Drug History Zopiclone 3.75mg ON PRN (Review Overdue) Clozapine 50mg OM and 75mg ON (Prescribed by the mental health team)

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1 Doctor s Instructions Patient: Pradeep Singh Age: 28 years old Last Consultations Dr Fitzpatrick 1 week ago Admin Note: Script request for zopiclone declined as medication review overdue, advised to make appointment with doctor for medication review. PMH Schizophrenia Drug History Zopiclone 3.75mg ON PRN (Review Overdue) Clozapine 50mg OM and 75mg ON (Prescribed by the mental health team)

2 Actor s Script *The most important things to remember have been underlined* Background (this information is for you please follow the script to determine when to disclose this information) You are Pradeep Singh a 28-year-old gentleman, with schizophrenia. You have come for some more sleeping tablets. During this consultation seem suspicious and anxious. Keep looking around the room (for cameras). You are worried the corps are after you. Opening Statement I need some more sleeping tablets. Next Statement If you are asked an open question next (e.g. tell me more how did it all start ) or any open question after this say: I just need the tablets, why did you call me in, you never call me in, usually you just give them to me did the corps ask you to tell me to come in? (You are worried this is all apart of a big plan to trap you) If the trainee asks any more open questions, ask them what they would like to know, and only given the information in the rest of this script if the trainee specifically enquires about it. History of Presenting Complaint You have had problems falling asleep over the last month You find it difficult to fall asleep and you keep waking up Over the last month the corps have been after you If asked to clarify, the corps are an organisation and they are trying to get you. They pass secret messages onto you via the television The messages say you are one of them You do not know what they do, or why they are after you, but you are scarred The only time you get relief is when it rains, because that s when the corps sleep You have never explicitly seen them You do not hear any voices You do not feel they can control you You do not feel they can put thoughts into your head / take them out You feel your thoughts are your own private thoughts and no one has access to them You are not depressed You cannot enjoy things in life because you are scarred As a result you cannot sleep You have no thoughts about harming yourself or ending your life You have no thoughts of harm towards others You do not hear voices telling you to harm other people You have not had any stressors recently You have no other symptoms

3 Past Medical History You deny you have any medical conditions. If the doctor says you have schizophrenia, say That s what the corps wants you to think If asked about history of being sectioned: You were sectioned 3 years ago, for around 3 months. Drug / Medication History You are not allergic to any medications Say you take the sleeping tablets to help you sleep If asked you do not take any other medication. If the doctor states in your notes it says you take clozapine, say I have to collect that every few weeks, and I pretend to take it, but I know it is poison so I have been throwing it away. You have been doing this for a month because that s when the corps decided to come after you. The clozapine was started 3 years ago. You have a blood test every month at the hospital they have been ok. Occupational History You do not work Social History You do not smoke You do not drink alcohol You smoke a couple of joints of cannabis a day (you have done this long term) You do not drive You live in a council flat alone You have no carers You have Disability Living Allowance, you have enough money coming in You have no family near by, you have no friends. You are all alone. Ideas The corps are after me Concerns As above Expectations No one can help me, I just need some tablets to help me sleep Examination If the doctor asks to examine you decline. Management If the doctor says he would like to discuss the case with the psychiatrist say I don t mind, but I need my sleeping tablets If the doctor mentions the possibility of admission: You are reluctant to go into hospital because you do not feel mentally unwell. I am fine doctor, I just need my tablets It is the corps who have tainted my records I cannot go into hospital However, if the doctor states ultimately the psychiatrist will decide what to do, but if it is thought you need to be admitted and you decline, the doctor

4 may have to call the police to take you into hospital / they may need to consider sectioning you; you agree to follow their plan because you do not want any trouble with the police or being sectioned again because that was horrible

5 Mark Sheet Schizophrenia Case Data Gathering and Clinical Practical Skills Onset of symptoms / Triggers / Stressors Insomnia (onset, difficulty falling asleep / interrupted, triggers) First Rank Symptoms, Persecutory delusions DSH / Suicide; Harm to others; Command hallucinations PMH: Date of diagnosis of schizophrenia, previous hospital admissions / sectioning DH: Is he taking his medications regularly, if not why? FH: Of schizophrenia Occupational Hx: Impact on work SH: Impact on social life. Social living arrangements, finances, support, need for additional support Lifestyle: Alcohol and drugs Law: Driving and Acute Psychosis Guidelines ICE & Examination: BP / BMI Patient Centred Management Lifestyle: Cannabis can make you feel worse Medical: Explain you feel it is a relapse of schizophrenia. Explain because he has been off clozapine for a while it may need to be re-initiated. State you will discuss this with the psychiatrist now, and they may either treat him at home with a lot of support, or they may recommend admitting him. If the patient declines admission state the psychiatrist will give an opinion, but if they recommend admission, and he declines the options are (i) urgent mental health act assessment or (ii) calling the police to section him to take him to A&E. If they decide to treat him at home agree short supply of hypnotic, if they decide to admit him they may give it to him on the ward Law: DVLA guidelines and psychosis if appropriate Appropriate Safety Netting / Follow Up (call the psychiatrist, while the patient sits in a place of safety e.g. nurses room) Interpersonal Skills Utilise the notes Active listening do not repeat questions Avoid medical jargon Appropriately ask about ICE Communication skills Non confrontational Put the questions into context (e.g. Sometimes people can hear things that other people can not hear, have you noticed this?. Sometimes people feel other people have access to their thoughts have you noticed this Tactfully try to explain your opinion Ask the patient what they know about schizophrenia Ask them if they know how it is treated Explain it is important to take the treatment and avoid drugs / alcohol to prevent deterioration Explain my concern is that because you have not been taking your medication you have deteriorated I know you feel you do not have schizophrenia, and I know it is difficult to hear this, but sometimes when people with schizophrenia deteriorate they often stop using their medication and they don t believe they have the condition because you have stopped taking the clozapine, if it is re-started it may have to be done slowly and under the care of the psychiatrist, so I am going to have to speak to the psychiatrist, and they will recommend either treating you at home with additional help, or admitting you Being tactful re: compulsory admission (e.g. I have to be honest with you, if the psychiatrist needs to admit you, and you refuse we may only have two options, one organising an urgent assessment to consider sectioning you or we may need to call the police to take you into hospital Total Score: / 9 Grade (CP, P, F, CF)