Chen's Suicide

By David Tang (5th year Medical Student)
Name
Chen Siu
DOB
04/11/1989 (28 years)
Occupation
Lawyer
History
Note for actor/actress: Quiet, silent, and expressionless. Not receptive to normal conversation. Not responsive if the interviewer is asking question at a normal, lively pace and tone. Unable to look at the interviewer in the face. Only answer if the questions are short and empathic. Do not volunteer information unprompted. 

I want to die… 
There’s no point in me living anymore. I left my family just to be with my partner… 
Even she chose left me… 
I have no one now. I am even bad at work. I could not concentrate, and I get agitated at my clients. My boss told me to take time off. 
I took paracetamol… loads… enough to kill me
I went to different pharmacies and buy them separately so that I won’t be found. 
My colleagues at work came to check on me. 
They got worried when they couldn’t get through to me. 
They called the police. 
I regret being found… 
I would rather die. I left a note. 
I want Dominica (my ex-partner) to regret that she left me… 
I don’t see a point in living on… 
I don’t know what to look forward to in life… 
I have no interest in my job which I used to enjoy, I have no energy 
They keep telling me that I’m worthless… 

[When prompted about hallucinations] I hear voices, in my head… when no one is in the room. I can’t stop them talking to me. It happened after I lost Dominica… 
[When prompted about what I want to do if I’m being sent home] I wanna go home. I don’t need to be in the hospital… I just want to lie in my bed and be away from people. 
[When prompted about my intention on committing suicide] I’ll jump right in front of the tube. That ought to do the trick…
Past Medical History
None
Drug History
None. No allergies
Family History
Mother was quite depressed after I was born but this got better. She had a lot of complications with massive bleeds when I was born
Social History
Occasional alcohol, non-smoker. Work colleagues always have it together and there is no room for slacking. If they find out they will fire me. My mother went through so much to have me, she would not understand
Introduction & consent

Name, age, occupation

Establishes duration of thoughts on self harm or suicide attempt

Establishes triggers/stressors/life events

Explores planning for most recent occurrence e.g. finances, letter, buying equipment or medication

Asks if this has occurred previously

Explores any precautions made

Explores method used

Explores purpose

Explores expectation of lethality

Asks how they were found

Asks how they feel about it now

Asks how they feel about being alive

Explores views of the future

Asks if they are likely to harm themselves again and reasons why (not)

Screens core symptoms of depression (low mood, anergia, anhedonia)

Screens for cognitive symptoms: feeling hopeless, worthless, helpless, poor memory/concentration and guilty

Screens hallucinations or delusions

Explores available support

Identifies level of insight and willingness to accept treatment

Looks for substance misuse

Previous medical & psychiatric history

Family history of psychiatric or medical disorders

Drug history, alcohol, smoking and allergies

Ideas "Was there anything you thought it might be?"

Concerns "What about it is worrying you in particular?"

Expectations "Is there anything in particular you were hoping we would to today?"

Communication skills (empathy and avoids jargon)

Summarises back to patient

Classifies immediate risk of further self harm & suicide and whether patient can be safely discharged

Questions to candidates: 

Q1. How would you manage the patient?

I would ensure that the patient is physically stable. Then I’ll perform a mental state examination and take a full psychiatry history. I’ll assess the patient’s capacity if she refuses medical treatment. I will also refer the patient to liaison psychiatry team for further assessment of her depression.

 Q2. What are the risk factors of suicide?

  • Life events and stressors 
  • Extreme social class (Class I and V) 
  • Social isolation 
  • Stressful occupation 
  •  History of mental health illnesses: depression, schizophrenia 
  • Previous attempts of suicide and self-harms 
  • Substance abuse and dependence 
  • Personality disorder 
  • Chronic physical illness 
  • Family history of suicide

Holly's Anxiety

By David Tang (5th year Medical Student)
Name
Holly Ryman
DOB
06/10/1982 (35 years)
Occupation
Housewife
History
I am fit and well. I recently moved to this area with my husband and my son and I am now registered to this practice. I do not have any medical illness as far as I am concerned. Always fit and well. 

[When asked about regular medications] However, I am currently taking 4mg of lorazepam daily for my ‘anxiety’ for two months now. 

[When prompted] I have butterflies in my stomach and difficulty breathing. I also experience numbness and chest discomfort, almost like an out-of-body experience, as though my own body isn’t real. It has been around a year now since I first noticed the issue. 

[Only if asked] The attack comes in episodes and it happens out of the blue and came unprovoked. It stops after 10 minutes or so but it’s difficult to get the timing right when I was in that state. It’s the worst feeling ever, and I wouldn’t wish my worst enemy to go through that. I find it difficult to concentrate because I keep worrying that the ‘episode’ will come back.

No suicidal or self harm ideation. Initially very reluctant to appreciate this might be a "mental health" or "psychiatric" issue but is willing to accept help if persuaded convincingly. Beginning to use alcohol with the lorazepam to extend the effect. 
Past Medical History
Glandular fever during university
Drug History
Vitamin D, Lorazepam
Family History
Father passed away from a stroke
Social History
Occasional alcohol, non-smoker, no support network as only recently moved to area
Introduction & consent

Name, age, occupation

Establishes duration of symptoms

Establishes triggers/stressors/life events

Explores pattern of anxiety

Explores content of obsessions

Screens if they are recurrent and unpleasant

Screens if they are resisted/senseless

Screens for physical symptoms of anxiety (sweating, palpitations, dry mouth, dizziness, nausea)

Screens psychological symptoms of anxiety (sleep, derealisation, fear, hypervigilance)

Explores methods to reveal anxiety (compulsions, substance misuse)

Explores views on consequences of behaviours

Screens for risk to others and self (including suicide)

Screens for depression (low mood, anergia, anhedonia)

Explores impact on occupation or social life

Explores available support

Identifies level of insight and willingness to accept treatment

Looks for substance misuse

Previous medical & psychiatric history

Family history of psychiatric or medical disorders

Drug history, alcohol, smoking and allergies

Ideas "Was there anything you thought it might be?"

Concerns "What about it is worrying you in particular?"

Expectations "Is there anything in particular you were hoping we would to today?"

Communication skills (empathy and avoids jargon)

Summarises back to patient

Gives reasonable differential diagnosis (Panic attack disorder, GAD, Depression, Organic)


Management point:

  • Consider how the patient was dispensed with a 2-month supply of lorazepam (benzodiazepine). It is classed as a controlled drug and it should not be prescribed more than 30 days, unless in special circumstances. Most NHS trusts do not go beyond 14 days for prescriptions of controlled drugs. 
  • Advise and education is important as psychoeducation improves patients’ understanding of their own illness. 
  • A referral for psychotherapy such as cognitive behavioural therapy might benefit some patients.
  • Other medications such as antidepressants and beta blockers can help to control the unpleasant adrenergic symptoms of panic attacks. Benzodiazepines are used to bridge the therapy until the antidepressant takes effect but often it should not be part of the long-term maintenance therapy. Expert psychiatry input can be sought regarding commencement and dosing of the medications. 

Top differentials: 

  1. Panic disorder – characterised by episodes of unprovoked anxiety attacks like in this history rather than constant feelings of anxiety as in GAD. 
  2. Generalised anxiety disorder – often, the feeling of anxiety spans a continuous duration of time in GAD 
  3. Depression – if symptoms of affective disorders, ie depression preceded the panic attack or the criteria for diagnosis has been fulfilled, diagnosis of depression takes precedence. 
  4. Substance abuse – withdrawal symptoms can often mimic episodic panic attacks 
  5. Organic disorders – endocrine disorders such as phaeochromocytoma, paraganglioma, and carcinoid syndrome could mimic panic attacks.

Emma's Eating Disorder

By Yasser Al-Obudi (5th year Medical Student)
Name
Emma Smith
DOB
12/01/2001 (17 years)
Occupation
College Student
History
I was brought in by her mother. She is worried that I am using things to help look after myself

[If pushed] I am looking after myself to lose weight. I am very proud of going from a size 14 to a size 8 because of how healthy I am feeling and looking. I have done so well in the last 6 months! 
"I can't be ill, I'm doing so well in school". I am aiming for A* in my A-level exams and I am doing very well. 
My mother doesn't know what a healthy diet is. It is important not to eat often and so I always tell my mum that I feel full. I refuse to open up about my diet, only stating that I eat very healthily. 

[Very reluctantly] Becomes angry and agitated when asked. "Please don't ask stupid questions." 
I have been unhappy with my looks since the age of 10. I always thought I was ugly, my friends just lie that I'm pretty to make me feel better. 

[If asked about laxatives directly] I got some laxatives from the pharmacy because the food I was eating wasn't coming out. It is only for constipation. I sometimes take a couple of doses a day until I'm getting it all out.  

[Physical symptoms] My periods have stopped. "It is ok, I checked - I'm not pregnant". Volleyball tires me out very quickly these days. 
She denies vomiting up any food or using any illicit drugs. She denies any recent episode of self-harm or any suicidal thoughts. Her mood is good, and she enjoys going to school. 
Past Medical History
General anxiety as a teenager
Anaphylaxis (4 years ago) - unclear cause 
1 episode of self-harm (cutting her arm) 6 years ago – but she regretted doing this
Drug History
None. Allergic to penicillin
Family History
None
Social History
Occasional cigarettes when hungry, no alcohol as that would be unhealthy. 
Lives with mother, father and one younger brother in a five-bedroom house. Father runs a very successful business and mother is a primary school headteacher. 
She regularly goes out with friends and is the captain of the girls’ volleyball team.
Introduction & consent

Name, age, occupation

Establishes duration of symptoms

Establishes triggers/stressors/life events

Explores pattern of eating disorder

Explores eating habits

Screens for vomiting and laxative abuse

Screens for exercise and drug use

Explores body image perception (body shape ideas, fear of fatness, perception of normal weight)

Screens for episodes of bingeing

Evidence of physical signs (cold, dizziness, weakness, thin hair)

Endocrine dysfunction (amenorrhoea, libido)

Explores views on consequences of behaviours

Looks for risk to self including suicide

Screens for Anxiety (feeling anxious, physical symptoms)

Screens for depression (low mood, anergia, anhedonia)

Explores impact on occupation or social life

Explores available support

Identifies level of insight and willingness to accept treatment

Looks for substance misuse

Previous medical & psychiatric history

Family history of psychiatric or medical disorders

Drug history, smoking and allergies

Ideas "Was there anything you thought it might be?"

Concerns "What about it is worrying you in particular?"

Expectations "Is there anything in particular you were hoping we would to today?"

Communication skills (empathy and avoids jargon)

Summarises back to patient

Gives reasonable differentials & discusses risk (Anorexia Nervosa, Body dysmorphia)