Cases/Mental Health

Schizophrenia Off His Medication Who Believes He Is Being Spied On — Free SCA Practice Case

Man with schizophrenia off his medication who believes he is being spied on

Station Timer

12:00

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

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Liam Doyle

Age

28 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient has phoned the surgery; he sounds agitated.

Reason for Encounter

"I need to talk to someone. There's this buzzing in my head, and I know my old geography teacher has been spying on me. Something's not right."

Medical Records

●PMH: Schizophrenia (diagnosed age 22; one previous hospital admission). Usually under the community mental-health team.
●Medications: Olanzapine (issued but not collected for several weeks; appears to have stopped).
●Allergies: NKDA.
●Recent notes: CMHT letter — stable on olanzapine at last review 4 months ago; care coordinator allocated.

Patient Script

For the friend playing the patient role

Character Overview: You are Liam, 28, with a diagnosis of schizophrenia. You stopped your olanzapine a few weeks ago because you felt well and disliked the weight gain, and you drifted out of contact with your mental-health team. Over the last two weeks the "buzzing" in your head has come back and you have become convinced that your former geography teacher is spying on you through your phone and TV. You are anxious and a bit suspicious, including of the doctor at first, but you are reaching out because you are frightened. You are not aggressive, and you do not want to hurt anyone or yourself, but you feel watched and on edge.

Opening Sentence: "Look, I don't know if I can trust anyone with this, but… there's a buzzing in my head that's come back, and I'm certain my old geography teacher is watching me — through my phone, the telly, everything. I know how it sounds. I just… something's wrong and I don't know what to do."

History if Asked (Data Gathering Phase)

●The symptoms: "The buzzing's like a low noise in my head — it started a couple of weeks ago. And I can't shake the feeling I'm being watched, that my old teacher's behind it somehow."
●The medication (only if asked): "I stopped the olanzapine about a month ago. I felt fine, and I hated the weight gain. I sort of lost touch with my team too — didn't answer their calls."
●Insight (partial): "Part of me knows it sounds mad — a teacher spying on me. But it feels completely real. That's what's scaring me."
●Sleep/self-care: "Not sleeping much. Not really eating properly. I've been keeping the curtains shut."
●Why he's calling: "Because I'm frightened and I don't know what's happening to me. I thought a doctor might help."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Liam believes, with fluctuating conviction, that his former teacher is surveilling him; part of him recognises this may be his illness returning. "I'm sure I'm being spied on — but a bit of me wonders if it's the schizophrenia coming back because I stopped my meds."
●Concerns: He is frightened — by feeling watched, by the buzzing, and by losing his grip; he does not want to end up back in hospital. "I'm scared of what's happening to me, and scared of being sectioned again."
●Expectations: He is reaching out for help but is wary; he is not sure what he wants beyond reassurance that he is not in danger and that someone will help. "I suppose I want to know I'm safe and that someone will actually help me."

If Asked — Mental State, Insight, and Risk (approached sensitively)

The patient answers these only when directly and sensitively asked.

●If asked to describe the "buzzing" / whether he hears voices: "It's more a noise than voices. I don't hear anyone talking to me or telling me to do things." (No command hallucinations.)
●If asked whether anything or anyone tells him to harm himself or others: "No — nothing's telling me to do anything. It's just the buzzing and the feeling of being watched."
●If asked about the belief and whether he plans to act on it (e.g. confront the teacher): "No, I don't want to confront him or hurt him — I just want it to stop. I've been avoiding going out, keeping away from everyone."
●If asked, sensitively, about thoughts of self-harm or suicide: "No, I don't want to hurt myself. I'm frightened, but I don't feel like ending things." (No suicidal ideation. Assess sensitively; no method detail sought or given.)
●If asked about self-care / eating / sleeping: "Sleep's bad, I'm not eating much, I've been shut in with the curtains closed."
●If asked about substance use: "No drugs, I don't really drink."
●If asked about his support / contact with his team: "I've a care coordinator but I've been dodging their calls. My mum lives nearby and she's worried."
●If asked about previous episodes: "I was in hospital once, a few years ago, when I was first diagnosed. I don't want that again."

Responses to Management (The Negotiation Phase)

●If the Doctor gently links the relapse to stopping medication: "So you think it's come back because I stopped the olanzapine? Not because someone's actually watching me?" (The tested point is conveying concern about a relapse without either colluding with or aggressively confronting the delusion.)
●If the Doctor proposes involving his mental-health team urgently: "You want to get my team involved? Will they section me?" (The tested point is negotiating urgent re-engagement with the CMHT/crisis team and being honest and reassuring about what that means.)
●If the Doctor discusses restarting medication: "Would I have to go back on the olanzapine? I really didn't like the weight gain."
●If the Doctor suggests a face-to-face assessment: "Do I have to be seen in person? I don't much want to go out."
●If the Doctor asks about involving his mum: "My mum could help, yeah. She's been trying to get hold of me."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Relapse of Psychosis After Stopping Medication

●Stopping antipsychotic medication (often because the person feels well or dislikes side effects such as weight gain) and disengaging from services are common triggers for relapse of schizophrenia.
●Relapse features include returning hallucinations, delusions (often persecutory), social withdrawal, self-neglect, and sleep disturbance.

Structured Risk Assessment — the Core Skill

●Assess risk to self (suicidal ideation, self-harm, self-neglect), risk to others (intent to act on delusions, command hallucinations to harm others, history of violence, access to means), and vulnerability — sensitively, and without naming specific methods.
●Command hallucinations and acting on persecutory beliefs are particularly important to elicit.

Urgent Assessment and Service Involvement

●A psychotic relapse needs urgent psychiatric assessment. Involve the community mental-health team / care coordinator and consider the crisis/home-treatment team; do not leave the patient to re-contact services alone.
●A full mental-state and risk assessment generally requires face-to-face contact.

Proportionate Management and the Mental Health Act

●Match the response to the risk: not-imminent risk with some insight can be managed urgently in the community; significant risk with loss of insight/capacity and refusal of voluntary help may require a Mental Health Act assessment.
●Voluntary engagement is always the aim; compulsion is a last resort.

Medication Re-engagement

●Encourage restarting antipsychotic treatment with specialist input, addressing the reasons for stopping (e.g. weight gain) and discussing alternatives and monitoring — collaboratively.

Family and Safety-Netting

●With consent, involve family (here, a nearby, worried mother) to support engagement and safety. Provide a clear crisis route (crisis lines / 999) and safety-netting.

Communication in Psychosis

●Do not collude with, or aggressively confront, delusions — acknowledge the person's distress and experience without endorsing the belief. Convey concern and care, not control, to keep a frightened, suspicious patient engaged.

Common Candidate Mistakes in This Case

●Inadequate risk assessment: not screening for command hallucinations, intent to act, self-neglect, and risk to self and others.
●Failing to involve mental-health services urgently: leaving a relapsing patient to re-contact his team himself.
●Colluding with or confronting the delusion: either endorsing or arguing with the persecutory belief.
●Mishandling coercion: threatening sectioning prematurely, or failing to recognise when escalation would be needed.
●No face-to-face assessment or crisis plan: managing entirely by phone with no in-person assessment or safety route.

Free MRCGP SCA practice case for GP registrars covering Schizophrenia Off His Medication Who Believes He Is Being Spied On — Mental Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

← Back to Free SCA Practice Cases