PLAB 2 Psychiatry: Mastering Self-Harm Assessment Guidelines

PLAB 2 Psychiatry: Mastering Self-Harm Assessment Guidelines

Self-harm and suicidal ideation are high-stakes, frequent scenarios in the PLAB 2 OSCEs. These stations test not only your knowledge of initial management guidelines but, crucially, your ability to communicate empathetically, establish rapport, and ensure patient safety within the UK legal and clinical framework.

Mastering the approach to a patient presenting with self-harm or overdose is non-negotiable for PLAB 2 success. Here is a guide based on key UK medical guidelines for managing this critical presentation.

1. The Immediate Clinical Goal: Risk Assessment

The immediate priority is twofold: assessing the patient’s current mental state and stratifying their immediate risk of suicide or further self-harm. In the PLAB 2 setting, this must be done compassionately and systematically.

A. Mental State Examination (MSE) Essentials:

Before delving into the act of self-harm, a quick MSE is vital. Focus on:

• Mood and Affect: How do they describe their feelings? Is their affect congruent with their mood?

• Psychotic Symptoms: Are there any signs of psychosis (e.g., hallucinations commanding them to harm themselves)? This elevates risk significantly.

• Cognition: Are they alert, oriented, and able to participate in the assessment?

B. Structured Risk Assessment (The ‘Lethality’ Check):

When discussing the self-harm act itself, maintain a non-judgmental tone. Key questions include:

2. Identifying High-Risk Factors

During your history taking, you must actively screen for factors that increase the immediate risk of further self-harm. High-risk patients often require immediate action, such as admission under the Mental Health Act (MHA).

Red Flags for High Risk:

1. Fixed or persistent suicidal intent: The patient insists they will try again soon.

2. Specific, highly lethal plan: E.g., planning to use a weapon or jump from a height.

3. Severe mental illness: Active psychosis, severe depression, or acute mania.

4. Lack of protective factors: No support network, homeless, or severe isolation.

5. Impulsivity and acute intoxication: Alcohol or drug misuse severely impairs judgment.

6. Recent loss or major life stressor: Bereavement, job loss, relationship breakdown.

3. Management Guidelines in PLAB 2 OSCEs

Your management plan must demonstrate that you prioritize safety and follow standard UK practice (NICE guidelines).

A. Safety First: The Immediate Plan

• Do not send the patient home alone if high-risk. If you suspect high immediate risk, your communication must shift to immediate safety planning.

• Consult/Refer: Immediately inform your senior doctor (Registrar/Consultant) and the mental health liaison team (MHLT).

• Documentation: Document everything meticulously: the risk factors identified, the protective factors, the patient’s capacity to consent to follow-up, and the specific plan agreed upon.

B. Determining the Need for Mental Health Act (MHA)

In the UK, involuntary admission (detention under the MHA 1983) is used when the patient poses a significant risk to themselves or others and lacks the capacity or willingness to accept treatment voluntarily.

If the patient has a high risk AND refuses voluntary admission/follow-up, you must state clearly in the OSCE:

“Given the serious nature of the attempt and the immediate ongoing risk, I am required to consult with the Mental Health Liaison Team and my senior doctor immediately to consider an assessment under the Mental Health Act. This is to ensure your safety and that you receive the necessary help right now.”

(Remember: In PLAB 2, you do not section the patient yourself; you initiate the process by consulting the MHLT/Senior.)

C. Ongoing Management and Discharge (Low/Medium Risk)

If the risk is deemed low to moderate and the patient agrees to follow-up, your plan involves:

1. Liaison Psychiatry Review: Ensure a mental health review is arranged before discharge.

2. Safety Plan: Collaboratively create a crisis plan (who to call, crisis team number, emergency services). This is critical for PLAB 2.

3. Support Systems: Involve family/friends (with patient consent) and ensure follow-up with their GP.

4. Addressing Underlying Issues: Plan referral for underlying conditions (e.g., starting an SSRI for depression, offering psychological therapy like CBT or DBT).

4. PLAB 2 Communication Skills: The Key to Passing

Self-harm scenarios are communication stations disguised as knowledge stations. Examiners look for:

• Empathy and Non-Judgment: Use phrases like, “I’m very sorry to hear you have been going through such distress,” and avoid moralizing or criticizing the action.

• Open, Closed, and Focused Questions: Use open questions to explore feelings, but closed, direct questions for immediate risk factors (e.g., “Do you currently feel like harming yourself?”).

• Clarifying Confidentiality: Explain that while everything is usually confidential, patient safety overrides this. “Because I am concerned about your immediate safety, I may need to share this information with the mental health team and my senior doctor to make sure you get the proper care.”

• Checking Understanding: End the consultation by ensuring the patient understands the plan and feels heard.

By following these structured guidelines and integrating compassionate communication, you will demonstrate the competence required to manage one of the most serious presentations in the PLAB 2 examination.