Malcolm is a 34-year-old man with a diagnosis of paranoid schizophrenia. He was admitted into high secure psychiatric care as a transfer from medium secure psychiatric care following absconsions and hostage-taking. His admission to medium security had been made by Court Order following a conviction for attempted murder. Assessment revealed a complex persecutory belief system (Delusions Rating Scale (DRS) = 18;

Haddock et al., 1999) and a separate grandiose belief system (DRS = 17). While Malcolm reported distress when thinking about unseen adversaries, there was no evidence of subjective distress about being specially chosen. Similarly, Malcolm's omnipotent and benevolent auditory hallucinations (Auditory Hallucinations Rating Scale (AHRS) = 14; Haddock et al., 1999) were not experienced by him as distressing. Malcolm had a history of depression and suicidal ideation. His current self-esteem, measured using the Culture-Free Self-Esteem Inventory (Battle, 1980) was rated as "low" (18, 25th percentile; Bartram, Lindley & Foster, 1991). He believed his "voice" was that of an "alien mentor-protector" who had promised him imminent rescue from his secure care. His psychological formulation involved low self-esteem, auditory hallucinations reflecting a wish to be free, and a compensatory grandiose belief of being an "intergalactic chosen one". He was certain he would be rescued and trusted implicitly in his "voice".

Multidisciplinary risk assessment concluded that Malcolm was at increased risk of suicide and/or hostage-taking in a bid to escape. Two clinical hypotheses were apparent. Firstly, since his hopes of rescue were delusional there was the possibility that he would be disappointed, perhaps experience low mood, and think his situation hopeless once the deadline for his rescue passed. Alternatively, it was possible that he might make an attempt to escape, perhaps taking a hostage in an attempt to secure his release. The multidisciplinary plan included: regular reviews of his mental state with the nursing team; individual work with his named nurse focused on increasing his self-esteem; and cognitive behaviour therapy targeting his auditory hallucinations and grandiose delusions.

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