Ideas of Reference — Free SCA Practice Case
Young mother with ideas of reference
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Sophie Turner
Age
24 years
Consultation Type
VideoAge
24
Situation
Video Consultation.
Reason for Encounter
"Patient requested an urgent appointment. Reception notes state she is feeling 'overwhelmed and having strange thoughts'."
Medical Records
- ●PMH: Mild depression in late teens (managed with talking therapies, no medication).
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●4 months ago: Uncomplicated Normal Vaginal Delivery (NVD) of her first child, a boy named Leo.
- ●6-week postnatal check: Reported feeling tired but bonding well with the baby. EPDS (Edinburgh Postnatal Depression Scale) score was 8/30 (Normal).
Patient Script
For the friend playing the patient role
Character Overview: You are Sophie. You are 4 months postpartum and profoundly sleep-deprived. Over the last week, you have started experiencing terrifying perceptual distortions. When you have the TV or radio on for background noise, you keep feeling like the presenters are making subtle, disparaging comments specifically about your parenting. Crucially, you still have some insight: when you turn the TV off, you can logically tell yourself it's impossible. But when it happens, the fear is overwhelmingly real. You are terrified you are developing schizophrenia and that you are going "mad." Your greatest, hidden fear is that if you admit these thoughts to a doctor, they will immediately call Social Services to take your baby away. You will not volunteer this fear about Social Services unless the doctor specifically asks what you are worried about or explores your reluctance to accept psychiatric help.
Consultation Flow & Responses:
- ●
The Opening
- ●
If the doctor asks an open question: "Hi Doctor. I didn't know whether to come in, but I think I'm losing my mind. I haven't been sleeping, and over the last few days, I keep having these bizarre thoughts that the people on the television and radio are talking directly to me."
- ●
Data Gathering (The Layers)
- ●
Layer 1: The Phenomenology (Delusions vs. Ideas of Reference):
- ●
"It happens mostly during the morning news. The presenter will say something about a news story, but it feels like it has a double meaning. Like they are hinting that I'm a bad mother, or that I'm not feeding Leo properly."
- ●
"No, I don't hear voices when the TV is off. It's just when it's on."
- ●
Layer 2: Insight & Reality Testing:
- ●
"Logically, I know it can't be real. I know a newsreader in London can't see me in my living room. But in that exact moment, my heart pounds and it feels 100% real. Am I going schizophrenic?"
- ●
Layer 3: Biological Symptoms & Risk Screen (Crucial):
- ●
"I haven't slept properly in weeks. Even when Leo sleeps, my brain is just racing. I'm exhausted but wired."
- ●
"I love Leo so much. I'm taking good care of him, he's clean and fed. I would never hurt him, and I haven't had any thoughts of harming him or myself."
- ●
Layer 4: ICE & The Core Revelation (The Hidden Fear) - ONLY REVEAL IF ASKED:
- ●
If the doctor asks: "What is your biggest worry about what's happening?" or "How does this make you feel about the future?"
- ●
Reaction (The Reveal): You grip your hands tightly and look terrified. "My biggest fear is that you're going to take Leo away. If I'm crazy, you have to call Social Services, right? Please don't take my baby. I am a good mum, I just need some sleep. I shouldn't have told you, I knew I shouldn't have come."
ICE — Ideas, Concerns, Expectations
(Actor guidance: Do not volunteer any of this unprompted. These responses surface only when the candidate directly explores the patient's perspective using ICE-style questioning.)
- ●
Ideas: "I think it might be schizophrenia. My nan had something like that — she used to say people on the telly were watching her. She ended up in a care home. I keep thinking maybe it runs in the family and it's starting with me now."
- ●
Concerns: "I'm terrified they'll say I'm an unfit mother and take Leo. That's the thing that keeps going round in my head. Even more than the TV stuff — it's the idea that someone will decide I can't look after my own baby. I'd rather just not tell anyone and deal with it myself."
- ●
Expectations: "Honestly, I just want someone to tell me I'm not going mad and that this will stop. I want to feel normal again. If there's something that could help me sleep properly, maybe that would fix everything — I don't know. I just want to be a good mum to Leo without feeling like I'm falling apart."
If Asked — Medical History and Medications
(Actor guidance: Respond naturally if the candidate asks about past medical history, previous mental health, or medications. Do not volunteer these details unprompted.)
- ●
If asked about previous depression / mental health history: "Yeah, I had a rough patch when I was about seventeen or eighteen. I was doing my A-levels and everything just got on top of me. I went to see a counsellor through the school and then had some CBT sessions through the GP. It helped quite a lot actually. I never took any tablets for it — I didn't want to go on antidepressants. It got better after a few months and I've been fine since. Well, until now."
- ●
If asked whether current symptoms feel similar to the teenage depression: "No, this feels completely different. Back then I was just sad and tired and couldn't be bothered with anything. This is... scary. I've never had anything like this before — thinking the TV is talking to me. That's not depression, is it?"
- ●
If asked about the 6-week postnatal check: "Yeah, I went for the check-up and everything was fine. They gave me a questionnaire — I think it was about my mood — and the doctor said my score was normal. I was tired but I felt alright then. It's only been the last few weeks that things have really gone downhill."
- ●
If asked about current medications: "No, I'm not on anything at all. I'm breastfeeding Leo so I'd be worried about taking anything anyway — would it get into the milk?"
- ●
If asked about allergies: "No, no allergies to anything."
Social History and Lifestyle Impact
(Actor guidance: These details can be shared naturally as part of conversation, particularly when the candidate explores daily routine, support, or how the condition is affecting day-to-day life.)
- ●
Occupation and daily life: Sophie is currently on maternity leave from her job as a teaching assistant at a primary school. She is at home full-time with Leo. Her husband, Matt, works as an electrician and leaves the house by 7am most mornings, returning around 6pm. During the day, Sophie is alone with Leo. Her mum lives about 40 minutes away and visits once a week.
- ●
If asked about her daily routine: "Matt leaves for work early so it's just me and Leo all day. I used to take him to a baby group on Wednesdays, but I stopped going a couple of weeks ago because I couldn't face being around other mums. I keep thinking they can tell something is wrong with me."
- ●
If asked about support network: "My mum comes over on Saturdays usually. She's been brilliant. But I haven't told her about the TV thing — she'd panic. Matt knows I'm not sleeping but I've played it down. I don't want to worry him — he's already stressed with work."
- ●
Lifestyle impact of the condition: "I've stopped watching the TV altogether, which sounds mad, but it's the only way I feel safe. The house is dead silent all day now — it's just me and Leo in this quiet flat and I think that's making the loneliness worse. I used to have the news or a podcast on while I was feeding him and it made me feel like there was another adult in the room. Now I can't do that. I've also stopped answering the door to the postman because last week I had this flash of a thought that he was checking up on me. I know that sounds insane. I'm basically just existing in this little bubble with Leo, and I can feel it shrinking."
If Asked — Associated Symptoms
(Actor guidance: Respond only when the candidate directly asks about specific symptoms. Keep answers brief and natural.)
- ●
If asked about hearing voices when the TV/radio is off: "No, nothing like that. It's silent when everything is off. It only happens when the TV or radio is on."
- ●
If asked about other hallucinations (visual, tactile, olfactory): "No, I haven't seen anything strange or felt anything weird on my skin or anything like that. It's just the TV thing."
- ●
If asked about paranoid thoughts beyond the TV (e.g. people following, watching, plotting): "Well, there was the postman thing I mentioned — I had this flash that he was checking on me. And at the baby group, I felt like the other mums were judging me. But I know that's probably just me being anxious and tired. Nobody's actually said anything to me."
- ●
If asked about thought insertion, thought broadcasting, or feeling controlled: "No, nothing like that. My thoughts are my own — they're just frightening ones."
- ●
If asked about mood — whether she feels low, tearful, or depressed: "I do cry quite a lot, usually in the evenings when I'm really tired. I wouldn't say I feel depressed exactly — it's more like I'm scared all the time. There's a difference, isn't there?"
- ●
If asked about anxiety or panic attacks: "My heart races when the TV thing happens — properly pounds. And sometimes I feel a bit sick with it. But I wouldn't say I have full-on panic attacks. It's more this constant low-level dread that something is wrong with my brain."
- ●
If asked about appetite or weight change: "I'm not eating properly. I forget to eat lunch most days because I'm so focused on Leo. I've definitely lost weight — my jeans are loose — but I haven't weighed myself."
- ●
If asked about concentration or memory: "Terrible. I can't focus on anything. I put the kettle on three times yesterday and forgot about it each time. I'm managing Leo's routine fine, but anything for myself just falls away."
- ●
If asked about guilt or feelings of worthlessness: "I feel like I'm failing him. Like every other mum has this figured out and I'm the only one who can't cope. But I know I'm looking after him properly — he's thriving. It's me that's not."
- ●
If asked about energy levels: "I'm absolutely shattered. But at the same time, I can't switch off. It's like my body is exhausted but my brain won't stop."
- ●
If asked about interest or enjoyment in things (anhedonia): "I don't really enjoy anything at the moment. I used to love reading and I haven't picked up a book in weeks. But I think that's just because I'm so tired — if I could sleep, I think I'd feel like myself again."
- ●
If asked about obsessional or intrusive thoughts about harming the baby: "No. Absolutely not. I have never had a thought about hurting Leo. I'd do anything to protect him. That's partly why I'm so scared — what if whatever is happening to me gets worse and I can't look after him properly?"
- ●
If asked about thoughts of self-harm or suicide: "No. I haven't thought about hurting myself. I need to be here for Leo — he needs me. I just want to get better."
- ●
If asked about use of alcohol or drugs to cope: "No, I don't drink at all at the moment because I'm breastfeeding. And I've never taken drugs."
- ●
If asked about bonding with the baby: "I love him completely. When he smiles at me it's the best feeling in the world. The bonding is fine — it's everything else around it that's falling apart."
- ●
If asked about rapid mood swings or elation: "No, I haven't felt high or overly happy or anything like that. It's all been on the low and anxious end."
- ●
If asked about any unusual beliefs about the baby (e.g. baby being special, chosen, in danger from outside forces): "No, nothing like that. Leo is just a normal, lovely baby. I don't have any strange thoughts about him."
Negotiation & Collaborative Management Plan
- ●
If the Doctor affirms the delusion ("What are the presenters saying to you?"):
- ●
Reaction: "So you believe it too? Are they really talking to me?" (Testing if the doctor improperly validates the ungrounded belief rather than grounding her.)
- ●
If the Doctor dismisses it as just "new mum tiredness":
- ●
Reaction: "But it feels so terrifyingly real. Is it normal for tired mums to think the TV is watching them?" (Testing the doctor's recognition of psychiatric red flags.)
- ●
If the Doctor immediately mentions calling Social Services or the Police:
- ●
Reaction: Panic, stands up. "No! I'm leaving. You're not taking him!" (Doctor must de-escalate and explain that the goal of perinatal mental health teams is to keep mums and babies together.)
- ●
If the Doctor suggests a referral to the Perinatal Mental Health Team / Crisis Team:
- ●
Reaction: Hesitant but listening. "Are they going to lock me up in a ward? Who will look after Leo?" (Doctor needs to explain Mother and Baby Units or intensive home treatment.)
Safety Netting / Follow-up
- ●If the Doctor asks to bring her partner/family in for support today:
- ●Reaction: "My husband is at work, but I can call him to come home. He knows I've been struggling with sleep, but he doesn't know about the TV thing. I think he needs to know now."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Ideas of Reference vs. True Auditory Hallucinations
- ●Ideas of reference describe the experience of perceiving neutral external stimuli — news broadcasts, overheard conversations, random events — as carrying a specific, personal meaning directed at oneself. Sophie believes the TV presenter is making coded comments about her parenting; this occurs only when the media is on.
- ●True auditory hallucinations are perceptions of voices or sounds in the absence of any external stimulus. The critical discriminating question is: 'Do you hear voices or sounds when the TV and radio are completely off?' A negative answer, as here, distinguishes ideas of reference from primary auditory hallucination.
- ●Partial insight — the capacity to recognise, when calm, that the belief cannot logically be real — is a clinically significant finding. It indicates the patient is not yet at the fixed-belief end of the psychotic spectrum, but insight alone does not confer safety: ideas of reference can harden into unshakeable delusions without prompt intervention.
- ●The phenomenological distinction matters clinically: it informs diagnosis, urgency, and the choice of language when explaining the presentation to the patient.
The Postpartum Psychosis Spectrum and Timing
- ●Classic postpartum psychosis typically presents within the first 1–2 weeks after delivery, characterised by rapid onset of mania, severe confusion, perplexity, delusions, and hallucinations. It is a psychiatric emergency with a recognised risk of infanticide and maternal suicide.
- ●This case represents a later-onset, less florid presentation: emerging at 4 months postpartum, driven by compounding severe sleep deprivation in a woman with a personal history of depression and a possible family history of psychotic illness. NICE (NG201 and CKS: Postnatal depression) recognises that the first postpartum year carries elevated risk for the full spectrum of perinatal mental illness, including presentations outside the classic early window.
- ●Risk factors for postpartum psychosis and severe perinatal mental illness with specific clinical relevance here:
- ●Personal history of mood disorder (adolescent depression managed with CBT)
- ●Possible family history of psychotic illness (maternal grandmother with similar symptoms)
- ●Primiparity and social isolation
- ●Severe, protracted sleep deprivation with a 'wired but exhausted' quality
- ●Candidates should recognise that a normal EPDS at 6 weeks does not exclude subsequent deterioration: the EPDS is a point-in-time screen, not a longitudinal guarantee.
Organic Exclusion Before Psychiatric Formulation
- ●New-onset acute mental state change in the postpartum period requires brief but explicit consideration of organic causes before a psychiatric formulation is settled on.
- ●Postpartum thyroiditis occurs in approximately 5–10% of women in the first year after delivery and can present with anxiety, perceptual disturbance, and mood dysregulation. TSH should be checked.
- ●Postpartum infection — including urinary tract infection, wound infection, and sepsis — can cause acute confusional states and perceptual disturbance.
- ●Substance use should be screened for, even briefly, as a cause of acute perceptual symptoms.
- ●In practice, this does not require a full medical workup before initiating urgent psychiatric referral; it means the referral letter should note that organic causes have been considered and basic investigations (FBC, TFTs, CRP, urine dip) are being arranged in parallel.
Urgent Psychiatric Assessment — The Correct Pathway
- ●Any woman presenting with new-onset psychotic symptoms, ideas of reference, or significant perceptual disturbance in the first postpartum year requires same-day urgent psychiatric assessment. This cannot be deferred to a routine outpatient referral.
- ●The primary route is the Specialist Perinatal Mental Health Team (PMHT). Where this is unavailable same-day or out of hours, the Crisis Resolution and Home Treatment Team (CRHTT) should be contacted.
- ●SSRI monotherapy is contraindicated as a first-line response to this presentation. If the underlying diagnosis is postpartum psychosis or bipolar affective disorder postpartum, antidepressant monotherapy without a mood stabiliser or antipsychotic can precipitate full mania or worsen psychotic symptoms. Medication decisions belong with the psychiatric team.
- ●The GP's role is to: (1) recognise the urgency; (2) make immediate contact with the PMHT or CRHTT; (3) establish a safety plan before the patient leaves; and (4) maintain continuity — agreeing a same-day or next-day GP follow-up call to confirm the referral has been actioned.
Medication Safety in Breastfeeding
- ●Sophie is breastfeeding and expresses specific concern about medication passing into breast milk. This concern must be acknowledged and addressed directly — not dismissed.
- ●The reassurance is accurate and important: medication choices for perinatal mental illness are routinely made with breastfeeding compatibility in mind, and the perinatal mental health team has specialist expertise in this area. Commonly used agents including certain antipsychotics and mood stabilisers have established safety profiles in breastfeeding; this is not a binary choice between treatment and breastfeeding.
- ●Failing to address this concern leaves a significant barrier to engagement with psychiatric care.
Safeguarding — The Honest and Therapeutic Approach
- ●Fear of child removal is among the most common barriers to maternal engagement with mental health services and is directly relevant to this case. Sophie will not disclose this fear unless the doctor specifically explores her concerns — making active ICE questioning essential.
- ●The correct response to this disclosure has two components:
- ●Honest: The threshold for statutory safeguarding intervention is not crossed by presenting to a GP with mental illness and accepting psychiatric help. Coming forward is not evidence of being an unfit mother — it is evidence of exactly the opposite.
- ●Therapeutic: Explain that Mother and Baby Units (MBUs) admit mothers and infants together specifically so that the therapeutic relationship between mother and baby is protected during inpatient treatment. Specialist perinatal teams are designed to keep families together, not to separate them.
- ●What must be avoided: an unconditional promise that Social Services will never be involved. If risk to the child meets the statutory threshold, involvement may be necessary. The honest position is that involvement, if it were to occur, would be focused on providing support — not removal — unless there is direct, immediate risk of harm. Making an unconditional promise is both clinically dishonest and, if broken, would cause profound harm to the therapeutic relationship.
Safety Planning and Safety-Netting
- ●A concrete safety plan must be established before the patient leaves the consultation:
- ●Sophie should not return home alone. Matt should be contacted to come home immediately.
- ●Sophie and Matt should be given clear, specific escalation instructions: call 999 or attend A&E immediately if she develops command hallucinations (voices instructing her to act), becomes unable to care for Leo, develops thoughts of self-harm or harming the baby, or if her insight deteriorates rapidly (i.e., she can no longer recognise that the beliefs may not be real).
- ●The PMHT or CRHTT contact number should be provided in writing.
- ●Safety-netting in this case is not generic. It must name the specific features that would constitute acute deterioration in a postpartum psychosis presentation. Telling a patient to 'come back if things get worse' is insufficient.
Common Candidate Mistakes in This Presentation
- ●Diagnosing postnatal depression or anxiety and prescribing an SSRI. The perceptual symptoms, sleep disturbance pattern ('wired but exhausted'), and ideas of reference place this on a more serious part of the perinatal mental illness spectrum. An SSRI without specialist review is not appropriate and carries risk of clinical deterioration.
- ●Attributing the presentation entirely to sleep deprivation. While sleep deprivation is a major precipitant and aggravant, it does not explain the emergence of ideas of reference. Dismissing the presentation as 'just tiredness' without psychiatric referral misses a potential emergency.
- ●Failing to ask about the hidden fear. Sophie's core barrier to engagement — the Social Services fear — will not surface unless the doctor directly asks what she is most worried about. Candidates who skip ICE exploration leave this case without ever addressing the most clinically important moment in the consultation.
- ●Validating the delusional content. Asking 'What exactly are the presenters saying to you?' in a way that implies the communications are real, or agreeing that the TV might be targeting her, reinforces the belief rather than grounding the patient. The correct approach is to acknowledge the terror of the experience while clearly framing it as a symptom of an unwell brain, not a real external event.
- ●Leaving Sophie alone. Initiating a referral and allowing Sophie to leave the surgery unaccompanied, without contacting Matt, represents a failure of immediate safety planning.
Mapped to the RCGP curriculum topic: Mental Health.
← Back to Free SCA Practice Cases