Candidate Instructions

You are working in an outpatient clinic and are about to see 23-year-old cricketer Mr Tommy Beans. Mr Beans presents with low mood following an unexpected mistake in a pivotal cricket match. He has refused to play for the team since this time and is expressing a number of cognitive distortions.

Identify the cognitive distortions and explain them to Mr Beans in a manner he understands.

Actor Instructions

You tend to take a long time to answer, especially at first. You make little eye contact. You feel worthless and upset and are quite bleak about your future.

You are 23-year-old Mr Tommy Beans, the star batsman for the semi-professional team Trent Albion Cricketers. You are the top-scoring batsman in the league so far, with a very impressive batting average of 74 runs after 12 Test matches. However, in a recent crucial match against your rivals, Barton Cricket Club, you were dismissed for just 22 runs after making a terrible shot that was easily caught. No other batsman on your team scored more than 10 runs and you lost the game decisively. You blame yourself for your team’s poor performance.

Since the match, you have felt hopeless about your future and are certain that you are a burden on the team. Consequently, you have refused to play despite the coach’s protests. You are increasingly sure you should retire despite your young age and otherwise fantastic performances. Your coach actually suggested you could go professional and mentioned that some teams have approached him about you already, but you didn’t believe him.

You have spoken about your recent worries with your family (a wife and two children), who are concerned and have urged you to seek support. You increasingly feel as though you are a failure as a father and a husband, although nobody in your family has ever said anything like this to you.

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  You tend to downplay anything good you have done (minimisation).

  
  
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  You tend to overplay/exaggerate the impact of anything bad you have done (maximisation).

  
  
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  You jump to negative conclusions based on small pieces of evidence without considering contradictory evidence (selective abstraction) and/or you use very poor-quality/unrelated evidence to reach these conclusions (arbitrary inference).

  
  
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  You assume that the worst possible outcome is going to be true (catastrophising).

  
  
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  You tend to view things as either totally perfect or totally awful (polarised/black-and-white thinking).

  
  
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  You tend to think that negative things are specifically because of you, even when they are probably not (personalisation).

If the candidate tests the conviction of your beliefs and shows you some inconsistencies in your logic, you do recognise there is a chance you may be wrong – even though it still feels true.

Feedback Domains

Author’s Note

Cognitive distortions can apply to any line of work, so you could easily adapt this station for practice using a different setting (e.g. a business executive after a deal gone slightly wrong). Alternatively, this could be a management station where you are asked to explain and discuss a specific proposed treatment for the patient’s depression (particularly cognitive behavioural therapy).

If you focus on testing the cognitive distortions, you will usually find you cover what you need to in this station. Do make sure that you ‘chunk and check’ (provide information in small chunks and check that it has been understood). It can be tempting to keep talking under the pressure of the exam – don’t be afraid of leaving some gaps for the patient to speak!

Candidate Instructions

You have recently taken over the care of an outpatient caseload and have found that one of your new patients, 42-year-old Mrs Julianna Forbes-Doherty, has not seen a clinician for almost a year after failing to attend a number of appointments for reported symptoms of anxiety and agoraphobia. You managed to hold one telephone appointment last week, and your consultant has suggested a home visit today.

The notes state that she was referred two years ago for online self-help and psychoeducation groups, but she made minimal progress despite reports from the facilitator of good attendance and motivation. She has been taking an SSRI for 18 months, but when you called her last week, she described only transient mild benefit from the medication and no change in her ability to cope with everyday life, which she continues to find overwhelming. She said she lost her job as a sales assistant in a clothing store two months ago after persistent problems with lateness due to her struggling to leave the house in the morning and sometimes standing by the door in a state of terror so severe she felt she might die. Since then, she has been ordering all her food and clothes online and can only leave the house or travel anywhere when she is with her supportive husband. She is desperate for support.

Discuss her previous experiences of treatment and form a new treatment plan with her. You should include an explanation of both systematic desensitisation and graded exposure therapy.

Actor Instructions

You are Mrs Julianna Forbes-Doherty, a 42-year-old woman. You present as low in mood but are relatively calm as you are in your own home environment. You are relieved to see that someone is coming to help you. You may become more visibly anxious when you think or speak about leaving the house or going into open spaces.

You have suffered with symptoms of anxiety (e.g. shakes, sweating, dizziness, feeling sick, feeling your heart is racing) for as long as you can remember but have only sought help in the last five years, mostly via your GP. You have been under specialist care of psychiatrists for outpatient appointments for two years, but after attending three times have not felt able to leave the house to attend any more. It was frightening to leave the house to attend appointments, and you have been disappointed with the response to treatment and become hopeless.

Your medication, prescribed by your outpatient psychiatrist, is sertraline, which you have taken ‘almost religiously’ every day for 18 months. It helped a little bit at first and you think it is probably still doing some good, but your life remains largely the same. You spend all day at home, criticising yourself for not getting out of the house and for losing your job as a sales assistant at a clothing store, which you had really enjoyed. Your experience of online self-help (which gave you various tasks to do to try to reduce your fear of going out) was that the principles were a little confusing, and you became overwhelmed by anxiety whenever you needed to complete a task, even if that task was just thinking about going out.

FIG-fig-c10.1You may (if you trust the candidate and feel a good rapport with them) agree to a therapy starting at the outpatient clinic – your husband could probably drive you – but you would strongly prefer the home setting.

Feedback Domains

Knowledge

The candidate must clearly understand the principles of graduated exposure therapy and systematic desensitization.

Graduated Exposure Therapy

This treatment introduces a progressive increase in exposure level to the fear/anxiety-provoking stimulus. In agoraphobia, this might involve thinking about leaving the house, walking to the door, holding the door handle, opening the door but not leaving, spending a few minutes outside, and so on.

The idea is to explain that anxiety usually follows a pattern of building and then gradually dissipates by itself in less than an hour. The candidate might draw a diagram similar to the one in Figure 10.1:

Figure 10.1 A typical response to an anxiety-provoking stimulus

It is explained that each time this happens (in the absence of avoidance or escape behaviours), anxiety naturally completely goes away (extinction). Each time extinction is achieved in relation to one anxiety-provoking stimulus, the brain learns that it survives and the anxiety was not needed. Hence, the maximum anxiety level is reduced a little the next time. This is called habituation. Gradually, the stimulus is stepped up until the patient’s anxiety is manageable despite the stimulus.

Systematic Desensitisation

In this therapy (which is ‘systematic’, i.e. graduated just as above), the main additional feature is the use of a counter-conditional stimulus – a relaxing stimulus. The idea is that it is hard to feel both relaxed and anxious simultaneously.

Usually, the therapist will work with the patient to find something relaxing (e.g. relaxation exercises) and then pair this up with tolerable levels of anxiety-provoking stimuli. The brain then learns to associate the stimulus with relaxation, so less anxiety is generated.

Related posts:

Chapter 6 – Child and Adolescent Psychiatry Chapter 7 – Learning Disability Psychiatry Chapter 8 – Forensic Psychiatry Chapter 9 – Addiction Psychiatry Chapter 11 – Eating Disorder Psychiatry Chapter 3 – International Medical Graduates and Black, Asian, and Minority Ethnic Candidates

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