Psych intro transcript — SMP305 lecture transcript

Sorry. You walk in. Because like place Mhm. So It. nice. Just If For OK. I see. I I. Yeah that's great. Alright. Because that's what's it may cause. I No. I just you know I 13 girls. I It. want That's on you. It's horrible. I didn't, there it is. I. Yeah. That's fine. OK. Right Yeah sorry, I just I know it's all. Yeah. It's like. Yeah. Yeah. I I I saw like I. No. Some something like crazy I. No. I'm so sorry about. Ma. I. I I. So She's she's. she's. but then he said. Yeah. Yeah, yeah, no, that's right, she's not. it's. here. OK I Oh. Right guys, well, um, crack on. I know it's warm today. Hopefully this room will stay this cool, but, um, I'm Chloe, I'm one of the higher trainees. I'm obviously not Will or Pranav, um, who are your, uh, psychiatry 3A leads. It's half term this week, so lots of people are off, so you've got me instead. Um, so we're gonna condense all the lecture stuff or like kind of going through stuff this morning. Um, I'm gonna aim to be done definitely by like 12 so that then you guys have got a break before you've got the coms um skills station this afternoon. Um, which is more about kind of going through some history taking, how to do it and stuff like that. So we'll go through the theory of it this morning and then you'll get some practise this afternoon. Um, so we're gonna go through like a little bit of an induction, we're gonna go through history taking, MSEs, um, a little bit about risk and a little bit about formulation as well. But it's kind of all condensed into a couple of different presentations. So we'll go through this, we'll then go through History and MSC, we'll have a quick little break and then we'll go through formulation. Um, but yeah, as I said, we should, should be done by 12. Um, but obviously if you've got any questions, just ask away. Um, I will like pause and if you have any questions, but yeah, feel, feel free to interrupt. So yes, we'll go through kind of what's expected of you in your psych placements, talk a bit about kind of what's gonna be covered in the ILAs and things like that, what assessments you need. Bear with me one second, my laptop's having a.

Moment. There we go. um, so what is psychiatry? So it is the medical model behind mental illness. So we treat it the same as any other illness that you might see in other um rotations. Psychiatry specifically looking at the medical side of it. um so how as doctors we view that we treat that. Um, obviously it is a little bit different in that when you go into your other rotations, often you can do a specific examination, a specific test, and that will come back positive or negative and will give you a clue as to what's going on. Psychiatry can be a little bit more grey than that, um, which sometimes people can find a bit difficult. Um, that's why we use things like the. ICD a bit differently to other specialties. So you might not have gone into the specialties and then and they might not use the ICD 10 for diagnosis in the way we do. We use that to look at the criteria that you need to meet and to get a certain diagnosis. So if ever you're in doubt about kind of thinking about a diagnosis, wanting to know how you might um give someone that look at the ICD. Um, and that outlines what are the core features and what are any extra features that you need for that diagnosis. So that's a really useful tool that we use kind of ongoing. The ICD 11 is the new one. we are using it half in practise now, um, for your exams and stuff at the minute it's still ICD 10, um, because that's the one that not. Everywhere you work won't be using the ICD 11 at the minute, so ICD 10 is the one that you guys definitely need to know. There's not that much difference between the ICD 10 and 11 for what you guys would, would need. Um, But yeah, so just to be aware, obviously like you can't go in and just do a certain test and know that someone's definitely got schizophrenia or depression. A lot of it is about getting to know someone, about honing your history taking and your MSE skills. So that is such a big part of this rotation. So just running through a few kind of different people that you might come across in your psych placement, so thinking about an older gentleman who's had memory difficulties, um you know having trouble at home, um not cooking, some safety risks. So this might be someone that you could see with a psychiatrist in a memory clinic. Thinking then about the next one, so a younger student um hasn't been leaving the house, um suspicious, broke into their roommate's flat, um, turned up to A&E hasn't had input with mental health services before, so people don't know what's going on. So was seen by a liaison psychiatrist. So they're psychiatrists that work into the physical health hospital. So they have a team um wherever you are, they'll be based kind of at the physical health hospital and they go and review people in A&E and AMU on the wards if there is a concern about um some a mental health condition. So, next one, so a younger student, um, finding placements very stressful, stopped eating, started to lose weight, um, which has made her feel in control, um. So seen by an eating disorder psychiatrist, so this is a service that there is eating disorder services in every location you'll go to, but there's not always eating disorder psychiatrists, um, but that is in Sheffield. They are the main service for the whole of South Yorkshire. Um So Pete, so middle aged, made redundant, low mood, um. Concerned, there's no motivation, no energy. Attempted to end his life by sitting in a car in a closed garage, so he was seen by the home treatment team. So that's a team of more intensive care. So say if you need input, home treatment team can come daily, sometimes even more than once a day. So when people are in a bit more of a crisis or an emergency situation, home treatment team is the team that might be involved. And then obviously someone say 13 years old, not going to school, and has suffered with bullying, finding secondary school overwhelming, breakdowns, and so seen by CAMHS, so child and adolescent mental Health Services. So I guess that's just to give an overview of the fact that psychiatry is actually very broad. We have lots of different um areas that people train into and become specialised in. Try and don't be overwhelmed by all the acronyms you're gonna hear, ask people so if someone, you know, says CAMHS and you've never heard of it or um. They wouldn't necessarily use HTT for home treatment, but you might see it written down like that, um, so just ask because we are aware we use a lot of different acronyms. These services are not the same in any other specialty, so do just just ask and and people will explain it. But hopefully throughout your placements you'll get moved round into different areas and obviously it is different depending on which locality you're in. But if you've got a specific thing you want to see, reach out to your consultant when you start, your supervisor when you start your rotation and say look, I really want to see some cameras. Um, do you know someone that I could go and shadow for a few days? I really want to see some kind of liaison because I'm interested in how that links with the physical health side of things. So there are opportunities. Yes, you'll get your placements, but if you are interested and you do want to seek out other things, do it, um, because yeah, they'll make it possible. So what's on your syllabus, so the main thing is kind of just expanding your communication skills um with patients, thinking about signs and symptoms of mental illness, um knowing kind of the comical common clinical um conditions um and psych emergencies as well. So how that will come out, so you've got your core problems. Um, which each core problem here. Which if we think about when we're looking towards exams as well, all of your exam questions come from these core problems, so they have to be linked to a core problem, so just kind of thinking about that um. And obviously you'll get. Introductions to these through your placements but also through your ILAs as well, I assume you've done ILAs in other rotations. Yeah, yeah, good. Um, so you know how they work, um. So yeah, so resources are available on Minerva, um, but there's lots of other things onto the Royal College of Psychiatry website has lots of good resources about interview skills, about about understanding schizophrenia, bipolar, lithium, so there's lots of resources available on there um that are good, um. Yeah. So what you're gonna have, so you're gonna have today which will cover the like kind of the basics of what you need to know to go into your site placement so that you'll be able to go and do a history, do an MSE um and get the most out of your placement. Obviously how your course works is that then you get the majority of your lectures in your next block because that'll be cases won't it? So you'll get more of the kind of detailed um. Stuff there and you get 3 days of psychiatry in that. So yeah, so today, unfortunately it won't give you everything you need to know uh to do your rotation but it will cover history taking and MSE so you'll be able to go in, you'll be able to do your assessments, um set yourself up ready to kind of learn what you can. So how to get the best, so turn up, um. You will see more, the more you get to know a team, the more they see your face, they will be like, oh yeah, there's a stu like come with us. um really try and embed yourselves in kind of the community teams, don't be afraid to just be like can I come with you? What have you got going on today? Um You don't always have to be with a doctor, so it is still relevant for you if nursing teams in the community teams are going on home visits just for you to get to meet people, meet a wide range um of people with different conditions, practise chatting to them, practise doing a bit of the MSC. The nursing team will not mind if you go out with them and they're doing something else and you say oh can I just chat to them for 1015 minutes to get a bit of that. So. Approach people, be confident, um, turn up the more you're there the more you will see. I know it's frustrating because sometimes there won't be stuff for you to do um same with every placement. Um, in MDTs where you're turning up for MDTs, try and get the list beforehand, go and chat to people before so you've got something to add because MDTs. They can be dry, you know, not going to hide that. In psychiatry ward rounds, MDTs we tend to sit in a room so it's not like your other placements where you'd have followed a consultant and you run round to different people's beds. We sit in a room, people come to us, they are longer um at the minute they're probably warm um so try and do anything you can to engage yourself a bit more in it. So know the patients, go and have a quick chat with them beforehand so when they come in you're a bit more awake and involved in it, you can feedback what you've learned about them. Um, and then obviously ILAs, um, as well. So you've done them before, um, they're the kind of flipped classroom, so come having looked at them, know a bit of information, all of the facilitators will obviously give you further information. We're not expecting you to know everything, but just come ready to have um. Have the conversations about that topic, um, and they go through all of the core, um, Diagnoses, so all of that information kind of thinking about your exams and going forward to them, this is what they should be linked to. OK. Yeah, and that's fine. I was just saying I've added some stuff about sustainability. So what do you need? So you need your 2 mini CETA, your 2 CBDs, and your 4 case summaries with reflections which go on your portfolio. Your CBDs can be done about your case summaries with reflections. So say if when you saw your consultant you were saying OK I've, can you read through these reflections that I've got on my portfolio and we'll discuss one of them to do a CBD that's absolutely fine. You can use the same for that. Um, one of your CBDs and one of your mini ket's needs to be done by your supervisor. So when you're meeting them for the first time try and kind of get a gist of what days they're in, what would be good days to do that, um. Consultants just get so busy, so do take a bit of initiative in trying to kind of start those conversations and be a bit authoritative about it, and no one's gonna mind you being like this is what I need, when can we do it? Um, for your mini cases and CBDs, as with other placements, it has to be F1 and above an F1, um, that signs it off. But also we have some of the clinical educators, so when you, if you're in Sheffield, if you go to your Wednesday afternoons with Gary and Hannah, they can do it as well. Um Yeah, and then your mid-placement and your end of placement. Um, as I said, consultants do get very busy. They will lose track of because they have students all the time, they will lose track of what week you're on. So do make sure you're just kind of getting that booked in if you can when you first meet them, get that mid one booked in and then when you're doing your mid one get the end one booked in. Just so that you you're not gonna run out of time um and you're gonna have, yeah, all of that. So what are the clinical cases, so yep, so you need 4 of them. Um, they're written on your e-portfolio, um, roughly kind of 600 words-ish, and they are the case summary with reflection. Um, so you will see a lot of cases in psychiatry that are easy to reflect on. Whether we think that written reflection is good or not, you know, personally, I don't necessarily agree with it, but it's something you're going to have to continue to do. I still have to do it as a higher trainee. So, you know, you just got to get used to it, um, whether it's useful or not. Um, some of you will also have kind of verbal, uh, reflective spaces, some of you might have access to balance groups, um, or the Wednesday kind of sessions in Sheffield with Gary where you can kind of go through cases and stuff like that, so there will be other. Spaces to reflect depending on what you find useful. Um, yeah, so that's saying that you can do it from case discussion groups, peer support, all of that. Yep, that, so what's expected of you, so yeah, so just turning up um. Engaging, trying to get the most out of your placement, trying to speak to as many people, um, doing your assessments. Um, and then, yeah, just professional behaviour, I mean, we don't need to say it, that's the same as every placement. Um, remembering that kind of if supervisors do flag it up that they haven't seen you, that you haven't done your assessments, like the medical school do add time on to the end you will be made to come back and do some more psychiatry. So if it's really not your thing and you hate it, which is absolutely fine, some of you will, so if you've been made for other specialties that's OK. You still have to come um because otherwise they'll just make you come back and do some more. So just get it out of the way if you don't like it, um. OK. So where to go if you've got problems, so usually, so obviously you'll have your clinical supervisor, there'll be placement leads as well wherever you are. So if you're in Sheffield, obviously you've got Will and Pranav who will be around um after this week um. They'll be, you'll be introduced to the other placement supervisors wherever you are, the medical education team where you'll be based are really useful, they have so many resources and they're nowhere to point you in the direction of, um. Obviously your placement team here and then Dav um as well. And psychiatry can be difficult, um, I don't know what you've all been through in your life. Some of you may have had contact with mental health services, some of your family might have. It can be really triggering, um. If you are finding it difficult, speak to your supervisor, they will understand um if you need to have, if there's certain things that you don't want to be a part of um if you don't want to go to eating disorder services or you don't want to go to CAMHS um that's fine. This placement is about you guys, there's plenty of other things you can see um. But we are aware that it can be difficult, so do just reach out if you if you are finding that um you know where you can access support from the university um but also things like IAT as well if you don't want to go through the university so talking therapies and things like that. um and a really good website, there's one at the bottom so Sheffield Mental Health um. Involves, it's got a list of all of like the third sector organisations that are available for support so you can just type in what it is, so if it's about grief, if it's about eating, whatever it is you can type that in and it shows all the resources that are available within Sheffield. Not just useful for yourselves but also useful for when you're seeing patients and stuff, especially liaison and things like that and knowing what resources are available. So this is slightly out of date having looked at it, but where else can you get psychiatry, um. Experience if you want to, so you'll have SSEs um in phase 3B, you'll have ECPs, electives, there's always options available um if you, are wanting to do it, reach out to our medical education. Um, team, if you're thinking about electives and stuff like that, there's always space that we can fit people in, um, and that's a bit more flexible. There's obviously only certain ECPs that are available, um, which you'll get to rank from that big booklet that you get given, um, but yeah, if you are. Interested just reach out um if you're interested in research, um, Scott Vic whose email is on there is he again is um or Will Gam who is one of your phase 2 a leads. They're really they're both involved a lot in research so if that's something that you're interested in, um, there are lots of options. Um There's options to become involved in the Royal College of Psychiatry as well, um, Congress is in June. The week of the 15th maybe. So I think it's quite cheap for medical students if you are really interested in psychiatry, your placements would definitely give you time off to go to that, it's in Liverpool. Um, That's your SSCs and the other thing is the David Stainer Prize as well, so each year. There's a prize given for commitment to psychiatry um in your phase 3 A placement. So a student will get that and you'll be nominated by kind of your placement leads as well. Um, and that comes with a certificate which is useful but also a little bit of a check, which is also quite nice. Um, so that's just for students who are kind of interested in psychiatry, doing maybe projects whilst you're on your placement, getting involved with research, things like that. So just throwing yourself into it. Right, any questions on that, on the placement? No, you'll get more specific information when you split off into your actual kind of localities tomorrow about your timetables and where you need to be and things like that. Right Apologies if you have different. Lecture slides on Minerva, um. Slightly more last minute that I've been subbed in um to do this so I'm just using my slides rather than uh Pranav's slides just because I will know where things are and what what I'm saying. Um, so we'll go through history taking and MSC. Oh Bit lengthy this, so we'll probably do history taking, then maybe we'll have a bit of a break so you don't have to listen to me chat forever, um, then come back for MSE and formulation. Got risk in here, the questions that we're gonna ask, OK? So What are we Gonna go through. So what we need to achieve throughout this is. Understanding the importance of basically getting to know people, building a rapport um during your history taking because that's where most of your information is going to come from in psychiatry. Um, this comes into your com skills um this afternoon as well because this is a chance where you're gonna get to practise this. It is just in groups of yourself, there's no actors there this afternoon, um, so it's just kind of little groups where you'll get to practise some of this. Um, think about key features of history taking, understand some of the signs and symptoms that we're gonna see, especially thinking about the MSC, um, and yeah, identify where you need where you might need to practise and where you might need to learn a bit more. So yes, so the aim of history taking as with every specialty is to understand the patient better and to be able to formulate their difficulties. So we know that in psychiatry we might not get a definite answer after our history taking, it might be that we are using a formulation approach to try and just look at what issues are coming up for this person, what can we do to help rather than focusing solely on exactly what the diagnosis is. Um You won't be able to, so when you're doing your assessments and things with with real patients, you will not be able to tick every single box of a history, you just won't. Even when I go and do it now and I assess people, I've come out and I'm like I haven't got that chunk and I haven't got that, that's normal. You've only got a certain amount of time and as much as we want to kind of follow our structure and push what we need to ask, sometimes you do just have to go with the flow of a conversation um. When you're meeting people for the first time, obviously for your assessments part of the history taking is kind of personal history, childhood history, things like that um that might not be doable, it might not be appropriate the first time you meet somebody, you might not have built up that rapport, someone might already be upset, it might not be appropriate. To delve into their kind of childhood trauma, the first time you're meeting someone, use your judgement um you know you're in this career for a reason, so yeah, use your judgement, use your skills that you've already got to know when to push something and when not to push something um. Obviously if someone is acutely psychotic, yes, push their delusions, push their hallucinations, try and get into that, but if you're meeting someone for the first time, just I guess consider some of those more sensitive things and whether it's appropriate or whether it's not. So general structure, so there's a few extra bits to what you might usually think of in a history, so we've got the presenting complaint, history of presenting complaint which is kind of usual that you're doing everything. um past psychiatric history alongside we're still doing past medical history, drug history, family history. We're going to consider social history a bit more maybe than other other specialties or a bit differently. um, forensic history. Um, pre-morbid, so what were they like before this? Personal history and then thinking about whether we need a collateral as well, um. So when we're thinking about the presenting complaint, so what is someone, what have they, say if you've seen someone as an inpatient, what have they come into hospital with? You're obviously gonna hopefully get a bit of information before you go and see someone, prepare yourselves so that you know what you're walking into. In general, a very good rule for psychiatry. Full stop, um, just yeah prepare yourself. So where can you get that information from? So you can get it from their their notes, you can get it from staff that are available and also kind of mental Health Act paperwork. So you'll see kind of the pink forms which will be there in physical real life before they're scanned on um and that will tell you about why someone has been sectioned if someone might be there under the Mental Health Act. I always tend to start with an open question, so again same skills as you're using all your other history taking um. If you know about why they've come into hospital, yeah, I tend to say right I I know a bit about why you've come into hospital but could you explain to me what's happened from your point of view, um. Starts a conversation, gets the ball rolling and then you can start to pinpoint the questions that you want to ask, or if you're seeing someone in clinic, so I have read some of your notes and I've got a, I've got a background of a bit of your history, but can you explain to me what's going on for you at the minute. So just starting with that general open question um. That's gonna let someone talk for a few minutes at least before you have to get involved again. Um Making sure when we're thinking about the um kind of history of the presenting complaint we're getting the onset, the duration, any triggers, any precipitating factors, so really nailing down that timeline of how this condition has started and presented. Um, and obviously with this you're gonna see lots of different things as a presenting complaint, so it might be depression, it might be mania, it might be psychosis, it might be anxiety, OCD. Could be dementia, so the history of presenting complaints is gonna be different for everybody you see. So just then thinking about some of these presenting complaints that you might get, what are the important questions we need to ask? So thinking back to kind of what it is that is our criteria for diagnosis, so this is when it's in the ICD is important cos that tells us what are the criteria. So looking at depression, so what are our three core symptoms, so we need to ask about low mood. Not enjoying things, so anhedonia and low energy levels, so there are 3 core symptoms that we need for a diagnosis of depression. If we don't have them, technically we can't say that there is a diagnosis of depression. But then there's lots of other symptoms that we can ask about as well, so asking about sleep, about appetite, about concentration, feelings of guilt, worthlessness, hopelessness, um, and then obviously going on to suicidal thoughts as well or self harm thoughts. Um, what's very important with when we're asking about suicidal thoughts is make sure we ask that first question. If somebody says no, that's fine, we can park that. If somebody says yes, there needs to be follow up questions. So we can't just say, OK, yes, yes, that's fine. If someone's got suicidal thoughts, there's a massive range, lots of people have suicidal thoughts and never ever plan how they would act on those thoughts, never have intent to act on those thoughts. So our secondary questions need to be, OK, how do you. Thought about how you would act on those thoughts, would you ever act on those thoughts? Lots of people would say no, I would never act on them, you know, I've got children, I would not do that to them or I've experienced loss by suicide so I wouldn't, I know the impact that has. So there's a big difference there, so just making sure that if it is a yes to that question, we're following up and we're doing the rest of our risk assessment because that's gonna tell us a big deal about maybe what our plans need to be with this person and how we're going to keep them safe. Obviously if you're seeing someone for the first time. You should be with somebody at all times. I would say don't ever go and do a history taking by yourself, um. Safety precautions on the wards and things like that, don't be alone, um. Take a member of staff ideally whether that's a junior doctor or a member of the nursing team, a HCA, whoever it is who can come with you, go with you. If they're adamant that there is nobody to come with you, go in pairs, so with two of you as medical students, um make sure from the wards you have an alarm, so all wards will all wards will have alarms. There'll be little like kind of grey things that you clip on to you um just means that if you are somewhere where people can't see you, there will be cameras and stuff on all the wards, but if you're somewhere where people can't easily see you, like if they're kind of in communal areas, it means that if you need assistance for any reason you can pull that alarm, it will sound all round the ward and where the alarm is coming from and people will come to you very quickly. I'm not trying to scare you, it is just practicalities of things you need to be safe, um, on your rotation, so these are things to be thinking about. So when you go and you are taking a history, also considering where you're sat in a room, um, so make sure you position yourself nearest to the door so that you can get out. Don't let someone block your exit, don't let, don't sit furthest away and then get someone to sit in between you and the door. Make sure you've got an exit route. It's all things that you. Wouldn't necessarily consider on other placements and maybe we are a bit too precautious about it. You know, I've been working in psychiatry for 6 years and I have never been assault I've never been assaulted. I've never thought I'm gonna be assaulted, but it's all these things that we just we plan for any eventuality, so just making sure you're thinking about these things, telling people where you're going, stuff like that. But anyway, that was a sidetrack from some stuff about depression. So mania or hypomania? Making sure that when we're seeing someone with this, so the difference between mania and hypomania is the time frame, so if it's going over those 7 days, then it's counting as mania, so making sure we're getting that time frame and also the interference with their daily life as well for it to be mania it needs to have had kind of a significant impact on their functioning in their daily life. Um, so things that we're gonna ask about there, so increased mood, mania doesn't always mean incredibly happy. Um, after we get past that stage, actually people just become pretty irritated and agitated and irritable. Um, so just because someone's presentation isn't like sheer joy and elation doesn't mean that they've not got mania, it might be that they're presenting a bit more on the agitated, um, side of things. Thinking again, so thinking mainly about the opposite of depression, so. Thinking again about energy levels, about sleep, about appetite, er racing thoughts, um, restlessness, so pacing, things like that that you might see, um impulsive behaviour, so whether that's with finances, drugs, sexual situations, so whatever that might be, so considering those risks there. Um And any issues that it might have had on their jobs, their relationships, things like that. So that's the main things to consider with mania. Obviously there are lots of risks with mania um in terms of kind of putting. Themselves in risky situations, especially yeah sexual situations, money, spending lots of money um doing things that they wouldn't usually do such as taking drugs, getting into problems with the law um that they wouldn't usually have done. So that's a really important part of your history and your risk assessment that you're going to do. So psychosis, so you'll you'll all see people who have psychosis. So in this we want to think about hallucinations, delusions and thought abnormalities, so thinking about thought disorder. So hallucinations can occur in any of the senses, um, but I guess there's some that we see more regularly. So auditory hallucinations is one of the commonest, you'll all see people who have auditory hallucinations, um, and that's more common in kind of our schizophrenia and also mood disorders as well. Um, so just asking kind of do you ever hear voices or noises that other people don't hear? That's, that's a fine question to ask. That's OK you can word it like that. Don't have to get kind of caught up in am I allowed to say the word voice, am I allowed to say this? People who experience it will know what you're saying, um, unless they've got absolutely no insight and then you'll be able to tell anyway, um, because you might notice people responding, kind of turning their head as if they're listening to something and then you can just say so what what are you what are you hearing right then, what, what is it that's going on for you? Um, so thinking about. Hallucinations, so in auditory, visual, um. Less common with schizophrenia, more common in some of our organic disorders, um, so especially Lewy body dementia, um, substance er withdrawal, um, especially things like opiates. Um, but sometimes we, you can see it in schizophrenia as well. Um, so yeah, so they're the main two, so when you're thinking about hallucinations, they're the main two modalities to go to make sure you're asking everybody, um, and then obviously you can go through kind of sensations, taste, smell as well. Taste and smell are a lot more common in organic stuff, so temporal lobe epilepsy, um. Brain tumours, things like that, we don't see as much of that um in our work. Um, delusions, there's not necessarily a set question to ask that gets you the answer to a delusion, it's just gonna come up in the conversation. Be curious. Um, this is where it's great to start pressing people if you are a nosy person. You're gonna get on well, um, just start quizzing people, asking all those questions, asking why, how, but how do you know that? Is there any chance that might not be the case? Um, are you 100% certain? That's always a great question when we're testing delusions because, you know, a delusion by nature, someone is certain of it. So if you're saying are you 100% certain that's the case, they'll be like well yeah. Um, so that's a very good question to ask, um. And then thought insertion withdrawn and broadcast, which we'll go through a bit more in the MSE section. So anxiety, so if anxiety is your um presenting complaint, there's lots of things that come into this so general anxiety, social anxiety, um, panic disorders, PTSD, OCD, so they all count in the anxiety um. Kind of umbrella term, so trying to kind of if you have a diagnosis of one anxiety disorder you're more likely to have a diagnosis of another anxiety disorder, so it's just using kind of some screening questions if we've got someone that's presenting with anxiety to rule out other anxiety disorders as well. So have you been worrying about a lot of things recently? Is it generalised or is it something specific? Is it just social um situations, is it in public or is it about absolutely everything? Do you get attacks of anxiety, so do you get sudden physical symptoms that take over, so thinking more about a panic disorder where you get them discrete panic attacks that will happen. Um Do you have any flashbacks, any nightmares, so thinking about PTSD? Do you have any unpleasant thoughts or images that keep coming into your mind, so thinking about OCD about those intrusive thoughts or images, um, and do you have to do any specific actions to reduce that anxiety? So again thinking about the compulsion part of OCD. So that's just some questions to um. Go very quickly go through kind of all of anxiety disorders. So substances, um, so we need to know what substance it is, how are you taking it, how much. I'm not great at knowing when somebody says right this many grammes. That doesn't mean a lot to me. um, so I tend to ask in. Money value, like how much are you spending on it a week because money, I can understand money more than I can understand grammes of different types of substances. Um so use what's like what you're going to understand and be able to um work out. So patterns, so when are they using it and what times of day, how often? Is it just so are they using cocaine only when they go and get drunk or is it kind of all the time, um. Have they been abstinent from it before, how did they achieve that, how long were they abstinent for, what broke that? um, what effects is that having on them? Is it affecting their relationships, their jobs, things like that, and also thinking about withdrawal symptoms as well. Um, and then duration, so when did they first use it, when did they last use it, things like that. So that's just an acronym that I like to use, just jogs my memory of the questions I need to kind of tick off when I'm seeing somebody who uses substances regularly. So That's our presenting complaints, they're the common ones you're gonna see. So then past psychiatric history, so what's important to ask, so have you had any diagnosis? Have you ever been under the community mental health team? um if you have what's been tried, what medications have you had, have you? Had any psychological therapy? Have you been in hospital before? If so, was it under the Mental Health Act, so did you go in informally as in you agreed you had capacity and you agreed to go into hospital or did we need to use the Mental Health Act to get you into hospital to keep you safe? um. And one of the questions we like to ask when somebody has been in hospital is whether they ever needed any time and so um PICU, which we use it as psychiatric intensive care unit. Obviously it's also the same acronym as paediatrics but we're not sending these people to paediatric intensive care. So you know just ask them whether they've spent any time there. The psych ICU is used for people who are a bit more risky, so they may be more risk to other people, they may also be more risk to themselves, um, or there may be a risk of absconding um so that's why we might put someone in a in a more intensive environment. It's just better ratios with staff to patients. Less stimulation um but that tells you something about that person's risk history if we're getting er if we're getting someone who we're seeing who has had time in in PICU before. Um, another important things that are gonna lead into our risk assessment, so. Any previous self-harm or um attempts to end their life. And I guess we need to kind of clarify on that if it's a yes, what was it? What did you do, if there was an attempt to end your life. What happened, did you spend any time in actual in hospital or actual ICU, so just clarifying those situations.

Oh. So social history, so much the same as kind of other specialties where you have gone into social history so thinking about their living arrangements. So who are they living with, especially are they living with any children um anyone who they might be have a caring role for, um, are they in a relationship, um. You know trying to get a little bit of information about what that relationship looks like, so is it a healthy relationship, is it not, um. Are they able to kind of care for themselves, do their own ADLs, um, yeah, are there any dependents? So children or pets, um, so when the AMPs do their assessments, so the approved mental health professionals, if we're looking at detaining somebody, that's always a question we ask obviously about children, but also about pets as well, um, because if you're detaining someone we need to make sure that everybody is safe so they will make sure that pets are put in kind of um. Council, um catteries, kennels, things like that to make sure they're looked after. Um, occupation or income, so seeing what um benefits people might be on as well, so asking people whether they're on, are you, what are you receiving you see are people receiving PI as well, um, so just kind of getting used to some of these questions and what they mean, so looking up. What is Universal Credit, what is PIP so that you know what those things are because you're gonna come into contact with a lot of people who are uh in receipt of those. Um, smoking and then drugs and alcohol as well if we've not already asked it in our kind of presenting complaint. Um, and yeah, so specifically asking about cannabis, so I get a lot of people where you're like, OK, are you taking any other substances and people will be like, no, no, no. And then you'll be like, OK, what about cannabis and they'll be like, oh yeah. The people don't see that as an illegal drug, um, because it's so widely used, so sometimes just making sure we specifically ask about that as well. Uh, because obviously it can have a massive impact on your mental state and your, um, hallucinations and stuff. So forensic history, so have you had any interactions with the police? Um, have you had any convictions? Did you spend any time in prison for those? That's enough questions that you need to ask. You'll get a lot of that information if someone's been seen before from previous notes. If you've got previous notes that document it, you probably don't need to ask. Again, um, but if you're being kind of assessed for one of your mini cases, um, then it's probably a good question just to, to throw in, have you had any, um, interactions with the police in the past? So your personal history and pre-morbid history, so as I said at the beginning, use your judgement as to whether these are appropriate questions to be asking. It's usually generally an easy one to throw in like you know like how would you describe your childhood. Um that's quite an easy one, that's not that's relatively vague, people can fill that in. Um, but what we want to know is about kind of their early development, their childhood in general, um, education, did they go to school, did they drop out of school, were they kicked out of school, what, um. Uh, qualifications did they manage to get, what's their employment history, have they been in paid employment, have they been able to hold down jobs, um, relate like a pattern of their relationships, um, and then obviously thinking about the pre-morbid bit, so how would you have described yourself before now, so before you presented with this, before you were, um, in mental health services, how would you have described yourself, how would other people have described you? Um, and that's where also, um, collateral history can come in really useful as well, um, but just making sure that obviously we can get history from somebody. Without needing consent. But It would break confidentiality if we were giving away anything about that person's care. So obviously we can get collateral history, we don't need someone's consent to gain information from somebody else, but say if someone's in an inpatient that person already needs to know that somebody is an inpatient in a psychiatric hospital, otherwise that would be breaching confidentiality. So if you're gonna speak to someone's family member, it's best just to double check with them, ask them if it's OK if you can just get a bit of information. So just some yeah, top tip, so keep it simple um try not to use medical words where possible. um people might not know what the word hallucination means um to just try to yeah use simpleish language. Um, take your time with it, um, it will take a bit of, it will be longer than your other specialties, so just take a bit more time getting to know someone, building up that trust before you delve into some of them deeper conversations. Yep, take a staff member with you, um, can be useful for the patient because they might already know that staff member so it bridges that relationship but also for, for your safety as well. Um, and yeah, use all the information that's already available. Perfect, any questions on history taking? No. Right, let's have a 5, 10 minute break because I've chatted a lot and then we'll go through mental state

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So this is the general structure that's kind of widely used. So aseptic, um. I kind of use it slightly differently in my own head, so you'll all find a pattern that works for you. But this is quite like a, a widely used one that people. Well, if you're trying to um verbalise or write down a mental state exam, they will know you're following this, um, so it's a good structure to to use. So A and B are kind of grouped together, so appearance and behaviour. So appearance, things that we are looking for. So what you want basically is to be able to conjure up a bit of an idea of this person from from what is written down. But what but also thinking about what is appropriate and what is important for us to know. So we don't need to write everything that's not relevant to mental health, men to like the mental state, if it's not gonna like help us. Um, if it's not gonna change over time, um, if it's not something we need to kind of. Take into consideration when we're thinking about treating someone or what their presentation might be. So what things do we need to look for, so we're looking for features that are distinguishing, so any scars that someone might have that might be from either trauma or self harm, um, things that describe that person, so brightly coloured hair, excessive makeup, so thinking that that is something that does change. Over time, especially in people who have mania or bipolar, that might be a sign of where they are at with their mental state. So you see we often see people whose makeup gets more elaborate, brighter when they are more on the manic side of things, so that is something that's appropriate to write down in your mental state exam. So thinking about weight, so is someone um malnourished, are they underweight, are they overweight, um, but just considering when we're writing these things in people's notes. How we're writing it because obviously people do have access to their medical notes, they have access to your clinic letters, things like that, so just making sure we're using polite ways of wording things, especially when it comes also to kind of personal hygiene um and things like that so you know if it's a fact that the person did smell of urine or whatever that's fine, you can write that but just you know making sure that you're you're aware that someone might read what you have written. Um, thinking about any other stigmata of disease, so the stuff that you'd look for anyway when you're doing all of your other examinations, you know, the looking from the end of the bed bit, what can you see, is there any evidence of any other diseases? Um, and thinking also about clothing. So is it appropriate for the weather? So if someone came today dressed in like a full snowsuit, obviously not appropriate for the weather, um, it's boiling. Um, but we also get that the other way around, so in winter, somebody coming in, not enough clothing. Is it provocative, um, for the situation that you're in? Is it the right way round? So I've had people who are so disorganised that they've got their clothes on kind of inside out and things like that, um, so just generally taking in the view of somebody like you would do when you're seeing anybody. behaviour We're thinking about whether we're able to build up that rapport and that connection with the person. Um, are they engaging, if so for how long are they only able to engage for kind of 5, 10 minutes before they walk off? Um, do they come back to the conversation? Um, do they make eye contact, so thinking about things like if you've got someone with depression who might be staring at the floor, um, for the whole conversation, or also is the eye contact too much? So have we got someone who's staring you out for the whole conversation as well? Um Their activity levels, so are they restless, are they pacing, are they appearing anxious, you know, twiddling their thumbs, um, kind of picking at their skin, things like that, or are they really slow in their movements? So psychomotor retardation is what we might call that so often seen people with severe depression, but also in catatonia as well, you might see that. Um, catatonia can be secondary to depression, but it also can be secondary to, um, schizophrenia or psychosis, um, and then the any abnormal movements, so tics, tremors, you'll see plenty of tremors, so if you're thinking about people with, um, Parkinson's or Lewy body dementia they might have tremors, um, medication like lithium can cause tremors, Epsy's, um, so all of those things you might notice. Um, So then the next one was speech. So you might see it written normal for RRTV so that means rate, rhythm, tone and volume. Really we shouldn't use acronyms like that because just thinking about going into your careers going forwards, you shouldn't really. Use acronyms that if a coroner picked up a piece of paper, they wouldn't know what it meant. Because if they don't know what it meant, it might not, might mean that someone else who can read the notes might not know what it means. So in general, we shouldn't really use things like that, but you might see it written because it is quite commonly used still in psychiatry. So breaking that down, so we want to think about the rate of someone's speech, so are they speaking really quickly, so thinking about pressure of speech that you might see in mania or are they speaking really slowly, so more common in depression. Um, and in some dementias as well. The rhythm of it, so is there any breaks, um, in the flow? So thinking about kind of any stutters, stammers, any slurring of speech as well. I don't think there is a difference. I think stutter and stammer, one of them is the American term and one of them is the British term, so I don't think there's actually a difference between those two, But that's kind of an issue either kind of initiating the word or like um Between the syllables of the word. Um, and then the tone as well, so. Usually when we speak, um there's different intonations throughout um our sentences, but is it, is the speech monotonous or is it tremulous, so when someone's about to cry or they're very upset? And then the volume of speech as well, so is someone whispering where you can hardly hear it again thinking about depression where someone might be very quiet, very reserved, looking at the floor, things like that, or are they shouting at you basically um hopefully. You won't have any of those situations because when you go into the wards you're gonna ask people who's appropriate for me to see um and they're not going to send you to someone who's going to be very angry and shout at you. But unfortunately it's something that I come into contact with. Um, so yeah, so that's the things we want to look at in speech, um. And especially thinking here so people can get confused with formal thought disorders and put formal thought disorders in the speech section, but it's not actually a problem with your speech, it's how your thoughts are being formed. So it comes later in kind of the thought category, even though it comes out in the way you speak, the issue is the thought being formed rather than a problem with your speech. So that's why it is later on. So the next thing we want to think about is emotions or affect, so. This can be a bit of a difficult concept to get your head around the difference between emotions and like mood and affect or emotion and affect. So mood we see as the kind of states over a prolonged period of time, so how someone feels over a prolonged period. And then the affect is how someone is reacting in that moment. So what we can observe and what we can see in response to what is going on around. So people tend to say the mood is kind of the overall climate of what is happening. And the affect is the weather that is happening right now. So someone might present as being depressed, that might be their overall mood and we can assess that subjectively, so how the person feels but objectively as well. So if I said right now that I was depressed, that's subjective, that's how I feel, but objectively you might say objectively you look euthymic, so you look in the middle, you don't look like you're manic, you don't look like you're high, but I also, I'm not presenting right now as if I'm depressed. You know, I'm, my speech is normal, my movements are normal, my affect hopefully you think is normal. Um, so I'm not presenting as if I'm depressed, so there is a difference there between what we might subjectively and objectively see in terms of mood. Affect then is how someone responds, so in terms of the questions we're asking, their facial expressions, their demeanour to what is going on around them. So what we might see is if. We might see someone's kind of affect go up and down throughout the conversation, so at one point they might be laughing and smiling and then at another point they might be crying, um, so that's seen as kind of labile affect, so going up and down. We might see that it is a bit blunted, so we might not be getting anything from that person, we might not be getting those facial expressions, that kind of response that we see in normal communication, so we would turn that a blunted affect. And the question that we really want to know is, is it congruent, so does the affect that we are seeing match up with the mood? So if somebody is saying they're depressed, if they're looking depressed, we're saying yep, definitely got depression, is their affects matching that? So are their facial features matching that? Are they crying? Are they speaking slowly? Is that matching up or are they presenting as laughing um kind of all over the place and then we'd say that that is not congruent, so the the affect is incongruent to the mood. OK, that takes a bit of practise, um, it makes a lot more sense when you start to see people um and you can kind of. Put that together, but just in general mood is over a prolonged period of time, subjective and objective and then affect is what we're seeing in response to our conversation there and then.

OK. Any questions on that? No, OK. So then perception, so we've been through this a little bit where we were thinking about our history taking. The main thing that we generally think about in this is our hallucinations. So a sensory perception without an external stimulus. So they are having the perception, it's just not been caused by something in the external world, so something that other people would also be able to hear, see, smell. We've talked about how it can be in any of the senses. Auditory being the most common one you're going to see. Things that we need to distinguish there then is, is it second person or third person. So second person auditory hallucinations being where the voices are talking directly to the person, so they're saying something to them. Third person being where they can hear voices, but they're having a conversation between themselves in the background, maybe chatting about something else, but maybe also talking about the person or doing a running commentary of what is happening, what they are doing. So that's a distinction that we often, often make. So when we're asking about voices and saying, do they talk directly to you or can you just hear them talking in the background and then trying to clarify what exactly is the nature of what they're saying, so are they saying quite horrible things about you? Is it distressing for you? So trying to clarify all of these bits, do you know who is saying. Can you put a a name or a face to the voice? Do you know who it is? That's an important question when we're trying to think about our risk assessment. Because if we think about this to others, if you've got a voice that's constantly talking to you and you're certain it's your neighbour and that voice is telling you that they're going to kill you, how are you going to respond to that? So making sure we're asking somebody then, OK, do you know who the voice is, yes, OK, have you got any thoughts about um. Going to going to find them, confronting them, what would you do if you did confront them? Um, are you having to do anything to keep yourself safe, especially when you go out in public? So are they carrying knives, are they sleeping with a knife next to their bed to keep themselves safe? So these are all things that we need to be considering in that hallucination category in terms of thinking about what could be risks. So that's kind of the the auditory category, visual, yep, so do you see things that other people say they can't see? Common things is, especially in trauma and trauma responses, the common thing you'll probably hear is yeah I see shadows out the corner of my eye. But when I turn there's nothing there. That's a common thing that we see, it's a really common trauma response. Um, so that's probably the most likely thing that you're gonna you're gonna see. Other things, so in substance withdrawal sometimes people see bugs, animals, things crawling. Um, that again is something that you might, you might, um, see on your placement. Other things as we said so olfactory gustatory less common in psychiatry and more common in temporal lobe epilepsy and some of the organic disorders. Um, tactile, so do you ever um have any strange sensations, um, do you feel anything on your skin? um. Again, it can happen in schizophrenia, but in a lot of the substance withdrawals people experience this, that crawling, that itching feeling on their skin. Um, passivity phenomenon is the. Thought that your actions are being controlled by others, now actions could be what you say, what you do, but also your body movements, so questions that I tend to ask is do you feel like you're in control of your body? That's the question I ask that that encompasses that. Now Illusions are also a disorder of perception. Um, but this is something you will have all experienced. So the difference between an illusion and a hallucination is that an illusion does have an external stimulus. So say when you're falling asleep and there's your dressing gown on the back of the door and you think it's a person. That is an illusion, so there has been an external stimulus, you've just interpreted it the wrong way. Or say when people look at clouds and you interpret it as a different thing, that's an illusion because there is an external stimulus that everybody else would be able to see. But you're just interpreting it slightly differently, so that's the difference between an illusion and a hallucination, whereas in a hallucination there's no external stimulus. Um Other things that we see in the perception category so depersonalization and derealisation, these are really common trauma responses again. So for people who have experienced a lot of childhood trauma, especially this is often seen as a learned response to basically shut your body down to not um take in what is going on around you. So depersonalization is when the the person feels like they're not real or they're not their true self. Everyone describes it differently. Um, sometimes people describe it as kind of as if they're looking down on themselves and they're, they're going around their life but they don't feel like it's really them. Um, sometimes people just say they feel a bit funny, and they feel like they're not real, they feel like they're in a film, um, things like that. So everyone describes it a bit differently, but just do you ever get times where you feel like you're not, you're not your true self, you don't feel real. Um, and the other way around to derealization is a sense that the, the world around them is not real, that something has changed. And these are forms of dissociation, um. Which again is is part of a long category, so these are at one end, so depersonalization, derealization, as we go through that kind of um gradient of dissociation we get like dissociative amnesia, so where people will lose bits of time in their day, they don't know what they've done in that time, and at the other end of that spectrum we've got dissociative identity disorder, so did, um, never seen it um. Some people are sceptical about its true existence, um, but there are some rare cases of it, but that's the sort of thing that you see in the films, um, and in TV programmes, um, and stuff like that. So what's the split, I think it is the film that's, uh, did, so you're realistically not gonna see that, but that's all on the spectrum and it starts with things like depersonalization, derealization, they're all a part of that dissociative category. So when we're thinking about thoughts, we need to break it down into a few bits. So we need to break it down into the form of the thoughts, um, so kind of. Yeah, how the thoughts are occurring, the content of the thoughts and the possession of the thoughts. So thought form is that those formal thought disorders, so this is why it comes into the thought category rather than the speech category, but you will notice these in how the person is speaking. So some things that we see, so loosening of associations, so where people will jump from topic to topic but you might not be able to see the links between them, so they're just going so that it's completely loose, so they're just going from one topic to the next. And you can't kind of see how they've jumped that whereas flight of ideas is where they're moving very quickly, jumping from one thing to the next, but you probably can kind of see how they've got from one thing to the next. So you know. There's times, there's one that I can think of where I asked someone what they wanted to do in the future and they said, you know, I want to go on holiday, I'm going to go to Turkey, I'm going to get my teeth done, and it was just kind of that jumps from one topic to the next, but you can see where the links are in how someone's got to the next bit of what they're saying. Circumstantial thoughts are if you think about a circumference of a circle, you'll ask someone a question, they'll go all the way round the circle so they'll discuss loads of other things, include loads of stuff in the conversation, but they will get back to the original point because the circumference always comes back, doesn't it? You'll all have friends who do this, so they'll start telling a story and then they'll go off and they'll fill in all this information in the story that you don't really need and then eventually they'll come to the point. So that's circumstantial. I can guarantee you'll all think of someone who does that, um. Tangential on the other hand, is like a tangent, so if you think a tangent never comes back, does it, it just is a line that goes off. So in that you'll ask a question, the person goes off and they never return to the original point, the original topic. So that's the difference between tangential and circumstantial. Things like thought blocking is where somebody is talking and then just all of a sudden they'll stop, they'll lose their train of thought completely um and it will just be gone. So and that's very obvious to see because someone will just stop kind of mid-sentence and have no idea what they were saying. Perseveration is where um words are. Or syllables are repeated, so you might ask someone a question at the beginning of your conversation, they'll say the answer to it and then they'll repeat that answer for lots of the other questions. It's more common in organic things, especially dementias, um you might see perseveration. Um, and neologisms are where. Someone has completely made up a word, so it might be a word that doesn't exist, or they are using a word in in the completely wrong context um. Yes, so that's sort of the main thought disorders that you might see. There are lots and lots. I wouldn't get bogged down with trying to make sure you've always got it perfect um. You would get multiple consultants in a room, see the same person and they might describe its slightly differently. I think in your MSE if you can just say, you know. That you you can describe what you have seen in terms of if somebody was jumping from topic to topic, that's fine, say that, you don't have to know exactly what is going on, if you can describe it, that's perfectly fine, people will know what you're on about. Um Yeah. I don't know whether this will play with sound. Let's give it a go, hope it doesn't shout at us. No We're not going to get Um, fine, we'll, I'll make sure that these ones are on. Min put on Minerva so that you can access that video, it's just, I'm a bit more of a visual learner, it just goes through that in a like, visual graphic way um which just helps me a bit. So then the thought content is where your delusions come into it, so those fixed firm beliefs that are um out of keeping with social and cultural norms. So other people will have different views to you, it does not mean that they are a delusion if they fit in with their cultural and social norms. Um, but they are fixed and they are firm, and that is where it comes in when I was saying this is a really good point for you to challenge somebody to start pushing back, why do you believe that, what is it that's giving you the evidence that that is the case? Are you 100% certain that that is what is happening? Other things that come into thought content, so obsessions um in terms of those intrusive unwanted um thoughts or images that keep coming in, compulsions are secondary to those, I guess they're not really kind of thoughts. Overvalued ideas, so a single abnormal belief, it's not got a full delusional framework, but it is preoccupying and it's held with quite a lot of conviction, not always out of keeping with social norms, so we might say that um people who have an eating disorder. have overvalued ideas, um, it isn't necessarily always classed as a delusional belief system, um, but it might be overvalued. And then thought content and It includes suicidal thoughts, so making sure we're asking those questions like we discussed earlier, so not only do you have thoughts of self harm or suicide, but do you have plans to act on it. And if you do have plans, what's stopping you from doing that, um, and then thoughts of violence towards others as well. So we've covered some of that in our hallucinations haven't we? But also yeah we need to ask about um thoughts of violence towards others. One thing that I guess I didn't cover in hallucinations was command hallucinations. um, so are the voices telling you to do anything, to act in a certain way? If they are, would you act on it or are you able to stop yourself from doing that? And if they are having commanding me to say yes they're telling me to do things, what is it? Are they telling you to hurt yourself? Are they telling you to hurt other people? That's the distinction we need to make. And obviously. In the delusions category, there's lots of different things you might see. So you might see someone with mania who's got grandiose delusions, so delusions of excessive self-worth or having a special power or having loads of money, so anything that's quite grandiose. You might see people who have, uh, with depression who have Cotard's syndrome, so the delusional belief that you're dead or that the inside of you is rotting, that's associated more with those negative things, so with depression. Um, then there's some other ones, so Capgrass, um, believing that a family member or a friend has been replaced by an impostor, um, or Fregoli thinking that strangers, um, are someone in disguise, so strangers are all the same person but in disguise as other people. Um, Othello syndrome, delusions of jealousy um being certain that your partner's cheating on you without any real evidence. um so there's lots of different delusions that you might see, all got fancy names um but yeah. So, And then thought possession. So Where, where does the person believe these thoughts are originating from or who's in control of them, so. Do you believe that anybody can put thoughts inside your head? Do you believe that anybody can take thoughts out of your head? And do you believe that other people can know what you're thinking without you kind of speaking them out loud. So that covers thought insertion, thought withdrawal and thought broadcast. And these are included in our kind of Schneider's first ranked symptoms of schizophrenia. So when we're asking these questions, although we don't necessarily use those now in our diag diagnostic criteria for schizophrenia, we still do ask the questions they are really useful because we don't tend to see these things in other psychotic disorders, um. So then the next thing that we're gonna think about is insight. So does the, is the person able to understand that they've got a mental health disorder? Do they know that they need support, medication, treatment, and are they willing to engage with that? So they're good questions to to ask if you're judging insights. So do you believe that any of this is related to your mental health? They're gonna give you a yes or no. Do you believe you need any support for your mental health? Because people might agree that yes I've got a mental health diagnosis but might not agree that they need any support for it. They might not be aware of the severity of the situation that is happening right now. So insight isn't just a yes or no, people can have partial insight, they can have some insight into what's going on but not full insight. Um, but they're two good questions to ask to clarify. And then cognition. So firstly whether someone is orientated to time, to place and to person, so very easy questions to just drop into your, to your history taking. Are they able to concentrate throughout the review and then can consider kind of full cognitive testing as well. In, in practise when you go out and do your kind of mini cakes and stuff, you're not going to do a full cognitive assessment. What some of your consultants might like you to say is kind of cognition not formally assessed. So if you're kind of writing it or saying it, word it in that way, it just shows that you know that in that area we would do a full MMSE or we would do a mini AceCE or whatever, but I've not done it today. So it just shows them that you know what would go in that category. OK, so risk then. We've just got, we've got a couple more slides and then we'll have another little break, so we're just gonna go through this is like this is about risk and then we're gonna think about kind of overdose or um suicide history taking. Um, So risks really really important part of psychiatry um we think about it probably in a slightly different way to other specialties just because it's so common um and it comes up in all of our conversations so we're gonna think we're gonna break it up, so we're gonna think about risks. To the person themselves, from themselves, so obviously we've got risk of self-harm and we've got risk of suicide. They are completely different, OK? Not everybody who self harms has suicidal thoughts or wants to end their life. There's lots of different reasons why someone might self-harm, so make sure we're asking both of those questions because people might have both, but they might have only one, and just because they don't have thoughts of self harming doesn't mean they don't have thoughts of suicide. So that's a very important distinction. The risk, there's obviously a risk of if we don't intervene, we don't help, there's a risk of deterioration in mental in their mental health. Self neglect, that's a really common thing that we see, so how are we assessing that? We're asking them about eating, drinking, personal care, um, you'll often see a lot more of that in your in looking at somebody as well, are they looking after themselves if you go on a home visit, what is the state of their environment like? Um, non-compliance with medication obviously comes with risks, um, not just for mental health but also physical health. So important we see lots of people who have diabetes, um, cardiac, um, conditions. Are they taking medications for that because obviously that has long term ramifications on their health if they're not. Um, obviously people are also at risk. Some people do risky behaviour, not because they want to end their life, um, but because there are other needs that they are, um, fulfilling by doing that behaviour, um, even if the. Intention is not to end their life in that way, there is always a risk of misadventure. So if someone is taking repeated overdoses, even if the risk is, even if the intention is not to end their life, there is always a risk of misadventure and risk of death by misadventure um from doing that. So that is something we need to always consider or if people are. Manic, um, and engaging in risk behaviour, believe they can fly, go into high buildings, things like that. I have seen people who on Christmas. Is it Christmas Eve I think it was, I had to detain somebody because they were manic and they thought they could fly um and they'd been out the night before and jumped off a bollard um and sprained their ankle. Um, and then I was like, OK, that's not too bad, um, kind of, you know, thought that meant they would realise they couldn't fly, but they were like, no, there just wasn't enough height. Obviously I couldn't fly off a bollard, there wasn't enough distance for me to be able to fly, so my next step is to jump off a building because that will give me enough distance to be able to fly. Um, so obviously they were then unfortunately detained for Christmas, but that's the sort of like misadventure risks that we're thinking about. Um, so what is it in their behaviour that isn't intentionally to harm themselves but could cause impact, um, drugs, things like that. Um, and then the risk to their future as well, so future implications, so in terms of jobs, education, finances, someone coming into contact with the law whilst they're mentally unwell, which can have implications on their future. Um, so they're all things that we consider kind of in the risk to self category. Then there's risk to others from the person. So violence towards others, especially thinking about kind of with the command hallucinations, um trying to um. Confront people who they believe might be involved in their delusion, delusional beliefs or hallucinations, um. Which is usually, so people with mental illness are far more likely to be the victim of violence than they are to be a perpetrator of violence, however, those things like delusional beliefs and hallucinations are usually the cause of violence when it occurs for someone with mental illness. Um, other risks to others, so Um, if somebody is in a caring role and they are mentally unwell, they might not be able to perform that caring role to the ability that they should be able to, so thinking about the risk of neglect in terms of children, um, or other or any dependents that might be in their lives. And carer burnout as well, which is really important we see it so much, um. Which is a, yeah, a significant risk of kind of that family relationship and the breakdown that can happen there. And then risk from others is the other category we see, so you're going to see lots of people who are quite vulnerable um and are open to being exploited um whether that's financially, sexually, whatever that is, cuckooing. So when people would use a property, so they would move into a person's property and use it um. For another purpose so it's often really for drug, um, drug crime that people use the property for, um, and also the risk of retaliation as well. So you guys will have a lot better understanding of mental health than the general population if you saw someone in the street that was mentally unwell. You might understand why the person's doing something, you might take a wide berth, you might not listen to them if they shouted something at you across the street, not everybody is like that. um, people are at significant risk of retaliation from others, um as well and as I said people with mental illness are um far more likely to be a victim of violence than they are to be a perpetrator of violence, um, and I think that's really important because yes, I have stressed to you. A lot about don't go alone, you know, don't sit yourself next to the door, take an alarm, all of this. You're going to see people in inpatient hospitals, they are the most unwell people that we could see, um, which is why we stress all these points. um so yeah it's more precaution than it is because we think anything is going to happen to you. Um just better to be safe. So thinking then about that the risks and things like that, if you are seeing somebody who has, so this is mainly written for kind of overdose history taking but it does work, you can adapt it for all um. suicide attempts. So what I tend to do is break it down into the before, the during and the after, which is gonna give you a key. Uh run through of what has happened, er, leading up to it, during it, and kind of how the person feels now. And that's gonna highlight to you what the risks might be ongoing. So the things we want to know before, so was there a precipitant, so why today? What changed in your life to mean that today was the day um that you took the action? Was it planned or was it impulsive? Um, did you do any final acts? So that means, did you sort your finances out, did you write a will, did you kind of put your house in someone else's name? So all of those things, so what planning had gone into sorting out um the stuff for afterwards? Did you take any precautions to not be discovered? um, so kind of making sure that you were doing it at a time where people weren't going to be in the house or you went to a location where people wouldn't find you, you turned your phone off so your location wasn't available, things like that, so what kind of um precautions had you done to make sure you weren't found or interrupted? And were you drinking any alcohol beforehand as well? So that's the before part. Obviously that is the same no matter what er suicide attempt it is um so all of those before questions are the same. The during bit then is what method was used. Um, so if it's medications, there's obviously maybe a few more questions to ask here. So what medications was it? How many were there? Um, how did you take them? Because actually if you think about someone who's taken 70 tablets, that is a lot of time that it takes. To swallow 70 tablets consistently each time you're making a conscious decision to swallow another tablet. Sometimes people kind of um crush them up into a little paste um with a bit of water because that's a lot easier so what have you done? How, how have you kind of taken them? Um, where did you get them all from? Um, have you been kind of not taking your prescribed medication to save them up? Had you been round, um, kind of 10 different supermarkets to get enough paracetamol because obviously there's limits on how many, um, paracetamol you can buy each time. Um When you, when they completed the action, did you believe that it would end your life? Um, that's a really key question. um, and then what did you do straight afterwards, so did you go and make yourself vomit, did you fall asleep, um, did you call for help? Help? Were you found? How did you end up from that situation to being where we are now um where wherever you're seeing the person or kind of if you're seeing them in in hospital afterwards, how did they get from being at home to being kind of in A&E or in ICU or whatever it was? Um So and then more of the after, so how do they feel about it now, um. What is their current mood, have they still got suicidal thoughts, um, if they were to leave hospital now, what would they do? um, so. Would you act on your thoughts again, um, would it be a different method, have they kind of tweaked it, anything like that? What protective factors are there? So this is another important part of our risk assessment is protective factors, so reasons why people stay alive, different for everybody, but what is it that would stop you acting on these thoughts, what are the protective factors for you? And would they accept any treatment, any mental health support? So that's In general, how I would take an overdose history. Um, but it is, yeah, tweakable for any kind of attempted, um, suicide or self-harm. Um, you can tweak that as well. We don't use scores like this to just um this is not the reason why we would admit someone to a mental health hospital but when say you're seeing someone in A&E or on liaison. Or you're trying to briefly think about kind of why so who might be more risky than others, until you have kind of seen lots of people and developed your own skills about how you do that. Things like the sad person scale is quite useful to think about who is more risky than others. So just going down it so males. Males are at an increased risk of completed suicide. um. Females are at an increased risk of self-harm and suicide attempts, but males are more likely to complete suicide because of often the difference in nature of how uh the methods that are used and the more violent methods. Age, so kind of the um extremes of age, um but in general I would worry heavily about a middle-aged man. That would be my kind of bit of a a trigger point where my mind's whirring and I'm thinking OK this could be more risky. Um, if someone's got a depression a depression diagnosis, um, if there's been previous attempts or previous input with psych um. Psych admissions, Alcohol use, um, rational thinking loss, so as in that they can't see how the situation could change, there could be any changes in the future, um, complete hopelessness basically. Um, if someone is single, separated, divorced, so all them things put someone at an increased risk. If they had an organised plan, so if they've thought it through, if they've done those final acts, and made sure that they weren't being found, um, they've done it in a place where they didn't think someone would see them, so all of those things that we thought about in the kind of history. Lack of social support and then other um conditions so other physical health conditions that someone might have especially things like chronic pain. So chronic conditions especially but things like chronic pain are really important to consider. And then as I said we don't necessarily use this in terms of if they're high risk on this score, we would definitely detain them because there's lots of other things that play into it. But whilst you're getting your heads round risk assessing somebody, it's a very useful tool to think about and to go through. Um, and they do use this in like A&E and stuff, um. To just consider risks.

So other things One slide on it, you know, um, the other things that we might do when we're clerking somebody in, we've done our history, we've done our MSE we would then also do a full physical examination of somebody including a brief neuro exam. We do our bloods to rule out any other causes, obviously there are physical health um conditions that can mimic um psychiatric illness, thinking about kind of hyperthyroidism, things like that um. anaemia, B12 deficiency, all of those kind of things. So yes, we do a full lot of bloods including some things that are needed if we are considering starting somebody on antipsychotic medications, so we're wanting their lipids and their HbA1C because all of our medications pretty much if they're antipsychotics can have some impact on metabolic functioning, um, prolactin because lots of our medications have an impact on that. um. We also would always consider when we're clerking someone in a urine drug screen, um, and a pregnancy test as well and then an ECG because again lots of our medications can have um. Uh, can affect the QT interval. Um, so we like to have a baseline ECG so that we know that if there are any changes, whether it is related to medication or not. Any questions on any of that? No? OK. Right, let's have. Another 5, 10 minutes then. Um, and then I do have, so we've got formulation to go through which won't be very long so I'm just gonna go through like the 5 P's of formulation. But I also have uh MSC bingo, if you'd like to play a round of bingo. No, yeah. Yeah, we'll do it. Just so you know, so you can get through them things. I'll get this done then.

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