MSE Elicitation Drills
Eliciting Delusions
Before we begin
Welcome. This is the first of the elicitation drills, on delusions. These are not talks you give. They are moves you make, to draw a specific piece of psychopathology out of a patient who may not hand it over.
Every drill has the same five parts. The trigger, what the patient says or does. The decode, what it means, which you keep in your head. The move, the principle. The words, an open question then a hooked follow-up off their exact phrase. And the check. Learn the shape and the whole category becomes one habit.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then hook off their exact words. You do not open with a checklist. You ask an open question, let them describe it in their own language, and then convert their exact phrase into the named phenomenon with a follow-up. This is the blind-unlock.
Two. Never the label in the room, and never take yes at face value. You keep the diagnostic word in your head, never say it to the patient, and you never argue with or reality-test a belief. And every yes gets a follow-up, because patients agree with a leading question and then describe something ordinary.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination of a patient with a possible psychotic illness, focusing on their abnormal beliefs. Elicit and characterise any delusions. You are in a clinic or a ward room, the patient opposite. You have around ninety seconds to a few minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient. Do not challenge or reality-test their beliefs.
Here is the shape of it. Open wide and let the belief surface in their words. Then, for each belief, do four things the mark sheet rewards, get its content, test how fixed it is gently, understand how it was arrived at, and weave in the risk it carries. Name the type of delusion only to the examiner, in your head, never to the patient.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the cue
You do not open by asking whether they are paranoid. You open wide and follow their lead.
Say something like this.
How have things been for you lately. Is there anything that has been worrying or frightening you, or anything going on that others do not seem to notice.
Then you stop talking, and you catch the door they open. If they mention people, or being watched, or a special meaning, you hook straight onto that word, warmly and curiously, never with doubt in your voice.
You mentioned people are against you. Tell me more about that. Who do you think it is, and how did you come to realise it.
Non-judgemental curiosity is the whole technique. You are not agreeing the belief is true, and you are not disputing it. You are understanding how they got there.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Marcus. He is guarded, watchful, and has not slept properly in days.
Slowly, if you are patient and unthreatening, it comes out. He believes a group is following him and means him harm, that they signal to each other about him, and that ordinary things, a parked car, a glance, a headline, carry hidden messages meant for him. He is reluctant, and he will test you, at one point asking whether you are one of them. He has done things to protect himself, and there lies the risk. He will not lay this out in order. It surfaces in pieces, and only if he trusts you. Reluctance is not absence.
That is your patient. Now every move is made through Marcus, catching his words and converting them.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Persecutory belief
Trigger. People are following me, they are out to get me, they want to harm me.
Decode, kept in your head. A persecutory delusion. Do not say the word. Characterise it.
The move. Get who, why, since when, how they came to know it, how sure they are, and what they have done about it, the last one is the risk.
Who do you think is behind it, and why you. When did you first realise. How did you piece it together. And has it made you do anything to keep yourself safe.
Check. Have you got the content, the origin, and the risk. Move on.
4.2 - Delusions of reference
Trigger. The television is talking about me, people on the street signal about me, the newspaper has messages for me.
Decode, kept in your head. Ideas or delusions of reference. Test whether it is a passing idea or a fixed belief.
The move. Ask directly whether ordinary things carry a special personal message, and how certain they are it is meant for them.
Do you ever feel that something on the television, or in the paper, or the way strangers behave, has a special meaning aimed just at you. Could it be coincidence, or are you sure.
Check. Idea or delusion. Note which. Move on.
4.3 - Grandiose belief
Trigger. I have special powers, a mission, great wealth, a unique importance.
Decode, kept in your head. A grandiose delusion, common in mania and in psychosis.
The move. Ask about special abilities, identity and mission, matter-of-factly, without mockery.
Do you feel you have any special powers or abilities that others do not have. Do you have an important role or mission. Tell me about it.
Check. Content noted. Move on.
4.4 - Delusional perception
Trigger. A completely ordinary thing suddenly told them something huge, a traffic light changing meant they were chosen.
Decode, kept in your head. Delusional perception, a first-rank symptom, a real perception given a delusional meaning out of nowhere.
The move. Find the exact moment it became clear, and what the ordinary thing was that carried the revelation.
Was there a moment when it all suddenly became clear to you. What was happening at that exact moment. What was it about that, that told you.
Check. If a normal event carried a self-referential revelation, that is delusional perception. Note it. Move on.
4.5 - Testing conviction, without reality-testing
Trigger. You need to know how fixed the belief is, but you must not argue with it.
Decode, kept in your head. A delusion is held firmly regardless of evidence for or against. But you gauge that gently, curiously, never combatively.
The move. Offer the possibility of doubt as a soft question, once, and watch whether it bends.
Is there any part of you that wonders whether there might be another explanation. If someone you trusted told you it was not so, what would you think.
Check. Firm regardless of everything is delusional. Bends and concedes doubt leans towards an overvalued idea. Never push past one gentle test.
4.6 - Onset and origin, primary versus secondary
Trigger. You need to know whether the belief came out of the blue or grew out of something else, like low mood.
Decode, kept in your head. A primary delusion arises fully formed from nothing. A secondary one grows from another experience, guilt in depression, or from hearing voices.
The move. Trace how it began and what was happening in their life and mood at the time.
Cast your mind back to when this first started. What was going on for you then. How was your mood, your sleep, in the weeks before.
Check. Primary or secondary. This shapes the diagnosis. Move on.
4.7 - Culture and the shared belief
Trigger. A belief that could be a religious or cultural conviction rather than an illness.
Decode, kept in your head. A delusion is out of keeping with the person's culture. A belief shared by their community, arrived at the normal way, is not a delusion.
The move. Ask whether others in their world share it, and how they came to it, before you call anything abnormal.
Is this something the people around you, your family or community, also believe. How did you come to hold it. Is it something you were taught, or something you worked out yourself.
Check. Shared and culturally normal is not a delusion. Note it. Move on.
4.8 - The risk woven in
Trigger. A persecutory or grandiose system that could drive action. Risk is a scored domain.
Decode, kept in your head. The belief matters clinically mostly through what it makes the person do. Screen it every time.
The move. Ask, without alarm, whether they have thought of acting against the persecutors, and whether any voice commands them.
Have you thought about doing anything about the people you believe are doing this. Has anything, or any voice, told you to do something. Have you taken any steps to protect yourself so far.
Check. Risk to others, and command, screened. This is never optional. Move on.
4.9 - Answering the challenge, are you one of them
Trigger. He turns it on you, are you one of them, are you working with them.
Decode, kept in your head. A test of safety and trust, not a question to laugh off. A persecuted person needs an honest, plain answer.
The move. Answer it plainly and kindly, acknowledge why he has to ask, then continue.
No. I am a doctor, I work here, and my only job is to try to help you. I can understand why you would need to ask me that.
Check. Trust protected. Move on.
When it is NOT a delusion. The comparators.
Half the marks in this drill are for excluding a delusion, not finding one. Here are the look-alikes to rule out.
5.1 - The overvalued idea
A belief that is strongly held and dominates the life, but is understandable within the person's world and concedes some doubt when gently tested. Where a delusion stays fixed regardless, an overvalued idea bends a little and often grows from a real cultural or personal seed. Say which it is out loud, to the examiner.
5.2 - Mistrust that predates the illness
A long-standing attitude, a distrust of doctors or authority that was there long before any illness, is a character trait, not paranoia. Ask, have you always felt this way, or did it start when you became unwell. Do not convert an attitude into psychopathology to justify a conclusion.
5.3 - The belief in a confused patient
Frightening beliefs in someone who is disorientated, muddled and fluctuating point to delirium, not a primary psychosis. The discriminator is orientation. Check the date and place. If they cannot tell you, the confusion, not the delusion, is the story.
Check. Name the thing you excluded, not only the thing you found. That is the mark.
The close
Close in five small movements. Never name a diagnosis or jargon to the patient. The formulation stays in your head.
One. Thank them.
Thank you for trusting me with all of that. I know it was not easy to say.
Two. Reflect it back, in their words.
Let me make sure I have understood. You have been feeling watched and followed, and that ordinary things seem to carry messages meant for you, and it has left you frightened and sleepless.
Three. Reassure, and promise safety.
I am not going to pretend I see what you see. But experiences exactly like these happen when someone becomes unwell in a particular way, and they do get better. You are safe here, and nothing will be done to you without it being explained first.
Four. Invite.
Is there anything I can answer for you, or anything I have got wrong.
Five. Signpost. To the patient, the next step in plain words. To the examiner, in your head, the named phenomena, the working diagnosis, the organic and drug screens, and the risk.
The two habits, again
Carry these two out of the room.
One. Open wide, then hook off their exact words. Let the belief surface in their language, then convert their phrase into the named phenomenon with a follow-up. The blind-unlock.
Two. Never the label in the room, and never take yes at face value. Keep the diagnostic word in your head, never argue or reality-test, and follow every yes with how, why, and since when. And the belief is the scenery, the origin, the fixity and the risk are the station.
Do those two things and this drill is yours.
Eliciting Hallucinations
Before we begin
Welcome. This is the second elicitation drill, on hallucinations. Perceptions without an object, most often voices, and the qualifiers that turn a bare yes into a scored answer.
The single commonest failure in this station is stopping at link two. A candidate elicits that there is a voice and moves on. The marks sit further along, at whose voice it is, whether it speaks in the second person or the third, whether it commands, and, above all, what it has made the person do. Find the voice, then walk the whole chain.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then hook off their exact words. Ask an open question, let them describe the experience in their own language, then convert their phrase into the named phenomenon with a follow-up. The blind-unlock.
Two. Never the label in the room, and never take yes at face value. Keep the word in your head, never say hallucination to the patient, and follow every yes, because a patient will agree to a leading question and then describe an ordinary thought.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination of a patient with a possible psychotic illness, focusing on their abnormal perceptions. Elicit and characterise any hallucinations. You are in a clinic or a ward room. You have around ninety seconds to a few minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient.
Here is the shape of it. Open wide and let the experience surface in their words. Then run the qualifier sweep the mark sheet rewards, the modality, whether it is truly perceived through the senses or inside the head, whose voice and how many, the person it speaks in, its content in their exact words, its frequency and whether it is there now, whether it commands, what they think causes it, and what they have done because of it. Name the type only to the examiner, in your head.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the cue
You do not open by asking whether they hear voices. You open wide and use the behaviour they give you.
Say something like this.
Have you had any experiences lately that other people did not seem to share. Can you hear anything besides me speaking, even when there is no one else around.
Then you stop talking, and you catch the cue. If they pause to listen, if their eyes drift, if they seem distracted by something you cannot hear, use it. This is one of the strongest openings in the whole subject, asking about the behaviour rather than the symptom.
I noticed you paused just then, as if you were listening to something. Can you tell me what you heard.
Warm, unhurried, curious. You are not doubting them and you are not confirming the voice is real. You are getting its shape.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Emeka. He is a young man, isolated for the past year, dropped out of his course, brought in by an early intervention team.
If you are patient, it comes out in pieces. He hears voices that seem to come from about a foot above his head, outside him, as clear as your voice. Usually they comment on what he is doing, he needs a bath, he knows what is happening, and sometimes they argue with each other about him. Occasionally he hears his own thoughts spoken aloud a second after he thinks them. He pauses mid-sentence to listen. He will not lay this out in order, and he is reluctant, because to him it is deeply personal. Reluctance is not absence. Press once, warmly, then again.
That is your patient. Now every move is made through Emeka, catching his words and converting them.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Establishing a true auditory hallucination
Trigger. He hears a voice when no one is there.
Decode, kept in your head. You must separate a true hallucination, perceived through the ears in outer space, from a thought heard inside the head, which is a pseudohallucination.
The move. Locate it. Through the ears, like my voice, or somewhere inside the mind. Outer space is the true hallucination.
Do you hear it through your ears, in the same way you are hearing me now, or is it more like a voice inside your own head. Where does it seem to come from.
Check. Through the ears, in external space, is a true hallucination. Note the location. Move on.
4.2 - Identity and number
Trigger. There is at least one voice. You do not yet know whose, or how many.
Decode, kept in your head. Identity and number are printed mark sheet items. A recognised voice, and whether it is one or several, both count.
The move. Ask whose voice, whether he recognises it, and how many there are.
Whose voice is it. Do you recognise it as anyone you know. Is it one voice, or more than one.
Check. Identity and number noted. Move on.
4.3 - Second person versus third person
Trigger. The voice says things about him or to him.
Decode, kept in your head. This is the central discriminator. Second person speaks to him as you. Third person speaks about him as he, and carries more diagnostic weight.
The move. Ask whether it addresses him directly or talks about him to someone else.
When it speaks, does it talk directly to you, calling you you. Or does it talk about you, calling you he, as though to someone else.
Check. Second or third person. This is the discriminator. Say which out loud to the examiner. Move on.
4.4 - Running commentary
Trigger. He needs a bath, he is opening the door. The voice narrates what he does.
Decode, kept in your head. Running commentary, a third person voice describing his actions as he does them. A first rank symptom.
The move. Ask directly whether it describes what he is doing while he is doing it.
Does the voice ever describe what you are doing, as you are doing it, like a commentary on your actions.
Check. Commentary confirmed. Move on.
4.5 - Arguing voices and thought echo
Trigger. More than one voice, and a delayed echo of his own thoughts.
Decode, kept in your head. Arguing voices talk to each other about him. Thought echo is his own thought re-experienced aloud, often a second later. Both first rank, and thought echo is the one candidates miss.
The move. Two separate questions. Do they talk to each other. Do you ever hear your own thoughts spoken out loud.
Do the voices ever talk to each other about you. And separately, do you ever hear your own thoughts said out loud, at the same moment you think them or just after.
Check. Arguing voices, and thought echo, each named. Move on.
4.6 - Content, in their exact words
Trigger. He is willing to say what the voice says.
Decode, kept in your head. The exact words matter, because content carries the risk and the mood congruence. A derogatory or commanding content changes the whole picture.
The move. Ask for the precise words, gently, and listen for whether they are cruel, accusing, or instructing.
What does it actually say. Give me the exact words, if you can. Are they unkind, or do they ever tell you to do something.
Check. Content in his own words, noted. Move on to the command question.
4.7 - Command hallucinations, the risk item
Trigger. A voice that instructs. This is a scored risk domain, and the negative must be recorded too.
Decode, kept in your head. Command hallucinations carry the acute risk. You need whether it commands, what it commands, and whether he has ever acted on it or feels compelled to.
The move. Ask whether it tells him to do things, what, and whether he has obeyed or resisted.
Does the voice ever tell you to do something. What does it tell you to do. Have you ever felt you had to obey it, or have you acted on it.
Check. Command, its content, and any acting, screened. If absent, say so out loud, it is a finding. Never skip this. Move on.
4.8 - Frequency, and is it there now
Trigger. You need the burden and the current state.
Decode, kept in your head. How often, how long, and whether it is present in the room right now, which tells you how acutely unwell he is.
The move. Ask frequency, duration, and the present moment.
How often do you hear it. How long has this been going on. Can you hear it right now, while we are talking.
Check. Frequency and current presence noted. Move on.
4.9 - The modality sweep and the consequence
Trigger. You have the voices. You must sweep the other senses, and find what it all drives.
Decode, kept in your head. Hallucinations occur in every modality. And the last question, what he has done because of it, is where self-neglect and risk live.
The move. Quick sweep of vision, smell, taste, touch, then the consequence.
Have you seen anything others could not see. Any strange smells or tastes, or odd sensations in your body. And because of all this, what have you found yourself doing differently.
Check. Other modalities swept, and the behavioural consequence found. That consequence is the risk. Move on.
When it is NOT a hallucination. The comparators.
Half the marks are for what you exclude. Here are the look-alikes to rule out, out loud, to the examiner.
5.1 - The pseudohallucination
A voice experienced inside the head, in inner subjective space, that the person knows is their own mind, is a pseudohallucination, not a true hallucination. The discriminator is location and quality, inside versus through the ears. It appears in grief, in trauma, in emotionally intense states, and it does not carry the same diagnostic weight. Locate every voice before you name it.
5.2 - The illusion
A misperception of a real external stimulus, a dressing gown on the door seen as a figure, a rustle heard as a whisper, is an illusion, not a hallucination. It needs a real object present and often fades on a second look or in better light. Ask whether there was something really there that was misread.
5.3 - The flashback and the vivid image
Reliving a traumatic event, or a cued, memory-based vivid mental image with insight intact, is not a hallucination of psychosis. The person knows it is a memory, it is tied to a trigger, and the reality testing is preserved. Do not convert a trauma flashback into a psychotic voice.
5.4 - The organic hint
Voices or visions in someone disorientated and fluctuating point to delirium. Well-formed visual hallucinations, an olfactory aura with brief stereotyped episodes and automatisms, raise a physical cause such as delirium or temporal lobe epilepsy. Check orientation and the time course. If the consciousness is clouded, the confusion, not the voice, is the story.
Check. Name the thing you excluded, not only the thing you found. That is the mark.
The close
Close in five small movements. Never name a diagnosis or jargon to the patient.
One. Thank them.
Thank you for telling me about all of this. I know these are very private experiences and it took courage to describe them.
Two. Reflect it back, in their words.
So you have been hearing voices, clear as anything, coming from just above you, mostly talking about you and sometimes to each other, and it has left you on edge and unable to rest.
Three. Reassure, and promise safety.
These experiences are very real to you, and I believe you. They can happen when the mind becomes unwell in a particular way, and they do get better with the right help. You are safe here.
Four. Invite.
Is there anything I can answer for you, or anything I have not understood properly.
Five. Signpost. To the patient, the next step in plain words. To the examiner, in your head, the modality, person and identity, the presence or absence of command, the pseudohallucination and organic exclusions, and the risk.
The two habits, again
Carry these two out of the room.
One. Open wide, then hook off their exact words. Use the pause and the drifting gaze as your door, then convert what he describes into the named phenomenon with a follow-up. The blind-unlock.
Two. Never the label in the room, and never take yes at face value. Keep the word in your head, locate every voice before you name it, and never stop at link two. Finding the voice is the start. Whose, what person, whether it commands, and what it drives, is the station.
Do those two things and this drill is yours.
Eliciting Passivity & Thought Interference
Before we begin
Welcome. This is the third elicitation drill, on passivity and thought interference. The experiences where the boundary between the self and the world has broken down, thoughts inserted, withdrawn or broadcast, and actions, feelings and impulses made by an outside force.
These are the hardest to elicit, because you cannot ask them as a list without sounding strange, and because the whole set turns on one word. The mark is not for the patient saying his thoughts are unwanted or intrusive. The mark is for alien, for not his own, for made by someone else. Ownership, not content, is the test every time.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then hook off their exact words. Take his own phrase, my mind is being interfered with, my thoughts are not mine, and convert it. Preface the closed run once, then run it without apologising again.
Two. Never the label in the room, and never take yes at face value. Every yes to a leading question gets the follow-up, whose thoughts are they, how do they get in, because patients say yes and then describe ordinary worry.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination of a patient with a suspected psychotic illness, eliciting any passivity phenomena and thought interference. You are in a clinic or a ward room. You have around ninety seconds to a few minutes. An examiner sits silent in the corner. Do not undertake a full risk assessment unless asked, and do not name a diagnosis to the patient.
Here is the shape of it. Open wide. Then cover the three thought phenomena, insertion, withdrawal and broadcast, marked together. Then the made experiences, made feelings, made impulses, made acts, and somatic passivity, the one left out. And, if it surfaces, the delusional perception. The word alien earns insertion. The word hear, not guess, earns broadcast. Name each only to the examiner.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the preface
You do not open with are your thoughts your own. You open wide, then, when you must go closed, you preface it once.
Open on his own words if he gives them.
You said your mind is being interfered with. Tell me what you mean by that, in your own way.
When you move to the closed questions, say the preface once, and you never have to apologise again.
I am going to ask you a few questions now that sound a bit odd. I ask everybody these. Just tell me yes or no, and then tell me a little more.
That single preface is what lets you run insertion, withdrawal, broadcast and the made experiences in one calm sequence without seeming to interrogate.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Tobias. He is keen to talk, he hopes a doctor might finally understand, and he says his mind is being revolutionised.
Take his word, revolutionised, and it unfolds. Thoughts arrive that are not his, put there by an outside agent. Sometimes his mind goes suddenly, completely empty, as if a thought were pulled out. He believes others can hear his thoughts directly. There is a made appetite and, if you ask, a made movement, his arms moved for him like a puppet, and a sensation imposed on his body from outside. Late, he may name the agent, and describe the exact moment an ordinary thing, a light bulb, told him it was all true. He will not run the list for you. Each item is a separate question. Reluctance and disorder are not the same as absence.
That is your patient. Now every move is made through Tobias, converting his phrases into the named phenomena.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check. Ownership is the test throughout.
4.1 - Thought insertion
Trigger. He has thoughts he says are not his, or that are put into his head.
Decode, kept in your head. Thought insertion, the experience of thoughts as put into the mind and therefore alien. The word that earns the mark is alien, not unwanted, not intrusive.
The move. Establish ownership first, then the mechanism, whose and how they get in.
Are the thoughts in your head always your own. Can thoughts ever be put there that are not yours, that feel like they belong to someone else. Whose are they, and how do they get in.
Check. Alien ownership, not just an unwanted thought. That is the mark. Move on.
4.2 - Thought withdrawal
Trigger. His mind goes suddenly blank, as if emptied.
Decode, kept in your head. Thought withdrawal, the subjective experience of a thought being suddenly taken out. Distinguish it from ordinary losing your train of thought by the sense of an external agent removing it.
The move. Ask about the sudden emptying and who does it.
Do your thoughts ever stop suddenly, so your mind goes completely empty, as if they had been taken away. Does it feel like something or someone is removing them.
Check. An external agent removing thoughts, not simple distractibility. Move on.
4.3 - Thought broadcast
Trigger. He feels others know his thoughts.
Decode, kept in your head. Thought broadcast, the feeling that thoughts are not confined to his mind and that others are privy to them. Do not settle for people can guess. The thoughts themselves must leave, and others must hear them.
The move. Push past guessing to hearing. Do the thoughts stay in, or get out.
Can other people know what you are thinking without you telling them. Do you mean they guess from your face, or that they can actually hear the thoughts themselves. Do your thoughts stay in your head, or do they get out.
Check. People can hear, not people can guess. That distinction is the mark. Move on.
4.4 - Made feelings and made impulses
Trigger. Feelings or urges that do not feel like his own.
Decode, kept in your head. Made affect and made impulse, emotions and urges experienced as manufactured and imposed from outside. Lost ownership of the inner life.
The move. Ask whether his feelings are his, and whether sudden urges belong to him.
Are the feelings you have your own feelings, or can someone put a feeling into you that you would not have had. Do you ever get a sudden urge to do something that does not feel like yours.
Check. Made feeling and made impulse noted. Ownership again. Move on.
4.5 - Made acts, the body moved for him
Trigger. His arms or body move without his willing it.
Decode, kept in your head. Made act, his own action experienced as controlled by an external force, the puppet experience. Often the most alarming, and the one that produces injury.
The move. Ask whether his movements are always his own doing, and use the puppet image.
When you move, is it always you moving. Has anything ever moved your arms or legs for you, as though you were a puppet, when you did not intend it.
Check. Made act confirmed. This is where risk to the body lives. Move on.
4.6 - Somatic passivity
Trigger. Bodily sensations he feels are imposed from outside.
Decode, kept in your head. Somatic passivity, physical sensations felt to be coming into the body from an external source. This is the one candidates leave out. Do not.
The move. Ask about imposed sensations and who is doing it.
Do you get any sensations in your body that somebody else is putting there. What does it feel like, and who do you think is doing it.
Check. Somatic passivity, the commonly missed item, is now covered. Move on.
4.7 - Delusional perception
Trigger. He says there was a moment when it all suddenly became clear.
Decode, kept in your head. Delusional perception, a real perception given, out of nowhere, a huge self-referential meaning with no logical link. A first rank symptom, released only with rapport.
The move. Find the exact moment and the ordinary thing that carried the revelation.
Was there a moment when everything suddenly became clear to you. What was happening at that exact moment. What was it about that, that told you.
Check. A normal perception carrying a delusional revelation is delusional perception. Note it. Move on.
4.8 - Naming the agent and the mechanism
Trigger. He hints at who is doing all this, and how.
Decode, kept in your head. The named agent and the mechanism, a chip, an implant, a transmitter, bind the phenomena into one system and shape the delusional content.
The move. For all of them, ask the same three, how, why him, and how long.
How do they do all this to you. Why you. And how long has it been going on.
Check. Agent and mechanism captured, the system understood. Move on.
4.9 - Weaving in the risk
Trigger. Passivity has driven action before, cutting to remove an implant, throwing away a phone. Risk sits at the far end of the chain.
Decode, kept in your head. These phenomena matter clinically through what they make him do, to himself or others, under external control he cannot resist.
The move. Ask, without alarm, whether the control has ever made him act, or harm himself to be free of it.
When you feel controlled like this, has it ever made you do something you would not choose. Have you ever tried to get rid of it, or to protect yourself, in a way that could have harmed you.
Check. Risk from passivity, screened. Never optional. Move on.
When it is NOT passivity. The comparators.
Half the marks are for what you exclude. Ownership is intact in all of these. Say so, out loud, to the examiner.
5.1 - The obsessional thought
An intrusive, unwanted, repugnant thought that the person recognises as their own and resists is an obsession, not thought insertion. The discriminator is ownership. The obsessional patient says it is my thought and I hate it. The psychotic patient says it is not my thought. Ask, does it feel like your own thought that you cannot get rid of, or a thought that is not yours at all.
5.2 - The anxious sense of being noticed
A socially anxious or paranoid person may feel others can tell what they are thinking from their face. That is a fear of being read, not thought broadcast, until the thoughts themselves are said to leave and be heard. Do not upgrade an anxious self-consciousness into a first rank symptom.
5.3 - The ordinary lost train of thought
Everyone loses their thread, especially when anxious, tired, or depressed. That is not thought withdrawal unless there is a sense of an external force removing the thought. Distractibility and psychomotor slowing are not passivity. Anchor withdrawal on the agency, not the blankness.
Check. Name the thing you excluded, not only the thing you found. Ownership is the whole test. That is the mark.
The close
Close in five small movements. Never name a diagnosis or jargon to the patient.
One. Thank them.
Thank you for trying to put such strange and unsettling experiences into words. That is not easy to describe.
Two. Reflect it back, in their words.
So it feels as though your own mind is not fully your own, thoughts arriving and leaving that are not yours, and at times your very body being moved for you.
Three. Reassure, and promise safety.
I believe these experiences are real to you. They can happen when the mind becomes unwell in a particular way, and they can be helped. Nothing will be done to you here without it being explained first.
Four. Invite.
Is there anything I have misunderstood, or anything you want to ask me.
Five. Signpost. To the patient, the next step in plain words. To the examiner, in your head, the named first rank phenomena, the obsessional and anxiety exclusions, the working diagnosis, and the risk that passivity carries.
The two habits, again
Carry these two out of the room.
One. Open wide, then hook off their exact words. Take his own phrase, revolutionised, interfered with, and convert it. Preface the closed run once, then run it calmly. The blind-unlock.
Two. Never the label in the room, and never take yes at face value. Ownership is the test, alien not unwanted, hear not guess, an external force not simple blankness. Follow every yes with whose, and how. The phenomenon is the scenery, the ownership and the risk are the station.
Do those two things and this drill is yours.
Eliciting Thought Form
Before we begin
Welcome. This is the fourth elicitation drill, on the form of thought, how thought is organised, as opposed to what it contains. Loosening of association, flight of ideas, tangentiality, circumstantiality, thought block, poverty of speech, perseveration, neologism.
This drill is different. You do not elicit thought form with a question. You elicit it by listening, and by giving the person room to talk. The whole skill is to notice the disorganisation as it happens, drop a one-line observation into the room at about minute two so the examiner hears you catch it, and then, crucially, exclude the things that imitate it. Most of the marks here are for what you rule out.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then listen. Ask a broad question that requires a longer answer, then let them run. You cannot hear form in yes or no replies.
Two. Never the label in the room, and separate form from content. Never say thought disorder, flight of ideas or poverty of speech to the patient. And never mistake a strange belief, calmly and logically told, for disordered form.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination, commenting on the patient's speech and the form of their thought. You are in a clinic or a ward room. You have around ninety seconds to a few minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient.
Here is the shape of it. Open wide and let them speak at length. As you listen, ask yourself one question, can I still reconstruct the link between one idea and the next. If yes, form is intact or only circumstantial. If no, it is loosening. Then name what you hear in one sentence to the examiner, with the specific sign and its consequence. And exclude the imitators, dysphasia, pressure of speech, and strange content told in clear form.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the test
You do not open with a closed question. You open with something that needs a paragraph to answer, and then you stop talking.
Say something like this.
Tell me, in your own words and in as much detail as you like, what has been happening in your life over the last few weeks, and how you have ended up here.
Then you listen, and you run the one test that decides everything.
The test. Try, silently, to write a one-sentence summary of the reply. If you can, the form is intact. If you cannot reconstruct how he got from the start of the answer to the end, even after he has finished, that is loosening of association. Say the test to yourself after every long answer.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Silas. He is guarded, shows little emotion, and is willing to speak but hard to follow.
As he talks you notice the ideas stop joining up. He moves from an old baby at his hostel, to an energy in his body that overcomes evil, to Armageddon and dark matter and the anti-Christ, and try as you might you cannot rebuild the bridge between them. He also stops mid-sentence and falls silent, and you must find out whether that is thought block, or whether he has paused to listen to something you cannot hear. His delivery is monotonous, and the content is strange, but the strangeness of what he believes is not the same as the disorder of how he says it. You will have to hold those two apart.
That is your patient. Now every move is made through Silas, naming the form and separating it from the content.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Here the words are mostly what you say to the examiner, not to the patient. Each drill is trigger, then decode kept in your head, then the move, then the naming sentence, then a check.
4.1 - Loosening of association
Trigger. Consecutive statements do not follow logically, and you cannot reconstruct the link even afterwards.
Decode, kept in your head. Loosening of association, also called derailment or knight's move thinking. The listener cannot rebuild the connection. This is the core of formal thought disorder.
The move. Do not interrupt to correct. Let it run, run the one-sentence test, then name it to the examiner, using the word logicality.
At times his consecutive statements did not follow logically from one another, and I could not reconstruct the link even afterwards. I would describe that as loosening of association.
Check. Loosening named, with logicality said out loud. Move on.
4.2 - Flight of ideas versus loosening
Trigger. Rapid speech jumping topic to topic.
Decode, kept in your head. In flight of ideas the links can be traced, by rhyme, by a distracting cue, by a chain association. In loosening they cannot. Speed alone does not decide it.
The move. Listen for whether you can follow the thread of the jumps. If you can trace each hop, it is flight. If not, loosening.
His speech was rapid and moved topic to topic, but I could trace the connections between the jumps, so I would call this flight of ideas rather than loosening of association.
Check. Traceable link is flight. Untraceable is loosening. The discriminator is stated. Move on.
4.3 - Circumstantiality and tangentiality
Trigger. Long, over-inclusive answers. In one, he eventually reaches the point. In another, his answers relate to the question but never arrive.
Decode, kept in your head. Circumstantiality takes the scenic route but arrives. Tangentiality veers off and never reaches the point. The difference is arrival.
The move. Notice whether the answer ever lands on what you asked.
His answers were over-inclusive but did eventually reach the point, which is circumstantiality. Where an answer related to my question but never arrived at it, I would call that tangentiality.
Check. Arrival separates the two. Named. Move on.
4.4 - Thought block
Trigger. Speech stops abruptly, mid-sentence, and the thought is gone.
Decode, kept in your head. Thought block, a sudden cessation of the stream of thought mid-flow, distinct from a slow start, which is increased latency, and from a pause to listen to a voice.
The move. When he stops, ask why, do not guess. The book's own instruction, use the cue he gives you.
You went quiet just then. Can you tell me what happened. Did the thought simply stop, or were you listening to something.
Check. A thought that vanished mid-sentence is block. A pause to listen is response to hallucination. A slow start is latency. Distinguished. Move on.
4.5 - Poverty of speech and content
Trigger. Replies are brief, quiet, trailing off, giving little information.
Decode, kept in your head. Poverty of speech, reduced amount, and poverty of content, plenty of words carrying little meaning. Before naming it, exclude a physical or motivational cause.
The move. Note the reduction, but caveat it, in learning disability or old age check the usual baseline and exclude pain, sensory impairment and a physical cause.
His speech was reduced in amount, quiet and trailing off. Before calling this poverty of speech I would want his usual level of communication, and I would exclude depression, pain, sensory impairment and a physical cause.
Check. Poverty named, but hedged against its imitators. Move on.
4.6 - Perseveration
Trigger. He keeps giving the previous answer, or repeating an action, after the topic or the rule has changed.
Decode, kept in your head. Perseveration, the inappropriate persistence of a response after it is no longer relevant. A frontal sign, pointing toward an organic picture.
The move. Notice the carry-over when you change the question, and name it as frontal.
He perseverated, continuing with the previous response after I had changed the question, which I would regard as a frontal sign worth pursuing organically.
Check. Perseveration named, and flagged as organic. Move on.
4.7 - Neologism and clang
Trigger. He uses invented words, or links words by their sound rather than their sense.
Decode, kept in your head. A neologism is a newly coined word with a private meaning. Clang association links words by rhyme or sound. Both are formal signs.
The move. When you hear an invented word, ask what it means to him, then name it to the examiner.
He used a word I did not recognise, so I asked what it meant to him, and it was a private coinage, a neologism. At times he rhymed, which I took as clang association.
Check. Neologism confirmed by asking its meaning, clang noted. Move on.
4.8 - The naming sentence, and the consequence
Trigger. You have the picture and must present it.
Decode, kept in your head. A good report has four parts, the global comment, the named phenomenon, the specific signs, and the functional consequence. The consequence is where the marks finish.
The move. Deliver all four in sequence, ending on what it has cost him.
Rate, rhythm and volume were as follows. The form showed loosening of association, with two neologisms. This affected the interview to the point that I could not complete the risk assessment, and it is why his hostel can no longer manage him.
Check. Global, named, specific, consequence. The full sentence. And if you heard nothing abnormal, say that too, it earns marks. Move on.
When it is NOT thought disorder. The comparators.
This is where most of the marks live. Every one of these imitates disordered form and is not it. Say the exclusion out loud.
5.1 - Dysphasia and word-finding difficulty
In dysphasia the thought is intact and the vehicle, language, is broken. He knows what he means but cannot find or order the words, often after a stroke or in dementia. Ask whether the grammar is wrong though the meaning is clear, and whether he struggles to find a word he clearly knows. Language, not thought, is the problem. This is the single most important exclusion in an older patient.
5.2 - Pressure of speech in mania
Rapid, loud, hard-to-interrupt speech with elevated or irritable mood is pressure of speech, a disorder of rate driven by mood, not necessarily of form. It may carry flight of ideas, but talkativeness alone, especially lifelong and without mood elevation, can be temperament or overactivity, not thought disorder. Anchor it to the mood.
5.3 - Strange content told in clear form
This is the classic trap. A patient calmly, logically and without pauses describes an extraordinary delusional system. The content is bizarre, the form is completely normal. A nervous candidate hears the strangeness and reports thought disorder. Wrong. Judge the how, not the what. Clear, logical delivery of a delusion is intact form.
5.4 - The organic and episodic mimics
Brief episodic arrests with lip-smacking and post-ictal confusion point to temporal lobe epilepsy, not thought block. Muteness with immobility is stupor, not poverty of speech. Reduced speech in learning disability can be pain, constipation, sensory loss or low mood. Exclude the body before you commit to the mind.
Check. Name the thing you excluded, not only the thing you found. In this drill, that is most of the marks.
The close
Close in five small movements. Never name a diagnosis or jargon to the patient.
One. Thank them.
Thank you for talking with me so openly, and for staying with it even when it was hard.
Two. Reflect it back, gently and in plain words.
I can see your thoughts have felt jumbled and hard to hold on to lately, and that it has been exhausting trying to make yourself understood.
Three. Reassure, and promise safety.
When the mind becomes unwell in a certain way, thinking can feel scattered like this, and it settles with the right help. You are safe here, and we will take it at your pace.
Four. Invite.
Is there anything you would like to ask me, or anything I have not understood.
Five. Signpost. To the patient, the next step in plain words. To the examiner, in your head, the named form, the dysphasia and pressure and content exclusions, and the functional consequence.
The two habits, again
Carry these two out of the room.
One. Open wide, then listen. Ask the question that needs a paragraph, then run the one-sentence test. If you cannot reconstruct the link, that is loosening. Drop the observation at minute two so the examiner hears you catch it.
Two. Never the label in the room, and separate form from content. Judge how he speaks, not how strange his beliefs are. And most of the marks are in the exclusions, dysphasia, pressure, and a clear-formed delusion. The content is the scenery, the form and its exclusions are the station.
Do those two things and this drill is yours.
Eliciting Depression & Low Mood
Before we begin
Welcome. This is the fifth elicitation drill, on depression and low mood. Drawing out the full picture of a depressive state, core, cognitive, biological, functional, and the risk, without turning it into a checklist.
This is the most familiar territory in psychiatry, and that is the danger. Anyone can ask are you low. The candidates who pass do it in a shape, they lead with an open question and let the person pour out their life, they split anhedonia into looking-forward and enjoying, they sweep the biology in one movement, they anchor worthlessness in the person's own role, and they reflect a phrase back after every answer so it never becomes an interrogation. Understandable sadness is still assessed fully. Do not shortcut it because the reason is obvious.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then answer through their life. Start with what has been happening, not with a symptom list, and let their revealed life become the material you ask through.
Two. Reflect before you probe. After each answer, give one phrase back, so the next question lands as care, not as a form being filled.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Assess this patient's mood. Elicit the symptoms of depression, cover the biological and cognitive features, and screen the risk. You are in a clinic or a ward room. You have around seven minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient.
Here is the shape of it, in blocks. First, open and hear the story. Then the core, low mood, loss of interest, low energy, with duration and diurnal variation. Then the cognitive triad, worthlessness, hopelessness, guilt, in the person's own role. Then the biology in one sweep, sleep with its shape, appetite, weight, energy, concentration. Then function, what have they stopped doing. Then risk. Reflect throughout.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the reflection
You do not open with how is your mood. You open on their life, and let the mood surface inside it.
Say something like this.
I gather things have been difficult recently. Can you tell me, in your own words, what has been going on for you, and how you have been in yourself.
Then you stop, and you leave real silence. A depressed person is slow to speak. Let the pause sit, do not rush to fill it. Then, when they give you something, reflect it back before you ask the next thing.
You said you feel like you are failing everyone. That sounds like a heavy thing to be carrying. Can you tell me more about that.
That reflection is the whole technique. Each question grows out of what they just revealed, so the assessment feels like being understood, not processed.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Lydia. She is slowed, quiet, slow to answer, and she has to think before each reply.
Something set it off, a loss, a relationship ending, a blow at work, and since then she has felt low almost all the time, worse in the mornings. Nothing gives her pleasure and she looks forward to nothing. She wakes between five and six and cannot get back to sleep. Food is bland and she has lost weight without trying. She believes she is worthless and has no future, and blames herself for what happened. She has stopped the things she used to do and spends much of the day in bed. If you ask directly, and only then, she says life is not worth living and she wishes she were dead. She will not lay this out in order. It comes out slowly, if you give her room.
That is your patient. Now every question bends around Lydia and the life she has shown you.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Core mood and its course
Trigger. She hints at feeling low.
Decode, kept in your head. Core low mood, its pervasiveness, its duration, and the diurnal pattern, worse in the mornings, which points to a biological depression.
The move. Ask how the mood is, why she feels it is that way, and whether it varies through the day.
How has your mood been in yourself. Is it there most of the day, most days. And is it the same all day, or worse at a particular time, first thing in the morning perhaps.
Check. Pervasive, sustained, worse in the morning. Core and course noted. Move on.
4.2 - Anhedonia, split in two
Trigger. She says nothing interests her any more.
Decode, kept in your head. Anhedonia is the higher mark when you split it, anticipatory, looking forward, and consummatory, enjoying in the moment. Ask both.
The move. Ask what she used to enjoy, whether she can still enjoy it while it is happening, and whether she looks forward to anything.
What sort of things did you used to enjoy. When you do them now, can you still enjoy them in the moment. And is there anything at all you find yourself looking forward to.
Check. Both anticipatory and consummatory anhedonia covered. That split is the mark. Move on.
4.3 - The cognitive triad, in her role
Trigger. She says she is failing, or useless.
Decode, kept in your head. The negative view of self, world and future, plus guilt. Worthlessness lands hardest when framed in the person's actual role, as a mother, a husband, at work, as a carer.
The move. Ask about worth in her role, about the future, and about self-blame, reflecting each back.
How do you feel about yourself as a person, in the role that matters most to you. When you look ahead, what do you see. And do you blame yourself for something you feel you have done.
Check. Worthlessness, hopelessness and guilt, in her own role. Move on.
4.4 - Hopelessness, and the bridge to risk
Trigger. She says there is no future.
Decode, kept in your head. Hopelessness is both a cognitive symptom and the single best bridge into the risk questions. Move from it into safety, gently.
The move. Take the future tense, then step, without a jolt, toward whether life feels worth living.
You said you cannot see a future. When someone feels as low and as hopeless as you describe, they sometimes feel life is not worth living. Has it been like that for you.
Check. Hopelessness elicited and used as the natural doorway to risk. Move on.
4.5 - Sleep, with its shape
Trigger. She mentions poor sleep.
Decode, kept in your head. The shape matters more than the amount. Early morning wakening, waking hours before her time and unable to return, is the biological discriminator.
The move. Ask not just whether she sleeps, but the pattern, and specifically the early hours.
How is your sleep. Is it hard to fall asleep, or do you wake in the night. Are you waking very early, before you need to, and unable to get back.
Check. Early morning wakening, the biological sign, specifically asked. Move on.
4.6 - The rest of the biology, in one sweep
Trigger. You have sleep. Now the body.
Decode, kept in your head. Appetite, weight, energy, concentration, and in older adults constipation, swept together so it flows rather than interrogates.
The move. One flowing sweep through the physical symptoms.
How has your appetite been, and has your weight changed. What is your energy like. And can you concentrate, on a book or the television, the way you used to.
Check. Appetite, weight, energy, concentration covered in one movement. Move on.
4.7 - Function, the symptom that earns the mark
Trigger. She has withdrawn from her life.
Decode, kept in your head. Function is what turns a symptom list into a clinical picture. What has she actually stopped doing, work, study, seeing people, self-care.
The move. Ask concretely what has fallen away.
What have you stopped doing that you would normally do. Are you managing work, or seeing people, or looking after yourself the way you would want.
Check. Functional impact named concretely. This is a scored item. Move on.
4.8 - Risk, received gently
Trigger. The hopelessness and the passive wish are there.
Decode, kept in your head. Move along the gradient, from life not worth living, to wishing to be dead, to active thoughts, to plans, to preparation. And in a carer or parent, screen thoughts about the person they care for too. Receive each answer without alarm.
The move. Walk the gradient calmly, thank her for each honest answer, and separate a passive wish from an active plan.
Thank you for telling me that. Have you got as far as thinking about ending your life. Have you thought about how. Have you taken any steps, or made any plans. And is there anyone else you worry about in all this.
Check. The full risk gradient, and any risk to dependents, screened gently. Never optional. Move on.
When it is NOT a primary depression. The comparators.
Half the marks are in seeing what else the low mood belongs to. Say the alternative out loud.
5.1 - Depression on a physical illness or endocrine cause
When the biological symptoms are out of keeping with the mood, tiredness, weight gain, constipation, dry skin, cold intolerance, stop and look at the body. An untreated thyroid disorder mimics and worsens depression, and resistant depression is not resistant if the thyroid was never checked. Say you would examine the physical health and check the bloods before escalating treatment.
5.2 - The depressive episode of a bipolar illness
A depression may be the low phase of a bipolar disorder. Always ask about past highs, times of elevated or irritable mood, reduced need for sleep, overspending, overactivity, because it changes the treatment entirely. Never assess a depression without screening for a previous mania.
5.3 - Grief, and the understandable reaction
After a loss, waves of sorrow triggered by reminders, and even hearing or sensing the person, are normal grief, not a depressive illness. The line is crossed by pervasive worthlessness, guilt unrelated to the loss, and a shutdown that does not lift. Do not pathologise ordinary sorrow, but do not miss a depression growing inside it either.
5.4 - The depression that hides as something else
A depressed professional may argue about the evidence rather than admit hopelessness. A depressed older adult may present with memory complaints, a pseudodementia. An agitated depression may look like anxiety. Listen for the depressive core beneath the presenting surface, and do not take the disguise at face value.
Check. Name what else the low mood might be, not only the depression. That is the mark.
The close
Close in five small movements. Never name a diagnosis or jargon to the patient.
One. Thank them.
Thank you for being so honest with me about how bleak things have felt. That cannot have been easy.
Two. Reflect it back, in her words.
So you have been feeling low nearly all the time, worse in the mornings, not enjoying anything, waking too early, and blaming yourself, and at times feeling life is not worth living.
Three. Reassure, and leave hope.
What you are describing is something we understand well and treat well, and people do come back from feeling exactly this low. You are not failing, and you are not alone in it.
Four. Invite.
Is there anything I have missed, or anything you would like to ask me.
Five. Signpost. To the patient, the next step and that support starts now. To the examiner, in your head, the depressive syndrome, the organic and bipolar and grief exclusions, and the risk with its plan.
The two habits, again
Carry these two out of the room.
One. Open wide, then answer through their life. Start on what has happened, leave silence for a slowed patient, and ask through the life she reveals, not down a list.
Two. Reflect before you probe. A phrase back after every answer, so it lands as care. Split anhedonia, shape the sleep, anchor worth in her role, and always screen the risk and a past mania. The sadness is the scenery, the shape and the risk are the station.
Do those two things and this drill is yours.
Eliciting Mania & Elevated Mood
Before we begin
Welcome. This is the sixth elicitation drill, on mania and elevated mood. Drawing out the manic syndrome, elation or irritability, grandiosity, reduced need for sleep, overactivity, pressured speech and disinhibition, from someone who feels marvellous and does not think he is ill.
Two things make this drill unlike the others. First, you must take control of the station, because a manic patient will talk over you and run the clock down, so you keep questions short and single, never bundled. Second, the strongest technique is to reflect the speed back to him, I notice you are talking very fast, I wonder if your thoughts are racing just as fast, which both demonstrates the sign to the examiner and opens him up. And the disinhibition, the overspending, the sexual risk, is where the marks and the danger sit.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then hook off their exact words, one at a time. Reflect his own phrase back, buzzing, unstoppable, an investment, and follow it with a single focused question. Never a compound question, he cannot track it.
Two. Never the label in the room, and take control gently. Do not say manic to him, do not argue with his good mood, and do not collude with it either. Set boundaries warmly and keep the wheel.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination of a patient with a possible manic episode. Elicit the core manic symptoms and screen the associated risk. You are in a clinic or a ward room. You have around seven minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient.
Here is the shape of it. Establish the elevated or irritable mood and how long it has lasted, at least a week for mania. Then the manic biology, reduced need for sleep with preserved energy, overactivity, pressured speech, racing thoughts, distractibility. Then grandiosity, tested for conviction. Then, and this is not optional, screen for psychosis, and screen the risk, overspending, sexual disinhibition, driving, aggression. Consider an organic or drug cause, and ask family history.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the reflection
You do not open by asking whether he is high. You open wide, catch the pace, and reflect it.
Say something like this.
I gather things have been moving very fast for you lately. Tell me how you have been in yourself, and how your mood has been.
Then, as he pours out, use the reflection that is the signature move of this station.
I can see you are talking very quickly and you seem to have so much energy. I am wondering, are your thoughts racing just as fast. And how has your sleep been.
That single reflection does three things, it captures pressured speech and flight of ideas for the examiner, it links naturally into the sleep question, and it makes him feel understood rather than challenged. Keep every follow-up short and single.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Elias. He had one episode like this before, did well on a mood stabiliser, and stopped it a couple of months ago. He is bright, fast, warm, and a little overfamiliar, and he does not think anything is wrong.
He feels wonderful, like he can do anything. His energy is through the roof, twice a day at the gym, and he sleeps about two hours and wakes buzzing, needing no more. He has bought thousands of pounds of equipment for a project, which he calls an investment he will make back when it takes off. He believes he has outgrown his job and is about to strike out alone. He talks fast, hard to interrupt, jumps between ideas, and becomes irritable if you slow him down or doubt his plans. The overspending, the grand plan and the irritability are where the risk lives. He will not hand you a symptom list. You take control and draw it out, one question at a time.
That is your patient. Now every move is made through Elias, short questions, reflected back, never bundled.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check. Short and single throughout.
4.1 - Elevated or irritable mood, and its duration
Trigger. He says he feels amazing, or unusually on top of the world, or unusually irritable.
Decode, kept in your head. Elevated, expansive or irritable mood is the core. Duration is diagnostic, at least a week for a manic episode. Expansiveness is a loss of the ordinary limits on the self, name that phrase.
The move. Confirm the elevation, then pin the duration, because dating the change is what makes it an episode rather than personality.
You say you feel wonderful, like you can do anything. How long have you felt this way, when exactly did it change.
Check. Elevated or expansive mood, dated to at least a week. Move on.
4.2 - Reduced need for sleep, with preserved energy
Trigger. He sleeps two or three hours and wakes buzzing.
Decode, kept in your head. The discriminator is reduced need, not insomnia. In depression he cannot sleep and is exhausted. In mania he does not need sleep and is energised. That contrast is the mark.
The move. Ask the hours, then ask the energy, and hold the two together.
How much are you sleeping. And with only two hours, how is your energy through the day, do you feel tired at all, or full of energy.
Check. Reduced need for sleep with preserved or increased energy. The contrast is diagnostic. Move on.
4.3 - Pressured speech and racing thoughts
Trigger. He talks fast, plentiful, hard to interrupt, jumping topic to topic.
Decode, kept in your head. Pressure of speech, a disorder of rate driven by mood, often carrying flight of ideas, the subjective racing of thought. Demonstrated live rather than merely asked.
The move. Reflect the observable sign and convert it into the subjective symptom.
I notice you are speaking very fast and it is hard for me to get a word in. Does it feel like your thoughts are coming faster than you can say them, one tumbling after another.
Check. Pressured speech observed, racing thoughts confirmed subjectively. Move on.
4.4 - Overactivity and distractibility
Trigger. Endless projects, the gym twice a day, unable to settle.
Decode, kept in your head. Increased goal-directed activity or psychomotor agitation, and distractibility, attention pulled by every passing thing.
The move. Ask what he has been doing with all the energy, and whether he can stay on one task.
What have you been getting up to with all this energy. Are you able to finish what you start, or do you find yourself pulled from one thing to the next.
Check. Overactivity and distractibility noted. Move on.
4.5 - Grandiosity, tested for conviction
Trigger. He believes he has outgrown his job, or has a special plan, ability or importance.
Decode, kept in your head. Grandiose thinking runs from inflated confidence to a frank grandiose delusion. You must test how fixed it is, because that decides mania versus mania with psychosis.
The move. Explore the belief warmly, then gently probe conviction and an alternative explanation, without mockery.
Tell me about this plan of yours. Do you feel you have abilities others do not have. How certain are you, and could there be any other explanation, could it be that you are unwell.
Check. Grandiosity elicited and its conviction tested. Confident idea or fixed delusion, note which. Move on.
4.6 - Screening for psychosis
Trigger. The grandiosity is intense, and the elation extreme.
Decode, kept in your head. You absolutely must ask about delusions and hallucinations, usually grandiose and mood congruent. Missing this is a common failure.
The move. Screen briefly but explicitly for voices and for any special powers or messages.
When your mind is racing like this, have you heard anything others could not hear. Have you felt you have a special mission, or that things around you carry a special meaning for you.
Check. Psychosis screened. Mania with, or without, psychotic symptoms. Never skip this. Move on.
4.7 - The risk of disinhibition, the heart of the station
Trigger. Thousands spent, called an investment, plus the grand plan. This is a risk flag, not a boast.
Decode, kept in your head. Excessive involvement in activities with painful consequences, overspending, sexual indiscretion, foolhardy ventures, reckless driving. Explore neutrally, without arguing the investment framing.
The move. Ask how much, whether it is unlike him, and sweep the other disinhibitions, sex, driving, conflict, without alarm.
That is a lot of new equipment. How much have you spent, and is that like you normally. Have you been taking any other risks, with money, driving, or relationships, that you might not usually take.
Check. Financial, sexual and behavioural disinhibition screened. This is the core risk. Move on.
4.8 - The organic screen, family history, and the relapse frame
Trigger. Especially in an older or first-episode patient, or where medication was recently stopped.
Decode, kept in your head. Steroids, stimulants, an intracranial cause and thyroid disease all mimic mania. Family history of mood disorder, and a stopped mood stabiliser, reframe this as a relapse. All scored only if asked.
The move. Brief physical and drug screen, then family history and the medication story.
Have you started any new medicines, steroids, or used any recreational drugs. Any headaches, or physical changes. Does mood illness run in your family. And you mentioned stopping your tablets, when was that.
Check. Organic and drug causes screened, family history and the stopped medication captured. This is a relapse, name it in your head. Move on.
When it is NOT mania. The comparators.
Half the marks are in what else the high belongs to. Say the alternative out loud.
5.1 - Hypomania versus mania
Hypomania has the elevated mood, energy, reduced sleep and wellbeing, but no psychosis and only modest functional disruption, over a shorter minimum duration. Mania has marked impairment, may have psychosis, and lasts at least a week. Grade the severity by the functional impact and the presence of psychosis, and say which you are describing.
5.2 - Drug-induced and organic elevation
Stimulants, steroids, an overactive thyroid and some brain lesions produce a manic-looking state. The chronology decides it, mood elevation that begins with the drug or the physical illness and settles when it is removed is not a primary bipolar mania. Always place the high against the timeline of substances and physical health.
5.3 - Elation as personality or culture
Some people are constitutionally exuberant, overfamiliar or talkative lifelong, with no dated change and no reduced need for sleep. A cheerful, expressive temperament, or a culturally expansive style, is not mania. The test is a distinct episode, a change from the person's baseline, dated in time.
5.4 - Agitated depression and the mixed state
Overactivity and irritability can be a mixed affective state, where manic energy and depressive despair run together, and the risk of suicide is then especially high. If a fast, driven, irritable patient also voices hopelessness or a wish to die, do not file it as simple mania. Screen the depressive pole and the suicide risk explicitly.
Check. Name what else the elevation might be, not only the mania. That is the mark.
The close
Close in five small movements. Never name a diagnosis or jargon to the patient, and do not argue him down.
One. Thank them, and meet the energy without feeding it.
Thank you for talking with me so openly. I can see how much is happening for you right now.
Two. Reflect it back, in his words.
So over the last while you have been feeling on top of the world, needing barely any sleep, full of energy and big plans, and spending freely on them.
Three. Plant a gentle seed of concern.
I am glad you feel so well. My one worry is that some of this, the sleeplessness and the spending, could cause you trouble later, and I would like to help you protect what matters to you.
Four. Invite.
Is there anything you would like to ask me, or anything you think I have not understood.
Five. Signpost. To the patient, a plan framed as keeping him safe and well. To the examiner, in your head, the manic syndrome with its duration, the presence or absence of psychosis, the organic exclusion, and the disinhibition risk.
The two habits, again
Carry these two out of the room.
One. Open wide, then hook off their exact words, one at a time. Reflect the pace back, buzzing, racing, an investment, and follow each with a single short question. Never bundle five symptoms into one, he cannot track it.
Two. Never the label in the room, and take control gently. Do not say manic, do not argue with the high, and do not collude with it. Screen the psychosis, screen the spending and the sex and the driving, and remember the elation is the scenery, the disinhibition risk is the station.
Do those two things and this drill is yours.
Eliciting Obsessions & Compulsions
Before we begin
Welcome. This is the seventh elicitation drill, on obsessions and compulsions. Drawing out intrusive thoughts and the acts done to neutralise them, and, above all, proving they are the person's own thoughts, hated and resisted, not put there from outside.
Two things make or break this station. First, shame keeps it hidden, so without a normalising opening she will never give you the content of the thought, and you cannot pass without the content. Second, one question decides everything, is the thought her own, or put there. Her own is an obsession. Put there is thought insertion, and you have walked into a psychosis station by mistake. And the mental compulsions, the silent counting and cancelling, are the single most missed thing in the whole subject.
Two habits carry every MSE drill. Keep them close.
One. Open wide and normalise, then take one thought all the way through. Reassure that intrusive thoughts are common and shameful to admit, then follow a single obsession from content to compulsion before collecting others.
Two. Never the label in the room, and always ask twice. Do not say the diagnosis. Ask the ownership question directly, and always ask a second time about the mental compulsions, because they are almost never volunteered.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination of a patient with possible obsessive compulsive disorder. Elicit and characterise the obsessions and compulsions and assess their impact. You are in a clinic. You have around seven minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient in a way that shames them.
Here is the shape of it. Open and normalise so she will disclose the content. Take one obsession through the four tests, mine, repeated, resisted, hated. Ask the ownership question that excludes psychosis. Cover the four forms an obsession takes, thought, image, impulse, doubt. Elicit both overt and mental compulsions. Show the loop, resistance raises anxiety, the compulsion relieves it briefly, the thought returns stronger. Measure time, interference, resistance, control. Grade insight. Screen comorbid depression and suicide.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the permission to speak
You do not open with what are your obsessions. You open by making it safe to say the unsayable. This line is not politeness, it is the key to the whole station.
Say something like this.
Before we start, I want to say something. A great many people get thoughts that come into their mind uninvited, thoughts they do not want and do not agree with. Nothing you tell me is going to shock me, and nothing you tell me means you are a bad person. Can you tell me what has been happening.
Then you stop and let her decide to trust you. Without that sentence, a person tormented by a thought of harming a child, or of contamination, will not give you the content, and the content is where the marks are. Warmth first, always.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Miss Delaney. She is exhausted, ashamed, and half-convinced she is going mad, or that the thoughts mean she is a monster.
Uninvited thoughts come into her mind, thoughts she finds repugnant and fights, and they horrify her precisely because they are the opposite of what she wants. She washes, and she also counts and repeats things silently in her head, which she will not mention unless you ask a second time. The acts give a few minutes of relief and then the thought returns, stronger. She fears that having the thought means she might act on it. She will not lay this out in order, and she is watching to see whether you will recoil. You will not.
That is your patient. Now every move is made through Miss Delaney, warmly, without a flicker of alarm.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - One obsession, all the way through
Trigger. She hints at a distressing recurrent thought but cannot say it.
Decode, kept in your head. Take a single obsession fully before collecting others. You need its actual content, gently drawn out.
The move. Ask about the one that troubles her most, and receive it without reaction.
Tell me about one of these thoughts, the one that troubles you most. What exactly goes through your mind. Take your time, there is nothing you can say that will shock me.
Check. Content of one obsession obtained. Now test it. Move on.
4.2 - The four tests, mine, repeated, resisted, hated
Trigger. She has described a thought.
Decode, kept in your head. An obsession is her own, recurrent, resisted, and distressing and senseless to her, ego dystonic. Four tests, four short questions.
The move. Run the four in order.
Does the thought feel like it comes from your own mind. Does it keep coming back even when you do not want it. Do you try to push it away or fight it. And how does it make you feel, does it feel like you, or completely unlike you.
Check. Mine, repeated, resisted, hated. The four tests passed, so this is an obsession. Move on.
4.3 - The single most important question, ownership versus insertion
Trigger. You have an obsession that looks classic. You must still exclude psychosis.
Decode, kept in your head. This one question separates obsessive compulsive disorder from a psychotic illness. Her own thought is an obsession. A thought put there from outside is thought insertion.
The move. Ask it explicitly, and let the answer decide which station you are in.
This is important. Do these thoughts feel like your own thoughts, even though you hate them. Or does it feel as though someone or something is putting them into your head.
Check. Her own, hated, is an obsession. Put there is thought insertion and a different station entirely. This is the pivotal exclusion. Move on.
4.4 - The four forms an obsession takes
Trigger. She has described obsessional thoughts. Candidates stop there and miss the other three forms.
Decode, kept in your head. Obsessions come as thoughts, images, impulses and doubts. The obsessional impulse, an urge to do something she would never want to do, is often the most frightening and the most misread as risk.
The move. Ask about images, impulses and doubt, one at a time.
Does it ever come as a picture in your mind rather than words. Do you ever get a sudden urge to do something you would never actually want to do. And do you find yourself doubting things you know you have already done.
Check. Image, impulse and doubt covered. Note the impulse is ego dystonic, not intent. Move on.
4.5 - Overt compulsions, then the mental ones, asked twice
Trigger. She mentions washing or checking.
Decode, kept in your head. Compulsions are overt, washing, checking, ordering, or covert, silent counting, repeating a word or prayer, cancelling the thought. The covert ones are the commonest thing missed. Ask a second time.
The move. Ask the visible acts, then ask again, specifically, about the ones inside her head.
What do you find yourself having to do afterwards, washing, checking, ordering, counting. And, separately, is there anything you do inside your head, counting silently, repeating a word, going back over it, cancelling it out.
Check. Overt and, crucially, mental compulsions both elicited. The second question is where the mark hides. Move on.
4.6 - Showing the loop
Trigger. She performs the act and gets brief relief.
Decode, kept in your head. Do not just record the behaviour, demonstrate the maintaining loop, resisting raises anxiety, the compulsion relieves it only transiently, and each repetition strengthens the obsession.
The move. Ask what happens if she resists, and how long the relief lasts.
What would happen if you did not do it. And once you have done it, how long does the relief last before the thought comes back.
Check. Anxiety on resistance, transient relief, the thought returning. The loop is shown, not just listed. Move on.
4.7 - Measuring severity, and grading insight
Trigger. You have the phenomena. Now quantify them.
Decode, kept in your head. Severity is measured on four axes, time, interference, resistance and control. Insight is graded good, poor or absent, and it changes management.
The move. Ask hours a day, the impact on life, and whether she sees the thoughts as excessive.
Roughly how many hours a day do all of these take up. How much is it getting in the way of work, family, ordinary life. And in yourself, do you feel these thoughts and rituals are excessive or unreasonable.
Check. Time, interference, resistance, control measured, insight graded. Move on.
4.8 - Screening the comorbid depression and risk
Trigger. She is worn down and ashamed.
Decode, kept in your head. About a third have comorbid depression, so screen mood and suicide. And be clear, harm obsessions are ego dystonic and are not an indicator of risk to others.
The move. Screen mood and suicide gently, and reassure her, silently to yourself, that the harm thought is not intent.
Living with this must be exhausting. How has your mood been through it. Have you ever felt so low or worn down that life did not feel worth living.
Check. Depression and suicide screened. The harm obsession is not risk to others, note that in your head. Move on.
When it is NOT obsessive compulsive disorder. The comparators.
Half the marks are in what the ritual or the thought actually belongs to. Say the alternative out loud.
5.1 - Thought insertion, the psychotic mimic
If the thought is experienced as not her own, put into her head by an external force, it is thought insertion, and you are in a psychosis station, not obsessive compulsive disorder. Ownership is the single dividing line. Never collect compulsions without asking whether the thought is her own, or you will misclassify a psychotic illness as OCD.
5.2 - Anankastic personality traits
Lifelong orderliness, perfectionism and checking that the person values and resists with little effort are obsessional personality traits, not OCD. Traits are ego syntonic, valued, and enduring. OCD is ego dystonic, hated, and episodic. The test is distress and resistance, not tidiness. A man who checks the door but shrugs it off easily has a trait, not the disorder.
5.3 - Eating disorder rituals
Cutting, mashing, separating food and counting calories look identical to compulsions but are driven by a different engine, an overvalued idea about shape and weight, which the person wants. Purging relieves guilt the way a compulsion relieves anxiety, but the outcome is desired. Ask what the ritual is for. If the answer is thinness, it is an eating disorder, not OCD.
5.4 - PTSD intrusions
Vivid, distressing images of a real traumatic event that intrude and cannot be dislodged are trauma intrusions, not obsessions. They are memory-based and tied to what actually happened, whereas an obsession is a senseless thought against the person's values. Anchor an intrusion to a real event and a trauma history, and it belongs to PTSD.
Check. Name what else the thought or ritual might be, not only the obsession. Ownership and the engine are the tests. That is the mark.
The close
Close in five small movements. Name it kindly, never shame her.
One. Thank them.
Thank you for telling me thoughts you have carried in shame for so long. That took real courage.
Two. Name it, and normalise it, in her words.
What you are describing has a name, and it is common. The thoughts you hate are the opposite of what you actually want, which is exactly why they torment you, and it means you are the last person who would ever act on them.
Three. Explain the loop, and leave hope.
The washing and the counting work for a few minutes, then the thought comes back stronger, and that is the trap. It is treatable, with a specific talking therapy and, if you wish, medication.
Four. Invite.
Is there anything you would like to ask me, or anything I have not understood.
Five. Signpost. To the patient, the next step and real hope. To the examiner, in your head, the ego dystonic obsessions, the exclusion of thought insertion, the overt and mental compulsions, the severity and insight, and the comorbid mood risk.
The two habits, again
Carry these two out of the room.
One. Open wide and normalise, then take one thought all the way through. Without the shame-lifting opening she will not give you the content, and you cannot pass without it. Follow one obsession from content to compulsion before collecting more.
Two. Never the label in the room, and always ask twice. Ask whether the thought is her own, because that one question decides OCD versus psychosis, and always ask a second time about the mental compulsions. An obsession is her own thought, repeated, resisted and hated, that is the whole test.
Do those two things and this drill is yours.
Eliciting Overvalued Ideas
Before we begin
Welcome. This is the eighth elicitation drill, on the overvalued idea, the belief that sits between a delusion and an obsession and is one of the three discriminations that separate a pass from a good pass.
An overvalued idea is an acceptable, comprehensible idea, pursued beyond the bounds of reason, that comes to dominate the person's life. It is not held with the fixed, unshakeable certainty of a delusion, and it is not the senseless, resisted, ego dystonic intruder of an obsession. It is a passionately held conviction, understandable in the light of the person's personality and history, that they own and defend but can, if gently pressed, concede a sliver of doubt about. The trap is that the belief may sound extraordinary, and a nervous candidate calls it a delusion. Falsity is not the test. The logic of how the person arrived at the belief is the test.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then place the belief on the spectrum. Draw out the belief and what it has cost, then probe the three axes, conviction, ownership and resistance, that locate it between delusion and obsession.
Two. Never the label in the room, and gently test, never argue. Do not name it to the patient. Offer the possibility of doubt once, warmly, and watch whether it bends. Do not push past a single gentle test.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a mental state examination of a patient with a strongly held, dominating belief. Characterise the belief and decide whether it is a delusion, an overvalued idea or an obsession. You are in a clinic. You have around ninety seconds to a few minutes. An examiner sits silent in the corner. Do not challenge or argue with the belief, and do not name a diagnosis to the patient.
Here is the shape of it. Draw out the belief and its history, how it began and grew from something real or understandable in the person's life. Establish that it dominates and disturbs their functioning. Then run the three separators, is it their own preoccupation they defend, is it held with absolute certainty or does it bend a little, and is it welcomed and pursued or resisted and hated. And check for the extreme overvalued belief that could drive violence.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the single gentle test
You do not open by challenging the belief. You open by understanding how they came to it and what it has cost them.
Say something like this.
I can see this matters enormously to you. Tell me how it began, how you came to be sure of it, and how it has affected your life.
Then, once you have the belief and its history, you apply the single most important move, the one gentle test of conviction, offered once.
Is there any part of you that ever wonders whether there might be another explanation. If someone you trusted told you they saw it differently, what would you think.
A delusion stays fixed regardless. An overvalued idea bends, just a little, and concedes the possibility. You never push past that one gentle test into an argument, because arguing hardens the belief and loses the mark.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Mrs Ashworth. She is intense, articulate, and utterly consumed by a single conviction that has taken over her life.
The belief grew out of something real or understandable, a slight, a health scare, a relationship, and over time it has hardened into a cause she pursues beyond all reason, writing letters, keeping files, letting work and relationships fall away. She holds it with great passion and defends it fiercely, yet it is unmistakably her own idea, one she owns and champions rather than one she fights. Pressed very gently, she will allow, grudgingly, that she cannot be completely certain, a chink a true delusion would not show. She will not lay this out in order, and she will test whether you are on her side.
That is your patient. Now every move is made through Mrs Ashworth, understanding, never arguing.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - The content and the dominating preoccupation
Trigger. A single belief that has taken over her life.
Decode, kept in your head. An overvalued idea is a solitary abnormal belief that comes to dominate the person's thinking and disturb their functioning. First establish the content and its grip.
The move. Draw out the belief and how completely it fills her days.
Tell me about this in your own words. How much of your time and energy does it take up now. What has it cost you, in work, or in the people around you.
Check. Content and dominating preoccupation established. Move on.
4.2 - The logic of arrival, the real test
Trigger. The belief sounds extraordinary, and you are tempted to call it a delusion.
Decode, kept in your head. Falsity is not the test. What matters is how she reached it, understandable reasoning from a real seed, or a leap of false, illogical certainty out of nothing. A partner may truly have been unfaithful, the question is whether she got there reasonably.
The move. Trace the reasoning, step by step, from the seed to the conviction.
Walk me through how you came to be sure of this. What first made you think it. What convinced you, step by step.
Check. Understandable reasoning from a real seed leans overvalued. A sudden, illogical, fully formed certainty leans delusional. The logic of arrival is the mark. Move on.
4.3 - Understandable in personality and history
Trigger. The belief fits the person she has always been.
Decode, kept in your head. An overvalued idea is understandable in the context of personality and history, similar in quality to a passionate political, religious or ethical conviction. It grows from who she is.
The move. Ask about the personal and historical soil the belief grew in.
Has this connected to something in your own life, or something that happened to you. Would people who know you say this fits the kind of person you have always been, someone who feels strongly about things.
Check. Rooted in personality and history, understandable in that light. That coherence is characteristic of an overvalued idea. Move on.
4.4 - Conviction, the gentle test
Trigger. You need to know how fixed it is, without arguing.
Decode, kept in your head. A delusion is impervious to all counter-evidence. An overvalued idea, pressed gently, concedes a sliver of doubt. You test once, softly, and read whether it bends.
The move. Offer the possibility of another view, once, and watch.
Is there any part of you that ever wonders if it could be otherwise. If someone you trusted saw it differently, could you allow even a small chance that they had a point.
Check. Concedes a little doubt, overvalued. Impervious, delusional. One gentle test only, never an argument. Move on.
4.5 - Ownership and welcome, separating from obsession
Trigger. You must exclude an obsession as well as a delusion.
Decode, kept in your head. An obsession is senseless, resisted and hated, ego dystonic. An overvalued idea is welcomed, defended and pursued, ego syntonic. The overvalued patient champions the belief, the obsessional patient fights it.
The move. Ask whether she wants the belief gone, or wants the world to see she is right.
Do you wish these thoughts would leave you alone, that you could be rid of them. Or do you feel they are important and right, and that you want others to understand them.
Check. Wants to be rid of it, resisted, is an obsession. Champions and defends it is overvalued. That separates the two. Move on.
4.6 - The classic homes of the overvalued idea
Trigger. The theme of the belief points to its usual clinical home.
Decode, kept in your head. Overvalued ideas cluster in recognisable places, morbid jealousy, health preoccupation, a belief about a defect in appearance, a conviction of infestation, a querulous or litigious grievance, and the drive to thinness in an eating disorder.
The move. Recognise the theme and probe it in its own terms, silently placing it in its category.
Tell me more about the specific worry, whether it is about your partner, your health, your appearance, or a wrong you feel has been done to you.
Check. Theme identified and placed, jealousy, hypochondriacal, dysmorphic, infestation, querulous, or eating disorder. Move on.
4.7 - The extreme overvalued belief and violence risk
Trigger. The belief is shared or amplified within a group and has hardened toward action.
Decode, kept in your head. An extreme overvalued belief, shared in a cultural, religious or subcultural group, can become more refined and more resistant to challenge, and can drive violent behaviour. This is a scored risk consideration.
The move. Ask, without alarm, whether the belief has moved toward action, and whether others share and reinforce it.
Have your feelings about this ever made you think about acting on it. Are there others who share this conviction with you, who feel as strongly. Have you made any plans.
Check. Amplification, group reinforcement and any move toward action screened. The risk of the extreme overvalued belief is not optional. Move on.
4.8 - The functional and self-directed risk
Trigger. The belief has cost her work, relationships and health.
Decode, kept in your head. Overvalued ideas cause disturbed functioning to the person or to others. In a health or appearance theme the risk turns inward, neglect, repeated surgery, self-harm.
The move. Screen the impact on her own safety and the depth of despair the belief has brought.
Has all this ever driven you to harm yourself, or to neglect yourself, or to feel life was not worth living. How has it left you feeling in yourself.
Check. Self-directed risk and mood screened. Move on.
The three-way separation. Delusion, overvalued idea, obsession.
The whole drill is one discrimination. Say which of the three it is, out loud, to the examiner, and say why.
5.1 - Against the delusion
A delusion is a false judgement held with extraordinary conviction and subjective certainty, impervious to all counter-evidence, and arrived at through false logic. The overvalued idea shares the intensity but not the imperviousness, it bends a little when gently tested, and it was reached by understandable reasoning from a real seed. Conviction and the logic of arrival separate them, not how strange the belief sounds.
5.2 - Against the obsession
An obsession is a thought that persists and dominates against the person's will, recognised as senseless or excessive, resisted and hated, ego dystonic. The overvalued idea is welcomed and defended, ego syntonic, pursued rather than fought. Resistance and ownership of the wish separate them, does she want it gone, or does she want to be proved right.
5.3 - Against a normal strong conviction
Passionate political, religious or ethical convictions are normal, and a belief shared and arrived at the ordinary way within a person's community is not psychopathology at all. What lifts an overvalued idea above a strong conviction is that it is pursued beyond the bounds of reason and disturbs the person's or others' functioning. Without that dominating, life-disrupting quality, it is simply a strongly held view.
Check. Name which of the three it is, and the axis that decided it, conviction, resistance, or the logic of arrival. That is the mark.
The close
Close in five small movements. Never name the diagnosis, and never argue the belief.
One. Thank them, and honour the strength of feeling.
Thank you for helping me understand how much this means to you and how hard you have fought for it.
Two. Reflect it back, without endorsing or dismissing.
I can see this has taken over a great deal of your life, and that you hold it with real conviction, and I want to understand it properly rather than brush it aside.
Three. Offer a way forward that does not require her to surrender the belief.
I am not asking you to give this up today. I would like to help with the toll it has taken on you, your rest, your health, the people you have drifted from.
Four. Invite.
Is there anything you would like me to understand better, or anything you want to ask me.
Five. Signpost. To the patient, help framed around the cost, not the belief. To the examiner, in your head, that this is an overvalued idea rather than a delusion or obsession, the axis that decided it, and the risk, to herself and, in the extreme form, to others.
The two habits, again
Carry these two out of the room.
One. Open wide, then place the belief on the spectrum. Draw out the belief and its cost, trace how she arrived at it, and locate it by conviction, ownership and resistance between delusion and obsession.
Two. Never the label in the room, and gently test, never argue. One soft test of doubt, and read whether it bends. Falsity is not the test, the logic of arrival is. The belief is the scenery, the discrimination and the risk are the station.
Do those two things and this drill is yours.
The Cognitive Examination
Before we begin
Welcome. This is the ninth elicitation drill, on the cognitive examination. Testing the machinery of the mind, consciousness, orientation, attention, memory, language, praxis and the frontal functions, at the bedside, and knowing what a deficit means.
This drill is different from the psychopathology drills. Here you are giving tasks, not eliciting symptoms, and the whole thing rests on one rule, test the level of consciousness first, because if the sensorium is clouded, every later test is contaminated and the answer is delirium until proven otherwise. Clear consciousness is the only ground on which a memory or language deficit means dementia rather than an acute confusional state. Structure protects you, run the domains in a fixed order, out loud, and you cannot get lost.
Two habits carry every MSE drill. Keep them close.
One. Screen the base before the detail. Consciousness and attention first. A drifting, fluctuating level of alertness reframes everything that follows as an acute problem.
Two. Never shame the patient, and set every task up kindly. Check sensory impairment first, warn them the questions start easy and get harder, and frame it as tests everyone finds tricky, never as an exam they are failing.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Perform a cognitive examination on this patient, or examine a specific domain such as the frontal or parietal lobe. You are in a clinic or on a ward. You have around seven minutes. An examiner sits silent in the corner. Do not take a full history, and do not name a diagnosis to the patient.
Here is the shape of it. Consent, and check hearing and vision first. Level of consciousness and attention. Orientation in time, place and person. Registration, then attention and calculation, then delayed recall. Language, naming, repetition, comprehension, reading, writing. Visuospatial and praxis. Then, if asked, the frontal battery, which the standard bedside memory test does not cover. Present the pattern, and say what a clear or clouded sensorium makes of it.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the base check
You do not open by testing memory. You open by making it safe and by clearing the ground, sensory first, then the base of the pyramid, consciousness and attention.
Say something like this.
I would like to do some tests of memory and concentration. Some are easy and some are meant to be hard, so do not worry if you cannot do them all. First, can you see and hear me clearly.
Then, before anything else, judge the level of consciousness and test attention, because this decides how you read everything after it.
Can you tell me the months of the year backwards, starting with December. And take seven away from a hundred, and keep going.
A patient who drifts, whose alertness waxes and wanes, who cannot hold the thread of a simple sustained task, has a clouded sensorium, and that reframes the whole examination as an acute confusional picture rather than a chronic one.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Mr Ainsworth, an older man sent from a medical or memory service with a concern about his memory.
How he performs is the diagnosis. If he is alert and steady but cannot lay down new memories, forgetting the address you gave him minutes ago while recalling his childhood clearly, that is a cortical amnestic picture. If he drifts and fluctuates, better one moment and muddled the next, that is a clouded sensorium and an acute story. If he fills the gaps in his memory with confident, plausible, untrue accounts, that is confabulation. If he is slowed, says I do not know to everything, and is really low in mood, that is a depressive picture masquerading as dementia. You will not know which until you test, in order, and watch.
That is your patient. Now every task is set up kindly, and every result is read against the level of consciousness.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check. Fixed order protects you.
4.1 - Consciousness and attention, tested first
Trigger. Any cognitive complaint. This is always the first domain.
Decode, kept in your head. Consciousness is the base of the pyramid. Clouding, drowsiness or fluctuation means an acute confusional state, and every later test is unreliable. Attention is its bedside proxy.
The move. Observe alertness, then test sustained attention with a reversed sequence.
Can you tell me the months of the year backwards, starting with December. And spell the word world backwards for me.
Check. Steady and accurate is a clear sensorium. Drifting, fluctuating, unable to sustain, is clouding, and the picture is acute until proven otherwise. This gates everything. Move on.
4.2 - Orientation
Trigger. The base is established.
Decode, kept in your head. Orientation in time, place and person. Time goes first and most sensitively. Disorientation in a fluctuating patient is delirium, in a clear steady one points to established dementia.
The move. Ask time, then place, then person, gently.
Do you know what day and date it is, the month, the season, the year. Do you know where we are, what kind of building, what town. And can you tell me who I am, and your own full name.
Check. Orientation mapped in all three spheres. Move on.
4.3 - Registration and immediate memory
Trigger. You will test delayed recall later and must plant the seed now.
Decode, kept in your head. Registration, immediate encoding, must be intact before delayed recall means anything. If he cannot register, a later recall failure is an attention problem, not a memory one.
The move. Give three items, or a name and address, and have him repeat them immediately, then tell him you will ask again.
I am going to say three things and I would like you to remember them, apple, table, penny. Can you say them back to me now. Hold on to them, I will ask you again in a few minutes.
Check. Registration confirmed. Now the seed is planted for delayed recall. Move on.
4.4 - Delayed recall and the amnestic pattern
Trigger. A few minutes and other tasks have passed.
Decode, kept in your head. Anterograde amnesia, the failure to lay down new memories, with relatively preserved old and immediate memory, is the cortical amnestic signature. The contrast, past clear, today will not stick, is the diagnosis.
The move. Ask for the three items back, and probe recent autobiographical memory against remote.
Can you tell me those three things I asked you to remember. Can you tell me what you had for breakfast, and what happened yesterday. And tell me about where you grew up.
Check. New material lost while remote memory holds is anterograde amnesia. Note the pattern against the clear sensorium. Move on.
4.5 - Confabulation
Trigger. He answers a memory question fluently, confidently, and it is not true.
Decode, kept in your head. Confabulation, the honest filling of memory gaps with plausible but false accounts, points to an amnestic syndrome such as the alcohol-related one, not to lying. The tell is a different account each time.
The move. Ask about a recent event you can check, then ask again later and compare.
Can you tell me about coming into hospital, how you got here and what has happened since. Do not worry if it is hazy.
Check. A confident, detailed, shifting account of the same event is confabulation. It marks an organic amnestic syndrome, not dishonesty. Move on.
4.6 - Language
Trigger. You need to separate a language problem from a thought or memory problem.
Decode, kept in your head. Naming, repetition, comprehension, reading and writing. A dysphasia, intact thought carried on broken language, imitates both thought disorder and dementia, so test it directly.
The move. Name objects, repeat a phrase, follow a three-stage command, read and obey a written instruction, write a sentence.
What is this called, and this. Please repeat, no ifs, ands or buts. Take this paper in your right hand, fold it in half, and put it on the floor. Read this and do what it says. And write me a full sentence.
Check. Naming, repetition, comprehension, reading and writing mapped. A word-finding or grammatical breakdown with intact meaning is dysphasia, not thought disorder. Move on.
4.7 - Visuospatial and praxis
Trigger. Parietal and constructional function, and the neglect of one side after a stroke.
Decode, kept in your head. Copying, clock drawing and intersecting shapes test visuospatial and constructional ability. Omitting one side of a drawing suggests hemispatial neglect. Gerstmann's cluster, finger agnosia, left-right disorientation, dyscalculia and dysgraphia, localises to the dominant parietal lobe.
The move. Ask him to copy interlocking pentagons, draw a clock to a set time, and, if indicated, show fingers and name left and right.
Please copy this figure, these two overlapping shapes. Now draw me a clock face with all the numbers, and set the hands to ten past five. Show me your right index finger, and touch your left ear with your right hand.
Check. Constructional ability, neglect and the parietal cluster tested. A focal higher-function deficit on an intact base is what makes lobe testing meaningful. Move on.
4.8 - The frontal and executive battery
Trigger. A personality change, disinhibition or apathy, especially after a head injury, where the standard bedside test is silent, because it does not assess frontal function.
Decode, kept in your head. Verbal fluency, abstraction, response inhibition and set-shifting probe the frontal lobes. Perseveration, persisting with a response after the rule changes, is the classic frontal sign.
The move. Fluency, proverb or similarity, a go-no-go or alternating task, watching for perseveration.
Name as many words as you can beginning with the letter F in one minute. Tell me how an apple and a banana are alike. And copy this alternating pattern, then keep it going on your own.
Check. Fluency, abstraction and set-shifting tested, perseveration watched for. Remember the standard memory screen does not cover this, so a frontal picture needs its own battery. Move on.
Reading the pattern. The comparators.
The marks are in what the pattern of deficits means. Say the interpretation out loud, always against the level of consciousness.
5.1 - Delirium versus dementia
Delirium is acute, fluctuating, with clouded consciousness and impaired attention, on a physical trigger, and it is reversible. Dementia is gradual, in clear consciousness, progressive. The single discriminator you tested first, the sensorium, decides it. A confused patient who drifts and cannot hold attention is delirious until proven otherwise, whatever the memory score.
5.2 - Depressive pseudodementia
A depressed patient may present with memory failure, but the pattern differs, they say I do not know rather than confabulate, effort is poor and mood is low, attention is impaired by anxiety while other domains are intact, and imaging is normal. Do not diagnose dementia in a profoundly depressed patient. Treat the depression and retest, the cognition often recovers.
5.3 - The amnestic syndrome
A dense anterograde amnesia with confabulation, but relatively preserved attention, language and old skills, on a background of chronic alcohol and thiamine deficiency, is a specific amnestic syndrome, often preceded by an acute confusional, unsteady, eye-movement disturbance. The preserved domains are the contrast that makes the diagnosis. Ask about the preceding acute phase and the drinking.
5.4 - Dysphasia and the focal deficit
A breakdown in language with intact thought is dysphasia, not thought disorder or global dementia, and it points to a focal dominant-hemisphere lesion. A single lobe's deficit, parietal, frontal, temporal, sitting on an otherwise intact base, is focal, not diffuse. Localise it rather than calling the whole cognition impaired.
Check. Name what the pattern means, read against the sensorium you tested first. That is the mark.
The close
Close in five small movements. Never name a diagnosis to the patient, and never let them leave feeling they failed a test.
One. Thank them, and lift the shame.
Thank you, that was a real effort and you stuck with it. Those tests are designed to be hard, and nobody gets them all.
Two. Reflect it back gently, without the labels.
Some things came easily, and a few, particularly holding on to new information, were harder work today, and that is useful for me to understand.
Three. Reassure about the next step.
This is one part of a bigger picture. We will put it together with some other checks before anyone draws conclusions, and there is help whatever we find.
Four. Invite.
Is there anything about your memory or thinking that has been worrying you that we have not touched on.
Five. Signpost. To the patient, the plan in plain, hopeful words. To the examiner, in your head, the level of consciousness first, the pattern of deficits by domain, the localisation or the acute-versus-chronic verdict, and the reversible causes to exclude.
The two habits, again
Carry these two out of the room.
One. Screen the base before the detail. Consciousness and attention first, always. A clouded, fluctuating sensorium makes the whole picture acute and every later score unreliable. Then run the domains in a fixed order so you never get lost.
Two. Never shame the patient, and read the pattern against the sensorium. Set each task up kindly, and interpret every deficit in the light of the level of consciousness. The individual scores are the scenery, the pattern and the acute-versus-chronic verdict are the station.
Do those two things and this drill is yours.
Assessing Insight
Before we begin
Welcome. This is the tenth elicitation drill, on insight. Not a box you tick at the end of a mental state examination, but a ladder every patient is standing on, and your job in the room is to say which rung, and what follows from it.
There is one wrong way to do this, and it fails the station instantly. You ask a person who is certain of their belief whether they think they are mentally ill, they hear an accusation, and the door closes. The fix is always the same, normalise first, name the treatment before the illness, then ask what they make of it, and end by stating their position back to them so there is nothing to fight. And remember the counterweight, full insight and high risk can sit in the very same patient, so insight is never on its own a measure of safety.
Two habits carry every MSE drill. Keep them close.
One. Climb the ladder from the bottom, gently. Move up the rungs one question at a time, and pass past insight before present insight, because admitting a past illness is far easier and opens the door to now.
Two. Never make it an accusation, and turn it into a management item. Put other people's worry first, name treatment before the label, and always finish on the willingness-to-accept-help question, because that is where insight becomes a plan.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
As part of a mental state examination, assess this patient's insight, sensitively, and comment on what it means for their treatment and risk. You are in a clinic or a ward room. You have around ninety seconds to a few minutes. An examiner sits silent in the corner. Do not argue the belief, and do not name a diagnosis to the patient.
Here is the shape of it. Run the chain, an experience happens, does it feel alien or normal, how does the person explain it, does the explanation admit illness, does it admit treatment, does it admit this treatment, and what do they then do. Ask it as five escalating, humane questions. Then place them on a rung and say, out loud to the examiner, what follows for adherence, for capacity and for risk.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the sentence that disarms
You do not open by asking whether they are ill. You open by making the abnormality belong to a category, not to them.
Say something like this, the sentence that both books rely on.
Sometimes I see people who report very similar experiences to yours, and for some of them it turned out to be something the brain was producing because of an illness, one that we can treat. I am wondering what you make of that possibility in your own case.
Three things make that work. It puts other people first, so the abnormality is a category, not a confession. It names treatment before it names illness, so the offer arrives before the label. And it ends by inviting a view rather than demanding a defence. Then you climb, one gentle rung at a time.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Callum. He is guarded, articulate, and entirely certain that his experiences are real and that nothing is wrong with him.
To him the belief is not alien, it is a revelation, and his explanation is simply that it is true. He can repeat the name of an illness he has been told he has, but the word carries no belief behind it, so he sees no need for treatment and wants to leave. Pressed gently and without confrontation, he may concede he has been unwell in the past, a chink that is far easier for him than admitting it now, and that admission is your way in. He will become irritable if he feels accused, and he will open up if he feels understood. Acknowledging a problem, the neighbours, the stress, is not the same as insight.
That is your patient. Now every move is made through Callum, as an offer, never an accusation.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check. Climb the ladder.
4.1 - Rung one, does anything feel wrong
Trigger. He behaves as though nothing is amiss.
Decode, kept in your head. Rung one, he does not experience anything as abnormal. Acknowledging a problem out in the world, the neighbours, is not acknowledging an illness in himself.
The move. Ask, softly, whether he thinks there is anything odd or different about what he has been experiencing.
Do you think there is anything odd, or out of the ordinary, about what has been happening to you. Or does it all feel entirely normal and real to you.
Check. Nothing feels abnormal is rung one. Note whether he locates the problem in others rather than himself. Move on.
4.2 - Rung two, can he see why others worry
Trigger. People around him are alarmed, he is not.
Decode, kept in your head. Rung two asks him to comment on other people's concern, not to confess his own. It is the humane rung, and often the first he can reach.
The move. Ask whether he can understand why others are worried, without asking him to agree they are right.
I can see the people around you have been worried. Can you understand why they might feel that way, even if you do not share it. Do you think it is reasonable for them to be concerned.
Check. Can see others' concern, without owning it, is rung two. Move on.
4.3 - Rung three, could he be wrong
Trigger. He is certain, and you want to find the edge of that certainty.
Decode, kept in your head. Rung three offers the possibility of doubt, once, gently. Any give here is a foothold. Never argue past a single offer.
The move. Ask whether there is any possibility, however small, that he could be unwell or mistaken.
Is there any possibility, even a small one, that some of this could be caused by an illness rather than being exactly as it seems. Could there be another explanation.
Check. Concedes a possibility is rung three, holds absolute certainty is below it. One gentle offer only. Move on.
4.4 - Rung four, the past-insight door
Trigger. He resists the idea of being ill now.
Decode, kept in your head. Past insight is far easier to admit than present insight, and it is the sleeper move. Admitting a previous illness opens the door to the present one.
The move. Ask about any time before when he was unwell, and whether this could be similar.
Have you ever been unwell in this way before, at a time you could look back on now and see as an illness. Does any of what is happening now feel at all like that.
Check. Admits a past episode, a door to present insight. This is the rung candidates forget to try. Move on.
4.5 - Rung five, illness, treatment, this treatment
Trigger. He may accept he is unwell but reject the specific help.
Decode, kept in your head. Full insight has three parts, that he is ill, that it needs treatment, and that it needs this treatment. A patient can hold one or two and not the third, and each gap is a different management problem.
The move. Separate the three, does he think he is unwell, does he think it needs treatment, does he accept the treatment offered.
Do you feel you are unwell in a way that needs help. Do you think that help should include treatment. And how do you feel about the particular treatment we are suggesting.
Check. Illness, treatment, this treatment, graded separately. Name which of the three is missing. Move on.
4.6 - Turning insight into adherence
Trigger. He has an objection to the treatment itself, side effects, a bad past experience.
Decode, kept in your head. Insight work and adherence work are the same conversation. Naming his objection and addressing it directly is what converts partial insight into taking the treatment.
The move. Name the disagreement out loud before you give your view, then address his stated objection head on.
You and I see this differently, and that is all right. Tell me your worry about the treatment itself, and let me see whether we can meet it, because I would rather find something you can accept than press one you cannot.
Check. Objection named and addressed. Insight turned toward a workable plan. Move on.
4.7 - Insight and capacity
Trigger. A decision has to be made, about admission, medication, or a physical treatment.
Decode, kept in your head. Insight is not the same as capacity. A patient can lack insight and still, or not, be able to understand, retain, weigh and communicate a decision. Test the capacity separately.
The move. Explore whether he can take in the information, hold it, weigh it against his belief, and tell you a choice.
Can I check my explanation has landed. Can you tell me back, in your own words, what I have said, what you think would happen with treatment and without it, and what you would choose.
Check. Understanding, retention, weighing and communication assessed. Insight and capacity kept distinct. Move on.
4.8 - Insight and risk, the counterweight
Trigger. He may have good insight and still be at high risk, or poor insight that drives danger.
Decode, kept in your head. Full insight does not close a risk assessment, a person can understand their depression completely and still intend to act. And poor insight can itself be the risk, the belief that drives a dangerous act. Insight questions here are risk questions.
The move. Screen the risk regardless of the rung, and ask what the belief, or the despair, might drive.
Whatever we make of all this, I need to ask, has any of it made you think of harming yourself, or of acting against anyone. Have you taken any steps.
Check. Risk screened independent of insight. Good insight is not safety, poor insight can be the danger. Never skip this. Move on.
When it is NOT lack of insight. The comparators.
Half the marks are in not misreading a patient as lacking insight. Say the distinction out loud.
5.1 - Disagreement is not lack of insight
A patient who understands their illness and treatment but declines a particular medication for a considered reason, side effects, a past harm, a value, has insight and is exercising a choice. Rational disagreement, or a preference you would not share, is not an insight deficit. Do not pathologise a reasoned refusal into an absence of insight to justify overriding it.
5.2 - Full insight coexisting with high risk
A person can fully accept their depression, know it needs help, have sought it, and still be at grave and immediate risk, disappointed to have survived and intending to try again. Insight has produced action, and the action has not yet produced safety. Never let good insight lower your guard. Rung five does not close the risk assessment.
5.3 - Cultural or explanatory framing
A person may explain their distress through a spiritual, cultural or religious framework rather than a medical one, and still recognise they are suffering and want help. That is a different explanatory model, not necessarily absent insight. Ask what they and their family believe is happening and what would help, and work within it rather than scoring it as a deficit.
Check. Name when it is a choice, a risk, or a different frame, not an insight deficit. That is the mark.
The close
Close in five small movements. Never argue him down, never label him to his face.
One. Thank them, and honour the honesty.
Thank you for talking this through with me so openly, even where we see it differently.
Two. Name the disagreement plainly, without contest.
We do not see eye to eye on what is causing all this, and that is all right. I am not trying to win an argument with you.
Three. Offer help framed around what he wants.
What I would like is to help with the things that are making your life hard right now, the sleeplessness, the fear, the strain with the people around you, whatever we call the cause.
Four. Invite.
Is there anything you would like to ask me, or anything you feel I have not understood.
Five. Signpost. To the patient, help on his terms and the door left open. To the examiner, in your head, the rung, what follows for adherence and capacity, and, always, the risk regardless of the rung.
The two habits, again
Carry these two out of the room.
One. Climb the ladder from the bottom, gently. One rung at a time, and reach for past insight before present insight, because it is the easier admission and the open door.
Two. Never make it an accusation, and turn it into a management item. Others' worry first, treatment before the label, and finish on willingness to accept help. Say which rung, and screen the risk anyway. The belief is the scenery, the rung and the risk are the station.
Do those two things and this drill is yours.
Eliciting Motor & Drug-Induced Signs
Before we begin
Welcome. This is the eleventh elicitation drill, on motor, behavioural and drug-induced signs. Restlessness, abnormal movements, stillness and posturing, and the crucial work of telling an inner urge from a drug effect, from anxiety, from mania, and from catatonia.
This drill turns on one question that sorts four different diagnoses, is there a feeling inside that makes you move, and can you sit still if you try. An irresistible urge in the legs is akathisia, and the antipsychotic must come down. Energy with a mission is mania, and treatment must go up. Dread with a content is anxiety. Nothing the patient notices at all, seen only by the family, is tardive dyskinesia. The stakes are real, get it wrong and you increase the very drug that is harming him. And with a still, posturing patient, you look at the movement before you listen to the speech, because catatonia hides in plain sight.
Two habits carry every MSE drill. Keep them close.
One. Ask what it feels like from the inside, and watch from the outside. The inner sensation, an urge, a dread, a mission, or nothing, is what separates the four. Pair it with what you observe, and where in the body it sits.
Two. Name the sign to the examiner, and let the timeline decide. Relate every movement to the medication, when it started, when it worsens, so the sign points to the right action, not the wrong one.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Assess this patient's abnormal movements or restlessness, or examine for drug-induced side effects, and advise on what it means. You are in a clinic, an emergency department, or a ward. You have around seven minutes. An examiner sits silent in the corner. Do not name a diagnosis to the patient in jargon.
Here is the shape of it. Address any concern first, gain consent, observe at rest. Ask the inner-sensation question that separates the four causes of restlessness. Locate the movement in the body and relate it to the drug and its timeline. For a still or posturing patient, run the catatonia screen, decreased motor, increased or abnormal motor, abnormal interaction, and tone. Then say the sign, and the action it dictates, to the examiner.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the one question
You do not open by naming a side effect. You open by addressing his distress and then asking the single question that does most of the work.
Say something like this.
Thank you for seeing me. I gather you have been feeling shaky, or restless, or not quite yourself. Before I examine anything, tell me what it is like from the inside.
Then the question that sorts four diagnoses at once.
Is there a feeling inside you that makes you have to move. And if you try, can you sit completely still, or is that almost unbearable.
An irresistible inner urge, worst when made to stand still, is akathisia. A driven energy with a purpose is mania. A fearful dread attached to a thought is anxiety. And if he is puzzled because he feels nothing and it is his family who noticed, you are looking at tardive dyskinesia.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Mr Okafor, a young man on an antipsychotic, sent because he is shaky, stiff, and cannot keep still.
His restlessness sits mainly in his legs, an inner drive he cannot resist, at its worst when he has to stand and wait, and it came on within weeks of a change to his medication. But the room can deceive you. The same story could be a driven manic overactivity on no antipsychotic at all, or an anxious agitation of the hands and face with dread behind it, or, in an older long-treated patient, small orofacial movements he does not even notice while his family do. And a different patient again may sit mute and still, holding an odd posture, which is not calm but catatonia. You will not know which until you ask the inner-sensation question and place it on the timeline.
That is your patient. Now every move is made through Mr Okafor, inside sensation and outside sign together.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Akathisia
Trigger. He cannot keep still, an urge mainly in the legs, worse when forced to stand and wait.
Decode, kept in your head. Akathisia, a drug-induced inner restlessness, coming on hours to weeks after starting or increasing an antipsychotic. The inner urge is the defining feature, not the visible fidget.
The move. Confirm the inner urge and its site, then tie it to the medication change and to standing still.
Is the feeling that drives you to move mostly in your legs. Is it worst when you have to stand still, like queueing. And did it begin around the time your medication was started or the dose went up.
Check. Inner urge, in the legs, worse standing still, dated to the drug, is akathisia. The action is to reduce or switch the antipsychotic, add propranolol, never an anticholinergic. Move on.
4.2 - Manic overactivity
Trigger. He is on the move, but going somewhere, with purpose and pressured speech, on no antipsychotic.
Decode, kept in your head. Manic overactivity is goal-directed, whole-body, driven by energy and a mission, not by an inner urge to move for its own sake. It settles if you listen and escalates if you challenge.
The move. Ask what he is trying to do, and read the mood and the speech around the movement.
What are you trying to do right now, where are you heading. And how are you feeling in yourself, is your energy up, are your thoughts racing.
Check. Goal-directed, whole-body, with elevated mood and pressured speech, no antipsychotic, is manic overactivity. The action is to treat the psychosis, not to add an anticholinergic. Move on.
4.3 - Anxiety and agitation
Trigger. Fidgeting hands, hand-wringing, face-stroking, with dread behind it.
Decode, kept in your head. Anxious agitation is worry with a content, the thought comes before the movement, and it sits in the hands and face, not an urge in the legs. Often no antipsychotic, or one that predates the movement.
The move. Ask what he is afraid will happen, and notice the movement follows the fear.
When you feel like this, is there something you are afraid is going to happen. Does a worried thought come first, and then the restlessness follow it.
Check. A fear with a content, movement following the thought, in the hands and face, is anxiety. The action is to treat the anxiety, and not to add an antipsychotic to it. Move on.
4.4 - Tardive dyskinesia
Trigger. Lip-smacking, tongue movements, choreiform movements, and he is unaware, the family noticed.
Decode, kept in your head. Tardive dyskinesia, orofacial first, emerging after months to years of antipsychotic exposure, often worsening when the dose is reduced, and typically not felt by the patient.
The move. Ask, because it is not observed by him, whether his family have noticed movements of his mouth or tongue, and examine at rest, mouth empty.
Have your family said your mouth, tongue or face seems to move on its own, even when you are not aware of it. May I watch your mouth and hands for a moment while you sit.
Check. Orofacial movements, unnoticed by him, after long exposure, is tardive dyskinesia. The action is to review the need for the antipsychotic, and anticholinergics can make it worse. Move on.
4.5 - Pseudoparkinsonism and acute dystonia
Trigger. Tremor, stiffness, slowness and a mask-like face, or a sudden sustained muscular spasm.
Decode, kept in your head. Drug-induced parkinsonism, tremor, rigidity, bradykinesia and a festinant gait, and acute dystonia, a sudden painful contraction such as a neck twist or an eye roll. Both are extrapyramidal, dystonia is an emergency.
The move. Ask about slowness, stiffness and shakiness, and examine tone, gait and face; for dystonia, recognise the acute sustained spasm.
Have you noticed slowness, stiffness or a tremor. Any sudden, painful tightening or twisting of your neck, eyes or jaw that you cannot control.
Check. Tremor, rigidity and bradykinesia is parkinsonism, a sustained acute spasm is dystonia. Dystonia needs an anticholinergic now. Move on.
4.6 - Catatonia, look at the movement first
Trigger. A still, mute patient holding an odd posture, or, conversely, purposeless overactivity and grimacing.
Decode, kept in your head. Catatonia. Look at the movement before you listen to the speech. It has a decreased-motor pole, stupor, mutism, posturing, staring, and an increased or abnormal pole, purposeless overactivity, grimacing, stereotypies, mannerisms.
The move. Observe first, then screen both poles.
I am going to watch you for a moment, is that all right. Are you able to speak to me. Can you tell me why you are holding your arm like that.
Check. Decreased motor with posturing and mutism, or increased purposeless motor, is catatonia. Screen both poles. Move on.
4.7 - The catatonic interaction signs and tone
Trigger. You suspect catatonia and must confirm the interaction signs.
Decode, kept in your head. The interaction abnormalities, negativism, echolalia, echopraxia, automatic obedience, and, on examination, waxy flexibility, clinch the picture. A lorazepam challenge is diagnostic and therapeutic.
The move. Test gently for echo phenomena, negativism and tone, and note if a benzodiazepine would both confirm and relieve it.
I am going to move your arm gently, tell me if it hurts. Repeat after me if you can. I will raise your hand and see whether it stays where I place it.
Check. Negativism, echo phenomena, automatic obedience or waxy flexibility confirm catatonia. Consider the lorazepam challenge. Move on.
4.8 - Malignant catatonia, the emergency
Trigger. Catatonia with fever, rigidity, and unstable pulse and blood pressure.
Decode, kept in your head. Malignant catatonia, an autonomic emergency overlapping with the drug-induced neuroleptic syndrome, needing urgent physical care and often electroconvulsive therapy. Rigidity and fever change everything.
The move. Check temperature and autonomic stability, and escalate; screen the muscle enzyme, hydration and clot risk.
Let me check your temperature, pulse and blood pressure. Have you had a fever, or felt your heart racing. This needs urgent physical attention as well as psychiatric.
Check. Fever, rigidity and autonomic instability signal malignant catatonia, a medical emergency. Enzymes, fluids, clot prophylaxis, urgent treatment. Move on.
The one question, four answers. The comparators.
The whole drill is one discrimination, made by the inner sensation. Say the answer, and the action it dictates, out loud.
5.1 - Akathisia versus anxiety
Both look restless. Akathisia is a bodily urge to move, mainly in the legs, with no fearful thought behind it, worst when made to stand still, and driven by the antipsychotic. Anxiety is a fear with a content, the worried thought comes first and the fidgeting follows, in the hands and face. The separating question is whether the drive is a physical urge or a dread. Wrong here, you increase a drug that is harming him.
5.2 - Akathisia versus manic overactivity
Akathisia is aimless, an urge to move for its own sake, and the patient wishes it would stop. Manic overactivity is goal-directed, going somewhere with purpose, and the patient is enjoying the energy. Ask what they are trying to do. Nothing, just cannot keep still, is akathisia and the drug comes down. A mission, and the drug goes up. Opposite actions from a similar look.
5.3 - Agitated depression, not a drug effect
A depressed patient may be still and retarded in the voice yet wring the hands or stroke the face, an agitated retarded depression driven by guilt and dread, not by an inner urge to move. Do not mistake this for akathisia and stop the antidepressant, which is exactly the wrong move. Comment on both signs, retardation with superimposed agitation, and treat the depression.
5.4 - Tardive dyskinesia, the unfelt sign
Tardive dyskinesia is the one the patient does not feel, orofacial movements the family notice, emerging after long exposure and often worse on dose reduction, disappearing in sleep. It is not akathisia, which is felt as an urge, and not a functional movement. Ask the family, examine at rest, and review the antipsychotic rather than reaching for an anticholinergic.
Check. Name the inner sensation, the sign, and the action it dictates. That is the mark, and the safety of the patient.
The close
Close in five small movements. Explain in plain words, never in jargon.
One. Thank them.
Thank you for describing this so clearly, and for letting me examine you. That helps me understand exactly what is happening.
Two. Name it plainly, without the label.
What you are feeling is very likely a side effect of the medication, that inner restlessness, and it is something we can put right by adjusting things, not something you have to endure.
Three. Reassure, and act.
This is treatable and often quickly. I would change the medication rather than add to it, and I will not leave you uncomfortable.
Four. Invite.
Is there anything you would like to ask me about the movements or the medicines.
Five. Signpost. To the patient, the adjustment and the follow-up. To the examiner, in your head, the named sign, its relation to the drug and timeline, and the action it dictates, up, down, switch, or emergency.
The two habits, again
Carry these two out of the room.
One. Ask what it feels like from the inside, and watch from the outside. The inner sensation, urge, dread, mission, or nothing, sorts the four causes of restlessness. Pair it with what you see and where it sits in the body.
Two. Name the sign to the examiner, and let the timeline decide. Relate every movement to the medication and its timeline, so the sign points to the right action. And with a still, posturing patient, look at the movement before you listen to the speech. The look is the scenery, the inner sensation and the action are the station.
Do those two things and this drill is yours.
Eliciting Somatic & Bodily Preoccupation
Before we begin
Welcome. This is the twelfth elicitation drill, on somatic and bodily preoccupation. Health anxiety, the fear of a serious illness, preoccupation with a defect in appearance, and the burden of physical symptoms that persist when the tests are normal.
This is belief intensity again, on a body theme, so the delusion, overvalued idea and normal-worry spectrum runs straight through it. Two things carry the station. First, the single thing that fails candidates, never let the patient leave thinking you have said the symptom or the feeling is not real, because the distress is real whatever its cause. Second, the safety-net structure that works across every version, normalise first, define the problem, then ask whether it has taken over the life. And the belief here is usually overvalued, held with a sliver of doubt, not a fixed delusion.
Two habits carry every MSE drill. Keep them close.
One. Open wide and normalise, then locate the belief on the spectrum. Draw out the worry in their words, then gauge conviction and doubt to place it between a normal worry, an overvalued idea, and a delusion.
Two. Never say it is not real, and always ask the impact. Validate the reality of the distress, and turn every strand toward how much of the life is now organised around it.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Assess this patient's health-related worry, bodily preoccupation, or concern about their appearance, and characterise it. You are in a clinic. You have around seven minutes. An examiner sits silent in the corner. Do not dismiss the symptom, and do not name a diagnosis in a way that implies it is imaginary.
Here is the shape of it. Normalise and draw out the preoccupation. Find the bodily misinterpretation, the ordinary sensation read as danger. Cover the checking and reassurance-seeking, or the avoidance. Establish that it persists after normal results, which is the hallmark. Measure the impairment and screen the mood. Then place the belief, usually overvalued, and screen the risk, self-neglect, repeated surgery, and suicide, especially where the theme is appearance.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the validation
You do not open by suggesting it is anxiety. You open by taking the distress seriously and drawing out the worry.
Say something like this.
I can see this has been frightening and exhausting for you, and I want to understand it properly. Tell me, in your own words, what you have been worried about with your health, or your body.
Then, throughout, hold to the one line that keeps the station open.
I want to be clear about one thing. I believe the distress you feel is completely real. Whatever we find is causing it, I am not going to tell you it is all in your mind.
Without that validation the patient stops trusting you, and the assessment ends. The reality of the suffering is never in question, only its cause.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Mrs Gresham, and she arrives with a thick file of normal test results and a fear that will not be soothed by any of them.
She worries, constantly, that she has or will get a serious illness. An ordinary bodily sensation, a flutter, an ache, a mark, is read as evidence of catastrophe. She checks her body, seeks reassurance, and has been through doctor after doctor and test after test, and each normal result calms her for only a day or two before the fear returns. Her life has narrowed around it. Pressed very gently, she can concede a small possibility she is mistaken, which places the belief as overvalued rather than fixed. A different patient with the same engine might instead be consumed by a defect in appearance, mirror-checking and avoiding being seen. She will not lay this out in order, and she is watching to see whether you, too, will dismiss her.
That is your patient. Now every move is made through Mrs Gresham, validating first, never dismissing.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - The preoccupation
Trigger. She is consumed by a fear about her health or her body.
Decode, kept in your head. The core is a persistent preoccupation with having or acquiring a serious illness, or with a perceived bodily defect. Establish its content and its grip.
The move. Ask what the worry is and how much of her thinking it occupies.
Do you worry a great deal that you have, or will get, a serious illness. How much of your day is taken up with this worry.
Check. Preoccupation and its content established. Move on.
4.2 - The bodily misinterpretation
Trigger. An ordinary sensation is read as a sign of disease.
Decode, kept in your head. The mechanism, the alarm system misreading normal bodily sensations as dangerous. Finding the misinterpretation is what explains the whole condition to her later.
The move. Ask what convinces her, and which sensations she reads as dangerous.
What is it that convinces you something is wrong. Are there particular feelings or sensations in your body that you read as a warning of something serious.
Check. The bodily misinterpretation identified. Move on.
4.3 - Checking, reassurance, or avoidance
Trigger. She examines herself, seeks reassurance, or avoids doctors entirely.
Decode, kept in your head. The behaviours split two ways, the checking and reassurance-seeking that briefly soothe, or the avoidance of tests and doctors that briefly spares the fear. Both maintain it.
The move. Ask about body-checking, reassurance-seeking, and avoidance.
Do you find yourself checking your body, or asking others, or looking things up, for reassurance. Or do you avoid doctors and tests altogether because it is too frightening.
Check. Checking, reassurance-seeking or avoidance mapped. Move on.
4.4 - Persistence after reassurance, the hallmark
Trigger. Normal results calm her only briefly.
Decode, kept in your head. The defining feature, the worry returns despite normal investigations, and the relief after a normal result is short-lived. This is what separates it from a reasonable concern.
The move. Ask directly whether the fear comes back after normal results, and how long the relief lasts.
When your tests come back clear, does the worry settle for good, or does it come creeping back. How long does the relief usually last.
Check. Persistence after reassurance, with only transient relief, confirmed. This is the hallmark. Move on.
4.5 - Testing the conviction
Trigger. You must place the belief on the spectrum.
Decode, kept in your head. Usually the belief is overvalued, held strongly but with a sliver of doubt, not a fixed hypochondriacal or nihilistic delusion where no doubt remains. The gentle test decides it.
The move. Offer the possibility she is mistaken, once, gently, and read whether it bends.
Is there any part of you, even a small part, that can allow it might be the worry playing tricks rather than a real disease. If the specialist were sure, could you hold that alongside your fear.
Check. Concedes a little doubt is overvalued, health anxiety. No doubt at all, a fixed conviction of disease or of the body rotting, leans delusional. Move on.
4.6 - The appearance variant
Trigger. The preoccupation is with a defect in appearance rather than an illness.
Decode, kept in your head. The same engine on a different target, a fixation on a feature the mind magnifies, with mirror-checking, camouflage, comparing, reassurance-seeking and avoidance, and a real risk of do-it-yourself or repeated cosmetic surgery.
The move. Ask about the feature, the checking, the camouflaging, and the pursuit of surgery, and cross-check eating and weight.
Is there a part of your appearance you feel is wrong or ugly, that others do not see the way you do. Do you check it in mirrors, hide it, or seek surgery for it. And what part does eating and weight play for you.
Check. Appearance preoccupation with checking and surgery-seeking, and eating cross-checked. Overvalued if she accepts others may not see it. Move on.
4.7 - Impairment and mood
Trigger. The worry has organised her life, and worn her down.
Decode, kept in your head. The functional cost and the comorbid depression, which is common and carries the risk.
The move. Ask what the preoccupation has cost her, and screen the mood.
How much of your life is now organised around this. What has it stopped you doing. And how has your mood been, living with this fear.
Check. Impairment and mood mapped. Move on.
4.8 - The risk
Trigger. The despair of the fear, or, in the appearance variant, the drive to alter the body.
Decode, kept in your head. Screen self-neglect, repeated or self-performed surgery in the appearance variant, and suicide, which the appearance preoccupation particularly carries.
The move. Screen self-directed risk and suicide gently.
Has this ever driven you to harm yourself, or to try to fix things in a way that could hurt you. Has it ever got so bad that you did not want to be here.
Check. Self-harm, self-surgery and suicide screened. Never optional in the appearance variant. Move on.
When it is something else. The comparators.
Half the marks are in what the preoccupation actually is. Say the distinction out loud, and never call the symptom unreal.
5.1 - Proportionate concern in real illness
A person with a genuine, serious physical illness may be understandably preoccupied with it, and that is proportionate concern, not health anxiety. The test is whether the worry is out of keeping with the actual medical situation and persists against clear evidence. Do not pathologise appropriate worry in someone who is truly ill, declare the physical findings and take them seriously.
5.2 - The hypochondriacal or nihilistic delusion
Where the belief is held with fixed, unshakeable certainty and no doubt, that the body is rotting, that an organ has died, that they are already effectively dead, it is a delusion, often within a severe depression, not health anxiety. The discriminator is conviction, no chink of doubt, and the mood-congruent, nihilistic quality. That carries a high suicide risk and is a different station.
5.3 - Bodily distress and unexplained symptoms
Where the burden is the physical symptoms themselves, real, distressing, and persisting when tests are normal, rather than a belief about disease, it is a bodily distress picture, not primarily a belief problem. Here the error is ignoring the symptom. Take the symptom itself seriously, ask what it stops her doing, and never imply it is invented.
5.4 - Functional neurological symptoms and idioms of distress
Non-epileptic seizures and other functional symptoms are genuine and involuntary, and the one thing that fails you is any hint she is putting it on. And a physical complaint may be a cultural idiom of distress, a way of expressing emotional pain, not psychopathology. Ask what the patient and family believe is causing it and what should be done, and never suggest the symptom is feigned.
Check. Name what else it is, and never call the symptom or the distress unreal. That single failure ends the station. That is the mark.
The close
Close in five small movements. Never say it is not real, never name jargon that shames.
One. Thank them, and validate.
Thank you for trusting me with this. I want to say again, the fear and the distress you feel are real, and I take them seriously.
Two. Explain the mechanism, in her words.
What seems to be happening is that your body makes ordinary sensations, as everyone's does, and the alarm system reads them as danger, so you check, or ask, or avoid, and the relief never lasts. That is why the tests keep coming back clear and you keep feeling frightened.
Three. Offer help, and leave hope.
This is treatable. A talking therapy shaped for exactly this helps a great deal, and where the anxiety is severe, medication can help too. And we can agree a plan around tests that protects you rather than feeds the fear.
Four. Invite.
Is there anything you would like to ask me, or anything I have not understood.
Five. Signpost. To the patient, help and a sensible plan around reassurance. To the examiner, in your head, the overvalued belief on a body theme, the exclusion of a delusion and of proportionate concern, and the risk, self-neglect, surgery and suicide.
The two habits, again
Carry these two out of the room.
One. Open wide and normalise, then locate the belief on the spectrum. Draw out the worry, find the bodily misinterpretation, and gauge the doubt to place it between normal worry, overvalued idea, and delusion.
Two. Never say it is not real, and always ask the impact. Validate the distress, or the station ends, and turn every strand toward how much of the life it has taken. The symptom is the scenery, the belief and its cost are the station.
Do those two things and this drill is yours.
Eliciting Eating Psychopathology
Before we begin
Welcome. This is the thirteenth elicitation drill, on eating psychopathology. Drawing out the beliefs and behaviours of an eating disorder, gently, from someone who often does not want to be found, and who may not believe she is unwell at all.
This drill needs the most care of any in the set. The engine is an overvalued idea, that weight and shape are the true measure of her worth, so central to who she is that she may perceive a dangerously low weight as normal. Two rules protect you and her. First, you never trade in numbers, no target weights, no calorie figures, no threshold hers to aim for, because the illness turns any number into a goal, and you must not become its ally. Second, you never imply this is a choice, a phase, or attention-seeking. You elicit the meaning and the behaviours and the physical danger, warmly, and you screen the risk without ever colluding with the drive to thinness.
Two habits carry every MSE drill. Keep them close.
One. Open wide and without judgement, then elicit the meaning behind the behaviour. Draw out what eating and weight mean to her, because the overvalued idea, not the number on a scale, is the illness.
Two. Never bargain over numbers, and never collude. Keep figures and targets out of the room, do not reassure her she looks fine, and frame the physical checks as care for her body, never as a threshold to beat.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Assess this patient for an eating disorder. Elicit the eating psychopathology and the associated behaviours, and consider the physical risk. You are in a clinic or on a medical ward. You have around seven minutes. An examiner sits silent in the corner. Do not name a diagnosis in a shaming way, and do not conduct a physical examination unless asked.
Here is the shape of it. Open warmly and without judgement. Elicit the overvalued idea of shape and weight, and what it means to her. Draw out the restricting and compensatory behaviours, and the rituals and concealment. Gently establish the physical consequences, framed as concern for her body, not as numbers. Screen the mood and suicide risk, which is high. And hold, throughout, that you neither collude with the illness nor treat it as a choice.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the two guardrails
You do not open by asking her weight, and you do not open by praising or worrying at her appearance. You open with warmth and curiosity about her, not her body.
Say something like this.
Thank you for talking with me. I am not here to weigh you down with rules or numbers. I would like to understand how things have been for you, with eating, and with how you feel about yourself. Can you tell me, in your own words.
Then hold both guardrails throughout. Do not offer numbers, targets or calorie figures, because the illness will seize them. And do not tell her she looks fine or looks too thin, because either one hands the illness ammunition. You stay on meaning and function, warmly, without a scale in sight.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Ruby. She is bright, guarded, and only half-willing to be here, because to her the eating is not the problem, it is the one thing keeping her steady.
It began understandably, a change in her body she disliked, which was real. But slimness was already part of who she felt she was, so the discomfort attacked her identity, not just her waist. Now weight and shape have become the measure of her worth. She restricts, she counts silently, she exercises out of fear rather than enjoyment, and she may cut, mash or separate her food, eat alone, and dress to conceal. People tell her she looks unwell and she simply does not let their words move her, she does not experience herself as thin. There are physical costs she may downplay, feeling cold, faint, her periods stopped. She will not lay this out in order, and part of her is testing whether you will try to take her control away.
That is your patient. Now every move is made through Ruby, gently, on meaning, never on numbers.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check. Meaning first, numbers never.
4.1 - The overvalued idea of shape and weight
Trigger. She judges herself, above all, by her weight and shape.
Decode, kept in your head. The core, an overvalued idea in which weight and shape are central to her self-identity, held beyond the bounds of reason. She may perceive her weight as normal or excessive when it is dangerously low.
The move. Ask what weight and shape mean to her, and how she sees her body, without offering any figure.
How do you feel about your body. How much does your weight or shape decide how you feel about yourself as a person. When you look at yourself, what do you see.
Check. Weight and shape central to self-worth, and a perception out of step with reality, is the overvalued idea. Note it, no numbers used. Move on.
4.2 - Restriction
Trigger. She eats less, avoids foods, skips meals.
Decode, kept in your head. Deliberate restriction, the calorie ceiling, the banned foods, the skipped meals, driven by her, not by illness or scarcity. Elicit the pattern, not the figures.
The move. Ask about the shape of her eating over a day, and what she allows herself, without asking for numbers.
Talk me through an ordinary day of eating for you. Are there foods you will not let yourself have, or meals you skip. Who decides what you eat.
Check. Deliberate self-imposed restriction established, described not counted. Move on.
4.3 - Compensatory behaviours
Trigger. She works to undo what she eats.
Decode, kept in your head. Weight gain prevented by various means, vomiting, laxatives, diuretics, diet pills, and exercise driven by fear rather than enjoyment, the sentence that converts sport into a compensatory behaviour.
The move. Ask gently and without alarm about the ways she manages her weight, and about the feeling behind the exercise.
Do you ever do things to get rid of what you have eaten, being sick, or using laxatives or other means. And your exercise, is it something you enjoy, or does it feel like something you have to do or else.
Check. Compensatory behaviours and fear-driven exercise elicited. Move on.
4.4 - Rituals and concealment
Trigger. Elaborate patterns around food, and hiding the eating.
Decode, kept in your head. Rituals, cutting, mashing, separating food, and concealment, baggy clothes, eating alone, refusing to be weighed, drinking water to seem heavier. These look like compulsions but their engine is the drive to thinness, which she wants.
The move. Ask about how she eats, and about eating with others, gently.
Do you have particular ways of eating, cutting food up small, separating it, taking a long time. Do you avoid eating in front of other people, or dress to keep this private.
Check. Rituals and concealment elicited. Note the engine is desired thinness, not an ego-dystonic obsession. Move on.
4.5 - Fear of weight gain and the meaning of change
Trigger. The thought of gaining weight is intolerable.
Decode, kept in your head. The fear of weight gain, or, where she does not voice it, the behaviour that reveals it. You ask about meaning, not about a specific amount she must not exceed.
The move. Ask what gaining weight would mean to her, in terms of feeling, not figures.
What would it feel like to you if your weight went up, even a little. What would that mean about you, in your own mind.
Check. The meaning of weight gain elicited, as feeling not number. Behaviour reveals the fear even where she does not state it. Move on.
4.6 - Physical consequences, framed as care
Trigger. The body is paying a price she may downplay.
Decode, kept in your head. The physical toll, feeling cold, faint or dizzy, periods stopping, hair thinning, and the cardiac risk that makes this dangerous. You ask about how her body feels, and frame any checks as concern for her heart, never as a target.
The move. Ask about how her body has been, and offer physical checks as care.
How has your body been coping, are you feeling the cold, faint or dizzy, has your energy changed. I would like to check your pulse and blood pressure today, because I care about protecting your heart.
Check. Physical consequences elicited and checks framed as care for her body, no thresholds named. Move on.
4.7 - Insight and control
Trigger. She may not see herself as unwell, and fears losing control.
Decode, kept in your head. Insight is often partial, and the eating can feel like the only source of control. Understanding what the illness does for her opens the way to help without a fight.
The move. Ask what the eating gives her, and gently what worries her, if anything, about where it is heading.
Some people find that controlling their eating is one of the few things that feels steady when everything else is hard. Is it like that for you. And is there any part of you that worries about where this is going.
Check. The function of the eating, and any foothold of insight, understood without confrontation. Move on.
4.8 - Mood and suicide risk
Trigger. The illness is exhausting and often carries depression.
Decode, kept in your head. Comorbid depression is common and the suicide risk is high. Screen mood and suicide gently, and note who supports her.
The move. Screen mood and suicide, and ask who knows and who is alongside her.
How has your mood been through all this. Have you ever felt so low or worn down that life did not feel worth living. Who knows about what you have been going through, and who is supporting you.
Check. Mood, suicide risk and support screened. High-risk, never optional. Move on.
When it is something else. The comparators.
Half the marks are in what the eating actually belongs to. Say the distinction out loud, never with a number.
5.1 - Ordinary body dissatisfaction and dieting
A person may dislike their weight and shape, have low self-esteem about it, and even eat out of control in the evenings, without an eating disorder. What is missing is the overvaluation of shape as the measure of worth, and any compensatory behaviour. Simply not liking one's size is an ordinary human position, not a diagnosis. Say that difference out loud rather than reaching for a label.
5.2 - Bulimia, binge eating, and the restricting picture, told apart
Recurrent binges with a loss of control, followed by compensatory purging, with weight often in the ordinary range, point to bulimia. Binges without compensation point to binge eating disorder. Marked restriction and very low weight point to the restricting picture. The engine, overvaluation of shape and weight, is shared, but the behaviours and the weight separate them. Ask about binges, loss of control, and compensation to place it, and never promise weight loss.
5.3 - Obsessive compulsive disorder and body dysmorphia
Rituals around food can look like the compulsions of obsessive compulsive disorder, but there the thought is ego-dystonic and resisted, while here the thinness is desired. And a preoccupation with a bodily feature that is not weight, checked in the mirror and hidden, is body dysmorphia, the same engine on a different target. Ask what the ritual is for, and what part weight and shape play, to tell them apart.
5.4 - Neurodevelopmental and sensory food selectivity
A lifelong avoidance of foods by texture, smell or colour, without any concern about weight or shape, is a sensory or neurodevelopmental food selectivity, not an eating disorder of weight and shape. The discriminator is the absence of the overvalued idea about body size. Ask whether the avoidance is about the food itself or about controlling weight.
Check. Name what else the eating might be, and the presence or absence of the overvalued idea. Never settle it with a number. That is the mark.
The close
Close in five small movements. No numbers, no collusion, never shame.
One. Thank them, and honour the trust.
Thank you for letting me in on something so private and so hard. I know part of you was not sure about being here.
Two. Name it kindly, as an illness, not a choice.
What you have described is a recognised illness, not a lifestyle choice and not attention-seeking. It has a way of making weight and shape feel like the most important thing about you, and of hiding how much your body is struggling.
Three. Offer help, and leave real hope.
People do recover from this fully. The main treatment is a talking therapy made for eating difficulties, alongside gentle support for your body, and your family beside you if you would like that. I am not going to take control away from you, I am going to help you get free of something that has taken it.
Four. Invite.
Is there anything you would like to ask me, or anything you are frightened of in all this.
Five. Signpost. To the patient, help framed as freedom, not restriction, and no numbers. To the examiner, in your head, the overvalued idea of shape and weight, the behaviours, the physical and cardiac risk, and the mood and suicide risk.
The two habits, again
Carry these two out of the room.
One. Open wide and without judgement, then elicit the meaning behind the behaviour. The overvalued idea, that weight and shape measure her worth, is the illness, not the number on a scale. Draw out what eating means to her.
Two. Never bargain over numbers, and never collude. Keep targets and figures out of the room, do not reassure her about her appearance, and frame the physical checks as care for her body. The eating is the scenery, the overvalued idea and the risk are the station.
Do those two things and this drill is yours.
Eliciting Personality & Interpersonal Pattern
Before we begin
Welcome. This is the fourteenth elicitation drill, on personality and interpersonal pattern. Drawing out an enduring way of being, and, just as importantly, deciding whether what you are seeing is a personality pattern at all, or an episode, a situation, or an acquired change wearing its clothes.
A personality pattern passes four tests, it is enduring, it is pervasive across situations, it began in adolescence or early adulthood, and it causes distress or impairment. Fail any one and you are probably looking at something else, and the exam builds whole stations out of that failure. And this is the subcategory where the words you choose are marked as hard as the symptoms you find, because a careless phrase, or the phrase personality disorder said as a verdict, loses the patient and the mark.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then run the four tests. Draw out the pattern in their own story, then check it is enduring, early, pervasive and impairing, before you call it anything.
Two. Never a verdict in the room, and mind the words. Never say personality disorder as a label that lands as judgement, describe a pattern, not a person, and use warm, non-pejorative language throughout, because it is scored as hard as the diagnosis.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Take a history from this patient to establish a psychiatric diagnosis, considering a personality difficulty, and characterise the interpersonal pattern. You are in a clinic or an emergency department. You have around seven minutes. An examiner sits silent in the corner. Do not label the patient pejoratively, and do not name a diagnosis as a verdict.
Here is the shape of it. Draw out the pattern through the person's relationships and history. Run the four tests, enduring, early, pervasive, impairing. Trace the loop, an early template of relationships, a characteristic feeling under stress, a behaviour that regulates it briefly, a consequence that confirms the template. Elicit the specific features, emotional instability, unstable relationships, disturbed self-image, impulsivity, abandonment fear, self-harm, emptiness, anger. Screen the risk, and read the relationship in the room.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the pattern question
You do not open with a list of traits. You open on the person they were before all this, and let the pattern show itself.
Say something like this.
Before we get to what brought you in today, I would like to understand you a little. Before all this, what sort of person were you, and has this been a pattern for you over the years, or is it something new.
Then you let the story run, and you keep asking the pattern question in different forms, because it carries the diagnosis.
How far back does this go, were you like this as a teenager. And is it the same at work, at home, and with friends, or only in one place.
Enduring, early, pervasive, all three carried in two questions. And near the end, the question almost nobody asks, what is it like sitting here talking to me right now, which opens the relationship in the room.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Elowen. She has come in after harming herself following a row, she is fed up, wary of yet another doctor, and she will only open up if you are respectful and explain why it matters.
If you are patient, the loop appears. Early on, a parent lost and another who neglected her, leaving a template that people leave and nothing lasts. A trigger, a partner accusing her, and a feeling that becomes unbearable within minutes. A behaviour that regulates it, drinking, harming herself, leaving first. A consequence, an ambulance, a busy department, a flagged record, a weary glance from a professional, which confirms the template, and round it goes. Her relationships start intensely and end in ruins, her sense of herself is unsteady, and emptiness sits underneath. She will test you, and the way she relates to you in the room is itself data. She will not lay this out in order, and she is braced for judgement.
That is your patient. Now every move is made through Elowen, warmly, with the words chosen as carefully as the questions.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - The four tests, is it a pattern at all
Trigger. A presentation that could be personality, or could be an episode.
Decode, kept in your head. Before anything, apply the four tests, enduring, early, pervasive, impairing. Fail one and it is not a personality pattern.
The move. Establish the timespan, the age of onset, the spread across settings, and the cost.
Has this been the way of things for years, or is it recent. Were you like this back in your teens. Does it show everywhere, work, home, friendships, or only in one place. And what has it cost you, in relationships, work, or trouble.
Check. Enduring, early, pervasive, impairing, all four met, is a personality pattern. Any failing, look elsewhere. Move on.
4.2 - The relational template
Trigger. Her relationships follow a painful, repeating shape.
Decode, kept in your head. The loop begins in early relational experience, which lays down a template for what relationships are and how they end. That template is the engine of the pattern.
The move. Ask how relationships usually start and end, and who was there for her growing up.
Tell me about your relationships, how do they usually begin, and how do they usually end. And who was around for you when you were growing up.
Check. The template, people leave and nothing lasts, and its origin, elicited. Move on.
4.3 - Emotional instability and the trigger
Trigger. Small things send her into an unbearable spiral.
Decode, kept in your head. Emotional instability, intense, rapidly shifting affect, triggered when the template is activated under stress, often around a perceived rejection.
The move. Ask what happens inside her when she senses someone is about to leave, and how fast the feeling comes and goes.
What happens inside you when you think someone is about to leave you. When those feelings hit, how quickly do they come, and how long do they last.
Check. Rapid, intense, abandonment-triggered affect, elicited. Move on.
4.4 - The regulating behaviour
Trigger. She does something to make the unbearable feeling stop.
Decode, kept in your head. The behaviour that regulates the feeling briefly, self-harm, an overdose, drinking, spending, leaving first, exploding. Ask what it did for her, because that is the formulation, not just the fact of it.
The move. Ask what the behaviour does for her, and what changes afterwards.
When you felt like that and did that, what did it do for you in the moment. What changed afterwards, inside, or around you.
Check. The regulating function elicited, not just the act. This is the formulation. Move on.
4.5 - Self-image, emptiness and anger
Trigger. An unsteady sense of self, a chronic emptiness, and angry outbursts.
Decode, kept in your head. Disturbed self-image, chronic feelings of emptiness, and inappropriate intense anger are core features. Ask them directly but gently.
The move. Ask about her sense of who she is, the emptiness, and the anger.
Do you have a steady sense of who you are and what you want, or does it shift. Do you often feel empty inside. And do you find your anger comes on suddenly and stronger than you would like.
Check. Self-image, emptiness and anger elicited. Move on.
4.6 - Self-harm as a separate enquiry, and transient symptoms
Trigger. She harms herself, and may describe brief paranoid or dissociative experiences under stress.
Decode, kept in your head. Recurrent self-harm, and transient stress-related psychotic or dissociative symptoms, are separate features to ask about explicitly, and self-harm to regulate affect is a different enquiry from an overdose to die.
The move. Ask about self-harm and its function separately, and about brief experiences of unreality or suspicion under stress.
Do you ever hurt yourself, and if so, what does it do for you. And when things are at their worst, do you ever feel disconnected, unreal, or briefly suspicious in a way that passes.
Check. Self-harm as its own enquiry, and transient dissociative or psychotic features, elicited. Move on.
4.7 - The relationship in the room
Trigger. How she relates to you shifts during the interview.
Decode, kept in your head. The transference, how she experiences you, warm then rejecting, idealising then devaluing, is live data, and asking about it is where a scored mark hides that almost nobody reaches for.
The move. Ask, simply and warmly, what this conversation is like for her.
Can I ask, what is it like sitting here talking to me right now. Has how you feel about me shifted at all as we have spoken.
Check. The in-room relationship named. This is the mark few candidates reach. Move on.
4.8 - The risk
Trigger. Recurrent self-harm and overdoses, and impulsive acts.
Decode, kept in your head. Suicide and self-harm risk are raised and fluctuating, and impulsivity drives danger. Screen both directions, and do not dismiss the risk because it is chronic.
The move. Screen suicide, self-harm and impulsive harm, taking each seriously.
Have you had thoughts of ending your life, as opposed to hurting yourself to cope. Have you acted on impulse in ways that put you or others at risk. What has kept you safe so far.
Check. Suicide, self-harm and impulsive risk screened, and the protective factors named. Chronic risk is still risk. Move on.
When it is NOT a personality pattern. The comparators.
Half the marks are in refusing to over-call a pattern. Each of these fails one of the four tests. Say which, out loud.
5.1 - The single episode
One bad night, an impulsive act after drinking, in someone whose mood is a little up and down but who is fine the next day and does not fear abandonment, is not a personality pattern. It fails the enduring test. The honest answer may be that the diagnosis is not clear, and tolerating that uncertainty, considering depression, an acute stress reaction and intoxication alongside, is itself the mark.
5.2 - The situational reaction
Isolation, anxiety, low mood, dependence, no sense of self, evasiveness with professionals, all can be the consequences of a live situation, above all an abusive, controlling relationship, rather than traits. A pattern that started in adulthood in response to another person's behaviour is not a personality pattern. Before you call anything enduring, ask what is currently happening to the person, and name coercive control by its right name.
5.3 - The acquired change
Disinhibition, impulsivity, apathy, coarsened behaviour and poor judgement beginning in middle age in someone previously mild-mannered, and progressing over years, is an acquired frontal change such as a dementia, not a personality disorder. It fails the early test. Rude emails and social transgressions can read like antisocial traits, but the late onset and the progression give it away. Ask when the change began and whether it has worsened.
5.4 - The neurodevelopmental mimic
Adult attention difficulty also starts in childhood, is pervasive, and produces impulsivity and friction, so it is the hardest comparator. But there the trouble is with attention and structure, not with relationships and identity, there is no abandonment fear, no unstable self-image, no self-harm, and the impairment tracks environmental demand. Ask whether the core difficulty is concentration or relationships.
Check. Name which test fails, episode, situation, acquired change, or neurodevelopment. That refusal to over-call is the mark.
The close
Close in five small movements. The words are marked as hard as the symptoms. Never a verdict.
One. Thank them, and honour the honesty.
Thank you for letting me understand so much of your life, including the hard parts. That took a lot.
Two. Name it as a pattern, not a person.
What you have described are long-standing difficulties, going back to when you were young, that show up across your life. We would understand that as a personality pattern. I know that phrase can sound like a judgement, and I do not mean it that way. It describes a pattern, not a verdict on who you are.
Three. Offer help, and leave hope.
There is no tablet for the pattern itself, but there is real treatment, a structured talking therapy, alongside help for any depression or anxiety, and a consistent team around you. People do get better with this.
Four. Invite.
Is there anything you would like to ask me, or anything I have got wrong.
Five. Signpost. To the patient, help framed as working together, not a label and a discharge. To the examiner, in your head, the four tests met, the specific features, the comparators excluded, and the fluctuating risk.
The two habits, again
Carry these two out of the room.
One. Open wide, then run the four tests. Draw out the pattern in her own story, then check enduring, early, pervasive and impairing before you name anything, and trace the loop from template to consequence.
Two. Never a verdict in the room, and mind the words. Describe a pattern, not a person, in warm non-pejorative language, because it is marked as hard as the symptoms. The traits are the scenery, the four tests and the words are the station.
Do those two things and this drill is yours.
Eliciting Neurodevelopmental Pattern
Before we begin
Welcome. This is the fifteenth elicitation drill, on neurodevelopmental pattern. Attention difficulty, the autistic profile, and intellectual disability, and the single question that runs under all of them, when did this start.
Here the examiner is not really asking what the symptom is, but when it began. A neurodevelopmental condition is lifelong, present from early development, even if it only became limiting when the demands of life outgrew the person's ways of coping, masking and compensation. So two errors sink candidates. One, calling a lifelong difference a new illness. Two, the opposite, when a person with a known disability presents with a new symptom, blaming it on the disability, diagnostic overshadowing, and missing a fresh, treatable problem on top of the lifelong baseline. Date everything, and adapt how you interview.
Two habits carry every MSE drill. Keep them close.
One. Anchor everything to the developmental timeline. For each difficulty, ask, was this there in childhood, or is it new, because lifelong versus new is the whole diagnosis.
Two. Adapt the interview, and never overshadow. Change how you ask, simple, literal, one thing at a time, and when a person with a disability has a new symptom, look for a fresh cause, never attribute it to the disability by default.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Take a history from this patient with a view to an initial diagnosis of a neurodevelopmental condition, or assess a new change in a patient with a known developmental condition. You are in a clinic. You have around seven minutes. An examiner sits silent in the corner. Adapt your communication, and do not name a diagnosis in a way they cannot follow.
Here is the shape of it. Adapt your interview to the person. Elicit the core domains, for attention, the inattention, hyperactivity and impulsivity, for autism, the social communication and the restricted, repetitive, sensory pattern, for intellectual disability, the adaptive functioning. Anchor each to early development. Trace how demand unmasked it. Screen the comorbidities and the raised risk. And where there is a new change, hunt for a fresh cause rather than overshadowing.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the developmental anchor
You do not open with a checklist read at speed. You open by adapting, and by orienting the whole history around childhood.
Say something like this, and then genuinely change how you interview.
I will ask fairly direct questions, one at a time, and if anything is unclear just tell me and I will put it another way. To understand this properly, I would like to go right back, what were you like as a child, at school, with other children.
Then, for every difficulty they raise, you drop the anchor that decides the diagnosis.
Has this been true since you were young, as far back as you can remember, or is it something that has changed more recently.
Lifelong points to a neurodevelopmental condition unmasked by rising demand. A new change on a lifelong baseline points to a fresh, treatable problem sitting on top. That single distinction is the station.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Nadia, referred after her work unravelled following a promotion, though the story runs back to childhood.
At school she was called lazy and difficult, shouted out answers, could not finish homework, could not hold her concentration on anything that did not grip her. She got by for years on ability and on workarounds, pacing while she thought, working from home, leaving the dull tasks late. Then a promotion into a structured office role removed every workaround at once, and the lifelong difficulty became disabling, which is why she is here now, not because anything changed in her but because the demands did. Another patient in this seat might instead have a lifelong autistic profile, or a lifelong intellectual disability, presenting with a new symptom that a careless clinician would wrongly blame on the disability. She will not lay it out in order, and she needs the questions direct and one at a time.
That is your patient. Now every move is made through Nadia, anchored to childhood, adapted to her.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Inattention
Trigger. Unfinished tasks, distractibility, forgetfulness, disorganisation, despite ability.
Decode, kept in your head. The inattention domain of attention-deficit difficulty, hard to sustain attention on ordinary tasks, though a highly stimulating task may still hold her, which does not exclude the diagnosis.
The move. Ask about sustaining attention, finishing, following through, and losing things.
Do you find it hard to hold your attention, to finish what you start, or to follow instructions to the end. Do you lose things, or leave tasks half done, even when you are trying.
Check. Inattention across ordinary tasks elicited. Move on.
4.2 - Hyperactivity and impulsivity
Trigger. Restlessness, talking over people, acting before thinking.
Decode, kept in your head. In adults the outward hyperactivity often quietens to an inner restlessness, while impulsivity, acting on urges without weighing consequences, persists.
The move. Ask about restlessness and about impulsive words and acts.
Are you restless, do you struggle to sit through a meal, a meeting, or a film. Do you interrupt people, or act before you have thought it through.
Check. Hyperactivity and impulsivity elicited. Move on.
4.3 - Childhood onset and pervasiveness
Trigger. You must prove it is lifelong and everywhere, not new and local.
Decode, kept in your head. Onset in childhood, before the early teens, and impairment in more than one setting, are required. Collateral, school reports, a parent, a partner, is the gold here.
The move. Anchor to school and ask across settings, and seek collateral.
Was this there at school, what did your reports say about you. Does it show at work as well as at home, in more than one part of your life. Is there anyone, a parent or an old report, who could tell me what you were like then.
Check. Childhood onset and pervasiveness established, collateral sought. Move on.
4.4 - Autism, the social communication domain
Trigger. Lifelong difficulty with the back and forth of relationships, reading people, and non-verbal signals.
Decode, kept in your head. The social communication and interaction domain of autism, difficulty with reciprocity, with reading tone, expression and intent, present from early childhood.
The move. Ask about friendships growing up, reading people, and eye contact and tone.
Growing up, did you find it hard to make friends, or to know what to say to people. How do you find eye contact, reading someone's tone of voice, or working out what they really mean.
Check. Social communication difficulty, lifelong, elicited. Move on.
4.5 - Autism, the restricted, repetitive and sensory domain
Trigger. Intense narrow interests, a need for routine, distress at change, sensory sensitivities.
Decode, kept in your head. The restricted, repetitive behaviour domain, insistence on sameness, deep circumscribed interests, and sensory hyper- or hypo-sensitivity.
The move. Ask about absorbing interests, routines and change, and the senses.
Are there subjects you get deeply absorbed in, more than others do. Do you have routines you need to keep, and how is it when plans change suddenly. How are you with noise, bright light, textures, or labels in clothing.
Check. Restricted, repetitive and sensory features elicited. Move on.
4.6 - Masking and the role of demand
Trigger. She coped for years, then collapsed when demands rose.
Decode, kept in your head. Masking and compensation, learned copying, rehearsed social behaviour, workarounds, hide a lifelong condition, which is exhausting and often unravels only when life outgrows it. Camouflaging is especially common in women.
The move. Ask how she coped before, and what changed to overwhelm the coping, showing it is unmasking, not new onset.
For years, how did you manage, what tricks or routines got you through. And what changed recently that made those stop working. Did the difficulty appear, or did the thing that had been hiding it fall away.
Check. Lifelong condition unmasked by rising demand, not a new illness, established. Move on.
4.7 - Comorbidity and the differential
Trigger. Years of struggle leave anxiety, low mood or substance use, and other conditions can mimic.
Decode, kept in your head. Comorbid anxiety, depression and substance use are the rule, and you must exclude a mood disorder, a psychosis, and substance effects as the primary cause, and consider a specific learning difficulty and overlapping autism or attention difficulty.
The move. Screen the companions and exclude the mimics, checking the pervasive-and-lifelong quality rather than discrete episodes.
Alongside all this, how have your mood and your worry been, and any drinking or drugs to cope. And are these difficulties there all the time and lifelong, rather than coming in distinct spells of high or low mood.
Check. Comorbidities screened, mood, psychosis and substance mimics excluded by their episodic quality. Move on.
4.8 - Risk, and never overshadowing
Trigger. Raised risk from impulsivity, vulnerability and, in a known disability, a new symptom.
Decode, kept in your head. Impulsivity raises accidental and deliberate harm, autistic adults carry a raised suicide risk, and people with disability are vulnerable to exploitation and abuse. And crucially, a new symptom on a lifelong baseline needs a fresh cause sought, never blamed on the disability.
The move. Screen impulsive and self-directed risk and vulnerability, and, for any new change, hunt a fresh cause.
Has your impulsiveness ever put you in danger, and have things ever felt so hard you did not want to be here. Has anyone taken advantage of you. And where something has changed recently, I want to look for a new reason, not just put it down to how you have always been.
Check. Impulsive and suicide risk, vulnerability, and the search for a new cause, all covered. Never overshadow. Move on.
Lifelong versus new. The comparators.
The whole drill is one axis, when did it start. Say the verdict, and its consequence, out loud.
5.1 - Neurodevelopmental unmasked, not new
When a lifelong difficulty becomes disabling only because a promotion, a move or a loss of support removed the workarounds, the condition did not begin now, it was unmasked now. Adult attention difficulty is childhood attention difficulty plus a longitudinal functional history. Say that the person did not change, the demands did, and do not mistake unmasking for new onset.
5.2 - Diagnostic overshadowing, the cardinal error
When a person with a known intellectual disability or autism presents with a new symptom, agitation, withdrawal, a change in behaviour, the error is to attribute it to the disability. Look instead for a fresh cause, a depression, a delirium, pain, constipation, sensory loss, or abuse. Often there are several causes at once. The autism has not changed, the new thing has. Never let the lifelong label hide a treatable new problem.
5.3 - Autism versus a psychotic illness
Lifelong social difficulty, literalness and intense interests are autism, present from childhood, whereas a new withdrawal, odd beliefs and perceptual changes emerging in adolescence or adulthood point to a psychosis, possibly layered on top. In a person with both, ask what has changed recently, because the autism is stable and the psychosis is the new, treatable layer.
5.4 - Attention difficulty versus its imitators
Distractibility and restlessness can be a mood or anxiety disorder, a sleep disorder, or substance intoxication, none of which are lifelong and pervasive from childhood. Stimulant intoxication in particular mimics attention difficulty. Anchor to childhood onset and pervasiveness, and exclude a discrete mood episode and current substance use, before settling on a neurodevelopmental cause.
Check. Name the verdict, lifelong unmasked, or new on a baseline, and its consequence. That axis is the mark.
The close
Close in five small movements. Simple, literal, hopeful, never shaming.
One. Thank them, and lift the blame.
Thank you for taking me right back through your life. So much of this has been carried as though it were a personal failing, and it is not.
Two. Name it plainly, as a difference or a new change.
What you describe fits a lifelong difference in how your mind works, one that only became overwhelming when the demands on you grew, not something you developed or caused. Where something has genuinely changed lately, I want to find and treat that in its own right.
Three. Offer help, and leave hope.
There is real help, understanding and adjustments, support and, where useful, treatment, and help for any anxiety or low mood alongside. Life gets markedly easier once the support fits how you work.
Four. Invite.
Is there anything you would like me to go over again, or anything you want to ask.
Five. Signpost. To the patient, the next step in plain words. To the examiner, in your head, the lifelong-versus-new verdict, the domains, the comorbidities and mimics excluded, and, in a known disability, the fresh cause you would not overshadow.
The two habits, again
Carry these two out of the room.
One. Anchor everything to the developmental timeline. For each difficulty, ask whether it was there in childhood or is new, because lifelong versus new is the whole diagnosis, and unmasking is not new onset.
Two. Adapt the interview, and never overshadow. Ask simply, literally, one thing at a time, and when a person with a disability has a new symptom, hunt a fresh cause rather than blaming the disability. The symptom is the scenery, its timeline is the station.
Do those two things and this drill is yours.
Eliciting Substance History & Dependence
Before we begin
Welcome. This is the sixteenth elicitation drill, on substance history and dependence. Drawing out the pattern of use, the dependence syndrome, and, above all, the temporal relationship between the substance and any psychiatric symptoms.
One word runs this whole subject, chronology. Two questions decide almost every station in it. First, what came first, the substance or the symptom. Second, did the symptom persist beyond the window in which the substance could still explain it. If the substance came first and the symptom cleared with abstinence, it is substance-induced. If the symptom came first, or outlasted abstinence, it is primary and the substance is a passenger. And there is a small technique that gets you candid answers, place the burden of denial on the patient, ask when they last drank, not whether they ever drink.
Two habits carry every MSE drill. Keep them close.
One. Open wide, then build the timeline. Draw out the use and the symptoms in their own words, then lay them on one timeline, because the order decides the diagnosis.
Two. Never judge, and place the burden of denial. No categorical judgements about the drinking or the drugs, and phrase questions so use is assumed, when did you last use, how much on a usual day, which draws out honest answers.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Take a substance use history from this patient, characterise any dependence, and establish the relationship between the substance and their symptoms. You are in a clinic, an emergency department, or a ward. You have around seven minutes. An examiner sits silent in the corner. Do not judge, and do not name a diagnosis prematurely.
Here is the shape of it. Open non-judgementally and quantify the use. Elicit the dependence syndrome, compulsion, impaired control, withdrawal, tolerance, the primacy of use over other things, and persistence despite harm. Ask about physical complications and past withdrawal events. Then the two chronology questions that decide substance-induced versus primary. Screen the risk, and consider the withdrawal emergencies.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the two questions
You do not open by asking whether they drink or use. You open assuming it, warmly, without judgement.
Say something like this.
When did you last drink, or use. And how much did you have that day, and how much on a usual day.
Asking when, not whether, places the burden of denial on them and gets you an honest figure. Then, once you have the pattern, you reach the two questions that are the whole subcategory.
Which came first, the drinking, or the voices and the fear. And when you have had a stretch without it, did the symptoms stop as well, or carry on.
Everything else, the units, the routes, the names of the drugs, is only evidence feeding those two answers, what came first, and did it persist.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Declan. He has been using heavily and has come, or been brought, with both a physical and a psychiatric story tangled together.
His use began socially, then became daily, and somewhere along the way the reasons changed, from pleasure to needing it just to feel normal and to keep the shakes away. He craves it, cannot stop once he starts, needs more than he used to for the same effect, and feels rough if a dose is late. Around all this sit symptoms, low mood, or fear, or voices, and the whole case turns on their order in time, did the using come first and the symptoms follow, clearing when he stops, or did the symptoms lead and the using rise to cope. He will give you the timeline only if you ask for it plainly and without judgement. He is braced to be lectured. You will not lecture him.
That is your patient. Now every move is made through Declan, building one honest timeline.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Compulsion and impaired control
Trigger. He craves it, and cannot stop once he starts.
Decode, kept in your head. Two features of the dependence syndrome, a strong compulsion or urge to use, and impaired control over onset, amount and stopping.
The move. Ask about the craving, and about control once he begins.
Do you get a strong urge or craving for it. Once you start, can you stop, or do you end up having more than you meant to.
Check. Compulsion and impaired control elicited. Move on.
4.2 - Withdrawal
Trigger. He feels rough, shaky, unwell if a dose is late.
Decode, kept in your head. A physiological withdrawal state on stopping or cutting down, or using to prevent it, a core dependence feature and a safety issue.
The move. Ask what happens to his body without it, and have him describe it in his own words.
If you go a day or two without it, what happens to your body. Can you describe those feelings to me in your own words.
Check. Withdrawal, and relief-use to prevent it, elicited. This also flags the emergencies. Move on.
4.3 - Tolerance
Trigger. He needs more than he used to.
Decode, kept in your head. Tolerance, a progressive need for higher amounts for the same effect, or a diminished effect from the same amount.
The move. Ask whether the same amount still does what it did.
Do you find you need more than you used to, to get the same effect. Or does the amount that once worked now do less for you.
Check. Tolerance elicited. Move on.
4.4 - Primacy and persistence despite harm
Trigger. Using has crowded out other things, and continued despite clear damage.
Decode, kept in your head. The salience of use, it takes priority over other interests and duties, and continued use despite clear harmful consequences, complete the dependence picture.
The move. Ask what he has given up for it, and whether he has kept using despite the harm.
Has it started to take over, crowding out other things you used to do or care about. Have you carried on even when it was clearly harming your health, your work, or your relationships.
Check. Salience and persistence despite harm elicited. The dependence syndrome is now complete. Move on.
4.5 - The complications and past withdrawal events
Trigger. A history of fits, the shakes, or hospital admissions.
Decode, kept in your head. Past withdrawal fits, episodes of seeing things, or admissions for the shakes, mark severity and risk, and point to the withdrawal emergencies.
The move. Ask directly about fits, hallucinations on withdrawal, and previous detox admissions.
Have you ever had a fit, or a spell of seeing things, or a time in hospital for the shakes, when you cut down or stopped. What treatment did you have.
Check. Complications and past withdrawal events elicited. Move on.
4.6 - Chronology, question one, what came first
Trigger. There is a psychiatric symptom, a psychosis, low mood, alongside the use.
Decode, kept in your head. The first of the two decisive questions. Did the substance come before the symptom, or the symptom before the substance. This is where the mark is.
The move. Lay the two on one timeline and ask plainly which led.
I want to get the order right. Did the heavy use come first and then the symptoms follow, or were the symptoms there first and the using grew to cope with them.
Check. The order established. Substance-first leans induced, symptom-first leans primary. Move on.
4.7 - Chronology, question two, did it persist
Trigger. He has had periods of abstinence.
Decode, kept in your head. The second decisive question. Did the symptom clear with sustained abstinence, or persist beyond the window the substance could explain. Persistence points to a primary disorder.
The move. Ask what happened to the symptoms during a genuine stretch without the substance.
When you had a real stretch without it, days or weeks, did the voices, or the low mood, settle as well, or did they carry on regardless.
Check. Persistence tested. Cleared with abstinence leans induced, outlasted it leans primary. The two questions together decide it. Move on.
4.8 - The risk and the withdrawal emergencies
Trigger. Heavy dependence, an unstable mental state, and physical withdrawal signs.
Decode, kept in your head. Screen suicide and risk to others, and recognise the emergencies, a withdrawal state with tremor and sweating can progress to fits and to a confused, clouded delirium, both medical emergencies.
The move. Screen the risk, and check for the physical withdrawal signs and confusion that signal an emergency.
Have things ever felt so bad you thought of ending your life. And right now, are you shaky, sweating, or feeling muddled or confused, because if so your body needs urgent attention alongside everything else.
Check. Suicide risk screened, and the withdrawal emergencies, fits and the confused clouded state, recognised. Never optional. Move on.
Substance-induced versus primary. The comparators.
The whole drill is the chronology rule, applied. Say the verdict, and the direction of the arrow, out loud.
5.1 - The substance-induced picture
Where heavy, sustained use came first and psychotic or mood symptoms developed during or shortly after intoxication or withdrawal, and would be expected to remit with maintained abstinence, it is substance-induced. Alcohol-related psychotic symptoms arising soon after abrupt cessation, in clear consciousness, are the classic example. Establish the chronology, use first, symptom after, clearing with abstinence, and that is the mark.
5.2 - The primary disorder the substance follows
Where the symptom came first and the use rose afterwards to cope, a jealous or persecutory belief, or a depression, that predates and outlasts the drinking, the disorder is primary and the substance is a consequence, not a cause. Show that the drinking was subsequent to the belief, or that the symptoms persist through abstinence, and you have made the point from the opposite direction. Sometimes the honest answer is that you cannot be sure which came first, and saying so, and why, is itself credited.
5.3 - Delirium tremens, the emergency mimic
A confused, disorientated, fluctuating state with tremor, sweating and often frightening visions, coming on days after stopping heavy alcohol use, is delirium tremens, a medical emergency, not a primary psychosis or a simple hallucinosis. The discriminator is the clouded consciousness. Screen for confusion and the physical signs, and treat it as urgent, because it can progress to seizures and death.
5.4 - The relapse aggravated by a substance
Where an established illness relapses after medication is stopped, with the substance restarted to cope, the relapse tracks the medication, not the drug, and the substance is an aggravator to be named and ranked, not the primary cause. Where several factors coincide, stress, non-adherence and use, name each and rank them rather than blaming one. Draw the timeline, then say which arrow is best supported.
Check. Name the verdict and the direction of causation, induced, primary, emergency, or aggravated relapse. Chronology is the mark.
The close
Close in five small movements. No judgement, ever.
One. Thank them, without judgement.
Thank you for being so straight with me about all of this. It is not easy to talk about, and it helps me understand what is really going on.
Two. Reflect the picture back plainly.
From what you describe, your body has become dependent on it, and we can see how the using and the other symptoms have run alongside each other over time.
Three. Offer help, and safety first.
This is treatable, and any cutting down needs to be done safely, with support, because stopping suddenly can be dangerous. We will look after your physical health and your mental health together.
Four. Invite.
Is there anything you would like to ask me, or anything I have not understood.
Five. Signpost. To the patient, help with the use and any illness alongside, done safely. To the examiner, in your head, the dependence features, the chronology verdict and its direction, the withdrawal emergencies, and the risk.
The two habits, again
Carry these two out of the room.
One. Open wide, then build the timeline. Draw out the use and the symptoms, then lay them on one timeline. Two questions decide it, what came first, and did it persist. Ask when they last used before you ask what they saw.
Two. Never judge, and place the burden of denial. No categorical judgements, and phrase questions assuming use, to get honest answers. The units and the drug names are the scenery, the chronology and the risk are the station.
Do those two things and this drill is yours.
Eliciting Risk
Before we begin
Welcome. This is the seventeenth and final elicitation drill, on risk. The domain where stations are failed outright, and the one the examiner is always, underneath everything, really asking, what has the psychopathology made this person do, or what might it drive them to do next.
Risk is not a checklist you rattle through at the end. It is a narrative you draw out, the shape of what happened before, during and after an act, or the gradient of an intention from a fleeting thought to a formed plan. Two things separate a pass from an excellent pass. First, you elicit it as a story, warmly, without a single categorical judgement, no that was a terrible thing to do. Second, you handle protective factors properly, a factor only protects against a specific risk, by a specific mechanism, for a specific time, so you say the factor, what it guards against, and what would remove it, never just read a list.
Two habits carry every MSE drill. Keep them close.
One. Ask for the narrative, then walk the gradient. Get a chronological account before, during and after, then place the current intent on the gradient from thought to plan to preparation.
Two. Never judge, and weigh every protective factor. No categorical judgements on anything they disclose, and for each protective factor, say what it protects against and what would take it away. Listing is not weighing.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Conduct a risk assessment of this patient, following an act of self-harm, an expressed intention, or a mental state that carries risk. You are in an emergency department, a ward, or a clinic. You have around seven minutes. An examiner sits silent in the corner. Do not be mechanical, and do not name a diagnosis to the patient.
Here is the shape of it. Draw out the narrative of any act, before, during and after. Establish the current intent along the gradient. Screen self-harm without suicidal intent as a separate enquiry. Elicit the background risk factors, previous attempts, illness, social change, substances. For risk to others, cover the drivers, target, means and disinhibitors. Weigh the protective factors properly. And tie the risk back to the psychopathology driving it.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the narrative
You do not open with a barrage of closed questions. You open by asking for the story, gently, and letting it lead.
Say something like this.
Thank you for talking to me, I know this is hard. Can you take me through what happened, in your own words, starting from before, when things began to build up.
Then you let the narrative run, and much of the assessment falls out of it, and you clarify with gentle questions rather than interrogating. Two rules hold throughout. Never a categorical judgement, no that was a terrible thing, no suicide is very serious, because it closes them down. And receive every honest answer, especially the frightening ones, with steadiness, so they keep telling you the truth.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Mr Halloran, medically cleared after an act of self-harm, or brought in after an intention was raised, and now sitting with you, drained and guarded.
There is a story here, a build-up over days or weeks, a precipitant, then the act itself, and an aftermath that tells you as much as the act. Whether it was planned or on the spur of the moment, whether he made final arrangements, whether he took precautions against being found or did it where he might be, whether he sought help or was discovered, whether he is relieved or disappointed to have survived, and whether the means are still within reach. Underneath sits the psychopathology, a depression, a delusion, a despair, that drove it, and around it the background risk and the fragile protective factors. He will give you the truth only if you neither flinch nor judge. He will not lay it out in order.
That is your patient. Now every move is made through Mr Halloran, as a narrative, without judgement.
Check. Let us take the drills, one at a time.
The drills, trigger, decode, move, words
Each drill is trigger, then decode kept in your head, then the move, then the words, then a check.
4.1 - Before, the planning and the final acts
Trigger. An act has happened, and you need what led to it.
Decode, kept in your head. The before, whether it was planned or impulsive, the intention behind it, how the means were obtained, and any final acts, a note, a will, giving things away, which mark high intent.
The move. Ask him to take you through the run-up, and cover planning and final acts.
Take me through that day, and the days before. Was this something you had planned, or did it happen on the spur of the moment. Did you write anything down, put affairs in order, or give things away.
Check. Planning, intention, means and final acts elicited. High planning and final acts mean high intent. Move on.
4.2 - During, the act and the expectation
Trigger. The act itself, and what he believed would happen.
Decode, kept in your head. The during, what he did, what he believed the outcome would be, whether anything else was taken with it, and, crucially, whether he acted where he might be found or made sure he would not.
The move. Ask what he did, what he expected, and about precautions against discovery.
What did you do, or take. What did you believe would happen. Did you do it somewhere you might be found, or did you make sure that you would not be.
Check. The act, the expectation, and precautions against discovery, elicited. Precautions against being found mean high intent. Move on.
4.3 - After, the discovery and the regret
Trigger. How the act ended, and how he feels now.
Decode, kept in your head. The after, how he was found, whether he sought help himself, how he felt physically and emotionally afterward, and, most important, whether he regrets surviving or is disappointed to be alive.
The move. Ask how he was discovered, whether he sought help, and how he feels about having survived.
How were you found, did you seek help yourself. And how do you feel now, knowing you survived, are you relieved, or do you wish it had worked.
Check. Discovery, help-seeking, and the crucial regret-versus-relief, elicited. Disappointment at surviving is high ongoing risk. Move on.
4.4 - The current gradient and access to means
Trigger. You must know where he is now, not just where he was.
Decode, kept in your head. The present intent runs along a gradient, a passing thought, an active wish to die, a formed plan, preparation. And whether he still has access to the means matters as much as the intent.
The move. Place him on the gradient now, and ask about ongoing access to means.
How are you feeling now, do the thoughts of ending your life continue. Do you have a plan. And is there anything still at home, tablets or otherwise, that we should sort out together.
Check. Current position on the gradient, and access to means, established. Move on.
4.5 - Self-harm without suicidal intent, a separate enquiry
Trigger. He may harm himself to cope, which is different from trying to die.
Decode, kept in your head. Self-harm to regulate an unbearable feeling, and an attempt to die, coexist and have different functions, and the presence of one tells you nothing about the other. It only appears if you ask a second, separate question.
The move. Ask separately about self-harm to cope, and what it does for him.
Separately from wanting to die, do you ever hurt yourself to cope, to get relief from how you feel inside. What does that do for you.
Check. Self-harm without suicidal intent asked as its own enquiry. Never assume one from the other. Move on.
4.6 - The background risk factors
Trigger. The act sits on a history that raises or lowers the risk.
Decode, kept in your head. The background, previous attempts, especially those needing medical treatment, past psychiatric history and current care, recent social change, unemployment, a relationship ending, and drug and alcohol use, plus the mood and any psychosis.
The move. Elicit the history, the recent losses, the substances, and the driving symptoms.
Have you tried to harm yourself before, and did any of those need treatment. What has changed in your life lately, work, relationships, home. How much are you drinking or using. And how has your mood been through this.
Check. Previous attempts, history, social change, substances, and mood elicited. Move on.
4.7 - Risk to others
Trigger. The mental state, or the history, raises a risk to another person.
Decode, kept in your head. For risk to others, the drivers in the mental state, a belief or a command voice, whether there is a specific target and whether he knows where they are, the means and any planning, and the disinhibitors, alcohol, drugs, past violence. In a perinatal or carer situation, the dependent is a risk to assess, not a reassurance.
The move. Ask about thoughts of harming others, a target, means, and the disinhibitors, calmly.
Have you had thoughts of harming anyone else. Is there someone in particular, and do you know where they are. Have you thought about how. And is there anything, drink or drugs, that makes those thoughts harder to control.
Check. Drivers, target, means and disinhibitors screened, and any dependent assessed as a risk, not a comfort. Move on.
4.8 - Weighing the protective factors
Trigger. He names reasons he has kept going, and you must not simply list them.
Decode, kept in your head. A protective factor guards against a specific risk, by a specific mechanism, for a specific time. A supportive partner protects only while present, a child protects only until the relationship with them is threatened, help-seeking protects only while he keeps engaging. Listing is not weighing.
The move. Draw out each protective factor, then, in your head and your summary, name what it guards against and what would remove it.
What has kept you going up to now. Who is at home with you tonight, and how much can you lean on them. Is there anything that, if it changed or was lost, would take that support away.
Check. Each protective factor stated with what it protects against and what would remove it. Three clauses, not a list. That is the excellent-pass mark. Move on.
Reading the risk. The distinctions.
The marks are in judging the risk, not merely collecting facts. Say the reading out loud.
5.1 - High intent versus high lethality
The seriousness of intent is not the same as the medical dangerousness of the act. A person who took a small overdose truly believing it would kill them, told no one, and took precautions against discovery, has high intent even if the act was medically minor. Judge the intent, from planning, precautions, final acts and regret, not the pharmacology alone. Underestimating a low-lethality act with high intent is the classic error.
5.2 - The physical risk that kills before the wish does
Sometimes the psychopathology drives a behaviour whose physical consequences will kill the person before any suicidal act, food and fluid refusal from a nihilistic delusion, profound self-neglect. Name both the expressed wish and the physical risk, and say which is likely to end life first. The passive death wish is not always the most urgent danger in the room.
5.3 - Full insight and full risk together
A person can understand their illness completely, have sought help, and still be at grave risk, disappointed to have survived and intending to try again. Insight, and even engagement, do not close a risk assessment. Never let a coherent, cooperative patient lower your guard. Assess the risk on its own terms.
5.4 - Uncertainty, held honestly
Sometimes the diagnosis and the risk are genuinely unclear, one act, a mixed picture, alcohol on board. The mark then is the ability to tolerate uncertainty, to consider depression, an acute stress reaction and intoxication together, and to manage the risk safely without forcing a premature label. Say what you do not yet know, and how you would keep the person safe while you find out.
Check. Read the risk, intent over lethality, physical over expressed, insight not equalling safety, uncertainty held. That reading is the mark.
The close
Close in five small movements. No judgement, and never leave without a plan.
One. Thank them, and honour the honesty.
Thank you for being so honest with me. What you have told me says two things, that you were serious, and that a part of you is here talking to me now.
Two. Name the illness driving it, gently.
I think there is an illness underneath this, and illnesses like this lie to people about whether things can change. It is treatable.
Three. Offer safety, together.
We will make a safety plan, written by you and me together, your warning signs, what you will do, who you will call, and we will make things at home safer and remove the means.
Four. Invite.
Is there anything you would like to ask me, or anything I have not understood.
Five. Signpost. To the patient, a clear plan and a date, you will not leave without one. To the examiner, in your head, the intent from before, during and after, the current gradient and access, the weighed protective factors, the risk to others, and the psychopathology driving it all.
The two habits, again
Carry these two out of the room.
One. Ask for the narrative, then walk the gradient. Get the story before, during and after, then place the current intent from thought to plan to preparation, and ask about access to means.
Two. Never judge, and weigh every protective factor. No categorical judgements, or they stop telling you the truth, and for each protective factor say what it guards against and what would remove it. The facts are the scenery, the reading of the risk is the station. And that is the last of the elicitation drills, carry the two habits into every one.
Do those two things and this drill is yours.