Collateral History
Dementia Collateral, the Memory-Clinic History
Before we begin
Welcome. This is the dementia collateral, the memory-clinic history. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A husband, or a wife, or a daughter has come to the memory clinic to describe a year of memory trouble in someone they love. Only they hold the baseline and the trajectory, because the patient can no longer report their own decline reliably, and often does not know how far it has gone. This is the station that teaches the whole family, so run it cleanly.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to take a collateral history from this relative about the patient's memory problems. You are not seeing the patient today.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: the baseline before it started, the timeline and its gradual shape, the five domains of dementia, the effect on daily function, the risks the relative can see, and the medical, family and social background, ending with what happens next.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their wife?
Two. Explain why their view matters, and thank them for coming.
Thank you so much for coming in. You live with them and see them every day, so you can tell me things they may not be able to tell me themselves, and that is genuinely the most useful part of the whole assessment.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is a spouse or an adult child who has watched the decline up close, can give a detailed and reliable account, and carries real worry, and often exhaustion, of their own. They hold the family history and the past medical history too. Take their account structerd and warm, and remember that the risks they describe, the wandering, the gas left on, are the part that changes what you do today.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Each cluster is the question to the informant, then why only they can give it, then what it tells you.
4.1 - The baseline, and the timeline
Ask the informant.
Can you take me back to before all this started, what was he like, and what could he do for himself? And when did you first notice a change, and has it come on slowly over months and years, or in sudden steps?
Why only they can give it. There is no score you can read cold, only a change from this person's own baseline, and the informant is the only source of that baseline.
What it tells you. A gradual, progressive decline over months to years points towards Alzheimer type dementia. A stepwise decline points towards a vascular cause. The shape of the onset is the diagnosis.
4.2 - The five domains
Ask the informant, in plain words for each.
Does he forget recent conversations, repeat himself, or misplace things, while older memories stay sharp? Does he struggle with familiar tasks like cooking or dressing? Any trouble finding words? Does he fail to recognise people or places he knows? And has he lost his drive or interest in things?
Why only they can give it. These are the amnesia, apraxia, aphasia, agnosia and apathy of dementia, and each shows in daily life, which only someone living alongside him sees.
What it tells you. Recent memory failing first, with distant memory preserved, is the early Alzheimer signature. Name the five domains and you have covered the syndrome.
4.3 - Function and daily living
Ask the informant.
What has he had to stop doing for himself? How is he managing money, bills, medication, cooking and washing?
Why only they can give it. Function is measured in the home, not the clinic, and the patient will often insist he is coping when he is not.
What it tells you. Loss of independence across daily activities is part of the diagnostic threshold and shapes the care plan.
4.4 - Ruling out the other dementias by what is absent
Ask the informant.
Has he had any strokes or vascular problems? Any detailed hallucinations, marked slowness or stiffness, or falls? Any big change in personality or disinhibited behaviour?
Why only they can give it. These are the flags for the other subtypes, and the informant is the one who has, or has not, seen them.
What it tells you. Vascular steps point to vascular dementia, hallucinations and parkinsonism and falls to Lewy body, personality change and disinhibition to a frontal type. Their absence is what lets you say Alzheimer, so the negatives are the diagnosis here.
4.5 - The risks, the part that changes today
Ask the informant.
Is he still driving? Any accidents or near misses at home, anything left on? Is he eating and drinking? Has he ever wandered or got lost? And, if I may ask gently, has he ever been aggressive, and how are you coping?
Why only they can give it. The risks live outside the consulting room, and the sensitive ones, aggression, the carer's own strain, the patient's vulnerability to others, are only reached if you ask kindly.
What it tells you. Driving, wandering, self-neglect, fire risk and carer stress are the findings that change the plan this week, not just the diagnosis. Excellent candidates always reach the carer and the vulnerability.
4.6 - The background
Ask the informant.
What is his medical history, and what medications is he on? Is there any dementia in the family? And who is at home, and what support is there?
Why only they can give it. The past medical, drug, family and social history are often held by the relative more completely than by the patient.
What it tells you. Reversible contributors, family risk, and the social scaffold you will build the care plan on.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Taking it as a thin patient history
Asking the informant the questions you would ask the patient wastes the station. Ask for the baseline, the trajectory and the risks, the things only they hold.
5.2 - Skipping the subtype-excluding negatives
Without asking about strokes, hallucinations, parkinsonism, falls and personality change you cannot say which dementia this is. The negatives are what make the Alzheimer label defensible.
5.3 - Missing the risks and the carer
Driving, wandering, food and fluid, and the carer's own strain are the scored, plan-changing findings. Reaching aggression and carer stress sensitively is what separates a good candidate from an excellent one.
5.4 - Closing on a bare diagnosis
Do not announce dementia and stop. Say it could be a dementia, most likely the Alzheimer type, that he needs assessing himself, and that reversible causes must be excluded first.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Summarise what they have given you, warmly.
From everything you have described, a gradual loss of recent memory over the last year, with his older memories intact, and the effect it is having at home.
Two. Name the picture without over-claiming it.
That pattern can point towards a dementia, and most often the Alzheimer type, but I want to be careful and not jump ahead, because we need to assess him properly and rule out other causes first.
Three. What happens next, for the patient himself.
The next steps are to see him, do some formal memory testing, check the blood tests his GP has probably started, and arrange a scan of the brain, partly to look for treatable causes.
Four. Support at home and for the risks.
We can bring in an occupational therapy assessment, and there are practical things for the wandering, like door alarms and tracking devices, and charities that support families going through this.
Five. Turn to the carer, and safety-net.
And I want to check how you are doing yourself, because this is a lot to carry. If anything worsens, or he is unsafe, here is how to reach us.
The thread of this station is baseline, trajectory, and the risks only an outsider sees, held together by care for the person describing it all.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is a collateral is not a shorter history, it is the baseline and the trajectory and the outside view of risk. Rule the other dementias out by their absent flags, and never hand a frightened relative a bare diagnosis.
Do those two things and any collateral station in this exam is yours to steer.
Delirium Collateral, Acute Against Chronic
Before we begin
Welcome. This is the delirium collateral, acute against chronic. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A relative describes a person who has become confused, and your job is to work out, from their account, whether this came on over hours to days or over months to years, because those are two completely different illnesses with two completely different responses. The informant holds the timeline, and the timeline is the diagnosis.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to take a collateral history from this relative about the patient's recent confusion. You are not seeing the patient today.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: the baseline and, above all, the shape and speed of the onset; the core features, inattention, fluctuation, altered awareness; the reversible-cause screen said out loud; the risks; and then the close that frames delirium as something to investigate and treat, not a diagnosis to settle.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their son?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming in so quickly. You know how he normally is, so you can tell me how big a change this is and how fast it happened, and that is exactly what I most need to know.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is a relative who is frightened, because the change has been sudden and dramatic and they may fear it is permanent. They hold the two facts that matter most, how sharp he was a week ago, and how fast he has changed. Reassure as you go, because delirium is common and often reversible, and a calmer informant gives a clearer history.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Each cluster is the question, why only they can give it, and what it tells you.
4.1 - The baseline and the speed of onset
Ask the informant.
How was he in himself a week or two ago, sharp, managing? And this confusion, did it come on over hours and days, or has it crept in slowly over months?
Why only they can give it. Only someone who knew the recent baseline can tell you how abrupt this is, and the patient cannot report his own timeline while confused.
What it tells you. An acute onset over hours to days, against a sharp recent baseline, is delirium. A slow decline over months is dementia. This single contrast is the point of the station.
4.2 - Fluctuation and inattention
Ask the informant.
Does it come and go through the day, and is it worse in the evening or at night? Can he follow a conversation, or does his attention drift away mid-sentence?
Why only they can give it. Fluctuation across a day and a sundowning pattern are only visible to someone with him for hours, not in a single snapshot.
What it tells you. A fluctuating course with prominent inattention, often worse at night, is the core of delirium. Inattention is the single most useful feature.
4.3 - Altered awareness and perception
Ask the informant.
Has he seemed muddled about where he is or what time it is? Has he seen or heard things that were not there, or become suspicious or frightened?
Why only they can give it. Disorientation and perceptual disturbance are reported by the witness, especially when the patient has no memory of them afterwards.
What it tells you. Clouding of awareness, disorientation and visual hallucinations support delirium over a primary psychiatric illness.
4.4 - The reversible-cause screen, said out loud
Ask the informant.
In the days before this started, any signs of infection, a urine or chest infection, a temperature? Any new medications, or recent surgery? Is he constipated, or passing water alright? In any pain? And does he drink alcohol, could he have stopped suddenly?
Why only they can give it. The trigger sits in the recent history, the new tablet, the fall, the infection, which the relative witnessed and the patient did not register.
What it tells you. Infection, drugs, constipation, retention, pain, metabolic upset and alcohol withdrawal are the common reversible causes. Naming this screen aloud is a scored, and clinically vital, move.
4.5 - The risks
Ask the informant.
Has he been unsteady or had any falls? Has he tried to wander, or become agitated, or pulled at anything like a drip or a dressing?
Why only they can give it. The behavioural risks of the confused state are seen by whoever is watching him.
What it tells you. Falls, wandering, agitation and pulling at lines are the immediate safety issues that shape where and how he is nursed.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Not pinning the onset
If you never establish whether this is hours-to-days or months, you cannot tell delirium from dementia, and the whole station collapses. Nail the speed and shape of the change first.
5.2 - Forgetting the cause screen out loud
Delirium always has a cause. A candidate who does not audibly screen for infection, drugs, constipation, retention, pain and withdrawal has missed the reason the station exists.
5.3 - Calling it a psychiatric diagnosis
Delirium is a medical emergency, not a psychiatric endpoint. Framing it as a mental illness to be managed on a ward, rather than a cause to be found and treated, is the wrong verdict.
5.4 - Leaving the relative frightened
The sudden change terrifies families. Reassure that delirium is common and often reversible once the cause is treated, while you stay honest that you must investigate.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Summarise the shape.
From what you describe, this came on quickly over a few days, it comes and goes and is worse at night, and he could not hold his attention, whereas before he was sharp.
Two. Name it as a state with a cause, not a fixed diagnosis.
That pattern points to something called delirium, an acute confusional state, which is usually caused by something physical and treatable rather than being a lasting condition.
Three. What happens next.
So the priority is to examine him and run tests, looking for an infection, a medication problem, constipation or anything else that could be behind it, and to treat that.
Four. Safety and orientation.
In the meantime we keep him safe from falls, and it helps to keep the room calm, well lit in the day, with familiar faces and his glasses and hearing aids to hand.
Five. Honest and reassuring, and safety-net.
Many people recover fully once the cause is dealt with, though it can take time, and I will keep you updated. If he becomes more agitated or unwell, tell the nurses straight away.
The thread of this station is the shape of the onset, and a cause to be hunted, not a diagnosis to be settled.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is acute and fluctuating against gradual and progressive. Pin the onset, screen aloud for the reversible cause, and frame delirium as a physical emergency to investigate, not a psychiatric label to apply.
Do those two things and any collateral station in this exam is yours to steer.
A Recent Change in Behaviour, with Risk
Before we begin
Welcome. This is a recent change in behaviour, with risk. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A relative comes to you shaken, sometimes hurt, because the person they have lived with for decades has changed into someone they do not recognise, and today that change has spilled into harm. This is a collateral and a risk assessment at once, and it opens not with a question but with an acknowledgement of what she is carrying.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to take a history from this relative about the recent changes in the patient's behaviour, and to conduct a risk assessment. You are not seeing the patient today.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: receiving her distress first, the trajectory and its slow shape, the domains of change with memory spared, the young-onset family clue, and the risk assessment, ending on her safety tonight and a picture held open.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their wife?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming, and I can see this has been frightening. Take your time. What you can tell me about how he has changed is the most important thing I will hear today.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is a wife who is frightened and often physically shaken, sometimes clutching her neck, sometimes in tears, because her husband, a quiet and kind man for thirty years, tried to hurt her this morning. She is grieving the person he was while frightened of the person he has become. Acknowledge that before you take a single fact, or you lose the communication domain and her trust with it.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Take the cue first, then the history, then the risk. Each cluster is the question, why only she can give it, and what it tells you.
4.1 - Receive the feeling first
Do this before any history. Name what you see.
Before anything else, are you alright? What happened this morning sounds very frightening, and I am sorry you have been through it. We can go at whatever pace you need.
Why it comes first. She is clutching her neck and crying. A relative who has just been assaulted by a loved one cannot give a history until her fear is acknowledged.
What it tells you. Nothing clinical yet, and everything about whether the rest of the station happens at all. This is the scored communication that unlocks the history.
4.2 - The trajectory, slow not sudden
Ask the informant.
When did you first notice he was changing, and has it been over years, gradually, or did it come on suddenly? What was he like before?
Why only she can give it. The years-long drift from the man she married is only visible to someone who has watched the whole arc.
What it tells you. A slow, progressive change over years, rather than an acute onset, points towards a frontal type of dementia rather than a delirium or an acute psychiatric episode.
4.3 - The domains of change, with memory spared
Ask the informant.
Has his personality changed, become disinhibited, tactless, or made embarrassing remarks in public? Any rudeness at work, or crude jokes out of character? Can he still plan and organise? Any word-finding trouble? And, importantly, is his day-to-day memory actually alright?
Why only she can give it. Disinhibition and social lapses are, by their nature, reported by the people around him, not by him.
What it tells you. Personality and behaviour change, executive difficulty and language change, with memory relatively spared, is the frontal picture. Saying that memory is spared is what earns the diagnosis, because it is the opposite order to the usual dementia.
4.4 - The young-onset family clue
Ask the informant.
How old is he? And is there anything like this in his family, any early dementia or a condition affecting personality?
Why only she can give it. The family history is held by the relative, and a relatively young patient makes it worth chasing.
What it tells you. A younger age of onset should prompt the family-history question, and a familial frontal dementia in a parent is a strong pointer.
4.5 - The risk assessment the assault demands
Ask the informant.
Has he threatened or hurt you or anyone before today? Has he ever behaved inappropriately or been sexually disinhibited towards others? Are there weapons at home, and who else is in the house, including children or vulnerable people?
Why only she can give it. The history of threat and violence, and the makeup of the household, are known to her and are the substance of the risk assessment.
What it tells you. Previous threats, disinhibited or aggressive acts, and vulnerable people at home define the risk and the safety plan you must make tonight.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Ploughing into history over her tears
Starting the questions while she is still shaking loses the communication domain and, often, her cooperation. Acknowledge the assault and her fear first, always.
5.2 - Missing that memory is spared
In this picture memory is the domain that is preserved. Failing to establish that leaves you calling it Alzheimer, and missing the frontal diagnosis the case is built around.
5.3 - Skipping the family history
A younger patient with personality change should always prompt the family-history question. Omitting it misses the single most telling clue.
5.4 - Doing the history but not the risk
The card asks for a risk assessment and the man tried to strangle her today. Previous violence, sexual disinhibition and the household must be covered, and her safety tonight addressed.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Acknowledge again, and summarise.
Thank you for telling me all of this when you are so shaken. What you describe is years of change in his character and behaviour, with his memory largely intact, ending in what happened today.
Two. Name the picture, held open.
That pattern can point to a change in the front part of the brain, a frontal type of dementia, but I do not want to jump ahead, he needs a full assessment before anyone can be sure.
Three. What happens next.
We will arrange to see him, examine him, do cognitive testing and a brain scan, and take a careful history of the family side too.
Four. Safety first, and tonight.
But my first concern is you and your safety. Given what happened this morning, let us make a plan for tonight so that you are not at risk while we sort the assessment out.
Five. Support and safety-net.
This is a frightening thing to live with, and there is support for families in your position. If you feel unsafe at any point, here is exactly who to call.
The thread of this station is her fear first, then the slow trajectory with memory spared, then the risk the assault demands.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is receive the feeling before the fact, and remember that in this collateral memory is the domain that is spared. Chase the family history in a younger patient, and never do the history while leaving the risk, or her safety tonight, untouched.
Do those two things and any collateral station in this exam is yours to steer.
Depression Collateral
Before we begin
Welcome. This is the depression collateral. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A husband, a daughter, a friend describes someone whose mood has sunk, and who may be too slowed, too hopeless, or too ashamed to give a full account of themselves. The informant sees the early waking, the untouched plate, the withdrawal, and sometimes the things said in the dark that the patient will not repeat to you. Risk is the reason this station matters.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to take a collateral history from this relative about the patient's low mood. You are not seeing the patient today.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: the change and its timeline with any precipitant, the biological symptoms seen from outside, the cognitive and psychotic features, the effect on function and self-care, and the risk, ending on a close that keeps safety at the centre.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their husband?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming. When someone is very low they often cannot say how bad it is, or they play it down, so what you have seen from the outside tells me things they may not tell me themselves.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is someone who loves the patient and has watched them fade, and who may be carrying their own fear that they should have acted sooner. They hold the timeline, the precipitant, and, crucially, any warning signs of suicide the patient has let slip. Take their account gently, and make the risk questions feel like care rather than interrogation.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Each cluster is the question, why only they can give it, and what it tells you.
4.1 - The change, the timeline, the precipitant
Ask the informant.
When did you first notice the change in her, and what has her mood done since, got slowly worse, or lifted at all? Was there anything that seemed to set it off, a loss, a bereavement, an illness?
Why only they can give it. The direction of travel, and the precipitant, are often clearer to the observer than to the patient inside it.
What it tells you. A mood that has worsened steadily, especially after a loss, and is no longer reacting, points to a depressive illness rather than an adjustment that is resolving.
4.2 - The biological symptoms from outside
Ask the informant.
How is her sleep, is she waking very early? What about her appetite and weight? Is she worse first thing in the morning? And has she slowed down, or lost interest in things she loved?
Why only they can give it. Early morning waking, weight loss, diurnal variation and psychomotor change are visible to someone in the house, and the patient may not connect them to mood.
What it tells you. The somatic cluster, early waking, appetite and weight loss, diurnal variation, anhedonia and slowing, is the marker of a more severe, biological depression.
4.3 - Cognitive and psychotic features
Ask the informant.
Has she been saying she is worthless, or blaming herself, or that things are hopeless? Anything stranger, that she is guilty of something terrible, that her body is rotting, or that she has no money when she has?
Why only they can give it. Guilt-laden and nihilistic statements are often confided at home, and the relative can report them where the patient will not.
What it tells you. Worthlessness, guilt and hopelessness deepen the picture, and nihilistic or guilt delusions signal a psychotic depression that changes the treatment.
4.4 - Function and self-care
Ask the informant.
How is she managing day to day, work, the house, washing and dressing? Is she eating and drinking enough?
Why only they can give it. The collapse of function and self-neglect are measured in the home.
What it tells you. Stopping eating and drinking, and marked self-neglect, are severity and safety markers that may force the pace of treatment.
4.5 - The risk, the heart of it
Ask the informant.
Has she said anything that worried you, that life is not worth living, or that you would be better off without her? Has she done anything to harm herself, or hinted at a plan? Is there anything at home she could use? Has she ever harmed herself before?
Why only they can give it. Suicidal talk, quiet preparations, and past attempts are frequently known to the family before anyone else, and the patient may deny them to you.
What it tells you. Expressed ideation, any plan or preparation, access to means and previous attempts are the findings that determine how urgently, and how safely, she is managed.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Gathering symptoms but ducking the risk
A depression collateral that does not reach suicide has failed at its central purpose. What the patient hides, the relative has often heard. Ask it, gently and directly.
5.2 - Missing the biological symptoms
Early waking, weight loss, diurnal variation and slowing are the severity markers and they are seen from outside. Skipping them under-rates the illness.
5.3 - Overlooking psychotic depression
Guilt and nihilistic delusions turn this into a psychotic depression with a different treatment. Ask about them, or you miss the diagnosis and the danger.
5.4 - Closing on a bare label
Do not just say depression. Summarise, name it as a likely depressive illness needing assessment of the patient herself, and put the safety plan at the centre.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Summarise warmly.
From what you have told me, her mood has sunk over the last couple of months, she is waking early, not eating, blaming herself, and you have heard her say she would be better off gone.
Two. Name it, held open.
That sounds like it could be a depressive illness, and possibly a severe one, but I would want to assess her myself before being sure.
Three. Safety at the centre.
What you have said about her thoughts of not wanting to be here concerns me, and it means we need to see her urgently and make sure she is safe.
Four. What happens next.
We will assess her, and depending on what we find, that may mean treatment at home with close support, or, if the risk is high, a period in hospital, and there are effective treatments for this.
Five. Thank them and safety-net.
You did the right thing coming in. If before we see her she says or does anything that frightens you, or you cannot keep her safe, here is who to call straight away.
The thread of this station is the biological depression seen from outside, and the risk the patient will not tell you but the relative has already heard.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is what the patient hides, the informant has watched. Gather the biological symptoms and the psychotic features from the outside view, and never let a depression collateral end without reaching, and acting on, the risk.
Do those two things and any collateral station in this exam is yours to steer.
Psychosis Collateral, with Risk
Before we begin
Welcome. This is the psychosis collateral, with risk. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A relative describes someone who has changed, become guarded, withdrawn, preoccupied, sometimes hostile, and who may believe nothing is wrong. The informant has watched the illness from outside and can tell you what the patient will not, the muttering, the barricaded door, the accusation against a neighbour. The risk lives in who the beliefs are about.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to take a collateral history from this relative about the changes they have seen in the patient, and to assess risk. You are not seeing the patient today.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: the timeline of change, the phenomena they have witnessed, insight and self-care, the risk, especially the target of any beliefs, and the background of substances, treatment and family history, ending on a held-open close.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their mother?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming in. He may not feel there is anything wrong, so the things you have noticed, the changes in him over these weeks, are especially important for me to understand.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is a parent or partner who has watched someone they love become a stranger, frightened by beliefs and behaviours they do not understand, and often exhausted and worried about what he might do. They hold the timeline and the observed phenomena, and they know who his suspicions are aimed at. Take their account seriously and calmly, and do not dismiss the fear behind it.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Each cluster is the question, why only they can give it, and what it tells you.
4.1 - The timeline of change
Ask the informant.
When did you first feel something was wrong, and how has he changed since? Has it been a gradual drift over weeks and months, or a sudden shift?
Why only they can give it. The slow withdrawal from friends, work and self-care is an outside observation, invisible to the patient living it.
What it tells you. A gradual decline in function with growing preoccupation supports an evolving psychotic illness, and dates its onset.
4.2 - The phenomena they have witnessed
Ask the informant.
Have you seen him talking or laughing when no one is there, or seeming to listen to something? Has he said things that did not make sense, that he is being watched, followed, or interfered with? Has he become suspicious of people?
Why only they can give it. Responding to unseen voices and voicing strange beliefs are often reported by the family long before the patient will admit to them, if he ever does.
What it tells you. Apparent hallucinatory behaviour and expressed delusional beliefs, witnessed from outside, build the psychotic picture the patient may deny.
4.3 - Insight and self-care
Ask the informant.
Does he think anything is wrong? How is he looking after himself, eating, sleeping, washing? Is he still working or seeing anyone?
Why only they can give it. The loss of insight and the decline in self-care are, again, seen from outside.
What it tells you. Absent insight and self-neglect raise both the severity and the difficulty of engaging him in treatment.
4.4 - The risk, and the target of the belief
Ask the informant.
Who are these suspicions aimed at, is it anyone in particular? Has he threatened anyone, or acted on any of it? Has he been aggressive, or frightened enough to try to protect himself? And any thoughts or talk of harming himself?
Why only they can give it. The family knows the target of a persecutory belief and any acts so far, which is exactly what a paper risk screen cannot capture.
What it tells you. A named persecutor, threats, acts, command phenomena or self-harm talk define the risk to others and to self and drive the urgency of the response.
4.5 - Substances, treatment and family history
Ask the informant.
Is he using any drugs, cannabis or others, or drinking? Has he had anything like this before, and is he on any medication for it, and taking it? Anyone in the family with similar problems?
Why only they can give it. Use, adherence and family history are frequently held more accurately by the relative than by the patient.
What it tells you. Cannabis or stimulant use, non-adherence to a known medication, and family history reframe the relapse and its likely drivers.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Asking as if the patient were present
The value here is what the family witnessed that the patient denies. Ask for the observed behaviours and the timeline, not the phenomenology you would take from the patient direct.
5.2 - Not finding the target of the belief
Risk in psychosis often sits in who the delusion is about. Failing to ask whom his suspicions are aimed at misses the core of the risk assessment.
5.3 - Ignoring substances and adherence
Cannabis and a stopped antipsychotic are the two commonest drivers of relapse. Omitting them leaves the picture unexplained.
5.4 - Breaching the patient's confidence
You may hear the family out, but you do not disclose the patient's private information to satisfy them. Hold the boundary you set at the start.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Summarise the observed change.
From what you describe, over the last couple of months he has withdrawn, seems to be responding to things you cannot see, believes he is being watched, and has grown suspicious, particularly of the neighbour.
Two. Name it, held open.
That pattern can point to a psychotic illness, but I would need to assess him myself before saying more.
Three. Address the risk.
What you have told me about his suspicions of the neighbour, and how frightened he is, matters, and it means we need to see him soon and think carefully about everyone's safety, his included.
Four. What happens next.
We will arrange to assess him, which sometimes takes some planning when someone does not feel unwell, and depending on what we find there are treatments that help a great deal.
Five. Support and safety-net.
This is frightening and wearing for you too. If he threatens anyone, or you feel unsafe, or he talks of harming himself, here is exactly who to call.
The thread of this station is the change seen from outside and the target of the belief, in a patient who may deny all of it.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is the outside view of an illness the patient denies, and the risk that lives in who the belief is about. Gather what they witnessed, find the target, ask about cannabis and adherence, and hold the patient's confidentiality even under a worried relative's pressure.
Do those two things and any collateral station in this exam is yours to steer.
The Angry or Complaining Relative
Before we begin
Welcome. This is the angry or complaining relative. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A relative comes to you angry, about a delay, a decision, a perceived failure of care, and the temptation is to defend the service or to promise anything to make the anger stop. Both fail. The station is a de-escalation with a history folded inside it, and it is won by receiving the feeling, finding the real grievance, and being honest about what you can and cannot do.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to speak with this relative, who is unhappy about the patient's care. You are not seeing the patient today.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The shape is: let them speak and receive the anger, find and acknowledge the legitimate grievance, set the confidentiality boundary calmly, gather what you can about the patient along the way, and offer concrete, honest next steps, without defensiveness and without over-promising.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their son?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming in, and I can hear that you are upset. I want to understand exactly what has happened, so please tell me in your own words, and I will listen.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is a relative who is angry, and often frightened underneath the anger, because someone they love is unwell and they feel unheard or let down. Sometimes the grievance is entirely fair. They are not the enemy, and meeting them with defensiveness or a flat denial confirms their worst fear. Meet the anger with attention, and the temperature comes down.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
The moves, in order
This is de-escalation first, history second. Each move is the trigger, the move, and the words.
6.1 - Let them speak, and receive it
Trigger. They arrive angry, talking over you.
The move. Do not defend. Sit down, give them the floor, and let the first wave pass without interruption.
Please, tell me everything, from the beginning. I am not going to interrupt, I want to hear all of it.
Why it works. Anger that is received loses its heat. Anger that meets a defence escalates. Listening is the first clinical act here.
6.2 - Find and acknowledge the real grievance
Trigger. Somewhere in the complaint is a legitimate point.
The move. Name it back, and validate it honestly, even if only in part.
If I have understood, you feel he was sent home too quickly and no one explained the plan to you, and I can absolutely see why that would make you angry. That should have been done better.
Why it works. People calm when they feel understood. A genuine, specific acknowledgement does more than any general apology.
6.3 - Set the confidentiality boundary, calmly
Trigger. They demand details about the patient's care or condition.
The move. Explain the boundary as protection, not obstruction, without a fight.
I want to be as open as I can. There are some things about his care I cannot share without his permission, because the same rule protects his privacy, and yours. What I can do is listen to everything you have seen, and take it seriously.
Why it works. Framing confidentiality as something that protects the patient, and them, keeps you honest without stonewalling.
6.4 - Gather what you can, along the way
Trigger. The complaint contains real clinical information.
The move. Fold the collateral into the conversation, the changes they have seen, the risks, the history.
While we talk, it really helps me to hear what you have noticed in him lately, how he has been in himself, so that whatever we do next is better informed.
Why it works. The angry relative is still the best informant in the room. You honour the complaint and gather the history at once.
6.5 - Offer honest, concrete next steps
Trigger. They want to know what you are going to do about it.
The move. Offer what you genuinely can, a review, a named contact, a formal complaint route, without promising what you cannot deliver.
Here is what I can do. I will make sure he is reviewed properly, I will be your point of contact, and if you want to take the complaint further, I will show you how, because you are entitled to. What I cannot do is promise an outcome before we have assessed him, and I will not pretend otherwise.
Why it works. Concrete, deliverable offers rebuild trust. Over-promising to end the confrontation destroys it the moment the promise breaks.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Getting defensive
Defending the service, or a colleague, against the first wave of anger confirms the relative's fear that no one is listening. Receive it first, defend nothing yet.
5.2 - Caving and over-promising
Promising a bed, an outcome, or a discharge to make the anger stop is a promise you may not keep, and it destroys trust when it breaks. Offer only what you can deliver.
5.3 - Breaching confidentiality under pressure
An angry relative is not a reason to disclose the patient's private information. Hold the boundary, and explain that it protects the patient.
5.4 - Missing the collateral entirely
So focused on the complaint that you gather no history at all is a missed opportunity. The angry relative still holds the outside view of the patient. Gather it while you de-escalate.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Summarise their grievance fairly.
So, to be clear, you feel he was discharged too soon and left without a plan, and that no one listened to your concerns, and I have heard that.
Two. Acknowledge what was not good enough.
Some of what you describe should have been handled better, and I am sorry for the part of this that we got wrong.
Three. Hold the boundary once more, gently.
There are limits on what I can share about his care, to protect his privacy, but that does not stop me taking everything you have said seriously.
Four. The concrete offer.
So here is what I will do, a proper review, myself as your contact, and the complaints route if you want it.
Five. Leave the door open.
Thank you for caring enough to come and say all this. If more occurs to you, or anything changes with him, contact me directly.
The thread of this station is receive the anger, find the real grievance, hold the boundary, and offer only what you can honestly deliver.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is the angry relative is frightened, and still your best informant. Receive the feeling before you defend anything, acknowledge the legitimate complaint, hold the patient's confidentiality, and never buy peace with a promise you cannot keep.
Do those two things and any collateral station in this exam is yours to steer.
Developmental History, from a Parent
Before we begin
Welcome. This is the developmental history, from a parent. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
An adult is being assessed for a possible neurodevelopmental condition, attention deficit hyperactivity disorder or autism, and the diagnosis turns on whether the traits were present in early childhood and across situations. The patient cannot report their own first years. Only a parent can, which makes this the collateral that is not a supplement to the history but the load-bearing part of it.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to take a developmental history from this parent about the patient. You are not seeing the patient today, and the focus is the early years.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: pregnancy, birth and early milestones; the childhood attention, activity and impulsivity, present early and in more than one setting; the social communication and restricted, repetitive patterns; school and function across settings; and the family history, ending on why the developmental account decides the diagnosis.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their mother?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming in. You are the only person who can tell me what he was like as a small child, and because these conditions begin early in life, your account of his early years is the most important part of the whole assessment.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is a parent, usually a mother, who has carried this child's whole story and often years of being told he was simply naughty, or lazy, or shy. She holds the milestones, the school reports, the early years no one else witnessed. Treat her account as the core evidence, not background colour, because for a neurodevelopmental diagnosis it is exactly that.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Each cluster is the question, why only they can give it, and what it tells you.
7.1 - Pregnancy, birth and early milestones
Ask the informant.
How was the pregnancy and the birth? And as a baby and toddler, when did he sit, walk and talk, and was there anything that worried you or the health visitor at the time?
Why only they can give it. No one remembers their own infancy, and the milestones and early concerns exist only in a parent's memory and the old records.
What it tells you. Delayed language and social milestones point towards autism, whereas milestones that were broadly normal with early over-activity point towards attention deficit hyperactivity disorder.
7.2 - Attention, activity and impulsivity, early and everywhere
Ask the informant.
As a young child, could he sit still and stay with a task, or was he always on the go, fidgety, unable to wait his turn, blurting things out? And was that the same at home and at school, and before the age of about twelve?
Why only they can give it. The cross-situational, before-twelve pattern is a matter of childhood record, which the adult patient cannot supply reliably.
What it tells you. Inattention, hyperactivity and impulsivity, present early and in more than one setting, are the core of attention deficit hyperactivity disorder. Present in only one setting, or new in adulthood, it is not.
7.3 - Social communication and repetitive patterns
Ask the informant.
As a child, how was he with other children, did he play with them and share their interests, or keep to himself? Did he make eye contact and read how people felt? Any very intense narrow interests, a need for routine, or distress at change, or unusual reactions to sounds, textures or lights?
Why only they can give it. The early social reciprocity and the restricted, repetitive patterns are seen by the parent across the child's whole development.
What it tells you. Early difficulty with social communication and reciprocity, alongside restricted interests, insistence on routine and sensory sensitivities, is the autism dyad.
7.4 - School and function across settings
Ask the informant.
How was school, academically and socially? Was he ever described as lazy or a daydreamer or disruptive? Did he need extra support, or move schools? How did he manage friendships and, later, work?
Why only they can give it. The school reports and the arc into adult function are held by the parent and the records, not the patient's own recollection.
What it tells you. A lifelong pattern of underachievement against ability, or of social difficulty, that spans school and work confirms the pervasive, developmental course.
7.5 - Family history
Ask the informant.
Is there anyone else in the family with attention problems, learning differences, or autism, diagnosed or not?
Why only they can give it. The family pattern, often undiagnosed in older relatives, is a parent's knowledge.
What it tells you. These conditions are strongly heritable, so a family pattern supports the diagnosis.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Treating the early years as optional background
For a neurodevelopmental diagnosis the childhood account is the evidence, not colour. Spend your time on the first years and the cross-situational pattern, because that is what the diagnosis rests on.
5.2 - Not establishing onset before adulthood
A condition that began in adulthood is not attention deficit hyperactivity disorder. Pin the presence of traits before about twelve, or the diagnosis is unsound.
5.3 - Not checking more than one setting
Traits in only one setting can be situational, not developmental. Ask specifically whether it was the same at home and at school.
5.4 - Missing the autism dyad or the ADHD triad
Ask across both, social communication and restricted patterns for autism, inattention and hyperactivity and impulsivity for attention deficit, because they overlap and co-occur, and a one-sided history misses it.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Summarise the developmental thread.
From what you describe, he was an active, impulsive child who could not settle at home or at school, well before secondary school, and was often called lazy when he was struggling.
Two. Name it, held open, and say why the history matters.
That lifelong, everywhere pattern is exactly what we look for, and it is why your account of his early years is so important, but I would still want to assess him directly before confirming anything.
Three. What happens next.
We will see him, use some structured questionnaires, and where we can, gather school reports, which strengthen the picture.
Four. Frame it usefully.
If it is confirmed, understanding it often makes sense of years of difficulty, and there is real help, practical strategies and, where appropriate, treatment.
Five. Thank them.
You have given me the part of the story only you hold, and that is genuinely the heart of the assessment.
The thread of this station is childhood onset and cross-situational pattern, the evidence only a parent can give.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is the collateral that is the diagnosis, not a supplement to it. Establish onset in early childhood and across every setting, cover both the autism dyad and the attention triad, and treat the parent's account of the early years as the load-bearing evidence it is.
Do those two things and any collateral station in this exam is yours to steer.
Carer Burden and the Carer's Assessment
Before we begin
Welcome. This is carer burden and the carer's assessment. In front of you is not the patient, but someone who knows them, a wife, a son, a carer, a nurse, and the card asks you to take a history from that person about someone who is not in the room.
A carer, often the exhausted spouse or child of someone with dementia or severe mental illness, is in front of you, and the card is not really about the patient at all. It is about the carer's own wellbeing, their health, their safety, their right to support. The failure mode is obvious once named, to treat the carer as an informant and mine them for the patient's history while their own needs go untouched.
The single biggest error in these stations is treating the collateral as a thinner version of the patient's history. It is not. It is the information only an outsider holds. Two habits carry every one of these. Keep them close.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
Ready. Let us sit down with them.
What this station looks like
Picture the room, and the card on the door. Near enough, this.
You are asked to speak with this carer about how they are managing in their caring role. The focus is the carer, not the patient.
Here is the shape of it. The consent-and-confidentiality opening. Then the informant-only material, the baseline before all this, the timeline and its shape, the behaviours the patient cannot or will not report, and the risks seen from outside. Then the close, held open, with the informant's feeling carried the whole way.
The clusters are: the caring role and a typical day; the toll on the carer's own physical and emotional health; coping, support and isolation; safety, for the carer and the patient; and the offer, the carer's assessment, respite, benefits and support, ending on the carer, not the patient.
Check. The shape is clear. Let us take the opening.
The opening, consent and confidentiality first
The opening is different from every other kind of station, because you are about to talk about a third party. Four moves, said to the informant, before you ask a single question about the patient. They are printed marks and they set the whole tone.
One. Introduce yourself and check who they are to the patient.
Hello, my name is Doctor, one of the psychiatry doctors. Can I check, you are their main carer?
Two. Explain why their view matters, and thank them for coming.
Thank you for coming in. I know we often focus on the person being cared for, but today I really want to focus on you, and how you are managing, because that matters in its own right.
Three. Set the confidentiality boundary, both ways.
Before we start, two things on privacy. I am very glad to hear what you have noticed, that helps me enormously. But there may be some things about them that I am not able to share back with you, because that is their private information, and I hope you understand. Is that alright?
Four. Ask permission to take their account.
Is it alright if I ask you some questions about how things have been?
Check. Consent taken, the boundary set both ways, not a fact gathered before it. Now the history.
Who is in front of you
In front of you is someone running on empty, who may never have been asked how they are, only how the patient is. They may feel guilty for struggling, resentful and then guilty for the resentment, and reluctant to admit they cannot cope. The whole skill is to keep the spotlight on them, gently, and to make clear that their own needs are legitimate.
Check. You know who the informant is, and what they are carrying. Now what to ask, one cluster at a time.
What to ask, one cluster at a time
Each cluster is the question, and what it opens up. Keep the focus on the carer throughout.
8.1 - The caring role and a typical day
Ask the carer.
Can you walk me through a typical day for you, from waking up? What does caring for him actually involve, and how much of it falls on you?
Why it matters. The concrete texture of the day reveals the true load, the broken nights, the constant supervision, better than any general question.
What it tells you. The scale and relentlessness of the caring role, and where it is heaviest.
8.2 - The toll on the carer's own health
Ask the carer.
How is all this affecting you, in your own body and mind? How is your own sleep, your health, your mood? Do you ever feel low, or overwhelmed, or resentful, and then perhaps guilty for feeling that?
Why it matters. Naming the difficult feelings, resentment, guilt, exhaustion, gives the carer permission to be honest about how hard it is.
What it tells you. Carer strain often shows as low mood, poor sleep, neglected health and social isolation, sometimes a depression of its own that needs treating.
8.3 - Coping, support and isolation
Ask the carer.
What helps you cope? Who else is around to share it, family, friends, any services? When did you last have a break, or time that was just yours?
Why it matters. Isolation is the core of carer burden, and the absence of any break is a red flag.
What it tells you. The support network, or its absence, and how close the carer is to the end of their reserves.
8.4 - Safety, both ways
Ask the carer, gently.
When things are at their hardest, does it ever feel unsafe, for you or for him? Has there ever been aggression, or a moment you were frightened, or worried you might snap? And how are you in yourself, any thoughts that it is all too much?
Why it matters. Carer breakdown and the risk that comes with it, in both directions, are only reached if you ask directly and without judgement.
What it tells you. Safety risks to the patient and the carer, and any risk to the carer's own wellbeing, that may need urgent support.
8.5 - The offer
Say to the carer.
There is real help, and you are entitled to it. You can have your own carer's assessment, separate from him, to look at your needs. There is respite care so you can get a proper break, there are benefits you may be able to claim, and there are organisations that support carers. May I set some of that in motion?
Why it matters. The carer's assessment is a statutory right, and most carers do not know it exists. Naming the concrete supports is the point of the station.
What it tells you. Nothing further, this is the deliverable, turning the conversation into help the carer can actually use.
The traps that fail this station
Half the marks in a collateral station are in the traps. Here are the ones that sink this one.
5.1 - Mining the carer for the patient's history
The commonest failure. The station is about the carer. Spending it taking a collateral on the patient, while the carer's own needs go unmentioned, misses the entire point.
5.2 - Not naming the hard feelings
Carers rarely volunteer resentment or guilt unprompted. Gently naming them gives permission and unlocks an honest account of the strain.
5.3 - Skipping the safety question
Carer breakdown carries risk both ways. Failing to ask, kindly, about aggression, fear and the carer's own wellbeing leaves a real danger unassessed.
5.4 - Not offering the carer's assessment
The carer's assessment, respite and support are the concrete deliverables. A sympathetic chat that offers no actual help has not done the job.
Check. Name the trap you just avoided. That is the mark.
The close, held open
Close in five small movements, and never on a bare diagnosis, because you are handing an anxious person a picture of someone they love.
Say something close to this.
One. Reflect the load back.
From what you have told me, you are doing almost everything, on broken sleep, with very little help, and it is taking a real toll on your own health and your mood.
Two. Validate it plainly.
That is an enormous amount to carry, and it is completely understandable that you are exhausted, and even that you sometimes feel resentful. That does not make you a bad carer, it makes you human.
Three. The concrete offer.
So I want to arrange a carer's assessment for you, look into respite so you can get a break, check what benefits you are entitled to, and put you in touch with a carers' organisation.
Four. Your own health.
And I want your own low mood and exhaustion looked at in their own right, because you matter here too, not only as his carer.
Five. Leave the door open.
You have carried this quietly for a long time. From now, here is how to reach support, and please do, before you reach breaking point, not after.
The thread of this station is the carer is the patient today, and the deliverable is real, named support, not sympathy alone.
The two habits, again
Carry these two out of the room.
One. Consent and confidentiality before the first question. You are talking about someone who is not in the room. So you open by explaining what you can and cannot share about the patient, and you ask the informant's permission to hear what they know. You never trade the patient's confidence to satisfy a relative, and you never leave the boundary unspoken.
Two. Ask for what only they can give, and hold the feeling while you do. A collateral is not a shorter version of the patient's own history. It is the baseline, the timeline, the behaviours the patient cannot or will not report, and the risks seen from the outside. And the informant is often frightened, grieving or angry, so you receive the feeling before you press for the fact.
The thread here is the direction of care flips, the informant is the person you are looking after. Keep the spotlight on the carer, name the guilt and resentment so they can be honest, ask about safety both ways, and always offer the carer's assessment and concrete support.
Do those two things and any collateral station in this exam is yours to steer.