Non-medication interventions, such as closer
observation or nursing the patient away from other
individuals, regular sedation etc)

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy,
4 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

5 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

6 Poor range of Symptomatology/psychopathology explored

Does not explore signs and symptoms competently

Aspects of history or mental state highlighted but not explored in depth or

appropriate manner
7 Inaccurate or misleading information discussed
8 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

NOTES- MANIA TREATMENT:

• This station assesses a candidate’s ability to discuss the care of a patient with an
episode of mania with a colleague.

• The station assesses the candidate's ability to resist pressure to make inappropriate
treatment or prescribing decisions and to justify their rationale.

4|Page
 • The patient in the scenario is clearly experiencing a marked episode of mania in the
context of a diagnosis of bipolar affective disorder.

• They have only recently been started on Olanzapine and have not started to
respond yet.

• They pose a risk to themselves as they are repeatedly intruding on the personal
space of other patients and they could respond aggressively towards the patient.

• The colleague that they speak to will insist that they change the patient onto Lithium
despite it having only been trialed for a brief period and not at the maximum dose.

• Candidates should elicit a history including the reason for the patient's admission
and their presentation on the ward since.

• Candidates should establish what medication the patient is prescribed and what
they have been willing to accept. Good candidates will establish whether the
patient is willing to accept other elements of care, including routine
observations and blood tests.

• Candidates should establish their colleague's expectations around medication and

why they feel that the patient should be started on Lithium.

• Good candidates will identify their colleagues concerns about the patient's risk of
being assaulted by other patients.

• Candidates should not start the patient on Lithium.

• Candidates should inform their colleague that starting Lithium at this stage would
not be advisable and provide an adequate explanation for this. Examples of
adequate explanations would include:

o 1. The patient has not been taking Olanzapine for a sufficient period of time.
Good candidates may refer to the medication's half-life and that it may not

5|Page
 be at a steady state yet. Very good candidates may specify that Olanzapine's
half-life is around 30 hours.

o 2. The patient has not trialed Olanzapine at the maximum dose. Good
candidates may mention the NICE guidelines which indicate that, in acute
mania, the first anti psychotic used should be trialed at the full dose before it
is changed to Lithium or another alternate agent.

o 3. The patient is not willing to receive observations or blood tests. These will
need to be carried out regularly if they started on Lithium. If they cannot be
performed the patient would be at risk of having sub-therapeutic levels or
developing toxicity.

• Their explanation should not solely be that the consultant on the ward may want to
make the decision themselves.

• Candidates should recognise that, while the Olanzapine is adequately trialed, the
patient is potentially at risk from others due to their restlessness and intrusive
behaviour.

• Candidates should discuss treatment options to mitigate this risk. These may
include non-medication interventions, such as closer observation or nursing
the patient away from other individuals. They may also suggest regular
sedation, using agents such as Clonazepam which the patient is already
occasionally receiving.

• Candidates should speak to their colleague in a respectful manner and avoid

becoming irritated or abrupt in their responses.

• Candidates should be able to resist pressure to follow their colleague's instructions

and provide a rationale for doing so despite being challenged on their decision.

Suggested Reading:

6|Page
Bipolar disorder: Assessment and management [Internet]. [London]: NICE; 2020
[Published date: 24 September 2014 Last updated: 11 February 2020; cited 2020 Oct 21].
Clinical guideline [CG185]. Available from: https://www.nice.org.uk/guidance/cg185/

7|Page
Topic 2:

CASC Lesson 11
SECLUSION REVIEW OF DEHYDRATED PATIENT
TASK:

Mr. Adrian James is a 27-year-old man who was admitted to his local PICU 3 days ago after
experiencing a relapse of paranoid schizophrenia associated with significant agitation. He
was placed in seclusion on the day of admission after becoming aggressive towards
nursing staff. You have been called to review his seclusion. Please take a handover from
the nursing staff and make a management plan.

CASE SYNOPSIS:

You are Connor/Cira O’Brien, a psychiatric nurse covering the seclusion suite in a PICU. You
have called the doctor to review a patient, Adrian James, who has been in seclusion for 3
days. Mr. James is a 27-year-old man who was admitted to the PICU 3 days ago after
experiencing a relapse of paranoid schizophrenia. He had stopped his prescribed
Clozapine around one week prior to admission and had rapidly become very unwell. He
was also experiencing auditory hallucinations of people mocking and denigrating him. This
led to him being aggressive towards a member of staff in a shop and being detained under
Section 136. He had been suspicious and irritable on the PICU, persistently refusing any
oral medication or any unsealed foodstuffs. He punched a nurse on the day of admission
after they tried to intervene in an argument he was having with another patient. He
required 8 staff to restrain and transfer him to the seclusion room.

He has threatened to assault anyone who approaches him and has made statements
about not getting his DNA without a fight. He has continued to be reluctant to accept food
and drink and has only had a limited amount since being in seclusion. He has not been
accepting any medication and has refused to have any physical observations, threatening
anyone who has offered. He has not been willing to talk to staff outside of making threats.
Mr. James has been complaining of a headache and dry mouth today but has continued to
refuse any food or drink. You don’t think that there are enough staff trained in safe
restraint on the ward today. He had roughly 600mls of fluid during the first 24 hours of
seclusion, around 300mls during the next and has only been taking sips out of the sink in
the seclusion room since then. You have not been able to estimate his urine output,
although he has not used the toilet for at least 12 hours.

If the doctor suggests that Mr. James could be dehydrated you will ask what symptoms or
signs they would expect to see if this was the case. If the doctor states that observations

8|Page
need to be done or Mr. James needs to be offered medication or other interventions you
ask about how they think this could be achieved in view of Mr. James’ aggression. If the
candidates suggests that the patient may need to go to a general hospital, then you will ask
how this can be safely arranged.

MARKING SHEET : SECLUSION REVIEW OF A DEHYRATED PATIENT

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit Relevant history – Circumstances of admission,
behaviour on the ward and circumstances of seclusion
Elicit history of progress since seclusion including
aggression and threatening behaviour towards staff
Request information regarding the patient’s physical
health and identify which information is available and
which is not
Identify signs that the patient is likely to be dehydrated,
such as limited oral intake, and symptoms of
dehydration
Identify that physical observations or blood tests must
be obtained to enable further management to be
planned
Identify that the patient must be rehydrated and suggest
how this may be achieved

9|Page
Candidates should consider the use of rapid
tranquilization to enable observations or investigations
to be performed.

Highlighting higher risk of neuroleptic malignant

syndrome if anti psychotics are administrated to a
dehydrated individual.
Any plan made by the candidate should be realistic in
nature and Suggest options for future management

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

8 Poor range of Symptomatology/psychopathology explored

Does not explore signs and symptoms competently

9 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

10 | P a g e
SECLUSION REVIEW OF DEHYDRATED PATIENT:

• This station assesses a candidate’s ability to identity that a secluded patient is

physically compromised and requires further examination and intervention.

• Candidates should elicit a brief history of the circumstances of the patient’s

admission including their diagnosis and recent non-compliance with medication.

• Candidates should establish how the patient presented on the PICU and the reason
for their transfer to seclusion. Good candidates will establish early that the patient
was experiencing persecutory ideation regarding food and fluids on the ward and
this was preventing them from eating and drinking adequately.

• Candidates should establish how the patient has presented while in seclusion,
including that they have continued to be aggressive and decline medication, as well
as food and fluids.

• Candidates should establish that the patient has not received any physical
observations during their time in seclusion and that their fluid intake has been
limited.

• Candidates should enquire about symptoms and signs of dehydration, including

reported lightheadedness, headache, dry mouth or lips, limited urinary output or
use of the toilet, feeling generally weak and sunken eyes.

• Candidates should establish that the patient is likely to be clinically dehydrated and
requires intervention.

• Candidates should establish a plan to obtain physical observations from the patient,
via persuading them if possible or via restraint if necessary.

11 | P a g e
 • Candidates may also wish to obtain blood tests to establish whether the patient has
elevated urea or creatinine. Candidates should be able to specify what
investigations they wish to conduct.

• Candidates should consider the use of rapid tranquilisation to enable observations

or investigations to be performed. Good candidates will state that they would use
Lorazepam for this as there is a higher risk of neuroleptic malignant syndrome if
anti psychotics are administrated to a dehydrated individual.

• Candidates should establish a plan to rehydrate the patient. It is reasonable for

them to initially plan to do this via providing oral hydration in seclusion and trying to
establish from the patient what they would find acceptable.

• Candidates should plan to transfer the patient to a general hospital to receive

hydration there if oral hydration fails or if the patient is discovered to be
significantly physically compromised.

• Candidates should state how they would plan to safely organise a transfer to a
general hospital, if this was necessary. This should include ensuring that the patient
has sufficient escorts so they can be safely managed in a general hospital, ensuring
that they receive medication to manage their agitation and persecutory delusion,
and liaising with the medical team ahead of any transfer. Candidates should also
plan to liaise with the patient’s responsible clinician and possibly with other senior
clinicians and service managers.

• Any plan made by the candidate should be realistic in nature and take the patient’s
presentation into account, e.g. they should not solely rely on being able to persuade
the patient to accept observations and treatment.

• Candidates should speak to the member of nursing staff in a respectful fashion and
collaboratively establish a management plan.

Suggested Reading:

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National Institute for Health and Care Excellence.Violence and aggression: Short-term
management in mental health, health and community settings[Internet]. [London]: NICE;
April 2015. (NICE guideline [NG10]). Available
from: https://www.nice.org.uk/guidance/ng10/

13 | P a g e
Topic 3:

CASC Lesson 11
OLANZAPINE WEIGHT GAIN AND MANAGEMENT
TASK:

Mr. Gregory Malvern is a 35-year-old man with a diagnosis of paranoid schizophrenia. He

was prescribed Olanzapine 10mg at night around 6 months ago to address a relapse. He is
now symptom free but has gained a significant amount of weight since starting the
medication and is keen to address this.

Please discuss weight management with him, including lifestyle modifications.

CASE SYNOPSIS:

You are Gregory Malvern, a 35-year-old man with a diagnosis of paranoid schizophrenia.
You were first diagnosed with this at the age of 23 after developing paranoid ideas about
your employer in an accountancy firm. You also experienced voices, which you believed
was your boss telling you about their plans. You were treated with Risperidone initially and
then changed to Quetiapine, which were not particularly effective. You were then switched
to Olanzapine and it was found that this was effective for you at a dose of 10mg at night,
although it led to you gaining 12kg in weight over the course of a few months. You then
gradually stopped the Olanzapine as you disliked the weight gain. You have been trialled
on Aripiprazole, Amisulpride and Haloperidol but found that they were not as effective as
Olanzapine. You experienced a further relapse 6 months ago and agreed to go back on the
Olanzapine as you recognise that it is the most effective medication for you. You recovered
over the course of 3 months and have remained well since, but have gained 12kg in weight
again. You are willing to continue with the Olanzapine but are concerned about the weight
gain and want to address it.

You have noted that your appetite has increased every time that you have started on
Olanzapine and you tend to eat more junk food. You have tried to snack in a healthy
manner but do end up eating crisps and chocolate. You also think that your food portions
when taking Olanzapine are larger than when you are not taking it. You tend to sleep for 10
hours a day when taking the Olanzapine. You have tried to exercise and are walking 3 times
a week for about 3km. You think that your weight is continuing to increase, but more slowly
than it was. You think that you are now 18kg heavier (current weight is 88kgs which used to
be 70Kgs) than you were when you first started Olanzapine. You have noted that you
struggle to run any distance and can get out of breath going up multiple flights of stairs,
although your ability to walk longer has been better since you have been exercising

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regularly. You have not followed any particular diets, nor have you taken part in any weight
loss groups as you have felt somewhat embarrassed about doing so. You used to smoke,
but are now vaping, and do not drink to excess. Your father had a heart attack at the age of
65 and had a stent inserted and seems to be doing well since.

MARKING SHEET : OLANZAPINE - WEIGHT GAIN AND MANAGEMENT

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit brief history of patient’s previous and recent
mental health difficulties
Elicit a history of the patient’s weight gain and its
temporal relationship to medication. Establish the
patient’s previous response to alternative medications.
Screen for any current adverse health consequences
and enquire regarding physical health monitoring

Inform the patient about the potential adverse health

consequences of their increased weight.

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Screen for any other adverse risk factors for
cardiovascular disorders or diabetes
Provide some general advice-ensuring regular meals
rather than snacking, removing unhealthy foods from
the house, increasing the proportion of low GI foods
(which are absorbed more slowly) and protein in the
diet to maintain satiety for longer, and increasing
exercise
Discuss lifestyle interventions, particularly (Formal
interventions like CBT or other group treatments are
more effective in leading to weight loss)
Discuss the use of Aripiprazole and Metformin and
what the potential benefits and risks would be

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

8 Poor range of Symptomatology/psychopathology explored

Does not explore signs and symptoms competently

16 | P a g e
 9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

OLANZAPINE WEIGHT GAIN AND MANAGEMENT: (NOTES)

• This station assesses a candidate’s ability to take a brief history of a patient

changing weight in the context of antipsychotic medication and to provide advice
about managing this, both pharmacological and non-pharmacological.

• Candidates should establish a brief history of the patient’s mental health difficulties.

• Candidates should gain an understanding of the weight gain that the patient has
experienced in the context of being prescribed Olanzapine and establish a temporal
relationship between the two.

• Candidates should establish how much weight the patient has gained as a result of
being prescribed Olanzapine.

• Candidates should establish that the patient has not responded adequately to
alternative anti psychotics and that Olanzapine is the most effective agent for them.

• Candidates should identify that the patient’s appetite tends to increase when taking
Olanzapine and that they are also less physically active than usual. Good candidates
will identify that these symptoms have been more prominent in the past when the
patient has recently started the medication and when they are still experiencing
psychotic phenomena.

• Candidates should enquire regarding methods the patient has used to lose weight
and what has prevented them from doing so in the past.

17 | P a g e
 • Candidates should establish whether the patient’s increased weight has led to any
physical health problems. They should enquire about any regular physical health
monitoring that the patient receives.

• Candidates should inform the patient that they are at increased risk of physical
health problems due to their increased weight, including Type II diabetes and
cardiovascular disease. Candidates may inform the patient that it may place them at
risk of dying earlier than they may do otherwise, but this should be handled
sensitively.

• Good candidates may mention the importance of compliance with medication and
that addressing the patient’s weight gain may reduce the likelihood of them
stopping medication in future, potentially preventing future relapses.

• Candidates should enquire about other risk factors for cardiovascular disease, such
as smoking and alcohol misuse.

• Candidates should advise that weight gain is a common side-effect of Olanzapine

use and that it appears that the patient’s pattern of increased appetite is in keeping
with this. Candidates can inform the patient that the weight gain associated with
Olanzapine is thought to be mediated via increased appetite and greater oral intake,
rather than any effect on metabolism.

• Good candidates may inform the patient that the possible interventions to address
weight gain associated with antipsychotics can all provide benefits, but that these
can be individually modest.

• Candidates should encourage the patient to make lifestyle changes in the first
instance. Candidates should advise the patient that formal interventions are more
effective in leading to weight loss than changes made by the individual and
encourage them to engage with available services.

18 | P a g e
 • Candidates should provide some general advice around addressing weight, such as
but not limited to: Ensuring regular meals rather than snacking, removing unhealthy
foods from the house, increasing the proportion of low GI foods (which are
absorbed more slowly) and protein in the diet to maintain satiety for longer, and
increasing exercise.

• Candidates should inform the patient that group interventions often involve
education around healthy eating, effective exercise and how weight is gained and
lost.

• Candidates should inform the patient that group interventions often also address
the relationship between eating and exercise behaviours and feelings, as this often
influences the ability of an individual to lose weight.

• Candidates should not advise the patient that they should change medications.
While anti psychotic switching is reasonable in some circumstances, this patient has
already trialed various alternative medications without benefit. They clearly respond
well to Olanzapine and repeated trials of other options could lead to their
experiencing a further relapse.

• Candidates could suggest introducing Aripiprazole as this can be associated with a

small reduction in weight when prescribed with Olanzapine. Good candidates will be
able to inform the patient that the average weight loss with this would be around
2kg.

• Candidates may suggest that the patient could be prescribed Metformin if other
interventions fail. This may aid their weight loss and reduce the risk of them
developing diabetes. This would have to be initiated and prescribed by their GP and
good candidates may be aware of this. Good candidates may also be able to inform
the patient that the average weight loss of this medication is around 3kg. Very good

19 | P a g e
 candidates may be able to advise the patient that they will require monitoring of
their renal function and vitamin B12 levels if this was prescribed.

• Candidates should speak to the patient in a respectful fashion and address their
queries in a sensitive manner.

Suggested Reading:

Cooper SJ, Reynolds GP, et al. BAP guidelines on the management of weight gain, metabolic
disturbances and cardiovascular risk associated with psychosis and antipsychotic drug
treatment. Journal of Psychopharmacology. 2016;30:717-48.

NICE Type 2 diabetes: prevention in people at high risk. NICE Public Health Guideline 38.
2012. London: National Institute for Health and Care Excellence.

20 | P a g e
Topic 4:

CASC Lesson 11
ASSESSMENT OF MOOD IN TERMINALLY ILL PATIENTS
TASK:

Mr. Patrick Jones is a 65-year-old man who is currently an inpatient at a general hospital.
He has a diagnosis of amyotrophic lateral sclerosis and had been admitted due to an
episode of pneumonia which has now been treated and he is due to return home to his
wife once his care package is ready. You have been called to assess him as he has informed
the ward staff that he is thinking of going to the Dignitas clinic to end his life. He can no
longer speak and communicates via writing notes and shaking or nodding his head. There
are no concerns around his cognitive functions.

Please assess his mood.

CASE SYNOPSIS:

You are Patrick Jones, a 65-year-old man who was diagnosed with Motor Neurone Disease
(MND), amyotrophic lateral sclerosis sub type, after developing muscular weakness around
18 months ago. This has gradually progressed and now you have marked weakness and
muscular stiffness in all your limbs. It started to affect your speech and ability to swallow
around 6 months ago and this has now reached the point that you cannot speak
meaningfully or swallow easily. You were recently admitted to hospital after developing a
pneumonia that is thought to be due to this difficulty swallowing. You were reviewed by
your neurology team during this admission and informed that you have a life expectancy of
around 18 months. Your speech and swallowing has gradually declined, with your voice
initially changing but it has become as soft as to be imperceptible and so you no longer try
to speak. Your swallowing difficulties initially started with just more solid foods, but you
now have problems with liquids and have now been told you have to use thickening agents
and only eat small amounts relatively often. Your wife supports you with dressing and
mobilising as you find these activities very tiring. You are conscious that your wife's life is
now dominated by caring for you and she gets limited time for herself. You feel guilty
about this and you have discussed employing carers to make things easier, although you
still think she will have to do a lot for you.

You do not have any significant mental health history.

You would describe your mood as low and frustrated. You have not been doing other
activities that you usually enjoy because of a lack of interest. You are sleeping more than
usual and feel persistently tired, although you think this is part of the MND. Your appetite is
worse than usual and you have lost around 2 stones in weight over the last year. Your

21 | P a g e
concentration has diminished and you find this frustrating. Your memory is not as good as
before but you feel this is down to your poor concentration. You don’t have any bad
thoughts about yourself and feel that you have had a good life. You do feel hopeless about
the future as you anticipate further limitation to your physical abilities and needing more
care from your family. You are particularly concerned about needing intimate care or being
completely dependent upon others. You do not feel you could cope with this as it is not
how you see yourself.

You have been thinking about going to Dignitas for the last 3 months. You had known that
you did not want to be more disabled in future although you saw this as being inevitable.
You had not considered suicide as an option but feel that going to Dignitas would be
different as you see it as choosing the manner of your death rather than giving up on life.
You are aware that your family would be upset by you dying, but feel that it may be better
for them if they do not have to see you suffer more first.

As you can no longer speak, you communicate with gestures, such as nodding or shaking
your head, and by writing short notes. Your muscular weakness and stiffness makes writing
longer notes very difficult. You carry a pen and notepad for this purpose.

MARKING SHEET : ASSESSMENT OF MOOD IN MND

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history of physical health problems and
their progression

22 | P a g e
Elicit current level of physical disability and the
patient's feelings about this
Elicit biological and psychological symptoms of
depression
Elicit thoughts around going to Dignitas including
evidence of planning, intent and weighing of options
Elicit concerns about the future, such as further
disability and the patient's concerns about needing care
from family
Elicit particular frustrations about speech and
swallowing impairments
Consider risks outside of going to Dignitas, particularly
harming self, refusing care and self-neglect
Respond to the patient's query about returning home
and provide a rationale for their decision

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

23 | P a g e
 8 Poor range of Symptomatology/psychopathology explored

Does not explore signs and symptoms competently

Aspects of history or mental state highlighted but not explored in depth or

appropriate manner
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

GUIDANCE NOTES- ASSESSMENT OF MOOD IN MND:

• This station assesses a candidate’s ability to conduct an assessment of mood in a

patient who has significant communication difficulties.

• Candidates should be able to adapt the interview to account for the patient's
communication needs. This should avoid using mainly leading questions but may
involve clarifying comments made by the patient.

• Candidates should address the patients concerns and thoughts about the end of
their life sensitively. It is expected that they challenge them.

• Candidates should elicit a history of patient's physical health difficulties and a rough
timeline of how these have progressed.

• Candidates should elicit how these changes have impacted upon the patient's life
and his feelings about them.

• Good candidates should identify that his speaking and swallowing difficulties are a
particular source of frustration and may elicit how this is related to his previous
career.

24 | P a g e
 • Candidates should perform an examination of the patient's mood and ask regarding
mood state, enjoyment of activities, cognitions and biological symptoms of
depression. Candidates should avoid assuming that the patient will inevitably be
depressed.

o The patient does exhibit some low mood, reduced enjoyment and interest in activities
and a negative view of the future, as well as thoughts around ending his life.

o The symptoms exhibited could be categorised as a mild or moderate episode of

depression, depending upon the manner in which the patient's experiences are expressed.

• Good candidates will show an understanding that some symptoms may be part of
the physical illness, particularly tiredness and poor concentration.

• Candidates should sensitively address the patient's thoughts around Dignitas and
ending their life. Candidates should elicit the evidence of planning, intent, and the
patient's weighing of the benefits and drawbacks of going to Dignitas.

• Good candidates will explore alternatives to going to Dignitas and how these may
address some of the patient's concerns.

• Candidates should perform a wider risk assessment, particularly any thoughts about
suicide, refusing care or self-neglect.

• Candidates may identify that the patient is not at immediate risk of coming to
harm.

• Candidates should respond clearly to the patient's question about returning home
and provide a rationale for any decision they make. The patient does not present an
immediate risk to himself and has the capacity to make decisions about their health.
He does not present as detainable under the Mental Health Act. Candidates should
not indicate that they will detain him under the Mental Health Act or utilise the
Mental Capacity Act. If they do, they must provide an explanation.

25 | P a g e
 • Candidates can request advice but should be able to explain what they need
assistance with.

• Candidates can offer follow-up from mental health services or to speak to the
patient's family. Good candidates may suggest input from third sector
organisations and offer to get information for the patient.

• Candidates should be respectful of the patient's decisions and not dismiss their
thoughts around Dignitas as being purely due to mental illness.

Further information:

Block SD. Assessing and Managing Depression in the Terminally Ill Patient. Annals of
Internal Medicine 2000;132:209-218. Available
from: https://www.acponline.org/system/files/documents/clinical_information/resources/e
nd_of_life_care/managing_depression.pdf

Guy M and Stern TA. The Desire for Death in the Setting of Terminal Illness: A Case
Discussion. Prim Care Companion J Clin Psychiatry. 2006; 8(5): 299–305. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1764532/.

26 | P a g e
Topic 5:

CASC Lesson 11
UREMIA RELATED COGNITIVE IMPAIRMENT/DEMENTIA
TASK:

Colin Douglas is a 76-year-old man who has been referred to your Older Person's
outpatient clinic with a 9-month history of increasing confusion. He has been accompanied
by his wife, Jane Douglas. Please take a collateral history from her and arrive at a diagnosis.
Do not provide a treatment plan or prognosis.

CASE SYNOPSIS:

You are Jane Douglas, the wife of Colin Douglas, and have attended the Older Person's
outpatient clinic with him today. You've been increasingly worried about him over the last 9
months. He had been more tired than usual and somewhat off his food before this, but
you assumed that this was just due to him getting older. He had also complained of cramps
in his legs and you noticed that his legs tended to move at night. His confusion started with
him finding it difficult to concentrate on televisions programmes or when reading the
newspaper. It seemed to gradually get worse with him starting to get confused over the
date and where things go in the house. The times when he is relatively lucid seem to be
reducing in frequency. He can generally get around the house at the moment but you
wouldn't trust him to go out by himself as you would be worried about him getting lost. He
can wash himself and won't let you help him with this or toileting; so far there haven't been
any issues with this. He can partially dress himself but needs your help with buttons and
similar as his left hand is too weak. His thinking seems to be slower than it was, but this
may be down to him being fatigued. He seems down in his mood and knows that he isn't
well. He has been progressively more exhausted over this time and seems so tired now
and is barely eating anything. You are convinced that this cannot be helping matters. He
has lost a substantial amount of weight; you're not sure how much as he never weighed
himself, but his clothes seem to be hanging off him.

His skin has been particularly dry and itchy over the last few months with no obvious
cause. He has said that he cannot taste or smell food as usual, even things which are
quite strong in flavour. Most oddly, he has had repeated bursts of hiccup ping over the
last few weeks, with no obvious cause. He had a stroke about 5 years ago when he
couldn't move his arm or leg on his left side at all. He was very confused when he went into
hospital but this cleared after about a week. More recently, this weakness has been more
obvious and you've had to help him getting dressed. He has high blood pressure and takes
Ramipril for it. He has not had any blood tests for a long time, certainly since before
starting the Ramipril 2 years ago.

27 | P a g e
MARKING SHEET : URAEMIA RELATED COGNITIVE IMPAIRMENT/DEMENTIA

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit time course of cognitive symptoms and the
nature of the patient's difficulties
Elicit characteristics of cognitive symptoms: impaired
concentration, variable memory impairment, slowed
cognitive processing
Elicit evidence of significant physical symptoms:
progressive fatigue and anorexia, weight loss
Further explore associated physical symptoms: dry skin
and pruritis, impaired smell and taste, hiccoughs,
uraemic foetor
Elicit previous medical history and risk factors:
(arteriosclerotic disease, CVA, hypertension, ACE
inhibitor use and prostatic obstruction), Elicit any
relevant family history
Communicate diagnosis of cognitive impairment
possibly secondary to an organic cause
Candidates may be able to offer renal impairment as
causation with a greater or lesser degree of
confidence. They must be able to name some potential
causes if asked by the relative

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

28 | P a g e
 (Use of predominantly closed questions/multiple questions/inappropriately phrased
questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

5 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

6 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

7 Poor range of Symptomatology/psychopathology explored

Does not explore signs and symptoms competently

Aspects of history or mental state highlighted but not explored in depth or

appropriate manner
8 Inaccurate or misleading information discussed

URAEMIA RELATED DEMENTIA:

• This station assesses a candidate’s ability to assess a patient with cognitive

symptoms due to an underlying organic process, in this case, uraemia.

• Candidates are expected to be able to identify that this patient's cognitive

impairment could be due to underlying organic pathology.

• This patient is likely to have a significant degree of renal impairment due to pre and
post-renal factors in terms of hypertension, ACE inhibitor use and prostatic
obstruction. His progressive physical and cognitive symptoms are a consequence of

29 | P a g e
 increasing uraemia due to renal failure. He may be more vulnerable to cognitive
symptoms due to the previous insult of a CVA.

• Candidates should clearly identify the time course of the patient's cognitive
symptoms and their nature.

• Good candidates may specifically ask about symptoms of: amnesia, agnosia,
apraxia, aphasia, depressive symptoms, personality change and psychotic
symptoms. They should identify that the patient's cognitive symptoms appear
to represent impaired concentration, variable disturbance in terms of
orientation and generalised cognitive slowing.

• Candidates may screen for depressive symptoms but should not pursue
questioning around a possible depressive illness.

• Candidates should identify that the patient is experiencing prominent physical

symptoms that are not clearly explained by the cognitive symptoms. Candidates
should identify, at the minimum, that the patient has been
increasingly fatigued and that his appetite has progressively and markedly
diminished.

• Good candidates will ask about other physical symptoms and identify that the
patient has some or all of the following: Hiccoughs, dry skin and pruritis, and
impaired taste and smell.

• Very good candidates may identify that he likely has uraemic foetor as his wife can
smell urine around him, even after he has washed and changed.

• Candidates should enquire about any previous medical history and should elicit a
history of a CVA. Good candidates will elicit a history of hypertension treated with an
ACE inhibitor and significant prostatic hypertrophy.

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 • Candidates should ask about any family history of memory impairment. Good
candidates will ask about any family history of significant medical problems. Very
good candidates may ask specifically about renal impairment.

• Candidates should identify that the patient's symptoms could have an organic
cause and explain this to the relative. It is entirely reasonable for candidates to
be unsure of the cause of the cognitive impairment and to state that they would
want to request investigations and then review the patient after these are available.
Candidates should be able to give some examples of possible organic causes of
dementia.

• Good candidates may spontaneously identify renal pathology as being one of the
likely causes.

• Very good candidates may confidently identify renal dysfunction as the likely cause
of the patient's symptoms and be able to clearly state why, in terms of their
symptoms (particularly progressive lethargy and anorexia, hiccoughs and uraemic
foetor) and pre-existing risk factors (arterosclerotic disease, hypertension, ACE
inhibitor use and prostatic obstruction).

• Candidates should take the history and provide examinations in a sensitive and
fluent manner.

Suggested Reading: David D, Fleminger S, Kopelman M, Lovestone S, Mellers J. Lishman's

Organic Psychiatry: A Textbook of Neuropsychiatry. 4th ed. London: Wiley-Blackwell; 2009.

31 | P a g e
Lesson 12:

TOPIC 1: OLD AGE MANIA-DRUG INDUCED

TOPIC 2: SPECIFIC PHOBIA-DRIVING
TOPIC 3: ASSESS-SUITABILITY FOR CBT IN PSYCHOSIS
TOPIC 4: ADOLESCENT OVERDOSE-BULLYING
TOPIC 5: 666-BAR CODE-OVERVALUED IDEA
LESSON 12
TOPIC 1: OLD AGE MANIA-DRUG INDUCED
TASK:

You are currently working with your local Home Treatment Team and have been asked to
review Mrs. June Trenton, a 65-year-old woman, at home after she was referred to the
team by her GP due to her family raising concerns about her behavior and her strikingly
irritable with them.

Please take a history from Mrs. Trenton and identify any relevant aetiological factors to
provide a provisional diagnosis. You do not need to establish a management plan.

CASE SYNOPSIS:

You are Mrs. June Trenton, a 65-year-old woman, who is due to be reviewed by the local
Home Treatment Team. They were contacted by your GP after your family raised concerns
about a recent change in your behaviour. You don’t see why everyone is making a fuss. You
feel better than you have done in years and have far more energy than usual. You feel that
your two daughters are just jealous as they were run ragged with their children and can’t
keep up with you. You also feel that they are envious of how confident you are, and how
men are finding you more attractive than them. You have only been sleeping for around 3
hours per night but don’t feel like you need any more. Your appetite seems to be rather
variable, with periods of not being interested in food, but then eating a lot at one time. You
will acknowledge that you have been feeling more irritable than usual.

You have been going on long walks through the countryside near your home and have
greatly enjoying these, but don’t feel like they are particularly tiring. You have been thinking
it would be nice to open a restaurant and have been booked cooking courses and
practicing frequently in the kitchen, even into the early hours.

You are very angry with your husband of 40 years as you are convinced that he is planning
on having an affair with your next-door neighbour You have seen her trying to hide around
corners but she always manages to disappear when you go over to confront her. You don’t
have any thoughts about harming them, but want to sell the house and move away,
perhaps Mauritius. You feel very optimistic about the future and have no thoughts of
harming yourself. You haven’t heard any voices or had any other unusual experiences. You
have a diagnosis of Parkinson’s and were started on a new medication, Sinemet, around 4
months ago. The dose was increased around a fortnight ago. You were finding yourself
being very stiff in the mornings and after periods of rest, but the medication seems to have
really helped and the symptoms now seem to have almost entirely cleared. You take
Ramipril for high blood pressure but no other medication.
MARKING SHEET : OLD AGE MANIA- DRUG INDUCED

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit recent history of elation, increased energy levels,
decreased sleep and irritability
Elicit recent history of overoptimistic ideation,
impulsivity, disinhibition and poor concentration
Elicit psychotic symptoms in terms of visual
hallucinations and persecutory delusions
Identify risks in terms of accidental fires due to
excessive cooking and poor concentration, and of other
accidents due to climbing on roof and similar
Enquire regarding other risks, particularly to husband
and neighbour, but also to self
Elicits previous medical history of Parkinson’s disease
and recent increase in dose of Co-Careldopa that is
temporarily related to the recent symptoms
Explains to the patient that they are currently unwell
with manic and psychotic symptoms, and that they may
be related to her medication

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
 2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

8 Poor range of Symptomatology/psychopathology explored
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

READING NOTES:

• This station assesses a candidate’s ability to assess an older individual with an

episode of mania in the context of Parkinson’s disease and the prescription of a new
dopaminergic medication.

• Candidates should elicit recent symptoms of elated mood including: elation,

irritability, overoptimism, increased energy levels, decreased need for sleep,
impulsivity, disinhibition, and impaired concentration.

• Candidates should elicit associated psychotic symptoms, including persecutory

delusions of the patient’s partner being unfaithful, and visual hallucinations of their
neighbour.
 • Candidates should identify that the patient may be at risk of harm due to
overactivity and unwise activities, such as repeated burning food and risk of fires
and climbing on their roof, and enquire about other potential risks associated with
elation and overoptimism, such as excessive spending, risky sexual behaviour,
dangerous driving etc.

• Candidates should specifically ask if the patient has any thoughts about harming
their husband or neighbour in view of their psychotic symptoms and their content.
Candidates should also ask whether the patient has any thoughts of harming
themselves.

• Candidates should establish the duration of the symptoms and that their onset
appears to be linked to the initial of Sinemet, Co-Careldopa, a dopaminergic
medication used in Parkinson’s disease.

• Candidates should ask about any previous personal history of mental illness, or any
family history of mental health difficulties.

• Candidates should explain to the patient that they believe that they are
experiencing an episode of manic and psychotic symptoms related to her Co-
Careldopa and that they will need treatment to resolve these symptoms.

• Candidates may suggest reasonable treatment strategies, such as reducing the dose
of the Co-Careldopa or cautiously introducing Quetiapine, but this is not necessary.
If they suggest potentially unsafe treatments, this will have a negative effect on their
mark for the station.

• Candidates should be sensitive but assertive in managing the interview, and not
irritable or aggressive with the patient. The patient will dominate the interview
unless they are interrupted to ask relevant questions.

Ref & Suggested Reading:

Ebmeier KP, O’Brien JT, Taylor J-P (eds): Psychiatry of Parkinson’s Disease. Advanced
Biological Psychiatry. Basel, Karger, 2012, vol 27, pp 53–60.

Zahodne, L.B., Fernandez, H.H. Pathophysiology and Treatment of Psychosis in Parkinson’s

Disease. Drugs Aging; 2008;25:665–682.
LESSON 12
TOPIC 2: SPECIFIC PHOBIA-DRIVING
TASK:

Mrs. Abigail Watson is a 35-year-old woman who has been referred to an outpatient clinic
after being in a car accident and experiencing ongoing significant anxiety about driving.
Please take a history of her core symptoms and make a diagnosis. Address her concerns.

CASE SYNOPSIS:

You are Mrs. Abigail Watson, a 35-year-old woman, who has been referred to a psychiatric
outpatient clinic by your GP after presenting to them with anxiety after a car accident. You
were in the car accident 3 months ago and have not been able to drive since. The accident
involved your car being struck on the passenger side while you were driving. The other
car’s brakes had failed and it had not been able to stop at the junction entering the main
road, which you were on. Your car was damaged, but was able to be repaired, and you
were not injured. The other driver experienced some facial injuries and was very apologetic
at the time. You were very upset and remained so for the next several days, as you felt
persistently anxious. You were initially unable to fall or stay asleep and you found that you
became less generally anxious over the next several weeks, although you did keep thinking
about the accident in quiet moments.

However, you now find yourself entirely unable to drive. Even thinking about it, you can feel
your heart beating strongly, your hands sweating and your breathing becoming more
rapid. You think about a similar accident happening again, and how you would cope with it.
You understand that your anxieties are excessive but feel unable to manage them. You
have continued to work and keep up with your usual activities. Fortunately, you are able to
do these using public transport or by walking. You don’t feel that your mood is low and
your energy levels feel generally normal. You don’t experience any nightmares.

You have always been anxious about driving and have generally avoided doing so in the
past. You have always worried about something going wrong while driving. For a long time,
you would feel extremely anxious before having a driving lesson. You failed your test 4
times as you kept getting overwhelmed and distressed, and feel that you only passed on
the fifth occasion “by fluke”. You were able to start driving with support from your husband
and would only make relatively local journeys.

In the end, please clarify the diagnosis and ask them to explain briefly? Check if this is PTSD
(Post traumatic stress disorder) as you have read about it on the Internet.

MARKING SHEET : SPECIFIC PHOBIA- DRIVING

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history of car accident and symptoms in
the immediate aftermath
Elicits relevant history of ongoing anticipatory anxiety
about driving, avoidance of it, and marked distress if
attempting to sit in the driver’s seat
Establishes that the patient does not have symptoms of
PTSD such as: re-experiencing, hypervigilance,
avoidance of being in cars or emotional numbing
Identifies previous history of specific phobia around
driving and that these symptoms lessened without
treatment but have worsened since the accident
Explain diagnosis of specific phobia and explain why a
diagnosis of PTSD would not apply

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,
 Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

8 Poor range of Symptomatology/psychopathology explored
9 Inaccurate or misleading information discussed
10 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

READING NOTES:

• This station assesses a candidate’s ability to identify a patient with a specific phobia
and distinguish this from PTSD in the context of this scenario.

• It assesses a candidate’s ability to explain the diagnosis and suggest a treatment

plan.

• Candidates should elicit a clear history of the events leading to the patient’s referral
including the accident and the duration of time since then.

• Candidates should elicit the patient’s initial symptoms following the traumatic event
including insomnia, affective changes and anxiety.

• Candidates should identify that the patient’s anxiety outside of driving gradually
diminished and that they generally returned to their usual functioning.
 • Candidates should ask regarding symptoms of PTSD, as this would seem to be
suggested by the initial task. They should identify that the patient does not report
any re-experiencing, marked avoidance of being in a car generally or signs of
hypervigilance or arousal.

• Candidates should ask about the patient’s previous feelings about driving. They
should identify that the patient has a previous history of marked anticipatory
anxiety around driving, avoidance of driving, and marked anxiety if they previously
had to, indicating a diagnosis of a specific phobia.

• Candidates should identify that the patient had a period of likely not meeting the
criteria for this disorder, as they were able to drive to a degree and not feel
profoundly anxious, but that the symptoms have markedly worsened following the
stress of the car accident.

• Candidates should be able to explain the diagnosis of specific phobia to the patient.
Good candidates will inform the patient that they do not meet the criteria for PTSD
and why this is the case.

• Good candidates will link the worsening in the patient’s symptoms to the car
accident, and explain that the trauma of this is related to their current difficulties,
although it does not change the overall diagnosis.

If there is adequate time and if the task required you to cover treatment plan, then should
also cover the following areas given below:

• Candidates should provide the patient with a treatment plan. Candidates should
advise the patient that they would benefit from graded exposure therapy and
explain what this is. It would be acceptable for candidates to not use the term
‘graded exposure therapy’ and advise the patient receive psychological input and
explain the same or similar principles.
 • Candidates should not advise the patient that they would benefit psychological
input or CBT, without explaining what this means.

• Candidates could offer medication, but it must not be the sole treatment offered.
Ideally, candidates should only suggest this if appropriate psychological input alone
was not sufficiently effective.

• Candidates should be able to explain that graded exposure therapy involves a

professional working with a patient to help them gradually become more
comfortable around a given feared stimulus, identifying similar, but less feared
stimuli, that the patient can be exposed to in a graded manner until they are able to
tolerate the original stimulus. Good candidates may relate this the experiences of
the patient’s sister, if they have elicited this information.

• Good candidates will advise that the therapy will need to consider that the
symptoms have worsened by a recent trauma, and that the professional delivering
the input will need to be conscious of this.

• Good candidates will advise that graded exposure therapy has a high efficacy in
treating specific phobias.

• Candidates should offer to answer any questions that the patient has.

• Candidates should communicate with the patient through the scenario in a sensitive
manner.

Suggested Reading:

Baldwin DS et al. Evidence-based pharmacological treatment of anxiety disorders, post-

traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005
guidelines from the British Association for Psychopharmacology. Journal of
Psychopharmacology; 2014 May;28(5):403-39. Available online
at: https://www.bap.org.uk/pdfs/BAP_Guidelines-Anxiety.pdf.

Choy Y, Fyer AJ, and Lipsitz JD. Treatment of specific phobia in adults. Clinical Psychology
Review; 2007; 27(3):266-86.
LESSON 12
TOPIC 3: ASSESS-SUITABILITY FOR CBT IN PSYCHOSIS
TASK:

Sam Guthrie is a 19-year-old man who is currently under the local Early Intervention
Service after developing first episode psychosis 6 months ago. His symptoms are currently
controlled on Risperidone although he continues to smoke cannabis at times. He is being
considered for CBT for psychosis.

Please explore historical and recent vulnerability factors for psychosis, establish a
preliminary formulation to understand his previous presentation and assess his suitability
for CBT for psychosis.

CASE SYNOPSIS:

You are Sam Guthrie, a 19-year man who is currently receiving treatment from the Early
Intervention in Psychosis Service after developing first episode psychosis 6 months ago.
You are now taking Risperidone and this has resolved your symptoms.

You became unwell after starting university to study chemistry around 8 months ago. You
had initially enjoyed it but started to find yourself getting suspicious of your flatmates after
around a month. You felt that they were gossiping about you and so you stopped spending
time with them. You were also hearing people whispering to you in your room, seemingly
trying to drive you mad. After you had been started on Risperidone and you had started to
improve, it was agreed that you could go home with your parents and be referred to the
Crisis Team in that area. You improved over the course of 2 months and then insisted on
returning to university as you were determined to make a success of your studies and not
have to repeat the year. You have remained well since and are continuing to take
Risperidone. You find it difficult to accept that you may have a psychotic illness and you
wonder about stopping your medication at times. You’ve not done so as you are afraid of
becoming unwell.

As far as you are aware, you were born at term after an unremarkable pregnancy. Your
parents have previously told you that you started to walk independently and say your first
words just before your first birthday. You have a sister who is 2 years younger than you
and remember your early childhood as happy. Your father ran a business manufacturing
plastic molds and your mother worked for the Citizen’s Advice Bureau. Unfortunately, your
father’s business had to close and you recall significant tensions at home around this time,
which never fully resolved. Your parents stayed together but would often bicker about
money and other matters and you didn’t feel that you could easily confide in them. You
recall home being tense at points, although you did have good times as a family as well.
You got on well at school and had a wide circle of friends. You realised that you were gay
when you were around 12 years of age but kept it to yourself. You came out to a close
friend in confidence when you were 14 but the next day in school you found that they had
spread it around widely. A lot of people were supportive but there was some bullying and
you feel that you have always been somewhat mistrustful of others since. You get on
reasonably well with your parents although still don’t often confide in them; you’ve been a
bit closer since your bout of illness. You get on well with your younger sister. You were
keen to return to university as you prefer not to live at home and you’re also conscious that
your family’s financial situation hasn’t been as good since your father lost his business so
you don’t want to put any more pressure on their finances. You also feel that you don’t
want your family, especially your sister, to worry about you.

Your paternal grandfather has a diagnosis of bipolar affective disorder and your father may
have had a depressive episode after he lost his business, but you’re not aware of any other
family history of mental health problems. You don’t use any substances other than
cannabis. You tend to smoke cannabis around twice a week but don't do it anymore.

You will accept the doctor’s formulation if it is reasonable and when they discuss CBT for
psychosis, you ask them how it works and how it could help you. If they provide a
reasonable explanation you will be willing to try this treatment.

MARKING SHEET : CBT FOR PSYCHOSIS

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history of the patient’s initial presenting
symptoms and their current mental state
Elicit predisposing factors for psychosis: Genetics,
pregnancy and delivery, early development, adverse
experiences during childhood and adolescence
Elicit possible precipitating factors: Starting university
and cannabis use
Elicit perpetuating factors: Ambivalence around
medication, continued cannabis use, ambivalence
around diagnosis
Elicit protective factors: Wanting to continue with
university, wanting to avoid further episodes of illness
and another admission, wanting to avoid worrying
family
Explanation of preliminary formulation of patient’s
symptoms and experiences - This formulation can then
be used to link the patient’s early life experiences and
underlying beliefs to their psychotic experiences, and
address how they may be prevented from occurring in
future
Explanation of CBT for psychosis and determining
whether the patient would be suitable for this. (The
patient would be likely to benefit as they are reasonably
psychologically minded, have a reasonable degree of
insight and are motivated to remain well)

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)
 Disorganised/unstructured consultation, Poor management of interview
6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Aspects of history or mental state highlighted but not explored in depth or
appropriate manner
8 Inaccurate or misleading information discussed

READING NOTES:

• This station assesses a candidate’s ability to elicit risk factors for psychosis, come to
a preliminary formulation of a patient’s case and assess their suitability for CBT for
psychosis.

• Candidates should elicit a brief history of the patient’s initial presentation and what
led to their initial admission.

• Candidates should gain an understanding of the timeline of the patient’s recovery.

• Candidates should establish the patient’s current treatment and that they are
compliant with this. Good candidates will identify the patient’s ambivalence about
medication and their concern about sexual side effects.

• Candidates should identify potential predisposing factors for psychosis including:

family history of psychotic disorder and adverse experiences during childhood and
adolescence. Candidates should enquire about pregnancy complications and birth
trauma. Good candidates may relate the patient’s experience of their trust being
violated and being unable to confide in others to their recent persecutory delusions.

• Candidates should identify precipitating factors for the patient’s presentation such
as cannabis use and a significant life changes, in terms of starting at university.

• Candidates should identify perpetuating factors which may result in the patient
being at increased risk of relapse, such as: continued cannabis use, ongoing stress
 due to university work, ambivalence over diagnosis, and ambivalence over
medication.

• Candidates should identify protective factors which may reduce the risk of the
patient relapsing, such as: motivation to remain well, motivation to avoid a further
hospital admission, the wish to avoid missing any more time at university, and
current effectiveness of medication.

• Candidates should be able to provide an initial formulation of the patient’s

difficulties, based upon the information above. This formulation should consider the
relevant factors, which could have influenced the patient’s presentation. It does not
need to be presented in terms of the 5 Ps (presenting problem, predisposing
factors, precipitating factors, perpetuating factors, and protective factors).

• Candidates should offer a brief explanation of how CBT in psychosis is thought to

work. Good candidates will relate this to the patient’s circumstances.

• CBT in psychosis works in various ways but it is often used to enable the patient and
therapist to gradually develop a formulation of a patient’s experiences to enable
them to understand these and how they may have come about. This formulation
can then be used to link the patient’s early life experiences and underlying beliefs to
their psychotic experiences, and address how they may be prevented from
occurring in future, or tolerated if they are ongoing. It can enable patients to gain
greater insight into their symptoms and experiences, improve medication
compliance, reduce unhelpful behaviours (such as cannabis use) and improve self-
esteem. Candidates should link this to the CBT concept of thoughts, feelings,
behaviours and bodily sensations being linked.

• Candidates should identify that the patient would likely be suitable for CBT for
psychosis and explain why. CBT should be offered to individuals with first episode
psychosis and the patient would be likely to benefit as they are reasonably
psychologically minded, have a reasonable degree of insight and are motivated to
 remain well. There are also matters that could be addressed in CBT such as: issues
around trust and confiding in others, avoiding cannabis use, continuing medication
and reducing self-stigma.

• It would be reasonable for candidates to offer the patient an opportunity to discuss

CBT in psychosis in more depth with the team psychologist, but they must provide
an explanation themselves.

• Candidates should communicate with the patient in a sensitive manner. Good

candidates will provide fluent formulations and explanations around CBT in
psychosis.

Suggested Reading:

Bertolote J and McGorry P. Early intervention and recovery for young people with early
psychosis: Consensus statement. British Journal of Psychiatry. 2005;187(48), s116–s119.

National Institute for Health and Care Excellence (NICE). (2014). Psychosis and
schizophrenia in adults:Prevention and management (Clinical guideline 178). NICE.

Turner DT, Van Der Gaag M, Karyotaki E and Cuijpers P. Psychological interventions for
psychosis: A meta-analysis of comparative outcome studies. American Journal of
Psychiatry. 2014;171,pp.523–538.

Hardy K. Cognitive Behavioral Therapy for Psychosis (CBTp) [Fact sheet]. Stanford
University Department of Psychiatry and Behavioral Health. Available
online: https://www.nasmhpd.org/sites/default/files/DH-CBTp_Fact_Sheet.pdf.
LESSON 12
TOPIC 4: ADOLESCENT OVERDOSE-BULLYING
TASK:

Miss Tiffany Blakewood is a 15-year-old girl who has recently been admitted to the
Paediatric ward via A&E after taking an overdose of 80 tablets of Paracetamol. She has
required N-acetylcysteine treatment, but is now medically cleared. Please take a relevant
history regarding her overdose and relevant aetiological factors, and assess her risk.

CASE SYNOPSIS:

You are Tiffany Blakewood, a 15-year-old girl who has been admitted to a paediatric ward
in your local hospital after taking an overdose of 80 tablets of Paracetamol. You have
received treatment for the overdose and are now physically well to go home. You took the
overdose two days ago and had been thinking about it for some time. You’ve been finding
things really difficult for the past year as you had to move school and away from a lot of
your previous friends, due to your parents’ changing their jobs. You had tried to make
friends when you arrived at the new school, but a group of girls in the same year, as you
have been constantly unpleasant towards you. It started with them just ignoring you, but
moved onto snide comments in classrooms and hallways and then deliberately bumping
you. They later got some of the boys at school involved who would shove you or lunge at
you when you were trying to walk past so they could laugh when you recoiled away. At first,
being at home gave you a degree of respite, but they then started sending abusive
messages through your phone and social media accounts, so you don’t feel like it ever
really stops.

You have been feeling increasingly low as a result of this bullying. You have been feeling
down and despairing about the situation and have found it really difficult to get up in the
mornings and drag yourself out of bed. You have tended to stay more and more in your
room than before; You find it difficult to get to sleep due to worrying about what might
happen at school tomorrow and you have been skipping meals on a regular basis recently
as you are just not feeling hungry. You think you have lost some weight but don’t know
how much. You feel anxious about going out of the house, and especially about going to
school, particularly on Sunday evenings. You couldn’t see a way out of going to school, and
you could not envisage the bullies stopping. And your parents and the teachers didn’t seem
to understand or care.

You kept thinking about taking an overdose, but were not set on it until 2 days ago, when
your form tutor found you crying and asked if it was because you were being ‘teased’,
which made you furious as they clearly didn’t understand anything about what was
happening to you. You went home immediately and took the overdose and went to bed,
hoping that you would die. Your parents checked on you when you didn’t come down for
dinner, but you said you were unwell and they let you sleep. You started vomiting in the
morning and your parents found the empty packets of Paracetamol under your bed when
they came in when they heard this. You did not tell them what had happened and only told
anyone about the overdose when you reached hospital. They immediately called an
ambulance and brought you to A&E. You didn’t write a note or similar as you felt that no-
one really cared about you.

You continue to feel disappointed that the overdose didn’t work and wish that it had. You
don’t have any current plans to take a further overdose or do anything else to harm
yourself. You feel that returning to school and being bullied again would be unbearable, as
would being mocked for having failed at ending your life. You have no thoughts about
harming any of your bullies, but would feel happy if they did come to harm.

You don’t have any history of mental health problems. You are not aware of any family
history of mental health problems and you are generally in good physical health.

MARKING SHEET : BULLYING-OVERDOSE IN ADOLESCENT

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history of circumstances leading to
overdose (moving to a new school, Bullying etc)
Elicits relevant history of the nature of the bullying and
how it has escalated in terms of severity of acts,
number of individuals involved and the pervasiveness
of the bullying, including via social media
Elicit a clear history of the overdose itself including:
planning, concealment of the overdose, not seeking
assistance and intent to die at the time
Elicit recent depressive symptoms in context of current
situation
Assess ongoing risk to self, including: presence of
ongoing hopelessness, suicidal ideation including
methods, wish the overdose had worked. Ask regarding
DSH and risk to others.
Identify other factors which may influence risk, such as
current parental support, alcohol or substance use,
stressors
Explicitly identify aetiological factors contributing to
overdose (including school move, escalating bullying,
depressive symptoms, limited support from parents and
teachers, and precipitants for suicidal ideation
worsening)

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

8 Poor range of Symptomatology/psychopathology explored
 9 Limited or Incomplete management plan,

Does not develop an adequate awareness of management of risk

READING NOTES:

• This station assesses a candidate’s ability to take a history from a young person who
has taken a relatively serious overdose. It also assesses their ability to determine
any aetiological factors which may have contributed to the overdose and assess risk.

• Candidates should take a focused history of events leading up to the overdose.

• Candidates should gain an understanding of the nature of the bullying and how it
has escalated over time and gradually involved more individuals.

• Candidates should identify that the bullying began after the patient moved schools,
and that it has involved an increasing number of people and has involved
increasingly aggressive and hostile acts towards the patient. Candidates should
identify that the bullying has spread to include abusive messages via social media
and that this has made the experience of being bullied more pervasive for the
patient.

• Candidates should elicit that the patient has sought assistance from their parents
and teachers but that the school have not provided any useful input, and that the
patient does not feel that they are adequately supported or understood by their
parents.

• Candidates should elicit that the patient is experiencing significant depressive

symptoms, including: low mood, diminished motivation, reduced enjoyment of
activities, social withdrawal, poor sleep, reduced appetite, hopelessness and
negative thoughts about herself.

• Good candidates will identify prominent ideas of helplessness, in terms of the

patient believing that their situation is inescapable and unmodifiable.
• Candidates should elicit a clear history of the overdose itself, in terms of it having
involved some planning and was thought about by the patient for several weeks.
Candidates should identify that the overdose was precipitated by an unhelpful
comment and that the patient wanted to die, attempted to conceal evidence of the
overdose and did not actively seek help. Good candidates may identify that while
the patient did not write a note, this was due to negative thoughts about herself.

• Candidates should identify that the school move, escalating bullying, including via
social media, and limited support from parents and teachers has contributed to the
onset of a depressive illness, suicidal ideation and the overdose.

• Candidates should identify precipitants for the suicidal ideation worsening,

including a new group being involved in the bullying, and apparent dismissiveness
from a teacher.

• Candidates should identify that the patient is experiencing ongoing thoughts of

hopelessness and active suicidal ideation with intent although no imminent plans.
Candidates should identify that they continue to wish that the overdose had been
successful.

• Candidates should enquire about ongoing suicidal ideation in detail and identify
that the patient has ongoing ideation about suicidal methods, but no active plans to
act upon them, in part as they are uncertain how to.

• Good candidates will enquire if the patient has been using alcohol or recreational
drugs, which may increase their risk of impulsivity. They may also enquire if the
patient feels there are particular events or stresses which may lead to their suicidal
ideation becoming stronger.

• Candidates should enquire about any history of self-harm. Good candidates will ask
about other areas of risk, particularly thoughts of harm towards the individuals who
have bullied the patient.
 • Candidates should ask if the patient has experienced any previous difficulties with
their mental health. Good candidates will ask about any family history of mental
health difficulties.

• Good candidates will also ask about the patient’s perspective on their relationships
with their family and identify that the patient feels different to their other family
members and has not felt understood in the past, possibly contributing to her
recent difficulties.

• Candidates should speak to the patient in a sensitive manner and respond

appropriately to her presentation in a manner that enables them to establish a
good rapport.

Suggested Reading:

Klomek AB, Marrocco F, Kleinman M, Schonfeld IS, Gould MS. Bullying, Depression, and
Suicidality in Adolescents. Journal of the American Academy of Child & Adolescent
Psychiatry; 2007; 46(1):40-49.

Pettit JW, Buitron V, Green KL. Assessment and Management of Suicide Risk in Children and
Adolescents. Cogn Behav Pract. 2018;25(4):460-472. doi:10.1016/j.cbpra.2018.04.001.
LESSON 12
TOPIC 5: 666-BAR CODE-OVERVALUED IDEA
TASK:

You are a psychiatry doctor working in an adult community mental health team. Mr. Erik
Jones is a 45-year-old man who has been referred by his GP. The GP has described that Mr.
Jones mentioned that a blood tube had a barcode with the “mark of the beast” and a
worldwide conspiracy when he was arranging some routine blood tests for him. The GP has
queried whether Mr. Jones has psychosis. Mr. Jones has agreed to attend the CMHT to
discuss his concerns.

Please assess Mr. Jones with a view to understanding the nature of his beliefs and
establishing whether or not he has a psychotic illness. At the end of the station you will be
asked to advice on your diagnostic impression.

CASE SYNOPSIS:

You are Mr. Erik Jones, a 45-year-old carpenter. You were attending the GP for routine
blood tests and you made a comment about the barcode on the blood tube. You are a
devoted member of the Baptist congregation, and have grown up in this community.
Regarding the 666 belief you refer to the new testament book of Revelations, quoting: "He
causes all, both small and great, rich and poor, free and slave, to receive a mark on their
right hand or on their foreheads, and that no one may buy or sell except one who has the
mark or the name of the beast, or the number of his name," reads the 13th chapter. "Let
him who has understanding calculate the number of the beast, for it is the number of a
man: His number is 666." You can say that you should not knowingly take the number 666,
however you have spoken to the religious leaders within your church and they have said
that although barcodes are well known to contain 666, that when it comes to health care
that is needed, then it is acceptable to allow these. You allowed the doctor to take the
blood tests. You try wherever possible to avoid products with barcodes.

You were first exposed to the idea of the beast in the bible study group as a teenager. You
met your wife at the bible study group and you learned about the various books of the
bible at the same time. You and your wife share the belief about 666. Your parents did not
worry about barcodes, but a number of the people you know at the church also hold this
belief. If the candidate asks if there is any chance that this might not be the case/that it’s
not the mark of the devil, you can say ‘Well, I guess so and I know that the bible can be
interpreted in lots of different ways. I’ve just noticed I always seem to have bad luck if I do
use something with a barcode. Nothing terrible, just like I might drop something at work.
So I just try to avoid barcodes where I can.’ You don’t drink or smoke. Within the church
your and your family’s beliefs are more devout than some other people, but you are not
thought of as strange within the community. You have never refused any medical
treatment for you or your family on the grounds of this belief. You feel a connection to God
through prayer, and have felt the Holy Spirit moving through you and you believe that he
guides your actions, but he does not control you and cannot move your body. You have no
previous history of contact with mental health services, and have never been depressed.
There is no history of mental health issues in your family.

MARKING SHEET : DELUSIONS VS OVERVALUED IDEAS (666 BAR CODE)

Candidate Name:

Candidate Number:

Examiner name/initials:

Examiner please circle one of the boxes

* OVERALL SEVERE FAIL BORDERLINE BORDERLINE PASS EXCELLENT

FAIL FAIL PASS PASS
JUDGEMENT

Please tick the boxes below

Competency Domains Very Poor Average Good Excellent

Poor
Elicit relevant history relating to the belief about 666,
barcodes and the devil – establishes the history of how
the patient came to believe this.
Assessment of how the belief relates to his family and
culture

(e.g.: is the belief in keeping with people in his church,

or is it unusual within this context).
Establish how much the belief affects the patient’s life.

Assessment of how the belief affects the patient, and

his family, and whether this poses any risk to himself
or his family.
Assessment for other psychotic symptoms –
hallucinations, passivity phenomena and ideas of
reference.
Ability to briefly screen for any other previous mental
health history and substance use.
Ability to communicate correct impression – that he
does not have a psychotic illness.
Ability to engage a patient who is hesitant, and unsure
why they have been referred to a psychiatrist and ability
to gently test beliefs in a non-judgmental way.

Detailed feedback with areas of concern (tick/shade the box)

1 Poor style of Questioning & lack of flexibility of questioning style

(Use of predominantly closed questions/multiple questions/inappropriately phrased

questions)
2 Poor active listening skills and use of cues

Failure to listen/identify/respond to concerns or cues from the interviewee

3 Lack of empathic response & missed opportunities in empathy, Poor body language,
Does not appear to develop rapport,

Lack of eye contact/non verbal responses, does not show appropriate attitudes or
behaviour
4 Lack of appropriate focus on the required task, Does not recognise the issues or
priorities in the consultation,

Inappropriate avenues of enquiry or discussion

5 Lack of Fluency on the required task (Interview/examination/discussion)

Disorganised/unstructured consultation, Poor management of interview

6 Omissions related to poor prioritisation of the task

Omissions related to lack of knowledge/ability

7 Does not demonstrate adequate skills in risk assessment

Inadequate or superficial risk assessment (just limited to presenting complaint)

8 Poor range of Symptomatology/psychopathology explored

Does not explore signs and symptoms competently

Aspects of history or mental state highlighted but not explored in depth or

appropriate manner
9 Inaccurate or misleading information discussed

Reading notes:
 • This station assesses the candidate’s ability to assess for possible mental disorder;
to explore an unusual belief and any associated risk.

• A good candidate will be able to establish rapport with the patient, to explore the
ideas around the 666 in a non-judgmental fashion with curiosity about the nature of
the belief. They will be able to demonstrate an ability to gently test the belief to
understand the degree of conviction (i.e.: is it a delusion, or an overvalued idea).

• An excellent candidate will explore how the idea about 666 developed, and will also
explore this within the context it arose (e.g.: as part of a religious family, acceptable
within the church).

• An additional important aspect of this station is to assess for other psychotic

symptoms which might point to a psychotic disorder (including hallucinations,
delusions of reference, passivity phenomena, other delusions).

• It is important to assess how much the belief affects the patient’s life – this relates to
the severity of the belief but also to risk. Therefore the candidate should explore
whether the belief about 666 has ever put the patient or anyone else at risk,
including children, and specifically with reference to the fact that the patient has a
child.

Tips for candidates:

When assessing possible delusions or overvalued ideas it is key to establish rapport with
the patient and to ask non-judgemental but curious questions to understand how the idea
came to be. Remember that although one definition of delusions is that they are ‘fixed,
false beliefs out of keeping with the patient’s social and cultural background’, the fact that
the belief is false is not the essential quality (Casey and Kelly, 2019). It is important to
understand how the person came to believe what they believe so that you can assess the
logic with which they arrived at this belief. A common example is where a person has a
delusional belief that their partner is unfaithful. This is culturally possible, and not bizarre
in any way, and it may be that the partner has been unfaithful, but if the person is
delusional they will have arrived at the belief through a false logic. This leads into the idea
of primary and secondary delusions. Primary delusions are those which arise out of the
blue. A secondary delusion comes from ‘another morbid experience’ for example a
delusion of ill health in someone who is depressed, or a delusion about being persecuted
by neighbours in someone who hears people talking about them.

For the purposes of this station it is important you can demonstrate an ability to ask about
someone’s beliefs system and to understand how it developed, to also gently test how
firmly held the belief is, and to assess how it is affecting their life. This will also allow you to
understand whether it is an overvalued idea which is understandable within the context of
their culture or religion.

Some questions which might be helpful in this situation:

Starting with “Your GP mentioned that you had been worried about the 666 in the barcode
of the blood bottle, can you tell me a bit more about this?”

“Would you be able to tell me a bit about how you reached this conclusion?” (looking to
understand how the person came to believe this).

“Is this something that other people in your family also think?” “And how about the people
in your church?” (you can be honest here and say you’re not familiar with that particular
religion, is it something that is usually part of the religion?) (looking for clarification of
whether this is in keeping with the rest of the family and community/church).

“What do you do when you encounter someone who doesn’t believe the same as you?”
(this can gently test whether the person is likely to be aggressive, or act on their beliefs, or
try to convert others) You can follow up with “Does it ever make you angry that people
don’t believe the same as you?”

(Having then heard what the patient is saying about the blood bottle, and once you have
some rapport you can gently test how firmly held the belief is. This is best done if you can
link to what they have already said). E.g.: “I understand you link the barcode with the mark
of the beast, but thinking about blood bottles – they are often used to help test people who
are unwell, to diagnoses diseases, to heal people, so is there a possibility that not all
barcodes are linked to the devil?” or even simpler “Is it possible there is another
explanation?”

It’s also important to think about any risks posed by holding this belief – in this case how
does this affect his life – E.g. “I can imagine this might be quite difficult as there are
barcodes everywhere these days, how do you manage with this?” and perhaps follow up
with “has it ever meant that you’ve refused a blood test, for you or your family?”
It is also important with this station to look for any other signs of a psychotic illness, so this
means asking about other ideas of reference, e.g.: “Do you ever seen any signs of god or
the devil in other places, like the TV, newspaper or on the radio?” and asking about voice
hearing, visual hallucinations, thought insertion or withdrawal or any other passivity
phenomena.

Phenomenology

In Sim’s Symptoms in the Mind, an overvalued idea is described as an ‘acceptable,

comprehensible idea pursued by the patient beyond the bounds of reason’ and can often
be associated with abnormal personality (Oyebode, 2018).

McKenna (1984) has also written about overvalued ideas and writes that it ‘refers to a
solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is
preoccupying to the extent of dominating the sufferer’s life’ (McKenna quoted in Oyebode,
2018).

In Sim’s it is reported that the idea is overvalued in that it causes disturbed functioning to
the person or others and that the background on which it is overvalued is not necessarily
false or unreasonable (Oyebode, 2018).

The first description of an overvalued idea was written by Wernicke in 1906 who developed
it in order to distinguish from obsession and delusion. He suggested that an overvalued
idea is an isolated notion with strong affect and abnormal personality and similar in quality
to passionate political, religious or ethical conviction and are understandable in the context
of personality and history (Oyebode, 2018).

Disorders associated with overvalued ideas include paranoid states (querulous or litigious
type), morbid jealousy, hypochondriasis, dysmorphophobia, Ekbom’s syndrome
(parasitophobia), anorexia nervosa (Oyebode, 2018).

Regarding delusions, Sim’s describes these as ‘false judgements that are held with extra-
ordinary conviction and incomparable subjective certainty and are impervious to other
experiences and to compelling.’ They are usually easily recognized when out of keeping
with the individual’s educational and sociocultural background (Oyebode, 2018).

More recently some authors have described a phenomenon of ‘extreme overvalued

beliefs’, which are shared by other people in a cultural, religious or subcultural group
(Rahman et al, 2020). This can be associated with amplification of the belief, it can become
more refined and more resistant to challenge and this can result in carrying out violent
behaviour in response.
An obsession (also sometimes termed a rumination) as described in Fish’s
psychopathology is ‘a thought that persists and dominates an individual’s thinking despite
the individual’s awareness that the thought is either entirely without purpose or else has
persisted and dominated their thinking beyond the point of relevance or usefulness’ (Casey
and Kelly, 2019). This is clearly not relevance here as the patient does not feel that the
thought is purposeless and does not appear to dominate his thinking. Nor does it cause
suffering or a sense of guilt, as is often see in obsessive compulsive disorder. The ideas
around 666 in this case are ego-syntonic rather than dystonic as would be seen in OCD.

Suggested reading:

• Casey P, Kelly B. Fish's clinical psychopathology: signs and symptoms in psychiatry.

Cambridge University Press; 2019 Jun 13.

• Oyebode F. Sims' Symptoms in the Mind: Textbook of Descriptive Psychopathology

E-Book. Elsevier Health Sciences; 2018 Sep 28.

• Rahman T, Meloy JR, Bauer R. Extreme overvalued belief and the legacy of Carl
Wernicke. The journal of the American Academy of Psychiatry and the Law. 2019 Jun
1;47(2):180-7.