Explain a first episode of psychosis to a young person and family — OSCE

Candidate instructions

Explain that a first episode of psychosis is a real and treatable medical illness, not a character flaw or a parenting failure; describe why prompt specialist referral matters through the duration-of-untreated-psychosis idea in plain terms; outline first-line antipsychotic treatment and what the medication will and will not do; address cannabis as a modifiable risk factor without blame; describe the metabolic monitoring plan; check understanding; and agree a shared written plan. The examiner plays a parent. [2] [4]

Candidate scenario

You are the paediatrician in the emergency department. A 15-year-old boy presented with persecutory beliefs, auditory hallucinations and four nights without sleep after six months of daily high-potency cannabis use. Organic causes have been excluded — normal physical and neurological examination, normal bloods, thyroid and urine drug screen pending, no fever or focal neurology. He has no active suicide plan. The parents are frightened, blame themselves, and want to know whether cannabis "caused this" and what happens next. [2] [5]

Marking domains

• Empathy, structure and agenda-setting, including parental fear and guilt
• Accurate plain-language model: psychosis as a real, treatable medical illness, not a character flaw
• Clear explanation of why early referral matters using the duration-of-untreated-psychosis rationale
• Balanced antipsychotic discussion: what it does, that side effects decide the choice (TEOSS in plain terms), and the monitoring plan
• Non-judgemental cannabis counselling as a modifiable risk factor
• Safety-net and shared written plan with a named contact, a timed review and an escape route if risk rises

Model outline

Open. Name the problem without blame: "What your son is experiencing is real and it is an illness — a first episode of psychosis, where the brain loses its grip on what is real for a time. It is not a character flaw, and it is not something you caused. It is serious, but it is treatable, and the most important thing is that we act early." [2]

The illness and the window. "Psychosis means he genuinely hears and believes things that are not there — to him they are completely real. We have checked there is no infection or other medical cause. The single most important thing now is timing: research shows that the sooner a young person starts specialist treatment, the better their long-term recovery. So getting him to the mental-health team quickly is not just paperwork — it is the treatment. I am making that referral today." [4]

Medication. "Treatment is usually a medicine called an antipsychotic, started by the specialist. A large study called TEOSS showed that the different medicines work about as well as each other, so we choose based on side effects, not on any one being stronger. It will help the voices and the fears settle. It is not a sedative to control him, and it is not for life necessarily — but it is usually continued for a year or two after a first episode to prevent relapse, and we never stop it suddenly." [1]

Cannabis without blame. "You asked about cannabis, and it matters. Studies show that cannabis — especially strong cannabis, used often and from a young age — raises the chance of psychosis, in a dose-related way. It did not help, and it may have helped trigger this. That is not about blame; it is something we can change, and cutting it down or stopping is now part of his treatment. We will support him with that, not punish him." [5] [6]

Monitoring. "Because these medicines can affect weight, blood sugar, blood fats and some hormones, we check his weight, waist, blood pressure, blood tests and a heart tracing before starting, then again at about a month, three months and every six months. We also ask about side effects like restlessness or sleepiness, and we check on his mood and safety every time we see him, because the risk can change." [1]

Close. Written plan: urgent specialist mental-health referral today, cannabis-reduction support, a baseline monitoring appointment, a named contact, a review date, and a clear escape route — "if his mood drops, if he talks about not wanting to be here, or if the voices tell him to do something dangerous, you call this number or bring him straight back." Invite questions and check understanding. [2] [4]