Assessment of Risk

Question 1

What is the difference between static and dynamic risk factors?

Answer 1

Static = unchangeable

Dynamic = changeable over time

Question 2

What are the two types of dynamic risk factors?

Answer 2

Chronic/stable - change slowly

Acute - change rapidly and can be triggers

Question 3

What is the mathematical approach to calculating risk called?

Answer 3

The actuarial approach

Question 4

What is the unstructured clinical approach to assessing risk?

What is the difficulty with this approach?

Answer 4

Uses clinicians judgment / gut feeling to determine.

Often overestimates the degree of risk. Important factors can be missed.

Question 5

What is the best approach to assessing risk?

Answer 5

The structured professional judgment - uses a pro forma + clinical experience and knowledge. Clinician retains discretion as to formulation of risk management plan.

Question 6

What is it important to think about when gathering a risk history?

Answer 6

Question 7

What are the 5 Ps of risk formulation?

Answer 7

Presenting Problem
Predisposing factors
Precipitating factors
Perpetuating factors
Protective / positive factors

Question 8

Once you have assessed risk, what is it imperative that you do?

Answer 8

Organise a risk management plan = strategies aimed at preventing a negative from occurring or minimising the harm caused.

Question 9

What should a management plan consider?

Answer 9

Medication
Psychological interventions
Interventions for alcohol / substance misuse if needed
Opportunities for social recovery

Question 10

What is positive risk management?

Answer 10

Question 11

Who should information about a risk management plan be shared with?

Answer 11

The carer and others affected
Possibly public in certain situations
Relevant professionals

Question 12

What is the best term to describe a patient who has killed themselves?

Answer 12

Completed suicide

Question 13

What is the leading cause of death in young people and new mothers?

Answer 13

Suicide

Question 14

What is the most common method of suicide?

Answer 14

Intentional overdose

Question 15

In acute-care psychiatric settings, when is the highest risk of suicide?

Answer 15

In the first 2 weeks - peaking on day 3

Question 16

What static factors can increase the risk of suicide?

Answer 16

Question 17

What dynamic factors can increase the risk of suicide?

Answer 17

Question 18

Which is the most important risk factor for suicide?

Answer 18

Mental illness - often with prior self harm

Question 19

What factors can help protect against suicide risk?

Answer 19

Question 20

What should be done for a patient who has thoughts / plans to end their life or have seriously self-harmed?

What time period should this be done within?

Answer 20

Full psychiatric Hx and MSE should be completed.
Referral to the mental health team within the house

Assessment for the patient should be done within 4 hours

Question 21

What Qs should you ask about suicide attempts?

Answer 21

Ask what happened
- Before
- During
- After

Before = the intended purpose, what triggered it, level planning, did they tell anyone, how dangerous did they understand the act to be at the time?

During = details of what they did, was there associated substance use, did they contact anyone for help, how were they found, did they get any medical attention

After = how do they feel now - regret?, do they wish they had died? do they still want to end their life? what plans do they have? what would stop them doing this, is there anything that could help them?

Question 22

What do you need to ask about when doing a risk Hx?

Answer 22

Presenting Issue
If self-harm/suicide - before, during, after
Mental health Hx and Tx - previous episodes, past diagnoses and Tx
Medical Hx and Tx - esp LT painful conditions
Fx and Personal Hx
Forensic Hx
Personality - esp dissocial or EUPD
Strengths and coping strategies -what has helped in the past
Substance misuse
Collateral Hx
Social Hx - inc intimate / supportive relationships, children?, social network/isolation, employment status, DV, financial, housing, legal problems, bereavement and other losses

+ Full MSE

Question 23

What are depressive Sx?

Answer 23

Low mood
Anhedonia
Low energy
Poor sleep
Poor appetite and weight loss
Early morning waking
Diurnal variation
Poor concentration

Question 24

What are psychotic Sx?

Answer 24

Delusions
Hallucinations

Question 25

How can you ask a person if they have ideas of ending their life?

Answer 25

Question 26

How is risk formulated?

Answer 26

By using a bio-psycho-social approach and considering the 5Ps

Question 27

What is the purpose of a risk management plan?

Answer 27

To reduce the identified risk

Question 28

What biological interventions can be given to high risk Ps?

Answer 28

DRUGS

Question 29

What psychological interventions can be given to high risk Ps?

Answer 29

Validating and empathic responses
CBT for depression / anxiety
DBT for EUPD

Allowing the P to feel understood can help mitigate the risk.

Question 30

What social interventions can be done for high risk Ps?

Answer 30

Question 31

What are the two opposing factors to be balanced when formulating risk management plans?

Answer 31

Empowering the P to take responsibility for their actions and engage with long term treatment v. supporting a P in distress who is asking for help to stay safe.

Question 32

What is the relationship between mental illness and violence?

Answer 32

Ps with mental illness are more likely to be a victim of violence than a person in the general population.

There is not the link to violence with mental health Ps as portrayed by the media.

Question 33

What negative impacts can arise from restrain and seclusion methods?

Answer 33

Acute emotional distress
Re-traumatisation
Loss of therapeutic trust
Loss of human rights - dehumanising

Question 34

Which mental illnesses do have moderately raised rates of violence?

Answer 34

Schizophrenia
Bipolar disorder

Question 35

Which Ps are most likely to be violent?

Answer 35

Triple morbidity Ps = severe mental illness + substance use disorder + antisocial personality disorder

Question 36

What are the static risk factors for violence?

Answer 36

Question 37

What are the dynamic risk factors for violence?

Answer 37

Question 38

What must you ask about the before, during and after period of a violent act by a P?

Answer 38

Before = what was the intended purpose? how dangerous did they understand the act to be? what was the trigger? was it impulsive of planned? how planned? did they think about consequences? did their thoughts and actions originate from within themselves - or was a perceived external influence that controlled them?

During - was there substance abuse? did they contact anyone for help? how were they found and brought for assessment?

After - how do the feel about harming others now? remorse? do they still want to harm others? is there an identified victim or clear plan? what would make them stop this? is there anything that could help the? are they willing to accept support?

Question 39

When taking a risk history - which factors can give a stronger propensity towards violence?

Answer 39

Mental health Hx = disengagement and non-concordance

FHx - early exposure to violence, crime, abuse, trauma and disrupted attachments

SHx - supportive relationships? children? radicalisation / violent subculture?

Forensic Hx - previous violence, DV?

Personality - antisocial traits? lack of empathy?

Strengths and coping strategies = what has helped previously?

Substance misuse?

Question 40

How do violent Ps often present on a MSE?
- Appearance & Behaviour
- Speech
- Mood
- Thoughts
- Perceptions
- Insight

Answer 40

Question 41

Which medications can be given for aggressive patients?

Answer 41

Question 42

What substance use services in the community are there?

Answer 42

Question 43

A 30 year old woman presents to A & E with thoughts to end her life in the context of depressive symptoms. Which historic factors are most likely to signify a high level of risk?
a. Cannabis use as a teenager
b. Diagnosis of chronic back pain
c. History of non-accidental overdoses
d. Mother passing away when he was 8 years old
e. Working as a health care assistant

Answer 43

Answer: c. History of non-accidental overdoses. Whilst substance misuse, a painful physical disorder and childhood loss are risk factors for suicide, the most significant risk factor is a history of self-harm - up to 60 % of those who die by suicide have previously self-harmed.

Question 44

In clinical practice, the approach to risk assessment is often based on “structured professional judgment”. Why is this usually the most appropriate approach?
a. It emphasises unchangeable static risk factors
b. It combines research evidence and a clinician’s discretion
c. It is quick
d. It offers a mathematical prediction of future risk
e. It relies on a professional’s ‘gut feeling

Answer 44

Answer: b. It combines research evidence and a clinician’s discretion. ‘Structured professional judgement’ combines a structured proforma of risk factors derived from research, and the clinician’s experience and knowledge of the service user.

Question 45

A 25 year old female is assessed by the liaison psychiatry team after an attempt to jump off a bridge, following the end of a relationship. Which dynamic risk factor was most likely to signify a high level of risk at the time of the event?
a. Access to prescribed antidepressants
b. Alcohol misuse
c. Significant debt
d. Symptoms of an eating disorder
e. Symptoms of generalised anxiety disorder

Answer 45

Answer: b. Alcohol misuse. 50% of attempts are associated with alcohol use within 6 hours. Alcohol increases emotional distress and impulsivity. Debt, access to medication and symptoms of mental disorder are also dynamic risk factors but in the context of this case, alcohol misuse appears to have been the most significant factor.

Question 46

A 28 year old man with a history of schizophrenia is being assessed under the Mental Health Act following his being violent towards a stranger in town. Which risk factor is most likely to signify a high level of future risk to others?
a. Command hallucinations
b. Compliant with depot antipsychotic
c. History of familial criminality
d. Living alone
e. Previous charge of common assault

Answer 46

Answer: a. Command hallucinations. Positive symptoms of psychosis are significant dynamic risk factors for violence. A history of familial criminality, living alone and history of assault are also risk factors but the clinical risk factor of psychosis is most significant. Compliance with treatment is a protective factor.

Question 47

A 55 year old female is being assessed following an intentional overdose of paracetamol. When assessing the circumstances of her overdose, which are the most important parts of the history to establish?
a. Details of events prior to the self harm, in particular the level of planning
b. Events following the self harm, in particular ongoing thoughts to end her life
c. Events before, during and after the self harm
d. What happened during the event, in particular whether alcohol was used
e. Whether they were brought in to hospital by emergency services

Answer 47

Answer: C Events before, during and after the self harm. When there has been an act of self harm, we need to systematically ask about events before, during and after the act.

Question 48

Risk formulation is the basis of a management plan. What are the most important 5 factors to include in a risk formulation?
a. Presenting problem, predisposing, precipitating, polysubstance and protective factors
b. Presenting problem, predisposing, precipitating, perpetuating and prognostic factors
c. Presenting problem, precipitating, physical, psychological, and protective factors
d. Predisposing, precipitating, perpetuating, protective and preferred treatment factors
e. Presenting problem, predisposing, precipitating, perpetuating and protective factors

Answer 48

Answer: e. Presenting problem, predisposing, precipitating, perpetuating and protective factors

Question 49

7) A core trainee on call is interviewing a patient who has presented after an episode of self harm and is asking them about thoughts of suicide. What is most likely to be the impact of this?
a. It will contribute to keeping the person safe
b. It will heighten the individuals distress level further
c. It will increase the risk of them planning to end their life
d. It will make the individual and health care professional feel uncomfortable
e. It will make the individual feel stigmatised

Answer 49

Answer: a. It will contribute to keeping the person safe. Assessing risk is an important part of the psychiatric history. When an individual presents with thoughts or an act of self harm, NICE guidelines highlight that the assessment must happen without delay (referral to mental health team within an hour & assessment within 4 hours).

Question 50

8) A 19 year old woman with suicidal thoughts has been diagnosed with severe depression and is keen to start medication as part of her holistic treatment plan. What is it most important to do?
a. Avoid discussing side effects initially, due to possible impact on adherence with treatment
b. Ensure at least one month’s supply to avoid withdrawal due to lack of medication
c. Prescribe the medication with the lowest risk of toxicity
d. Do not prescribe medication but refer for urgent psychological therapy in the first instance due to risk of overdose
e. Avoid SSRIs due to the increased risk of suicidal thoughts in young people

Answer 50

Answer c. Prescribe the medication with the lowest risk of toxicity. Treatment of severe depression should be initiated without delay; psychological therapy should be within the treatment plan but medication should be prescribed in addition to this. Short periods of medication should be prescribed to limit access to methods of self harm. The most effective antidepressant with the fewest side effects is the most appropriate choice; suicidal ideation should be monitored in keeping with NICE guidance (states that in people aged 18-25 who are at increased risk of suicide, clinicians should be aware of the increased prevalence of suicidal thoughts in the initial stages of antidepressant treatment and ensure that a risk management strategy is in place, including appropriate monitoring).

Question 51

9) You are an FY2 doctor and have been asked to interview a patient on their admission to the mental health ward. The patient has a history of violence towards others. What is it most important for you to do as part of the assessment?
a. Ask about violence in a non-direct manner
b. Continue the assessment even if you feel uncomfortable
c. Establish rapport by showing concern for the individual’s situation
d. Gather collateral information after the assessment
e. Offer the individual the choice of where to sit

Answer 51

Answer: c. Establish rapport by showing concern for the individual’s situation. Demonstrate an empathic, non judgmental manner - reassure that you are there to support them, including in managing their risk. Be as knowledgeable as possible prior to the interview – including what is the historic risk and what are the known triggers. Do not see the individual alone if there is a known risk. Give the person adequate space and sit yourself by an escape route. If you feel threatened, terminate the interview and leave the room. When asking about violence, questions should be direct and honest.

Question 52

10) A GP is talking with a patient about the loss of their brother, who died by suicide. What is the appropriate term to use?
a. Deliberate self harm
b. Committed suicide
c. Completed suicide
d. Parasuicide
e. Successful suicide

Answer 52

Answer: c. completed suicide. It can be difficult to know which terms to use. You may have heard older terms which we no longer use such as “Parasuicide” and “deliberate self harm”, which can imply blame. “Committed suicide” can imply crime. “Successful suicide” is insensitive at a time of great loss. Self harm is defined as ‘any intentional self-poisoning or injury irrespective of the motive’. At present we describe ‘completed suicide’ when this results in a person ending their life.