Schizophrenia (King Charles)
Where you are:
You are FY2 in GP.
Who the patient is:
Father of Michael Jones, a 28-year-old gentleman booked a video call appointment for his son because he is not behaving himself for the last few weeks.
What you must do:
Talk to him, manage him accordingly and address his concern.
Patient’s information (Station flow):
- Michael Jones has been feeling that King Charles is his biological father and he is going to meet him at the Buckingham Palace.
- He has not discussed this with anyone because he is afraid of being harmed by others. He has no insight. He has no visual or auditory hallucinations, no suicidal thoughts, and mood is not low (8/10).
- He does not smoke or drink, but he does cannabis for a few months.
- He used to work at a bank, but he recently lost a job a month ago.
Data Gathering
Introduction (video call approach):
- Hello, I am Dr (name), one of the junior doctors calling from the GP surgery. Are you Michael Jones? - Yes
- I can see that your father has booked you in for this appointment. Is it a good time to talk? - Yes
- Can you please confirm your date of birth? - (confirmed)
- Q: I can see you are worries now (Acknowledge). So, what is your next plan of action? - I a m going to meet my father
- Q: Where will you be meeting your father? - at the Buckingham Palace
- Q: When are you going to meet your father?
- Q: How will you go there? Will you bring anyone with you when you go there?
- Q: What do you think will happen if you go to the Buckingham Palace?
- Q: What will you do if you meet King Charles? (do not use the term your father)
- Q: Did you have any sorts of flu like symptoms or fever episodes a few weeks before?
- Q: Did you have any frequent going to loo, any pain on urination, any cough, any chest pain, any loose motion, any rashes on the body?
- Q: Do you feel cold when others feel hot or vice versa?
Assessment of risk of harm to self-including neglect
- Q: I can see that you mentioned that you are afraid of being harmed by others. How are you coping with that?
- Q: Is there anything else that is worrying you?
- Q: Do you have any sleep problem? Any loss of appetite or weight? Any concentration problem? Any loss of sexual function? (Ask one by one)
- Q: How is your mood, is it okay? Could you score your mood on a scale of one to ten, one being lowest and ten being the highest. - 8/10
- Q: Would you say that your mood has been going ups and downs these days?
- Q: When people get stressed, they tend to have idea of harming themselves. Has it ever been the case with you?
Assessment of risk of harm to others
- Q: I can see that you have worried about being harmed. How are you prepared to handle that?
- Q: Do you carry anything with you to protect yourself? - No
Psychosis symptoms assessment
- Q: Sometimes when people go through difficult times in their lives they tend to hear, see, or feel things that are not real, have you ever experienced this? - No
- Q: Do you have any thought problems like someone putting ideas into your mind or someone taking thoughts out of you without your consent or feels that your thoughts are being assessed by others? - N o
- Q: Do you feel that you have lost interest in interacting with others or has not enjoyable moments in your life? - No
- Q: Do you think others are watching you, talking about you, or having a go at you for no good reason?
- Q: Do you think something strange is happening that you can’t explain?
Support system + Insight
- Q: Who do you currently live with?
- Q: Have you talked to anyone about this, may be your family or friends? - No
- Q: Do you have any friends you usually talk to? - N o
- Q: What do you do for a living? - I used to work a t a bank. I lost my job a month ago. - Are you on any benefits?
- Q: Do you drive? - if driving - Advise patients to inform the DVLA. Driving should cease during the acute illness (all drivers) and until stable with insight for ≥ 3y (lorry/bus drivers).
- Q: Michael, do you think you might need help from us?
Others
- P2 + MAF + DESA - I smoke cannabis. (Explore more on cannabis)
- ICE assessment - “C- Do you have any other concern?” “E — Is there anything in particular that you are hoping we should do for you today?”
Management
- Note: Ask the patient to go to the hospital if in GP surgery or convince to keep him in the hospital if in A&E. He needs to be assessed by the psychiatrist.
- Convincing the patient (You are allowed to tell that he has schizophrenia)
- “Thank you for your information, Michael. From what we have discussed so far, I am a bit concerned about you. You mentioned that your biological father is King Charles, and you are going to meet him at the palace, am I right?”
- "So, this whole idea about (narrate short) meeting your father at the palace seems a bit out of reality Michael. But this does not mean that you are making things up or you are wrong, you know. I feel that these ideas you just mentioned could be symptoms of what is going on inside your brain,
- what we call it psychosis episode, which could be early symptom of something like schizophrenia"
- “Sometimes, when you have a stressing point in life like losing a job for example, you can start to have these ideas you know. This means that you might not be mentally well.”
- “For this I would like you to go to the hospital now because you are also worried that people might harm you. So, this can affect your mental health in the long run” - N o I don’t want to g o Doctor. - ask why? (May I know the reason why?)
- Offer alternative - “Okay, I can see that you don’t wish to go to hospital, I can arrange you to be seen by Crisis Resolution and Home treatment team (CRHTT). A team of specialists are going to visit you at your home and take care of you. What do you think about this?” - That i s fine then Doctor.
- Mention about anti-psychotic medication - “They will run some blood tests including FBC, TFT, LFT, KFT, imaging scans to make sure you are safe moving forward and they will start you on a special medication called risperidone and olanzapine (Anti-psychotic) to help you in the long run”
- We will also be arranging regular follow-up with you and also provide you social support, if necessary, as well especially you mentioned that you have recently lost a job.
- Note: All psychosis episodes need to be assessed by specialist psychiatrist. GP cannot start the patient on anti-psychotic medication, but GP can arrange follow-up and give repeat prescriptions if necessary. CBT is not started as first line because patient does not have insight and CBT alone will not help the patient.
- Safety net: suicidal episode, harms to others.