11/13/24, 8\:12 PM Guide | Psychiatric risk assessment

Psychiatric risk assessment

Table of contents

Introduction

Conducting a risk assessment is integral to any psychiatric history and often appears in OSCE stations. Any mental health
condition can increase a patient's risk, for example\:
Depression can lead to suicide ideation and deliberate self-harm
Mania may cause reduced risk awareness, leading to dangerous driving
Psychosis may come with command hallucinations to hurt others
Post-traumatic stress disorder (PTSD) can lead to alcohol use as a way of managing unbearable memories
There are three broad areas to consider\:
Risk to self
Risk from others
Risk to others
When assessing risk, you should be empathetic, curious, and ask for speci
have any thoughts or plans to harm themselves or others.
This guide provides a general framework for performing a psychiatric risk assessment in an OSCE setting.

Assessing risk to self

Risk to self can be subdivided into the following sections\:
Personal safety
Personal health

Personal safety

Ask the patient if they are experiencing any thoughts of harming themselves and whether they plan to act on these thoughts.
It is also important to ask about deliberate self-harm, which some patients may undertake not with suicidal intent but as a way
of managing overwhelming and di
and stigma, helping the patient talk more about this challenging topic.
Ways of approaching this might include\:
“ S o m e t i m e s , w h e n p e o p l e a r e g o i n g t h r o u g h d i
t h i s s o m e t h i n g y o u’ v e e x p e r i e n c e d ?”
“ D o y o u h a v e a n y p l a n s t o a c t o n t h o s e t h o u g h t s ?”
“ P e o p l e c a n s o m e t i m e s h u r t t h e m s e l v e s a s a w a y o f m a n a gi n g o v e r w h e l m i n g e m o t i o n s o r f e e l i n gs o f n u m b n e s s– i s t h i s
s o m e t h i n g y o u’ v e e v e r d o n e ? I f s o , w h a t t h i n g s d o y o u d o t o c o p e w i t h t h e s e f e e l i n gs ?”
If the patient has attempted to harm themselves
If the patient has attempted to harm themselves, it is important to take a detailed history of events before, during and after the
episode of self-harm. For more information, see our guide to performing a suicide risk assessment.
What was going through their mind when they harmed themselves?
Check for any delusions of control or command hallucinations
Clarify details about the method of the attempt at self-harm/suicide (e.g. what tablets did they take and when?)
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Be aware of methods with high lethality, such as hanging
Were any preparations made? Did they make attempts not to be found? Did they make a will or leave a note?
“ S o m e p e o p l e m i g h t m a k e p r e p a r a t i o n s s u c h a s ge t t i n g t h e i r a
s o m e t h i n g y o u d i d ?”
“ D i d y o u l e t a n y o n e k n o w w h a t y o u p l a n n e d t o d o ?”
“ D i d y o u t h i n k y o u’ d b e f o u n d ?”
Was the attempt planned or an impulsive action?
“ W a s t h i s s o m e t h i n g y o u’ d b e e n p l a n n i n g f o r a w h i l e ?”
“ D i d y o u m a k e a n y p r e p a r a t i o n s ?”
What was their assessment of lethality?
“ W h a t d i d y o u t h i n k w o u l d h a p p e n ?”
“ W h a t o u t c o m e w e r e y o u h o p i n g f o r ?”
“ D i d y o u e x p e c t t o d i e ?”
Did alcohol play a role at all?
Were they drunk/under the in
Did they drink alcohol to help ensure the attempt was successful?
How do they feel about the attempt now?
Are they regretful of their actions?
Are they upset the attempt was unsuccessful?
Do they have any further plans to harm themselves?
“ D o y o u t h i n k y o u w o u l d t r y t o h a r m y o u r s e l f a g a i n ? “
“ D o y o u t h i n k y o u w o u l d b e a b l e t o k e e p y o u r s e l f s a f e ?”
Be aware of ongoing access to means (e.g. stockpiles of medication at home, knives etc.)
Can they identify any protective factors?
Family, friends and pets are commonly cited protective factors
“ W h a t w o u l d s t o p y o u f r o m h a r m i n g y o u r s e l f a ga i n ?”
“ I s t h e r e a n y t h i n g t h a t h a s b e e n h e l p f u l i n k e e p i n g y o u r s e l f s a f e i n t h e p a s t ?”
“ W o u l d y o u b e a b l e t o r e a c h o u t f o r s u p p o r t i f y o u f e l t l i k e h a r m i n g y o u r s e l f a ga i n ? W h o w o u l d y o u c o n t a c t ?”
Are there any risk factors in the history?
Any family history of suicide?
Any precipitating triggers?
Ask about psychosocial stressors such as
Any recent losses?
Are they socially isolated?

Personal health

Mental health conditions can impair a person's ability to look after their health in many ways. For example\:
Depression can lead to self-neglect due to feelings of worthlessness and a lack of motivation
Psychosis can lead to reduced oral intake if people are experiencing command hallucinations not to eat or drink
Mania can impair people's judgment and lead to risky behaviour, such as driving too fast or engaging in unsafe sexual
practices
PTSD or past trauma may lead to patients self-medicating with alcohol or drugs as a way of coping
Substance abuse
Does the patient use alcohol or drugs as a way of managing di
" W h e n t h i n g s a r e d i
Neglect
Consider personal hygiene, nutrition and safety\:
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“ A r e y o u m a n a g i n g t o l o o k a f t e r y o u r s e l f a t t h e m o m e n t ?"
“ W h e n d i d y o u l a s t h a v e s o m e t h i n g t o e a t ?”
"W h e n p e o p l e a r e s t r u g g l i n g w i t h t h e i r m e n t a l h e a l t h , s t r u g g l i n g w i t h ?"
"I s a n y o n e t e l l i n g y o u n o t t o t a k e c a r e o f y o u r s e l f ?"
" A r e y o u t a k i n g m o r e r i s k s t h a n y o u n o r m a l l y w o u l d ?"
i t c a n b e d i
Concordance
Psychiatric diagnoses can increase the risk of non-concordance with medication, whether through impairing judgement (e.g. in
mania or psychosis) or by interfering with patients' ability to perform activities of daily living (e.g. in depression).
“H a v e y o u b e e n t a k i n g y o u r p r e s c r i b e d m e d i c a t i o n ?"
“ A r e y o u a b l e t o a t t e n d y o u r a p p o i n t m e n t s ?”
"H o w o f t e n d o y o u r e m e m b e r t o t a k e y o u r t a b l e t s ?"
"I s a n y o n e t e l l i n g y o u n o t t o t a k e y o u r t a b l e t s ?"
Physical health
Chronic illnesses and pain can increase the risk of harm to self, especially in older adults\:
"D o y o u s u

Assessing risk from others

It is important to clarify if the patient is at risk from others. Consider whether there are any safeguarding concerns, and state
that you would discuss these with a senior clinician at the earliest appropriate opportunity. Remember that patients who rely on
others for their care may be at risk of neglect and/or
Patients may be unable to speak openly in front of others and ensure that you can speak to the patient alone if you have
concerns. Remember that it is not best practice to use family or friends as interpreters.
Patients who are experiencing abuse from others can feel ashamed. Being empathetic and non-judgmental can help
encourage patients to talk about these di
" D o y o u f e e l s a f e a t h o m e ?"
"I c a n s e e h o w h a r d t h i n g s a r e f o r y o u a t t h e m o m e n t . I s t h e r e a n y o n e i n p a r t i c u l a r m a k i n g y o u f e e l s c a r e d o r u n s a f e ?"
"I s t h e r e a n y o n e c o n t r o l l i n g y o u o r s t o p p i n g y o u l i v i n g y o u r l i f e h o w y o u w a n t t o ?"
Domestic violence and abuse
It is important to remember to ask about domestic violence and abuse, as mental health conditions are possible indicators of
domestic violence or abuse.
Domestic abuse is de
b e h a v i o u r , v i o l e n c e o r a b u s e b e t w e e n t h o s e a g e d 1 6 o r o v e r w h o a r e f a m i l y m e m b e r s o r w h o a r e , o r h a v e b e e n , i n t i m a t e
p a r t n e r s . T h i s i n c l u d e s p s y c h o l o g i c a l , p h y s i c a l , s e x u a l ,
-b a s e d v i o l e n c e
a n d f o r c e d m a r r i a g e .
"
1
All genders can experience domestic abuse, and it is estimated that 2.4 million adults experienced domestic abuse between
October 2021 and March 2022, equating to 5% of the adult population
It can be helpful to frame questions using statements such as " I t i s n o t u n c o m m o n f o r p e o p l e w h o e x p e r i e n c e m e n t a l h e a l t h
d i
a b o u t i t r o u t i n e l y .
"
Questions to ask include\:
"H o w a r e t h i n g s a t h o m e ?"
"H a s a n y o n e a t h o m e h u r t y o u o r t h r e a t e n e d t o h u r t y o u ?"
" D o e s a n y o n e a t h o m e c o n t r o l o r i s o l a t e y o u ?"
"H o w d o e s y o u r p a r t n e r t r e a t y o u ?"
"A r e y o u h a v i n g a n y p r o b l e m s w i t h y o u r p a r t n e r ?"
" D o e s y o u r p a r t n e r e v e r h u r t o r t h r e a t e n y o u ? D o t h e y e v e r f o r c e y o u t o d o t h i n gs y o u d o n' t w a n t t o d o ?"
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"A r e y o u a b l e t o s a y n o t o y o u r p a r t n e r ?"
"H o w d o y o u r f a m i l y t r e a t y o u ?"
" D o e s a n y o n e i n y o u r f a m i l y p o l i c e y o u r b e h a v i o u r ?"
If you have any concerns that a patient may be at risk from others, it is important to always discuss with a senior clinician and
consider whether a safeguarding referral may be warranted.

Assessing risk to others

Ask the patient if they are having any thoughts or have made any plans to harm others. Again, normalising statements can help
elicit this.
“ S o m e t i m e s , w h e n p e o p l e a r e g o i n g t h r o u g h d i
“ D o y o u h a v e a n y p l a n s t o a c t o n t h o s e t h o u g h t s ?”
Clarify if they are experiencing any command hallucinations or delusions of control\:
“ I s a n y o n e t e l l i n g y o u t o h a r m o t h e r p e o p l e ?”
“ D o y o u f e e l i n c o n t r o l o f y o u r t h o u g h t s a n d a c t i o n s ?”
t h e y m i g h t h a v e t h o u g h t s t o h a r m s o m e o n e e l s e . I s t h i s

References

1. NICE. Domestic violence and abuse. Published in 2016. Available from\: [LINK]
2. O
from\: [LINK]
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/history/psychiatric-risk-assessment/ 4/4