Symptom Clusters & ICD

Before we begin

Welcome. This is the Neurotic, Stress-Related and Somatoform bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of anxiety, trauma, obsession and bodily distress. Almost every member is treated with a talking therapy first and an antidepressant second, and almost every member is kept alive by avoidance, of the place, the thought, or the sensation. Name the avoidance, and you have found the treatment.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the conditions where fear, worry, or a physical symptom has grown larger than the life around it, without any break from reality.

The task on the door is nearly always the same shape. Draw out the cluster of symptoms, reach the particular condition, and give a formulation in three parts, biological, psychological and social.

The thread through the whole family is that the talking therapy usually matters more than the tablet, and that avoidance, of the trauma, the feared place, the intrusive thought, or the bodily sensation, is the engine that keeps each one running.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

I can see something has been weighing on you. Tell me, in your own words, what has been happening, and how it has been affecting you.

Then you stop, and you listen for which member of the family this is. A trauma being relived. A worry that will not switch off. A fear of one particular thing. A thought they cannot expel. A fear about the body. The shape of the answer tells you which set of questions to reach for.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Post-traumatic stress disorder

First, post-traumatic stress disorder. The reliving of a trauma in the present, with avoidance and a body still braced for danger.

Then, to close, these.

How long has it been now, since the day it happened? What has all of this stopped you doing? Work, driving, going out, sleeping in your own bed? Have you been drinking, or using anything, to help you cope with it? Have you felt at any point that you did not want to go on?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

Thank you for telling me all of that. From what you have described, being back there in flashbacks and nightmares, staying away from anything that reminds you, and being constantly on edge since it happened, what you have is post-traumatic stress disorder. It is a recognised condition, it is common after something like this, and it is treatable. We would treat it in three ways. Medically, with an antidepressant such as sertraline or venlafaxine. Psychologically, and this is the main treatment, with trauma-focused cognitive behavioural therapy, or with eye movement desensitisation. And socially, with help for your sleep, cutting down the alcohol, and support at work while you recover. Most people get better.

Complex post-traumatic stress disorder

Next, complex post-traumatic stress disorder. All of PTSD, plus damage to the feelings, the self, and the ability to be close, after trauma that went on for a long time.

Then, to close, these.

Was this something that happened once? Or something that went on for a long time? How safe do you feel now, today, where you are living? Who is there for you at the moment? What would you most want to be different, if we could help with one thing first?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From everything you have told me, this is post-traumatic stress disorder, but of the kind we call complex, because it came from something that went on for a long time. That is why it affects not only your memories, but how you handle your feelings, how you see yourself, and how close you can let people get. The treatment has the same three parts. Medication, usually an antidepressant, to steady things. A longer, phase-based talking therapy, which begins with safety and stabilisation before it ever touches the trauma itself. And practical support, with housing, safety, and the people around you. This takes longer than ordinary PTSD, and it does get better.

Adjustment disorder

Adjustment disorder. A real and understandable reaction to a recent event, that has grown beyond what the person can carry alone.

Then, to close, these.

How long is it now since all of this happened? What has it stopped you doing? Has anything helped at all, even a little? Have you had any thoughts of harming yourself since it began?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you are describing is an adjustment disorder. It means your symptoms are a real and understandable reaction to what has happened, but they have gone beyond what you can carry on your own. It is not a lifelong illness, and for most people it settles within months. The main treatment is not a tablet. It is problem-solving and brief talking therapy, and time. We would only use medication if your sleep or your mood became severe. And practically, we would look at what can be lifted off you at work and at home while you recover. I would also like to see you again soon, to make sure this is settling and not deepening.

Prolonged grief disorder

Prolonged grief. Grief is not an illness, but when it stays this intense and this disabling, long past what is expected, it needs help of its own.

Then, to close, these.

How long is it now since they died? What have you not been able to go back to since? Who is around you at the moment? Are you eating, and sleeping, and looking after yourself?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you are living with is grief, and grief is not an illness. But when it stays this intense for this long, and stops you living, we call it prolonged grief disorder, and there is help for it. The main treatment is a talking therapy built specifically for grief, which helps you hold the loss without it holding you. Antidepressants are not the first answer for grief itself, though we would use one if a depression has grown alongside it. And socially, bereavement support and the people around you matter as much as anything I can prescribe. You are not going mad, and you are not failing at this.

Generalised anxiety disorder

Generalised anxiety disorder. Worry that is not attached to one thing, that moves from subject to subject, and that will not switch off.

Then, to close, these.

How long has the worrying been going on like this? What has it stopped you doing? How much coffee, tea or energy drink are you having in a day? Are you using alcohol to take the edge off it? And how has your mood been, alongside all the worry?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From what you have told me, this is generalised anxiety disorder. The worry is not attached to one thing, it moves from subject to subject, you cannot switch it off, and it has been going on for months and is showing in your body. It is very treatable. Medically, an antidepressant such as sertraline is the first-line treatment, and it works on the worry, not just the mood. Psychologically, cognitive behavioural therapy is at least as effective, and the benefit lasts longer. And practically, cutting the caffeine and the alcohol, regular exercise and better sleep make a real difference. We would avoid diazepam and its relatives, because they help for a fortnight and cause a problem for years.

Panic disorder

Panic disorder. Recurrent attacks of terror out of the blue, and then the fear of the next one keeping the whole thing alive.

Then, to close, these.

How often are these attacks coming now? Have you started avoiding anywhere because of them? Has a doctor checked your heart and your thyroid? How much caffeine, alcohol or cannabis is going in? And how has your mood been between the attacks?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you are having are panic attacks, and the condition is panic disorder. What is happening is that your body's alarm system is firing when there is no danger, and then the fear of the next one keeps it going. The attacks are horrible, and they are not dangerous. We treat it in three ways. Medically, with an antidepressant such as sertraline. Psychologically, with cognitive behavioural therapy, which teaches you to stop fighting the symptoms and stop avoiding the places. And practically, by cutting caffeine, alcohol and cannabis, and by gradually going back to the places you have started to avoid. Most people improve a great deal.

Agoraphobia

Agoraphobia. The fear is not really of the shop or the bus, but of being somewhere you could not escape from, or could not get help.

Then, to close, these.

How long has it been building up like this? When did you last manage to go out on your own? Who does the shopping, and the appointments, at the moment? How has your mood been, being in the house this much?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is agoraphobia. The fear is not really about the shop or the bus. It is about being somewhere you feel you could not get out of, or could not get help. Every time you avoid, the fear gets a little stronger, which is why it has spread. The main treatment is psychological, a graded return, step by step, at a pace you set, which is sometimes called systematic desensitisation. Medication, usually an antidepressant, helps to make that possible. And practically, we would look at support to get you out of the house in the first weeks, and at your mood, which almost always drops when life shrinks like this.

Social anxiety disorder

Social anxiety disorder. Not a fear of company, but of being watched and judged, which is why speaking up and eating in front of people are the hardest.

Then, to close, these.

How long have you felt like this in front of people? Were you a shy child? Or is this a change in you? Do you have a drink before these situations? What has it cost you at work, and outside work?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

This is social anxiety disorder. The fear is not of company. It is of being watched and judged, and that is why speaking up and eating in front of people are the hardest. Treatment works well. Psychologically, cognitive behavioural therapy for social anxiety is the most effective single treatment, and it works partly by dropping the safety behaviours. Medically, an antidepressant such as sertraline or escitalopram. And practically, we would want to look at the drinking before events, because it works beautifully in the short term and makes everything worse over time.

Specific phobia

Specific phobia. A fear of one thing that is out of proportion, that the person already knows is out of proportion, and that they have organised their life around avoiding.

Then, to close, these.

How long have you been frightened of it? Has anything happened around it, that started this off? Do you feel faint at the sight of it, or only frightened? What have you had to give up in order to keep away from it?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is a specific phobia. It is a fear that is out of proportion, that you already know is out of proportion, and that you have organised your life around avoiding. Medication has a very small part to play here. The treatment is psychological, a graded exposure, where you meet the thing you fear in small steps until your body learns it is safe. It is one of the most effective treatments in the whole of psychiatry. Practically, we would look at what avoiding it has cost you, because that is often the part worth treating first.

Obsessive-compulsive disorder

Obsessive-compulsive disorder. The thoughts are the person's own, they do not want them, they fight them, and the rituals bring a few minutes of relief and then feed the whole thing.

Then, to close, these.

How long has this been part of your day? When you are calm and away from it, do you think the fear is realistic? How much of the day is going on the checking and the washing? Has your mood dropped with all of this? Have you ever had a treatment for it before, and did it help?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you are describing is obsessive-compulsive disorder. The thoughts are your own thoughts, you do not want them, you try to fight them, and the rituals bring relief for a few minutes and then feed the whole thing. That is the trap, and it is not a weakness. We treat it in three ways. Medically, with a high dose of an antidepressant such as sertraline or fluoxetine, and it takes longer to work here than it does in depression. Psychologically, with exposure and response prevention, which is the most important part. And practically, by getting the people at home to stop taking part in the rituals, kindly, because reassurance keeps it alive.

Body dysmorphic disorder

Body dysmorphic disorder. The mind fixes on a feature and magnifies it, so that what the person sees is genuinely not what others see. It is not vanity, and it is exhausting.

Then, to close, these.

How long have you felt this way about your appearance? Have you had, or asked for, any cosmetic treatment for it? What has it stopped you doing? Work, friends, going out? Has it ever got so bad that you did not want to be here?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

This is body dysmorphic disorder. It is a condition where the mind fixes on a feature and magnifies it, so that what you see is genuinely not what other people see. It is not vanity, and it is exhausting. Treatment works. Medically, an antidepressant, usually fluoxetine, and often at a high dose. Psychologically, cognitive behavioural therapy shaped for this condition, which works on the mirror checking, the comparing and the reassurance seeking. And practically, I would gently advise against further cosmetic procedures, because they very rarely help and often move the focus onto something else.

Health anxiety

Health anxiety. The body makes ordinary sensations, as everyone's does, and the alarm system reads them as danger, so the person checks, or asks, or avoids, and the relief never lasts.

Then, to close, these.

How long has the worry about your health been going on? How many doctors and how many tests have you been through for this? How long does the relief last after a normal result? And how has your mood been alongside the worry?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is health anxiety. Your body produces ordinary sensations, as everybody's does, and the alarm system reads them as dangerous, so you check, or you ask, or you avoid, and the relief never lasts. That is why the tests keep coming back normal and you keep feeling frightened. The treatment is mostly psychological. Cognitive behavioural therapy for health anxiety is very effective. Medically, an antidepressant helps where the anxiety is severe. And practically, we would agree that you see one doctor, at planned intervals, with no new tests unless there is a clear reason. That last part is treatment, not neglect.

Bodily distress disorder

Bodily distress disorder. Real physical symptoms that take up so much attention, and cause so much distress, that they have taken over the life. The first thing you say is that the symptoms are real.

Then, to close, these.

How long have you had these symptoms now? How much of your day goes on them? What have they stopped you doing? How is your mood, living with this? I want to be clear with you. I believe your symptoms are real.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

I want to start by saying that your symptoms are real. I am not telling you it is all in your head. What I think is happening is bodily distress disorder, where real physical symptoms take up so much attention and cause so much distress that they have taken over your life. Treatment has three parts. Psychologically, cognitive behavioural therapy, which is the strongest treatment we have here. Medically, an antidepressant, which helps pain and distress even without depression. And practically, one doctor, planned reviews, and a gradual return to activity rather than waiting to be pain-free before you start.

Dissociative disorders

Dissociative disorders. Genuine neurological-seeming symptoms, weakness, seizures, gaps in memory, that are not put on and not under control, where the connection between mind and body has been interrupted.

Then, to close, these.

When did this start, and what was happening in your life around then? What can you not do now, that you could do before? Have you had any injuries during these episodes? Has anything like this ever happened to you before?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is a dissociative disorder. The symptoms are absolutely genuine, they are not put on, and they are not under your control. What has happened is that the connection between the mind and the body has been interrupted, often around a time of great stress. The most important part of the treatment is this explanation, because understanding it is what allows it to improve. Then, psychologically, cognitive behavioural therapy and physiotherapy working together. Medically, we treat any depression or anxiety underneath. And practically, we stop the unnecessary tests, because each one makes recovery harder. Many people get better.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one line. Fear, worry or a bodily symptom, kept alive by avoidance, and lifted by a talking therapy first and a tablet second.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Mood (Affective) Disorders bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the mood disorders. The low pole, the high pole, and the severe forms where the mood has bent reality into a delusion. The one question that changes everything is whether the person has ever swung the other way, because a single past high turns a depression into a bipolar illness and changes the treatment.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the disorders of mood. The depressive pole, the manic pole, and the severe presentations where mood has produced a delusion or a hallucination.

The task is to establish the episode, judge its depth, and above all ask whether the person has ever swung the other way, because one past high changes a depression into a bipolar illness and changes the treatment entirely.

The thread is that you never assess a low mood without screening for a past high, and you never treat a high without protecting the person from their own judgement while it lasts.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

Tell me how you have been in yourself lately, in your mood and your energy, and how long it has been this way.

Then you listen for the pole. Low, flat, slowed, hopeless, is the depressive end. High, fast, needing no sleep, is the manic end. And whichever you find, you always ask about the opposite pole, because the answer decides the diagnosis.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Depressive episode

First, the depressive episode. Low mood most of the day, nearly every day, for more than two weeks, with the enjoyment gone and the body and sleep changed.

Then, to close, these.

How long has it been like this now? Two weeks, or longer? What has it stopped you doing? Has there ever been a spell when the opposite happened, when you were unusually high, or did not need sleep? How much are you drinking at the moment? And have you had any thoughts of ending your life?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From everything you have told me, you have a depressive episode. Your mood has been low most of the day, nearly every day, for more than two weeks, you have lost your enjoyment, your sleep and appetite have changed, and it is affecting what you can do. This is an illness, not a character flaw, and it is one of the most treatable conditions in medicine. Medically, an antidepressant such as sertraline. Psychologically, cognitive behavioural therapy, and the two together do better than either alone. And socially, sleep, activity, exercise, and taking some pressure off you while you recover. Most people make a full recovery.

Psychotic depression

Psychotic depression. A depression that has become severe enough to bend reality, with mood-congruent beliefs of guilt, punishment or a body that is rotting. It is treatable, often quickly, and usually in hospital.

Then, to close, these.

How long have you felt this way? How much have you been eating and drinking? Have you had any thoughts that you deserve to be punished, or that you deserve to die? Is there anyone at home with you? I would like to get you seen quickly, because I think this is treatable and you are suffering a great deal.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is a severe depression, and it has become severe enough that it is affecting the way you see the world, which is why you have come to believe those things about yourself. Those beliefs are a symptom of the illness. That means they will lift as the illness is treated. This needs treating quickly and usually in hospital. Medically, an antidepressant together with an antipsychotic, and where it is very severe, or you are not eating and drinking, electroconvulsive therapy works quickly and well. Then talking therapy once you are recovering, and support at home afterwards. People do get fully better from this.

Manic episode

The manic episode. Raised or irritable mood, energy up, needing no sleep, and the judgement affected in ways that are hard to see from the inside. Part of a bipolar illness.

Then, to close, these.

How long has this been going on now? Has any of it caused you trouble? With money, with driving, with people? Are you taking anything at the moment, any drugs, or steroids, or new tablets? Who is at home with you, and are there children at home? Would you be willing to come into hospital, so we can help you safely?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What is happening to you is a manic episode, which is part of bipolar affective disorder. Your mood is high, your energy is up, you do not need sleep, and your judgement is being affected in ways that are hard to see from the inside. The immediate treatment is medical, an antipsychotic such as olanzapine or quetiapine to settle things quickly, and then a mood stabiliser such as lithium to keep you well. Alongside that, talking therapy and psychoeducation, so you learn your own early warning signs. And socially, sleep, no drugs or alcohol, and protecting your money and your job while you recover. I would like you to come into hospital so we can do this safely.

Hypomania

Hypomania. A raised mood with more energy and less need for sleep, that has not gone far enough to stop the person functioning or to tip into psychosis. Taken with past lows, it points to a bipolar illness of the second type.

Then, to close, these.

How many days has this been going on now? Has anyone had to step in, or has anything gone wrong because of it? Have you had spells of low mood in the past? Are you taking any medication, and have you started or stopped anything recently?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have had is a hypomanic episode. It is a raised mood, with more energy and less need for sleep, but it has not gone far enough to stop you functioning. Taken with your past periods of low mood, this points to bipolar affective disorder, of the second type. Medically, we would think about a mood stabiliser, and we would be careful with antidepressants on their own, because they can push you up. Psychologically, psychoeducation and therapy help you recognise the early signs. And socially, a regular sleep routine is one of the single most protective things you can do.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one rule. Never assess a low without screening for a past high, and never treat a high without protecting the person's judgement while it lasts.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Perinatal and Women's Mental Health bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the illnesses of the perinatal period. They range from the common and community-managed, postnatal depression, to the emergency that must be admitted the same day, postpartum psychosis. Running through all three is one question about the baby, and the answer decides how fast you must move.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the mental illnesses that arrive in pregnancy and the weeks after birth.

The task is to place the mother on a spectrum of urgency, from a depression treated in the community, through an obsessional disorder that needs reassurance and therapy, to a psychosis that is a same-day emergency.

The thread is that every perinatal station is also a risk assessment of two people, the mother and the baby, and that the pivotal question is always what kind of thought she is having about the child.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

Having a new baby can be one of the hardest times, and it is common to struggle. Tell me how you have been in yourself since the birth, and how things are with the baby.

Then you listen for which it is. A sustained low mood and difficulty bonding is depression. Frightening thoughts she resists is an obsessional disorder. A rapid, perplexed, fluctuating state with strange beliefs is a psychosis, and it is an emergency.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Postnatal depression

First, postnatal depression. Common, affecting around one mother in ten, not her fault, and not a sign she is a bad mother. The bonding is often the concern the referral leads with.

Then, to close, these.

How long is it now since the baby was born? Are you breastfeeding at the moment? Who is helping you? Are you getting any sleep at all? Have you had any thoughts of harming yourself, or any thoughts about the baby that frighten you? Has anything like this happened to you before, or to anyone in your family?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is postnatal depression. It is common, it affects around one mother in ten, it is not your fault, and it does not mean you are a bad mother. It is very treatable. Medically, an antidepressant, and there are ones we can use safely while you are breastfeeding, such as sertraline. Psychologically, cognitive behavioural therapy or interpersonal therapy, which is often the first choice where symptoms are mild or moderate. And socially, practical help with sleep and feeds, the health visitor, support with bonding, and the people around you. You will get better, and the bond with your baby recovers as you do.

Postpartum psychosis

Postpartum psychosis. A rapid-onset illness in the days after birth, affecting the way the mother sees things. It is a psychiatric emergency, and it has one of the best recoveries in the whole of psychiatry.

Then, to close, these.

How many days is it since the birth? Who is with the baby right now? Have you or anyone in your family ever had a high or a low period, or been in hospital for their mental health? I am worried about you, and I would like to admit you and the baby together to a specialist unit, today.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What is happening is postpartum psychosis. It is an illness, it has come on very quickly after the birth, and it is affecting the way you are seeing things. It is a medical emergency, but I want you to hear the other half of that. It has one of the best recoveries in the whole of psychiatry. Medically, an antipsychotic, often with lithium, and electroconvulsive therapy where it is very severe. Practically, admission to a Mother and Baby Unit, so you and your baby stay together. And afterwards, talking therapy, and a plan for any future pregnancy, because the risk comes back. You are unwell, and you will recover.

Perinatal obsessive-compulsive disorder

Perinatal obsessive-compulsive disorder. Frightening intrusive thoughts of harm coming to the baby, that horrify the mother. The single most important thing you say is that these thoughts are a symptom, and the opposite of intent.

Then, to close, these.

How long have these thoughts been coming? Do they horrify you? Are they the very last thing you would ever want? What have you stopped doing with her because of them? I want to say this clearly. These thoughts are a symptom, and they are the opposite of what you want. They do not mean you will act on them.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is obsessive-compulsive disorder, of the kind that arrives after childbirth. I want to say the most important thing first. These thoughts horrify you. That is exactly what tells me they are obsessions, and it is the opposite of intent. Mothers with this condition are not the ones who harm their babies. Treatment works well. Medically, an antidepressant such as sertraline, which is compatible with breastfeeding. Psychologically, cognitive behavioural therapy with exposure and response prevention. And practically, support from the perinatal team, and stopping the checking and the avoidance so you can get back to being with her.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one question. What kind of thought is she having about the baby, feared, or believed, and how fast must you therefore move.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Psychotic Disorders and Descriptive Psychopathology bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of psychosis and of the descriptive work on abnormal belief. It runs from first-episode psychosis and schizophrenia, through the phenomenology that decides where a belief lands, to the encapsulated delusional disorders where one fixed belief sits in an otherwise intact life. You never argue with a belief; you understand it, characterise it, and treat the illness behind it.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the psychotic illnesses, and of the descriptive psychopathology, delusion, overvalued idea, primary and secondary, that underpins them.

The task is to elicit the psychotic symptoms without arguing with them, to characterise the beliefs, and to place them, first episode, schizophrenia, delusional disorder, or a look-alike, before giving the formulation and the risk.

The thread is that the risk lives in what the belief makes the person do, and that in the encapsulated forms, morbid jealousy and erotomania, the safety of another person is part of the station.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

I would like to understand how things have been for you. Have there been experiences lately that others did not seem to share, or beliefs that people around you have found hard to accept?

Then you listen for the shape. A fuller picture of voices, interference and withdrawal is a first-episode or schizophrenic illness. One fixed, encapsulated belief in an otherwise intact life is a delusional disorder. And whatever the belief, you never dispute it, you characterise it.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

First-episode psychosis and schizophrenia

First, first-episode psychosis. The mind has started producing experiences, voices or beliefs, that feel completely real from the inside but come from the illness. Treating it early makes a real difference.

Then, to close, these.

How long has all of this been going on? What has it stopped you doing? College, work, seeing people? Are you using any drugs at the moment, cannabis or anything else? Do the voices ever tell you to do things, and have you ever come close to doing them? What do you think is causing all of this yourself?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have been experiencing is called psychosis. It means the mind has started producing experiences, voices or beliefs, that feel completely real from the inside but are coming from the illness. This is a first episode, and treating it early makes a real difference to how well you do. Medically, an antipsychotic, at the lowest dose that works, with monitoring of your weight, your bloods and your heart. Psychologically, cognitive behavioural therapy for psychosis, and family work, which is one of the strongest ways of preventing relapse. And socially, support with college or work, and stopping the cannabis, which is the single biggest thing you can do yourself.

Delusion, the full assessment

The full assessment of a delusion. Not a diagnosis in itself, but the descriptive work that decides where a belief lands. You never argue with it, you understand it, and you characterise it.

Then, to close, these.

How long have you believed this now? What have you done about it so far? What are you planning to do next? Do the people around you, your family, your community, see it the same way? Has this belief changed how you eat, sleep, or where you go?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

I can see that this belief feels completely real to you, and I am not going to argue with you about it. What I can tell you is what I think is happening. I think you are unwell, and that the illness has made this belief feel certain. That is called a delusion, and it is a symptom, in the same way that a fever is a symptom. It is treated with an antipsychotic medication, which works on the certainty and the distress rather than by arguing you out of it. Alongside that, talking therapy that helps you look at the evidence at your own pace, and practical support so that this belief costs you less in your work and your relationships while you recover.

Overvalued idea

The overvalued idea. A belief you can follow the logic of, arrived at understandably, but that has come to dominate the life. It is not mad, and the difficulty is not the belief itself but how much room it takes up.

Then, to close, these.

How long have you thought this way? How much of your day goes on it now? What have you changed in your life because of it? Do the people you worship with, or the people around you, believe the same thing? If someone showed you good evidence against it, would you look at it?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have described is what we call an overvalued idea. I can follow how you arrived at it. It is not mad, and I am not going to tell you it is nonsense. The difficulty is not the belief itself. It is how much of your life it is now taking up. That is what I would like to help with. Medication has a limited role here, unless there is a depression or anxiety underneath, which we would treat. The main treatment is psychological, working on how much room it takes up and what it is costing you. And practically, we would look at the parts of your life that have shrunk around it.

Delusional disorder and morbid jealousy

Delusional disorder. The mind has become absolutely certain of one thing, and everything else about the person is working, which is exactly why it is so easy to miss. In the jealous form, it is one of the highest-risk beliefs in psychiatry.

Then, to close, these.

How long have you believed this about her? Outside of this, how is work, and how is everything else? How much are you drinking at the moment? What has happened when you have been most certain? Has it ever come to anything physical? Are there children in the house? And where is she right now?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

I think what is happening is an illness called a delusional disorder. It means the mind has become absolutely certain of one thing, and it will not shift, even when the evidence is against it. Everything else about you is working, which is exactly why it has been so hard for anyone to spot. Medically, an antipsychotic is the treatment, and it works slowly, so it needs patience. Psychologically, cognitive behavioural therapy where you are willing to engage. And practically, and I have to be honest with you about this, we have to think about your partner's safety, and about the drinking, because that pours petrol on it. I would rather tell you that to your face than go behind you.

Erotomania

Erotomania. The delusional-disorder belief that a particular person, often of higher status, is secretly in love with the patient. The management is as much about the safety of the other person as about treatment.

Then, to close, these.

How long have you known that she feels this way about you? Have you ever spoken to her, or met her? Have you written, called, or gone to find her? What did you make of it when she said no? What are you planning to do next, and what would you do if someone stood in the way?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

I think you have an illness called a delusional disorder, of the kind where the mind becomes certain that someone is in love with you. It is a real illness, and it is not your fault, and it is treatable. Medically, we treat it with an antipsychotic. Psychologically, with therapy once you are more settled. And practically, I have to be straightforward with you. Contacting her, or going to find her, will end in the police and in court, and that will harm you more than it will harm her. Part of my job is to help you keep out of that, and part of it is to make sure she is safe. I will always tell you what I am doing.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one line. Never argue with a belief, characterise it, and remember the risk lives in what it makes the person do, and in the encapsulated forms, in the safety of someone else.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Substance Use and Addictive Disorders bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the addictive disorders. Every member shares the same dependence syndrome, a compulsion, impaired control, tolerance, withdrawal, and the primacy of use. What differs is the drug, the emergency each can produce, and whether stopping suddenly is merely unpleasant or genuinely dangerous. You never judge, and you place the burden of denial on the patient by asking when they last used, not whether they use.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of dependence, across alcohol, opioids and the sedative drugs.

The task is to establish the dependence syndrome, recognise the emergency each substance can cause, and set out a safe plan, always in three parts, biological, psychological and social.

The thread is chronology, whether a psychiatric symptom came before or after the use, and safety, whether the withdrawal is the harmless kind or the kind that seizes and kills.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

I would like to understand your drinking, or your using, without any judgement. When did you last have some, and how much do you have on a usual day?

Then you build the timeline. When it started, how it grew, whether the body now needs it, and how any other symptoms, voices, low mood, confusion, sit in relation to the use. The order in time decides the diagnosis.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Alcohol dependence

First, alcohol dependence. The drinking is no longer fully under control, it has taken priority over other things, and the body has become used to it. You are not there to judge.

Then, to close, these.

How long has it been at this level? What is the longest you have gone without a drink, and what ended it? Have you ever had a fit, or seen things, when you stopped? Are you driving? And is anyone depending on you at home? What would you like to happen next, if we could help?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From what you have described, you have alcohol dependence. That means your drinking is no longer fully under your control, it has taken priority over other things, and your body has become used to it, which is why you shake in the morning. This is treatable, and I am not here to judge you. Medically, a planned detoxification with chlordiazepoxide, thiamine to protect your memory, and then a medication such as acamprosate or naltrexone to help you stay stopped. Psychologically, motivational work and relapse prevention. And socially, the alcohol service, peer support, and help with the job and the family. I would ask you not to stop suddenly on your own, because that is the dangerous way to do it.

Alcoholic hallucinosis

Alcoholic hallucinosis. The drinking has caused voices, but the mind is otherwise clear, the person knows where they are, and they are not confused. That clear sensorium is what tells you this is not the dangerous confusion of withdrawal delirium.

Then, to close, these.

How long have you been hearing them? Are you still drinking now, or have you cut down? Do they ever tell you to do anything? Do you know where you are, and what day it is? I am asking because it matters for the diagnosis. The good news is that this usually settles once the drinking is treated.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is called alcoholic hallucinosis. It means the drinking has caused you to hear voices, but your mind is otherwise clear, you know where you are, and you are not confused. That is important, because it tells me this is not the dangerous confusion we call the withdrawal delirium. It usually clears once the drinking is treated. Medically, we may use a short course of an antipsychotic, along with thiamine and a planned detoxification. Psychologically, relapse prevention work. And socially, the alcohol service and support at home. The voices are frightening, and they are not permanent.

Delirium tremens

Delirium tremens. A severe alcohol withdrawal with clouded consciousness, tremor, sweating and frightening visions, coming on a few days after the last drink. It can be dangerous, and it is treated now, not later.

Then, to close, these.

When did you last have a drink? Do you know where you are at the moment? Have you had any fits since you stopped? I am going to keep you here and treat this now, because it can become dangerous if we do not.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What is happening to you is called delirium tremens. It is a severe withdrawal from alcohol, and it is the reason you are confused, shaking and seeing things. I need to be honest with you. This can be dangerous if it is not treated, and that is why I want to keep you here. Medically, we treat it with a benzodiazepine such as chlordiazepoxide, with fluids, and with thiamine injections to protect your memory. We will monitor you closely for fits. Once you are through it, we will talk about the drinking itself and get the alcohol service involved. You are safe here.

Opioid dependence

Opioid dependence. The body has adapted to the drug, which is why the person gets ill without it. That is a physical process, not a failure of will, and treatment works.

Then, to close, these.

How long has it been at this level? Are you injecting? And do you ever share anything? Have you been tested for hepatitis and HIV? Have you ever overdosed? Do you use on your own? Do you have naloxone at home? What would you like from us? Are you looking to stop, or to stabilise first?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is opioid dependence. Your body has adapted to the heroin, which is why you get ill without it, and that is a physical process, not a failure of will. Treatment works, and people do recover. Medically, opioid substitution treatment with methadone or buprenorphine, so you are stable and not chasing it every day, plus testing for hepatitis and HIV, vaccination, and naloxone to keep at home. Psychologically, keyworking and relapse prevention. And socially, help with housing, money and the people around you. One thing I must say. If you stop for a while and then use your old amount, that is when people die. Please take the naloxone.

Benzodiazepine dependence

Benzodiazepine dependence. Often prescribed, and this is what these medicines do when taken for a long time. It is not the person's fault, and the plan is always a gradual reduction, never a sudden stop.

Then, to close, these.

How long have you been taking them now? Have you tried to come off before? What happened when you did? How is your memory, your balance, and your driving on them? I want to reassure you. We would never stop these suddenly. We would come down slowly, and at a pace you agree to.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What has happened is that your body has become dependent on the lorazepam. That is not your fault. It was prescribed to you, and this is what these medicines do when they are taken for a long time. The plan is a gradual reduction, and I want to reassure you that we will never stop it suddenly, because that can cause fits. Medically, we usually switch to diazepam, which is longer acting, and then come down slowly at a pace you agree to. Psychologically, cognitive behavioural therapy for the anxiety underneath, because if we do not treat that, the reduction will not hold. And practically, regular reviews, and no rush.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is two lines. Chronology decides substance-induced from primary, and safety decides everything, never let alcohol or a sedative be stopped suddenly and alone.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Organic and Neurocognitive Disorders bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the disorders of the brain itself. An acute, reversible confusion, the four progressive dementias, and the amnestic syndrome of long-term drinking. The whole family turns on one discrimination, delirium versus dementia, and each dementia announces itself by what changed first, memory, steps, personality, or hallucinations and stiffness.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the organic and neurocognitive disorders, where the trouble is in the physical brain.

The task is to separate the acute and reversible, delirium, from the chronic and progressive, dementia, and then to name which dementia by the shape of its onset, before giving the formulation and the support.

The thread is the level of consciousness, clouded and fluctuating in delirium, clear in dementia, and the search for reversible and physical causes before anything is put down to a permanent decline.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

Tell me what you, or the family, have noticed changing, and when it began, and whether it has been steady, or come and gone, or come on in steps.

Then you listen for the shape. Sudden, fluctuating and clouded is delirium. Gradual is a dementia, and what changed first, memory, planning in steps, personality, or hallucinations with stiffness, names which one.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Delirium

First, delirium. An acute confusion caused by something physical, with a fluctuating course and an impaired attention at its centre. It is not dementia, and it is usually reversible once the cause is found.

Then, to close, these.

Do you know where you are at the moment? And what time of day it is? Have you been seeing anything that other people cannot see? Are you sleeping at night, or in the day? Spoken to the family, when exactly did he change, and is he the same all day, or worse at some times? There is usually a physical cause for this, and once we find it and treat it, this settles.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What has happened to him is delirium. It is an acute confusion, caused by something physical, and it is why he is muddled, why he is seeing things, and why he is better at some times of day than others. It is not dementia, and it is usually reversible. The most important treatment is medical, which is to find and treat the cause. An infection, constipation, dehydration, or a medication. Alongside that, practical measures matter enormously. Familiar faces, his glasses and hearing aid, daylight, quiet at night, and orientation. We use sedating medication only if he is distressed or at risk. It can take some weeks to clear completely.

Alzheimer's dementia

Alzheimer's dementia. The commonest dementia, gradual, affecting recent memory first, which is why old memories are intact and yesterday's conversation is not. No cure, but a great deal that can be done.

Then, to close, these.

How long have you been noticing this? What have you had to stop doing for yourself? Are you still driving? Are you managing your money and your tablets? Who is at home with you, and how are they coping?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What the tests and your story point to is Alzheimer's disease. It is the commonest form of dementia. It affects recent memory first, which is why old memories are intact and yesterday's conversation is not. There is no cure, and I am not going to pretend otherwise, but there is a great deal we can do. Medically, a medication such as donepezil, which can help symptoms and slow the day-to-day decline for a period. Psychologically, cognitive stimulation therapy, which has good evidence. And socially, this is where most of the help lives. Support at home, memory clinic follow-up, carer support, financial help, lasting power of attorney, and an honest conversation about driving.

Vascular dementia

Vascular dementia. Damage to the brain's blood supply, coming on in steps rather than gradually, and affecting planning and speed more than memory. The most important treatment is protecting the brain that remains.

Then, to close, these.

Did it come on in steps, with sudden drops, or slowly all the way? Have you had a stroke, or a mini-stroke, or been told about your blood pressure? What have you had to stop doing? Are you still driving? The most important thing we can do now is look after your blood pressure, your sugar and your cholesterol.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is vascular dementia. It is caused by the blood supply to the brain being damaged, which is why it has come on in steps rather than gradually, and why the planning and the speed are more affected than the memory. The single most important treatment is medical, and it is not a memory tablet. It is controlling your blood pressure, your diabetes, your cholesterol, and stopping smoking, because that is what protects the brain you still have. Alongside that, cognitive stimulation and rehabilitation, treatment of any depression, and practical support at home. The memory medications are not licensed for this type, and I would rather tell you that than start something that will not help.

Frontotemporal dementia

Frontotemporal dementia. A dementia of the front of the brain, where the personality and behaviour change before the memory does, which is why it is so often mistaken for depression.

Then, to close, these.

Spoken to the relative, did his personality change before his memory did? Has he said or done anything in public that he never would have before? Has what he eats changed at all? How are you coping, at home, with all of this? This is a form of dementia, but not the usual kind, and that is why it has been hard to name.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What I think this is, is frontotemporal dementia. It is a form of dementia that affects the front of the brain, which is why the personality and the behaviour changed before the memory did. That is why it has been so often mistaken for depression. I want to be honest. There is no medication that slows it, and the memory medicines used in Alzheimer's do not help here and can make it worse. What does help is practical and psychological. Structure and routine, changing the environment rather than arguing with the behaviour, speech and language therapy where the words are affected, treating distress with an antidepressant rather than an antipsychotic, and above all, real support for you as the family. You are carrying a great deal.

Lewy body dementia

Dementia with Lewy bodies. Fluctuating cognition, well-formed visual hallucinations, and parkinsonism, together in one person. And a severe sensitivity to certain antipsychotics that you must warn about.

Then, to close, these.

Does she have good days and bad days, or good hours and bad hours? What does she see? Are they clear and detailed? Has she had any falls? Has she ever had a bad reaction to a medication for her mind? I want to be clear with you. Certain antipsychotic medicines are dangerous in this condition, and we will avoid them.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What she has is dementia with Lewy bodies. It explains all three things you have described. The good days and bad days, the seeing of people who are not there, and the stiffness and the falls. There is something I must be very clear about. Certain antipsychotic medicines are dangerous in this condition and can cause a severe reaction, so we avoid them, and you should tell any doctor who treats her. Medically, a medication such as rivastigmine often helps the hallucinations and the thinking. Practically, falls prevention, good lighting, and a medication review to remove anything sedating. And socially, carer support, because this one is hard to live with.

Korsakoff syndrome

Korsakoff syndrome. Long-term drinking and a lack of vitamin B1 have injured the part of the brain that lays down new memories, so the past is clear and today will not stick, and the mind fills the gaps without knowing it.

Then, to close, these.

Can you tell me again where we are, and what brought you in? How much have you been drinking, and for how long? Have you been eating properly through that time? How are you managing at home? Who is helping you? Your memory has been injured by the drinking, and we will support you with that, rather than test you on it.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is Korsakoff's syndrome. Long-term drinking, together with a lack of vitamin B1, has injured the part of the brain that lays down new memories. That is why the past is clear and today will not stick, and why your mind fills the gaps without you knowing it is doing so. That filling in is not lying. Medically, high-dose thiamine, given by injection first, and complete abstinence from alcohol, because that is what stops it getting worse. Practically, memory aids, routine, notebooks, and a supported placement where you have help. Some of it recovers slowly. Some of it stays, and we build around it.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one discrimination. The shape of the onset and the clarity of consciousness separate the reversible confusion of delirium from the progressive dementias, and each dementia is named by what changed first.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Eating and Feeding Disorders bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the eating disorders. All three share one engine, an overvalued idea that weight and shape are the true measure of a person's worth. What separates them is the behaviour, restriction, binge and compensation, or binge alone. You elicit the meaning behind the behaviour, you keep numbers and targets out of the room, and you never let the illness recruit you as its ally.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the eating disorders, all driven by an overvalued idea about weight and shape.

The task is to elicit the psychopathology and the behaviours sensitively, judge the physical risk, and give a formulation that names the illness as an illness, not a choice.

The thread is that you draw out the meaning rather than the numbers, you never collude with the drive to thinness or reassure about appearance, and you always screen the mood and the physical danger.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

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.

Then you listen for the behaviour, which tells the members apart. Marked restriction and a low weight. Binges followed by vomiting or laxatives. Or binges without any compensation. And you hold, throughout, that the overvalued idea is the illness, not the number on a scale.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Anorexia nervosa

First, anorexia nervosa. A serious illness, not a lifestyle choice and not attention-seeking, that makes weight and shape feel like the most important thing about the person, and that hides how ill the body is getting.

Then, to close, these.

What has your weight done recently, and how do you feel about that? Have your periods stopped? Are you feeling cold, faint, or dizzy? What would it mean to you, in yourself, to put on a little weight? I would like to check your pulse, your blood pressure and your bloods today, because I care about protecting your heart. Who knows about this, and who is supporting you?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is anorexia nervosa. It is a serious illness, and it is not a lifestyle choice or something you are doing for attention. The illness makes weight and shape feel like the most important thing about you, and it is very good at hiding how ill your body is getting. Treatment has three parts. Medically, looking after your heart and your body, and careful refeeding, because feeding you too fast is itself dangerous. Psychologically, and this is the main treatment, a specialist therapy for eating disorders, or family therapy where you are younger. And socially, support with school or work, and your family alongside you. People do recover from this fully. I am not going to take control away from you, I am going to help you get free of something that has taken it.

Bulimia nervosa

Bulimia nervosa. A cycle. You restrict, the body drives a binge, the shame drives the vomiting, and the vomiting makes the next binge more likely. That is why willpower has not broken it, and it is not a lack of willpower.

Then, to close, these.

How often is this happening now, and for how long has it been going on? Any dizziness, palpitations, or swelling by your jaw? How are your teeth? Who knows about this? And how has your mood been? Have you ever harmed yourself?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is bulimia nervosa. It is a cycle. You restrict, then the body drives a binge, then the shame drives the vomiting, and the vomiting makes the next binge more likely. That is why willpower has not broken it, and it is not a lack of willpower. Treatment is effective. Psychologically, guided self-help first, then cognitive behavioural therapy for eating disorders, which is the main treatment. Medically, fluoxetine at a higher dose than we use for depression, and blood tests to check your salts, plus a dentist, because the acid damages the enamel. And socially, regular eating, and support so you do not have to keep it secret. I will not be talking to you in numbers or targets, I will be helping you get free of the cycle.

Binge eating disorder

Binge eating disorder. Real episodes of loss of control, with no purging afterwards, so it is often missed and the person is simply told to eat less. That is not treatment.

Then, to close, these.

How often is this happening, and for how long? Do you do anything afterwards to make up for it? How do you feel about yourself afterwards? How has your mood been alongside this? Has your health changed because of it?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you have is binge eating disorder. The binges are real episodes of loss of control, and because you do not purge afterwards, it is often missed, and people are told simply to eat less. That is not treatment. Psychologically, guided self-help and then cognitive behavioural therapy for eating disorders is the first-line treatment, and it works. Medically, we would treat any depression alongside, and look after your related health without making your weight the focus of the conversation. And socially, regular meals rather than restriction, because restriction is what sets up the next binge.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one line. The overvalued idea of shape and weight is the illness, so elicit the meaning, never the numbers, and never let the illness make you its ally.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Neurodevelopmental Disorders bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the neurodevelopmental conditions. Every member is lifelong, present from early development, even when it only becomes limiting as the demands of life outgrow the person's ways of coping. Two errors sink the station, calling a lifelong difference a new illness, and, the opposite, blaming a genuinely new symptom on the disability. Date everything, and adapt how you interview.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the neurodevelopmental conditions, present from early childhood.

The task is to establish the lifelong pattern, adapt the interview to the person, and, where there is a new change on a known baseline, hunt a fresh cause rather than overshadowing.

The thread is a single axis, lifelong versus new, and the cardinal rule that a new symptom in a person with a disability needs a fresh cause found, never attributed to the disability by default.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

Say something like this.

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?

Then, for every difficulty they raise, you drop the anchor that decides it. Has this been true since you were young, or is it something that has changed more recently. Lifelong points to a neurodevelopmental condition unmasked by demand. New on a lifelong baseline points to a fresh, treatable problem on top.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Attention deficit hyperactivity disorder

First, attention deficit hyperactivity disorder. Present since childhood, showing in more than one part of the life, and costing real things. It is not laziness, and it is not an intelligence problem.

Then, to close, these.

Was this there at school? What did your reports say about you? Does it show at work as well as at home? What has it cost you? Jobs, money, relationships, driving? Is there anyone who knew you as a child that I could speak to? How much alcohol or anything else are you using to manage it?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From everything you and your mother have told me, you have attention deficit hyperactivity disorder. It has been there since childhood, it shows in more than one part of your life, and it has cost you real things. It is not laziness, and it is not an intelligence problem. Treatment is not only medication. Medically, a stimulant such as methylphenidate or lisdexamfetamine, with your blood pressure, pulse and weight monitored, or atomoxetine if a stimulant is not suitable. Psychologically, cognitive behavioural therapy adapted for attention difficulty, and coaching. And practically, structure, lists, alarms, adjustments at work, and treating the alcohol if it has been doing the job of the medication.

Autism spectrum disorder

Autism spectrum disorder. Not an illness and nothing to cure, but a lifelong difference in how the person processes people, information and the world. What we treat is anything that is causing suffering.

Then, to close, these.

Has this been the way you are since you were a small child? Where does it cause you the most difficulty now? Is there anyone who remembers your early childhood that I could speak to? How is your mood, and your anxiety, alongside all of this? What would help you most, if we could change one thing about how the world meets you?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From what you have described, and from what your childhood history tells me, you are autistic. I want to be careful with my words here. This is not an illness and there is nothing to cure. It is a lifelong difference in how you process people, information and the world around you. What we treat is anything that is causing you suffering. Medically, any co-occurring anxiety, depression or attention difficulty. Psychologically, adapted therapy, which needs to be more concrete and more visual than standard therapy. And socially, and this is the biggest part, adjustments. At work, at appointments, with noise and light, and with how much notice you get before things change. The diagnosis itself often helps people a great deal.

Intellectual disability

Intellectual disability. Present since childhood, graded on both intellectual and everyday functioning. When someone with a disability presents with a new change, you look for a fresh cause first, and never blame it on the disability.

Then, to close, these.

Spoken to the carer, what could he do a year ago that he cannot do now? How is he with money, with travel, with looking after himself? Is he in any pain? Constipated? Any trouble with his teeth, or any fits? Has anything changed around him? A move, a new member of staff, a loss? Nothing here should be put down to his disability until we have checked his body first.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

What you are describing in him is a change from his usual self, and I do not want to put that down to his learning disability, because that is a mistake we make too often. First, medically, we look for a physical cause. Pain, constipation, teeth, an infection, seizures, or a medication side effect. Then we look at his mental health, because depression in someone with a learning disability often shows as withdrawal and behaviour rather than as words. Then, psychologically and socially, we look at what has changed around him, and whether the behaviour is communicating an unmet need. Medication for behaviour is the last resort, not the first. And we would want to be sure that nobody is mistreating him.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one axis. Lifelong versus new, and a new symptom in a person with a disability gets a fresh cause found, never blamed on the disability.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Personality Disorders bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family of the enduring patterns of relating and feeling. The modern frame grades the disorder by severity and describes it by trait, with the borderline pattern as its most examined form. The whole skill is telling a lifelong pattern from an episode, a situation, or an acquired change, and doing it in warm, non-pejorative language, because a pattern is described, never a person judged.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the personality disorders, the enduring patterns of self and relationships.

The task is to establish that the difficulty is a genuine pattern, enduring, pervasive, early and impairing, describe it without judgement, and offer a plan whose heart is a structured therapy, not a tablet.

The thread is that the words are marked as hard as the symptoms, that you describe a pattern rather than label a person, and that you refuse to over-call a pattern where an episode, a situation, or an acquired change fits better.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them lead.

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 run the four tests in your head, enduring, early, pervasive, impairing, and you draw out the relational pattern, how relationships start and end, the sense of self, the emptiness, and the way feelings come and go under stress.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Personality disorder, the ICD-11 frame

First, the personality disorder itself, in its modern frame. Long-standing difficulties, going back to youth, showing across the life rather than in one place. You describe a pattern, not a person, and the words are marked as hard as the symptoms.

Then, to close, these.

How long have things been this way for you? Since your teens, or is this new? What is still working in your life? How much are you drinking or using? What would you want to be different, a year from now? I am not going to label you and leave. This is something we can work on together.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From what you have told me, the difficulties you have had are long-standing, they go back to when you were young, and they show up across your life rather than only in one place. We would describe that as a personality disorder. I know that phrase can sound like a judgement, and I do not mean it as one. It describes a pattern, not a verdict on who you are. There is no tablet for the pattern itself. Medically, we treat depression, anxiety or anything else alongside it. Psychologically, and this is the real treatment, a structured therapy such as dialectical behaviour therapy or mentalisation-based therapy. And socially, stability, a consistent team, and a plan that everyone follows. People do get better with this.

Borderline pattern

The borderline pattern. Intense feelings that come fast and settle slowly, relationships that get very close then break, a sense of emptiness, and self-harm that is doing something for the person rather than being simply attention-seeking.

Then, to close, these.

How long has it been like this? Since you were a teenager? What does the cutting do for you? How do you feel just before, and just after? Who is in your life at the moment that you trust? What has helped in the past, even a little? Are you safe to go home tonight, and what would you do if it built up again?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

From everything you have told me, the pattern is a long-standing one, going back to your teens. Intense feelings that come fast and take a long time to settle, relationships that get very close and then break, a sense of emptiness, and the cutting, which I understand is doing something for you rather than being simply attention seeking. That pattern is what we call the borderline pattern. Medication is not the main treatment, and I would be cautious about adding tablets. The real treatment is psychological, dialectical behaviour therapy or mentalisation-based therapy, which teach you to hold the feeling without acting on it. And practically, one consistent team, a crisis plan you have helped write, and making the home safer.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one discipline. Establish a genuine pattern by the four tests, describe a pattern not a person, and refuse to over-call it where an episode, a situation, or an acquired change fits better.

Do those two things and any station in this family is yours.

Before we begin

Welcome. This is the Risk Assessment bank. A family of conditions, taken one at a time, each drawn out the same way, and each closed the same way.

This is the family that is not a diagnosis but a task, and the one that fails stations outright. Risk is a narrative you draw out, warmly and without judgement, not a checklist you rattle through. The examiner is always asking the same thing underneath, what has the illness made this person do, or what might it drive them to do next, and how well have you weighed the factors that hold them back.

Two habits carry every one of these cluster stations. Keep them close.

One. One question opens each symptom. You do not fire a checklist. For each feature you want, you have a single, natural opening question. You ask it, you let them talk, and you move on the moment you have what you came for. The list lives in your head, never in your mouth.

Two. Never close on a bare diagnosis. You name the condition plainly, in words the person can hold, and then, in the same breath, you give the plan in three parts. Biological, psychological, social. A name without a plan frightens people. A name with a plan is treatment.

Ready. Let us walk in.

What this family is

Picture the family as a whole before you meet its members.

This is the family of the risk assessments, to the self and to others. It carries no ICD code, but it decides more stations than any diagnosis.

The task is to draw out the risk as a story, before, during and after an act, or along the gradient of an intention, and then to weigh it, and set a plan and a safety net.

The thread is that you never pass a categorical judgement, that you weigh protective factors rather than listing them, and that you are honest about what you cannot keep confidential when someone is in danger.

Check. Does the shape of the family make sense. Good. Let us find the opening.

The opening, shared across the family

However the door is labelled, you open the same way, warm and wide, and let them 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. You clarify gently rather than interrogating, you place the current intent along the gradient from a passing thought to a formed plan, and you weigh what holds the person back.

Then, once you know which member of the family you are in, you switch to its own questions, one opener per symptom, and you close on its own formulation.

Check. Shall we meet them, one at a time. Let us.

Suicide risk after an attempt

First, suicide risk after an attempt. You draw it out as a narrative, before, during and after, never as a checklist, and you never pass a categorical judgement, because that closes the person down.

Then, to close, these.

How do you feel now, knowing that you survived? Do you still feel the same way as you did that day? What has kept you going up to now? Is there anything at home, tablets or anything else, that we should sort out together? Who is at home with you tonight?

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

Thank you for being so honest with me. What you have told me tells me two things. That you were serious that night, and that part of you is still here talking to me now. I think you have a depressive illness, and depression is treatable, and it lies to people about whether things can change. Medically, we would start an antidepressant and review you quickly. Psychologically, talking therapy, and in the meantime a safety plan written by you and me together. Your warning signs, what you will do, who you will call. And practically, making the house safer, removing the tablets, and getting the people who care about you involved. You will not be leaving here without a plan and a date.

Violence risk

Violence risk. Structured around the history, the current drivers in the mental state, and the situation. You are honest and plain, and you tell the person that where someone is in danger you cannot keep it between you, and you will tell them before you tell anyone else.

Then, to close, these.

Is there someone in particular that you feel this way about? Have you thought about how? Is there anything at home? What has stopped you so far? I have to be honest with you. If someone is in danger, I cannot keep that between us, and I will tell you before I tell anyone else.

Then you name it plainly, and you give the plan in three parts. Biological, psychological, social.

Thank you for telling me. I am going to be straight with you, because I think you would rather I was. I think you are unwell, and that the illness is driving these thoughts, and that means they can be treated. Medically, an antipsychotic, and if you have stopped your medication, we need to restart it, possibly as a long-acting injection. Psychologically, work on the beliefs and the anger once you are settled. And practically, admission, sometimes under the Mental Health Act, so that you are safe and so is everybody else. I also have to tell you that where someone is specifically at risk, I cannot keep that between us. I will tell you before I tell anyone else. I would rather do this with you than to you.

Telling them apart. The discriminators.

Half the marks in any cluster station are for telling the members apart. Say the discriminator out loud.

Check. Name the one that fits, and the feature that decided it. That is the mark.

The two habits, again

Carry these two out of the room, whichever member of the family you met.

One. One question opens each symptom. Ask the single opener, let them talk, move on. The full list stays in your head.

Two. Never close on a bare diagnosis. Name it plainly, then the plan in three parts, biological, psychological, social.

The thread through this whole family is one line. Draw the risk out as a narrative, never a checklist, judge intent over lethality, weigh every protective factor, and be honest about the limits of confidentiality.

Do those two things and any station in this family is yours.