Abstract
You are working in liaison psychiatry and have been asked to review Mrs Brenda Willows, a 64-year-old woman admitted to the orthopaedic ward. Mrs Willows is now in her third day of recovery following lumbar decompression surgery, and the ward nurses have expressed concerns that she has suddenly become confused, agitated, and tremulous.
Practice Stations
Station 9.1: Delirium Tremens
Station 9.2: Opiate Dependence
Station 9.3: Alcohol-Induced Psychotic Disorder
Station 9.4: GBL
Station 9.5: Delirium Tremens Management
Station 9.6: Alcohol Dependence
Physical Examination
Station 9.7: Cerebellar Examination
Station 9.1 (90 Seconds)
Candidate Instructions
You are working in liaison psychiatry and have been asked to review Mrs Brenda Willows, a 64-year-old woman admitted to the orthopaedic ward. Mrs Willows is now in her third day of recovery following lumbar decompression surgery, and the ward nurses have expressed concerns that she has suddenly become confused, agitated, and tremulous.
Perform a mental state examination with a view to establishing a diagnosis.
Actor Instructions
You are Mrs Brenda Willows, a 64-year-old retired banker. You are terrified and visibly agitated. You find it difficult to keep still on your seat and frequently stamp down on the floor as if attempting to squash things.
If asked about your current experiences, explain that you can see a mass of insects emerging from the walls of the ward and scuttling on the floor toward you.
You are preoccupied with the insects and find it difficult to concentrate on the questions the candidate is asking. However, if the candidate is able to distract you, for example, by asking you to focus on them, relax and attempt to engage with the conversation.
If asked, you remember being admitted to the hospital for surgery on your back, but describe the events since the operation as ‘a blur’. You characterise your mood as frightened, and you have a horrible feeling that your life is in imminent danger. You deny any suicidal ideation or thoughts of self-harm.
When asked about your thoughts, you deny any worries about anyone interfering with your thoughts or controlling you in any way, and you deny experiencing any auditory hallucinations. The insects you can see on the floor are real, and you are confused about why the candidate cannot see them.
At some point during the scenario, shout out in a fearful manner.
If asked what is bothering you, explain that you can feel the insects crawling up your legs under your hospital gown.
If asked, you are unable to remember the present date, the name of the hospital, or the profession of the candidate.
If asked, you admit that you have been drinking several bottles of red wine on a daily basis since you retired four years ago. You last consumed alcohol the day before your operation. You have no previous mental health history and have never used illicit drugs.
Feedback Domains
Examination
The candidate is able to elicit the pertinent psychopathology (e.g. visual hallucinations, tactile hallucinations, confusion, and lack of insight).
The candidate demonstrates that they have considered each domain of the mental state examination. For appearance, behaviour, and speech, this may be achieved by commenting on observations during the assessment (e.g. ‘I notice that you appear quite agitated’).
The candidate remembers to assess risk to self when exploring mood.
Differential Diagnosis
The patient in this scenario is acutely confused, agitated, and hallucinating following recent spinal surgery. The differential diagnoses for the candidate to consider are as follows:
Delirium tremens
Delirium (e.g. secondary to infection, constipation, inadequately controlled pain)
Psychosis
Acute intoxication (e.g. alcohol, illicit substance, prescribed medication)
It is imperative that the candidate asks the patient about their alcohol intake history in this station in order to ascertain the correct diagnosis. The combination of alcohol dependence, recent alcohol discontinuation, and a suggestive clinical presentation (e.g. hallucinations, agitation, confusion, tremor, autonomic hyperactivity) makes delirium tremens the most likely diagnosis (see Station 9.5).
Communication
The candidate effectively utilises simple distraction techniques (e.g. reassuring the patient that they are safe, redirecting attention from the hallucinations) to reduce levels of agitation and engage the patient in the assessment.
The candidate acknowledges and explores the patient’s abnormal perceptions (visual and tactile hallucinations) but avoids colluding in their existence.
Station 9.2 (90 Seconds)
Candidate Instructions
You are working with the liaison psychiatry team. Mr Mark Smith, a 39-year-old man, has self-presented to the ED demanding to see a doctor. He informed staff that he would not leave the department until he was provided with methadone. Due to his level of agitation, nursing staff have requested a psychiatric review.
Explore Mr Smith’s concerns and elicit a substance use history.
Actor Instructions
You are Mark Smith, a 39-year-old unemployed man. You have attended the ED to request methadone, as you have not been able to visit the pharmacy to receive your regular script. You present as irritable and agitated because you have started experiencing unpleasant withdrawal symptoms (e.g. runny nose, sweating, abdominal cramps, and nausea).
You normally collect your methadone from your local pharmacy each morning. However, due to being unaware of the bank holiday opening times, you have not had any methadone for over 24 hours.
You have been prescribed methadone for the past two years since you ‘kicked’ your heroin habit. You have not used heroin since starting methadone and describe yourself as ‘clean’. You are worried that if you do not receive your methadone soon, the withdrawal symptoms will worsen and you may be unable to resist the urge to buy heroin.
If asked, you are prescribed 60 mg of methadone daily, which does not require supervised administration from a pharmacist.
If asked, you started smoking heroin in your early 20s, but this soon progressed to injecting the drug on a daily basis. Before quitting, you were spending up to £150 per day on your habit, which was funded by begging and petty theft. You admit to having previously shared needles, but you have been checked for blood-borne viruses since starting methadone. You have never suffered an intentional or accidental opioid overdose.
You smoke 40 cigarettes per day and estimate that you drink two cans of standard-strength lager each evening. You do not currently use any illicit drugs or other prescription medications; however, you admit that before you started injecting heroin, you used to smoke cannabis daily.
Feedback Domains
Additional Relevant History
The candidate elicits information regarding the patient’s methadone maintenance treatment:
Dosage
Duration of treatment
Compliance
Date and time of last prescription
Location of dispensing pharmacy
Supervised versus unsupervised dispensing
Concurrent use of heroin or prescription opioid analgesics
The candidate asks in detail about other substance use:
Alcohol
Tobacco
Sedative hypnotics (e.g. benzodiazepines, barbiturates, ‘z’ drugs)
Cannabis
Opioids (e.g. heroin, prescription opioid analgesics)
Psychostimulants (e.g. cocaine, amphetamines, ecstasy)
Other drugs (e.g. hallucinogens, ketamine, GHB/GBL, anabolic steroids, Khat, volatile solvents, synthetic drugs)
For each individual substance used, the candidate determines the following:
Quantity and frequency of use
Pattern of use (e.g. sporadic, daily, socially)
When last used
Total duration of use
Route of use (injected, oral, snorted, smoked)
The patient in this station admits to previous intravenous drug use. In these circumstances, it is important that the candidate enquires whether the patient has ever shared needles and whether they have been tested for blood-borne viruses. It may also be appropriate to request to examine the patient’s arms to inspect for recent track marks.
A comprehensive substance misuse history will include past medical and psychiatric history, family history, social history, and medications.
Risk Assessment
The candidate establishes that the patient has started experiencing opioid withdrawal symptoms and is considering buying heroin if unable to obtain methadone. This presents risks of accidental overdose, relapse of heroin dependency, exploitation from drug dealers, and criminal behaviour to obtain money to fund addiction.
The candidate appreciates the risk of iatrogenic overdose if methadone is administered before a patient’s regular dosage, and last known prescription, is confirmed.
The candidate enquires whether there is a history of intentional or accidental opioid overdose.
Communication
The candidate approaches the history in a nonjudgmental manner while being sensitive to the patient’s social situation and background. Patients may be reluctant to disclose information regarding alcohol or substance misuse if they sense prejudice.
In order to minimise patient irritability and frustration, the candidate is able to explain that their line of questioning is a routine part of a substance misuse assessment and helps identify any health concerns.
Author’s Note
The onset of opioid withdrawal symptoms from methadone ranges from 24 to 48 hours, in comparison to four to six hours for heroin. It is important to remember that uncomplicated opioid withdrawal is not life-threatening; however, opioid overdose can be fatal.
If opioid replacement therapy is not possible (e.g. unable to discuss with pharmacy, unable to obtain methadone out of hours), symptomatic treatment may be offered in the interim with medication such as benzodiazepines, hyoscine butylbromide, loperamide, and clonidine.
Patients who admit to using heroin on top of their methadone maintenance therapy can sometimes be offered naloxone to take home for emergency use in case of accidental opioid overdose.1
Station 9.3 (90 Seconds)
Candidate Instructions
You are working with a general adult community mental health team. Mrs Kristina Balashov, a 49-year-old woman, has been referred to your team by her GP due to concerns about a recent deterioration in her mental health characterised by strange beliefs about her neighbour. In the referral letter, the GP mentions that Mrs Balashov has a history of alcohol misuse.
Take a focused psychiatric history with a view to establishing a diagnosis.
Actor Instructions
You are Mrs Kristina Balashov, a 49-year-old Russian woman. You have attended today’s appointment at your GP’s request; however, you do not understand why he has referred you to a psychiatrist. You present as friendly, open, and relaxed.
You have been visiting your GP regularly since abnormal liver function tests were identified as part of a routine health check-up. Your GP believes the abnormal results are due to your alcohol intake.
You have always enjoyed alcohol and used to have a couple of glasses of wine after work with your late husband. However, since he passed away five years ago, you have steadily been drinking more. You estimate that you have been drinking two bottles of red wine a day for at least four years. You did not think this was a problem as you never get ‘drunk’, and it has never interfered with your work as a cook at a local primary school.
Following your GP’s advice, you have decided to completely abstain from alcohol. You had your last glass of wine exactly one week ago and remember feeling a little shaky and nauseous for a few days, but these symptoms gradually settled down on their own.
When you last visited your GP, you disclosed that you have not been getting much sleep for a number of days. You explain that during the night you can hear your neighbour singing nursery rhymes through the keyhole in your front door, but whenever you open the door to tell him to stop, there’s no one there. You know it’s your neighbour because you recognise his voice. You do not know why he is tormenting you, as you used to have a good relationship with him.
If asked, you have not yet approached your neighbour about his behaviour, as you do not like confrontations.
If asked, you deny any other psychotic symptoms (e.g. delusional perception, thought interference, passivity phenomenon, or delusions of control). Neither have you experienced any visual hallucinations. You deny any recent changes in your mood and describe having a productive and enjoyable life. You vehemently deny any thoughts of self-harm or suicide.
If asked, you are oriented to time, place, and person. You deny any confusion or difficulty with your memory. Other than the first couple of days after stopping drinking, you have not felt physically unwell or shaky.
You have no previous history of mental illness and no psychiatric family history that you are aware of. You have no significant past medical history and are not prescribed any regular medications. You deny ever having experimented with illicit drugs.
Feedback Domains
Knowledge
The diagnosis of alcohol-induced psychotic disorder is characterised by psychotic symptoms (e.g. hallucinations, delusions, disordered thinking) that develop during or shortly after intoxication or withdrawal from alcohol.
The quantity and duration of alcohol use must be excessive, and the psychotic symptoms must not be:
Mistaken for psychotic-like symptoms of altered behaviour, perceptions, or cognition that may be reasonably expected during alcohol intoxication or withdrawal
Better explained by a primary psychotic disorder (e.g. schizophrenia)
Associated with a pre-existing psychotic disorder
Differential Diagnosis
The differential diagnoses to consider in this station include the following:
Substance-induced psychotic disorder (e.g. alcohol-induced psychotic disorder)
Delirium tremens
Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder, acute and transient psychotic disorder, mood disorder with psychotic symptoms)
Secondary psychotic syndrome (e.g. psychosis secondary to a medical condition)
The candidate is able to demonstrate that an alcohol-induced psychotic disorder is the most likely diagnosis by establishing the chronology of events (i.e. hallucinations developed shortly after sudden cessation of chronic alcohol misuse).
The candidate rules out delirium tremens by enquiring about the presence of physical symptoms (e.g. tremor, diaphoresis) and screening for confusion.
The remaining differential diagnoses can be ruled out by reviewing past psychiatric history, risk factors for primary psychotic disorders (e.g. age of onset, family history, recent major life stressors), substance use history (including prescribed medications), and past medical history.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
