The Extreme Psychiatry Guide to

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The Extreme Psychiatry Guide to

• Dr Strings
• MRCPsych
• Staff Grade Liaison Psychiatry

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Psychosis ICEs

• Take a history of psychotic symptoms
• Ie delusions hallucinations
• Elicit
• Delusions or
• Hallucinations or
• Psychotic Symptoms (both)
• NB Elicit means here-and-now mental state
• Do not automatically think psychosis
  schizophrenia
• Mania
• Depression
• Organic stuff (incl. drugs / alcohol)
• Schizophrenia

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Psychosis ICEs - Communication Marks

• Introduce yourself
• Establish rapport
• Appropriate use of questions
• open / closed / clarifying
• Verbal non-verbal encouragement
• Acknowledge the patients feelings concerns
• Encourage Qs deal with them appropriately
• Summary and analysis of history

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Adapted Logbook Mark Scheme

• Past Hx Psych disorder
• Incl drugs alcohol
• Thought interference
• TI TW TB
• Passivity
• Special meanings in events and experiences
• Anyone trying to harm pt
• Feelings of power or self importance
  (grandiosity)

• Feelings of guilt or worthless
• Hallucinations in all modalities
• AH VH TH OH GH
• Ax insight attribution of symps
• Effect on life, coping, plans
• Think about RISK

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Tips...

• Be interested and find out the full story
• Theyre being watched Why? How? Since when? Who
  by?
• RESPOND Shock! Upset! Delight! Amazement!
• If YOU were being filmed all day how would YOU
  feel?
• You dont believe it, but believe that THEY
  believe it
• You can check for conviction, but
• Never make the Pt feel like theyre mad / silly
• Dont fall into colluding with a patient, either.
• Remember
• This may be the most important thing in their
  life
• And YOU may be the only person who has listened
  to them

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More Tips

• Try and use OSCE instructions as opener
• The GP told me youve been having a stressful
  time at college. Hes asked me to spend a bit
  more time talking to you about it Is that OK?
• Your parents seem to be very worried about you
  Why do you think they are so worried?
• If they are distracted, ask why
• If sensitive, could open up their world to you
• Can you hear or see something I cant?
• Is something making it hard for you to
  concentrate?
• They may be suspicious of you
• You can help them by telling their story to the
  Dr
• Otherwise confidential

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Other Tips

• Comment on cause / context
• You seem very sad do you think that might have
  something to do with you feeling so guilty?
• Do you think the cannabis might have made you
  more edgy around your friends than usual?
• If you get a manic patient
• Keep firm boundaries (say NO!)
• Be interested, but not OTT they get excited
• Be ready for lability / irritability.
• Stay calm, apologise, change subject or get out
  if fearful
• NB If you are asked to assess for depression or
  mania, look for other symptoms not just
  psychosis! Energy, mood, confidence, etc

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Psychotic Symptoms (1)

• Delusions
• A (usually false) belief
• Held with absolute certainty
• Despite evidence to the contrary and
• Out of keeping with social, cultural or
  educational background
• NB Patient sees it as a NORMAL thought
• Need to probe test but be gentle. This isnt
  about trying to prove them wrong they wont
  believe you AND they wont like you if you try!

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Psychotic Symptoms (2)

• Hallucinations
• A perception in the absence of a stimulus
• Can be any modality so ask for
• Auditory
• Visual
• Tactile (superficial or deep somatic)
• Gustatory
• Olfactory
• SEEM AS REAL AS A REAL THING
• E.g AH seem as real as my voice now
• just without a source
• Nb illusions misperception of a stimulus
• This is not a psychotic symptom

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3 Main Psychotic Flavours

• Grandiose
• Depressive
• Persecuted (paranoid)
• Bear these in mind, since youll often get
  connected THEMES and it may help you with
  diagnosis
• BUT remember, flavours dont diagnosis

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Grandiose

• Delusions
• Importance / specialness / talents / missions /
  money / sexy / friend to the stars
• Can be persecutory (e.g. people envious)
• Reference often on TV / papers
• Auditory Hallucinations
• may be complimentary / jealous
• Could be someone important, talking e.g. God

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Depressive

• Delusions
• Nihilism (absence of stuff)
• Rotting organs (Cotards)
• Pt may believe they are dead
• Poverty
• Worthlessness
• Guilt
• Persecutory (often feel they deserve this)
• Hypochondriacal
• Hallucinations
• Auditory voices telling them how worthless they
  are
• Visual (rarely) scenes of destruction or poverty

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Persecutory (paranoid)

• Voices
• Saying nasty / unnerving stuff
• People talking about them?
• Delusions
• Persecution, conspiracy plots poisons!
• Reference (TV, radio, people looking at them)
• Can get very complex

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Schneiders First Rank Symptoms

• Delusions of Thought Interference
• Withdrawal, insertion or broadcasting
• 3rd Person Auditory Hallucinations
• Commentary / discussing Pt between themselves
• Thought Echo
• Delusions of Control or Passivity
• Made acts/impulses/affect
• Delusional Perception
• Delusional interpretation of a normal, real
  percept
• E.g. traffic lights DID change delusions irt
  this
• NB Does NOT mean patient has schizophrenia (can
  be seen in other illnesses) but makes diagnosis
  more likely (e.g. ICD-10)

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Asking about Delusions (1)

• Is there anything worrying you?
• Do you have any ideas your friends dont agree
  with?
• Has anything out of the ordinary happened
  recently?
• Anything scared or upset you?
• How do you get on with other people?
• Is anyone trying to make life difficult for you?
• Follow / watch / spy / hurt / trick / poison?
• Have you got people around you you can trust?
• Do people gossip about you?
• Have you ever seen stuff on TV / papers you felt
  was specially meant for you / about you?

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Asking about Delusions (2)

• Is anyone trying to control you? (How why?)
• Make you do / say / think things? Can you resist
  them?
• Can anyone mess with your thoughts / mind?
• Do you ever feel like the thoughts in your head
  arent yours?
• Can anyone push / force / put their thoughts into
  your head /- without talking to you?
• Can they take thoughts out of your head? Read
  your mind?
• Do you ever feel like everyone knows what youre
  thinking?
• /- as if your thoughts escape from your head
  against your will?
• How do you see the future? (doomed Vs mission)
• Have you any special talents / anything youre
  really good at?
• Howd you see yourself compared w others?
  (worthless V grand)

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Asking about Delusions (3)

• Test conviction
• How do you know this is going on?
• Do you have any proof (e.g. for the police)?
• Sometimes when people are stressed, their minds
  can play tricks on them Is that possible with
  you?
• Could this be an elaborate hoax / a trick / a
  nasty joke?
• What do your family / mates think?
• Why do you think dont they agree?
• Look at effect on life emotions, coping, plans
• Risk self others?
• Cant take it? Retaliation?

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Asking About Hallucinations (1)

• When people are under stress (as you have been,
  with the FBI) sometimes they have strange /
  scary experiences Have you?
• You seem like a sensitive person Do you ever
  pick up on things that other people cant?
• Can you hear / see things other people dont
  notice?
• Have you seen (or heard) anything thats worried
  or upset you, recently?
• Do people talk about you / gossip about you?
• Do you ever hear people talking, but
• cant see where they are?
• You thought you were alone?

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Asking About Hallucinations (2)

• If voices
• Can Pt give example of what they say/do
  impression?
• Who is / are talking?
• When do you hear this?
• Do they ever tell you to do things?
• Do you obey? / Can you resist?
• WHY / How are you hearing this? (microchips?
  Beams?)
• Where do they sound like theyre coming from?
• int subjective (Pseudohalluc) / ext objective
  (halluc) space
• Do they ever say your thoughts out loud?
• NB Unless Pt calls them voices, dont call
  them voices stigmatising gives message you
  dont believe them (Mad people hear voices)

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Asking About Hallucinations (3)

• Seen anything
• you cant explain?
• scared you?
• seemed strange / unusual?
• Ghosts? Spirits? Visions? People?
• Any funny feelings in your body?
• E.g. Link to persecutors? Do they touch you?
• Any strange tastes or smells?
• Does food taste normal?
• Test conviction, explanation and effect on life
  as for delusions

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Assess Insight

• Is there anything wrong?
• If so Is it an illness?
• If so Is it a psychiatric illness?
• Would the teams plan help?
• E.g. medications
• Are they willing to follow the plan?
• e.g. take tablets, stay in hospital

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Final Tips

• DONT PANIC
• Always say youd get senior help if you need to
  make a big decision / dont know
• Remember, they are not looking for PERFECT
  doctors, just SAFE doctors
• See as many patients as you can this year
• Practice skills in everyday life
• Ask for feedback
• Give a damn

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Go See Some Patients!

• Your Teaching Team Are
• Richard Jenny (Actors)
• Mich, Bruce, Sam Will (Yr 4 Peer Facilitators)
• Strings Elizabeth (Trickcyclists)
• Some examples taken from OSCEs In Psychiatry, by
  Albert Michael excellent book!
• nb this is for MRCPsyche, not MBBS
• www.extremepsychiatry.com
• For extra copies of handouts
• www.myspace.com/stryngs
• Buy my wonderful albums
• They will inspire you to pass your OSCEs.