EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Sarah’s presentation?

• Prompt: How do you differentiate between bipolar disorder with psychosis and schizoaffective disorder?
• Prompt: What other medical or substance-related causes should be considered?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors should be assessed for immediate safety?
• Prompt: What laboratory or imaging tests may be relevant?

Q3. How would you explain the diagnosis and next steps to Sarah and her mother?

• Prompt: How do you ensure engagement despite Sarah’s poor insight?
• Prompt: How do you discuss treatment options and the need for urgent psychiatric input?

Q4. Outline your management plan for Sarah’s acute episode.

• Prompt: When would you consider hospital admission under the Mental Health Act?
• Prompt: What pharmacological and non-pharmacological treatments are appropriate?

Q5. What preventive strategies should Sarah follow for long-term stability?

• Prompt: How can she recognise early warning signs and prevent relapse?
• Prompt: What role do lifestyle modifications and support networks play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Sarah’s presentation?

A structured approach is required to differentiate between primary mood disorders with psychosis, primary psychotic disorders, and secondary causes.

• Affective Psychosis (Most Likely in This Case):
  • Bipolar disorder with psychotic features – Grandiosity, reduced need for sleep, pressured speech, delusions.
  • Schizoaffective disorder – Mood and psychotic symptoms occurring together but also separately.
• Primary Psychotic Disorders:
  • Schizophrenia – Persistent psychotic symptoms, negative symptoms, functional decline.
• Secondary Causes (Must Exclude):
  • Substance-induced psychosis – Recent drug use (e.g., cannabis, stimulants, hallucinogens).
  • Medical causes – Thyroid dysfunction, CNS infections, autoimmune encephalitis, vitamin deficiencies.

A competent candidate prioritises bipolar disorder with psychotic features while considering other medical, psychiatric, and substance-related causes.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Mood symptoms: Episodes of depression, past hypomanic/manic episodes.
  • Psychotic symptoms: Onset, duration, severity, presence of hallucinations.
  • Risk assessment: Suicidal thoughts, harm to others, self-neglect.
  • Substance use: Recent alcohol, illicit drug use (stimulants, hallucinogens).
• Investigations:
  • Urine drug screen – To rule out substance-induced psychosis.
  • Thyroid function tests – Hyperthyroidism can mimic mania.
  • B12, folate – Deficiencies can cause psychiatric symptoms.
  • CT brain (if focal neurological signs or atypical features) – To exclude organic pathology.

A competent candidate conducts a thorough risk assessment and orders relevant investigations to exclude medical and substance-related causes.

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Q3: How would you explain the diagnosis and next steps to Sarah and her mother?

1. Acknowledge concerns:
   • “I understand this experience has been distressing, and I appreciate you both coming in today.”
2. Explain likely diagnosis:
   • “Your symptoms suggest a mood disorder, possibly bipolar disorder with psychotic features, which means your mood and thoughts are affected at the same time.”
3. Address need for treatment:
   • “This is a treatable condition, and with the right support and medication, most people improve significantly.”
4. Discuss next steps:
   • “We need to assess your safety, order some tests, and involve a psychiatrist to guide treatment.”
5. Reassure while addressing insight limitations:
   • “I know you may not feel unwell, but we want to help you think clearly and feel in control again.”

A competent candidate communicates clearly, reassures the patient, and ensures family involvement while acknowledging impaired insight.

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Q4: Outline your management plan for Sarah’s acute episode.

1. Immediate Safety Assessment:
   • Assess risk of harm to self/others – If high risk, consider involuntary hospital admission under the Mental Health Act.
   • Ensure supervision at home – Engage family, crisis team if needed.
2. Pharmacological Management:
   • Antipsychotic medication (e.g., olanzapine, risperidone) – For acute psychotic symptoms.
   • Mood stabiliser (e.g., lithium, valproate) – For long-term mood control.
3. Referral and Ongoing Monitoring:
   • Urgent psychiatric review – To determine inpatient vs outpatient management.
   • Regular GP follow-up – Monitor medication response, side effects.

A competent candidate ensures acute safety, initiates treatment, and refers for specialist care.

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Q5: What preventive strategies should Sarah follow for long-term stability?

1. Medication Adherence:
   • Regular mood stabilisers and antipsychotics – Reduces relapse risk.
   • Monitoring for side effects – Weight gain, metabolic syndrome.
2. Early Warning Signs & Relapse Prevention:
   • Recognising early symptoms – Reduced sleep, irritability, impulsivity.
   • Psychological therapy – CBT, psychoeducation on mood regulation.
3. Lifestyle & Support Strategies:
   • Routine sleep schedule – Sleep deprivation is a trigger for mania.
   • Support network – Family, mental health team, community support groups.

A competent candidate provides a structured approach to relapse prevention, lifestyle modifications, and medication adherence.

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SUMMARY OF A COMPETENT ANSWER

• Recognises bipolar disorder with psychotic features as the most likely diagnosis while excluding secondary causes.
• Takes a structured psychiatric history, including mood symptoms, psychotic features, substance use, and risk assessment.
• Orders appropriate investigations, including urine drug screen, thyroid function tests, and metabolic screening.
• Clearly explains the condition and need for treatment, addressing limited insight and involving family support.
• Develops a structured management plan, including safety assessment, medication initiation, and specialist referral.
• Provides long-term preventive strategies, ensuring relapse prevention, medication adherence, and lifestyle modifications.

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PITFALLS

• Failing to assess risk adequately, leading to missed opportunity for urgent psychiatric intervention.
• Not considering secondary causes, such as substance use or medical conditions.
• Over-reassuring the patient despite impaired insight, delaying treatment.
• Not involving family or support services, reducing adherence to long-term management.
• Neglecting relapse prevention strategies, leading to future hospitalisations.

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REFERENCES

• RACGP – RACGP Guidelines on Mental Health Management
• GP Exams – Affective psychosis

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD