Introduction
‘Hi, I’m Dr X, one of the psychiatry doctors in the team, it’s nice to meet you. I understand from your GP you’ve been having some difficulties recently?
Patient response…
Statement of empathy
I’m really sorry to hear that you’ve had these difficulties AROUND SLEEP/PAST TRAUMA/NIGHTMARES, I wonder if you can tell me a bit more about this? (OPEN QUESTION).
Patient response…
Questions around presenting complaint (using ICD criteria)
Trauma (‘I’m so sorry you had some terrible experiences, would you be able to tell me any more about them? If it’s too difficult then don’t worry… – ASK ABOUT THE INCIDENT DURING THE OVERSEAS SERVICE AND IF THEY CAN RECALL WHAT HAPPENED
Reliving (‘have you had any nightmares? Have you ever had any vivid images or flashbacks while you’ve been awake?). FOR FLASHBACKS YOU COULD ASK SOMETHING LIKE: “Have you ever acted as if you were back in that moment—like ducking down, or feeling you were back there?”
Avoidance (‘Do you ever avoid doing things or going places as a result of how you think and feel?’) – Examples: avoiding military-related triggers, crowds, fireworks, busy roads.
Vigilance (‘Do you ever feel ‘on edge’ or startle easily?) – e.g. could ask : Do everyday noises, like loud bangs or doors slamming, set you off?”
Emotional numbing (‘do you feel a lack of enjoyment in things you used to enjoy?’ Do you ever feel detached from others?’) – could ask ‘how is your connection with your family / friends?
Length (when did the traumatic event happen, how long have you had these symptoms for?)
Other key symptoms:
Sleep – Can I ask how you’ve been sleeping lately? (IF PROBLEMS WITH SLEEP THEN EXPLORE FURTHER)
Appetite – Can I ask how you’ve been eating and drinking lately?
Screening of differential diagnoses
Just a few other quickfire questions if that’s ok?
Depression: ‘Do you ever feel low in mood at all?’
OCD: ‘Do you ever feel like you have specific rituals or compulsions?
Psychosis: Sometimes when people are struggling they can hear things that others can’t hear, or see things that others don’t see. Have you ever felt like this?
Anxiety Disorders: Do you ever get panic attacks? Do you ever get any physical symptoms like a racing heart or sweating?
Mania: Do you ever feel like your thoughts are racing or your unusually happy in mood?
1st Rank: Do you ever feel like others can take thoughts out of your head, or put thoughts into your head? Do you feel others can control your limb movements? Do you ever hear any voices commentating about you?
Risk
TO SELF: Sometimes when people are struggling a lot, they can have thoughts of wanting to harm themselves, have you ever felt like that? Similarly, another question we have to ask everyone – have you ever thought about wanting to end your life at all? – (In this scenario, if not volunteered, ask: “You mentioned having access to firearms for sporting use—are these kept securely? Have you ever considered using them in distress?”
TO OTHERS: If specific people have been identified as being potentially at risk then ASK SPECIFICALLY about them – otherwise ask ‘have you ever had any thoughts about wanting to harm anyone else?
FROM OTHERS: If specific people have been identified as being potentially a risk to the patient then ASK SPECIFICALLY about them – otherwise ask ‘do you feel at risk from anyone in particular?’
NEGLECT / DETERIORATION: Do you feel that you are able to look after yourself day-to-day? – Probe for difficulties with self-care, getting out of bed, or maintaining routines.
DRUGS / ALCOHOL/SMOKING: (essential – ask about this with the risk questions): A few other questions, we have to ask everyone – do you smoke at all? Do you drink alcohol? (IF YES THEN ASK FOLLOW UP QUESTIONS – how much/how often/withdrawal symptoms/effect on life etc), do you take any illegal drugs? (again if yes then follow up)
Further Background History
Past Medical History:
Do you have any medical problems that you’re aware of? (IF YES THEN EXPLORE FURTHER – how long for, what are they, day to day impact etc) – Add: “Any lasting injuries from your time in the service or from sports?”
Past Psychiatric History:
Have you ever had any mental health problems before? Have you ever been under any mental health teams? Have you ever had to go to a mental health hospital?
Drug history:
Do you take any regular medications? (ask them to list name and indication if so)
Social History:
I’m really sorry that you’ve been struggling, I wonder if you can tell me more about how you spend your time day-to-day nowadays? (OPEN QUESTION TO LEAD INTO SOCIAL / OCCUPATIONAL / DAY TO DAY HISTORY)
Make sure in social history you cover:
HOBBIES: what do you enjoy? Do you still enjoy this?
RELATIONSHIPS: Can I ask if you’re in a relationship at the moment? Has your relationship been impacted by your symptoms? (ASK MORE DETAIL IF SO)
OCCUPATION: Do you work at all? If so what do you do? How have your symptoms impacted upon your work? (PROBE MORE INTO OCCUPATION IF IT SEEMS RELEVANT TO PRESENTATION / RISK)
Forensic History:
Can I ask if you’ve ever been in trouble with the police before?
Premorbid history (ask throughout – compare how he’s been feeling now compared with before the trauma)
Clear ending summary
So just to summarise Captain Hughes, you’ve told me you’ve been suffering from nightmares and difficulty sleeping for the past month. This started soon after you suffered a near-death experience while serving abroad for the military. You struggle to go outside and startle easily, and tend to avoid social occasions that might remind you of your time in the army. You’ve never had any medical or mental health problems before, and haven’t had any thoughts of wanting to harm yourself or others. You live with your wife and two children, but currently are not able to work due to your symptoms. Does all that sound correct?
It sounds like Captain Hughes you are likely suffering from Post Traumatic Stress Disorder, or PTSD, triggered by the awful experience you had while serving. In the next appointment we can talk through the diagnosis and treatment options, but in the meantime I can give you a leaflet. Do you have any other questions at this stage? (IF JUST A HISTORY TAKING STATEMENT THEN THIS PARAGRAPH IS OPTIONAL AND NO NEED TO GO INTO MANAGEMENT OPTIONS)
Panda’s Note 🐼
This is a relatively straightforward station – however the fact it is straightforward means that a fair amount of detail is required when you take a history to elicit all the psychopathology.
This is a classic PTSD station—thorough exploration of trauma and its impact is essential. In this scenario, always ask specifically about military triggers, avoidance, functional impact, alcohol use, and secure storage of firearms.
Balancing sensitivity with comprehensive coverage of symptoms, risks, and social factors is key to excelling on this scenario.