Análisis de resultados

Consider a biological/psychological/social approach:

Biological

Medication: in the first instance, you would consider atypical neuroleptics. Many people claim efficacy of atypical neuroleptics against negative symptoms compared with older drugs. The best evidence exists for amisulpride for primary negative symptoms.

Psychological

Psychotherapeutic assessment for CBT: it is reported that people with chronic schizophrenia are no more cognitively impaired than other schizophrenic diagnostic subgroups, and so they may be suitable. However, motivation may be a problem.

Social

Need increased prompting and support with hygiene and self-care. Additional help needed with bill payments, food, shopping, etc.

Family/carers to be educated and advised on the disorder and their possible input.

Patients may require admission to hospital or a supported environment if they represent a risk to themselves through self-neglect.

ASK WHETHER HE HAS ANY OTHER QUESTIONS

THANK HIM

FOR EXTRA MARKS

If time allows, exclude dementia, an organic syndrome and chronic depression.

Try to establish whether negative symptoms are primary or secondary: Primary: transient or enduring.

Secondary to: positive symptoms: as a consequence of paranoid symptoms depression: social withdrawal

EPSE: bradykinesia, etc.

The chronic syndrome is often characterised by thought disorder, underactivity, reduced drive, social withdrawal and emotional apathy. The earlier a psychotic disorder is treated, the less likely the person is to go on to develop a negative syndrome.

FURTHER READING

Carpenter WT, Jr. The treatment of negative symptoms: pharmacological and methodological issues. Br J Psychiatry Suppl 1996; (29): 17–22.

Waddington JL, Youssef HA, Kinsella A. Sequential cross-sectional and 10- year prospective study of severe negative symptoms in relation to duration of initially untreated psychosis in chronic schizophrenia. Psychol Med 1995; 25: 849–57.

STATION 1

This 35-year-old woman took a large paracetamol overdose several days ago. She has developed fulminant hepatic failure and needs an urgent liver transplantation. The physicians have told you that she is alert and not delirious. They have asked you to assess her as they want to make sure she has capacity before transplantation. Assess this patient’s capacity.

Can she consent to treatment?

[advice on page 136]

STATION 2

A fitness instructor of 24 years, James Dawson is currently admitted having had a hypomanic episode. He experienced his first hypomanic episode at 18 years of age. His father was diagnosed with bipolar disorder as a young man and was treated with lithium to good effect.

Mr Dawson is looking for information about lithium and is curious about his suitability for the treatment.

[advice on page 138]

STATION 3

This patient complains of chest pain. Examine their cardiovascular system.

[advice on page 141]

STATION 4

Ms Martin, a 28-year-old bank clerk, describes experiencing recurrent and unpredictable attacks of anxiety or panic. The attacks start suddenly, are extremely distressing and last for a few minutes, sometimes longer. She says that the episodes can happen anywhere.

Discuss the most likely diagnosis and the differential diagnosis. How will you manage this woman?

Stations 133

STATION 5

This 73-year-old man had a cerebrovascular accident several years ago, from which he made a good physical recovery. His GP referred him to psychiatric services with a possible depressive episode. The specialist registrar asks you to see the man in the day hospital, as he has commitments elsewhere. From the notes available, you notice that in a cognitive assessment 2 years ago, the man drew only half a clock face.

Assess his parietal lobe function.

[advice on page 145]

STATION 6

This gentleman presented to the A&E department in the early hours of the morning. He remains slightly drowsy, but he has been cleared from a medical perspective. The nursing staff have been too busy to gather any personal information from the man but mention that he smells ethanolic.

Assess this gentleman.

[advice on page 147]

STATION 7

This 30-year-old postman has given himself up to the police, claiming he can ‘no longer hide from them’. The police are concerned about his mental state and inform you that he has been mumbling to himself. He appears to be exhausted and distractible. Assess his mental state.

Do not enquire about his past history.

[advice on page 149]

STATION 8

A 28-year-old woman has been unable to return to work for 6 months following a flu-like illness. The acute illness has resolved but she remains exhausted and achy. She is referred to your clinic, as various doctors have been unable to find a physical cause. Discuss the most likely diagnosis.

How will you begin to help this woman?

STATION 9

This 75-year-old woman has recently made a will. You have been asked to see her because her children are concerned about her ability to construct an appropriate will. They have raised her ‘failing memory and change in behaviour’.

Assess her testamentary capacity.

[advice on page 154]

STATION 10

Give advice to this patient who takes lithium for a bipolar affective disorder and is planning to travel to a tropical country.

[advice on page 156]

STATION 11

Mr Stanley, a patient of yours, is due to receive ECT in a few days. As part of his preparation for treatment, you requested a chest X-ray. The X-ray is shown below. Your consultant asks you to comment on the film.

Stations 135

STATION 12

This woman is attending the outpatients’ department following instruction from her family doctor. Her doctor informs you that the patient is convinced that Robbie Williams is in love with her. The doctor, who assumed she was joking, made a sarcastic comment and was shocked by the hostile response that it provoked.

Take a history of erotomania.

STATION 1: CAPACITY

INTRODUCE YOURSELF

‘Hello, my name is Dr Smith. I’m one of the psychiatrists.’

SET THE SCENE

Explain that you are a psychiatrist and that you have been asked by the doctors looking after her to talk to her.

ASK FOR PERMISSION

‘Would that be OK?’

This is a very sensitive case where you must show the examiner that you can be empathetic.

Ask whether she remembers the events that led to the overdose and how she feels about it now:

Does she regret the overdose? Does she wish she had died?

Does she understand that she needs a transplant, and why?

Does she understand what will happen if she does not have a transplant?