Psychiatric Consultation – Psychosis Suspected

Summary: The case involves a young male patient whose mother is concerned about his behavior, although the patient himself does not report any complaints. The scenario focuses on a psychiatric evaluation, specifically considering schizophrenia. The candidate is expected to explore psychiatric symptoms, offer reassurance, and manage time effectively while gathering data and providing management.

Key Points:

• Main topic/system involved: Psychiatric Assessment (Schizophrenia)

  • The patient presents with concerns raised by his mother about changes in behavior.

  • The candidate should explore key symptoms of schizophrenia: hallucinations, delusions, and thought disorders (insertion/withdrawal).

  • Open-ended questions are crucial to encourage the patient to share more about his experiences.

• Communication and rapport:

  • It is important to establish trust early by offering reassurance, including the use of the term "confidentiality."

  • Use empathy and appropriate language to handle the patient's possible resistance or lack of insight.

• History-taking:

  • Explore both psychiatric history and the social context, including recent stressors (job loss, relationship issues).

  • Ask specific questions about hallucinations ("Have you seen or heard things that others can't?") and delusions ("Do you feel like people are trying to harm you?").

  • A risk assessment for self-harm or harm to others must be completed.

• Time management:

  • Focus on covering all key areas within the first four minutes, leaving sufficient time for management.

  • Avoid dwelling on one symptom for too long, and move efficiently from one area to another (e.g., hallucinations, delusions, risk assessment).

    
    

Important Considerations:

• Use of confidentiality: Emphasize that the discussion is confidential, and reassure the patient, especially if they express distrust.

• Risk of self-harm: Always assess for risks of self-harm or harm to others.

• Time awareness: Ensure data gathering ends within four minutes to allow sufficient time for management discussions.

• Involvement of family: The patient's mother's concerns need to be acknowledged as part of the assessment.

  
  

Diagnostic Approach:

1. Data gathering:

   • Introduce yourself, confirm the patient's identity, and briefly acknowledge the mother’s concerns.

   • Open-ended questions to gauge the patient’s thoughts and experiences.

   • Screen for core symptoms of schizophrenia (hallucinations, delusions, thought disorders).

   • Assess mood and risk factors, such as recent stressors, self-harm, or harm to others.

2. Risk assessment:

   • Direct questions about self-harm, harm to others, and psychosocial stressors.

   • Explore the patient's insight into their condition, as this can impact management.

     
     

Management:

1. Diagnosis Communication:

   • Explain that schizophrenia is suspected, but use simple language, focusing on common symptoms of the condition (e.g., "Sometimes when people are stressed, they may hear things others don’t").

   • Normalize the experience, and provide reassurance.

2. Immediate Plan:

   • Discuss a referral to a mental health specialist or Early Intervention in Psychosis service.

   • Offer safety netting by outlining when to seek immediate help (e.g., worsening symptoms or thoughts of self-harm).

3. Further Investigations:

   • Depending on time, discuss potential further investigations (e.g., blood tests) if needed to rule out other causes, but focus on immediate management.

4. Follow-up:

   • Arrange for a follow-up appointment and discuss the importance of ongoing assessment.

     
     

Communication Skills:

• Empathy: Express understanding and use supportive language. Build rapport through active listening.

• Avoid jargon: Use simple, clear language to explain the diagnosis and management.

• Reassurance: Regularly reassure the patient about confidentiality and safety, particularly when exploring sensitive topics.

• Active listening: Pay attention to the patient’s verbal and non-verbal cues to adjust your approach if needed.

  
  

Ethical Considerations:

• Confidentiality: Reassure the patient that the consultation is private.

• Consent: Ensure implied consent is obtained before proceeding with more personal or invasive questions.

  
  

Additional Resources:

• GMC Good Medical Practice (2024): Offers guidance on confidentiality, patient communication, and risk management in clinical practice​.

• PLAB Examiner Tips: Time management and concise communication are crucial for the PLAB 2 OSCE stations​​.

This structured approach will help ensure the patient feels safe, heard, and respected while you gather essential diagnostic information and provide an appropriate management plan.