Acute psychosis — mental-state and risk assessment

PLAB 2 & PRES 3 · psychiatry · hard · 8 minutes

Candidate brief

You are an FY2 doctor/SHO in the Emergency Department. Mr Daniel Ahmed, 24, has been brought in by his older brother because he has become increasingly suspicious, is hearing voices and was found standing dangerously close to the edge of their apartment balcony. Assess his mental state and immediate risks, consider possible causes and arrange an appropriate management and escalation plan. No physical examination is required, but verbalise any examination, investigations and safety measures you would undertake.

What examiners look for

Psychosis describes symptoms such as hallucinations, delusions and disorganised thinking. A first episode does not automatically establish schizophrenia. Communicate calmly in a quiet environment. Maintain personal space, avoid sudden movements and use one lead speaker where possible. Do not argue with delusions or confirm them as true. A helpful response is: “I understand that this feels very real and frightening to you. I have not seen evidence that people here are monitoring you, but I want to help you feel safe.” Ask directly about: Suicide and self-harm. Command hallucinations. Thoughts of harming others. Access to weapons. Dangerous actions driven by beliefs or voices. Self-neglect, exploitation and vulnerability. The safety of dependants and other people. Obtain collateral history because insight and recall may be limited. Information can be received from relatives even when confidentiality limits what can be disclosed back. Consider organic and substance-related causes, including delirium, infection, neurological disease, endocrine or metabolic illness, medication effects, intoxication and withdrawal. Cannabis may precipitate or worsen psychotic symptoms, but cannabis use should not lead to dismissal of a possible primary psychotic disorder. Offer voluntary assessment and treatment first. Use restrictive or involuntary measures only when legally justified and necessary for safety. Rapid tranquillisation is not routine treatment for psychosis. Use verbal de-escalation first and reserve emergency medication for immediate serious risk under an approved protocol. Do not promise a diagnosis, medication duration or prognosis during the initial ED assessment.

Guideline references

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