Candidate Instructions

You are working in liaison psychiatry. Mr Theophilus Grantley, a 21-year-old student, has been brought to the ED by his friends due to concerns that he is not eating. He has been isolating himself, and they fear he is depressed.

Interview Mr Grantley and take an appropriate history.

Actor Instructions

You are Mr Theophilus Grantley, a 21-year-old male English literature student. You are content to be in the ED because you think there is something wrong with your body, but you are not sure what.

Throughout the interview, your manner is very perplexed and you do not show much emotion. You speak quite monotonously, and there is sometimes a bit of a delay in your answers to questions. Sometimes your answers do not address the question and are a bit random.

You have been feeling ‘strange’ for the last few months, but you are starting to realise what has been happening. You think people have been coming into your room every night and raping you. You don’t remember it happening because they put a ‘memory glove’ over you. However, you are fairly sure it has taken place because in the morning, the shadows through the curtains fall on a different part of the room. You have no other evidence of having been raped.

You don’t know who is doing this, but it might be related to Nazis, as your hall of residence has a German-sounding name. You are beginning to think that your friends who brought you here must know something about it.

You do not ‘hear voices’ and are annoyed if this question is asked in an insensitive manner because you know you’re not mad. You do want medical help, though, because you don’t know what these disgusting people have been doing to you.

Your mood is ‘Okay’, but you are concerned about your situation. There aren’t many activities you enjoy anymore because you need lots of time to think through what is happening. Your sleep and energy levels are fine. You do not think you are underweight.

You do not want to harm yourself – you want to save yourself from these people. You have called the police about it, but they didn’t seem to want to help; however, you wouldn’t dream of confronting your persecutors because there are too many of them.

You don’t have any history of mental illness, but your uncle was ‘really odd’ and spent lots of time in a ‘mental hospital’. You occasionally smoke cannabis but otherwise do not use alcohol or drugs.

Feedback Domains

Author’s Note

There is a large amount of psychotic content in this station, and a good candidate will demonstrate the extent of the systemisation of the delusion. Variants on this station might include more specific tasks, such as assessing delusional beliefs or determining whether a delusion is primary or secondary.

Candidate Instructions

You are called to assess Ms Lizzie Eustace, a 22-year-old woman, in the ED. She has been flagged as a frequent attender. She has been medically cleared after presenting with an intentional overdose of 12 tablets of paracetamol 500 mg.

Take a history from Ms Eustace to establish a psychiatric diagnosis.

Actor Instructions

You are Ms Lizzie Eustace, a 22-year-old unemployed woman who has dropped out of university. You feel fed up with the hospital and want to go home. You do not see why you have to speak to yet another doctor. You will only be persuaded to discuss more about yourself if the doctor is respectful and explains why it is important to speak to them.

This morning, you had an argument with your boyfriend, Freddie, on the phone. He accused you of flirting with another guy, when actually you were just being friendly. Freddie shouted at you, and you yelled back at him, ‘Get out of my life!’ You then drank half a bottle of wine and took the paracetamol tablets that you had in the cupboard. You wanted to end your life at the time and thought that you had nothing left to live for.

You then called an ambulance a half hour later because you didn’t want to die and you were worried about your cats if you did. You shouted at the paramedics because one of them rolled their eyes at you. You now feel okay and just want to go home. You no longer wish to end your life.

You have taken several overdoses in the past, sometimes paracetamol, sometimes ibuprofen. Usually, it was only a few tablets. You sometimes self-harm by using a razor blade to cut your arms; this relieves some of the frustration you often experience.

Your mood seems to go up and down all the time (within a few minutes); even things like being stood up by a friend can make you want to end your life. You think of yourself as pretty worthless. You get angry with yourself and with others a lot. You always seem to be getting into arguments with other people and you don’t know why. With a previous boyfriend, you’d sometimes hit each other during these arguments, but nobody got hurt.

Your mother always used to say that you have ‘no sticking power’, and you know that you give up on things easily. You tend to do things on the spur of the moment and then regret them afterward, like when you saw a necklace you liked in a store and stole it; this led to a police caution.

You have dropped out of university and don’t know what to do with your time now.

You have had a series of short-term relationships. To start with, the guy seems like the best person in the world – really kind and sympathetic – but after a few weeks, you inevitably find out that he is an idiot. There seems to be a pattern – you can’t live with them and you can’t live without them. You always worry that they’re going to leave you, but you can’t stand them when they’re around.

You know you drink quite a lot of alcohol, bingeing on bottles of wine three to four times a week. You’ve experimented with cannabis, ecstasy, and ‘meow meow’, but you’ve never injected drugs.

You don’t hear voices, but you do sometimes worry that people are ‘out to get you’, though you know they’re not really.

Feedback Domains

Candidate Instructions

You are working in liaison psychiatry and have assessed Mr Septimus Harding, a 63-year-old man on the cardiology ward. He had a non-ST-elevation myocardial infarction (NSTEMI) three weeks ago, and the ward staff are concerned that he is not making sufficient progress.

He describes feeling ‘really rubbish’ ever since his heart attack, having previously felt very positive and carefree – he was particularly looking forward to retirement. He lacks the energy to make progress with his cardiac rehabilitation even though the doctors tell him that his heart is doing well. He said that ‘all the fun just seemed to be sucked out of life’. His real passion in life was music, but he can’t have his cello on the ward to play.

His mood just seems to be getting worse. He tends to wake up at 4:00 a.m., but he’s not sure if that’s just the beeping from all the machines. He has lost his interest in food and just eats because the nurses tell him he has to; he doesn’t like the hospital food anyway. He thinks he has lost a bit of weight.

He tells you that he feels very guilty about his wife having to travel up to the hospital so often. He thinks that the NSTEMI is all his own fault because he has never been a person who exercises much. He is worried that he might lose his job.

Previous medical history: Essential hypertension, type 2 diabetes

Current medication: Amlodipine 10 mg OD, metformin MR 1 g OD, aspirin 75 mg OD, clopidogrel 75 mg OD, atorvastatin 80 mg OD, bisoprolol 2.5 mg OD

Social history: Lives with his wife in a flat; has a difficult relationship with his daughter, as he doesn’t like her husband; works as a salesman

Substance use: Has not drunk anything since being admitted to the hospital, but used to drink three to five pints of beer each night; used to smoke 30 cigarettes per day but has been told he should quit; has never used recreational drugs

Risk: Denies any thoughts of ending his life or harming others, no previous history of other relevant risk behaviours

There is currently a bright young medical student in your team, Henrietta Lacks. The consultant has asked you to present the case to her as a teaching opportunity.

Present the case to the medical student and answer her questions. Explain the most likely diagnosis and discuss an appropriate management plan.

Actor Instructions

You are Henrietta Lacks, a medical student in a liaison psychiatry team. It has been arranged that the doctor in front of you is going to teach you about an interesting case. The case regards a person whom the doctor recently assessed, who had become very low in mood following a heart attack (you should ideally say ‘myocardial infarction’, which means the same thing). Time is limited, so if the doctor is taking a very long time (e.g. two to three minutes) answering one question and you think they will run out of time before answering them all, try to move them on to another. Your questions are as follows:

1. 
   

   (1) Ask the doctor to summarise the case.

   
   
2. 
   

   (2) Ask whether there is any additional information they would like to know. If they need prompting, ask whether there is anybody else it could be helpful to speak to, as you’ve often seen other doctors do this.

   
   
3. 
   

   (3) Ask what they think the most likely diagnosis is, and whether there are other possibilities. Keep this relatively brief.

   
   
4. 
   

   (4) Ask for their treatment plan. If they do not cover each of biological (e.g. medications, alcohol reduction), psychological (e.g. a ‘talking therapy’ such as cognitive behavioural therapy or interpersonal therapy), and social factors (e.g. peer support, sick note for employer), then encourage them to consider those they have missed (e.g. ‘Is there anything psychological that could be done to help?’). If they do not cover short- and long-term management, encourage them to consider both (e.g. ‘What about in the longer term?’).

Encourage the candidate to be specific. If they mention antidepressant medication, ask them which one(s) and why. If they mention psychological therapy, ask which modality (i.e. type) they would consider.

Feedback Domains

Author’s Note

Depression following myocardial infarction is common, and the NICE guidance for depression in people with chronic physical health problems is a bit different from other groups. First-line interventions for mild to moderate depression are a structured group physical activity programme, a peer support programme, guided self-help based on CBT principles, or computerised CBT. If depression is moderate to severe, the same algorithm for those with and without chronic physical health problems is used and offers either an antidepressant or a high-intensity psychological therapy (usually CBT or IPT).

Variants on this station could include discussing the diagnosis with a consultant, taking a social history, or including a capacity assessment.

Candidate Instructions

You are working in a community mental health team. You have been asked to conduct an initial assessment for Mrs Arabella Gresham, a 52-year-old woman who has been referred by her GP, Dr Thorne, for ‘constant, baseless concerns about her health’.

Mrs Gresham has had a wide variety of investigations, including X-rays, ultrasound scans, and CT scans, which have revealed no abnormalities. She recently had liver function tests (which were normal), performed after she raised concerns that her skin was yellowing (although medical professionals did not perceive any change in the colour of her skin or corneas).

Take a brief history from Mrs Gresham and explain the diagnosis and management plan.

Actor Instructions

You are Mrs Arabella Gresham, a 52-year-old housewife. You are feeling very anxious and uncomfortable about this appointment. However, you are happy to answer any questions the doctor may have.

Your problems started six years ago when your mother died from pancreatic cancer. A few months after she died, you started to worry that you might have cancer. You sometimes feel a rumbling in your stomach and worry that this might be a sign. Occasionally, when you look in the mirror you think you are going a bit yellow, which could also mean you have cancer like your mother. You saw your GP, who performed some blood tests, but the normal results did not reassure you.

Since then, you have been worried about lots of diseases. Usually it is a type of cancer that you have read about in a magazine or online. Sometimes it is about other diseases, such as vasculitis, for which you think you might have some of the symptoms, such as tiredness and feeling cold sometimes.

Recently, you have been concerned that you might have an osteosarcoma because sometimes you get pain in your joints. Your GP said it was probably just arthritis, and this reassured you to start with. However, you then became anxious about it again and got an X-ray. This was normal, but you have read that it doesn’t always show up on an X-ray, so you are worrying about it again.

Your worries about your health do affect your life quite a lot. You spend a couple of hours each day reading online about your worries. You probably see your GP every week, and you have gone to the ED a few times in the last year because you thought you had something serious. You like to have tests done, but often you don’t find the results that reassuring.

You have had lots of blood tests and a couple of CT scans in the past. These investigations never seem to make you feel any better, as you worry that they must have missed something. You are under a surgeon because of a strange feeling in your abdomen, but he is useless and won’t operate to see what is going on.

You live with your husband and your grown-up son. Your husband is a stockbroker, and you think he may be having some financial difficulties at the moment.

You are not sure what is going on, but your husband thinks you are a ‘hypochondriac’. You would like to get help because this is really getting you down. You are interested in an explanation of your problems. If the doctor suggests a form of talking therapy, ask what it would involve.

Feedback Domains

Author’s Note

The actor has a lot of material in this station, but don’t feel you have failed if you have not managed to elicit all the content. One of the main challenges in this station is to take a very concise history to establish a diagnosis. An explanation of health anxiety is challenging, and it can be helpful to practise a few bullet points that you can deliver in an exam.

Candidate Instructions

You are working on an acute male inpatient ward. Mr Gerald Palliser is a 25-year-old man with paranoid schizophrenia who is currently under your care. This is his second psychiatric admission and, after two months on the ward, he remains psychotic. He is experiencing persecutory delusions about the prime minister monitoring his phone and the Chancellor of the Exchequer trying to change his money. He hears third-person auditory hallucinations, which he perceives to be other patients on the ward talking about him. He is frequently verbally abusive and occasionally physically violent.

On his first admission, he was treated with aripiprazole and seemed to improve, but since then he has relapsed despite reasonable compliance. During this admission, he was initially treated with olanzapine without effect. He is currently being treated with haloperidol 10 mg BD, but his psychosis does not seem to have improved. He is also being treated with clonazepam 1 mg QDS and promethazine 25 mg BD.

After a discussion in ward round, a decision has been made to initiate treatment with clozapine. This will be cross-titrated with the haloperidol.

Gerald’s mother, Mrs Glencora Palliser, would like to speak to you about her son’s treatment plan.

Explain the current plan to Mrs Palliser and answer her questions. You have Gerald’s permission to disclose details of his treatment.

Actor Instructions

You are Mrs Glencora Palliser, the mother of Gerald Palliser. You are worried about your son but keen to hear what the doctor has to say.

Your son became unwell about three years ago when he started talking about trees speaking to him. He seemed to get better with a medication called aripiprazole during his first admission, but since then it doesn’t seem to have been doing much for him.

During this admission, you have seen Gerald more unwell than he has ever been before, and he seems to have gotten worse rather than better. You are aware that he has been treated with two different antipsychotic medications already during this admission, but you do not know their names. You know that the doctors and nurses are trying to help your son, but you are concerned that they seem to be making less progress than on Gerald’s previous admission.

You are open to trying a new treatment, but you want to know quite a lot of detail about it first. You have not heard of clozapine before, but you hope it is not an awful old-fashioned drug that would turn Gerald into a zombie.

If clozapine is discussed, you would like to know the answers to the following questions:

• 
  

  If it is so good, why hasn’t it been tried before?

  
  
• 
  

  What are the side effects?

  
  
• 
  

  What can be done if it causes him to put on weight?

  
  
• 
  

  Won’t clozapine mean that he dies young with all the side effects it causes?

  
  
• 
  

  Is there any monitoring that needs to take place?

  
  
• 
  

  How often will he need to have blood tests?

  
  
• 
  

  How long does it take to work?

  
  
• 
  

  In the past, doctors have discussed with you the possibility of giving Gerald an injection to help him take his medicines. Would this be possible with clozapine?

  
  
• 
  

  He seems to be on a lot of medications at the moment, and clozapine would just be another one. Is there any way we could reduce his medications?

You are keen to hear the answers to these questions and, if the answers sound reasonable, you agree that clozapine treatment may be in Gerald’s best interests.

Feedback Domains

Author’s Note

When explaining clozapine therapy, it is common to discuss haematological monitoring, but do not omit the other equally important aspects of monitoring, particularly vigilance for infections and constipation.

Candidate Instructions

Mr John Bold is a 34-year-old man who self-presented to the ED in order to view his medical records. He is not known to psychiatric services, but nursing staff report that he is thought to have a mental illness. He is referred to the mental health liaison team for an assessment because he is behaving bizarrely.

Conduct an examination of Mr Bold’s mental state.

Actor Instructions

You are Mr John Bold, a 34-year-old man. You are rather dishevelled and very agitated. You are wandering around when the doctor enters. You speak quickly, and it is sometimes difficult for the doctor to get a word in. You move from one topic to another without the connection between topics being obvious. You are irritable and are sometimes distracted by things in the room. However, if the doctor is willing to listen, you are prepared to sit down after about a minute. You respond best to simple, brief questions; you lose concentration if the doctor tries to talk at length.

The main thing you want to talk about is how you have a mission to find all corruption ‘anywhere, everywhere, in the whole world’. You believe that there is a conspiracy involving the health service, Hiram’s Hospital, and the church. Between them, they are managing to embezzle ‘a million thousand billion pounds’. You are concerned because you have a lot of money (you own all of Europe), so you believe that they will try to take money from you. Consequently, you have come to the hospital to find your medical records to prevent them from using these against you.

You have contacted lawyers in the last few days in order to take action against this conspiracy involving bishops and the hospital. You have also written to newspapers, but they have not published your letters. You have tried to involve a woman called Eleanor who you think loves you, although you don’t have any evidence for this – you just know it.

You believe that you are the only person who is able to get to the bottom of this conspiracy because you have special powers, such as being a genius, being able to see people’s souls, and being the greatest supermodel ever.

You have no thoughts about harming yourself or others. You have a council flat elsewhere in the country, but you came here in order to stop the conspiracy. You have not been hearing voices or seeing anything unusual.

Feedback Domains

Candidate Instructions

You are working in a community mental health team. You had been due to complete an initial assessment with Ms Lily Dale, a 21-year-old woman who had been referred for low mood and poor oral intake. However, she has not attended and instead her mother, Mrs Mary Dale, has come.

Take a collateral history from Mrs Dale about her daughter, Lily. Lily has given permission for you to speak to her mother.

Actor Instructions

You are Mrs Mary Dale, mother of 21-year-old Lily. Lily was due to have an initial appointment today with the community mental health team, which you have been eager for her to attend. However, this morning Lily said she just couldn’t face coming, so you decided to come on your own. You are very apologetic about this and are very grateful that the doctor has agreed to see you. You are worried about your daughter and keen for her to get all the help she can.

Lily was doing really well up until about a year ago. She was studying English literature at university and had a lovely boyfriend called Rupert. However, Rupert broke up with her this time last year, and she’s been heartbroken ever since. Initially, you just thought that she would get over it, but it’s been a long time now and, if anything, she’s just gotten worse.

You took Lily to see the GP a few weeks ago because she is eating so little. She says that food just tastes so bland now, and she’s not interested in it. You manage to get her to eat a small breakfast (e.g. a couple of slices of toast), but she then won’t eat anything until the evening, and even then, she only finishes half a meal. It doesn’t seem like she is trying to lose weight; she just isn’t interested in food. You estimate she has lost about a stone in weight over the last six months.

Her mood is low almost all of the time. She used to enjoy seeing friends, but she doesn’t seem to have any interest in them anymore. She had to drop out of university because she said she couldn’t concentrate and that her memory ‘wasn’t up to it’. She spends most of her day lying in bed, and she doesn’t seem to have the ‘get-up-and-go’ she used to.

Lily doesn’t seem to be particularly anxious, but she does seem to feel guilty a lot of the time. You don’t think she did anything wrong in the relationship, but she is constantly blaming herself for the break-up. Related to this, she thinks that she is a worthless individual, which doesn’t make sense because she has everything to live for. She doesn’t see it that way, though, and thinks that she has no future ahead of her.

Lily has never had any episodes like this in the past. She used to binge-drink quite a lot when at university, but she doesn’t drink much now. She doesn’t use illegal drugs at the moment, but you’re not sure what she used at university.

Feedback Domains

Candidate Instructions

You are working on an acute psychiatric ward where a 54-year-old man, Mr Josiah Crawley, has just been admitted. Prior to admission, he was being treated under the home treatment team (HTT) for depression. The HTT had been particularly concerned about Mr Crawley’s poor self-care and limited oral intake.

Unfortunately, Mr Crawley was unable to engage with the HTT, and they were having difficulty gaining access to his accommodation for assessments. Consequently, he was admitted to the hospital for further assessment and treatment.

The HTT report that Mr Crawley’s recent compliance with his prescribed medication has been poor and that prior to admission he had been spending most of the day sitting in a dirty armchair in his living room.

He has a background of recurrent depression that has required ECT in the past.

Please assess Mr Crawley’s mental state.

Actor Instructions

You are Mr Josiah Crawley, a 54-year-old man. You are feeling very low and anxious. When the candidate enters, you are sitting down, anxiously stroking your face. You do not look up when the candidate enters, and you do not speak initially. After about 30 seconds, you say, ‘Oh dear, oh dear’. When you speak, your voice is quiet and you sometimes trail off at the end of sentences. You only give short answers to questions.

If the candidate gives you space, you gradually open up. You are worried about a cheque you wrote for a plumber when you were in your 20s. You think you may have misspelt the name of the person on it, preventing the plumber from getting their income. You think that you are therefore an evil person. It is an awful situation because you have no money at all to pay this plumber now. Your wife keeps saying that you have money, but you don’t believe her.

You are feeling very low, and nothing gives you pleasure anymore. You do not know when you last slept. You see no point in eating or drinking, and you don’t know when you last did either.

Feedback Domains

Author’s Note

The key to this station is getting the patient to open up by using effective communication skills. This may take some time, and some candidates will get nervous during this period. However, it is quite common for actors’ instructions to include an initial minute or two when they are not encouraged to engage.

Candidate Instructions

You are working in a community mental health team. Major Jim Pountney, a 45-year-old man, has been referred by his GP for difficulties coming to terms with some of his experiences whilst on a tour of duty in Afghanistan.

Take a history in order to arrive at Major Pountney’s diagnosis.

Actor Instructions

You are Major Jim Pountney, a 45-year-old officer in the British Army. You are very ‘on edge’. You are constantly anxious and are unable to relax throughout the consultation.

You joined the Army after graduating from university and have been a soldier ever since. You have enjoyed your career and have been successful. However, two years ago, when you were on a tour in Helmand Province in Afghanistan, something awful happened.

After a few days, you started to have nightmares. It was the same dream over and over again in which you were riding along in the convoy before the IED exploded. You then started to experience something similar during the day – you would start to feel as if you were back in the moment; at times, you would even start acting as if the event were happening all over again. Initially, this tended to be triggered by travelling in armoured vehicles, but over the last 12 months it has started occurring indiscriminately. Vivid pictures of the explosion and the bodies come into your mind sometimes; you can’t get rid of them, and they are very distressing.

You find that you are quite on edge these days. Any loud noise, such as a door slamming or fireworks going off, can make you really jump. Additionally, you have noticed that you seem unable to experience emotions in the ways you used to. You know your wife and children care for you, but you lack the ability to engage emotionally with them. You find it very difficult to sleep at night and often don’t drop off until about 2:00 a.m.

Initially, you kept working after the traumatic event, but you have been off on sick leave for the last six months, partly because of the stress and partly because you have been unable to concentrate. You find yourself constantly mulling over what happened and wondering whether it was your fault.

The stress has had a massive effect on your life. You are not sure if you will ever be able to go back to work. It has also meant it is harder for you to pursue your interests in local politics. Your family are very sympathetic, but it feels as though you are still away on tour – there is a sense in which you are just not with them. You are a bit more irritable, but you are never verbally aggressive or violent. You avoid travelling because being in a vehicle reminds you of what happened and gives you flashbacks.

You would not say that your mood is low, but rather ‘just numb’. You find it difficult to enjoy things because of this. You constantly feel sleep-deprived, but your energy levels are fine when you get out of the house. You do not tend to worry much about things unrelated to your traumatic experiences. You have never had a panic attack. You want to get better and do not want to end your life. You do have access to firearms, but you have never considered using them in a civilian context.

Feedback Domains

Author’s Note

This is a quite straightforward station, as it essentially just requires a history of PTSD. However, this means that quite a lot of detail is expected in the questioning in order to elicit the many facets of the psychopathology.

Candidate Instructions

You are working out of hours providing liaison psychiatry cover to an ED. Mr Ferdinand Lopez, a 30-year-old man, was brought in by police last night after a staff member raised concerns about his behaviour on the platform of a busy railway station.

Conduct a risk assessment of Mr Ferdinand Lopez.

Actor Instructions

You are Mr Ferdinand Lopez, a 30-year-old taxi driver. You feel very stressed, but you are willing to speak. You have come to the end of your tether and do not know what to do next.

The relationship with your girlfriend, Emily, has been rocky for a few months. You would probably have broken up if it weren’t for the nine-month-old baby girl you have together. You argue frequently, but there has never been physical violence. Your daughter is getting on really well.

One of your ex-girlfriends, Tara, is due to be in town this week, and you had arranged to meet up with her. Yesterday, Emily suggested in a half-joking way that you were cheating on her with Tara. This made you very upset and angry because you have been working really hard to keep the relationship with Emily together.

In a moment of extreme distress and frustration last night, you spontaneously decided to end your life by throwing yourself in front of one of the trains at a nearby station. You had not planned this in advance, but you scribbled a note to Emily on your way to the station to tell her how hurt you felt. You loitered around on the platform waiting for a fast train. A staff member came up to you because she was concerned about the way you were behaving. As she tried to engage you, you threatened to jump onto the rails. A few passers-by managed to stop you and hold you until the police arrived.

Looking back on it now, you think it was all a bit stupid really and are pleased that people intervened to stop you. You don’t want to end your life anymore because you see things a bit more positively. Emily has come in to visit, and you have made up.

You have never tried to end your life before. However, about five years ago, when you were evicted from the flat you were living in for smoking cannabis, you self-harmed by cutting the backs of your arms with a pencil sharpener blade.

In the future, you want to have another child and have ambitions to set up your own taxi firm. You hope you won’t do anything like this again, but you could imagine it happening if things do not work out with Emily. You would be willing to stay a bit longer in the ED, see your GP, or talk to someone about what happened.

In general, your mood is a bit ‘up and down’. You find that even small things can send you into a downward spiral where you ‘can’t think straight’. However, you usually feel fine the next day. You are able to enjoy things like going out for the night. Your energy and sleep are generally fine, but they are impacted by having a baby.

Feedback Domains

Author’s Note

The diagnosis is not clear in this scenario, so it is a lesson in being able to tolerate uncertainty. The patient is certainly very impulsive, and this elevates the risk. The use of alcohol prior to the attempt should be identified because this alters the risk and represents a therapeutic target.

Candidate Instructions

You are working in an ED. Mr Obadiah Slope, a 38-year-old man with known paranoid schizophrenia, has been brought to the hospital by staff at the hostel where he resides. They state that he has been hearing voices and behaving ‘oddly’. They are worried he is relapsing. He is known to a community mental health team and has recently been switched from risperidone to aripiprazole 10 mg.

Conduct a mental state examination of Mr Slope.

Actor Instructions

You are Mr Obadiah Slope, a 38-year-old man with a history of schizophrenia. You are suspicious of what is happening and a bit unclear about what is going on. You are willing to speak to the doctor, but you show very little emotion. Occasionally, you stop and stay quiet for a few seconds, as you are hearing something others cannot hear. You sometimes say things that do not logically follow from each other.

You first noticed something strange was happening a couple of weeks ago. You realised that unbeknownst to everyone else, there was a baby in the hostel who is actually very old – hundreds of years old in fact. You also discovered that there is ‘energy’ in your body that can overcome evil.

You are concerned that others can read your mind and take thoughts out of your head. You are unclear why they might do this, but you have been reading about issues like Armageddon, dark matter, and the anti-Christ that all seem to relate to this.

Most of these revelations just came to you suddenly – you just knew they were true. You became suspicious about the hostel manager a few days ago when you saw somebody cycling on the pavement.

You do not want to harm anybody. You have no thoughts of harming yourself – you want to live so you can get to the bottom of all this.

Your mood is ‘just the same – not up, not down’. You do not see anything abnormal, but you do sometimes feel as if people are moving your arms for you. You know you are in the hospital, whom you are speaking to, and what time it is.

You know you have been diagnosed with schizophrenia in the past, but you don’t believe it really. You certainly don’t think you are mentally unwell at the moment. You have not taken any drugs. You are eating and drinking normally.

Feedback Domains

Candidate Instructions

You are working on an acute inpatient unit. Your colleague has asked you to review Mrs Agatha Achebe, who is a 31-year-old woman with a long-established diagnosis of paranoid schizophrenia. She was switched from aripiprazole to haloperidol three weeks ago, but she is now ‘non-adherent’ with her medication, stating that it is ‘driving her mad’. Your colleague has been unable to convince her to take the medication.

Please explore Mrs Achebe’s concerns regarding her current medication; once you have identified her main concern, please attempt to explore possible solutions.

Actor Instructions

You are 31-year-old Mrs Agatha Achebe. You have been diagnosed with paranoid schizophrenia since you were 23, and this is your second inpatient admission. Due to concerns that aripiprazole was not fully controlling your symptoms, you have been switched to haloperidol. The dosage has been steadily increased to 15 mg over 24 hours and has been effective, insofar as you are free of psychotic symptoms.

Unfortunately, over the last few days you have noticed that you are struggling with a feeling of ‘ants in your pants’; you are unable to sit still for more than 10 minutes at a time before a horrible feeling of tension and restlessness (mainly in your legs) compels you to get up and move. This sensation is at its worst when you are having to stand still (e.g. when queueing for medication). Subjectively, you feel anxious, tense, and generally ‘awful’ (in a way that you struggle to put into words). During your discussion with the doctor, you struggle to sit still at all and feel the urge to pace, cross your legs, and roll on the balls of your feet. At times, you must stand up, walk a few steps, and sit back down again. You have no feelings of stiffness, tremor, or other EPSEs.

This feeling is getting in the way of your ability to sleep, eat, and enjoy anything in life. You were worried you were relapsing, but this feels very different.

You are otherwise managing well on the ward and are keen to ensure your mental illness is well managed with a medication you can take in the longer term. You have no other psychiatric symptomatology (no depressive, anxious, or psychotic symptoms), and you have no plans to harm others.

Your main concern is that you are taken seriously, and that your doctor will work with you to help find an appropriate solution.

Feedback Domains

Author’s Note

It is unlikely that you will be required to take a history, examine the patient, and offer advice for treating akathisia in one station. However, a combination of two of these is certainly possible, and it is worth practising all three, just in case.

A key feature in this station is taking akathisia seriously, as it is often missed in clinical practice and the consequences of this (in terms of misery, medication non-adherence, and worse) can be significant.

Candidate Instructions

You are working in a busy psychiatric outpatient department. You are scheduled to see Corporal Ernie Wratten, a 29-year-old soldier, for a follow-up appointment.

Corporal Wratten was recently placed on medical leave from the Army due to his intense desire to wash his hands and clothes for hours at a time. Your consultant recently completed an initial assessment and made a diagnosis of obsessive compulsive disorder (OCD). Corporal Wratten’s Yale-Brown Obsessive Compulsive Score was 25/40, suggestive of ‘severe OCD’. Corporal Wratten has returned to the clinic today to discuss the diagnosis and learn about potential treatment options.

Briefly explain the diagnosis of OCD and outline the treatment options for this disorder; you do not need to take a history or assess risk.

Actor Instructions

You are Corporal Ernie Wratten, a 29-year-old soldier. You have attended clinic today to discuss your recent diagnosis of OCD. You present as calm and settled, and are happy to engage with the candidate.

You are in agreement with the diagnosis of OCD, having read up about it online. You know that you have ‘bad thoughts’ that come into your mind again and again, despite your best efforts. These thoughts make you anxious because they are both upsetting and, you feel, absurd. You know that ‘giving in’ to the desire to wash your hands will make the thoughts come back stronger, but you find them ‘uncontrollable’. In your case, you are embarrassed, as you can’t stop thinking about being infested with lice and scabies (which you know is not true). Washing your hands and clothes offers some relief, but this doesn’t last long.

You are keen for any help available, but you are unsure if anything will work or if ‘people with this problem ever get better’. You are unsure about talking therapy, as you worry the doctor will just ask you about your (perfectly happy) childhood, but you are willing to consider all options.

If given the opportunity to ask questions, you ask that while you agree with the diagnosis, you wonder whether maybe you could finally get rid of these thoughts if you washed your hands and clothes ‘properly’ (you do not know what this means), or whether you could maybe have a course of antibiotics ‘just in case’. You are receptive to explanations why this would not be helpful. You are unsure about taking an antidepressant because you are not depressed, and you have heard that antidepressants are ‘addictive’.

Feedback Domains

Author’s Note

OCD is relatively easy to explain and is therefore a highly examinable topic. It is also a pleasant opportunity to discuss a condition with a high treatment success rate. It is important to normalise symptoms and emphasise hope for recovery, as those with anxiety disorders will often suffer with their symptoms for years before seeking professional help.

It is worth having a broad understanding of CBT and how SSRIs are prescribed, as both are first-line treatments in several different psychiatric conditions. This will allow you to approach a number of possible CASC stations.

Candidate Instructions

You are working in an outpatient clinic. You have been asked to see Mr Henry Little, a 34-year-old accountant who has been experiencing ‘sudden and unbearable terrors’ that are making his life ‘completely miserable’.

Take a history of these symptoms with a view to reaching a diagnosis.

Actor Instructions

You are 34-year-old Mr Henry Little. You are generally calm and engaged with the process. You are unsure whether you should be seeing a psychiatrist, as you initially thought your symptoms were due to ‘heart problems’. You are worried you won’t be taken seriously by this doctor.

You have been experiencing intermittent ‘bouts of terror’ for the last three years. These occur roughly once a week, with no obvious trigger. They feel ‘indescribably awful’, as if ‘I’m going to die’, and last for roughly 15–30 minutes. The first symptom you notice is your mouth getting dry, and then quickly your heart begins to thud in your chest, you feel as though you can’t breathe, you become dizzy, and – weirdly – your lips and fingers tingle. You worry that you’ll die if the episode doesn’t pass in time, which only heightens your distress, as you feel there must be something medically wrong. The main feeling is one of ‘absolute terror’, but when things get very bad, it feels as though ‘the world isn’t real anymore’, which makes you worry you’ve gone mad. You feel the intense urge to get out of whatever situation you are in.

As a result of these episodes, you socialise less and have avoided taking on a management role at work (for fear you’ll have an attack whilst supervising others). In general, you wouldn’t describe yourself as an anxious person; you manage well in crowds as well as when socialising one-to-one. There has been no obvious traumatic event triggering these symptoms.

You recently went to your GP for a ‘full check-up’, including a 24-hour cardiac monitor and blood tests (including thyroid function and full blood count) – nothing untoward was found.

Feedback Domains

Author’s Note

Panic attack disorder is a relatively straightforward topic and rewards familiarity with the anxiety disorders as a whole, to allow rapid exclusion of other anxiety problems. A focus on the patient’s subjective experience, as well as what they attribute these symptoms to, is key.

You may be asked to offer a brief overview of the CBT model for panic disorder or a brief overview of treatment options.

Candidate Instructions

You have been asked to review 45-year-old Ms Clarissa Jones. She has been treated for a depressive episode for the last eight months by her GP. She has tried a number of medications (fluoxetine for three months, citalopram for three months, and currently mirtazapine for two months) and has attempted psychological therapy.

Please take a history of Ms Jones to assess for treatment-resistant depression and briefly discuss appropriate management strategies.

Actor Instructions

You are Ms Clarissa Jones, a 45-year-old woman. You are feeling low and hopeless. This is your third bout of depression: you had a three-month episode in your late teens, which resolved spontaneously, and another in your mid-30s, which responded to fluoxetine and CBT co-therapy. This is the first time you have suffered an episode that is as bad and as prolonged as this.

For the last eight months, you have felt low in mood every day. This is associated with tearfulness and a marked feeling of distress, which is worse in the mornings. You do not enjoy the things you used to (e.g. spending time with your supportive husband, reading) and you lack motivation, spending whole days in bed. You struggle to sleep and wake around 5:00 a.m. each day; you lack appetite and have lost at least a stone. You are beginning to lose hope in ever recovering.

You have no thoughts of ending your life – you are deeply religious and to harm yourself would be a ‘grave sin’ (although you often fantasise about being caught up in an accident or a terrorist attack). You have never wanted to harm others. You feel guilty about being unproductive during the day, but have no irrational thoughts of being a bad person (e.g. harming others, being responsible for tragedies). You have no concerns about your health. You do not feel anxious about any particular matter. There has never been a time when you have been ‘high’ or ‘up’ in mood. You do not drink or use other substances.

You have been prescribed three antidepressants during this current bout of depression; you have taken them consistently when prescribed, with no breaks in treatment, and had minimal side effects – even at maximal doses. You tried as hard as you could to engage with CBT, but this was difficult due to lack of energy. You have never had ECT.

You have had a recent check-up with your GP. You have no biochemical or hormonal abnormalities, and no difficulties with chronic pain.

Feedback Domains

Author’s Note

This is a difficult station to master, as there is a large amount of material to cover. It is important that you are able to cover the relevant ground without feeling rushed. This will come with practice, and this is, in many ways, a standard history (i.e. history of presenting complaint, historical treatments).

Candidate Instructions

You are working in a CMHT and are due to see 27-year-old Mr Carl Bianco for a medication review. Mr Bianco has suffered with bipolar affective disorder since the age of 23. Since diagnosis, he has required five inpatient admissions due to manic episodes.

In terms of medication, Mr Bianco has previously been trialled on quetiapine and sodium valproate; however, he continued to experience manic and depressive relapses on a regular basis.

Mr Bianco was discharged from the hospital six weeks ago after suffering a manic relapse. He was treated with olanzapine while in the hospital and has continued to take it since discharge. Although he has remained well, he has been complaining of significant weight gain and lethargy.

When well, Mr Bianco has very good insight into his mental illness and avoids risk factors that he recognises can precipitate a relapse (e.g. lack of sleep, stress, drugs and alcohol).

Mr Bianco has always been compliant with his prescribed medication and regularly attends his outpatient appointments. He is currently well and wishes to discuss alternative medication options.

Discuss lithium therapy with Mr Bianco.

Actor Instructions

You are Mr Carl Bianco, a 27-year-old music student. You suffer from bipolar affective disorder and are keen to discuss any alternative medication with your doctor. You have been very unwell in the past, with multiple hospitalisations, and you are willing to consider most options for your treatment. Your only relevant medical history is acne when you were an adolescent and a family history of high blood pressure.

You are keen to take charge of your illness and wish to take notes during the assessment.

You explain that you are particularly concerned about side effects (olanzapine caused you to put on 10 kg) as well as the impact medication may have on having children – you are hoping to start a family with your partner. You are particularly receptive if your doctor allocates time to discuss side effects.

Feedback Domains

Author’s Note

Lithium is a big topic, and there is a lot to cover. It is important to show an understanding of the basics, and if you feel there is information you don’t have at your fingertips right there and then, don’t try to make something up. Offer an outline of the information and state you will be able to give more information at a later point.

Candidate Instructions

Mr Ron McMurphy, a 64-year old man, has been admitted to your ward with a recurrence of psychotic depression. He has sadly not responded to two separate courses of high-dose antidepressant therapy, lithium augmentation, and antipsychotic medication. His mental state continues to deteriorate, and he has been refusing food and fluid over the last three days. There are increasing concerns that he is at risk of renal injury (due to his rising creatinine) or complications such as thromboembolism. At present, he is not communicating in any way and appears to have fallen into a state of depressive stupor.

Following the ward round, the consultant has recommended electroconvulsive therapy (ECT). As Mr McMurphy is not communicating, it is determined that he lacks capacity to consent to treatment at this time.

Mr McMurphy’s daughter, Kasey, has asked if she could speak with you separately, as she is unhappy with the proposed management plan.

Speak to Ms Kasey McMurphy to explore her concerns and to explain the rationale, potential side effects, and alternatives to ECT.

Actor Instructions

You are Ms Kasey McMurphy, Ron’s daughter. The welfare of your father is your primary concern. Your (deceased) mother told you that he had previously suffered from problems with ‘feeling down’ but had never suggested how bad things could get. You don’t know much about mental health or psychiatry and have no idea why your father has become so depressed, though you harbour suspicions it is due to a ‘bad childhood’.

You are worried your father is getting worse, despite being treated with many different medications. You are aware that he is not eating or drinking, but you are unaware of the potential complications of this.

You have heard of ECT, or ‘shock therapy’, but did not know it is still being used. As far as you are aware, it stopped being used in the last century and was used in ‘asylums’. You fear that the treatment is painful and that your father will never forgive you for letting the doctors do this to him.

All told, your priority is doing the best for your father, and any scepticism is borne of a desire to ‘get it right’. You want to care for him in the same way he has always cared for you.

Feedback Domains

Author’s Note

ECT explanation is relatively straightforward; therefore, it is an important station to be familiar with. You are strongly advised to have all the relevant information ‘to hand’ so that even under stressful exam conditions you can rely on knowing what topics to cover and what to say.

As well as knowledge, you must show sensitivity and empathy. ECT is a treatment that carries the weight of significant fear and stigma, partly due to cultural representations. Consequently, you must be able to simultaneously normalise its usage in those who need it but not dismiss the concerns raised by those you are speaking with.

Candidate Instructions

You are working in an Early Intervention for Psychosis (EIP) service. You have been asked to assess Mr Kurt Tailor, a 25-year-old man who was referred following a year’s history of becoming more socially isolated, having dropped out of university, and having started saying ‘odd things’ to his mother.

Speak to Mr Tailor with a view to eliciting the first-rank symptoms (FRS) of schizophrenia. Do not undertake a risk assessment or explore other diagnoses.

Actor Instructions

You are Mr Kurt Tailor, a 25-year-old man. You are keen to speak to a doctor about what you have experienced. You feel that your family doesn’t understand the strange experiences you have been having, but you hope that a doctor might. Throughout the interview, just as at home, you feel slightly confused, as if something were ‘not quite right’ with the world, but you are only just starting to understand what.

Your main concern is that your mind is being ‘revolutionised’ (the only word that seems to describe what is happening). Thoughts feel as if they are not yours, but rather just appear in your head, and you suspect they are actually the thoughts of those around you. Equally, your thoughts feel as if they are ‘leaking’ out of your head, and you feel that others can pick up on them.

Over the last few months, you have been increasingly convinced that this is the work of the ‘Illuminati’ and that you are able to ‘tune’ (i.e. hear their secret communications). You experience this as voices emanating about a foot above your head. They are usually commenting about you (e.g. ‘he needs a bath’, ‘he knows what’s happening’), but they sometimes argue with each other as well. Occasionally, they seem to be saying the things you are thinking on a one-second delay.

Increasingly, you worry how much of your thoughts are yours. They feel as if they have been ‘made’ by the Illuminati, and some of the things you feel, even your desire to eat, seem to be coming from outside. Last week, you began scratching your nose and felt this was because you were being ‘puppeteered’. Increasingly, you are feeling this more ‘persuasively’, to the extent you can feel the vibrations of their speech in your belly.

Feedback Domains

Author’s Note

FRS are considered persuasive, but not diagnostic, of schizophrenia. It is important to appreciate that they can appear in other disorders (e.g. bipolar affective disorder or delirium) and that there are other features commonly seen in schizophrenia (e.g. psycho-social decline, negative symptoms such as apathy and lack of motivation). However, in light of both their historical significance and presence in many patients with schizophrenia, it is important you are aware of them.

Candidate Instructions

You are working in the liaison psychiatry department of a busy teaching hospital. You have been called to one of the medical wards to determine whether a patient there ‘has capacity’ to refuse insulin.

Mr William Cheshire is a 56-year-old male with a previous history of paranoid schizophrenia and type 2 diabetes mellitus. He is known to be poorly compliant with his physical health medications and suffers from a range of micro- and macrovascular complications.

Mr Cheshire was admitted to the hospital three days ago, having been found collapsed in the street. Upon arrival to the hospital, he was found to be in a state of hyperosmolar non-ketotic coma. He required emergency treatment but is now stable.

Mr Cheshire has been assessed by a consultant endocrinologist on the ward and has been informed that he requires insulin to manage his high blood sugar levels. Despite this advice, Mr Cheshire has been refusing all doses of insulin since admission.

Assess Mr Cheshire’s capacity to refuse insulin.

Actor Instructions

You are Mr William Cheshire, a 56-year-old man. You are frustrated at being in the hospital and at being ‘lectured to’ by various doctors; you have been told you are not even allowed to leave the ward to smoke until you are seen by ‘a doctor from the liaison team’. When you discover that you are speaking to a psychiatrist, you are automatically on the defensive, as you think that the staff here are attempting to make out that you are ‘mad’.

You are aware that you have a diagnosis of diabetes, which you have been managing through a healthy diet and exercise. Your GP has discussed medication with you in the past; however, you have not felt it was necessary.

You do not feel you are unwell in your mental state and have been fully adherent with your olanzapine, knowing that if you do not take it, you will hear voices and develop delusions (these are invariably grandiose delusions that you are a prophet; you do not have persecutory delusions, and your thoughts about the poor intentions of doctors predates your becoming unwell). You do not wish to die and have no symptoms of low mood; in fact, you are keen to be as fit and healthy as you can be, and wish for a long life.

You are fully orientated to time, person, and place and, despite your high blood sugars, are not in any way confused. You are happy to consult with the psychiatrist, as long as they are open about why they are assessing you in this way.

Ultimately, you wish only to be approached by doctors as equals, as opposed to feeling as though medication is being ‘forced’ on you. If given the opportunity, you would appreciate another discussion with the diabetic team to ensure that there is no alternative to insulin medication.

Feedback Domains

Author’s Note

This is a station that rewards good communication skills as much as knowledge about a given intervention. Capacity assessments are a common task in clinical practice and could be examined as stations in the CASC within several different sub-specialties (see Stations 5.9 and 7.2).

Candidate Instructions

You are working on a general adult psychiatric ward. Mr Frank Anders, a 21-year-old man, has recently been admitted to the ward and was reviewed today at ward rounds.

Mr Anders dropped out of university six months ago due to being unable to keep up with his coursework. His friends commented at the time that he was increasingly isolating himself in his room and had stopped socialising, which was very out of character. Mr Anders moved back home with his parents but remained reclusive. His parents have been concerned that he is depressed, as they report they have been having difficulty persuading him to shower and change his bedsheets. Recently, he has been refusing to eat any meals unless he prepares them himself, and his parents have noticed he has started muttering to himself.

Prior to his admission, Mr Anders’s parents were awoken by Mr Anders shouting and screaming. They found him in his bedroom clutching a knife and bleeding from a laceration on his upper arm. An ambulance was contacted, and he was transferred to the ED; there, his wound was sutured and he was referred to the liaison mental health team, who recommended a psychiatric admission.

During the ward round today, Mr Anders disclosed that he had been attempting to remove a microchip from his arm, as the archangel Gabriel had warned him that it had been implanted by MI5 in order to control his thoughts. He admits that he has been communicating with the archangel for several months.

Your consultant suspects Mr Anders is psychotic and has commenced treatment with olanzapine.

Mr Anders’s mother, Ms Carol Anders, has attended the ward and has requested to speak with you about her son’s diagnosis. Mr Anders has consented for you to share information with his mother.

Address Ms Anders’s concerns and answer any questions she may have.

Actor Instructions

You are Ms Carol Anders, Frank’s mother. You present as upset and angry and do not let the candidate speak until you have got your concerns off your chest.

While visiting Frank on the ward earlier, you overheard a nurse refer to Frank as having schizophrenia. This confused you, as you believe schizophrenia is a condition associated with drug use and violence. You think Frank is simply depressed because ever since he dropped out of university six months ago, he has been isolating himself in his room and has lost interest in all his old hobbies and friends. Depression would also explain why he self-harmed by cutting his arm prior to admission.

Once you have expressed your concerns, ask the candidate to explain what’s wrong with Frank and how they arrived at their diagnosis. Specific questions you would like answered during the consultation are as follows:

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  What’s the difference between psychosis and schizophrenia?

  
  
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  What causes psychosis?

  
  
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  How is psychosis treated?

  
  
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  Will Frank ever get better, and, if so, will he become unwell again in the future?

Feedback Domains

Related posts:

Chapter 7 – Learning Disability Psychiatry Chapter 8 – Forensic Psychiatry Chapter 9 – Addiction Psychiatry Chapter 10 – Psychotherapy Chapter 11 – Eating Disorder Psychiatry Chapter 3 – International Medical Graduates and Black, Asian, and Minority Ethnic Candidates

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