Risk Assessment - Mental State Examination Patient Psychiatric Clerking

Risk Assessment

This section deals with making an assessment of a patients risk of harm to self. A suicidality screen should be should be included in all psychiatric interviews. A full risk assessment is only called for in certain situations e.g. suicide attempt, auditory hallucinations commanding self harm.

A risk assessment can be split into three sections; The act; Mental state and History. The style of layout used here is adapted from oxford handbook of psychiatry [1]

Each of the three sections below highlights many of the factors which indicate a patient is at risk of attempting/reattempting suicide...

The Act

Intent	Clear intention of death by patient Previous intentions / Future intentions
Method	Use of sever and instantly fatal methods Much effort and endeavour to carry out the act
Planning	Advanced preparation (duration, detail) Assistance (e.g. forums, websites...) Precautions to avoid getting caught / stopped
Triggers	Risk of re-experiencing trigger or situation
History of similar acts	May have been unsuccessful but will learn from previous failings

Patient History

Recent life events	Bereavements and loss Major changes or upheaval in life Undue stress
Psychiatric History	Psychiatric risk factors e.g. severe depression, anxiety, persecutory delusions, hallucinations, DSH, dysmorphophobia Traumatising experience
Medical History	Chronic debilitating illness Recent declines in physical health
Social Circumstances	Poor housing Financial difficulties Social isolation, Lack of support Work problems Legal problems
Family History	Family difficulties / breakdown Lack of support Suicide in 1st degree relatives Chronic / debilitating diseases in family

The Mental State

Attitude	Disappointed / indifferent at being alive Intent on suicide again
Affect	Depressed Anxious Incongruous affect
Thoughts	Thoughts of ending life Feelings of worthlessness Thoughts of hopelessness for future Delusional system involving suicide Self hate / loathing
Perceptions	Unbearable hallucinations Hallucinations commanding or about suicide

Example. Mr. Obejenca

The Act
Mr. Obejenca's tried to kill himself by hanging himself with a hose pipe attached to the garage ceiling. He said it was an impulsive act after an argument with his wife who had just said she wanted a divorce "it was a impulse thing you know I wasn't thinking straight the stupid woman had just dropped a bomb shell on me had she not?" He claimed he had not planned it or taken any precautions to prevent being stopped or caught. His wife found him 5 minutes later collapsed.

He said he "didn't think it would work but half did want it to" "I just wasn't thinking straight" He has attempted suicide once before by slashing his writs in march 04 after loosing his job.

History
Mr. Obejenca's has been unemployed for 3 years since he was made redundant from his job as a airport luggage handler. He described his relationship with his wife as "tense and unpredictable" "for the last 6 months" Increasingly difficult financial situation and Mrs. Obejenca's insisting on the need to send money home to Nigeria had put further strain on the relationship. He has had difficulty with a number of debtors who have repossessed his car, some furniture and their TV.

He has longstanding hypertension, impotence, diabetes and is also overweight with a BMI of 28. He suffered from a broken wrist after a fall 3 years ago which has resulted in chronic persistent neuropathic pain in the ulnar distribution of his right hand. He has a past psychiatric history of depression, psychotic depression and paranoid personality disorder. His mother suffered from bipolar disorder.

Mental State
A time of examination Mr. Obejenca's was in a drowsy state lying down in bed in a hospital gown. He was tearful but also came across as very amotivational. He stated he was feeling very down and was having difficulty going to sleep. He stated that he was tired and needed to rest. He would "be in a better frame of mind to deal with things then"

He has no history of violence to others.

Summary
Although Mr. Obejenca's stated that it was an impulsive act but he has a history of 1 previous attempt and a past psychiatric history. On a background of recent relationships difficulties, on going health and financial problems his risk increases. Overall this is a high risk for reattempt.

1 Semple D., et al. Oxford handbook of Psychiatry. Oxford university Press., 2005, pp.731