OSCEs & CASCs

Week 2

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OSCE 5

Candidate instructions

Scenario

Frank Maloney is a 22 year old man who has been accompanied to the psychiatry outpatient clinic by his father who has concerns
regarding Frank’s current mental state. Frank has become more withdrawn and has been mumbling to himself on a daily basis over
the past three weeks. Earlier today, he broke the family television set by repeatedly hitting it with a hammer.

TASK: Take a history of psychotic symptoms.

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OSCE 5 – Take a history of psychotic symptoms

Actor instructions

Background
 You are Frank Maloney, a 22 year old man who has been accompanied to the psychiatry outpatient clinic by your father who has
concerns regarding your current mental state.
 The candidate has been informed that you have become more withdrawn and have been mumbling to yourself on a daily basis
over the past three weeks.
 The candidate has also been told that earlier today, you broke the family television set by repeatedly hitting it with a hammer.
 The candidate’s task is to take a history of your psychotic symptoms.

Interaction with the candidate

 Your appearance is dishevelled.
 You do not smile. Your facial expression is blunted.
 You look around the vicinity during the interaction with the candidate. If asked as to what you are doing, you can reply that you
are looking for CCTV cameras.
 You mumble to yourself at intervals during the interview. If you are asked about this by the candidate you say you are “talking to
them”. If asked further about this, you admit that you are talking back to the “voices”.

History of presenting difficulty and core symptoms – changes over the past three weeks
 Delusions
o Delusion of persecution:
 You believe that you are being followed and monitored by “the company”. If asked about “the company” by the
candidate, you decline to elaborate.
 When you were walking down a street three weeks ago you saw a white van driving in the opposite direction to yourself.
You then noticed the van doing a U-turn and driving in the same direction in which you were walking. You believe that
the van was following you. If you are asked by the candidate as to why the van might be following you, you say “I have
too much information”. You decline to elaborate further.
 You have seen people nodding to each other which you know means that they are communicating to each other about
you.
 You have not left the house for the past two weeks as you are concerned for your safety. You believe your life is in
danger from “the company”.
 You have seen various cars driving slowing past your house and others parked outside your house for various intervals.
You believe these people are following and monitoring you.
 You are unsure whether or not your house (in which you share with your parents) has been bugged.
 You have never had any dealings with the Gardaí or with any unscrupulous individuals.
 You are 100% certain that you are being followed and monitored by “the company”.
o Delusion of reference: you have been receiving “messages” from the television. You believe that newsreaders have been
warning you that your life is in danger from “the company”. You are 100% certain of this.
o Delusion of poverty: you do not believe that you are penniless or that you lack any necessary resources to survive (e.g. food,
water, shelter or clothing).
o Delusion of grandeur: you do not believe that you have any special powers, special abilities or a special mission.
o Delusion of guilt: you do not believe that you have committed any crime or that you are specifically responsible for
anyone’s misfortune.
o Nihilistic delusion: you do not believe that the world is over, that you are dead or that your skin (or other body part) is
rotting.
o Delusion of infidelity: you are not currently involved in a romantic relationship. You have never had the belief that someone
has been sexually unfaithful to you.
o Delusion of love: apart from your parents, you do not believe that anyone is in love with you (e.g. a neighbour or celebrity).
o Delusion of infestation: you do not believe that any part of your body is infested with any form of parasite.
o Delusion of doubles: you do not believe that anyone known to you has been replaced by a double.
o Made acts and impulses: you do not believe that you are made to do something under the control of someone else.
o Made movements: you have noticed your right hand making a fist on a few occasions. This movement was not voluntary and
was not under your control. You found this frightening. You are unsure who or what might have caused this to happen.
o Made emotions: you do not believe that you have ever been made to experience someone else’s emotions. You believe that
you are under control of your own emotions.
 Hallucinations
o Hallucination versus pseudohallucinations: you have been hearing “voices” outside (not inside) your head. These “voices”
are as clear as the candidate’s “voice” or that of one of your parents, when they are talking to you.
o Auditory hallucination:
 Second/third person auditory hallucination: the “voices” talk directly to you (using your first name) and talk about
you among themselves (e.g. “Frank, you are stupid”, “he is a bad person and should be punished”). The “voices” are
talking to you, and about you, in a derogatory fashion during the interview with the candidate. You are distressed about
these “voices”.

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  Number of voices: you have been hearing two “voices”.
 Gender of voices: the “voices” you hear are those of men.
 Voices known/unknown to the person: the “voices” do not belong to anyone you know.
 Validity: you believe that the “voices” belong to real people. However, you do not know where these people are
located.
 Pattern: you have been hearing these “voices” every day over the past three weeks. The duration of the day that you
have been experiencing these “voices” has been increasing from a few minutes to several hours. You now hear these
“voices” in the mornings, afternoons and evenings. You find these “voices” very distressing. You have not been able to
“block out” the “voices” (e.g. you have tried listening to music at high volumes and distracting yourself in various
ways but you have not been able to “block out” the “voices”).
 Running commentary: you have heard the “voices” commenting on what you are doing as you are doing it (e.g.
“Frank is getting out of bed. Frank is walking towards the bathroom. Frank is going to the toilet. Frank is flushing the
toilet. Frank is washing his hands. Frank is walking back to his bedroom…..”).
 Command hallucination: the “voices” told you earlier today to smash up the family television with a hammer. You
were afraid to disobey the “voices” by not smashing up the television. This was the first time that the “voices” have
given you a command to do something.
 Thought echo: you have never heard your own thoughts spoken out loud, like an echo.
o Visual hallucination: you have not seen anything unusual or out of the ordinary. You do not believe that you have seen
anything that anyone else would not be able to see.
o Olfactory hallucination: you have not smelt anything unusual or out of the ordinary. You do not believe that you have smelt
anything that someone else would not be able to smell.
o Gustatory hallucination: you have not tasted anything unusual or out of the ordinary. You do not believe that you have
tasted anything that someone else would not be able to taste.
o Tactile hallucination: you have not felt anyone touching you when nobody has been around
o Kinaesthetic hallucination: you do not believe that your limbs are twisted.
o Somatic hallucination: you have not experienced any unusual sensation inside your body (e.g. electricity).
o Hypnagogic hallucination: you do not experience vivid hallucinations when you are going to sleep.
o Hypnopompic hallucination: you do not experience vivid hallucinations when you are waking from sleep.
o Extracampine hallucination: you have not heard “voices” from people who are many miles away or in a different country.
o Functional hallucination: (i.e. a hallucination in one modality of sensation which occurs after experiencing a normal
stimulus in the same modality of sensation, e.g. hearing “voices” when your doorbell rings). You have not had this
experience.
o Reflex hallucination (i.e. a hallucination in one modality of sensation which occurs after experiencing a normal stimulus
in a different modality of sensation, e.g. hearing “voices” when you see a bird). You have not had this experience.
o Elementary hallucination: you do not see flashes of light or hear rustling of leaves.
 Formal thought disorder
o Thought insertion: you believe that negative thoughts have been put into your head by “the company”. This has happened
against your will and is outside of your control. Examples of such thoughts include that you are a bad person, you are an evil
person and that you do not deserve to live).
o Thought withdrawal: you sometimes lose thoughts from your head. You believe that “the company” is responsible for
taking these thoughts out of your head.
o Thought broadcasting: you do not believe that other people can read your thoughts.
 Insight: you do not believe that you are unwell. You do not believe that you need treatment or hospitalisation.

Risk
 To self: over the past two weeks you have thoughts from time to time of ending your life. You believe that “the company” will
torture you before killing you. You therefore think it would be preferable to end your life painlessly yourself. You have not
considered any particular method which might be effective in ending your life. You cannot guarantee your personal safety.
 To others: you do not have (and have never had), any ideas, thoughts or plans to harm anyone.
 From others: you do not believe that you have been taken advantage of by anyone. Nobody has been asking you for money or
for anything out of the ordinary.

Impact on life – employment and relationships:

 Your quality of life has diminished over the past three weeks.
 You have been spending progressively more time at home as you have been concerned for your safety from “the company”
whom you believe wants to end your life.
 You have not left the house for the past two weeks. You live with your parents.
 You have been spending most of your time alone in your bedroom. You keep the curtains closed in your bedroom in an effort to
prevent “the company” from seeing you.
 You generally prefer to spend time by yourself but you have one friend (a male two years younger than you) who lives near you.
You met your friend at secondary school and would tend to see him approximately once a week for a chat. You have not met up
with your friend for the past month. You have not had any telephone contact with your friend.
 You left school after completing your Leaving Cert at the age of 18 years old. You passed your Leaving Cert. You did not attend
college and have never engaged in paid employment. You receive disability allowance.

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 You are not currently in a romantic relationship. You have never had a serious romantic relationship. You “went to the cinema a
few times” with a girl when you were aged 14 years. You have never had sexual relationship.
 You are an only child.

Associated difficulties
 Alcohol and illicit substances: you do not drink alcohol and have never used any drugs. You have never misused prescription
medication. You do not smoke cigarettes.
 Mood: you do not feel depressed. You have not experienced any difficulties with your sleep, appetite or energy level.
 Anxiety: you do not suffer from anxiety. You do not feel on edge. You do not feel anxious in crowds or when using public
transport. You do not feel anxious in small group gatherings. You have never had a panic attack. You have not noticed your heart
pounding in your chest (palpitations) or experienced excessive sweating.

Support network
 You are close to your parents.
 You generally prefer to spend time by yourself but you have one friend (a male two years younger than you) who lives near you.
You met your friend at secondary school and would tend to see him approximately once a week for a chat. You have not met up
with your friend for the past month. You have not had any telephone contact with your friend.

Past psychiatric history

 You were admitted to a psychiatric hospital (against your will) two years ago. You spent two months in hospital. At that time,
you were hearing “voices” and believed that people wanted to harm you. You were prescribed medication in hospital
(“Zyprexa”).
 You have been attending the psychiatry outpatient department since you were discharged from hospital two years ago.
 You do not think that you have ever been given a formal psychiatric diagnosis.
 You have never harmed yourself in the past.
 You have never harmed anyone else.

Medical history
 You do not suffer from any medical difficulty.
 You do not have any history of head injury.

Medication
 You were prescribed “Zyprexa” when you were admitted to a psychiatric hospital two years ago. You have been prescribed this
medication since that time.
 You have been reducing your own dose of “Zyprexa” because you have been putting on a lot of weight which you attribute to this
medication.
 You have not taken any “Zyprexa” for the past six weeks.
 You do not take any other medication.

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 OSCE 5 – Take a history of psychotic symptoms
Component Unsatisfactory (component not undertaken) Satisfactory(component undertaken but not fully) Excellent (component undertaken fully)
Candidate rapport & empathy  Candidate rapport & empathy 0 1 2
Introduction  Name & role provided 0 1 2
 Purpose of the interview 0 1 2
 Consent for the interview 0 1 2
History of the presenting  Symptom duration 0 1 2
difficulty  Trigger/stressor associated with onset 0 1 2
 Course of symptoms 0 1 2
 Insight 0 1 2
Core symptoms  Delusions
o Delusion of persecution 0 1 2
o Delusion of reference 0 1 2
o Delusion of poverty & delusion of grandeur 0 1 2
o Delusion of guilt 0 1 2
o Nihilistic delusion 0 1 2
o Delusion of love & delusion of infidelity 0 1 2
o Delusion of doubles & delusion of infestation 0 1 2
o Made acts & impulses 0 1 2
o Made movements & made emotions 0 1 2
o Overvalued idea vs delusion 0 1 2
 Hallucinations
o Auditory hallucinations
 Number of voices 0 1 2
 Gender of voices 0 1 2
 Hallucinations vs pseudohallucinations 0 1 2
 Second/third person 0 1 2
 Running commentary 0 1 2
 Command hallucinations 0 1 2
 Thought echo 0 1 2
o Visual & olfactory hallucinations 0 1 2
o Gustatory hallucinations & tactile hallucinations 0 1 2
o Kinaesthetic & somatic hallucinations 0 1 2
o Hypnagogic & hypnopompic hallucinations 0 1 2
o Extracampine hallucinations 0 1 2
o Functional & reflex hallucinations 0 1 2
o Elementary hallucinations 0 1 2
 Formal thought disorder
o Thought insertion 0 1 2
o Thought withdrawal 0 1 2
o Thought broadcasting 0 1 2
Risk  To self 0 1 2
 To others 0 1 2
 From others 0 1 2
Impact on life  Quality of life 0 1 2
 Work & relationships 0 1 2
Co-morbidity  Alcohol & illicit substances 0 1 2
 Depression 0 1 2
 Anxiety 0 1 2
Past psychiatric history  Psychiatric illness 0 1 2
 Self-harm 0 1 2
Global mark – based on:  Interview, attitude, competence, AND performance 0 1 2

Total mark: Examiner’s comments: 45

 Take a history of psychotic symptoms – questions to ask and areas to cover

Introduction
 “Good afternoon. Are you Frank Moloney?”
 “Frank, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital. I have been asked by my
consultant to talk with you about how you have been feeling. Would it be okay if we spoke for a while?”
 “Can you tell me how you have been feeling lately?”

History of presenting difficulty

 Symptom duration
o “For how long have you felt like that?”
o “How long have you been feeling this way?”
 Trigger/stressor associated with onset
o “What was happening in your life around the time you started feeling like that?”
o “Was there any particular stress or difficulty that you can pinpoint around the time you started feeling like that?”
 Course of symptoms
o “How have you been doing since you started feeling like that?”
o “Take me through how you have been feeling, including any changes over time”.
o “Do you feel like that all of the time or some of the time?” “Can you tell me more about this?”
 Insight
o “Do you think that you are currently unwell?
o “Do you think you need treatment?”

Core symptoms
 Delusions
o Delusion of persecution
 “Do you ever think that anyone is watching you, monitoring you or following you?” “Can you tell me more about this?”
 “Is anyone out to get you?” “Can you tell me more about this?”
 “Do you think that anyone wants to harm you in any way?” “Who wants to harm you?” “Why would they want to harm
you?” “How do you know that they want to harm you?”
 “Do you think that there is a conspiracy against you?” “Can you tell me more about this?”
 “Is anyone plotting against you?” “Can you tell me more about this?”
 “Do you think that you are deliberately ill-treated by others?” “Can you tell me more about this?”
 “Do you think that people are talking about you behind your back?” “Can you tell me more about this?”
 “Do you have any concerns about your food or fluids?”
o Delusion or reference
 “Do you receive any messages from the television or the radio?” “Can you tell me more about this?”
 “Do you ever think what is being said on the television or the radio is specifically about you or your life?”
o Delusion or poverty
 “Do you believe that you are impoverished or that you are lacking basic essentials in your life such as food, water, shelter
or clothing?” “Can you tell me more about this?”
o Delusion of grandeur
 “Do you believe that you have any special powers or abilities that the average person might not have?” “Can you tell me
more about this?”
o Delusion of guilt
 “Do you feel particularly guilty about anything?” “Can you tell me more about this?”
 “Do you think that you deserve to be punished for anything you have done?”
o Nihilistic delusion
 “Do you think that the world is over or that you are already dead?”
 “Do you believe that your skin or any part of your body is rotting?”
o Delusion of love
 “Is a celebrity or anyone apart from your family in love with you?” “Can you tell me more about this?” “How do you
know that they are in love with you?”
o Delusion of infidelity
 “Are you currently involved in a romantic relationship?” “Has your current partner or any previous partner been sexually
unfaithful?” “How do you know they were unfaithful?” “Did they tell you they were unfaithful?” “Did you ever follow
them or monitor them in any way?”
o Delusion of doubles
 “Has anyone known to you been replaced by an exact double?” “Can you tell me more about this?
o Delusion of infestation
 “Do you think that you are infested with a parasite, insect or bug?” “How do you know that you are infested?” “What
evidence do you have that you are infested?” “How did you become infested?” “Have you seen a doctor about this
problem?”
o Made acts and impulses
 “Are your actions and impulses under your own control?”

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  “Do you ever think that your actions and impulses are being controlled by someone else or by something external to your
body?” “Can you tell me more about this?”
o Made movements
 “Are your movements under your own control?”
 “Do you ever think that your movements are being controlled by someone else or by something external to your body?”
“Can you tell me more about this?”
o Made emotions
 “Are your emotions under your own control?”
 “Do you ever think that your emotions are being controlled by someone else or by something external to your body?”
“Can you tell me more about that?”
o Overvalued idea vs delusion
 “How certain are you of that belief?” “Is it possible that there might be an alternative explanation?” “Is there any
possibility you might be mistaken?”
 Hallucinations
o Auditory hallucinations
 “Do you ever hear voices when nobody else is around?” “Can you tell me more about this?”
 “Apart from my voice, can you hear any other voice at the moment?” “Can you tell me more about this?”
 “How often do you hear the voices?” “Is there any particular time of the day that you hear the voices?” “Do you hear
voices every day?” “How much of your day is occupied by the voices?”
 “How does it make you feel to hear the voices?”
 “Does anything make the voices louder or more intense?”
 “Does anything reduce the voices or make them disappear altogether?”
 “Have you tried to block out the voices by wearing earplugs, listening to loud music or any other method?” “Have you
managed to reduce, or block out, the voices?”
 “Can you give me some examples of what the voices say?”
 “How many voices do you hear?”
 “Are the voices male or female or both?”
 “Do you recognise the voices?”
 “Are the voices inside your head or outside your head?” “How clearly can you hear the voices?”
 “Do you know where the voices might be coming from?”
 “Do the voices talk to you or do they talk about you?”
 “Do the voices refer to you by your name or do they say ‘you’ or ‘he/she’?”
 “Do the voices ever comment on what you are doing as you are doing it?” “Can you give me an example of this?”
 “Do the voices ever give you instructions or commands?” “Do the voices ever tell you to do something?” “Can you tell me
more about this?” “What do the voices tell you to do?” “Do you do what the voices tell you?” “Have the voices ever told
you to harm yourself?” “Have the voices ever told you to harm anyone else?”
 “Do you ever hear your own thoughts aloud like an echo?”
o Visual hallucinations
 “Have you been seeing anything unusual or anything that other people do not see?” “Can you tell me more about this?”
o Olfactory hallucinations
 “Have you experienced any unusual or unpleasant smells that other people have not noticed?” “Can you tell me more
about this?”
o Gustatory hallucinations
 “Have you experienced any unusual or unpleasant tastes that other people have not noticed?” Can you tell me more about
this?”
o Tactile hallucinations
 “Have you felt anyone touching you when nobody else is around?” “Can you tell me more about this?”
 “Have you experienced any unusual sensations on your body or your skin?” “Can you tell me more about this?”
o Kinaesthetic hallucinations
 “Do you believe that your limbs are twisted?”
 “Do you ever think that some part of your body is moving when it is not actually moving at all?”
o Somatic hallucinations
 “Have you experienced any unusual sensations inside your body such as electricity?” “Can you tell me more about this?”
o Hypnogogic hallucinations
 “Do you experience any visions or voices as you are drifting off to sleep?” “Can you tell me more about this?”
 “Do you experience any unusual sensations on your body or your skin as you are drifting off to sleep?” “Can you tell me
more about this?”
o Hypnopompic hallucinations
 “Do you experience any visions or voices as you are waking up from sleep?” “Can you tell me more about this?”
 “Do you experience any unusual sensations on your body or your skin as you are waking up from sleep?” “Can you tell
me more about this?”
o Extracampine hallucinations
 “Have you ever heard voices from people who are many miles away or in a different country?” “Can you tell me more
about this?”

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 o Functional hallucinations
 “Do you ever hear a voice after experiencing another sound, e.g. after hearing a doorbell ring or a dog barking?” “Can you
tell me more about this?”
o Reflex hallucinations
 “Do you ever hear a voice after seeing something, smelling something, tasting something or after you touch something or
someone touches you?” “Can you tell me more about this?”
o Elementary hallucinations
 “Do you hear sounds which are not voices such as the rustling of leaves when there are no leaves around?”
 “Do you see flashes of light when there is no such light around?”
 Formal thought disorder
o Thought insertion
 “Do you experience thoughts being put into your head by someone or something external to yourself?” “Can you tell me
more about this?” “How often does that happen?” “What thoughts are put into your head?” “Where do you think these
thoughts might be coming from?” “How does it make you feel to have thoughts put into your head?”
o Thought withdrawal
 “Do you experience thoughts being taken out of your head by someone or something external to yourself?” “Can you tell
me more about this?” “How often does that happen?” “What thoughts are taken out of your head?” “Where do you think
your thoughts go when they are removed from your head?” “How does it make you feel to have thoughts take out of your
head?”
o Thought broadcasting
 “Do you ever think that other people can read your thoughts?” “Who can read your thoughts?” “How do you know that
they can read your thoughts?” “How does it make you feel?” “Are you able to keep any of your thoughts private?”

Risk
 To self
o “Do you have any thoughts of harming yourself?” “Can you tell me more about this?” “Have you thought about what you
might do to harm yourself?” “Have you made any plans to harm yourself?” “Can you tell me more about this?”
o “Do you ever wish you were dead?” “Do you want to harm yourself?” “Why do you want to harm yourself?”
o “Have you ever thought life was not worth living?” “Can you tell me more about this?”
o “Do you think that you actually would harm yourself in any way?” “What do you think you might do?”
 To others
o “Do you have any thoughts of harming someone?” “Can you tell me more about this?” “Have you thought about what you
might do to harm that person (those people)?” “Have you thought about what you might do to harm that person (those
people)?” “Can you tell me more about this?”
o “Do you think that you actually would harm that person (those people) in any way?” “What do you think you might do?”
 From others
o “Has anyone taken advantage of you recently in any way?” “Can you tell me more about this?”
o “Sometimes when people are unwell they can become vulnerable. Have you felt this way?” “Have you considered yourself in
a particularly vulnerable position with anyone recently?” “Can you tell me about this?”
o “Have you given away any money or possessions to anyone lately?” “Can you tell me more about this?”

Impact on life
 Quality of life
o “How would you describe your current quality of life?”
o “Has your quality of life changed?” “Can you tell me more about this?”
 Work attendance and performance
o “Are you currently employed?” “What is your job?” “For how long have you been working in this job?”
o “Have you been attending work every day?” “Have you missed any days at work?” “Have you needed to take any time off
work lately?” “Why did not attend work on those days?”
o “When were you most recently at work?”
o “Are you arriving on time for work?”
o “How is your productivity at work?” “Are you able to achieve what you need to achieve at work?” “Has anyone at work
commented on a change in your productivity?” “Can you tell me more about this?”
 Relationships (both romantic and friends)
o “Are you currently involved in a relationship?” “How would you describe the relationship?” “Are there any significant
difficulties in the relationship?” “How has your partner reacted to you being unwell?” “Are you spending as much time with
your partner as you did when you were feeling well?” “Do you enjoy spending time with your partner?”
o “Do you have friends?” “How many friends do you have?” “How often do you meet up with friends?” “Are you spending as
much time with your friends as you were when you were feeling better?” “What do you do when you meet up with friends?”
“Do you enjoy spending time with your friends?”

Co-morbidity
 Alcohol and illicit substances
o Alcohol
 “How often do you drink alcohol?”

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  “What do you drink?”
 “How much alcohol would you drink on a typical day that you would be drinking?”
 “Has your use of alcohol increased or decreased over time?” “Can you tell me more about this?”
 “Why do you drink alcohol?”
 “Do you drink alone or with someone else?”
 “What do you think about the amount of alcohol that you are consuming?”
 “Do you think that you need any help in relation to the level of your alcohol intake?”
o Illicit substances
 “Do you take any cannabis, cocaine, heroin, lsd, ecstasy or any other drugs?”
 “How much do you take?”
 “Has your use increased or decreased over time?” “Can you tell me more about this?”
 “Why do you take drugs?”
 “Do you take drugs alone or with someone else?”
 “What do you think about the amount of drugs that you are taking?”
 “Do you inject drugs?”
 “Do you think that you need any help in relation to your use of drugs?”
 Depression
o Mood
 “How would you describe your mood at the moment?”
 “Have you noticed any changes in your mood?” “What changes have you noticed?”
 “For how long has your mood been affected?”
 “Is your mood low every day or do you have good days and bad days?”
 “Is your mood getting better or worse or staying the same over time?”
 “Is there any particular time of the day when your mood is at its lowest?”
 “If you had to rate your mood on a scale between zero and ten in which zero is the worst you have ever felt in your life
and ten is the best you have ever felt, how would you rate your mood right now?” If the person responds by rating their
mood as three out of ten – “when was your mood most recently four out of ten?”
 “Is there anything which improves your mood such as being around family or friends?”
 “Has anyone in your family said anything to you about a change in your mood?”
o Interest/anhedonia
 “What are your hobbies and interests?”
 “Are you still involved in your hobbies and interests as much as you were in the past?”
 “Do you enjoy watching television or listening to music?”
 “How you feel around family and friends?”
 “Do you enjoy spending time with family and friends?”
 “How have you been spending your day lately?”
 “Do you have the same degree of interest and enjoyment in activities now that you had in the past?”
o Energy
 “How would you describe your energy level?”
 “Are you able to complete all of your everyday tasks during the day?”
 “Do you stay awake during the day or have you been taking any naps?” For how long have you been napping during the
day?” “Why do you nap during the day?”
 “Are you feeling more tired than usual during the day?”
o Concentration
 “How is your concentration?”
 “Are you able to follow the main storyline in a film or a television programme?”
 “Do you remember what you read or do you have to read the same paragraph a few times to remember what you read?”
 “Please subtract 7 from 100”. “Subtract 7 again from your answer” (ask for this to be done six times, with the patient
providing their answer on each occasion before they make a further subtraction).
 “Could you please say the months backwards for me?”
 “Please list the days of the week backwards”.
o Self-esteem and self-confidence
 “How would you describe your self-esteem and self-confidence?”
 “Have you noticed any changes in your self-esteem and self-confidence?” “What changes have you noticed?”
o Guilty and worthless
 “Do you believe that you have done anything wrong?”
 “Do you feel guilty about anything in particular at the moment?” “Can you tell me about that?”
 “Are you blaming yourself any more than usual at the moment or do you tend to blame yourself a lot?”
 “Do you believe that you have committed a crime, done something terrible or deserve to be punished?” “Can you tell me
about this?”
o View of the future
 “How do you view the future?”
 “How do you see yourself six months from now?”
 “What would you like to do when you get out of hospital (or when you are feeling better)?”
o Sleep
 “Have you noticed any changes in your sleep?”
49
  “On average, at what time do you tend to go to bed at night?”
 “How long does it take you to go to sleep?”
 “Do you sleep through the night?” If the patient says they wake up during the night – “How many times would you tend
to wake up during the night?” “How long does it take you to get back to sleep?”
 “At what time do you wake in the morning?”
 “Is there any noise that has been waking you up earlier than usual (or during the night)?”
 “What do you do when you wake in the morning – do you get up out of bed or do you stay on in bed?”
 “Do you stay out of bed during the day?”
 “Do you nap during the day?” “For how long do you nap during the day?”
o Appetite
 “How would you describe your appetite?”
 “Have you noticed any changes in your appetite?” “What changes have you noticed?”
 “What have you eaten today so far?”
 “What did you eat yesterday?”
 “Do you enjoy what you are eating?”
 If the person says they have been eating less than usual – “Can you tell me the reason for this?” “Are you intentionally
trying to lose weight?”
 “Have you noticed any recent changes in your weight?” “What changes have you noticed?” “Over what time span have
you noticed that weight change?”
 “Have you noticed the waistband of your trousers (or skirt) becoming more loose over time?”
 Anxiety
o “Do you suffer with anxiety?” “Can you tell me more about this?” “Is the anxiety there all the time or some of the time?”
“When do you feel anxious?”
o “Do you have any difficulty going to a shopping centre or to the cinema?” “What difficulties do you have?” “Is it easier for
you if someone you trust is with you when you go to a shopping centre or to the cinema?”
o “Do you ever have to give a presentation at work?” “How do you find that?” “Do you eat in restaurants?”
o “Do you ever suffer from episodes of shortness of breath, heart palpitations and sweating?” “Can you tell me about this?”
“How long do these episodes tend to last?”
o “Is there any particular object or situation which you avoid because of extreme anxiety?” “For example, some people become
extremely anxious if they are in an elevator or an enclosed space”.

Past psychiatric history

 Psychiatric illness
o “Have you ever been diagnosed with a psychiatric illness?” “What was your diagnosis?” “Who diagnosed you - was it GP or
a psychiatrist?” “Have you been prescribed medication in the past for a psychiatric illness?” “What medication were you
prescribed?” “Did you take the medication?”
o “Have you ever been an inpatient in a psychiatric hospital?” “How many inpatient admissions have you had?” “How long on
average have your admissions been for?” “When was your most recent inpatient admission?” “What treatment did you receive
in hospital?”
 Self-harm
o “Have you ever harmed yourself in the past?” “What have you done to harm yourself?” “When did you first harm yourself?”
“When did you most recently harm yourself?” “Did you receive medical treatment after harming yourself?” “Why did you
harm yourself?” “What did you think would happen when you harmed yourself?”

50
OSCE 6

Candidate instructions

Scenario

Joseph Byrne is a 32 year old man who is currently an inpatient on the psychiatry ward. Joseph has recently been diagnosed with
schizophrenia. Your consultant has asked you to meet Joseph’s father (David) who is currently unaware of Joseph’s diagnosis.

TASK: Discuss with Joseph’s father, Joseph’s diagnosis of schizophrenia AND the management options available for schizophrenia.
Assume that you have obtained consent from Joseph to talk to his father.

51
OSCE 6 – Explain schizophrenia to a relative of a patient

Actor instructions

Background
 You are David Byrne, the father of Joseph, a 32 year old man who is currently an inpatient on the psychiatry ward.
 Joseph has recently been diagnosed with schizophrenia.
 The candidate’s consultant has asked them to meet you.
 You are currently unaware of Joseph’s diagnosis.
 The candidate’s task is to discuss with you, Joseph’s diagnosis of schizophrenia AND the management options available for
schizophrenia.
 The candidate was asked to assume that they have obtained consent from Joseph to talk to you.

Interaction with the candidate

 You appear distressed about your son’s wellbeing and his future.
 You do not know anything about schizophrenia or its treatment.
 You do not know if anyone in your family had a psychiatric illness.
 You do not think that Joseph ever took drugs.
 Allow the candidate to speak and to discuss this topic with you.
 Do not ask the following questions unless this content is not covered by the candidate -
o What is wrong with my son?
o What is schizophrenia?
o What causes schizophrenia?
o Is there something that I did wrong to make him sick?
o Is schizophrenia the same as a split personality?
o Will he get better?
o Will he be in hospital for most of his life?
o How is schizophrenia treated?
o Is there anything else that I should know?

52
 OSCE 6 – Explain schizophrenia to a relative of a patient
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
Candidate rapport & empathy  Candidate rapport & empathy 0 1 2
Introduction  Name & role provided 0 1 2
 Purpose of the interview 0 1 2
 Consent for the interview 0 1 2
Person’s existing knowledge  Asks about person’s existing knowledge of the condition 0 1 2
Explains diagnosis  Explains the diagnosis 0 1 2
Aetiology  Biological
o Genetics
o Neurodevelopmental hypothesis 0 1 2
o Organic factors (risk in people with temporal lobe epilepsy, Huntington’s disease, traumatic brain injury)
o Substance misuse
 Psychological
o Life events 0 1 2
 Social
o Unemployment
o Urban > rural 0 1 2
o Premorbid characteristics
o Migration
Epidemiology  Incidence (number of new cases of schizophrenia diagnosed each year): 15-20 per 100,000 per year
 Prevalence (estimated population living with schizophrenia at any given time): 0.5-1% 0 1 2
 Mean age at onset: ♂ = 22 years, ♀ = 26 years
 ♂ = ♀ (1.5:1)
Core symptoms  Positive vs negative symptoms 0 1 2
 Hallucination vs delusion (with examples) 0 1 2
 Symptoms present most of the time for one month or longer 0 1 2
 Thought insertion, withdrawal, echo, broadcasting 0 1 2
 Delusions of control, influence or passivity 0 1 2
 Breaks in train of thought incoherent/irrelevant speech or neologisms 0 1 2
 Third person auditory hallucinations 0 1 2
 Running commentary 0 1 2
Potential co-morbid  Alcohol, illicit substances, nicotine
conditions 0 1 2
Management  MDT involvement (give examples) 0 1 2
 Biological (antipsychotic classification with examples, main side effects of antipsychotics, depot) 0 1 2
 Psychological (CBT, family therapy, art therapy) 0 1 2
 Social (social skills training, clubhouses, vocational & rehab training, befriending) 0 1 2
Relapse  Compliance
 Do not stop medication suddenly – risk of relapse 0 1 2
 Relapse signature
 High expressed emotion
Prognosis  Prognosis (25% full recovery, 40% recurrent episodes, 35% high rate of hospital admission & social disability) 0 1 2
Patient questions  Asks the patient if they have any questions 0 1 2
Global mark – based on:  Interview style, AND attitude, AND competence, AND performance 0 1 2

Total mark: Examiner’s comments:

53
 Explain schizophrenia to a relative of a patient – questions to ask and areas to cover

Introduction
 “Good afternoon. Are you David Byrne?”
 “David, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital. I have been asked by my
consultant to talk with you about Joseph’s illness and suitable treatment options. Joseph has given his consent for me to talk with
you”.
 “Would it be okay with you if we spoke for a while?”
 “I understand from my consultant that Joseph’s diagnosis has not yet been discussed with you. Is this correct?”
 “Joseph has schizophrenia”.

Patient’s existing knowledge

 “Do you know anything about schizophrenia?”

Explains diagnosis
 “Schizophrenia is a major psychiatric disorder, or cluster of disorders, characterised by psychotic symptoms that alter a
person’s perception, thoughts and behaviour”.
 “Each person with the disorder will have a unique combination of symptoms and experiences”.
 “Typically, there is an initial stage (known as a prodromal period) often characterised by some deterioration in personal
functioning. This includes memory and concentration problems, unusual behaviour and ideas, disturbed communication,
social withdrawal and reduced interest in daily activities. These are sometimes called ‘negative symptoms’”.
 “The prodromal period is usually followed by an acute episode marked by hallucinations, delusions, and behavioural
disturbances. These are sometimes called ‘positive symptoms’ and are usually accompanied by agitation and distress”.
 “A hallucination is a false perception in the absence of a real external stimulus. Hallucinations can occur in any of the five
senses of sight, hearing, smell, taste and touch, e.g. a person experiencing an auditory hallucination hears a voice or voices
when nobody else is around”.
 “A delusion is a fixed, false, unshakeable belief held in the face of evidence to the contrary, that is out of keeping with an
individual’s social and cultural background, e.g. someone may believe that they are being harassed, persecuted or conspired
against when nobody is in fact harassing, persecuting or conspiring against the person at all”.

Aetiology
 Biological
o “Genetics is an important biological cause for schizophrenia. Someone is more likely to develop schizophrenia if they have a
family member who has schizophrenia. The risk is greater if a first degree relative has the illness, e.g. the risk is greater if
someone has an affected parent, sibling or child than when more a distant relative has this condition”.
o “The risk of developing schizophrenia with no relative affected is 1%. The risk is approximately 13% for children of one
affected parent, 46% for children with two affected parents and 10% if a sibling has schizophrenia”.
o “It has been postulated that schizophrenia is due to excess of a chemical called dopamine in the brain. It has also been
postulated that schizophrenia is due to over-activity of a chemical called serotonin”.
o “The neurodevelopmental hypothesis looks at developmental factors, e.g. schizophrenia is more common among people born
in the winter and spring than in those born in the summer (more common between January and April in the
northern hemisphere, and between July and September in the southern hemisphere). Prenatal exposure to infection (such as
influenza), malnutrition or stress, are associated with an increased risk of schizophrenia. Obstetric complications (e.g.
umbilical cord around the neck of the baby) are associated with an increased risk of schizophrenia. Non-right handedness
(i.e. left handedness or mixed handedness) is associated with an increased risk of schizophrenia. People who develop
schizophrenia show abnormalities in their development that precedes disease onset. Children who later develop
schizophrenia as adults have been shown to be distinguished by their peers by lower educational test scores, delayed motor
milestones and have been shown to perform poorly in sports and handicrafts compared to normal peers. Children who later
develop schizophrenia have been shown to have worse peer relationships than people who do not develop schizophrenia”.
o “There is an increased risk of schizophrenia in people with chronic temporal lobe epilepsy, Huntington’s chorea and traumatic
brain injury”.
o “Adolescent cannabis use is associated with an increased risk of developing schizophrenia”.
 Psychological
o “Life events are potential psychological causes for schizophrenia. Childhood trauma is associated with an increased risk of
developing schizophrenia. Separation from a parent for six months before the age of five years is associated with increased
risk of developing schizophrenia. Compared to individuals who do not have schizophrenia, people with schizophrenia may
have more life events particularly clustered in the three weeks preceding relapse or admission”.
 Social
o “Regarding possible social causes for schizophrenia, there is an increased risk among migrants. The risk persists into second
generation migrants”.
o “There is an increased risk of schizophrenia in people living in urban versus rural areas”.
o “People with schizophrenia are more likely to live alone, be unmarried and have fewer friends than unaffected individuals
who do not have schizophrenia. These patterns frequently began before the illness”.
o “Someone with schizophrenia is more likely to be unemployed than a person who does not have this condition. This does not
mean that people with schizophrenia cannot attend college or cannot work”.
54
Epidemiology
 “The incidence or number of new cases of schizophrenia diagnosed each year is 15-20 per 100,000 per year”.
 “The prevalence or estimated population of people who are living with schizophrenia at any given time is 0.5-1%”.
 “The mean age of onset of schizophrenia is 22 years for males and 26 years for females”.
 “Schizophrenia is more common in males than females, with the male to female ratio being 1.5 to 1”.

Core symptoms
 “The symptoms of schizophrenia include hallucinations and delusions as I have already mentioned”.
 “Someone with schizophrenia may experience thought insertion in which they believe someone or something is putting thoughts
into their head, thought withdrawal in which they believe someone or something is taking thoughts out of their head, thought
echo when they hear their own thoughts aloud as an echo, or thought broadcasting when they believe that other people can read
their thoughts”.
 “They might believe that someone or something is controlling or influencing their actions or the movement of part of their body
such as an arm or leg”.
 “The auditory hallucinations or voices in schizophrenia are often third person in nature, e.g. the voices refer to the person or talk
about the person among themselves using ‘he’ or ‘she’”.
 “A running commentary can occur whereby the person hears the voices commenting on what they are doing as they are doing it,
e.g. ‘he is scratching his nose. He is getting out of bed. He is walking across the floor to the bathroom. He is going to the
toilet….’”.
 “There may be breaks in the train of thought resulting in incoherent or irrelevant speech or neologisms in which the person uses
words that only have mean to the individual who uses them”.
 “Symptoms of schizophrenia should be present for most of the time during a period of one month or more”.

Potential co-morbid conditions

 “Someone with schizophrenia may be more likely to misuse alcohol and/or illicit substances than an individual who does not
have schizophrenia. Alcohol and/or illicit substances might be used for example as a coping mechanism”.
 “The rate of cigarette smoking in people with schizophrenia is higher than that of the general population. People with
schizophrenia who smoke do so at heavier rates than the general population”.

Management
 “The management of schizophrenia involves a multidisciplinary team approach with input from different mental health
disciplines. For example, the consultant psychiatrist responsible for the care of the patient and their junior doctors (psychiatry
registrars) monitor the mental state of the patient at regular intervals as an inpatient if the person is admitted to a psychiatric ward
and on an outpatient basis. They discuss with the patient about how they are feeling at that point in time and during the days,
weeks or months prior to assessment. The psychiatrist is responsible for prescribing medication and monitoring the patient’s
progress on that medication. Ward nursing staff monitor the progress of patients admitted to psychiatric wards. A community
psychiatric nurse (CPN) monitors the progress of outpatients. A CPN meets up with patients in an outpatient facility or
sometimes in the home of the patient. A social worker can assist patients who are homeless or have difficulty in accessing
suitable accommodation. Social workers also organise and manage packages of support to enable people to lead the fullest lives
possible. Social workers assist people in poverty to improve their financial position, informing them about their entitlements and
helping them to access training, work opportunities and benefits. The role of the occupational therapist (OT) is to help patients
improve or maintain skills for day to day activities and well-being. OTs work with individuals to help them maintain or achieve
independence in their activities of daily living (e.g. buying food for oneself and preparation of meals). A psychologist assists a
person in reduce their psychological distress, as well as in enhancing and promoting psychological wellbeing”.
 Biological
o “Before antipsychotic medication is started, baseline investigations are undertaken, e.g. weight, waist circumference, pulse and
blood pressure, fasting blood glucose, blood lipid profile and prolactin hormone level. There should also be an assessment of
any movement disorders and an assessment of nutritional status, diet and level of physical activity”.
o “Antipsychotic medications are broadly divided into first generation or typical antipsychotics, e.g. haloperidol; and second
generation or atypical antipsychotics e.g. olanzapine, quetiapine, risperidone”.
o “Atypical antipsychotics are usually prescribed to treat schizophrenia”.
o As a class, atypical antipsychotics may have a lower risk of movement disorders as a side effect than typical antipsychotics”.
o “Typical antipsychotics still play an important role in schizophrenia and offer an alternative to atpicals when atypicals are
poorly tolerated or where typicals are preferred by the patients themselves”.
o “Antipsychotics can be given as a long-acting depot injection into a large muscle such as the upper arm or the buttocks,
allowing for sustained medication release over one to four weeks. Depot injections reduce relapse rates of schizophrenia.
Antipsychotic depot injections are indicated when the patient is poorly compliant with oral treatment, the person has not
responded to oral medications or when there are memory problems or other factors interfering with the person’s ability to take
medications regularly”.
o “Antipsychotics do not ‘cure’ schizophrenia. They treat symptoms in the same way that insulin treats diabetes”.
o “Antipsychotics may be able to affect the natural course of schizophrenia. Repeated relapse of illness is associated with
decline. Prevention of relapse by using antipsychotics may improve outcome. Longer duration of untreated psychosis is
associated with poorer outcome”.
o “Any medication has possible side effects. Some people experience side effects with medication while others do not
experience any side effects. Possible side effects of antipsychotic medication includes sedation, weight gain, dry mouth,
55
 blurred vision, constipation, increased or decreased blood pressure and reduced seizure threshold. A patient taking
antipsychotic medication is monitored carefully by their treating team for side effects”.
 Psychological
o “Family interventions and cognitive behavioural therapy (CBT) can increase the chance of staying well”.
o “A family intervention is often offered to people with schizophrenia who are living, or in close contact, with their family”.
o “Cognitive behavioural therapy (CBT) is a type of psychotherapy (or ‘talking therapy’) that is based on the theory that
psychological symptoms are related to the interaction of thoughts, emotions, physical symptoms and behaviour. The therapist
and the patient both actively work together in a therapeutic alliance (collaborative empiricism) to understand the link
between the patient’s current thoughts, emotions, physical symptoms and behaviour, in order to directly challenge the
thoughts, emotions and behaviour that may be maintaining symptoms of depression or other illness, with the goal of
providing symptom relief and the development of new skills. CBT is a collaborative, active, goal focused therapy which
focuses on current symptoms and problems (i.e. ‘the here and now’) and not those from the past. Problem solving is
important approach in CBT. CBT is usually given on a one to one basis. CBT involves approximately 12-20 sessions. The
initial assessment is followed by 6-20 hour long sessions”.
 Social
o “Social management of schizophrenia may involve social skills training which teaches people about the verbal and non-verbal
behaviours involved in social interactions so that they can determine how to act appropriately in the company of other people
in a variety of different situations, clubhouses which can offer an employment programme designed to integrate interested
members back into the community, or vocational and rehabilitation training offering supported employment with individually
tailored job placement, rapid job search and the provision or ongoing job support. Isolation is a common problem for
people with mental illness. Befriending is a relationship between a volunteer befriender and a befriendee within a structural
framework. This is usually a time limited relationship which enables a person to widen their own social network, increase
independence and make informed choices, so enabling them to live life to the full. Support groups such as Mental Health
Ireland provide care, support and friendship for people with mental illness. Some people find patient advocacy beneficial. The
Irish Advocacy Network provides a peer advocacy service with people who have personal experience of mental health
difficulties who achieved a sufficient level of recovery”.

Relapse
 “In order to reduce the risk of relapse, it is important for someone with schizophrenia to take their medication daily as prescribed.
If any unpleasant side effects are experienced, these should be discussed with the psychiatrist. Often these side effects can be
managed by altering the dose of medication or changing to a different medication”.
 “It is essential not to stop medication suddenly due to the risk of relapse”.
 “It is important to teach patients and a close family member/partner to recognise the warning signs of relapse (relapse signature)
so that they can seek early treatment, e.g. irritability, paranoia that someone is watching or following the person, or them hearing
voices in their head”.
 “High expressed emotion is a predictor of symptomatic relapse following discharge from hospital. Those people from families
with high expressed emotion relapse more frequently than those who are from families without high expressed emotion.
Components of high expressed emotion are critical comments, hostility and emotional over-involvement”.

Prognosis
 “Generally, it has been estimated that for people with schizophrenia, 25% will experience a full recovery, 40% will
experience recurrent episodes with some degree of social disability and periods of unemployment; and 35% will experience
long-term schizophrenia with a high rate of both hospital admission and social disability”.

Patient questions
 “Do you have any questions?”

56
OSCE 7

Candidate instructions

Scenario

Lucy Jacobs is a 34 year old lady with schizophrenia who is currently an inpatient on the psychiatry ward. Your consultant believes
Lucy should start on clozapine. Your consultant has asked you to talk to Lucy about clozapine.

TASK: Explain clozapine management to Lucy. This is the first conversation Lucy will have had about clozapine.

57
OSCE 7 – Explain clozapine management to a patient

Actor instructions

Background
 You are Lucy a 34 year old woman with schizophrenia who is currently an inpatient on the psychiatric ward.
 The candidate’s consultant has asked them to meet you to discuss clozapine.
 The candidate’s task is to explain clozapine management to you.
 This is the first conversation you will have had about clozapine.

Dialogue with the candidate

 You do not have any prior knowledge of clozapine.
 Allow the candidate to speak and to discuss this topic with you.
 Do not ask the following questions unless this content is not covered by the candidate -
o What is clozapine?
o Why should I take clozapine?
o Will I get better with clozapine?
o Is clozapine dangerous?
o What are the main side effects of clozapine?
o Those side effects sound frightening. Is there an alternative to clozapine?
o How are those side effects managed?
o What would be the next step if clozapine does not make me better?

58

Candidate rapport & empathy
Introduction
Patient’s existing knowledge
Type of medication
Mechanism of action
Main indication
Positive effects
Registration
Initiation
FBC
Investigations
Side effects
(& management of same)
Monitoring
Lifestyle considerations
Response rate
Patient questions
Global mark – based on:
OSCE 7 – Explain clozapine management to a patient
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
 Candidate rapport & empathy 0 1 2
 Name & role provided 0 1 2
 Purpose of the interview 0 1 2
 Consent for the interview 0 1 2
 Asks about patient’s existing knowledge of clozapine 0 1 2
 Atypical antipsychotic (second generation antipsychotic) 0 1 2
 Blocks dopamine & serotonin in brain  reduces levels of dopamine & serotonin 0 1 2
 Treatment resistant schizophrenia 0 1 2
 Reduces suicidality
 Acts on both positive & negative symptoms
 Less extrapyramidal side effects 0 1 2
 Reduced periods of hospitalisation
 Improved general functioning
 Registration with CPMS 0 1 2
 Usually commenced as an inpatient 0 1 2
 Dose titrated up slowly
 FBC monitoring & frequency 0 1 2
 Baseline physical examination & vital signs (blood pressure, pulse, temperature, respiratory rate)
 Baseline investigations (including FBC, LFT, RFT, fasting glucose, fasting cholesterol & lipids, weight & BMI, ECG) 0 1 2
 Plasma level monitoring
 Agranulocytosis (incidence 0.8%) or neutropenia (incidence 3%)
 Sedation
 Weight gain
 Constipation
 Hypersalivation 0 1 2
 Hypotension (or hypertension)
 Tachycardia
 Nausea
 Fever
 Seizures
 Clozapine clinic 0 1 2
 MDT input (with examples) 0 1 2
 Changes in cigarette smoking & caffeine intake can affect clozapine metabolism  discuss any changes with psych so that 0 1 2
monitoring & dose adjustments can be made safely
 Response in 30-60% of people with treatment resistant schizophrenia
 Compliance important 0 1 2
 Clozapine augmentation
 Asks the patient if they have any questions 0 1 2
 Interview style, AND
 Attitude, AND 0 1 2
 Competence, AND
 Performance

Total mark: Examiner’s comments:

59
 Explain clozapine management to a patient – questions to ask and areas to cover

Introduction
 “Good afternoon. Are you Lucy Jacobs?”
 “Lucy, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital. I have been asked by my
consultant to talk with you about clozapine. Would it be okay with you if we spoke for a while?”

Patient’s existing knowledge

 “Have you ever heard of clozapine or do you know anything about this medication?”

Type of medication
 “Clozapine is a second generation or atypical oral antipsychotic medication”.
 “Antipsychotic medications are broadly divided into first generation or typical antipsychotics, e.g. haloperidol; and second
generation or atypical antipsychotics e.g. olanzapine, quetiapine, clozapine”.
 “Atypical antipsychotics are usually prescribed to treat schizophrenia”.

Mechanism of action
 “In people with schizophrenia the level of some brain chemicals can be increased, e.g. dopamine and serotonin. The increased
level of these brain chemicals is thought to produce the symptoms associated with the condition such as disturbances in thinking,
emotions and behaviour”.
 “Clozapine acts to decrease the raised levels of dopamine and serotonin in the brain which can result in an effective treatment for
the disturbances in thinking, emotions and behaviour of schizophrenia”.

Main indication
 “The main indication for clozapine is treatment resistant schizophrenia. That means schizophrenia which has not responded
adequately to treatment despite the use of adequate doses of at least two different antipsychotic medications, at least one of which
was an atypical medication other than clozapine”.

Positive effects
 “Clozapine reduces suicidality, hostility, aggression and both positive and negative symptoms”.
 “Positive symptoms include delusions and hallucinations. A hallucination is a false perception in the absence of a real external
stimulus. Hallucinations can occur in each of the five senses of sight, hearing, smell, taste and touch, e.g. a person experiencing
an auditory hallucination hears a voice or voices when nobody else is around. A delusion is a fixed, false, unshakeable belief held
in the face of evidence to the contrary, that is out of keeping with an individual’s social and cultural background, e.g. someone
may believe that they are being harassed, persecuted or conspired against when nobody is in fact harassing, persecuting or
conspiring against the person at all”.
 “Negative symptoms include memory and concentration problems, unusual behaviour and ideas, disturbed communication,
social withdrawal and reduced interest in daily activities“.
 “Clozapine also reduces periods of psychiatric inpatient hospitalisation and results in improved general function of the person
taking this medication”.

Registration
 “Before someone is prescribed clozapine they must be registered with an approved monitoring system such as the Clozapine
Patient Monitoring Service (CPMS). Each patient prescribed clozapine receives a unique, identifying CPMS number”.

Initiation
 “Initiation of clozapine is done either as an inpatient or where appropriate facilities exist for monitoring (e.g. at a day
hospital) but usually as an inpatient”.
 “A normal white cell count must precede treatment initiation”.
 “Full blood counts must be repeated and results sent to CPMS at weekly intervals for 18 weeks and then fortnightly until one
year. Blood monitoring continues monthly after one year of treatment”.
 “The dose of clozapine should be titrated up slowly”.
 “If the patient has not received clozapine for 48 hours or longer, clozapine should be restarted at the starting dose and re-titrated
upwards”.

Investigations
 “Before someone starts on clozapine they usually have a full physical examination and their vital signs are measured (e.g. blood
pressure, pulse, temperature and breathing rate)”.
 “Baseline investigations before starting clozapine include blood tests (full blood count, liver function tests, kidney function tests,
fasting cholesterol, lipids and glucose level), ECG or heart tracing, chest x ray and weight”.
 “Blood levels of clozapine are measured during treatment in order to determine the correct dose of clozapine that the person
should be taking”.

60
Side effects
 “Possible side effects of clozapine include a reduction in white blood cells. The risk of this occurring is reduced by means of the
regular blood monitoring”.
 “Other main side effects include sedation, weight gain, constipation, increased amount of saliva in the month, increased or
decreased blood pressure, increased heart rate, nausea, fever and seizures”.
 “If side effects occur they can often by managed accordingly. For example, a reduction in the morning dose of clozapine can
reduce sedation. Diet and exercise can manage weight gain. A high fibre diet and possibly laxatives can manage constipation.
Kwells or travel sickness tablets can reduce the increased level of saliva. Carrying a cloth to absorb the saliva and using an extra
pillow at night are other useful methods of managing increased saliva levels. Reducing the dose and/or slowing down the rate of
clozapine increase can often manage increased or decreased blood pressure and increased heart rate. Standing up slowly can also
be useful with reduced blood pressure”.

Monitoring
 “Someone taking clozapine usually attends the Clozapine Clinic here in the hospital. It is at the Clozapine Clinic that a nurse
takes their blood at weekly intervals for 18 weeks and then fortnightly until one year. Blood monitoring continues monthly after
one year of treatment. Results of the full blood counts are faxed by the Clozapine Clinic to the Clozapine Patient Monitoring
Service (CPMS)”.
 “The management of schizophrenia involves a multidisciplinary team approach with input from different mental health
disciplines. For example, the consultant psychiatrist responsible for the care of the patient and their junior doctors (psychiatry
registrars) monitor the mental state of the patient at regular intervals as an inpatient if the person is admitted to a psychiatric ward
and on an outpatient basis at the Clozapine Clinic. They discuss with the patient about how they are feeling at that point in time
and during the days, weeks or months prior to assessment. The psychiatrist is responsible for prescribing medication and
monitoring the patient’s progress on that medication. Ward nursing staff monitor the progress of patients admitted to psychiatric
wards. A community psychiatric nurse (CPN) monitors the progress of outpatients. A CPN meets up with patients in an
outpatient facility or sometimes in the home of the patient. A social worker can assist patients who are homeless or have
difficulty in accessing suitable accommodation. Social workers also organise and manage packages of support to enable people to
lead the fullest lives possible. Social workers assist people in poverty to improve their financial position, informing them about
their entitlements and helping them to access training, work opportunities and benefits. The role of the occupational
therapist (OT) is to help patients improve or maintain skills for day to day activities and well-being. OTs work with individuals to
help them maintain or achieve independence in their activities of daily living (e.g. buying food for oneself and preparation of
meals). A psychologist assists a person in reduce their psychological distress, as well as in enhancing and promoting
psychological wellbeing”.

Lifestyle considerations
 “Changes in cigarette smoking and caffeine intake can affect clozapine metabolism. It is therefore important to discuss any
changes in your cigarette smoking and caffeine intake with your psychiatrist so that appropriate monitoring and clozapine dose
adjustments can be made safely”.
 “If you stop smoking while on clozapine the level of clozapine in your body can nearly double which could make you feel unwell.
You should let your psychiatrist know if you are planning on giving up smoking, reducing smoking or have stopped smoking”.

Response rate
 “Response to clozapine occurs in 30-60% of people with treatment resistant schizophrenia”.
 “Clozapine augmentation can be used in cases of inadequate response to clozapine. Suggested options for augmenting clozapine
include adding a second antipsychotic medication, e.g. haloperidol, risperidone, aripiprazole, or omega-3-triglycerides”.

Patient questions
 “Do you have any questions?”
NOTE: If the OSCE task is to determine if a patient is suitable for clozapine AND to explain clozapine management to a patient:
 Confirm schizophrenia diagnosis: take a history of symptoms consistent with a diagnosis of schizophrenia – see ICD-10 criteria for schizophrenia, consider
delusions, hallucinations, positive symptoms & negative symptoms. Ask about current psychotic symptoms.
 Confirm treatment resistant schizophrenia: ask about antipsychotic medications tried to date – names of antipsychotics, doses, duration of treatment,
compliance, response to antipsychotics, currently prescribed antipsychotics (the patient should have had an adequate trial of at least two antipsychotics, one of
which was an atypical).
 Consider non-psychotropic medication the patient might be taking: clozapine must not be started concurrently with medication known to have a substantial
potential for causing agranulocytosis (e.g. co-trimoxazole, carbamazepine).
 Consider co-morbid medical conditions where clozapine is contraindicated: ask about medical history – clozapine should not be prescribed in people with a
history of toxic or idiosyncratic granulocytopenia/agranulocytosis, history of clozapine induced agranulocytosis, uncontrolled epilepsy, impaired bone marrow
function, severe renal or cardiac disorders (e.g. myocarditis), circulatory collapse and/or CNS depression, active liver disease associated with nausea, anorexia or
jaundice, progressive liver disease, hepatic failure, paralytic ileus. Patients with rare hereditary problems of galactose intolerance, lapp lactase deficiency or
glucose-galactose malabsorption should not take clozapine.
 Proceed to explain clozapine management to the patient as detailed in OSCE 7.

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OSCE 8

Candidate instructions

Scenario

Barry Matthews is a 54 year old man who has been referred to the psychiatry outpatient clinic by his GP. According to the GP referral
letter, over the past year, Barry has been following his wife when she leaves the house and he has repeatedly accused her of being
unfaithful, which his wife has denied.

TASK: Take a relevant history from Barry, focusing on the GP’s concerns.

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OSCE 8 – Take a history from a morbid jealousy patient

Actor instructions

Background
 You are Barry Matthews, a 54 year old man who has been referred to the psychiatry outpatient clinic by your GP.
 According to the GP referral letter, over the past year, you have been following your wife when she leaves the house and you
have repeatedly accused her of being unfaithful, which your wife has denied.
 The candidate’s task is to take a relevant history from you, focusing on the GP’s concerns.

Interaction with the candidate

 You are a somewhat reluctant historian.
 If the candidate mentions the content of the GP referral letter, you become annoyed and irritable with the candidate, saying “I am
not mad. There is nothing wrong with me. This is a waste of time, me coming here”.
 You are intermittently irritable with the candidate during their assessment of you.

History of presenting difficulty

 Five years ago you married your wife, Caroline, a 32 year old full-time zookeeper in Dublin Zoo.
 You dated Caroline for roughly one year prior to your marriage.
 Shortly after your marriage, you noticed that Caroline was flirting a lot with other men and “giving them the eye”. This upset you
greatly. You confronted Caroline about her behaviour but she denied she was flirting with anyone.
 Two years ago you noticed a strange red car parked outside your house on a number of occasions which you knew was evidence
Caroline was being sexually unfaithful.
 You have seen a man’s face in the clouds. The face strongly resembled your neighbour David. You believe this was evidence that
Caroline has been having an extramarital affair with David.
 You are 100% certain that Caroline has been having an affair.
 You have confronted both Caroline and David about their affair. Both individuals have insisted they are friends and that they
have never been romantically involved. You do not believe these assertions.
 Over the past year, you have been following your wife when she leaves the house. You do not think that your wife is aware that
you have been following her.
 You have seen your wife talking to one of the male zookeepers in a manner which you consider inappropriate for a married
woman (e.g. “giggling like a schoolgirl” and “batting her eyelashes”).
 You regularly check your wife’s worn underwear in the laundry basket, looking for semen stains.
 You regularly check your wife’s mobile phone text messages in an attempt to “intercept” texts from someone with whom she has
been having an affair. Similarly, you scrutinise any post sent to your wife.
 Last week you got your wife to perform a home-made lie detector test. You shone a bright light in your wife’s eyes while you
questioned her regarding her infidelity. You could see beads of sweat appearing on her forehead. Her palms were sweaty and she
was trembling. These were all signs that she had indeed been unfaithful. Your wife denied she had been unfaithful but you saw
the physical evidence for yourself during this home-made lie detector test.
 You became very annoyed when your wife failed the home-made lie detector test. You grabbed her by her hair and pulled her to
the ground. You punched her four or five times in the chest and shoulder. This was the first time you had physically assaulted
your wife. You believe that she “deserved what she got” and that “she had it coming to her” for having been unfaithful to you.
 You have a two year old son (Derek) with your wife. You have started to think that Derek might not be your son. You believe
that Derek strongly resembles your neighbour David. This has upset you greatly. You have confronted Caroline about your
suspicions. She has said that you are definitely Derek’s father and that she has never been sexually unfaithful to you. However,
you do not believe Caroline on either account.
 You believe that your marriage is a “sham” and that Caroline has been “playing (you) for a fool”.
 You do not have any ideas, thoughts or plans to harm yourself.
 You have considered giving David “a good hiding” to teach him a lesson for making a fool out of you. You have never harmed
David but you cannot guarantee 100% that you will not give him “a good hiding” at some point. If you are asked by the candidate
as to what you mean by “a good hiding”, you become very annoyed and irritable and decline to explain what you mean.
 You do not have any current plans to harm anyone else (e.g. your child).
 You do not now, and never have, felt “down” in yourself. You feel annoyed and frustrated with your situation.
 You sleep well at night.
 Your appetite and concentration are good.
 You do not now, and never have, heard “voices” in your head.
 You do not believe that you have any special powers or special mission.
 You do not believe that thoughts are being put into your head or being taken out of your head.
 You do not believe that anyone can read your thoughts.
 You do not believe that anyone is watching you or following you or that anyone wants to physically harm you in any way.
 You do not receive any messages from the television or the radio. You do not believe what is said on the television or the radio
relates to you or your life in any way.
 You do not believe that your movements or actions are outside of your control (you do not believe that anyone or anything makes
you move or act in a certain way).
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 You do not believe you are unwell. You do not believe that you need treatment. You do not believe that you need psychiatric
hospitalisation.

Past psychiatric history

 You have never seen a psychiatrist in the past.
 You have never been an inpatient in a psychiatric hospital.
 You have never been diagnosed with a mental illness in the past, by your GP or any other doctor.
 You have never harmed yourself in the past.

Personal history
 You were working as a bank clerk for 25 years, up until the age of 50 years when you retired on health grounds. You suffered a
heart attack which prompted your retirement.
 You had two serious relationships prior to meeting your wife. These relationships lasted for six years and eight years
respectively. You suspect that both of these women had been on cheating on you. These relationships ended when the women left
you. One woman moved to the USA and the other to the UK, after your relationship ended. If the candidate asks whether you
were following either of these women or checking up on them in any way during your time in these relationships, you become
angry and irritable, and refuse to answer the question.
 Five years ago you married your wife, Caroline, a 32 year old full-time zookeeper in Dublin Zoo.
 You dated Caroline for roughly one year prior to your marriage.
 You have a two year old son (Derek) with your wife. You do not have any other children.
 You do not have any friends.

Alcohol and substance misuse history

 For the last number of years you have been drinking alcohol on an almost daily basis.
 The amount of alcohol you consume has increased over time.
 For the past year you have been consuming one bottle of red wine daily, in the evenings at home on your own.
 You do not believe that you consume a large amount of alcohol.
 You drink alcohol to cope with stress you have been put under with your wife’s infidelity.
 You most recently consumed alcohol (one bottle of red wine) last night.
 You have a craving for alcohol, feel a compulsion to drink alcohol and feel “shaky” and sweaty the next morning, after having
consumed alcohol the previous evening.
 You have never taken illicit substances, head shop products or bought tablets on the streets.
 You have never misused prescription or non-prescription medication.
 You do not smoke cigarettes.

Medical history
 You consider your memory to be good.
 You have mild asthma but do not need to take medication.
 You do not have any other medical problems.
 You do not have a history of head injury.

Family history
 Your parents are deceased. They both died of “old age”.
 You have two older brothers. You have not maintained contact with your brothers. You “drifted apart” over the years. You have
not been seen your brothers in a number of years.
 None of your family have a history of mental illness.
 None of your family have harmed themselves deliberately or tried to end their lives by suicide.

Forensic history
 You have never had any involvement with the Gardai or the criminal justice system.
 You have never attended court and have never been in prison.
 You do not have any charges pending.

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Candidate rapport & empathy
Introduction
Infidelity
Other psychotic symptoms
Considers
Risk
Past psychiatric history
Personal history
Forensic history
Global mark – based on:
Total mark:
OSCE 8 – Take a history from a morbid jealousy patient
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
 Candidate rapport & empathy 0 1 2
 Name & role provided 0 1 2
 Purpose of the interview 0 1 2
 Consent for the interview 0 1 2
 Degree of conviction re wife’s infidelity (overvalued idea vs delusion) 0 1 2
 Stalking 0 1 2
 Checking behaviour 0 1 2
 “Evidence” for infidelity 0 1 2
 Accusations of infidelity 0 1 2
 Duration of belief and progress over time 0 1 2
 Physical assault on wife 0 1 2
 Insight 0 1 2
 Other delusions (e.g. persecutory, grandiose, control or influence) 0 1 2
 Hallucinations 0 1 2
 Thought insertion, withdrawal, broadcasting 0 1 2
 Depression 0 1 2
 Alcohol & illicit substances 0 1 2
 Physical health 0 1 2
 To self 0 1 2
 To others (to wife AND to child AND to perceived love rivals) 0 1 2
 From others 0 1 2
 Past history of psychiatric illness 0 1 2
 Past history of self-harm 0 1 2
 Jealousy in previous relationships 0 1 2
 Forensic history 0 1 2
 Interview style, AND
 Attitude, AND 0 1 2
 Competence, AND
 Performance
Examiner’s comments:
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 Take a history from a morbid jealousy patient – questions to ask and areas to cover

Introduction
 “Good afternoon. Are you Barry Matthews?”
 “Barry, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital. We received a referral from
your GP for you to be seen by us here in the outpatient clinic. I have been asked by my consultant to talk with you. Would it be
okay with you if we spoke for a while?”
 “Can you tell me in your own words why you think your GP might have referred you to be seen in our outpatient clinic?”
 “For how long have you been with your wife?” “How is your relationship with your wife?” “Have you noticed any significant
difficulties in your relationship?” “Can you tell me more about this?”

Infidelity
 “How have you come to the opinion that your wife is having an affair (or having affairs)?”
 “For how long have you thought your wife is having an affair (or having affairs)?”
 “How did you originally start thinking that your wife was having an affair (or having affairs)?”
 “What evidence do you have that your wife is having an affair (or having affairs)?”
 “Are you certain that she is having an affair (or having affairs)?” “Is there any chance that you might be mistaken?”
 “Is there any other explanation apart from her having an affair (or affairs)?”
 “Do you follow your wife when she leaves the house?” “Can you tell me more about this?” “Why do you do follow your wife?”
“When did you start following her?” “How often do you follow her?”
 “Have you followed anyone with whom you think she might be having an affair?” “Can you tell me more about this?”
 “Do you check texts and/or telephone records on your wife’s mobile phone?”
 “Do you monitor her computer usage?” “Can you tell me more about this?”
 “Do you check any of your wife’s clothing or your bed sheets when searching for evidence of affairs?”
 “Have you ever performed a lie detector test on your wife?” “Can you tell me more about this?”
 “Do you know the identity of the person/people with whom you believe your wife is having an affair?” “Who is this person/these
people?”
 “Have you asked your wife if she is having an affair?” “What did she say?”
 “Have you ever confronted the person (or people) with whom you believe your wife is having an affair?” “Can you tell me more
about this?” “What happened?”
 “How does it make you feel when you think of your wife having an affair (or having affairs)?”
 “Have you ever punched, kicked or hit your wife?” “Can you tell me more about this?” “What do you now feel about having
punched/kicked/hit your wife?”
 “Have you ever punched, kicked anyone with whom you believe your wife has been having an affair?” “Can you tell me more
about this?” “What do you now feel about having punched/kicked/hit this person?”
 “Have you imposed any restrictions on your wife such as prevented her from leaving the house?”
 “Do you think that you are currently unwell?” “Do you think you need treatment?”

Other psychotic symptoms

 Delusions
o “Do you think anyone is watching you or following you or out to get you in any way?”
o “Do you receive any messages from the television or the radio?” “Do you ever think what is being said on the television or the
radio is specifically about you or your life?”
o “Do you believe that you have any special powers or a special mission?”
o “Do you ever think that your bodily movements, mood or emotions are being influenced by an outside force and are not under
your own control?”
o “How certain are you about this belief?” “Is there any possibility you might be mistaken?”
 Hallucinations
o “Do you hear any voices when nobody else is around?” Are these voices inside your head or outside your head?” “How
many voices do you hear?” “Are the voices male or female?” “Do you recognise the voices?” “Do the voices speak directly
to you or do they speak about you among themselves?” “Can you give me some examples of what the voices say?” “Do the
voices ever give you commands to do something?” “Do the voices comment on what you are doing as you are doing it?”
o “Have you been seeing anything unusual or anything that other people do not see?” “Can you tell me more about this?”
 Thought insertion, withdrawal, broadcasting
o “Do you ever think that thoughts are being put into your head or taken out of your head?” “Can you tell me about this?”
o “Do you ever think that other people can read your thoughts?”

Considers
 Depression
o Mood
 “How would you describe your mood at the moment?”
 “Have you noticed any changes in your mood?” “What changes have you noticed?”
 “For how long has your mood been affected?”
 “Is your mood low every day or do you have good days and bad days?”

66
  “Is your mood getting better or worse or staying the same over time?”
 “Is there any particular time of the day when your mood is at its lowest?”
 “If you had to rate your mood on a scale between zero and ten in which zero is the worst you have ever felt in your life
and ten is the best you have ever felt, how would you rate your mood right now?” If the person responds by rating their
mood as three out of ten – “when was your mood most recently four out of ten?”
 “Is there anything which improves your mood such as being around family or friends?”
 “Has anyone in your family said anything to you about a change in your mood?”
o Interest/anhedonia
 “What are your hobbies and interests?”
 “Are you still involved in your hobbies and interests as much as you were in the past?”
 “Do you enjoy watching television or listening to music?”
 “How you feel around family and friends?”
 “Do you enjoy spending time with family and friends?”
 “How have you been spending your day lately?”
 “Do you have the same degree of interest and enjoyment in activities now that you had in the past?”
o Energy
 “How would you describe your energy level?”
 “Are you able to complete all of your everyday tasks during the day?”
 “Do you stay awake during the day or have you been taking any naps?” For how long have you been napping during the
day?” “Why do you nap during the day?”
 “Are you feeling more tired than usual during the day?”
o Concentration
 “How is your concentration?”
 “Are you able to follow the main storyline in a film or a television programme?”
 “Do you remember what you read or do you have to read the same paragraph a few times to remember what you read?”
 “Please subtract 7 from 100”. “Subtract 7 again from your answer” (ask for this to be done six times, with the patient
providing their answer on each occasion before they make a further subtraction).
 “Could you please say the months backwards for me?”
 “Please list the days of the week backwards”.
o Self-esteem and self-confidence
 “How would you describe your self-esteem and self-confidence?”
 “Have you noticed any changes in your self-esteem and self-confidence?” “What changes have you noticed?”
o Guilty and worthless
 “Do you believe that you have done anything wrong?”
 “Do you feel guilty about anything in particular at the moment?” “Can you tell me about that?”
 “Are you blaming yourself any more than usual at the moment or do you tend to blame yourself a lot?”
 “Do you believe that you have committed a crime, done something terrible or deserve to be punished?” “Can you tell me
about this?”
o View of the future
 “How do you view the future?”
 “How do you see yourself six months from now?”
 “What would you like to do when you get out of hospital (or when you are feeling better)?”
o Sleep
 “Have you noticed any changes in your sleep?”
 “On average, at what time do you tend to go to bed at night?”
 “How long does it take you to go to sleep?”
 “Do you sleep through the night?” If the patient says they wake up during the night – “How many times would you tend
to wake up during the night?” “How long does it take you to get back to sleep?”
 “At what time do you wake in the morning?”
 “Is there any noise that has been waking you up earlier than usual (or during the night)?”
 “What do you do when you wake in the morning – do you get up out of bed or do you stay on in bed?”
 “Do you stay out of bed during the day?”
 “Do you nap during the day?” “For how long do you nap during the day?”
o Appetite
 “How would you describe your appetite?”
 “Have you noticed any changes in your appetite?” “What changes have you noticed?”
 “What have you eaten today so far?”
 “What did you eat yesterday?”
 “Do you enjoy what you are eating?”
 If the person says they have been eating less than usual – “Can you tell me the reason for this?” “Are you intentionally
trying to lose weight?”
 “Have you noticed any recent changes in your weight?” “What changes have you noticed?” “Over what time span have
you noticed that weight change?”
 “Have you noticed the waistband of your trousers (or skirt) becoming more loose over time?”

67
 Alcohol and illicit substances
o Alcohol
 “How often do you drink alcohol?” “What do you drink?”
 “How much alcohol would you drink on a typical day that you would be drinking?”
 “Has your use of alcohol increased or decreased over time?” “Can you tell me more about this?”
 “Why do you drink alcohol?” “Do you drink alone or with someone else?”
 “What do you think about the amount of alcohol that you are consuming?”
 “Do you think that you need any help in relation to the level of your alcohol intake?”
o Illicit substances
 “Do you take any cannabis, cocaine, heroin, lsd, ecstasy or any other drugs?”
 “How much do you take?”
 “Has your use increased or decreased over time?” “Can you tell me more about this?”
 “Why do you take drugs?” “Do you take drugs alone or with someone else?”
 “What do you think about the amount of drugs that you are taking?” “Do you inject drugs?”
 “Do you think that you need any help in relation to your use of drugs?”
 Physical health
o “How is your physical health?” “Have you been diagnosed with any medical conditions?”
o “Do you have any history of diabetes, epilepsy, cancer or Parkinson’s disease?”
o “Do you have any problems with your memory?”
o “Do you have a history of head injury?”

Risk
 To self
o “Do you have any thoughts of harming yourself?” “Can you tell me more about this?” “Have you thought about what you
might do to harm yourself?” “Have you made any plans to harm yourself?” “Can you tell me more about this?”
o “Do you ever wish you were dead?” “Do you want to harm yourself?” “Why do you want to harm yourself?”
o “Have you ever thought life was not worth living?” “Can you tell me more about this?”
o “Do you think that you actually would harm yourself in any way?” “What do you think you might do?”
 To others
o “Do you have any thoughts of harming someone?” “Can you tell me more about this?” “Have you thought about what you
might do to harm that person (those people)?” “Have you thought about what you might do to harm that person (those
people)?” “Can you tell me more about this?” “Do you think that you actually would harm that person (those people) in any
way?” “What do you think you might do?”
o “Have you ever thought of harming your child?” “Can you tell me more about this?”
o “Have you ever thought of harming your wife?” “Can you tell me more about this?”
o “Do you have any thoughts of harming someone with whom you think your wife might have been having an affair?”

Past psychiatric history

 Psychiatric illness
o “Have you ever been diagnosed with a psychiatric illness?” “What was your diagnosis?” “Who diagnosed you - was it GP or
a psychiatrist?” “Have you been prescribed medication in the past for a psychiatric illness?” “What medication were you
prescribed?” “Did you take the medication?”
o “Have you ever been an inpatient in a psychiatric hospital?” “How many inpatient admissions?” “How long on average have
your admissions been for?” “When was your most recent inpatient admission?” “What treatment did you receive in hospital?”
 Self-harm
o “Have you ever harmed yourself in the past?” “What have you done to harm yourself?” “When did you first harm yourself?”
“When did you most recently harm yourself?” “Did you receive medical treatment after harming yourself?” “Why did you
harm yourself?” “What did you think would happen when you harmed yourself?”

Forensic history
 “Have you ever been in trouble with the Gardai?” “Have you ever been in prison?”
 “Have you ever had to attend court?” “Do you have any charges pending?”

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OSCE 9

Candidate instructions

Scenario

Adam Shanley is a 36 year old man with schizophrenia who has come to the psychiatry outpatient department for review. Adam is
prescribed antipsychotic medication.

TASK: Physically examine Adam for extrapyramidal medication side effects.

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OSCE 9 – Extrapyramidal side effects: physical examination

Actor instructions

Background
 You are Adam Shanley, a 36 year old man with schizophrenia who has come to the psychiatry outpatient department for review.
 You are prescribed antipsychotic medication.
 The candidate’s task is to physically examine you for side effects to your antipsychotic medication.

Interaction with the candidate

 You are co-operative with the candidate.
 There should be minimum conversation in this station as it is a physical examination.
 You are currently prescribed haloperidol 10mg twice daily.
 You take your medication daily as prescribed.
 You have been prescribed the same medication for the last few years.
 You cannot remember when your medication, or the dose, was last changed.
 You have not noticed any side effects from your medication.
 You have not experienced any abnormal movements anywhere in your body or a feeling of unpleasant restlessness.

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 OSCE 9 – Extrapyramidal side effects: physical examination
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
Candidate rapport & empathy  Candidate rapport & empathy 0 1 2
Introduction  Name & role provided 0 1 2
 Purpose of the physical examination 0 1 2
 Consent for the physical examination 0 1 2
 Explains what they are going to do 0 1 2
Current medication  Asks name and dose of current medication 0 1 2
 Asks about recent medication changes 0 1 2
 Asks about medication compliance 0 1 2
 Asks for presence of any side effects 0 1 2
Initial observation  Observes patient at rest 0 1 2
 Asks about presence of any abnormal movements (mouth, face, arms, hands, legs, feet) 0 1 2
Akathesia  Asks about akathesia 0 1 2
Mouth  Asks the person if there is anything in their mouth & if they wear dentures 0 1 2
 Looks inside mouth & observes tongue. Twice 0 1 2
 Asks person to protrude tongue. Twice 0 1 2
Tremor or other abnormal  Asks person to extends arms outwards, palms down 0 1 2
movements  Asks person with sit with hands on knees, legs slightly apart, feet on floor 0 1 2
 Asks person to sit with arms unsupported 0 1 2
Finger repetition tapping  Asks person to tap their thumb with each finger as fast as possible for 10-15 seconds. Tests both hands. 0 1 2
Tone  Flexes & extends both forearms 0 1 2
 Flexes & extends at both elbow joints 0 1 2
 Flexes, extends & rotates both wrists 0 1 2
 Moves neck from side to side, chin to chest & head backwards 0 1 2
 Asks person to shrug shoulders & then to drop their shoulders 0 1 2
 Asks person to extend arms out to side & then to drop arms 0 1 2
Glabellar tap  Glabellar tap 0 1 2
Standing  Asks the person to stand up & observes the patient in profile 0 1 2
Gait  Asks the person to walk a few paces 0 1 2
Global mark – based on:  Interview style, AND
 Attitude, AND 0 1 2
 Competence, AND
 Performance

Total mark: Examiner’s comments:

71
 Extrapyramidal side effects: physical examination – questions to ask and areas to cover

Introduction
 “Good afternoon. Are you Adam Shanley?”
 “Adam, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital”.
 “I understand that you are prescribed some medication by our team. Can you tell me the medication you are prescribed?”
 “Do you take your medication as prescribed?”
 “When was the last time that the type or dose of your medication was changed?”
 “Sometimes people can experience side effects from medication. Have you noticed any unpleasant side effects?” “What side
effects have you experienced?”
 “Would it be alright with you if I did a short physical examination on you to check for medication side effects?”

Physical examination
 Initial observation
o Observe the patient at rest for a few seconds.
o “Have you noticed any abnormal movements of your mouth, face, arms, hands, legs or feet?” If yes – “please describe the
movements you have noticed”. “To what extent do these movements currently bother you or interfere with your daily
activities?”
 Akathesia
o “Do you have a feeling of unpleasant inner restlessness?” “Do you feel the need to move your legs due to unpleasant inner
restlessness?”
o Observe for the person’s inability to remain seated or the need to stand up and start pacing.
 Mouth
o “Do you have anything in your mouth at the moment such as gum?” If they have something in their mouth – “I would be
grateful if you would remove that from your mouth for the few minutes that I am examining you”.
o “What is the current condition of your teeth?” “Do you wear dentures?” “Do your teeth or dentures bother you at the
moment?”
o “Please open your mouth”. Observe the tongue at rest inside the person’s mouth for any abnormal movements. Observe the
level of salivation. Do this twice.
o “Please stick out your tongue”. Observe any abnormalities of tongue movement. Do this twice.
 Tremor or other abnormal movements
o “Please stretch both of your arms out in front of you, palms down”. Observe trunk, legs and mouth.
o “Please sit on the chair with your hands on your knees, your legs slightly apart and your feet flat on the floor”. Observe the
whole body for movements while the person is in this position.
o “Please sit on the chair with your hands hanging unsupported”. If male, between his legs. If female and wearing a dress,
hanging over her knees. Observe hands and other body areas.
 Finger repetition tapping
o “Please tap your thumb with each of your fingers as quickly as possible for 10 to 15 seconds, first with our right hand and
then with your left hand”. Observe facial, hand and leg movements. Normally one would be able to tap 40-50 times in 15
seconds.
 Tone
o “Please relax your arms as much as possible. I am going to move your arms and your wrist”. Take the person’s arm with one
of your hands and clasp their elbow with your other hand. Flex and extend the person’s left and right forearm, one at a time.
Flex and extend the person’s elbow joint. Flex, extend and rotate the left and right wrist, one at a time. Distract the person by
asking them to tap their thigh with their hand on the side that you are not examining.
o “Please relax your head and neck. I am going to move your head”. Stand behind the patient. Move their head slowly from side
to side. Move their chin to their chest and their head backwards.
o “Please shrug your shoulders”. “Now let your shoulders drop”. Observe the speed of shoulder dropping.
o “Please stretch your arms out to both sides”. “Now let them drop”. Observe the speed of arm dropping.
 Glabellar tap
o “I am going to tap your forehead, at the base of your nose. Try not to blink”. Normal glabellar tap response is 0-5 blinks, > 21
is the maximum on the Simpson-Angus Extrapyramidal Side Effect Scale.
 Standing
o “Please stand up”. Observe all body areas, hips included. Observe the person in profile for truncal unsteadiness and/or
abnormal movements.
 Gait
o “Please walk a few paces, turn and walk back to the chair”. Do this twice. Observe hands and gait. Look for reduced swinging
of arms, slow gait, shuffling gait.

72
OSCE 10

Candidate instructions

Scenario

Betsy Tracy is a 32 year old lady who is an inpatient on the psychiatry ward. Betsy was admitted three weeks ago with an acute
psychotic episode. She was successfully treated with haloperidol. Her mental state has now returned to baseline. Betsy is ready for
discharge. She is concerned about the possibility of developing Parkinson’s disease with continued use of haloperidol. She has an
uncle with Parkinson’s disease.

TASK: Explain extrapyramidal side effects and their management to Betsy. Do NOT take a history.

73
OSCE 10 – Explain extrapyramidal side effects to a patient

Actor instructions

Background
 You are Betsy Tracy, a 32 year old lady who is an inpatient on the psychiatry ward.
 You were admitted three weeks ago with an acute psychotic episode.
 You have been successfully treated with haloperidol (an antipsychotic medication).
 Your mental state has now returned to baseline.
 You are ready for discharge.
 You are concerned about the possibility of developing Parkinson’s disease with continued use of haloperidol.
 You have an uncle with Parkinson’s disease.
 The candidate’s task is to explain to you, movement side effects (known as extrapyramidal side effects) of antipsychotic
medication and their management.
 The candidate has been asked not to take a history from you.

Interaction with the candidate

 You are polite and co-operative with the candidate.
 You are worried that you might develop Parkinson’s disease with continued use of haloperidol. You have heard that this is a side
effect of haloperidol.
 You are unsure if you should continue to take haloperidol.
 You do not have any prior knowledge of extrapyramidal side effects.
 Allow the candidate to speak and to discuss this topic with you.
 Do not ask the following questions unless this content is not covered by the candidate -
o Might I develop Parkinson’s disease if I continue to take haloperidol?
o How are movement side effects treated?
o Is there anything else that I should know?

74
 OSCE 10 – Explain extrapyramidal side effects to a patient
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
Candidate rapport & empathy  Candidate rapport & empathy 0 1 2
Introduction  Name & role provided 0 1 2
 Purpose for the interview 0 1 2
 Consent for the interview 0 1 2
Parkinson’s disease vs  Distinguish Parkinson’s disease from parkinsonism 0 1 2
parkinsonism
Types of EPSEs  Dystonia
o Sustained involuntary muscular spasms which are often painful
o E.g. neck twisting, back arching, forcible closure of eyelids, upwards deviation of eyes 0 1 2
o Prevalence: approx 10%
o More common in young males, neuroleptic naïve, use of high potency agents (e.g. haloperidol)
 Parkinsonism
o Tremor, rigidity, bradykinesia 0 1 2
o Prevalence: approx 20%
o More common in elderly females, those with pre-existing neurological damage (e.g. head injury, stroke)
 Akathisia
o Feeling of unpleasant inner restlessness & a compelling need to be in constant motion
o E.g. rocking while standing/sitting, lifting feet, crossing/uncrossing legs while sitting 0 1 2
o Prevalence: approx 25%
 Tardive dyskinesia
o Repetitive, involuntary, purposeless movements
o E.g. grimacing, tongue protrusion, lip smacking, lip puckering, rapid eye blinking, rapid movement of extremities 0 1 2
o Prevalence: approx 5%
o More common in elderly females, presence of organic brain illness, alcohol dependency, affective illness, diabetes &
intellectual disability, those who had acute EPSEs early in treatment, concomitant anticholinergic treatment
Management of EPSEs  Dystonia
o Withdraw offending agent 0 1 2
o Reduce the dose
o Anticholinergic (e.g. procyclidine, biperiden)
 Parkinsonism
o Withdraw offending agent
o Reduce the dose 0 1 2
o Change to an atypical
o Anticholinergic (e.g. procyclidine, biperiden)
 Akathisia
o Withdraw offending agent
o Reduce the dose 0 1 2
o Change to an atypical
o Propanolol or clonazepam or cyproheptadine (antihistamine) or mirtazapine or trazodone
o Anticholinergics are generally unhelpful
 Tardive dyskinesia
o Withdraw offending agent
o Reduce the dose 0 1 2
o Change to an atypical
o Clozapine
Questions  Asks the patient if they have any questions 0 1 2
Global mark – based on:  Interview style, AND attitude, AND competence, AND performance 0 1 2

Total mark: Examiner’s comments:

75
 Explain extrapyramidal side effects to a patient – questions to ask and areas to cover

Introduction
 “Good afternoon. Are you Betsy Tracy?”
 “Betsy, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital”.
 “I understand you are concerned that you might develop Parkinson’s disease with haloperidol. Is that correct?”
 “Would it be okay with you if I spoke to you about the potential movement side effects of medications such as haloperidol?”

Parkinson’s disease vs parkinsonism

 “Parkinson’s disease is a progressive disorder of the central nervous system that affects movement. It develops gradually,
sometimes starting with a barely noticeable tremor in just one hand. While a tremor may be the most well-known sign of
Parkinson's disease, the disorder also commonly causes stiffness or slowing of movement. Parkinson’s disease cannot be cured.
Medication may improve symptoms for people with this condition”.
 “Parkinsonism is a movement side effect which can occur with mediations such as haloperidol”.
 “Parkinsonism is not the same as Parkinson’s disease”.
 “Tremor, rigidity and slowing of movement can occur in parkinsonism. However, these are medication side effects and are not
permanent for the person”.
 “If the offending medication is withdrawn or the dose is reduced, the parkinsonism side effect resolves”.
 “Alternatively, the offending medication may be changed to a newer or atypical antipsychotic such as risperidone or the person
may be given a medication to counteract the parkinsonian side effect such as procyclidine or biperiden”.

Types of EPSEs
 Parkinsonism
o “Parkinsonism is one of the four types of movement side effects of medications such as haloperidol”.
o “These movement side effects are known as extrapyramidal side effects”.
o “The prevalence of parkinsonism or the number of people affected at any one time is approximately 20%”.
o “Parkinsonism is more common in elderly females and those with pre-existing neurological damage (e.g. head injury,
stroke)”.
 Dystonia
o “Dystonia consists of sustained involuntary muscular spasms which are often painful (e.g. neck twisting to one side, arching
of the back, forcible closure of the eyelids, upward deviation of the eyes)”.
o “The prevalence of dystonia is approximately 10%”.
o “Dystonia is more common in young males, people who are taking antipsychotic medication for the first time and with use of
high potency medication such as haloperidol”.
 Akathisia
o “Akathisia is a movement disorder characterised by a feeling of unpleasant inner restlessness and a compelling need to be in
constant motion (e.g. rocking while sitting or standing, lifting the feet as if marching on the spot, crossing and uncrossing
the legs while sitting)”.
o “People with akathisia are unable to sit or keep still, describe restlessness, fidget, rock from foot to foot and pace”.
o “The prevalence of akathisia is approximately 25%”.
 Tardive dyskinesia
o “Tardive dyskinesia comprises repetitive, involuntary, purposeless movements (e.g. grimacing, tongue protrusion, lip
smacking, puckering of the lips, rapid eye blinking, rapid movement of the arms or legs)”.
o “The prevalence of tardive dyskinesia is approximately 5%”.
o “Tardive dyskinesia is more common in elderly females, in people who have medical brain illness, alcohol dependency,
mood disorder, diabetes, intellectual disability, and in those individuals who experienced acute movement side effects early
in antipsychotic treatment”.

Treatment of EPSEs
 “I have already discussed the treatment for parkinsonism”.
 “The treatment for dystonia involves withdrawing the offending agent, reducing the dose or using a medication to counteract this
side effect (e.g. procyclidine, biperiden)”.
 “The treatment for akathisia involves withdrawing the offending agent, reducing the dose, changing to a newer/atypical
antipsychotic such as risperidone or adding another medication such as an antihistamine”.
 “The treatment for tardive dyskinesia involves withdrawing the offending agent, reducing the dose, changing to a newer/atypical
antipsychotic such as risperidone or using a medication called clozapine which is an atypical antipsychotic medication also used
in treatment resistant schizophrenia”.

Questions
 “Do you have any questions?”

76
CASC 2 Station 1

Candidate instructions

Scenario

Juana Cassara is a 28 year old woman who was brought to the emergency department of your hospital by ambulance following an
overdose. She has been fully medically cleared at this point. You have been asked by the medical team to assess Juana.

TASK: Take a relevant history from Juana, focusing on her presenting difficulties and past psychiatric history AND perform a risk
assessment.

NOTE: This is a linked station. In the station after this you will meet with your consultant to discuss Juana’s case.

77
CASC 2 Station 1 – Take a relevant history from a self-harm patient and perform a risk assessment

Actor instructions

Background
 You are Juana Cassara, a 34 year old woman who was brought to the emergency department of the hospital by ambulance
following an overdose.
 You have been fully medically cleared at this point.
 The candidate has been asked by the medical team to assess you.
 The candidate’s task is to take a relevant history from you, focusing on your presenting difficulties and past psychiatric history
AND perform a risk assessment.

Interaction with the candidate

 You are upset and on the point of tears at intervals throughout the interview.
 You spend the interview staring at the floor in front of you. You do not make eye contact with the candidate.
 Your speech is relatively low but is audible.
 You make short statements in response to the candidate’s questions.

Circumstances surrounding the overdose

 Before the self-harm
o Two weeks ago, your husband of six years informed you that he has been having an affair with another woman for the past
four years. He told you that he is in love with this other woman, that he wants a divorce from you, and that he is leaving you
to be with this other woman.
o You did not know your husband was seeing another woman.
o You have been devastated for the past two weeks since your husband spoke to you about his affair.
o You have been crying a lot and feeling down in yourself.
o Last night at about 11pm, you decided that your life was no longer worth living.
o You went to the medicine cabinet in your house and collected all the tablets you could find which comprised approximately
50 tablets in total, a mixture of your husband’s heart medication, anti-histamine tablets and paracetamol. You are unsure as to
how many tablets of each of these three types of medications were contained within the total of 50 tablets that you found.
o You brought the 50 tablets up to your bedroom, with a bottle of red wine.
o You did not write a suicide note.
o You did not make a will or give away any of your possessions.
 During the self-harm
o You got into bed, took the 50 tablets and consumed approximately half of the bottle of red wine, over the space of
approximately 20 minutes. You did not take any drugs at the time of the overdose.
o You thought that you would die by taking this overdose.
o You were alone in the house at the time. Your husband had left the house. You assumed he had gone to stay with his
girlfriend.
o You were not expecting your husband to return to the house as he had taken his belongings with him when he left the house
that same morning.
o You closed the door of your bedroom but did not lock it.
 After the self-harm
o After taking the overdose, you lay down on your bed to die.
o You did not telephone or text anyone after taking the overdose.
o Your husband returned to the house at about 10am the following morning to obtain his coat which he had forgotten to take
with him the previous day when he left the house.
o Your husband found you in bed, with pill bottles and pill boxes on the floor next to the bed.
o Your husband telephoned an ambulance which brought you to the emergency department.
o You are disappointed that you are not dead.
o You wish that the overdose had killed you.
o You still have thoughts of ending your life. When you leave the emergency department you plan to go to a number of
pharmacies to buy a large quantity of paracetamol so that you can take a more substantial overdose which will kill you this
time.

Presenting symptoms
 Your mood has been low for the past two weeks since your husband of six years informed you that he has been having an affair
with another woman for the past four years. He told you that he is in love with this other woman, that he wants a divorce from
you, and that he is leaving you to be with this other woman.
 You thought that the relationship between you and your husband had been going well.
 Your mood has been low every day over the past two weeks.
 You are unsure if there is a particular time of the day at which your mood is at its lowest. Your mood feels constantly low
throughout the day.
 Nothing helps you feel better.

78
 You cannot identify anything in particular over the past two weeks since your husband spoke to you which has made you feel
worse.
 You have been staying at home for the past week. You have been mostly lying in bed all day in a darkened room.
 You have been crying a lot.
 You have not been interacting with family or friends.
 You have not attended work for the past week.
 You have not been showering or washing yourself or changing your clothes.
 You have been wearing the same nightdress every day for the past week and have not changed into any other clothes during that
time.
 Ordinarily, you would attend work every day and spend time with your husband in the evenings, chatting or watching television.
You have not been spending time with your husband in the evenings over the past week because he has been spending
progressively less time at home with you.
 You have lost interest in watching television over the past two weeks.
 You have not been doing anything over the past two weeks, apart from spending the day at home in bed.
 Your energy level has reduced over the past two weeks. You feel drained of energy and fatigued.
 You are unsure if your concentration and attention level has altered.
 Your self-esteem and self-confidence has reduced. You have a low opinion about yourself. You feel unlovable and undesirable.
You think that there must be something wrong with you for your husband not to love you anymore and to want to be with another
woman.
 You feel guilty, wondering what you could have done differently so that your husband would not have wanted to be with another
woman.
 You still love your husband and want to be with him but you know he does not want you anymore.
 You do not see a future for yourself.
 You still have thoughts of ending your life. When you leave the emergency department you plan to go to a number of pharmacies
to buy a large quantity of paracetamol so that you can take a more substantial overdose which will kill you this time.
 You have been sleeping for most of the day over the past week.
 Your appetite has reduced over the past week. You have not had the interest to prepare food for yourself. You have eaten a bowl
of cereal “here and there”. You have not weighed yourself recently but you might have lost some weight as your nightdress has
become more lose.
 You do not hear any “voices” when nobody else is around.
 You do not see/taste/smell anything unusual.
 You do not believe that anyone or anything is watching you or following you or monitoring you in any way.
 You do not have concerns for your personal safety from anyone or anything.
 You do not believe that anyone or anything might harm you. You do not get any “messages” from the television/radio/written
material (you do not believe what you hear on television/radio or read is about you or your life).
 You do not believe that you are dead or that your skin/any part of your body is rotting.
 You do not believe that you have any special powers or special mission or special abilities.

Past psychiatric history

 You do not have any past history of psychiatric illness or contact with a mental health service.
 You do not have any past history of self-harm.

Family history
 Your parents are alive and well. They are both relatively healthy.
 You have one sibling, an older sister.
 You have a good relationship with your family.
 To the best of your knowledge, nobody in your family has a history of psychiatric illness.
 Nobody in your family have ever harmed themselves or died by suicide.

Past medical and surgical history

 You do not have a history of diabetes, asthma, epilepsy or other significant medical illness.
 You do not have a history of head injury.

Alcohol and substance misuse history

 You do drink alcohol. You are a teetotaller. Prior to consuming the half bottle of red wine with the overdose, you had not drank
alcohol previously.
 You have never taken illicit substances.
 You have never bought tablets on the streets.
 You have never used Head Shop products.
 You have never misused prescription or non-prescription medications.

79
Current medications
 You are not currently prescribed any medication.

Personal history
 You were born in Mexico. Your parents are both Mexican and live in Mexico (as does your sister, your only sibling). You have a
good relationship with your parents and your sister.
 You came to Ireland ten years ago to learn English.
 You have not seen your parents or your sister since you left Mexico ten years ago.
 You have kept in contact with your parents and your sister via email and Skype. You have not sent an email to your family or
engaged in Skype with them over the past two weeks as you have felt so upset. Ordinarily, you would email and Skype your
family two or three times per week.
 You have been working as a receptionist in a GP surgery for the past six years. You have enjoyed your job during this time. You
have not attended work for the past week as you did not feel up to going to work.
 You have been married to your husband Carlos for the past six years. Carlos is from Chile. He has been living in Ireland for the
past seven years. Carlos works in IT.
 You do not have any children.
 You have two good friends (both Mexican) who live relatively close to you. You would usually meet up with them once a week,
for a few hours over the weekend. You would go to one of their homes or they would come to your home and you would talk to
each other. You have not felt up to seeing your friends over the past two weeks. You have not been in telephone (voice or text)
contact with them. You have had your telephone turned off over the past week. You therefore do not know if they have contacted
you by telephone.

80

Candidate rapport & empathy
Introduction
Circumstances of the self-
harm
Presenting symptoms
Past psychiatric history
Alcohol & substance misuse
history
Personal history
Global mark – based on:
Total mark:
CASC 2 Station 1 – Take a relevant history from a self-harm patient and perform a risk assessment
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
 Candidate rapport & empathy 0 1 2
 Name & role provided 0 1 2
 Purpose of the interview 0 1 2
 Consent for the interview 0 1 2
 Before the self-harm
o Psychological stressor (e.g. conversation with husband) 0 1 2
o Mental illness 0 1 2
o Planning (e.g. planned vs impulsive act) 0 1 2
o Suicide note 0 1 2
o Last acts 0 1 2
 During the self-harm
o Quantity of tablets consumed 0 1 2
o Associated use of alcohol/illicit substances 0 1 2
o Expectations of self-harm (e.g. death) & perceived lethality of attempt 0 1 2
o Alone 0 1 2
o Intervention unlikely 0 1 2
o Precautions against discovery 0 1 2
 After the self-harm
o Help seeking behaviour 0 1 2
o Desire to undertake further self-harm 0 1 2
o Regret to be alive vs regret engaged in self-harm 0 1 2
 Duration 0 1 2
 Depressed mood 0 1 2
 Loss of interest & enjoyment 0 1 2
 Decreased energy & fatigability 0 1 2
 Tiredness after slight effort 0 1 2
 Decreased concentration & attention 0 1 2
 Decreased self-esteem & self-confidence 0 1 2
 Bleak & pessimistic views of the future 0 1 2
 Guilt & unworthiness 0 1 2
 Ideas of self-harm or suicide 0 1 2
 Disturbed sleep 0 1 2
 Decreased appetite 0 1 2
 Psychotic symptoms 0 1 2
 Past history of psychiatric illness 0 1 2
 Past history of self-harm 0 1 2
 Alcohol use 0 1 2
 Illicit substance use 0 1 2
 Work & relationships 0 1 2
 Interview style, AND
 Attitude, AND 0 1 2
 Competence, AND
 Performance
Examiner’s comments:
81
Take a relevant history from a self-harm patient and perform a risk assessment – questions to ask and
areas to cover

Introduction
 “Good afternoon. Are you Juana Cassara?”
 “Juana, my name is Dr Alice Williams. I am an intern on the psychiatry team here in the hospital. The medical team have cleared
you medically and have asked me to see you”.
 “Would it be okay with you if we spoke for a while?”
 “Can you tell me why you were brought here to the emergency department?”

Circumstances of the self-harm

 Before the self-harm
o “Have you experienced any recent stressors such as an argument with someone close to you, a death of a friend or relative, or
the loss of a job?” “Can you tell me more about what happened?”
o “How have you been feeling since that stressful event?”
o “Did you plan to take the overdose or was it a spur of the moment decision?” If the person says they planned the overdose -
“for how long were you planning to take the overdose?”
o “Did you write a suicide note?”
o “Did you undertake any last acts before the overdose such as giving away money or any of your possessions?”
 During the self-harm
o “How did you harm yourself?”
o “How many tablets did you take in the overdose?” “Were they all of the tablets that you had in your possession at the time?”
o “What tablets did you take?”
o “Whose tablets were these that you took?” “Were these prescription medications?”
o “Did you drink any alcohol with the overdose?” “How much alcohol did you take?” “When was your last drink prior to taking
the overdose?”
o “Did you take any drugs with the overdose?”
o “What did you think would happen by taking the tablets?”
o “Where were you when you took the tablets?”
o “Was there anyone else in the house at the time you took the tablets?” “Who else was in the house?” “Where were they when
you took the tablets?”
o “When did you think that your husband might return to the house?”
o “Did you lock the door of your bedroom (if overdose was taken in the bedroom)?”
o “Did you close the curtains?”
o “Did you stop the post before you took the overdose?”
 After the self-harm
o “What did you do after you took the tablets?” “Did you telephone or text anyone or did you lie down on your bed and not
contact anyone?”
o “What is your opinion now about having taken the tablets?” “Was it a good decision to have made or was it a bad decision?”
o “Are you pleased to be alive?” “Are you glad that the overdose did not kill you?”
o “Do you have any thoughts at the moment of harming yourself?” “Can you tell me more about this?” “Have you made any
plans to harm yourself?”

Presenting symptoms
 Mood
o How would you describe your mood at the moment?”
o “Have you noticed any changes in your mood?” “What changes have you noticed?”
o “For how long has your mood been affected?”
o “Is your mood low every day or do you have good days and bad days?”
o “Is your mood getting better or worse or staying the same over time?”
o “Is there any particular time of the day when your mood is at its lowest?”
o “If you had to rate your mood on a scale between zero and ten in which zero is the worst you have ever felt in your life and
ten is the best you have ever felt, how would you rate your mood right now?” If the person responds by rating their mood as
three out of ten – “when was your mood most recently four out of ten?”
o “Is there anything which improves your mood such as being around family or friends?”
o “Has anyone in your family said anything to you about a change in your mood?”
 Interest and enjoyment
o “What are your hobbies and interests?”
o “Are you still involved in your hobbies and interests as much as you were in the past?”
o “Do you enjoy watching television or listening to music?”
o “How you feel around family and friends?”
o “Do you enjoy spending time with family and friends?”
o “How have you been spending your day lately?”
o “Do you have the same degree of interest and enjoyment in activities now that you had in the past?”

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 Energy
o “How would you describe your energy level?”
o “Are you able to complete all of your everyday tasks during the day?”
o “Do you stay awake during the day or have you been taking any naps?” For how long have you been napping during the
day?” “Why do you nap during the day?”
o “Are you feeling more tired than usual during the day?”
 Concentration
o “How is your concentration?”
o “Are you able to follow the main storyline in a film or a television programme?”
o “Do you remember what you read or do you have to read the same paragraph a few times in order to remember what you
read?”
o “Please subtract 7 from 100”. “Subtract 7 again from your answer” (ask for this to be done six times, with the patient
providing their answer on each occasion before they make a further subtraction).
o “Could you please say the months backwards for me?”
o “Please list the days of the week backwards”.
 Self-esteem and self-confidence
o “How would you describe your self-esteem and self-confidence?”
o “Have you noticed any changes in your self-esteem and self-confidence?” “What changes have you noticed?”
 Guilty and worthless
o “Do you believe that you have done anything wrong?”
o “Do you feel guilty about anything in particular at the moment?” “Can you tell me about that?”
o “Are you blaming yourself any more than usual at the moment or do you tend to blame yourself a lot?”
o “Do you believe that you have committed a crime, done something terrible or deserve to be punished?” “Can you tell me
about this?”
 View of the future
o “How do you view the future?”
o “How do you see yourself six months from now?”
o “What would you like to do when you get out of hospital (or when you are feeling better)?”
 Ideas of self-harm or suicide
o “Do you have any thoughts at the moment of harming yourself?” “Can you tell me more about this?” “Have you made any
plans to harm yourself?”
 Sleep
o “Have you noticed any changes in your sleep?”
o “On average, at what time do you tend to go to bed at night?”
o “How long does it take you to go to sleep?”
o “Do you sleep through the night?” If the patient says they wake up during the night – “How many times would you tend to
wake up during the night?” “How long does it take you to get back to sleep?”
o “At what time do you wake in the morning?”
o “Is there any noise that has been waking you up earlier than usual (or during the night)?”
o “What do you do when you wake in the morning – do you get up out of bed or do you stay on in bed?”
o “Do you stay out of bed during the day?”
o “Do you nap during the day?” “For how long do you nap during the day?”
 Appetite
o “How would you describe your appetite?”
o “Have you noticed any changes in your appetite?” “What changes have you noticed?”
o “What have you eaten today so far?”
o “What did you eat yesterday?”
o “Do you enjoy what you are eating?”
o If the person says they have been eating less than usual – “Can you tell me the reason for this?” “Are you intentionally trying
to lose weight?”
o “Have you noticed any recent changes in your weight?” “What changes have you noticed?” “Over what time span have you
noticed that weight change?”
o “Have you noticed the waistband of your trousers (or skirt) becoming more loose over time?”
 Psychosis
o Hallucinations
 “Do you hear any voices when nobody else is around?” Are these voices inside your head or outside your head?” “How
many voices do you hear?” “Are the voices male or female?” “Do you recognise the voices?” “Do the voices speak
directly to you or do they speak about you among themselves?” “Can you give me some examples of what the voices
say?” “Do the voices ever give you commands to do something?” “Do the voices ever comment on what you are doing as
you are doing it?”
 “Have you been seeing anything unusual or anything that other people do not see?” “Can you tell me more about this?”
o Delusions
 “Do you think anyone is watching you or following you or out to get you in any way?”
 “Do you receive any messages from the television or the radio?” “Do you ever think what is being said on the television or
the radio is specifically about you or your life?”

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  “Do you think that you have done anything seriously wrong such as committed a crime and/or deserve to be punished?”
 “Do you believe that any part of your body is rotting or dead?”
 “How certain are you about this belief?” “Is there any possibility you might be mistaken?”

Past psychiatric history

 Psychiatric illness
o “Have you suffered with low mood in the past?” “How times?”
o “Have you ever experienced the opposite difficulty to what you are now having whereby you felt much happier than usual,
had lots of energy and had more thoughts than usual coming into your head?” “How long did this last for?” “Did you see a
doctor?” “What treatment did you receive?” “How many times has this happened to you?”
o “Have you ever been diagnosed with a psychiatric illness?” “What was your diagnosis?” “Who diagnosed you - was it GP or a
psychiatrist?” “Have you been prescribed medication in the past for a psychiatric illness?” “What medication were you
prescribed?” “Did you take the medication?”
o “Have you ever been an inpatient in a psychiatric hospital?” “How many inpatient admissions have you had?” “How long on
average have your admissions been for?” “When was your most recent inpatient admission?” “What treatment did you receive
in hospital?”
 Self-harm
o “Have you ever harmed yourself in the past?” “What have you done to harm yourself?” “When did you first harm yourself?”
“When did you most recently harm yourself?” “Did you receive medical treatment after harming yourself?” “Why did you
harm yourself?” “What did you think would happen when you harmed yourself?”

Alcohol and substance misuse history

 Alcohol and illicit substances
o Alcohol
 “How often do you drink alcohol?”
 “What do you drink?”
 “How much alcohol would you drink on a typical day that you would be drinking?”
 “Has your use of alcohol increased or decreased over time?” “Can you tell me more about this?”
 “Why do you drink alcohol?”
 “Do you drink alone or with someone else?”
 “What do you think about the amount of alcohol that you are consuming?”
 “Do you think that you need any help in relation to the level of your alcohol intake?”
o Illicit substances
 “Do you take any cannabis, cocaine, heroin, lsd, ecstasy or any other drugs?”
 “How much do you take?”
 “Has your use increased or decreased over time?” “Can you tell me more about this?”
 “Why do you take drugs?”
 “Do you take drugs alone or with someone else?”
 “What do you think about the amount of drugs that you are taking?”
 “Do you inject drugs?”
 “Do you think that you need any help in relation to your use of drugs?”

Personal history
 Work attendance and performance
o “Are you currently employed?” “What is your job?” “For how long have you been working in this job?”
o “Have you been attending work every day?” “Have you missed any days at work?” “Have you needed to take any time off
work lately?” “Why did not attend work on those days?”
o “When were you most recently at work?”
o “Are you arriving on time for work?”
o “How is your productivity at work?” “Are you able to achieve what you need to achieve at work?” “Has anyone at work
commented on a change in your productivity?” “Can you tell me more about this?”
 Relationships (both romantic and friends)
o “How would you have described your relationship with your husband?” “Are there any significant difficulties in the
relationship?”
o “Do you have friends?” “How many friends do you have?” “How often do you meet up with friends?” “Are you spending as
much time with your friends as you were when you were feeling better?” “What do you do when you meet up with friends?”
“Do you enjoy spending time with your friends?”

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CASC 2 Station 2

Candidate instructions

Scenario

Your consultant is waiting to discuss Juana with you.

TASK: Present Juana’s history to your on-call consultant, focusing on Juana presenting difficulties and past psychiatric history AND
risk assessment. Your consultant will ask you some questions relating to this case.

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CASC 2 Station 2 – Present a history of self-harm and a risk assessment to a consultant

Introduction
 You are Dr Stacy Chambers, the on call consultant psychiatrist.
 The candidate has assessed Juana Cassara in the previous station (the first part of this linked station).
 Juana is a 34 year old woman who was brought to the emergency department of the hospital by ambulance following an
overdose.
 She has been fully medically cleared.
 The candidate was asked by the medical team to assess Juana.
 In the first part of this linked station the candidate’s task was to take a relevant history from Juana, focusing on her presenting
difficulties and past psychiatric history AND perform a risk assessment.
 The candidate’s task in this station is to present Juana’s history to you, the on call consultant, focusing on her presenting
difficulties and past psychiatric history AND risk assessment. The candidate was informed that you will ask them some questions
relating to this case.

Interaction with the candidate

 Allow the candidate to talk and provide you with information.
 Only ask the following questions if this material is not discussed by the candidate -
o Can you please present the case that you have just seen?
o What do we know about risk in this case?
o What was the mental state examination?
o What is your differential diagnosis?
o How would you manage this case?
o Does Juana need to be admitted to hospital? Why do you think she should (or should not) be admitted to hospital?

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Candidate rapport & empathy
Introduction
Circumstances of the self-
harm
Presenting symptoms
Past psychiatric history
Alcohol & substance misuse
history
Personal history
Mental state examination
Formulation
Differential diagnosis
Investigations
Management
Global mark – based on:
Total mark:
CASC 2 Station 2 – Present a history of self-harm and a risk assessment to a consultant
Component Unsatisfactory Satisfactory Excellent
(component not (component undertaken (component
undertaken) but not fully) undertaken fully)
 Candidate rapport & empathy 0 1 2
 Name & role provided 0 1 2
 Purpose of the interview 0 1 2
 Consent for the interview 0 1 2
 Before the self-harm
o Psychological stressor (e.g. conversation with husband) 0 1 2
o Mental illness 0 1 2
o Planning (e.g. planned vs impulsive act) 0 1 2
o Suicide note 0 1 2
o Last acts 0 1 2
 During the self-harm
o Quantity of tablets consumed 0 1 2
o Associated use of alcohol/illicit substances 0 1 2
o Expectations of self-harm (e.g. death) & perceived lethality of attempt 0 1 2
o Alone 0 1 2
o Intervention unlikely 0 1 2
o Precautions against discovery 0 1 2
 After the self-harm
o Help seeking behaviour 0 1 2
o Desire to undertake further self-harm 0 1 2
o Regret to be alive vs regret engaged in self-harm 0 1 2
 Duration 0 1 2
 Depressed mood 0 1 2
 Loss of interest & enjoyment 0 1 2
 Decreased energy & fatigability 0 1 2
 Tiredness after slight effort 0 1 2
 Decreased concentration & attention 0 1 2
 Decreased self-esteem & self-confidence 0 1 2
 Bleak & pessimistic views of the future 0 1 2
 Guilt & unworthiness 0 1 2
 Ideas of self-harm or suicide 0 1 2
 Disturbed sleep 0 1 2
 Decreased appetite 0 1 2
 Psychotic symptoms 0 1 2
 Past history of psychiatric illness 0 1 2
 Past history of self-harm 0 1 2
 Alcohol use 0 1 2
 Illicit substance use 0 1 2
 Work & relationships 0 1 2
 Provides a mental state examination 0 1 2
 Provides a formulation of the case with relevant predisposing, precipitating & perpetuating factors (bio-psycho-social) 0 1 2
 Provides a differential diagnosis (providing evidence for/against each possibility) 0 1 2
 Discussion of appropriate investigations (biological, psychological, social) 0 1 2
 Discussion of appropriate management (biological, psychological, social) 0 1 2
 Interview style, AND attitude, AND competence, AND performance 0 1 2
Examiner’s comments:
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