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Table 8.1 4 × 3 framework
Factors\dimension Biological Psychological Social
Precipitating Alcohol excess Losses: g/father; over 2 years, also lost
job and home
Predisposing Family history of alcoholism;
female gender doubles rates of
depression after menarche
Maintaining Refused GP prescription of
antidepressant
Father drank to excess during her
childhood; divorce (no children) owing
to husband’s drinking
Sense of failure over her job, marriage,
drinking
↓Contacts after funeral; argued
with her sister
Isolated: lost friends when
fired from her job; during same
period, her marriage failed
On own by day; lives 30 km from
usual supports
Protective She is not alcohol dependent Links alcohol misuse to her low mood Some local links; sister is
supportive
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of PTSD, although even this diagnosis is
constructed on a vulnerable predisposing
personality. We might use 4 × 3 framework
for ‘Mary’ as illustrated in Table 8.1. Aetiology
is more difficult with disorders that are
predominantly psychosocial (e.g. eating disorders
and psychoses) and do not have clear biological
antecedents. Both, however, have physical
sequelae (weight loss and gain, respectively) that
can become biologically maintaining factors.
Even that most medical (biological) of diagnoses,
delirium, has psychosocial maintaining factors
and psychosocial treatments.
3. Differential diagnoses: by convention, we list
the likely diagnosis (diagnoses) first, and give an
indication of severity. Then we open a discussion
during formulation on a differential. When we
find evidence that falls short of establishing an
alternative diagnosis, we might say ‘I considered
X but I out ruled it owing to Y, as she had
only two associated factors present’. Thinking
about other diagnoses are part of this (Box
8.11). Comorbid conditions are common, and
interlinked: formulation seeks to clarify their
importance, for example primary depression
example above (Mary), made worse by alcohol.
4. Investigations: many physical health test results
will return the same day to reassure or point
to pathology (full blood count, biochemistry
of kidney and liver); others (thyroid,
cortisol, hepatitis screen, HIV, autoimmune
encephalitis screen) can take longer. One test is
immediate—a urine test. A urine drugs screen
is mandatory in new psychosis presentations,
HCG necessary in young women who might
be pregnant, and urinalysis rules out urinary
tract infection in confused older people. Specific
pathology (central nervous system [CNS]) may
require brain scans and other testing, such as an
electroencephalogram (EEG). We rely too on
psychological testing batteries that build on the
findings of this interview, which often lead to
better psychotherapy choices.
5. Management plan: is the whole point of
formulation. Interventions are biological, such
as stopping or starting medications, reducing
Table 8.2 The anxiety and depression detector
Question: ‘In the past 3 months…′ Disorder
uncovered by
question
1. ‘Did you ever have a spell or an
Panic disorder
attack when all of a sudden you felt
frightened, anxious or very uneasy?’
2. ‘Would you say that you have been
bothered by ‘nerves’, feeling anxious
Generalized
anxiety disorder
or on edge?’
3. ‘Would you say that being anxious or
Social phobia
uncomfortable around other people
is a problem for you in your life?’
4. ‘Did you have a period of 1 week or
Depression
more when you lost interest in most
things you usually enjoyed?’
5a. ‘Some people have terrible
experiences happen to them (give
Post- traumatic
stress disorder
examples of personal trauma, sexual
assault or seeing someone badly
injured or killed). Has anything like
this ever happened to you?’ If the
answer is yes
5b. ‘Have you had recurrent dreams or
nightmares about this experience, or
recurrent thoughts or flashbacks?’
(Source: Means-Christensen, AJ., Sherbourne, CD., Roy-Byrne, PP., et al (2006).
Using five questions to screen for five common mental disorders in primary care:
diagnostic accuracy of the Anxiety and Depression Detector. General Hospital
Psychiatry, 28(2), 108–118.)
alcohol, improving sleep, taking regular exercise;
psychological, such as problem- solving therapy to
reduce self- harm recurrence, or more complex
psychological therapies (see later); and social, such
as leaving the house each day, joining a group, (re)
connecting with friendship networks. Without
the history and MSE, we would not be in any
position to make these recommendations. Ideally,
the person who shares the plan with the patient
is the person who explored these details: this will
achieve ‘sign up’. If risks have been identified,
you need to set out the short- term management
of these: actions to protect children at risk; home
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Psychiatric assessment
Box 8.11
Physical illness that manifests as psychiatric symptoms:
‘organic psychiatry’
Cognitive deficits: chronic (dementia), acute (delirium),
acute on chronic… or congenital as intellectual disability
Alcohol or substances: misuse, intoxication, dependence and
withdrawals
Mood disorders or Psychosis: e.g.
Anxiety disorders: (see Box 8.7 and Table 8.2) plus others,
e.g. acute stress reaction, prolonged grief disorder, complex
post-traumatic stress disorder (PTSD) and obsessivecompulsive disorder (OCD)
Somatoform disorders (medically unexplained symptoms/
functional somatic symptoms; see Boxes 8.15 and 8.16)
Dissociative (conversion) disorders (see MSE) and
neurasthenia
Eating disorders (see Box 8.9) Non-organic sleep disorders
ARFID: see text Sexual dysfunction, non-organic
Disorders of adult personality and behaviour: personality
disorders
Factitious illness (malingering) is a diagnosis of exclusion.
ARFID, avoidant or restrictive food intake disorder.
treatment team or admission, etc. These plans
need contingencies if the patient fails to sustain an
improvement, or deteriorates. It is good practice
to share widely the drivers of named risks with
other professionals to encourage their vigilance
for changes, if the plan needs to be escalated in
the short or medium term.
Specialist presentations require a thorough history
and MSE plus the following.
Diagnostic hierarchy in Psychiatry – diagnoses
higher up this list take priority over lower ones
delusional
disorder, schizophrenia
(see Box 8.8)
(features of both)
Schizoaffective
disorder
Gender identify disorders
Disorders of sexual preference
Psychosexual development
disorders
Detailed cognitive examination (neuropsychiatric
assessment)
Cognitive impairment will be flagged in the referral
or assessment process. We are accustomed to this
approach in people over 65 years of age given their
dementia prevalence of 5%, but consider this in some
other groups: head injury and loss of consciousness,
systemic illnesses with CNS manifestations (HIV,
systemic lupus erythematosus [SLE], Covid- 19,
thyroid, sarcoid, paraneoplastic syndromes) and
rare dementias in younger groups. Some impaired
patients, especially those with advanced education,
can hide their deficits in social exchanges, and (owing
to their design) score better than their abilities on
formal cognitive testing. Most of your assessment is
contained in standard history and MSE, but even on
initial assessment, you need to test mental capacity.
Here, we evaluate urgent and immediate questions:
does this patient understand and retain the (broad)
reasons why he is in hospital? Does he understand the
treatments on offer and the effects of those treatments?
If his capacity is impaired, we then need to comment
on and make a recommendation if this patient
refused to stay in the current hospital setting. Does he
understand the consequences of stopping treatments?
Does he also understand the risks of attempting to
‘go home’ (he may not know where he lives despite
his wish to go there), the hazards of travelling there
and how others might take advantage of him in
that process. The law assumes capacity and our due
diligence (communication aids, multiple assessments,
sometimes multiple assessors) to establish its absence.
It is decision- specific and, for example, a patient could
lack capacity for immediate care decisions, but be
capacitous to decide longer term choices—last will
and testament or power of attorney. Box 8.12 sets
out six common instances where patients benefit
from detailed neuropsychiatric assessment. This is
not a complete list, omitting for example post- stroke
depression (incidence approximately 50%), many
require specialist teams and some are strong risk
factors for completed suicide.
Children and young people
As standard, children have a parent present at
interview, and there are several other differences
from adult interviews. The doctor must rely on
several interdisciplinary assessments, understanding
the child’s home life as a system (he is a symptom
of family- based problems, not the problem child
with symptoms), specific developmentally aware
psychological testing and collateral history from
schools (requires parental permission). A subset of
children may have started out in abusive domestic
settings, and may have lived in institutional care. The
diagnostic categories are also different, with diagnoses
of conduct and emotional disorder that are unique
to children: 6% and 4% community prevalence,
respectively. Some assessments are highly specific to
the child’s age, such as a mother– infant interaction
observed by perinatal teams (whose initial focus is the
mother’s mental disorder); play therapy/assessment
in very young children; educational psychology
assessment (measuring intelligence quotient (IQ)) is
just one aspect of psychometric testing) that may be
linked to evaluation for attention deficit disorder and
many others. The last 20 years has seen rising rates
of mental disorders and self- harm in children, and
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Box 8.12
Neuropsychiatry: six common clinical presentations
Working clinical diagnosis Approach/likely findings Instruments/course
Dementia Chronic course of global cognitive
impairment
Addenbrooke’s Cognitive Examination (ACE)
III; full battery of testing from Memory Clinic to
time interventions over decline
Age- associated cognitive decline Age over 50, gradual onset and >6 months;
subjective difficulties, but not global
ACE, MOCA: usually normal in non- memory
domains; depression is common and treatable
cognitive impairment
Traumatic brain injury (TBI) Initial post-traumatic amnesia, then
behavioural changes, low mood comes later;
apathy and abnormal premorbid personality
indicate poorer prognosis
Functional cognitive disorders Common: memory problems in depression
Often: memory problems as a functional
disorder, or as part of health anxiety
Rare: psychogenic amnesia
Epilepsy:
Prodrome ± aura
Seizure ± loss of consciousness
(LOC)
Seizure: partial or general.
Nonepileptic attacks last longer
One-third of epileptic seizures have
psychiatric manifestations and
comorbidities, higher in temporal lobe
epilepsy (TLE); frequency of diagnoses:
anxiety, NEAs (up to one-third of seizure
presentations); depression, then psychosis
EEG useful in prolonged confusion to identify
limbic or other seizures; scanning may show
specific damage associated with (e.g. affective
or paranoid psychosis)
Subset of depression has cognitive deficits
that persist when mood lifts; with functional
(as with memory lapses), there are
inconsistencies; treat dissociation for amnesia
Psychometric tests help identify cognitive
deficits; radiology to exclude structural
pathology; video EEG to define actual seizure
activity; tracing (not visuals) is normal in
NEAs. Both epilepsy and NEAs run a chronic
course, and often co- occur.
(5–30 min) than seizures, and
patient can remember events
during apparent LOC.
Frontal lobe syndrome/symptoms Changes to personality, mood, social
awareness and behaviours: new onset
impulsivity/disinhibition; MSE shows
attention and memory problems but
collateral history key.
EEG, electroencephalogram; MOCA, Montreal cognitive assessment; NEA, non-epileptic attacks.
(Source: Daniel David, Simon Fleming, Michael Kopelman, Simon Lodestone, John Millers. Lishman’s Organic Psychiatry: A Textbook of Neuropsychiatry, 4th Edition. WileyBlackwell, 2012.)
Generic psychometric tests often in normal
range; show inflexibility within testing—
Wisconsin Card Sorting Test; become
‘impulsive rule breakers’, aggression hard to
manage.
the figures cited here may be an underestimate. Up
to 10% of children have an anxiety disorder, mostly
social phobia, specific phobias, panics or general
anxiety. A 2% prevalence of hyperkinetic disorders
is generally accepted, but United States diagnostic
rates are higher than the rest of the world. Around
1% of children have eating disorders, and a smaller
proportion have some of the other disorders listed
in Box 8.11.
People with intellectual disabilities and/or on
the autism spectrum
Collateral history from multiple sources guides the
approach here. There may be locations that suit
the patient better, perhaps seeing him in his own
home, or favourite toys and objects to bring into the
interview to improve rapport. In general, shorter,
low- intensity multiple interviews work well. Up to
2% of the population have intellectual disability
(ID), to varying degrees (Box 8.13), and only some
will need psychiatric support. Mental disorders are
up to five times more prevalent in people with ID,
and they also have higher alcohol misuse. Depending
on diagnostic criteria for autism (Box 8.14), 75%
people on the autism spectrum also have ID, and
therefore a more thorough cognitive assessment
will be required. In some groups, typically Down’s
syndrome, there may be a loss of social functioning
in early adult life indicating Alzheimer’s and other
dementias.
Autism spectrum disorder (ASD) has a 1% prevalence in the child population, with a male- to- female
ration of 3:1. Many good sources previously have
cited this ratio as higher, leading to ASD being under
diagnosed in females. The history and MSE, together
with parents’ collateral, will raise the suspicion of
adult ASD; school difficulties, especially adjusting to
new schools or new teachers, problems making new
friends and challenges with independent living. Your
enquiries may provoke anxiety in the patient—even
for factual answers. Note these and try to formulate
other information indicating social and communication difficulties. Back up clinical impressions with intelligence testing and educational assessments. Most
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Psychiatric assessment
Box 8.13
Clinical features of learning disability
ICD10 classification of intellectual disability
Category IQ level Features ‘Mental age’ (years)
Borderline learning
disability
Mild learning
disability
Moderate learning
disability
Severe learning
disability
Profound learning
disability
ASD teams use validated assessment interviews to
confirm or rule out autism. Once ASD has been
agreed as a diagnosis, work to create the best support system for patient and carers (this can be low
level, low intensity but with contingencies) and treat
mental disorder comorbidity in the usual ways in
these contexts.
70–84 Live independently as adults, difficulty sustaining employment.
More vulnerable to exploitation
50–69 Superficially normal social and language skills; appear normal
(people with lower IQ tend to be dysmorphic) with minimal deficits
in motor skills; may require additional social supports during crises
35–49 Can learn social and communication skills; self- care with
supervision; a minority can lead independent lives
20–34 Very poor social and communication skills; require daily supervision
and the provision of structure. Associations with genetic
conditions—with reduced life expectancy. Frequent central nervous
system pathology: cerebral palsy, epilepsy, hydrocephalus and
autism
<20 Sometimes no social or language skills; require full- time, often
institutional, care
supporting these patients earlier. One useful practice
is to weigh all patients at medical contacts, and share
results with other health professionals. There are
emerging screening tools, but again, they depend on
self- disclosure. Treatment is complex, but the best
outcomes are seen from flexible, outreach eating
disorders services over long- term engagement.
11
9–10
6–8
3–5
<3
Patients with eating disorders/disordered eating
Patients with eating disorders/disordered eating
are not a different species. However, achieving a
diagnosis and thereby the best treatment has become
more difficult in the digital age where patients
are aware of the criteria used to diagnose eating
disorders (see Box 8.9); they engage with others
on social media who have made efforts to conceal
both symptoms and the effects of their mental
disorder. Drivers of concealment are the cognitive
distortions of anorexia (low weight of itself makes
these overvalued ideas stronger as weight reduces)
and the stigma of an eating disorder. Above many
other ‘unpopular’ groups who have mental disorders
(including self- harm and addictive behaviours), many
health professionals have negative attitudes about
eating disorders. The disorders are seen (wrongly)
as self- inflicted, a ‘lifestyle choice’ or rooted in
excessive self- absorption. It may not be conscious
to either professional or patient, but the patient
is also expecting a negative reaction to disclosure
of eating problems. Untreated, these disorders
have the worst outcomes of any mental disorders,
except dementia, through suicide and the physical
sequelae of starvation. In acute settings, there are
frequent interdisciplinary disputes; the disorder is
psychological, but emergency medical treatment
(perhaps forced feeding under mental health
legislation) is necessary. Positive developments, such
as the integration of physical and mental health
information records, may help in identifying and
Persistent physical symptoms (PPS)/Medically
unexplained symptoms (MUS)
Illness gives us biological disadvantages, and doctors
find it hard to understand that someone might
apparently ‘choose’ to become or remain ill. People
do not usually get ill to benefit from illness (often
called secondary gain; primary gain is the direct
relief from symptoms). Illness roles might reflect a
familial response (although well- intentioned) that
maintains some behaviours and symptoms (in that
order). In some cases, the symptoms have been
encouraged by excessive medical investigations (Box
8.15), and these may have been arranged by doctors
for financial gain. The term MUS was coined by, then
later abandoned by, psychiatrist David Goldberg as
a way of stating that current science cannot find (or
explain) objective pathology, but the patient still
has ‘symptoms’ from which he seeks relief. The
term incorporates situations in which there is no
identified pathological disease process but sometimes
exaggerated or abnormal physiology; examples here
might be lowered pain threshold, delayed gastric
emptying, visceral hypersensitivity, etc. The cycle
that begins at the clinic is one of a patient’s search
for more investigations, disappointment at negative
(normal) results, rising physician frustration, further
maladaptation (avoidance primarily) and ‘doctor
shopping’ for different opinions to repeat the cycle
(see Box 8.15). The interview is a standard psychiatric
interview, but with direct conversations with the
referring clinician and primary care physician, very
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Box 8.14
Links between signs and symptoms of autism spectrum disorders and ICD10 diagnostic criteria
Garland summary of changes to autism diagnosis
Domain ICD diagnostic criteria Clues from history/examination
Development:
required only for
a diagnosis of
childhood autism
Social Qualitative abnormalities in at least two of the following:
Communication Qualitative abnormalities in at least one of the following:
Behaviour Restricted, repetitive and stereotyped patterns of behaviour,
Garland, J., O’Rourke, L., & Robertson, D. (2013). Autism spectrum disorder in adults: Clinical features and the role of the psychiatrist. Advances in Psychiatric
Treatment, 19(5), 378-391. doi:10.1192/apt.bp.112.010439.
(Sources: Lord 1989.1994; World Health Organization 1992: Fitzgerald 2001.)
Abnormal or impaired development before the age of 3
years in at least one of the following:
(a) Receptive or expressive language in social
communication
(b) Development of selective social attachments or
reciprocal social interaction
(c) Functional or symbolic play
(a) Failure to adequately use eye- to- eye gaze, facial
expression, body posture and gesture to regulate social
interaction
(b) Failure to develop peer relationships that involve a
mutual sharing of interests, activities and emotions
(c) Lack of socioemotionalal reciprocity or lack of
modulation of behaviour according to social context or a
weak integration of social, emotional and communicative
behaviours
(d) Lack of spontaneous seeking to share enjoyment,
interests or achievements with other people
(a) Delay or total lack of spoken language, not accompanied
by an attempt to compensate through the use of gesture or
mime (childhood autism only)
(b) Relative failure to initiate or sustain conversational
interchange with reciprocal responsiveness
(c) Stereotyped and repetitive use of language or
idiosyncratic use of words or phrases
(d) Lack of varied, spontaneous make- believe or social
imitative play
interests and activities in at least one of the following:
(a) An encompassing preoccupation with at least one
stereotyped and restricted interest which is abnormal in
content or focus, or at least one interest which is abnormal
in intensity and circumscribed nature
(b) Apparently compulsive adherence to specific, nonfunctional routines or rituals
(c) Stereotyped and repetitive motor mannerisms, such as
hand/finger flapping or twisting or complex whole- body
movements
(d) Preoccupations with part- objects or non- functional
elements of play materials
Clear delay in use of speech to communicate.
No single words by 2 years of age.
No phrase speech by 3 years of age.
Lack of direct eye contact and poor
modulation of eye contact to regulate social
interactions
Restricted or inappropriate range of facial
expression
Lack of emotional expression
Absence of dose- sharing friendships or
relationships
Dislike of physical contact and impaired
ability to comfort others
Lack of social chit- chat or ‘small tat’ when in
company
Abnormal play: dislike of shared play, lack of
symbolic use of toys in childhood
Poor flexibility in language expression
Lack of descriptive, conventional or
informative gestures
Lack of creativity and fantasy in thought
processes
Lack of emotional response to another’s
verbal and non- verbal overtures
Impaired use of cadence of speech to reflect
communicative intent
Use of echolalia, neologisms and pronoun
reversal
Lack of spontaneous conversation or sharing
of personal information
Imposition of non- functional rigidity and
routine on everyday and novel experiences
Resistance to change in routine or
environment
Abnormal play: preoccupation with parts of
objects
Lack of spontaneity, initiative and creativity
Lack of spontaneous imitation/mirroring of
others
Unusual sensory- seeking or sensoryavoidance behaviours
Increased sensitivity to noise
Temper/outbursts
Aggression
Self- injury
Anxiety symptoms
Difficulties in the educational or occupational
environment
Sleep difficulties
Eating disturbances
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Box 8.15
Early experience → Predisposing
Persistent physical symptoms (medically unexplained symptoms)
→ Thinking styles → Health anxiety
factors
Difficult pregnancy/
birth; low birth weight
Infant special care unit
Genetic links for minority: chronic fatigue syndrome
Variation (between one, the expected rate and six- fold increases) in reporting childhood sexual abuse, or other traumas
Common story of recent precipitant of symptoms: stress, infection
Excessive health preoccupations: these are overvalued ideas, not delusions
Physiology (e.g. borborygmi or flatus per rectum) interpreted as symptoms
Significant time reading about health; searching online for ‘symptom’ explanations
Worst case scenario planning: what if questions, assumption ‘this could be serious’
Joins online discussions or social media forum to discuss health and diseases
Focus on biomedical (rather than psychosocial): wish for complex investigations
Looking for cure through medication and (less commonly) surgical procedures
Disagreement with doctors* (almost universal) leading to doctor shopping
Language of disability with secondary withdrawal (leaves job or training, inactivity, refusal of social opportunities, becomes
housebound)—reinforced by family
*
Good evidence that for some patients, there are iatrogenic harms as part of the process: the doctor pushes for investigations and prescribes something, anything
(because that is what doctors do), then gets frustrated with or loses interest in the patient when symptoms persist and the results are (inevitably) ‘negative’.
Parental anxiety
Attachment issues
Family illness
All or nothing ‘worst
case scenarios’
Family culture
Excessive
focus on ill
health
careful reading of all medical sources and particular
attention to the system from which persistent
physical symptoms arise (Box 8.16). If you can strike
a balance between acknowledgement of symptoms
(that are real despite negative tests), sharing your
understanding of medical investigations and systems,
while opening up psychosocial explanations, then
this will be a therapeutic assessment. MSE findings
may differ from other mental disorders:
Thoughts show abnormal belief systems—about
where organs are located, how the body works
(and breaks down) and overvalued ideas about
the salience of some bodily sensations that have
been upgraded or labelled as symptoms. Record
the intrusion of the patient’s opinions about
‘diagnosis’ and his interpretation of what other
doctors have said; these answers usually intrude
even when your questions are open ones to
establish the physical symptoms.
Try to characterize the nature of anxiety (about
which symptoms? What might this be? Concerns
that ‘they have missed’ cancer), its degree and a
summary of dates of onset and progression.
Depression is very common in PPS/MUS, but
easily missed owing to the emphasis on physical
symptoms, investigations and other doctors’
actions. It is also treatable (usually cognitive
behavioural therapy [CBT] plus antidepressants),
allowing for relief of symptoms and progress.
When MUS symptoms run a chronic course, cluster
into systems (see Box 8.16), and polypharmacy
gets established, sleep is a key outcome measure.
Ask about its lack, or excessive daytime sleep in the
housebound patient, and link this to questioning
about suicidal ideas. A subset of these patients
become desperate when hospital clinics discharge
them; as a rule, they communicate distress to
others as physical symptoms or not at all, plus they
have supplies of lethal prescribed medication.
Perceptions of bodily touch/movement/pain may
be independent of any stimulant. Sequences, such
as eating, can have conditioned responses, such
as an expectation of nausea or vomiting based on
past experience.
Insight: this is frequently absent even if insight is
defined that psychosocial stressors are driving and
maintaining these symptoms.
In the collaborative history, describe the current
social setting in full: what supports might be put at
risk if the patient recovered from these symptoms
(people including regular contacts with health
professionals, family and professional carers,
financial benefits, housing, disability status)?
Assessing forensic risk
Consider this scenario: a prisoner is transferred to
your unit, and you need to assess his safety, potential
risks to others and make contingency plans. You
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need to know the offence that led to conviction, and
all previous crimes. Breaking societal rules covers a
multitude of issues. The main concerns are violence
to others, but even a history of acquisitive crime
(stealing without threat of violence) also predicts
Box 8.16
Functional somatic syndromes
System/specialty Common, named syndromes
Cardiology Noncardiac chest pain (Da Costa’s
syndrome)
Respiratory Hyperventilation syndrome
Gastrointestinal Globus hystericus
Nonulcer dyspepsia/functional
abdominal pain
Irritable bowel syndrome
Neurology Chronic headaches (tension
headaches)
Nonepileptic attacks
(pseudoseizures)
Infectious disease Chronic fatigue syndrome/myalgic
encephalopathy. Long COVID
Rheumatology Fibromyalgia
Orthopaedic Chronic low back pain with no
physical abnormality
Ear, nose and throat Globus syndromes (subjective
obstruction)
Functional dysphonia
Gynaecology Chronic pelvic pain
Dental Temporomandibular joint
dysfunction
Atypical facial pain, burning mouth
syndrome
Pain/any system Somatoform pain disorder
Multiple systems Somatization disorder (Briquet’s
syndrome)
increased future violence. Most people on a custodial
sentence have personality difficulties (see Box 8.10),
of which impulsivity is central to understanding
their risks to others. Neither an actuarial assessment
(calculating the odds, with reference to demographics
and previous behaviours) nor unstructured clinical
interviews are sufficient in this situation, even
with maximum information gathering. Structured
interviews, such as the historical clinical risk (HCR20, management), are used to integrate our diagnoses
(personality, substances, psychosis) with these
factors, and to anticipate settings in which violence
is more likely to occur. Box 8.17 summarizes similar,
collaborative approaches to risk formulation. As
with general formulations, the patient needs to hear
the conclusions and the basis for any decisions that
have an impact on his liberty. Some traits are less
amenable to interventions, for example dissociality
and detachment (see Box 8.10), and transfer to longterm facilities (such as prison or treatment units) is
decided by specialists to contain these behaviours
in the medium term. When a patient engages with
this process to ameliorate treatable components, reevaluation will be key to moving him on.
Referring someone for psychotherapy
Most aspects of formulation link to any potential
benefits of psychotherapy. In essence, build on
the insight and motivation that you find to allow
discussion of the best therapy modality for this
patient. Therapy must have an evidence base
(CBT works better than antidepressants in the
short- and long- term in people with mild to
moderate depression), and your formulation must
be a coherent account of this person, highlighting
potential focus points for therapy. The main
determinants of choice are what is available
locally, waiting times, affordability (if the patient
is to pay for this) and the commitment needed
Box 8.17
The five key elements of a risk formulation
Predisposing factors
These are social or environmental experiences or biological aspects
of a person’s history that are associated with problems in later life;
examples include poor attachments, early emotional trauma or head
injury.
Motivating factors
In terms of motivation, it is important to consider the relative roles
of intrinsic influences and circumstances. Generally, the former give
rise to greater concern than the latter. For example, consider the
difference between a violent offender who deliberately harms people
he believes to have wronged him and another violent offender who
once lost his temper in a particularly heated situation.
These are strengths within the person or external factors that reduce risk. An example would be effective coping skills or a
supportive family.
(Source: Baird J, Stocks R. Risk assessment and management: forensic methods, human results. Advances in Psychiatric Treatment. [Online] Cambridge University Press;
2013;19(5): 358–365. DOI:10.1192/apt.bp.111.009407.)
Precipitating factors
These can be immediate triggers to an event, such as an
argument, or more general circumstances in a person’s
life, such as stress. They also include destabilizing
experiences, such as a deterioration in mental health,
and disinhibiting factors, such as intoxication.
Perpetuating factors
These are characteristics of offenders or their
circumstances that mean they continue to be risky.
An example would be unhealthy relationships or poor
engagement with treatment.
Protective factors
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Psychiatric assessment
to attend and practice its recommendations. Try
to see therapy beyond the one- to- one ‘on the
couch’ stereotype; social prescribing (short of
formal therapy), peer support, couples and family
therapy are all proven interventions. People with
a personality disorder (see Box 8.10) do well in
group therapy as they learn to mentalize their
interactions with others, although a relationship
with a care coordinator for frequent reviews is part
of this. Most treatment programmes for addictions
are based on motivational interviewing that divides
patients into different stages on their journey. Stage
1 is the Precontemplation Stage in which the person
does not intend to change behaviours as he does
not view himself as having a problem. Stage 2
is the Contemplation Stage in which at times the
patient might have made links between substance
use and consequences but have not made efforts
to change. Stage 3, Preparation, weighs up the
positives and negatives of continuing to consume
versus cessation, perhaps towards a plan, on which
he has not yet acted. Stage 4 is the Action Stage in
which attempts to cut down, even stop, are made.
Often, asking and getting help is central to this.
Stage 5, the Maintenance Stage, must have lasted for
a minimum of 6 months; behaviours have changed
with a sense there is ‘no going back’, even if the
patient has not achieved complete abstinence.
Last in, Stage 6, Termination Stage, the person has
achieved abstinence and put measures in place to
reduce lapses and relapses.
SECTION TWO
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ASSESSMENT IN PARTICULAR GROUPS
Patients presenting as
Introduction
A medical emergency requires swift recognition
and prompt action. Recognition of urgency does
not necessarily require a precise diagnosis; the fact
that the patient is dangerously unwell is usually
obvious owing to an abnormality revealed by the
internationally recognized assessment system for
critically ill people of Airway, Breathing, Circulation,
Disability and Exposure of the patient (ABCD
and E). When an abnormality is found it should
be acted upon and followed by a reassessment to
establish if the intervention was useful. The clinician
simultaneously needs to decide during this time as
to whether and when summon help if available.
The importance of clinical assessment
High- quality history taking and clinical examination
will usually identify a diagnosis in a timely fashion
and enable the initiation of appropriate investigation
and management plans. In modern medicine, much
has been made of the awareness of ‘vital observations’
or ‘vital signs’, which are often recorded by nursing
staff and are usually available prior to a doctor’s
clinical assessment. It should be remembered
that observations support clinical diagnosis and
management and do not replace them.
The relationship between good history taking,
sound examination skills and the ordering of
appropriate investigations is as important in an
emergency situation as in any other clinical setting.
Many could try to argue that with the advancement
of science, history taking and clinical examination
should be superseded by simple awareness of available
investigations. A poorly taken and rushed history,
followed by numerous irrelevant investigations, is
poor- quality medicine. Such an approach often leads
to a wrong or missed diagnosis and some abnormal
results of uncertain significance. Investigations
are not always risk free, and patients should not
be exposed unnecessarily to interventions, such as
ionizing radiation, without serious thought.
emergencies
9
Geraint Morris
This chapter deals with conditions requiring
assessment and management within the first hour and
focuses on the presenting complaint. Recognizing
the nature of an emergency presentation begins with
how the patient comes to medical attention. This may
be from information provided by the patient himself
or witnesses such as paramedical (e.g. ambulance)
staff, friends, family or concerned members of the
public. The clinician will make an initial assessment
by simply observing the patient; no apparent signs
of life should initiate a life support response. If
the patient is alive, then the general impression of
how sick a patient appears is a reasonably accurate
judgement of urgency. The experienced clinician
will make these decisions in seconds. A particular
clue will be in the respiratory rate and effort. An
increased respiratory rate and work of breathing are
the first physiological parameters to be altered in the
shocked state and are often the subtle clues that alert
a clinician to an unwell patient even from the end
of the bed. Observing and recording this parameter
for all patients is a fundamental part of developing a
sound clinical method in emergency situations.
Urgency of response depends on the patient’s
responses when you are using the ABCD and E system
of assessment. A talking patient has a patent airway,
can maintain sufficient respiratory effort to make the
vocal cords vibrate and move enough air to allow gas
exchange. Similarly, if the patient is talking he must be
perfusing his brain with sufficient oxygen to undertake
the processes of speech as well as being responsive
enough to do so. The clinician therefore has a degree
of time with which to make further assessments and
management decisions in this situation.
It should be stressed that the aim of this chapter is
to help the reader develop a logical method for the
clinical assessment of the acutely presenting patient.
Although the topics covered here relate to common
acute presentations, greater detail relevant to these
presentations has not been provided, because much
of this will be dealt with elsewhere in this book. It
is also hoped that the reader will not look on this
chapter as an amalgamation of lists, but rather as an
approach to logical thinking.
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Patients presenting as emergencies
Diagnosis versus resuscitation
Sometimes, the severity of illness dictates that lifesaving resuscitative treatment should begin before any
diagnosis is reached, especially in acutely ill patients with
problems such as shock or breathlessness. However, it
should be possible to make an underlying diagnosis
(or a differential diagnosis) in the majority of cases; an
acutely ill patient may not clinically improve until the
treatment based on the correct diagnosis is provided.
Acute resuscitation and the formulation of diagnoses
will often be performed successfully in tandem.
The pyrexial and septic patient
Patients frequently present to emergency
departments with signs and symptoms of infection,
as do existing inpatients, irrespective of the cause
for initial hospital admission. Severe infections
have the potential for significant morbidity and
mortality, and it is vital that they are identified
and diagnosed promptly. Although the majority of
patients presenting with fever will have an infective
cause that can be easily elicited from the history and
examination, it is also well recognized that there are
many non- infective inflammatory causes (Table 9.1).
Infection with evidence of life- threatening organ
dysfunction is now defined as sepsis. Patients with
suspected sepsis who do not respond to immediate
resuscitative measures are considered to be in septic
shock. Delays in initiating treatment for sepsis, in
particular the correct antibiotics, have consistently
been shown to lead to a worse prognosis. Screening for
evidence of organ dysfunction initially revolves around
physiological parameters and historical details, such as
Table 9.1 Logical thinking for patients presenting with fever
Mechanism Common or important examples
Infection Viral (upper respiratory, lower respiratory
(Covid-19), infectious mononucleosis,
hepatitis A); bacterial (less- common
causes include infective endocarditis,
meningitis, tuberculosis, spontaneous
bacterial peritonitis, pleural empyema,
cholangitis); parasitic (malaria,
schistosomiasis); fungal
Systemic
inflammation
Malignancy and
granulomatous
disease
Drugs Prescription; recreational (e.g. ecstasy)
Rheumatoid arthritis; systemic lupus
erythematosus (SLE); polymyalgia
rheumatica; Wegener’s granulomatosis;
inflammatory bowel disease; malignant
neuroleptic syndrome; blood transfusion
reaction
Solid tumours; lymphoma; leukaemia;
amyloidosis; sarcoidosis
reduced urine output and, most important, episodes of
confusion or drowsiness. The brain is the organ most
sensitive to metabolic derangements and any evidence
of impairment from baseline should be taken seriously.
Sepsis can be further broken down into amber and red
flag sepsis owing to risk factors (immunosuppression),
recent historical events (recent surgery), physiological
changes and the need for additional oxygen.
The history will often suggest the source of
infection (cough, abdominal pain, dysuria, headache).
Other important features include details of any
recent travel (country and duration of residence), a
drug and lifestyle history (including any recreational
drug use), weight loss, chronic illness and any risk
factors for immunosuppression, such as recent
chemotherapy, steroid therapy and the possibility of
human immunodeficiency virus (HIV) infection.
Initially, the examination should focus on critical
issues that need immediate action. If the patient
has a raised pulse, heart rate or respiratory rate,
prolonged capillary refill, hypoxia or hypotension,
then oxygen, intravenous fluids and appropriate
antibiotics should be administered urgently before
embarking on a detailed examination (if possible and
time allows, take blood cultures before administering
antibiotics, because this may be the only opportunity
for some time during what may be a long and
severe illness to obtain cultures that are completely
free of antibiotics). In searching for a source, look
for exudate or pus at the back of the throat. Lung
auscultation may reveal features of acute bronchitis
(wheeze) or consolidation. Heart murmurs in the
presence of fever may indicate infective endocarditis.
The abdominal examination should identify any
tenderness (e.g. right upper quadrant in cholecystitis,
loin in pyelonephritis). If the patient complains
of headache, look for features of meningism.
Lymphadenopathy and superficial or skin abscesses
should be noted as part of a thorough ‘top- to- toe’
examination. Less obvious sites should not be missed,
especially cavities (e.g. a retained vaginal tampon
leading to toxic shock), skin folds and the perineum.
Immediate investigations may include those
which lend support to an inflammatory process
(white cell count, C- reactive protein), severity of
infection (blood lactate), consequences such as
volume depletion (urea and electrolytes), underlying
predisposition (blood sugar) and source (urinalysis,
urine culture, blood culture, chest X- ray). In response
to the history and examination, one may proceed to
throat swab, blood films for malaria, faeces analysis
(toxin or culture), lumbar puncture, transthoracic
echocardiogram or abdominal imaging (ultrasound
or computed tomography (CT) scan).
The patient with chest pain
Although most patients who present with chest
pain will not have clinically significant coronary
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