Station 53
Peter Drinkwater
Age: 16 years old male
Full Case
Patient’s Data
Patient’s name: Peter Drinkwater
Age: 16-year-old male
Past medical history
- Eczema
Drug and Allergy History
- Oilatum cream
- Eumovate cream (used during flares)
- No Known Drug Allergies
Recent Notes/Consultations
- Nil
Caller: Lisa Drinkwater (mother), calling to discuss her son’s condition.
Patient's Story (Role player’s brief)
Patient’s Story
You are Lisa Drinkwater, the mother of Peter Drinkwater, a 16-year-old boy. You’re calling today because you’re very concerned about changes in your son’s behaviour over the last 2–3 weeks.
Peter has been behaving unusually. He says people are watching him, and you’ve heard him talking to himself as if he’s speaking to people who aren’t there. He says he hears 2 voices. Thevoices sometimes tell him to take his clothes off inappropriately, and at other times, they tell him that he is from Africa and is a king there, even though he has never been to Africa and has no known connection to it.
He has also become increasingly irritable. He often gets angry, shouts irrationally, and has threatened to cause harm, particularly towards you and his 12-year-old sister.
He has no fever and has not been unwell in anyway.
You’re extremely worried that something might be seriously wrong with him mentally.
You’ve asked Peter to see the GP, but he’s refused.
Social History: You’ve found out he’s been drinking alcohol and smoking. While you’re not sure about drug use, you have smelled cannabis in his room before. He is in Year 11 and currently preparing for his GCSE exams.
There is a family history of mental illness — schizophrenia in Peter’s cousins (your niece and nephew), and bipolar disorder in his father, which is currently well controlled.
Ideas: You suspect this might be a mental health problem.
Concerns: You’re scared he may harm himself or his younger sister.
Expectations: You want help and advice on what can be done urgently.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset and duration of hallucinations.
- If one type of hallucination is present, ask about others. For example, if a patient reports seeing things that others do not (visual hallucinations), ask whether they also hear voices that others can’t hear (auditory hallucinations) or experience unusual sensations, such as feeling something crawling on their skin when nothing is actually there (tactile hallucinations)
- If auditory hallucinations are reported, ask what the voices say or instruct the patient to do.
- Ask about paranoid ideation, such as the feeling that people are talking about them.
- Ask about unusual thoughts that may suggest psychosis, such as feeling like thoughts are being taken out of their mind (thought withdrawal), believing that someone is putting thoughts into their head (thought insertion), feeling that other people can hear or know what they’re thinking (thought broadcasting), or giving a personal or strange meaning to something ordinary, like , thinking that seeing a black cat walk past means someone is trying to harm them (delusional perception).
- Ask directly about any thoughts of self-harm, suicide, or intention to harm others.
- Ask about any previous personal history of mental health disorders.
- Screen for red flags such as headache, fever, or neck stiffness to rule out viral encephalitis or meningitis.
- Ask if the patient has been physically unwell prior to symptom onset (e.g. cough, urinary symptoms) to rule out infection/sepsis that has caused delirium.
- Ask about substance use, including drugs, alcohol, and smoking.
- Ask about his home and school life, and explore how these recent changes in behaviour may be affecting his daily routine, studies, and relationships with family or classmates.
- Ask about any previous diagnosis of depression, psychosis, or personality disorders.
- Ask about family history of schizophrenia, or other mental health conditions.
- Give a diagnosis of acute psychosis
Example of explanation to patient
Lisa, I can hear how worried you are about Peter, and I want to thank you for reaching out, it’s the right thing to do. From what you’ve described, the change in his behaviour, talking to himself, and feeling watched, it does raise concerns that Peter may be experiencing symptoms of a mental health condition called psychosis
Psychosis is condition where a person loses touch with reality. This can involve seeing or hearing things that aren’t there (hallucinations), having unusual beliefs (delusions), or experiencing confused thinking. Are you following me so far?
There are a few possible reasons why Peter might be experiencing these symptoms. One possibility is that he might be developing a mental health condition like schizophrenia, which can affect how a person sees and understands the world around them. Another possibility is that this could be linked to substance use. You mentioned you’ve smelt cannabis in his room, and sometimes cannabis, especially in younger people, can sometimes lead to similar symptoms
I want to reassure you that we take this very seriously. The most important thing now is to urgently get Peter assessed by the mental health team today so we can understand what’s going on and offer him the right help and support.
He may be reluctant to speak to us right now, but we will still go ahead and urgently refer him to the mental health crisis team today. They are trained professionals who specialise in supporting young people and will try their best to engage with Peter in a gentle and understanding way.
However, if he continues to refuse help and his symptoms pose a serious risk to himself or others, they do have the legal authority to arrange an assessment and admission even without his consent. This is called a Mental Health Act assessment, you may have heard this referred to as being ‘sectioned’ and is used only when absolutely necessary, to keep the person and those around them safe.
Management
Management
- Urgently refer patient same day to Local CAMHS (Child and Adolescent Mental Health Services) crisis team for assessment of possible first episode psychosis.
- Inform the mother that the CAMHS crisis team will arrange to visit patient at home to assess him and offer support. If they feel that admission is necessary for his safety or the safety of others, they will recommend admission to a mental health unit. If Peter refuses admission and is deemed to be at significant risk, they may proceed with compulsory admission under the Mental Health Act.
- While admitted, he will undergo further investigations, including blood tests, to rule out any underlying physical causes for his symptoms and he may be offered medication. If there is confirmation of cannabis use, the team may also involve a drug and alcohol support service to help him reduce or stop use and provide ongoing support.
- Encourage the mother to keep him safe at home, ensure sharp objects, medications, and substances are out of reach.
- Make a safeguarding referral due to concerns about Peter’s behaviour at home, particularly the risk he may pose to his younger sister, to ensure appropriate support and protective measures are put in place for the family. Safeguarding team will assess the situation holistically, offer support to the whole family, and help ensure everyone is safe. This may include offering family support services, liaising with mental health teams, and ensuring the younger sibling’s wellbeing is monitored.
- Offer follow-up appointment for the mother to check in and provide support, including signposting to young person mental health charities or parent support groups.
- Reassure the mother she has done the right thing and that early intervention gives the best outcomes.
- Advise the mother to call 999 or go to A&E if Peter becomes aggressive, suicidal, or appears to be in immediate danger.
Learning point from this station:
Psychotic signs and symptoms such as hallucinations, delusions, and disorganised thinking are hallmark features of psychotic disorders, most commonly schizophrenia. However, they can also arise acutely from substance misuse (e.g. cannabis, LSD), certain medications (such as corticosteroids), and underlying medical conditions including infections like sepsis, viral encephalitis, or meningitis. In any presentation of new-onset psychosis, it is essential to rule out secondary causes before assuming a primary psychiatric diagnosis, especially in adolescents.
Early identification and referral to specialist services, such as CAMHS (Child and Adolescent Mental Health Services), is critical for timely diagnosis and intervention.
Where there are concerns about risk to others, such as younger siblings, a safeguarding referral is essential to ensure the safety and support of the entire family.