Mental state examination, risk and psychiatric emergencies

Why this matters on day one

Psychiatric presentations arrive on medical wards constantly — delirium, self-harm, alcohol withdrawal, capacity questions. You are expected to assess mental state and risk competently, and to know which situations cannot wait.

The sequence

1. 1Structure the MSE. Appearance and behaviour; Speech (rate, volume, form); Mood (subjective and objective) and affect; Thought (form and content — delusions, obsessions); Perception (hallucinations); Cognition; Insight. Record what the patient said, in their words, alongside your interpretation.
2. 2Assess risk properly. Risk to self: thoughts, intent, plan, means, preparatory acts, protective factors, previous attempts and their lethality. Risk to others, including children and dependants. Risk from others. Risk of neglect. Ask directly — asking about suicide does not plant the idea.
3. 3Exclude the organic. New psychiatric presentation in an older patient, or any fluctuating course, is delirium until proven otherwise: glucose, infection screen, U&E, calcium, B12, TFT, medication review, and imaging where indicated. Use the 4AT.
4. 4Know the emergencies. Active suicidal intent with a plan and means. Serotonin syndrome and neuroleptic malignant syndrome. Lithium toxicity. Delirium tremens and Wernicke encephalopathy (give PABRINEX before glucose in suspected alcohol dependence). Acute dystonia and catatonia. First-episode psychosis with risk.
5. 5Escalate and document. Involve the psychiatric liaison team early. Document capacity, risk and your plan explicitly. Know that the Mental Health Act sections 5(2), 2 and 3 exist and who can apply them — you cannot, as an FY1, but you must recognise when they are needed.

What goes wrong

• Attributing a new confusion in an older patient to dementia or "behavioural" causes without excluding delirium.
• Not asking about suicidal thoughts because it feels intrusive.
• Giving glucose before thiamine in alcohol dependence — precipitating Wernicke.
• Documenting "no suicidal ideation" without recording what you asked.
• Forgetting dependants when assessing risk.