Auditory Hallucinations – OSCE Case

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Sam, a 25 year old man, is brought into the hospital by the police due to public concern regarding bizarre and distressed behaviour in the city centre. The police say Sam will only speak of being “scared of them”.Β  He’s currently curled up in a ball in the corner of the room. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

  • Auditory hallucinations
  • Behaviour/personality change
  • Fixed abnormal beliefs
You might also be interested in our collection of 800+ OSCE Stations, including a range of psychiatry stations.

Mental health act

Section 136

  • Section 136 allows police to bring a person from a public place to a place of safety.
  • The place of safety can be ED, a police station or a specific β€˜136 Suite’.
  • A person can be held under Section 136 for 24 hours and this can be extended by a further 12 hours if needed (to allow completion of the assessment)
  • During this time an assessment of the individual should take place by a mental health professional.

If a person:

  • has/is deemed to have a mental disorder which requires assessment or treatment
  • is suffering from a sufficiently serious disorder that means admission is necessary for the health and safety of the patient or the public
  • requires hospital admission for assessment/treatment
  • is unable and/or unwilling to agree to hospital admission

Two registered medical practitioners (one of which must be Section 12 approved) and an approved mental health professional (AMHP – usually a social worker) submit reports which support that the case satisfies the above criteria.

For more information, see our guide to the Mental Health Act.


History

β€œThey’reΒ after me…they’reΒ going to get me.Β I’veΒ heard them talking about me.”

β€œThey know whatΒ I’mΒ doing, they know where I am. They follow me everywhere. They put a tracker in my head while I was asleep a year ago. Now they know where I am and what I think.”

β€œThey know what I’m thinking, and they make me think about hurting my family. I don’t want to hurt my family, but I keep getting these thoughts…it’s getting worse.”

β€œThe chip was put in my brain last year.Β They’veΒ been getting louder ever since.”

It is not possible to obtain any more history from Sam.


Differential diagnoses

  • Acute psychosis (including drug-induced psychosis)
  • Schizophrenia
  • Schizoaffective disorder
  • Bipolar disorder
  • Delusional disorder
  • Schizotypal personality
  • Third-person auditory hallucinations
  • Thought insertion
  • Thought broadcasting
  • Collateral history (e.g. friends, partners, family)
  • GP records (including past medical history and regular medications)
  • Police records (previous episodes)

Investigations

  • Drug screening (urine & blood) – cannabis, amphetamines, LSD, cocaine
  • Full blood countΒ – white cells/infection markers
  • Urea & electrolytes – electrolyte disturbances may indicate an underlying medical cause
  • CT/MRI head – to rule out organic causes (e.g. encephalitis, space-occupying lesion)
  • EEG – if seizure activity suspected

Collateral history

You return to Sam to discuss the need for blood tests and find someone sitting with him. Jane introduces herself as Sam’s mother and explains that Sam usually lives with her. She explains that Sam is known to have schizophrenia.

This was diagnosed during university and has been somewhat turbulently managed since. He has been on several antipsychotic medications in the past four years, none of which have seemed to control the symptoms. Sam has been unable to find a job since university and has few friends. There is no known illicit drug use, and he has no other medical history.


Management

Sam has a history of schizophrenia that has not responded to first-line treatments (treatment-resistant schizophrenia).

Clozapine is indicated for treatment-resistant schizophrenia, specifically when the illness has beenΒ unresponsive to at least two antipsychotic medications (at least one of which is an atypical antipsychotic).

  • Baseline blood tests – FBC (clozapine can potentially cause fatal agranulocytosis)
  • Cardiovascular risk assessment (BMI, fasting lipids) – clozapine increases the risk of cardiovascular disease, including myocarditis
  • Fasting blood glucose or HbA1c – clozapine is associated with an increased risk of diabetes
  • Baseline vital signs – clozapine can cause postural hypotension (so if a patient already had low blood pressure or issues with postural hypotension, it may not be appropriate)
  • ECG – to establish a baseline – clozapine is associated with an increased risk of cardiovascular disease
  • Often initiated during an inpatient stay, commencing at a low dose and then slowly titrated upwards.
  • Plasma clozapine levels should be measured after reaching the initial target dose (approximately two weeks).
  • Blood pressure should be monitored regularly, as postural hypotension can occur.

For the first month, patients on clozapine should have the following monitored:

  • Vital signs (e.g. fever in agranulocytosis or postural hypotension)
  • ECG (monitoring for acute changes such as those seen in myocarditis or myocardial infarction)
  • CRP (useful if considering infection in the context of agranulocytosis)
  • Troponin levels (raised in myocarditis and myocardial infarction)

Agranulocytosis

  • During the first six months of treatment, WCC should be measured weekly, then fortnightly.
  • 1 in 1000 people on treatment develop agranulocytosis, usually in the first six months of treatment.
  • Clozapine should be temporarily stopped or discontinued if agranulocytosis develops.

Weight gain and impaired glucose tolerance

  • Weight should be monitored regularly as weight gain is likely in patients taking clozapine.
  • Insulin resistance may also develop, so HbA1c should be monitored every six months.

For more information, see our guide to clozapine counselling.


References

  1. Royal College of Psychiatrists. Being sectioned. Available from: [LINK].
  2. UK Government. Mental Health Act of 1983. Available from: [LINK].
  3. Dr Roger Henderson. Schizophrenia. Updated May 2016. Available from: [LINK].
  4. NICE. Psychosis and schizophrenia in adults. Updated in 2014. Available from: [LINK].

 

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