MEDICAL SERVICES
PROVIDED ON BEHALF O F THE DEPART MENT FOR W ORK AND PENSIONS
Training & Development
Mental Health Support Scenarios
Mentor’s Notes
MED-MHSS~001
Version: 4 Final
10 December 2014
Medical Services
Foreword
This training has been produced as part of a training programme for Health Care
Professionals approved by the Department for Work and Pensions Chief Medical
Adviser to carry out benefit assessment work.
All Health Care Professionals undertaking medical assessments must be registered
practitioners, who in addition, have undergone training in disability assessment
medicine and specific training in the relevant benefit areas. The training includes
theory training in a classroom setting, supervised practical training, and a
demonstration of understanding as assessed by quality audit.
This training must be read with the understanding that, as experienced practitioners,
the Health Care Professionals will have detailed knowledge of the principles and
practice of relevant diagnostic techniques and therefore such information is not
contained in this training module.
In addition, the training module is not a stand-alone document, and forms only a part
of the training and written documentation that a Health Care Professional receives.
As disability assessment is a practical occupation, much of the guidance also
involves verbal information and coaching.
Thus, although the training module may be of interest to non-medical readers, it
must be remembered that some of the information may not be readily understood
without background medical knowledge and an awareness of the other training
given to Health Care Professionals.
Office of the Chief Medical Adviser
December 2014
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Document control
Superseded documents
Version history
Version
Date
Comments
4 Final
10th December 2014
Signed off by MAT and CMMS
4b Draft
1st December 2014
Updated following review by Medical Advisory
Team
4a Draft
17th November 2014
Updated for consistency with Update to
Standard 1b/2014
3 Final
26th March 2014
Signed off by HWD and CMMS
Changes since last version
General formatting and amendment of layout throughout document
Section 1.1 – question 3 – more information added to discussion points for self harm/suicidal
tendency
Section 2 – more information added in the scenario on behavioural / anger issues
Section 3 - additional information added in scenario on self harm/suicidal tendency
Section 5.1 – additional information added to discussion points of the case
Section 8 – more detail added to scenario to be more consistent with significant restriction in
personal action, rather than severe
Section 8.1 – reference to update to standard on substantial risk added
Section 9 – scenario amended to suggest a more stable condition, with admission being 5
rather than 2 years ago and less intensive specialist input
Section 9.1 – additional points added for mentor on change of scenario which might suggest
application of substantial risk
Section 10 – scenario amended to allow more consistency in descriptor choice
Section 10.1 – descriptor choice and mentor notes amended for more consistency
Next steps – link to NICE pathways updated
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Outstanding issues and omissions
Updates to Standards incorporated
Issue control
Author:
Medical Training & Development
Owner and approver:
Clinical Director
Signature:
Date:
Distribution:
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link to page 9 link to page 10 link to page 11 link to page 14 link to page 18 link to page 21 link to page 25 link to page 30 link to page 33 link to page 34 link to page 38 link to page 44 link to page 48 link to page 52 link to page 57 link to page 59
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Contents
Introduction
6
Section One - Cases for Discussion
7
1.
Discussion Case One
8
2.
Discussion Case Two
11
3.
Discussion Case Three
15
4.
Discussion Case Four
18
5.
Discussion Case Five
22
6.
Discussion Case Six
27
Section Two - Practice Scenarios
30
7.
Practice Scenario One
31
8.
Practice Scenario Two
35
9.
Practice Scenario Three
41
10.
Practice Scenario Four
45
11.
Practice Scenario Five
49
Next steps
54
Observation form
55
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Introduction
The Health Care Professional (HCP) new entrant training courses consider the assessment
of mental health conditions from the disability analyst’s perspective, including review of
mental health conditions commonly seen, application of the mental state examination, review
of levels of disability and indicators of severe mental health problems. During this training
HCPs undertake self directed learning of relevant reading including the
EBM Mental Health
Problems – Key Points and Analytical Guidance and the
Mental Illness, Current Therapeutics
and Management documents.
These scenarios are designed to help consolidate the HCP’s learning and provide a basis for
discussion with an experienced HCP. New Entrant HCPs should complete these scenarios
within the first 4 weeks post training. Established HCPs may also find them useful in order to
keep abreast with legislative changes.
Ideally it should be a Mental Function Champion (MFC) who delivers this consolidation of
training. If a MFC is not available then it should be an HCP with experience in assessing
mental health cases (the HCP delivering this training will be referred to as the mentor in the
remainder of the document).
This document contains the information on the Discussion and Practice Case Scenarios,
together with Guidance Notes on each case for the mentor. A separate document –
Mental
Health Support Scenarios for HCPs – contains the Discussion and Practice Case Scenarios
only which is to be used by the HCPs undertaking the consolidation of mental health training.
The first section contains scenarios for discussion. It is designed as a one to one discussion
exercise between the HCP and the mentor.
The second section contains practice case scenarios. These are to be used to complete an
ESA 85 report on the LiMA training server. The HCP will have to choose an appropriate
outcome (descriptors, support group or exceptional circumstances) and justify their opinion in
the Personalised Summary Statement (PSS). The case will then be reviewed by the mentor
and discussed with the HCP. The mentor should ensure that local unit log-ons and training
NiNos are available for the practice case scenarios.
Further guidance is provided in each section.
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Section One - Cases for Discussion
This section contains cases for discussion between the HCP and the mentor.
Each case contains a scenario to be read by the HCP. There are several initial questions to
be completed by the HCP and the answers discussed with the mentor.
Guidance notes are provided for the mentor following each case with the significant points
which need to be discussed with the HCP highlighted.
These cases are designed to highlight important points and guidelines when dealing with
claimants with mental health conditions.
The role of the Mental Function Champion should be highlighted throughout the case
discussions.
Each case should take approximately 30 minutes.
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1. Discussion Case One
Name:
Mr John Carden
Age:
33 years old
Med 3:
Schizophrenia
ESA 50: not returned
History at assessment:
Diagnosed with Schizophrenia about 10 years ago. He is under the care of a psychiatrist
and CPN both of whom see him at home. He sees his CPN twice weekly. There is no
history of self harm. Last hospitalisation was 8 years ago (sectioned under the mental
health act).
On depot medication fortnightly.
Lives alone in a one bed roomed flat.
He spends almost all of the time in his flat. He has no routine, he sleeps and gets up when
he feels like it. He says there is no need to change clothes and wash as he is not going
out. His CPN will prompt him on the days he visits to get washed and change his clothes.
He spends days watching TV. He is able to get to the local shop for groceries. He eats
mostly snack food.
He is not in contact with his family. He has no friends that he is in contact with. He does
not like having to speak to people.
Mental State Examination (MSE) Findings:
Unkempt, wearing dirty clothes
Poor rapport, poor eye contact, flat affect, appeared timid
Spoke very little, required prompting, speech bizarre at times
No insight
Questions:
1. What are your initial thoughts about this case?
2. Are there any key indicators of concern in the history and mental state examination
findings?
3. What further information might be asked for in the history?
4. What areas should be probed in claimants with schizophrenia?
5. Are there any other mental state examination findings that should be assessed?
6. What is the suggested outcome in this case?
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1.1 Mentor Guidance Notes for Discussion Case One
This is a claimant with a severe mental illness who presents unwell with multiple
indicators of significant mental health problems (key indicators). It is designed to allow
a discussion around severe mental illness and the presence of key indicators of
concern within an assessment.
1. What are your initial thoughts about this case?
Claimant has a Severe Mental Illness (this is an important point)
Consider Support Group or mental health risk NFD
Briefly discuss the clinical features of Schizophrenia (positive and negative features).
Include the importance of the severe functional effects that the negative features of
schizophrenia can cause.
2. Are there any key indicators of concern in the history and mental state
examination findings?
Under psychiatrist and CPN
Sees CPN twice weekly
Depot medication
Seen at home by psychiatrist and CPN
Self neglecting
Lack of social contact
MSE findings (unkempt, poor rapport, poor eye contact, flat affect, spoke very little,
required prompting, speech bizarre at times, no insight)
Discuss with the HCP the meaning of key indicators of concern (essentially an alarm
bell) and what their presence in a case might mean. Ensure the HCP knows what
constitutes indicators of concern.
Discuss with the HCP the identification of fertile areas for further investigation in the
history and typical day. Ensure the HCP fully appreciates that the history, including
condition history and typical day should be tailored to the specifics problems indicated
by the claimant or noted by the HCP during the assessment.
3. What further information might be asked for in the history?
Other indicators of concern - Is claimant under a Care Programme Approach
(CPA), involvement of home treatment or early intervention teams, history of
substance misuse?
Self harm/suicidal thoughts – it is not enough to enquire about past history of self
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harm/suicidal tendency, the HCP has to ensure there are no current thoughts/plans
/intent for self harm/suicide
Any side effects of medication - which could lead to non compliance with treatment
Presence of other medical conditions – physical or mental health
4. What areas of the history should be probed in claimants with schizophrenia?
Daily functioning: on surface may appear to be fine but when probed further it may
be revealed that the claimant is not actually functioning that well
Personal action: getting up, washing, dressing, cooking, housework, shopping
Socialising: seeing family and friends
Getting about: leaving house, how often, where do they go, etc
Coping with change: dislike of disruption to routine- especially in some individuals
with more active psychosis
Behaviour: interaction with others, conflict with others, inappropriate behaviour due
to psychosis, aggressive behaviour
Remind the HCP that they need to have enough evidence to support their opinion. It is
important to ask about the activities where they think the claimant may be struggling.
5. Are there any other Mental State Examination findings that should be assessed?
Abnormal thought processes and content or abnormal perceptions (including
delusions and hallucinations)
Check the HCP understands the definition of delusions and hallucinations:
Delusions: unchanging fixed beliefs that are held on inadequate grounds, are not
affected by rational argument, persist in spite of contrary evidence and cannot be
explained by culture or religion.
Hallucinations: a perception experienced in the absence of an external stimulus to
the corresponding sense organ. It is experienced as a true perception and seems
to come from outside the head.
Ask how HCP would check if they are present?
Ask HCP their understanding of insight and how to assess this
Importance of exploring past or current history of self harm and suicidal thoughts /
plans / intent
6. What is the appropriate outcome in this case?
Functional Support Group – Personal Action
It is more appropriate to place in a functional Support Group where this is
appropriate, rather than mental risk SG, as with a functional SG the HCP is able to
curtail the assessment to minimise distress to claimant
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2. Discussion Case Two
Name:
Mr Jedi Jackson
Age:
28 years old
Med 3:
Depression
ESA 50: has written “I have depression and I have trouble controlling my behaviour”.
Learning tasks – no problem
Awareness of hazard – has written “I don’t do any cooking.”
Initiating personal action – has written “I can’t be bothered with day to day stuff.
My wife nags me to do things, otherwise they wouldn’t get done.”
Coping with change – no problem
Getting about – no problem
Coping with social situations – has written “I have no interest in socialising.”
Behaving appropriately – has written “I get so angry that I have problems dealing
with people. I’m always arguing with my wife. I punched my neighbour after he
complained about my dog barking.”
History at assessment:
Diagnosed with depression about 12 months ago by GP. He was referred for counselling
which he thought was rubbish and not helpful at all. Started on citalopram about 6 months
ago. He thinks there has been some slight improvement since starting medication. He feels
low and angry that he is unable to find work.
He lives with his wife and young son (2 years old) in a house. He was fired from his last job
18 months ago after he was caught stealing from the company and has not been able to
find work since.
Main symptoms from depression are feeling low, mood swings and anger.
He wakes when his wife gets up to look after their son. Often he will stay in bed for a few
hours watching the TV in the bedroom. He doesn’t have anything to get up for. His wife
mostly looks after their son but he will look after him when his wife goes out shopping or
when she goes out to meet her friends. He gets washed and dressed most days. He often
feels like he can’t be bothered but knows it annoys his wife if he stays in his pyjamas all
day.
Sometimes he will go to the job centre to look for work, but after so long without a job he
now feels ‘what is the point’. His mood feels low during the day. He argues a lot with his
wife, this has increased over the last 6 months. He often feels angry; angry that he doesn’t
have a job, angry that they are struggling to pay the bills, angry that his wife keeps nagging
him. He has never hit his wife, but he has shoved her a couple of times during a few of
their really bad arguments. The neighbours complained to the police during their last
argument a few weeks ago. He doesn’t know why, they were just yelling at each other as
usual.
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He will spend most of the day at home. He can’t afford to do much else. He has an x-box
console which he plays games on. It keeps his mind occupied. Sometimes he will watch
TV, but there is a lot of rubbish on daytime TV and he finds it a bit boring.
He sees his friends occasionally. He sometimes meets them in the pub for a drink. It’s
good to get out of the house and away from his wife who seems to spend the whole day
complaining.
There is no computer in the house but he does have a mobile phone which he uses to
keep in touch with friends and family.
He has a dog. He wil walk it most days although some days he can’t be bothered. It does
bark at times and the neighbours have complained. He can’t see what the problem is, dogs
are supposed to bark! He got into a fight with one of the neighbours after they reported him
to the council about a month ago. He punched the neighbour and was cautioned by the
police. The fact that the neighbour complained still makes him feel really angry, so he is
avoiding this neighbour as he feels he might punch him again for getting him in trouble with
the police. It is only this one particular neighbour that he seems to keep having problems
with. He has never got into any arguments or fights with any strangers or with any of his
friends.
Mental State Examination Findings:
Appears well, normal build, normal complexion, does not look tired, appears kempt,
wearing casual clothing
Normal facial expression, good rapport, normal eye contact, coped at interview, does not
appear anxious, not hostile or irritable
Normal amount, rate, volume and content of speech
No thoughts of self harm
Did not require any prompting, general memory and concentration adequate
Good insight
Questions:
1. What are your initial thoughts about this case?
2. Is there any other information that should be sought in the history?
3. What descriptors do you think would apply for appropriateness of behaviour?
4. What pieces of evidence support your descriptor choice?
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2.1 Mentor Guidance Notes for Discussion Case Two
This is a claimant with mild depression and anger management issues. There are no
significant mental health issues. It is designed to allow discussion of assessment of anger
and behavioural issues in claimants. It may be helpful to have a copy of the Revised WCA
handbook (either hard copy or on SharePoint) at hand.
1. What are your initial thoughts about this case?
Depression appears mild
Claimant has anger management issues not necessarily related to his mental health
condition, he feels frustrated at being out of work, however there is evidence he can
control his behaviour
2. Is there any other information that should be sought in the history?
History of drug and alcohol misuse (cocaine use can cause similar behaviour and
alcohol can fuel arguments & fights)
3. What descriptor do you think might apply for the appropriateness of behaviour
activity?
‘None of the above apply’
If HCP has applied any other descriptors, explore what evidence has been used and
discuss
4. What evidence that supports ‘none of the above apply’ descriptor?
Mental health condition is mild
Can look after a small child safely
He is aware of his anger problems and takes steps to avoid confrontations
Normal MSE findings with normal insight
Further questions to ask HCP:
What is the scope for the Appropriateness of Behaviour descriptor?
There has to be evidence of a disorder of mental function (present in this case but it
is mild)
What behaviour is considered unreasonable in an average workplace? (likely to be
more than just verbal aggression alone)
There must be evidence that the claimant is unable to control their behaviour
Problems with behaviour are directed against a variety of individuals and not towards
a particular individual only
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What are fertile areas in the history for evidence of appropriateness of behaviour?
Previous occupational history
Shopping
Childcare
Parents evenings at school
Relationships with neighbours
Ability to cope at appointments: GP/ hospital etc
Ability to cope with bills and on the phone
Dealing with finances and bills at the post office
Appointments with people in authority such as the bank manager / social worker /
benefits personnel
What kind of information/evidence might support the claimant having problems with
appropriateness of behaviour?
Significant condition with associated lack of insight eg brain injuries, dementia,
psychosis, learning disabilities
Abnormal MSE findings – poor insight, poor rapport, evidence of a thought disorder,
cognitive impairment, hostility, irritability, aggressive manner towards HCP or other
staff
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3. Discussion Case Three
Name:
Mr Jason Cleaver
Age:
35 years old
Med 3:
Anxiety
113: Mild depression and Anxiety. Not seen often at practice, last was over a year ago.
Has been under the psychiatrist. Has improved. Recently discharged from CMHT care.
Letter from psychiatrist: Dated 6 months previously. Contains the following: “Jason has
long standing depression and anxiety. Whilst under the care of the CMHT his condition has
improved, he is able to socialise in the community and he describes his anxiety as
improved. He has been discharged back to the care of his GP.”
ESA 50: Completed by claimant’s mother - has written “I have severe depression and
anxiety. I can not live by myself and I require a carer.”
Learning tasks – has written “I have difficulty learning any new task. My mother
has to help me.”
Awareness of hazard – has written “My mental state is such that I am unable to
cook. My mother does all the cooking.”
Initiating personal action – has written “I need prompting to get dressed and
washed. I don’t do any personal action at all.”
Coping with change – has written “I can not cope with any change, my mother
has to look after my daily affairs.”
Getting about – has written “I do not leave the house by myself.”
Coping with social situations – has written “I do not socialise. I stay in my room. I
only see my family.”
Behaving appropriately – has written “I have episodes when I get very angry and
I yell at my family. These episodes are very distressing for my family to deal
with.”
History at assessment:
Attended for the assessment with his mother, who was very keen to speak on her son’s
behalf. She said it was because he would not give the full picture of his disability, and as
she was her son’s carer, she would be able to provide a much more accurate overview.
With explanation and reassurance to both the claimant and his mother, the claimant was
able to give most of the history himself.
Medication: venlafaxine 225mg daily, propranolol 40 mg daily, mirtazepine 45mg daily.
He was diagnosed with anxiety and depression as a teenager. It has been much worse
over the last 5 or 6 years. Before that he was living independently in a flat and working as
an architectural draughtsman. He had to stop work after his anxiety worsened to the point
that he was having panic attacks at work. He was finding it difficult to go out, so moved
back home with his parents so that they could assist him.
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Mother says he is still under the care of the psychiatrist, they have an open appointment so
can return at any time.
He sleeps poorly and usually lies awake worrying. Feels un-refreshed in the morning when
he wakes. Wakes at different times. He will get dressed and washed most days. Says he is
able to do this on his own. He will sometimes join his parents for breakfast downstairs but
often his mother will bring him breakfast in his room.
Has a TV in his room which he has on for background noise. Doesn’t real y pay attention to
it. He is not interested in any of the programmes on TV. He does have a games console
which he uses during the day to play games, although not every day.
He was able to go to the psychiatrist by taxi by himself, but he could not travel by public
transport. Currently he does not leave the house and actually spends most of the time in
his bedroom. He feels unwell and anxious all the time and does not want to see anyone.
He has not seen any friends for the last 3 months. Except for appointments, he last left the
house 3 months ago when he went to the supermarket with his mother.
He will sort out his usual bills and appointments but if he receives anything new or an
appointment is changed at the last minute, then he lets his mother deal with these as he
does not feel up to dealing with any stress at present. She wants him to go back to see the
psychiatrist but he does not feel well enough to make the trip to the hospital to see him. He
has been to his GP 4 weeks ago, with his mother, but although he managed to keep his
appointment, he did not like the fact that it was a locum doctor who saw him, as he does
not feel comfortable with strangers.
Mental State Examination Findings:
Appears unwell, overweight, very pale complexion, looks tired, appears kempt, wearing
casual clothing
Reduced facial expression, poor rapport, poor eye contact, significant difficulty coping at
interview, appeared anxious, fiddling constantly
Reduced amount of speech, spoke quietly, content of speech normal
Occasional thoughts of self harm, would never act on it because of the effects on his
parents. No active plans or intent. Has never actually self harmed or made any suicide
attempts.
Did not require any prompting, general memory and concentration adequate
Normal cognitive assessment
Adequate insight
Questions:
1. What are your initial thoughts about this case?
2. What descriptors do you think might apply in the Mental Function Assessment?
3. What pieces of evidence support each of your descriptor choices?
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3.1 Mentor Guidance Notes for Discussion Case Three
This is a claimant where there is inconsistency between the medical evidence on file and
the evidence obtained at assessment. It is complicated by an over-protective mother.
However the evidence from the typical day is supported by the abnormal mental state
examination findings and overall there is likely to be significant disability.
1. What are your initial thoughts about this case?
Conflicting evidence from GP/psychiatrist and evidence at assessment
High level of disability on the Typical Day
High level of medication
Abnormal MSE findings
Likely to have significant disability
2. What descriptors do you think might apply in the Mental Function Assessment?
Learning: None of the above apply
Hazard awareness: None of the above apply
Personal action: None of the above apply
Coping with change: CC(c) cannot cope with minor unplanned change
Getting about: GA(b) unable to get to a familiar place alone
Socialising: CS(c) engagement in social contact with unfamiliar people precluded
majority of the time
Appropriateness of behaviour: None of the above apply
3. What pieces of evidence support each of your descriptor choices?
Discuss with the HCP which pieces of evidence support each of their descriptor
choices (especially if the HCP’s descriptor choices are different from the above)
Further questions to ask HCP:
What if the medication was citalopram 20mg and the MSE findings were normal, how
might that affect the descriptor choices?
Further probing of the claimant’s history would be necessary. The HCP would need to
logically reason the inconsistent evidence (the FME, MSE, level of medication are all
consistent with low level of disability, only the Typical Day History is consistent with high
level of disability).
It may be possible to apply and justify ‘none of the above apply’, discuss with HCP.
Ask the HCP to take a few minutes to write a PSS for this case and review.
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4. Discussion Case Four
Name:
Ms Helen Chin
Age:
32 years old
Med 3:
Depression
ESA 50: Has written “I see my GP for my medical conditions.”
Learning tasks – has written “It depends how I am feeling.”
Awareness of hazard – has written “When I am very depressed I can’t be bothered.”
Initiating personal action – has written “When I am very depressed I can’t be
bothered.”
Coping with change – has written “I hate going out and doing things when I am very
depressed.”
Getting about – has written “I hate going out and doing things when I am very
depressed.”
Coping with social situations – has written “I don’t like to talk to people especially
when I am very depressed.”
Behaving appropriately – has written “Friends and family say I am snappy especially
when I feel very low.”
History at assessment:
Attended assessment alone.
She was diagnosed with anxiety and depression 3 years ago following the break up of a
relationship. She was referred to the Community Mental Health Team (CMHT) two years ago
after she took an overdose and was admitted to hospital for 3 days. She overdosed on
Paracetamol and Diazepam with a 750 ml bottle of Vodka. Her cousin found her
unconscious. He happened to come home early from work that day. She was in contact with
CMHT up until a year ago when she was discharged from their care.
She thinks she is better now, but she still gets bouts of low mood and anxiety. She sees the
GP every 2 months. She says GP is thinking about referring her for CBT. Currently taking
citalopram 40 mg daily.
She usually has initial insomnia at night, and eventually gets to sleep about 1 am. She wakes
up about 9 am despite feeling tired and un-refreshed. She does not feel like washing and
dressing, but usually gets around to doing so daily most weeks. About every 6-8 weeks her
mood gets lower and she does not want to wash and dress. She tries to clean the house
most of the time except for those periods when mood gets very low. She goes to the local
shops for groceries. She avoids going into town as she gets too anxious when it is crowded.
During the day she usually tries to watch TV. She follows the chat shows and likes to watch
Coronation Street. She spends the evening at home with her cousin. They watch TV
together. He encourages her to get out and about and would take her to the cinema once a
month.
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Mental State Examination Findings:
Looks tired
Casually dressed
Fiddling with her fingers
Reduced eye contact
Adequate concentration and general memory
Speech - normal content, normal rate and volume
Questions:
1. What are your initial thoughts on this case?
2. Are there any key indicators of concern in the history?
3. What further information might be asked for in the history?
4. Are there any other Mental State Examination findings that should be assessed?
4.1 Mentor Guidance Notes for Discussion Case Four
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This is a claimant with depression that has improved after a significant self harm attempt a
couple of years ago. It is designed to allow discussion around levels of severity of depression
and self harm issues.
After discussing the initial case you will change the scenario slightly to reflect a greater level
of disability and risk (see below)
1. What are your initial thoughts on this case?
She still has features of depression but of variable severity. More probing in history is
necessary to clarify the extent
2. Are there any key indicators of concern in the history?
She has a previous history of self harm (two years ago)
Contact with CMHT (1 year ago)
Not clear if she still has any current / recent self harm / suicidal thoughts
Why is the GP thinking about referring to CBT?
3. What further information might be asked for in the history?
More details on current symptoms
Discuss any current or recent self harm / suicidal thoughts
Address variability more. Clarify how long the periods of lower mood last
Enquire further about activities of daily living such as cooking and eating, getting
about and interacting with others
4. Are there any other Mental State Examination findings that should be assessed?
General appearance – any signs of neglect
Rapport
Other indicators of anxiety such as sweating
Behaviour – irritability?
Cognition – orientation and memory
Insight
Self harm / suicidal thoughts or actions – plans, nature, intent and frequency
It may be useful to discuss the diagnostic features of depression and indicators of severity
(see Mental Illness document) at this point.
Change the scenario
Discuss with the HCP
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Last admission for self harm 9 months ago
Still seeing CMHT, the CPN visits at home every two weeks. Has a CPA
CRISIS team contact 5 months ago as felt suicidal
Dresses most days of the week, but prompted about twice a week by cousin and
sister. Sister moved in to help keep eye on her. She has self harm thoughts every few
weeks. Feels hopeless and not sure if she wants to live. Sister now supervises
medication
Ask the HCP what their thoughts on this updated scenario are and how the outcome
may differ from the original scenario?
There are more key indicators of concern:
Recent history of self harm and ongoing thoughts
Hopelessness
Higher levels of input
CPA in place
Risk needs to be considered in the second scenario. Although the information is limited with
the second scenario, an outcome of applying the mental risk Support Group should be
discussed.
Ask about prognosis: at least 6 -12 months would be appropriate. If time allows – discuss
prognosis in such cases.
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5. Discussion Case Five
Name:
Mr Quentin Reeve
Age:
34 years old
Med 3:
Drug addiction
ESA 50: Has written “I am depressed a lot and don’t I want to do anything. I hate forms
and my sister is helping me fill this one out. I kicked the drugs but the alcohol is my
comfort. I tried detoxification for alcohol and it has not worked yet. When I have the
strength I may try again. My sister and counsel or keep nagging me to try again.”
Learning tasks – has written “I hate reading; I can’t be bothered to learn anything
new.”
Awareness of hazard – has written “My sister and mother cook for me; I would burn
the house down as I do not concentrate on things.”
Initiating personal action – has written “Most of time I can’t be bothered to get up and
get washed and dressed. My sister and mother nag me to do things.”
Coping with change – has written “I hate change. Don’t bother to go anywhere.”
Getting about – has written “I prefer to stay at home. My mum and sister nag me and
take me out.”
Coping with social situations – has written “I was a crack head and I don’t like people,
they make me scared. I am paranoid. I only trust my sister and mother.”
Behaving appropriately – has written “I try to keep to myself. Some days I get irritable
with my sister when she nags me.”
History at assessment:
Greeted in side room at MEC as he had told the receptionist that he was too anxious to stay
in waiting room.
Sister present at assessment.
He gave up heroin and crack and is trying to cut down his alcohol intake now. He attends
alcohol services for individual counselling every two weeks. The counselling started 6
months ago. He tried cannabis four years ago but stopped after only a few weeks. He has
had one hospitalisation four years ago, when he was hearing things and had thoughts people
were trying to poison his food. He now describes feeling paranoid around people and panics
when outside the house. Two years ago he stopped drinking for a few months and GP
started him on an antidepressant. The antidepressant was stopped after 6 months as he had
started to drink again. He says the GP will treat the anxiety and depression, but told him he
needs to be clean from drugs and excessive alcohol first. He is still drinking alcohol every
day but is trying to cut down the amount he drinks.
Lives with mother and sister. He sleeps poorly as things are always on his mind. Drinking
alcohol helps him sleep. He gets up at different times. His sister and mother encourage him
to get up as he often feels tired and low. His appetite is poor. He spends most of the day in
his room drinking lager or out in the garden alone having a cigarette. Every few days he goes
to the local shop alone to buy alcohol and cigarettes.
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He knows the shop keeper from childhood. His mother helps him to get ready and takes him
to the appointments with the counsellor. He doesn’t think he would go otherwise. He missed
his grandmother’s funeral 4 months ago as he was too anxious to travel to her town 15 miles
away. He finds alcohol calms him down and makes him feel less anxious. When he is not
able to have a drink he gets irritable.
Mental State Examination Findings:
Looks tired
Thin
Well kempt, casually dressed
Restless, fiddling with his fingers
Avoided eye contact
Speech - normal content, normal rate
Faint smell of alcohol
Questions:
1. What are your initial thoughts on this case?
2. Are there any key indicators of concern in the history?
3. What further information might be asked for in the history?
4. What areas should be probed in claimants with drug and alcohol misuse?
5. Are there any other Mental State Examination findings that should be assessed?
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5.1 Mentor Guidance Notes for Discussion Case Five
This claimant has a history of significant alcohol use and at least moderate depression with
features of anxiety. It is designed to allow discussion of assessment of claimants with drug
and alcohol misuse. With more detail, the HCP may be able to advise on a functional support
group, such as personal action or coping with change, or mental risk in this case.
1. What are your initial thoughts on this case?
This claimant has a history of significant alcohol use and some features of depression
and anxiety.
With further information and clarification, he may have significant restriction overall
(considering areas such as personal action, going out and social engagement).
2. Are there any key indicators of concern in the history?
Previous mental health admission, but not within the last 12 months (unclear if was
under section)
Ongoing alcohol misuse
Alcohol services involvement
Significant support from family
Need to probe and clarify paranoid feelings as these may be significant. Discuss
assessment of paranoia (not taken at face value, needs to be probed during assessment
to understand what the claimant means by the term):
o paranoia refers to feelings of distrust, suspicion or persecution that are not based in
reality
o paranoid does not just mean persecutory, but also allows people to define things
around them to have a special, personal significance
o paranoia leads a person to think they are being singled out in a negative way, people
will often look for evidence to prove they are being singled out and refuse to see that
they have an exaggerated view of their own significance
o paranoia is a mental symptom of many types of mental illness
Discuss definitions of delusions and hallucinations and how these are assessed (see case
one for definitions)
3. What further information might be asked for in the history?
Quantity of alcohol consumed per day/week
Clarify what is meant by paranoid, description of what happens
Probe around hallucinations noting any further episodes
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Clarify what is meant by panic
Any other mental health symptoms: mood, motivation, concentration
Further detail in typical day - explore motivation issues around self care activities
(washing, dressing, eating etc). Get indication of
frequency and
extent of prompting.
Ask about other domestic activities such as cleaning and shopping
Explore behaviour and interaction with others
Claimant well kempt today and casually dressed: sensitively explore how they
prepared for today
Ask about self harm / suicidal tendency
4. What areas should be probed in claimants with drug and alcohol use?
Condition history
Quantity of alcohol consumed
If possible, estimate units
Type of drugs used
Frequency of drug intake
Any specific symptoms and how long these last
Any withdrawal symptoms
Clarify things such as blackouts if mentioned: What does the claimant mean? Is it a
drunken stupor?
Last alcohol / drug detoxification
Explore current treatment, any further plans for detoxification, effects of treatment
Lifestyle – Chaotic?
Other medical conditions present – liver failure, cardiomyopathy, oesophageal
varices? May need to perform an appropriate physical examination if relevant
5. Are there any other Mental State Examination findings that should be assessed?
Rapport
Other indicators of anxiety such as sweating
Behaviour – irritability?
Speech – volume
Cognition – orientation and memory
Insight
Self harm / suicidal thoughts or actions
Abnormal Thoughts and perceptions
Level of intoxication (noted faint smell of alcohol)
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Discuss how a claimant who is intoxicated at assessment and persistently
uncooperative should be handled at assessment.
Refer to the Revised WCA Handbook subsection on the uncooperative claimant
Refer to Unacceptable Claimant Behaviour Procedure Process Guide
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6. Discussion Case Six
Name:
Ms Jeannie Smythe
Age:
24 years old
Med 3:
Mild depression
ESA 50: Has written “I have very bad depression. I am very unwell and I cannot work.”
Learning tasks – has written “I’m not able to learn any new tasks.”
Awareness of hazard – has written “I can’t cook and I have no awareness of
hazard.”
Initiating personal action – has written “I don’t do any personal action, my
depression is very bad.”
Coping with change – has written “I can not cope with any change.”
Getting about – has written “I do not leave the house by myself.”
Coping with social situations – has written “I do not socialise at all. My depression
is very bad.”
Behaving appropriately – has written “I have episodes of inappropriate
behaviour.”
History at assessment:
Diagnosed with depression after the breakdown of a relationship 6 months ago. It is
managed by her GP. No referral to secondary services. She is waiting to start a course of
counselling.
Not on any medication.
Last worked 3 months ago as a florist’s assistant, was laid off because the business was in
financial difficulties.
Lives alone in a 1 bedroom flat.
She sleeps poorly, she lies awake feeling sad. She will then wake late in the morning. She
will often lie in bed until late morning. She does not get dressed or washed.
She doesn’t do any housework or cooking. She doesn’t like to go shopping, she can’t be
bothered. She doesn’t see anyone, and spends all day in her flat alone. She does not go
out to socialise. She has to be accompanied if she leaves the flat.
She has a mobile phone but doesn’t use it.
She can’t cope with any change, and she often yells and screams at people as she has no
patience at the moment.
Mental State Examination Findings:
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Appears well, overweight, normal complexion, does not look tired, appears kempt, wearing
casual clothing
Normal facial expression, good rapport, normal eye contact, coped at interview, does not
appear anxious
Normal amount, rate volume and content of speech
No thoughts of self harm
Did not require any prompting, general memory and concentration adequate
Good insight
Questions:
1. What are your initial thoughts about the case?
2. What further information from the typical day would be useful?
6.1 Mentor Guidance Notes for Discussion Case Six
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This is a case where there is significant inconsistency between the history given at
assessment and the Med 3/clinical history/MSE findings. It is designed to help HCPs
develop further questioning / probing skills and logical reasoning of these inconsistencies
to provide a robust justification.
1. What are your initial thoughts about the case?
Significant inconsistency within the evidence presented
Evidence suggesting mild disability: Med 3, clinical history and normal MSE
findings
Evidence suggesting significant / severe disability: Typical Day History
2.
Ask the HCP how they might resolve it – Typical Day history needs to be probed in
greater depth. Discuss the need for asking probing questions at times.
It might be useful to role-play this with the mentor acting as the claimant, revealing the
further information only if sufficiently probing questions are asked.
Further information:
Stays in bed late watching TV most mornings, but if she does have to get up for something
specific, she will get up and make it to the appointment. Lies in bed because she has
nothing else to get up for. When she gets up, she generally does get dressed and she has
a shower most days. She does not like being dirty. Although she doesn’t feel like cleaning
the house she still does the housework. It is only a small flat and doesn’t take her very long
per week. She does not like to have a dirty kitchen or bathroom.
She doesn’t like going to the supermarket as there are too many people there. So she
does most of her shopping at the local shops. Sometimes she will go to the supermarket in
the evenings, when there are less people, as things are cheaper in the supermarket. She
goes shopping alone. None of her family or friends live close by.
She spends the day watching TV or reading. She goes to the library in the town centre
once a fortnight to get some books. She has a computer at home and uses the internet to
keep in touch with friends and family. She has a pet rabbit and some goldfish. She doesn’t
see her friends that often, none of them live close by. She keeps in touch via Facebook
and perhaps once or twice a month will catch up for a coffee or a film. She manages her
own household affairs. She has had a couple of episodes where she has got frustrated
with poor customer service and ended up yelling at people. She knows she shouldn’t but
her illness seems to have made her less patient than before.
Now ask HCP for level of disability and suggested descriptors:
No significant functional restriction with ‘None of the above apply’ descriptors for all
mental function categories
If there is time, ask the HCP to spend a few minutes writing a PSS and review.
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Section Two - Practice Scenarios
These practice scenarios are designed to be completed using LiMA on the training server.
Local training NiNos should be used.
The whole case report should be completed and then the case discussed with the mentor.
An hour is allocated for each case, including discussion. Therefore the HCP is advised to
enter only minimal essential information in the history section, along with the MSE findings
and to concentrate on choosing an appropriate outcome and justifying this by completing the
PSS. The case should be finished in about 45 minutes to allow 15 minutes for discussion.
The mentor may need to prompt to ensure these timings are followed. The review and
discussion of each case is important and designed to consolidate learning and should not be
skipped.
There are 5 cases, 3 compulsory and 2 optional. Three cases should be completed in a
session.
Guidance notes for the mentor are provided for each case. For each case there will be some
relevant points about the case to be brought out in the ensuing discussion. Suggested
outcomes and a suggested PSS are provided for each case. It should be an opportunity for
HCPs to discuss and consolidate learning around levels of evidence required to support
descriptor choices as well as appropriate justification of opinion.
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7. Practice Scenario One
Name:
Mr John Taggart
Age:
27 years old
Med 3:
Bipolar Disorder
113:
Bipolar disorder for 5 years. Under regular psychiatric review. Stable
on medication. No recent hospitalisation. No active psychotic features.
No self harm tendency.
None of the boxes suggesting any functional restrictions were ticked
with comment: “Has been stable for past few years, lives with family
but able to function well for most of the time”
Able to attend for assessment using public transport or taxi
No history of threatening or violent behaviour
Additional comment: “Would benefit from supported or voluntary work”
ESA 50: He has written “I am bipolar and I see my CPN and Psychiatrist often. I am
not as bad as I was five years ago when I was hospitalised.”
All physical function descriptors – no problem
Learning tasks – has written “It depends how I am feeling.”
Awareness of hazard – has written “When I am very depressed I can’t be
bothered. When I am manic, anything goes.”
Initiating personal action – has written “I do manage but when I am very
depressed I can’t be bothered.”
Coping with change – No problem
Getting about – No problem
Coping with social situations – has written “When I am very depressed I don’t
want to talk.”
Behaving appropriately – has written “When I am manic I get very excited.”
Information from Assessment:
Clinical History
It started 5 years ago when he was at university studying computer science. He was
admitted to a psychiatric unit for 3 months. He did not go back to university. Three
years ago he had delusional thoughts, he thought he was a new superhero and he
could stop speeding motorists by flying from a pedestrian bridge over the motorway.
He was sectioned and admitted to the psychiatric unit for three weeks.
He now sees the CPN every 6 weeks and the psychiatrist every 3 months, but he can
see the psychiatrist more often if the CPN thinks he needs to be seen.
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The psychiatrist usually reviews his medication at each visit. He has regular blood
tests every 3 months. His describes his mood as a bit low most of the time with
occasional days when it gets even lower. He also gets periods where his mood lifts to
the extent that he becomes very active with him not wanting to sleep much. These
episodes of excess activity may occur about 2 times a year and can last between 3-7
days. He was told by his psychiatrist that he may get these episodes from time to
time and these are hypomanic episodes. The psychiatrist advised him not to stop the
medication because he is feeling energised. He has learned to look out for these
episodes and tries to keep taking his medication. The last hypomanic episode was
three months ago and lasted about 7 days. His family usually realise when these
episodes are in progress as he becomes more talkative, impatient and at times
irritable. They alert the CPN to ensure he is supported during these episodes. The
family are very supportive. He had CBT 2 years ago. He has no current thoughts of
self harm/suicide.
The last time he had such thoughts was around the time of admission 3 years ago.
Medication
Lithium 250 mg twice daily
Olanzapine 10 mg once daily
Side effects
Reports weight gain and feeling tired.
Social and Occupational History
Lives with parents and sister. His sister, Jane, gave him a lift and was present during
the assessment.
He last worked 5 years ago as a part time shop assistant while at university. He never
returned to work after the first hospital admission.
Typical Day History
He usually sleeps well except for the periods when he becomes more active. He goes
to bed about 11 pm and gets up around 9 am. When he is having an active episode
he can stay up until 3 am but still gets up at his normal time. During these periods he
would spend hours and hours on the computer surfing the internet or writing multiple
computer programmes none of which he ever finishes. He gets irritated and a bit
snappy with his sister if she disturbs him during these writing sessions.
He usually manages to get washed and dressed when he is feeling low. On the odd
day every few weeks he will stay in bed without getting washed or dressed. On these
days he would only get up to go to the toilet, have a snack and take his medication.
The family usually leave him alone on these days. He gets back to his usual self after
a day or two.
After the other family members leave for work, he takes the dog for a walk in the local
park. He then spends the rest of the day watching TV or using the computer. He likes
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chat shows and movies. He selects movies from the on demand TV service. Most
days he spends about 1- 2 hours on the computer. He plays computer games as well
as Sudoku puzzles online and chats with two of his friends from school days. They
both live in Edinburgh now and run a small IT firm. There is an occasional day every
few weeks when he cannot manage to chat to them as he feels low and cannot be
bothered. Apart from those friends in Edinburgh, he has lost contact with his other
friends.
He learned to cook before going to University and now manages simple meals most
of the time except for those days when he is feeling very low. Sometimes he helps his
sister plan and prepare a more elaborate meal for the family. His older brother, kids
and wife visit for these meals. His sister is attending catering school and wants to be
a chef. He reports no recent kitchen accidents. He may go to the supermarket with
his sister when they have a big meal planned. Otherwise, he goes to the local shop
about once or twice a week alone to get bread and milk etc.
He previously played the lottery but stopped 3 years ago, when he was unwell. At that
time he was sure it was his turn to win and spent a lot of money on tickets. He had
multiple problems with excessive spending at that time but this is now under control.
He manages his own finances mainly through internet banking.
He previously liked driving and was his sister’s ‘taxi’ before she learnt to drive.
However, since his first hospitalisation he rarely drives as he finds it too stressful. He
last drove 7 months ago when went to the local garden centre with his mum to collect
some items. She is an avid gardener and has a greenhouse with orchids and exotic
plants. He catches the bus on his own into town once or twice a week. He visits
charity shops to see if he can find second hand computer games.
He usually spends the evenings with his mum, dad and sister. They encourage him
to keep active and would chat with him about their day at work or college. After
chatting and watching TV, he goes to bed.
Mental State Examination
Casually dressed, well kempt, looks well
Slightly reduced eye contact, normal facial expression
Not restless or irritable
Adequate rapport, adequate concentration, general memory and recall adequate
Speech normal rate, volume and content
No thought or perception disturbance
No self harm thoughts
Normal insight
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7.1 Mentor Guidance Notes for Practice Scenario One
This is a claimant with bipolar disorder, who is relatively stable. It is an opportunity to
consolidate learning around clinical features and treatment of bipolar disorder along
with a need to assess variability and whether it is appropriate to apply the mental risk
NFD (exceptional circumstances).
The case is designed so that there is insufficient evidence to support the application
of the risk NFD.
The 113 confirms stability, with no evidence to suggest that substantial risk would
apply.
Careful review of justification of the non application of the risk NFD is required. It is
not sufficient to say there is no evidence that the claimant is at risk. His diagnosis and
medication could be considered key indicators of concern, but there is insufficient
other evidence to suggest he is at risk.
Suggested Outcome:
None of the scoring descriptors apply and all areas should be: ‘None of the above
apply’
None of the Support Groups or Exceptional Circumstances apply in this case
Sample PSS:
Mr Taggart has bipolar disorder and is currently under the care of the psychiatrist. He
has had no recent psychiatric admissions or thoughts of self harm. He has episodes
of feeling very low on the odd day every few weeks. He also has episodes of
hypomania about twice per year lasting up to a week. However, the majority of time,
despite some ongoing low mood, he is able to manage a number of activities unaided
including his own medication, self care and interaction with his family.
With the exception of slightly reduced eye contact, the mental state examination was
normal which is consistent with the history.
Significant restriction of mental function is unlikely.
Remind the HCP they can call and discuss any mental health case they are
unsure about with the MFC.
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8. Practice Scenario Two
Name:
Mrs Jayne Cresswell
Age:
45 years old
Med 3:
Depression
ESA 50: Has written “I have been diagnosed with depression. It affects every part of
my life. Everything is a struggle currently.”
All physical function descriptors – no problem
Learning tasks – no problem
Awareness of hazard – has written “I don’t have the energy or concentration to
cook or drive.”
Initiating personal action – has written “I struggle with my motivation, it’s hard to
find the energy to do anything. “
Coping with change – no problem
Getting about – no problem
Coping with social situations – has written “I have no interest in seeing either
friends or family.”
Behaving appropriately – no problem
Information from Assessment:
Clinical History
She attended with her husband who provided the majority of the history.
She was diagnosed with depression about 12 months ago. She has a history of
depression, first diagnosed when she was 20. She was admitted to hospital for 2
months after a serious suicide attempt at that time. She has had episodes of
depression intermittently since that time. The last was about 5 years ago. This current
episode was precipitated by the death of her grandmother who she had been very
close to.
She was diagnosed by her GP and commenced her on citalopram. There was no initial
improvement and she was referred to the CMHT. Her medication has been increased
and changed several times over the last 10 months. There has been some gradual
improvement but she has significant ongoing symptoms. She currently sees a CPN
every fortnight and the psychiatrist every month. Her main symptoms are low mood,
fatigue and feelings of hopelessness, with poor sleep and poor concentration.
She has occasional thoughts of self harm. No active plans (when she was first
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diagnosed she had thoughts of self harm and was formulating plans around collecting
tablets, it has improved with treatment)
Medication
Venlafaxine 150mg daily
Fluoxetine 60 mg
Social and Occupational History
She attended the Medical Examination Centre with her husband, who was present
during the assessment and provided most of the history.
They live in a semi detached house and have no children.
Typical Day History
She sleeps poorly. She has difficulty getting to sleep, as she keeps worrying about
things. She then wakes early (4-5 am). She remains in bed in the morning, as she
does not wake refreshed. She lacks the energy to get up and get going in the morning.
Her husband has been very supportive. Initially he took time off work to look after her
when she was really unwell at the beginning of this episode. He often needs to prompt
her to get out of bed, although this has improved recently. She may manage this on
her own a couple times a week now. He will bring her a cup of tea and some toast in
bed. She doesn’t have much of an appetite and has lost about a stone in weight since
she became unwell.
On the days that she does get out of bed without prompting, she generally has a
shower and gets dressed, but on the other days her husband needs to chivvy her
along about these things. She just feels so tired.
Her sister lives near by and often comes to spend the day with her, whilst her husband
is at work. It is something her husband has arranged, she doesn’t really feel like
seeing anyone including family, but she accepts they are doing it to try to help her.
She used to be an avid reader but does not have the concentration to read currently.
She might flick through a few magazines that her sister brings around but she doesn’t
take anything in. Sometimes the TV is on but she has no interest in watching any
programmes. Her sister likes to watch daytime TV, but whilst she is sitting there with
her sister, she is not following the programmes. She feels low all the time and is often
tearful during the day. She can’t see how things wil improve and feels everything is
hopeless. She has occasional thoughts of self harm, but would not act on them
currently as she could not do that to her husband.
Her sister or her husband will take her out for a drive a few times a week. She will go
but has no interest in these outings. They go to places she has not been before but
she can’t remember the place names. She never goes out on her own as she always
feels too tired and she does not like talking to strangers. She has stopped going
shopping and her sister or husband does this now.
Her husband does the housework, cooking and running of the household currently. If it
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was left to her it wouldn’t get done. She will tidy up a bit on her better days and may do
the dishes, however she avoids anything to complex. Also she is too distracted in the
kitchen, there were a couple of incidents where she left something boiling on the stove
and wandered away. It set the smoke detector off on both occasions. Her husband
and sister frequently ensure she does not use the cooker but she usually manages to
make herself a cup of tea or some toast. She has also stopped driving because her
husband does not allow her to, she thinks she could still drive but lacks motivation to
do so, however her husband indicated that the last time she drove, she went the
wrong way down a one way street and nearly crashed into another car. Since then he
has not really allowed her to drive.
She has not used the computer at home since she became unwell. She does have a
mobile phone and her husband will call to talk to her a few times during the day. She
used to ignore it, but now she does answer it, as she knows her husband worries if
she does not answer. She does not like it when someone knocks on the door
unexpectedly, but she will still see who it is and just send them away if she does not
know who they are.
She has stopped seeing her friends as she just does not feel up to it. It is too tiring and
she has no interest in seeing anyone.
Mental State Examination
Appears unwell, thin, pale complexion, looks tired, appears kempt, wearing casual
clothing
Reduced facial expression, poor rapport, poor eye contact, has psychomotor
retardation
Spoke very little, spoke quietly, content of speech normal
Occasional thoughts of self harm, no active plans
Needed frequent prompting, appears distracted, concentration poor, general memory
adequate
Had some difficulty coping with assessment and often looked to husband for
reassurance, she let him do most of the talking and only answered some direct
questions herself
Limited insight
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8.1 Mentor Guidance Notes for Practice Scenario Two
This claimant has severe depression and there is sufficient evidence contained within
the scenario to apply the mental risk SG. The case is designed to allow discussion
around the clinical features of depression, indicators of severity of depression, and
the risk NFD/SG
Ask the HCP if they think the claimant has a severe mental illness. The answer
should be yes.
Review the case once the HCP has completed it. Check the MSE findings have been
entered correctly. Check the descriptor choices and overall outcome.
Suggested Outcome
Mental Health Descriptors:
Learning: LT(d) None of the above apply
Hazard awareness: AH(b) Frequently require supervision
Personal action: IA(b) Cannot initiate personal action for the majority of the time
Coping with change: CC(d) None of the above apply
Getting about: GA(b) Unable to get to a familiar place alone
Socialising: CS(c) Unable to engage with unfamiliar person for majority of the time
Appropriateness of behaviour: IB(d) None of the above apply
Exceptional circumstances
This would be curtailed as the claimant would have scored over the threshold
Support Group
The Mental Risk SG should have been applied in this case
If different descriptors are chosen, go through each one discussing what evidence
supports that descriptor choice, it may also be useful to review the scope of each
descriptor.
Look to see whether the mental risk SG has been applied. Discuss the indicators in
this case that would make application of the risk SG appropriate?
Background of significant mental health problems (suicide attempt and
hospitalisation, albeit a long time ago – not enough on it’s own but consider in
combination with other factors)
Level of input – under CMHT with input from CPN and psychiatrist
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Medication regime, on second line treatment for depression
Attended the MEC with her husband, could not have come by herself
Did not cope that well during the assessment, in fact she was quite withdrawn,
with poor eye contact and poor rapport and most of the history was provided
by the husband
Appears significantly depressed at assessment
Discuss that it is not one isolated piece of evidence in this case that suggests the risk
SG is appropriate to apply, rather it is the overall combination of several factors.
Discuss that Risk NFD can still be applied when a claimant is below threshold and
that Risk SG may be applied to claimants regardless of whether they are below or
above threshold.
Remind HCPs that when assessing the risk NFD/SG in mental health cases, it is not
just about the risk of suicide. Risk of deterioration in mental health if they are found fit
for work or work related activity must also be considered. Remind HCPs on the
Update to Standard on substantial risk in claimants with a mental health problem.
HCPs have to consider what will be the impact of the WFI (Work focussed interview)
process on the claimant. Ensure the HCP understands what the WFI process entails.
Other things that could be considered when considering risk (but which are not
present in this case) are:
Suicide risk or recent history of significant suicide attempts
Recent hospitalisation (voluntary/under section)
Need for home visits by GP, care workers or Atos
Living circumstances, living alone, unsupported
Occupational history (repeated job failures, length of time since they have
worked)
Substance misuse
Co-existing physical or mental health conditions
Co-existing social/family problems – separation/divorce, bereavement, court
procedures, etc
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Sample PSS
Mrs Cresswell has depression and she is being treated with significant anti-
depressent medication. She is receiving intensive support from the CMHT. She
continues to have significant depressive symptoms and is requiring a lot of support
from her family to help her function on a day to day basis. She has had some
accidents at home due to poor concentration, and often needs prompting for self care
although she does manage independently on some days. She does not go out alone
and does not like talking to people other than close friends and family. Mental state
examination was consistent with significant depression and anxiety. She is likely to
have substantial functional restrictions with hazard awareness, personal action, going
out and social interaction, although not with learning tasks, coping with change and
behaviour. However she also has suicidal thoughts, intensive mental health input
and support from family, and it is likely that there would be a substantial risk to her
mental health if she was found capable of work or work related activity.
Remind the HCP they can call and discuss any mental health case they are
unsure about with the MFC.
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9. Practice Scenario Three
Name:
Mr David Ford
Age:
23 years old
Med 3:
Psychosis
113: Psychosis, seen by psychiatrist. On medication. Not seen recently.
ESA 50: He has written “I have been diagnosed with psychosis. I used to hear voices at
times. My medication helps.”
All physical function descriptors – no problem
Learning tasks – has written “It depends how I am feeling.”
Awareness of hazard – no problem
Initiating personal action – has written “Sometimes I cannot be bothered.”
Coping with change – has written “I don’t like changes.”
Getting about – has written “Sometimes I can’t be bothered to go out.”
Coping with social situations – has written “Sometimes I do not feel like talking.”
Behaving appropriately – has written “I used to be very irritable, but this is not as bad
as before. My medication helps.”
Information from assessment:
Clinical History
The condition started about 5 years ago when he was admitted to the mental health unit. He
was behaving strangely at work over a few days and one afternoon he was checking behind
all the televisions looking for the three people who were speaking to him. He became very
disruptive and the police were called and took him to hospital. He was sectioned and
remained in hospital for 4 weeks. He had been smoking a lot of cannabis prior to becoming
unwell and he was diagnosed with a drug related psychosis. For the first year after his
diagnosis he was seeing the CMHT almost every 1- 2 weeks. The frequency was gradually
reduced and he now sees the psychiatrist every year and the CPN every 6 months. At the
time of onset he was having disturbing hallucinations, with three people talking to him all
about different things. These took a while to get under some control with medication. He has
had CBT and his immediate family also attended family intervention. He no longer hears the
voices now; he has not heard any voices for a couple of years. He was also very suspicious
of people and refused to eat anywhere other than home when he first became unwell. He is
less suspicious now and no longer feels everyone is out to poison him. He describes himself
as paranoid of strange people and takes a while to get accustomed to anyone. He thinks his
medication makes him feel quite tired. There have been no further psychiatric admissions.
No current thoughts of self harm / suicide, has never really had any such thoughts.
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Medication
Olanzapine 10 mg once daily – has been on same dose for a few years
Side effects
Reports weight gain and feeling tired
Social and Occupational History
Attended the assessment alone. Used the bus, journey took 20 minutes with a 10 minute
walk from bus stop to Medical Examination Centre.
Lives with his cousin in a two bedroom house.
He worked as a retail assistant in an electronics store up until the hospital admission 5 years
ago. He never returned to work after hospitalisation.
Typical Day History
He usually goes to bed around 11 pm and most of the time drops off to sleep almost
immediately. He usually gets up between 8 and 9 am just in time to see his cousin off to
work. He gets his own breakfast. He likes to prepare bacon and eggs. He takes his
medication and then has a quick wash and gets dressed before sitting to watch morning TV.
Occasionally (once every few months) he doesn’t get washed and dressed until late
afternoon just before his cousin returns.
He is currently helping his cousin paint and decorate the house. His cousin leaves small
tasks for him to do during the day. The bulk of the work is being done over the weekend
when his cousin is home. His cousin is glad to have him home to receive the deliveries.
When he first moved in he found it difficult to even answer the door to the postman, as he
thought people were coming to collect him and take him away. He now knows the postman
well and chats with him. He is able to answer the door and receive the deliveries from the
hardware company and he likes to pack items away in the shed. He is currently searching
the internet for stereo equipment as his cousin is planning to upgrade the home cinema
system.
He gets himself a sandwich for lunch. Most afternoons he reads magazines and surfs the
internet. A few afternoons he would start preparing the vegetables and other ingredients for
dinner. He does some general tidying up. He may go to the local shop to get any missing
ingredients. While there, he may purchase credit for his mobile phone. He uses his mobile
phone for emergencies and to keep in touch with his sister who lives in Wales. He visits her
about three times a year. He travels alone by train for the 2 hour trip. He avoids making the
trips during busy periods and holidays as he finds this more stressful.
When his cousin returns home, they chat and watch TV together. Most days at about 7 pm
the cousin would start getting the main meal ready. They both stay in and watch TV. He
prefers to watch comedies and dramas. He avoids watching science fiction and horrors as
these make him feel distressed.
Occasionally the cousin may go to the pub after work. On those evenings, he would make
himself beans on toast or heat up left-over food using the microwave. On these evenings he
may do a bit more reading or surfing the internet.
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Some weekends he goes out with his cousin for a meal and a movie. They used to go to the
same restaurant all the time, but over the last few months they have been trying different
places. He now feels comfortable enough to place orders for himself and is enjoying going to
the new restaurants. He only has a small glass of wine with the meal as he does not want the
alcohol to interfere with his medication.
Mental State Examination
Alert throughout, not tired looking
Well kempt, casually dressed
Average build
No psychomotor retardation or agitation
Reduced facial expression however maintained appropriate eye contact
Adequate concentration and memory
Speech rate, volume and content normal
No self harm/suicidal ideas
No obsessions
No delusions
No hallucinations
No other abnormal thoughts or perceptions
Good insight
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9.1 Mentor Guidance Notes for Practice Scenario Three
This claimant has a diagnosis of psychosis. This case can be used for a discussion around
psychosis (itself not a diagnosis, rather a symptom) that can touch on the clinical features
of psychosis, treatment and assessment.
Suggested Outcome
None of the scoring descriptors apply and all areas should be: ‘None of the above apply’
None of the Support Groups or Exceptional Circumstances apply in this case
In the risk NFD/SG justification the HCP needs to address why the claimant is not at risk
in view of the diagnosis. Key point is the hallucinations have stopped and he has insight.
He is reasonably stable with the current treatment and functions on a day to day basis. It
is not sufficient to say there is no evidence that indicates that the claimant is at risk (his
diagnosis and medication could be considered key indicators of concern).
Develop discussion around how the situation may be different if having the claimant
reported frequent disturbing hallucinations, more intensive support from mental health
specialists or recent increase in dosage of medication. Discuss potential mental state
findings associated with significant active psychosis symptoms including reduced
concentration and appearing distracted.
Sample PSS
Mr Ford was diagnosed with drug related psychosis. His condition has improved with
treatment and is reasonably controlled with medication currently. He no longer has
frequent, disturbing hallucinations and has not been admitted to hospital since the original
admission 5 years ago. He is able perform a number of self care activities independently,
use new technology such as the internet, travel independently and interact normally with
strangers when required. This is consistent with his mental state findings which were
broadly normal with no psychotic features.
Remind the HCP they can call and discuss any mental health case they are unsure about
with the MFC.
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10. Practice Scenario Four
Name:
Miss
Molly Mears
Age:
20 years old
Med 3:
Moderate
Learning Disability
ESA50:
Not returned
Information at assessment:
Clinical History
Mother explained that the ESA 50 wasn’t returned as it was not received. They have
recently moved. Mother advised that Molly has problems with learning tasks, hazard
awareness and getting about.
She was diagnosed with Learning Disability at age 9. Attended a mainstream
primary and secondary school. Had a statement of needs during secondary
education, which meant she was supported by a teacher’s assistant in all of her
classes. Did not obtain any GCSEs on leaving school at age 16. Attended college
and completed a life skills course.
Medication
On no medication
Social and Occupational History
Attended with her mother who helped Molly give the history.
Lives with her mother, in a house. Has never been employed. Did a couple of work
placements in Tesco and at the local garden centre, but there was no job at the end
of it. She was taught how to stack shelves in both placements.
Typical Day History
Sleeps well. Her mother wakes her up in the morning about 7 am. She gets out of
bed and gets washed and dressed every day. She does not require any prompting
to do this. She can get her own breakfast (cereal / toast) and a hot drink.
She helps her mother with the housework. She has the same chores each week, so
she knows what to do. It took her a little while to learn what was required for each
chore. Her mother had to remind her over several days until she remembered what
was required. Now she is able to vacuum and do the laundry regularly (sorting
clothes, setting the machine and hanging clothes to dry). She has to perform the
chores on the same day of the week and in the same order as otherwise she
becomes anxious and makes mistakes.
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She can make simple snacks/meals she has been taught to make unaided/
unsupervised (such as beans on toast etc) but can’t cook anything more
complicated without help. She is not able to follow a recipe and she has had a few
accidents with the cooker so her mother does not let her use it on her own. She
understands the dangers of using a cooker and will not use it if she is unsupervised.
However she enjoys cooking and so helps her mother when they make more
complicated meals in the evening which she knows she would not be able to do on
her own.
Her mother works so she spends the day either at home alone or at her
grandmother’s house. Her mother indicated that she prefers to avoid leaving Molly
on her own for long periods of time if possible. Molly has been known to give money
to anyone who asks for help, regardless of whether they are genuine or not. Her
mother will drop her over to her grandmother’s house as it is on the other side of
town. She could not manage to get there on her own as it requires a complicated
bus journey and then a 20 minute walk.
She can manage a simple bus journey (i.e. one without any changes) after being
shown where to get on and off a couple of times. She used to go to college by bus
by herself. She does not like travelling on the bus by herself as she is always
anxious that something may happen. A few weeks ago, the bus had to pass through
a different route due to road works. She did not know where she was going and
became very upset. Although the bus still stopped at her usual stop, she had to call
her mother to come for her as she was too distressed.
She has been taught how to start and use the computer for simple tasks. She is able
to use face book to keep in touch with a few friends from college and family. Her
mother had to set the account up to ensure the security settings were correct and
put an icon on the desktop for her. She also has some simple games she enjoys
playing. Her mother has bookmarked them, so she can find them easily. She does
not use the computer for anything else.
They have a dog and a cat, which keep her company during the day when she is at
home. She is able to walk the dog alone a couple of times a day around the block
(she does not have to cross any roads). There is also a local park on the way where
she can play ‘fetch’ with the dog, which she really enjoys. She always fol ows the
same route and would not venture anywhere different as she might get lost and not
be able to find her way home.
She can go to the local shops, 2 blocks away. She has to cross a quiet road, which
she can manage, although she would struggle on a busy road as she tends to forget
which way she has to look to cross a road when it is very busy.
She likes spending time with her grandmother. They will often go out to different
places, and she enjoys these outings. She knows that her grandmother will take her
to different places and she can cope with these because she is not alone. They will
go to different cafés for coffee and lunch and they also go to museums sometimes.
She could not go to these places alone as she would not know how to get there.
She has a mobile phone and she can use it to phone family and friends. She does
not use text as she finds it a bit confusing and her reading and writing is not the
best. Her contract is capped and her mother deals with the bills as she had to pay a
lot of money initially before her mother sorted out the contract for her.
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Mental State Examination
Appears well, normal build, normal complexion, does not look tired, appears kempt,
wearing casual clothing
Normal facial expression, good rapport, normal eye contact
Slightly tense and apprehensive although her mother had prepared her for the
interview and what she was to expect during the assessment
Normal amount, rate, volume and content of speech
No thoughts of self harm
Required some prompting, but general memory and concentration adequate
Good insight
Could not complete 5 rounds of serial sevens
Could not calculate change
Could remember 2 objects at registration but could not recall any of the 3 objects
later in the assessment
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10.1 Mentor Guidance Notes for Practice Scenario Four
This is case where the claimant has a moderate learning disability. It is designed to
allow a discussion around the diagnosis of learning disability, levels of disability and
cognitive examination at assessment.
Suggested Outcome
Mental Health Descriptors:
Learning: LT(c) Cannot learn anything beyond a moderately complex task
Hazard awareness: AH(c) Occasionally requires supervision
Personal action: IA(d) None of the above apply
Coping with change: CC(c) Unable to cope with minor unexpected change
Getting about: GA(c) Unable to get to an unfamiliar place without being accompanied
Socialising: CS(d) None of the above apply
Appropriateness of behaviour: IB(d) None of the above apply
None of the Physical Scoring Descriptors, Exceptional circumstances or Support
Groups apply in this case
Sample PSS
Miss Mears has a learning disability. She is able to self care and learn tasks such as
setting a washing machine but would be unable to manage more complex tasks. She
has to follow a routine and has to be prepared for any changes as she becomes
distressed with unexpected events. She requires help and supervision for more
complex tasks in the kitchen and help with more complex journeys, although she
does go out alone in places she is familiar with. While she is able to recognise
hazards in her own daily environment (such as dangers of the cooker), she may fail to
recognise a potential hazard if outside of her usual environment (such as crossing as
busy street). It is likely that she will sometimes require supervision.
These findings are consistent with mental state examination findings of significant
impairment of cognitive function.
Remind the HCP they can call and discuss any mental health case they are
unsure about with the MFC.
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11. Practice Scenario Five
Name:
Ms Jenny Joseph
Age:
22 years old
Med 3:
Asperger’s and Anxiety
113: “Has Asperger’s syndrome but has recently become very anxious. She has been
referred to specialist psychological services.”
ESA 50: has written “I have Asperger’s and I was working before. I hate being
around people as they misunderstand me.”
All physical function descriptors – no problem
Learning tasks – no problem
Awareness of hazard – no problem
Initiating personal action – no problem
Coping with change – has written “I don’t like changes.”
Getting about – has written “depends on where I have to go and who is there.”
Coping with social situations – has written “I don’t like talking.”
Behaving appropriately – has written “I can get irritable when I am upset or
scared.”
Information at assessment:
Clinical History
(Most of the history provided by mother)
She was diagnosed with autism at age three when mother noticed that she was not
speaking or interacting socially like her older siblings did at the similar age. In her teens the
diagnosis was changed to Asperger’s syndrome. Her paediatrician told her that the main
problem with her autism was the impairment of her social skills rather than her learning as
she had a good IQ. She attended a main stream school. She had support from child
psychology services to deal with social skills and anxiety as she was somewhat disruptive
when she got very anxious at school. She later attended college and did a life skills course
to further improve her social skills as well as undertaking a bookkeeping course. She was
able to finish the course and obtain an administrative job in a local shop.
She lost her job 9 months ago when the business closed. Since then she has been unable
to find another job. This makes her feel frustrated and low most days. Her anxiety has also
worsened and she has become a bit more withdrawn since losing her job.
She gets anxious most days especially when she has to leave the house or go to new
places. She gets panicky at changes. When asked to describe panic, her mother reported
that Jenny gets very distressed, sweaty, trembles and short of breath. This can last for up to
10 minutes after leaving the area or situation, but also leaves her restless for the rest of the
day. She often gets irritable, but not violent. Her GP became concerned about the
increasing anxiety and started her on medication and referred her to a psychologist with
interest in autism.
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Medication
Sertraline 50 mg daily
Social and Occupational History
Attended the assessment with her mother. Got a lift with older brother.
Lives with her parents and younger brother.
Stopped working 9 months ago due to redundancy. Worked in a shop.
Typical Day History
Usually goes to bed around midnight. Usually sleeps well. Gets up on her own between 8 -
10 am. Previously she got up earlier when she was working and was able to get herself
ready on her own. She was always early for work. She was able to get a job though the
help of her local branch of an autism charity. Her previous manager and team leader were
very understanding and had input from the specialist employment services of the charity on
how to deal with autism. She worked in the cash room, counting money and was
responsible for reporting cashier variances to her team leader. She never worked on the
shop floor as she found interacting with the customers very stressful. Before starting the job
full time she had a coach from the charity who attended work with her for six weeks. Her
coach also gave tips to the manager and other employees to raise their awareness of
autism. Her team leader learned some techniques and took over as her mentor when she
started to work full time 3 years ago.
Now when she is sad, she sometimes does not feel like washing and dressing, but she
does generally manage this independently most days. She usually does her own laundry
and helps with the housework occasionally. She usually keeps her own room clean and tidy
and makes sure everything remains in the exact place. The family know not to reorganise
the items in the bathroom as this upsets her.
She spends most of the day in her room doing Sudoku puzzles on the computer. She
keeps in touch with her team leader from work via the internet. Her team leader moved
away to Bristol as she found a job there. Jenny would like to go to Bristol and visit, but she
thinks the journey would be too stressful as she has never visited there before. Her coach
from the charity had taught her the route to work. This was a single 10 minute bus journey.
One morning the bus did not turn up due to an accident. She got very distressed and
returned home. Her older brother heard about the incident and offered to drive her to work
but she was so distressed, she stayed in her room at home for the entire morning. When
her team leader called, her mother explained what had happened and he advised that she
took the remainder of the day off.
She occasionally manages to go to the local shop alone to get bread and milk if her mother
asks her to go. She does this alone as she knows the shop keeper. She never goes to the
large supermarket alone. She used to go with her mother and younger brother up until 6
months ago. However, as her anxiety got worse, she would no longer make the trip there.
She is able to travel to her GP surgery alone. She always keeps the appointments and gets
there on time. The surgery is 10 minutes walk away. She does not speak to anyone on her
way there. She knows the receptionist there and usually has no problems booking in. Two
weeks ago when she visited the GP surgery, she returned home very distressed. She
locked herself in her room for the rest of the day and did not even come out for supper.
When her mother eventually persuaded her to chat, she told her mum that her usual
receptionist was not there and a stranger was asking her lots of questions.
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Her mother explained that she usually has to prepare Jenny for any interviews and unusual
appointments. She had cancelled her first WCA assessment as she had 10 days to prepare
and was anxious about making the half hour journey to the MEC. Mother arranged for an
appointment 4 weeks later. Mother is currently preparing her for the visit to the
psychologist. This specialist psychologist is in another town, 45 minutes away. The brother
has already booked time off of work to give them a lift to the health centre as they doubt
Jenny would tolerate the train journey.
She gets upset with her brother if he comes into her room and moves anything around.
When they were much younger this was the source of major arguments and fights. Now
she just gets upset and shouts at him. She likes to play games on her X box and computer.
Eighteen months ago she purchased an X-box kinect sensor and two discs with dance
routines. Recently her brother took the dance discs up without her permission as he had a
group of friends from college over. She got very upset when she noticed both her discs
were missing and had a shouting match with him the following day.
She chats with her younger brother briefly most days. Her older brother lives away from
home but he visits regularly. They try to invite her out to the movies, but she always refuses
as she does not like the crowds. When her younger brother brings friends over
unexpectedly, she would refuse to come out of her room. She never answers the door even
if she is expecting a delivery of items she may have ordered online. She does not answer
the house phone even if she is home alone. She only uses her mobile phone for text
messaging. Recently when she was home alone, her mother called the landline as she
forgot her mobile home and wanted to ask Jenny to take the clothes out of the machine.
She refused to answer the phone. Her mother eventual y stopped by her brother’s
workplace and got him to send a text message to her about the clothes in the machine.
She does not usually attend extended family events. Three months ago her mother and
father persuaded her attend her cousin’s wedding reception. They tried to prepare her for
the event by explaining to her about the number of people coming and how they may want
to chat with her. However, she only spent 30 minutes at the reception as there were too
many people there and she could not chat with anyone. Lots of relatives and other people
who had not seen her for many years were coming up to her trying to chat. She was getting
very anxious and seemed to be ignoring all of them. Her mother noticed how irritable and
anxious she was getting and took her home.
Mental State Examination
Well kempt
Casually dressed
Average build
Avoided eye contact throughout the assessment, appeared restless and tense
Fiddling with her fingers throughout the assessment
Adequate concentration and memory
Spoke very little but volume and content normal
No self harm ideas
Appeared reluctant to enter the assessment room. Asked mum to speak for her very early
on in the interview. Difficult to establish any useful rapport
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Only spoke with mother in very short sentences. Appeared to ignore all questions directed
towards her and blurted out “ask mum” from very early in the interview
Appeared somewhat restless, anxious and uncomfortable throughout the assessment
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11.1 Mentor Guidance Notes for Practice Scenario Five
This claimant has Asperger’s syndrome (the high functioning end of the autistic spectrum).
She does not have a significant learning disability. However she has significant impairment
of her social skills. She gets significant anxiety with changes to her routine.
Review the case once the HCP has completed it. Check the MSE findings have been
entered correctly. Check the outcome and descriptor choices.
Suggested Outcome
None of the Physical Scoring Descriptors, Exceptional Circumstances (NFD) or Support
Groups apply in this case
Mental Health Descriptors:
Learning: LT(d) None of the above apply
Hazard awareness: AH(d) None of the above apply
Personal action: IA(d) None of the above apply
Coping with change: CC(c) Cannot cope with minor unplanned changes
Getting about: GA(c) Unable to get to an unfamiliar place without being accompanied
Socialising: CS(c) Engagement with someone unfamiliar is not possible for the
majority of the time
Appropriateness of behaviour: IB(d) None of the above apply
Look at the evidence used to support descriptor choices if any different descriptors are
chosen by the HCP. The coping with social engagement activity descriptor may be debated
by some suggesting CS(b) instead but in the scenario the evidence and information
suggests it is likely at CS(c) level.
Sample PSS
Ms Joseph has Asperger’s and significant anxiety. She has significant difficulty coping with
unexpected changes in her routine and finds it very difficult to communicate with strangers.
She gets irritable at times, but never violent. She is able to travel to local, familiar places to
attend planned appointments. However she is unable to travel to unfamiliar places. She
recently commenced medication for anxiety and is awaiting psychology input.
At interview she was anxious and had reduced rapport. This was reasonably consistent with
the restrictions reported in her typical day.
Discuss
Although she has worked previously, this was with lots of support to get her ready for the
working environment and at a specific place. Discuss how this may affect the prognosis.
She would likely need time to find suitable employment and get support in finding such
employment. A 6 months prognosis is unlikely to be adequate.
Remind the HCP they can call and discuss any mental health case they are unsure
about with the MFC.
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Next steps
At end of the discussion and practice scenario sessions ask the HCP if there are any areas
where they are unsure and direct them to the following appropriate references.
Useful References
EBM protocols
Revised WCA Handbook
Mental Illness: Current Therapeutics and Management (Distance Learning) MED-
CMEP~0085
Davies T. Craig T. (2009) ABC of Mental Health. London: Wiley-Blackwell
Dogra N. Lunn B. Cooper S. (2011) Psychiatry by Ten Teachers. London: Hodder Arnold
NICE Clinical Guidelines & Pathways:
http://pathways.nice.org.uk/
www.nice.org.uk
Quick reference and full guides available on a range of mental health conditions
including:
Anxiety
Depression
Bipolar Disorder
Schizophrenia
Autism
Alcohol Dependence and Harmful Alcohol Use
Re-iterate the role of the MFC and that they can be contacted at any time to discuss cases.
Check the HCP is aware how to contact the MFC in their local area.
Mental Health Support Scenarios
4 Final
Mentor’s Notes
MED-MHSS~001
Page 54
Medical Services
Observation form
Please photocopy this page and use it for any comments and observations on this
document, its contents, or layout, or your experience of using it. If you are aware of
other standards to which this document should refer, or a better standard, you are
requested to indicate this on the form. Your comments will be taken into account at
the next scheduled review.
Name of sender:
________________________ Date: _____________
Location and telephone number:_________________________________
Please return this form to: XXXXXXXXXXXX
Service Delivery Lead
Atos Healthcare
3300 Solihull Parkway
Birmingham Business Park
Birmingham
B37 7YQ
Mental Health Support Scenarios
4 Final
Mentor’s Notes
MED-MHSS~001
Page 55