Abstract
You have been called to a police station to assess Mr Ryan Churchill, a 47-year-old man who has been arrested for alleged indecent exposure.
Practice Stations
Station 8.1: Indecent Exposure
Station 8.2: Paedophilia
Station 8.3: Morbid Jealousy Risk Assessment
Station 8.4: Erotomania Risk Assessment
Station 8.5: Pyromania
Station 8.6: Erotomania Management
Station 8.7: Violence Risk Assessment
Station 8.8: Morbid Jealousy Explanation
Station 8.1 (90 Seconds)
Candidate Instructions
You have been called to a police station to assess Mr Ryan Churchill, a 47-year-old man who has been arrested for alleged indecent exposure.
Take a history and conduct a risk assessment.
Actor Instructions
You are Mr Ryan Churchill, a 47-year-old unemployed man who has been arrested after a complaint from a neighbour that you have been sunbathing naked in your garden.
You are angry that you have been arrested and feel offended that you have been accused of indecent exposure. You do not understand why you are being assessed by a psychiatrist and are reluctant to engage with the assessment.
You admit that you have been sunbathing in your garden naked most days for the past two weeks. You are aware that the garden is visible from your neighbour’s kitchen window and acknowledge that they can easily see you. In your opinion, you should be free to wear whatever you want on your own property and feel that the neighbour is a ‘prude’.
If the candidate is nonjudgemental and reassures you about the purpose of the assessment, open up and engage.
You admit that since you separated from your wife the previous year, you have become sexually attracted to your female neighbour. You are aware that she works from home and is alone in the house during the day. You started sunbathing naked because the idea of your neighbour seeing you naked sexually aroused you. You did not think that your neighbour would contact the police, as you naively thought she might ‘like what she sees’.
If asked, you have developed an erection on several occasions while sunbathing in the garden and have started masturbating more recently. You accept that it is possible that your neighbour may feel intimidated and frightened. You deny having ever physically approached your neighbour; however, you confess that you have fantasised about this.
If asked, before you met your ex-wife in your early 20s, you occasionally exposed your genitals to unsuspecting women in the street. You found the act sexually arousing and exciting. You have never previously been arrested for this behaviour and have no other criminal history.
If asked about your sexual preferences, you describe yourself as heterosexual and deny any paraphilic interests (e.g. voyeurism, underage children, sadomasochism). You report having a ‘high sex drive’ and regularly access legal online pornography.
If asked about your sexual history, you describe finding it difficult to speak to women when you were a young man, as you felt sexually inadequate. Your first sexual experience was with your ex-wife, and you had a healthy and enjoyable sex life during the time you were married.
You have no memory problems, have no changes in your mood, and have never experienced hearing voices. You rarely drink alcohol, and you do not use any illicit substances. You have no previous mental health history. You have no children.
Feedback Domains
Risk Assessment
The candidate is able to establish the increasing risk toward the female neighbour, as evidenced by the progression of sexually inappropriate behaviour (i.e. indecent exposure, sexual gratification, fantasising about physically approaching her). The candidate elicits that Mr Churchill is aware that the neighbour is alone in the house during the day.
The candidate considers the risk to the wider public. In this station, Mr Churchill has a previous history of exhibitionism that should be explored fully. It is also important to ascertain whether there is any risk to children.
Additional Relevant History
A psychosexual history should be considered in any station involving a sexual offence. The candidate is able to ascertain information regarding sexual orientation, previous sexual relationships, use of pornography and sexual fantasies/fetishes (type and frequency), any sexual difficulties, and any history of sexually inappropriate behaviour/offences.
As is routine in forensic stations, it is important to determine whether there is a past psychiatric, forensic, and substance misuse history.
Differential Diagnosis
The candidate has ruled out erotomania by testing Mr Churchill’s degree of conviction in his belief that the neighbour reciprocates his feelings. The candidate has screened for other major mental health disorders that may explain the actor’s presentation (e.g. schizophrenia, bipolar affective disorder, autism spectrum disorder).
Communication
The candidate addresses the station in a nonjudgemental manner and reassures the patient of their role as a medical professional. When asking intimate questions, it is done in a sensitive and neutral way (e.g. ‘I know this might be embarrassing, but I need to ask you some personal questions …’).
Author’s Note
If the station included someone older, it would be prudent to cast the differential net wide and consider other causes of disinhibition, such as frontotemporal dementia (see Station 5.5).
Station 8.2 (90 Seconds)
Candidate Instructions
You are about to see Mr Brian Spittleford, a 30-year-old man. He has self-presented to the ED requesting to speak to someone from the mental health team but will not disclose the reason.
Explore the patient’s concerns and conduct a risk assessment.
Actor Instructions
You are Mr Brian Spittleford, a 30-year-old primary school caretaker. You have attended the ED this evening as you are worried you can no longer control your sexual urges and need help. You are very nervous, but you are willing to speak to a psychiatrist if they reassure you that the consultation will remain confidential.
For as long as you can remember, you have been sexually attracted to young girls, usually under the age of 12. You used to just fantasise about sexual intercourse with young girls; however, over the past few years you have been accessing sexual images of children on the internet, which you have been hiding on a pen drive.
You disclose that last week you were asked to babysit a friend’s eight-year-old daughter, Lily, which you readily accepted. You spent four hours alone with Lily, and during this time you watched cartoons together on the living room sofa. While sitting with Lily, you became sexually aroused and developed an erection. You did not physically touch Lily, and you do not think she noticed the erection. Since this time, you have been having recurrent sexual fantasies about Lily.
If asked, you are aware that sexual relationships between adults and children are wrong and you do not believe Lily reciprocates your feelings. You feel ashamed and disgusted about your feelings and urges toward young girls. You have no thoughts of self-harm or suicide.
If asked, your first sexual experience was when you were 10 years old during lunch break with a girl in your class. You found this experience confusing but enjoyable. You describe yourself as heterosexual but acknowledge having a sexual preference for young girls. You have had several short relationships with women in the past, but these all ended due to lack of sexual interest.
You have never been in contact with mental health services in the past. You have never been arrested, and you do not drink alcohol or take illicit drugs. You describe your mood as anxious, and you report difficulty sleeping at night due to the fear of being arrested. You deny any other psychiatric symptoms (e.g. hearing voices, unusual thoughts, difficulty thinking).
Feedback Domains
Knowledge
The candidate is able to explain that doctors have a legal and ethical duty to maintain patient confidentiality; however, this duty is not absolute. Doctors are obliged to breach confidentiality if the disclosure of information is necessary to prevent serious harm (to the patient or others) or if the disclosure is required to prevent, detect, or prosecute serious crime.
Risk Assessment
The candidate is able to assess the escalating risk toward the eight-year-old child by eliciting the following information about the patient:
He is trusted to babysit the child on his own.
He happily agreed to babysit, despite acknowledging the risk he poses to children.
He admitted to being sexually aroused when alone with the child.
He does not know whether the child saw his erection.
He describes fantasising about the child and is worried he cannot control his sexual urges.
The candidate identifies some protective factors from the scenario:
He self-presented to the hospital requesting help.
He is willing to disclose information to a medical professional.
He is aware that his feelings and urges toward children are wrong and cannot be reciprocated.
The candidate considers the risk to the general public:
Access to children: He works as a primary school caretaker.
Accessing and storing illegal child pornography: This criminal offence indirectly contributes to child exploitation.
The candidate screens for thoughts of self-harm and suicidal ideation (this patient group has a high risk of suicide following exposure).
Communication
It is important to make the patient feel at ease in order to obtain the required information for the station. This may be achieved by highlighting the protective factors (e.g. ‘You’ve done the right thing by coming here today’).
Station 8.3 (90 Seconds)
Candidate Instructions
You are working in a general adult community mental health team. Mr Eric Giles, a 35-year-old man, has been referred by his GP due to concerns regarding his mental state.
Elicit a focused history to determine the likely diagnosis and conduct a risk assessment.
Actor Instructions
You are Mr Eric Giles, a 35-year-old builder. You visited your GP two weeks ago because you have been feeling increasingly stressed, which is causing you to have trouble sleeping. You are unclear why your GP has referred you to see a psychiatrist, as you had simply expected some sleeping tablets. Although you are feeling ‘on edge’, you are happy to speak to the candidate to discuss your concerns.
You believe that the cause of your stress is your partner, Carol. You have been in a relationship with Carol for three years; you live together and do not have any children. Carol has been having multiple affairs with different men. You initially became suspicious of her infidelity six months ago when you smelt men’s aftershave on her coat as she returned home from work. Since this time, you have noticed Carol flirting with nearly every man she meets. For example, earlier today you overheard her saying good morning to the postal carrier in what you describe as a ‘seductive’ manner. You have concluded that she must be sleeping with each of these men and estimate that she has had over 500 different lovers over the past six months.
If asked, you do not believe there is any other possible explanation for your perceived ‘evidence’ of Carol’s infidelity.
If asked, you have been secretly checking Carol’s mobile phone for messages from suspected lovers and have begun following her when she leaves the house. You have confronted Carol about your suspicions on several occasions, which invariably resulted in heated arguments. She has repeatedly denied the affairs; however, you are still convinced she is being unfaithful and have made the decision to obtain a confession from her ‘one way or another’. If pushed to specify what you mean, you disclose that you are prepared to use physical force and have been researching injectable ‘truth serums’ on the internet.
If asked, despite being suspicious of every man Carol comes in contact with, you have no intention to approach nor harm any of the suspected lovers.
You deny feeling depressed and describe your mood as ‘stressed’. You have no thoughts of self-harm or suicidal ideation and deny ever experiencing hallucinations. You have never seen a psychiatrist before.
You have not been sleeping well and have started calling in sick to work in order to dedicate time to gather further evidence of the affair. You have been drinking more alcohol recently due to the stress and currently drink five to six cans of beer each day. You deny any illicit drug use. You do not carry any weapons and do not have access to any firearms.
If asked, you previously served a two-year prison sentence for actual bodily harm against an ex-partner and remain subject to a restraining order due to this offence.
Feedback Domains
Risk Assessment
The candidate is able to ascertain that Mr Giles poses a high risk to his partner:
The level of risk has been steadily increasing; initially, it started with suspicions but has now moved to spying, stalking, confrontation, arguments, and consideration of physical force.
There has been internet research into potentially dangerous methods of obtaining a confession.
Mr Giles demonstrates delusional thinking and has no insight into his current mental state.
He has a previous violent forensic history toward an ex-partner.
The candidate assesses the risks to others:
There is no intention to confront or harm any suspected lovers.
He lives alone with his partner (no children, no vulnerable adults).
The candidate screens for any risk to self:
He has no suicidal ideation or thoughts of self-harm.
His alcohol consumption has increased.
Potential threat to job: He has been calling in sick to work to stalk his partner.
Differential Diagnosis
In order to determine the diagnosis of morbid jealousy, the candidate is able to demonstrate that they have tested the patient’s conviction of belief to differentiate between an overvalued idea (strongly held rational or irrational belief, yet amenable to alternative explanation) and a delusion (belief is fixed, unshakable, and unyielding to contrary evidence).
The candidate screens for other primary psychotic disorders (e.g. schizophrenia, bipolar disorder) to show the examiner that they have considered these as explanations for the patient’s delusion.
The candidate demonstrates that the increased alcohol intake was subsequent to the development of the delusion rather than the delusion being secondary to an intoxicating substance.
Station 8.4 (90 Seconds)
Candidate Instructions
You are working out of hours in the ED and have been asked to review Mr Carlos Sánchez, a 28-year-old man who is becoming increasingly agitated after his demands to see a female staff member were declined.
Carry out a focused history to establish the likely diagnosis and conduct a risk assessment.
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