8.1
Indecent exposure OSCE risk: (progression & intent) (opportunity/alone times) (wider public & children) (past exhibitionism) (psychosexual quick‑6) (risk‑linked plan)?
Elicit escalation clearly: nude → erections → masturbation; arousal from being seen; any thoughts of approaching/contacting her; what stops you.
Fix opportunity: knows she’s home/alone, times of day, vantage points, privacy measures.
Wider public: prior exposures, other victims, stalking/following, presence of children/teens overlooking the garden.
Psychosexual quick‑6: orientation; relationships; porn type/frequency; paraphilias/fetishes; sexual difficulties; libido change/drivers.
Plan—link to risks: immediate ‘no outdoor nudity’, strict no‑contact, avoid her hours/line‑of‑sight, environmental controls (screens/fencing), urge‑delay tactics, private masturbation only, reduce triggers, agree to police/CPN follow‑up, refer to psychosexual/forensic services, consider CBT/relapse‑prevention.
Document denial of intent to approach/violence, confirm safeguarding for children, and seek collateral if legal context permits.
8.2
Risk & Safeguarding. Outline the structure (before–during–after; now–next–near); essentials to elicit (access, arousal, contact, concealment, control, illegal images, future contact/work access, grooming/online, prior acts, protective factors, suicidality); mandatory actions (breach confidentiality; safeguarding lead/LADO/police); immediate safety plan.
Structure: cover the index event with before–during–after, then the risk triad now–next–near.
Elicit: planning/intent; supervision/opportunity; arousal/loss‑of‑control; any physical contact; whether child noticed/told; concealment; device use (type/storage); frequency/escalation; access at work/home; future babysitting/shifts; grooming/online contact; prior acts; triggers/coping strategies; protective factors; suicide screen.
Actions: state confidentiality exception; involve on‑call safeguarding, LADO, and police re indecent images; ensure no further contact with Lily; immediate removal from child‑facing duties; safe discharge arrangements; referral to specialist forensic service and STOP IT NOW; urgent follow‑up.
Avoid: promising absolute confidentiality, delaying the safeguard pivot, or omitting documentation of admissions.
8.3
Morbid jealousy : structure? test conviction vs overvalued idea? risk (intent/means/opportunity/timeframe & escalation)? forensic/legal? others/self? substances (temporal)? job impact? immediate safety? DDx?
Structure: state agenda, anchor onset→progression→last 48h.
Conviction test: “What else could explain this?”, “What might change your mind?”, “How certain 0–100%?”.
Risk: intent, planned method (incl. needles/‘truth serums’/chemicals), access, opportunity, immediacy; document escalation (suspicion→checking→following→confrontations).
Forensic/legal: past violence; any restraining orders/bail/licence.
Others: confirm no intent towards third parties. Self: SI/SH negative.
Substances: quantify; establish increase AFTER jealousy; link to confrontations.
Function: work impact (e.g., calling in sick). Immediate safety: consent to contact partner (or consider necessary disclosure), separation tonight, remove means, avoid alcohol, urgent team review; consider police/safeguarding/MARAC; MHA if high, imminent risk. DDx: morbid jealousy (delusional) vs overvalued idea; screen for primary psychosis/mania (brief): hallucinations, reduced need for sleep, disinhibition; consider substance/organic causes.
8.4
ED erotomania risk history—focus fast: fixed reciprocation? duration ≥3 months? contact pattern (visits, messages, gifts, monitoring, waiting)? proximity/access (workplace/home, travel plans tonight, tickets, transport)? means/capability (weapons, MMA, allies)? response if blocked/escalation history? risk to self? rule out mania/psychosis briefly. Synthesize top risks + immediate safeguards.
Establish fixed, reciprocated-belief and timeframe.
Detail stalking: frequency, methods (ED attendances, messages, gifts), monitoring/following, waits at workplace/home.
Probe immediate plan: seeing her tonight, tickets bought, transport, taking her home/abroad, bags packed.
Test escalation: past reactions when blocked; what he’d do now; who else involved.
Check capability: weapons/access, MMA training, intoxication.
Victim-boundaries: prior warnings, staff requests to stop, police/court orders.
Brief screens: mania (reduced sleep, increased energy/risk), primary psychosis (voices, passivity), substances.
Risk synthesis: high risk to named staff due to fixed erotomanic delusion, repeated approaches, stated intent and capability.
Immediate safeguards: separate from staff member, constant observation, security presence, remove triggers, notify duty manager, consider MHA assessment.
8.5
Pyromania OSCE risk — prompts: meaning/motive; before–during–after; triggers/intox; pattern & early fascination; sexual arousal?; risk appreciation & consequences; recidivism; comorbids (psychosis/depression/PD/LD); forensic history; concrete plan; what to trim? how to structure?
Elicit motive as tension relief vs revenge/self-harm/control. Map before‚during‚after: trigger, affect; arousal/relief, planning, location/materials/others present/intox; insight, concealment, consequences.
Quantify pattern: age of onset, frequency, escalation, carrying lighters/flammables, indoors vs outdoors.
Ask sensitively about **sexual arousal or excitement **with engines/equipment.
Test awareness: who could have been harmed, legal consequences, willingness to change; gauge likelihood of repetition.
Screen comorbids: psychosis, mood, neurodevelopment/LD, personality traits; brief alcohol/drug screen.
Forensic history (police, warnings).
Trim long mood/sleep detail to one-liners to free time for risk depth and planning.
Safety plan: remove/lock away ignition sources, avoid alcohol when distressed, alternative tension release (ice cube, cold shower, grounding/breathing, call a friend),
rapid help routes (university counselling, GP, liaison team, crisis line), agreed follow‚Äëup; consider consented info‚Äësharing with accommodation for fire safety.
Close with a succinct recap and commitment plan.
8.6
Erotomania DDx & Management: Key features? (>3m duration, inaccessible target, stalking, risk, no insight). Priority DDx to exclude? Immediate setting & legal pathway? Long‑term bio/psycho/social plan? Collateral sources?
Dx: Erotomanic delusional disorder. Features: >3 months since handshake, inaccessible public figure, approach/stalking, weapon carriage, absent insight. DDx: schizophrenia/schizoaffective, bipolar mania w/ psychosis, substance‑induced (cannabis),
organic (neurological/encephalopathy).
Immediate: medical clearance + tox screen; safe ED containment; assess capacity (decision‑specific); likely MHA detention; admit to acute ward or PICU (not high/medium secure unless extreme); remove weapon; observation & de‑escalation ± rapid tranquilisation protocol.
Long‑term: first‑line antipsychotic with monitoring; CBTp for beliefs; cannabis cessation support; structured violence + stalking risk assessments; consider restraining order; liaise FTAC; CMHT follow‑up, relapse plan, Section 117 aftercare if detained.
Collateral: police incident & prior records, GP summary, family, employer.
CASC Collateral: Cognitive Decline — MAPS‑RA
Prompts: Memory? Aphasia? Praxis? Attention? Agnosia? Orientation? Risks (wandering/door/hob/finances)? Differentials (vascular/LBD/FTD/depression/alcohol/meds)? Time‑savers? Close (synthesis + plan)?
Alzheimer’s domains (screen fast):
• Memory: short vs long; misplacing; lists/appointments; anniversaries.
• Language: word‑finding + understanding.
• Praxis/IADLs: wash/dress/cook/shop/phone/finances (buttons/shaving).
• Attention/Executive: follow TV/book; multi‑step tasks.
• Agnosia: recognise familiar/less familiar people.
• Awareness/Visuospatial: getting lost; orientation (time/place/person); driving.
Risk (tie to history): wandering/supervision; door left open; gas hob + smoke alarm; meds/OTCs (anticholinergic load); financial exploitation/scams; tech/bill‑pay errors; carers’ strain.
Differentials (tight sweep):
• Vascular: stepwise? HTN, DM, IHD/AF, stroke/TIA, smoking.
• Lewy body: visual hallucinations, fluctuations, falls, parkinsonism, REM‑sleep behaviour.
• FTD: disinhibition, apathy, loss of empathy, rituals, dietary change, early FH.
• Depression: low mood/anergia/poor concentration.
• Alcohol/Drugs: misuse; OTC/herbal anticholinergics.
• Sensory: quick hear/vision screen.
Process: MAPS‑RA (≈90s): Memory, Aphasia, Praxis, Sustained attention → Risks → Alternatives.
Time‑savers: sleep/hearing/vision single screen, move on.
Close (30s synthesis): “Year of steady decline in memory, word‑finding, IADL/visuospatial issues; no personality change. Favors Alzheimer‑type; still exclude LBD/vascular; check labs/meds. Risks: hob/door/finances.”
