Why Psychiatric Stations Require a Different Approach
Psychiatric OSCE stations are marked differently from clinical history stations. The balance shifts heavily towards communication — how you ask matters as much as what you ask. Patients may be distressed, guarded, or reluctant to disclose. Creating psychological safety is a prerequisite for gathering useful information.
The core framework is: presenting complaint → full psychiatric history → Mental State Examination (MSE) → risk assessment.
The Full Psychiatric History Structure
🧠 Mnemonic
PC, HPC, PMHx, DHx, FHx, SHx, MSE, Risk — the same structure as all history taking, but with psychiatric-specific content throughout.
Opening the Consultation
Psychiatric history openings require particular care:
"Thank you for coming in today. I know this can feel daunting, so I want you to know that everything we discuss is confidential — unless I have serious concerns about your safety or someone else's. I'm here to listen and understand what's been happening for you. Can you start by telling me a bit about how you've been feeling recently?"
Don't rush. Psychiatric patients often need more time to find words for their experiences.
Depression Screen
The PHQ-2 is your starting point:
"Over the last two weeks, have you been feeling down, depressed, or hopeless?"
"Have you had little interest or pleasure in things you normally enjoy?"
If yes to either, expand with the full depressive symptom screen.
SIGECAPS — Depressive Symptoms
🧠 Mnemonic
SIGECAPS (also remembered as symptoms of depression):
- Sleep — "How has your sleep been? Do you wake early in the morning and can't get back to sleep?"
- Interest — "Have you lost interest in things you used to enjoy?"
- Guilt — "Have you been feeling guilty or worthless?"
- Energy — "How are your energy levels? Do you feel tired all the time?"
- Concentration — "Have you been finding it hard to concentrate?"
- Appetite — "How has your appetite been? Have you noticed any weight changes?"
- Psychomotor — "Have people noticed you moving or speaking more slowly? Or have you felt very restless?"
- Suicidal ideation — see risk assessment section
Also ask:
- Duration: "How long have you been feeling this way?"
- Course: "Has it been there all the time or does it come and go?"
- Biological features: morning worsening, early morning waking, weight loss, reduced libido
- Precipitants: "Did anything happen around the time this started?"
Anxiety Screen
"Do you feel anxious or worried a lot of the time?"
If yes, clarify the type:
| Type | Key feature | Key question |
|---|---|---|
| Generalised Anxiety Disorder | Persistent, pervasive worry | "Is it about one specific thing or lots of different things?" |
| Panic disorder | Discrete panic attacks | "Do you get sudden episodes of intense fear with physical symptoms?" |
| Social anxiety | Specific social fear | "Is it mainly in social situations?" |
| PTSD | Following a trauma | "Did something traumatic happen before this started?" |
| OCD | Obsessions and compulsions | "Do you have unwanted intrusive thoughts or feel you have to do things repeatedly?" |
Panic Attack Symptoms
"During these episodes, do you get a racing heart, difficulty breathing, sweating, chest tightness, or a feeling like something terrible is about to happen?"
Psychosis Screen
Approach this sensitively — patients with psychosis often lack insight:
"Sometimes when people are going through a difficult time, their mind can play tricks on them. Has anything like that been happening for you?"
Hallucinations
- Auditory: "Have you heard sounds or voices that other people couldn't hear?" → "Were they inside your head or outside, like a real voice?" → "What did they say? Did they speak to you directly?" → "Did they tell you to do anything?"
- Visual: "Have you seen things that other people couldn't see?"
- Other: "Any unusual smells or sensations?"
Delusions
- Persecutory: "Have you felt that someone is trying to harm you or is following you?"
- Reference: "Have you had the feeling that things on TV or in the newspaper had a special meaning for you?"
- Passivity/control: "Have you felt like your thoughts or actions were being controlled by an outside force?"
- Thought insertion/withdrawal: "Has it ever felt like thoughts were being put into your mind, or taken out?"
First Rank Symptoms of Schizophrenia (Schneider)
- Thought insertion, withdrawal, broadcasting
- Made actions, feelings, impulses
- Auditory hallucinations (running commentary, third person, voices discussing patient)
- Delusional perception
💎 Clinical Pearl
When asking about psychotic symptoms, frame them as normal and common: "These are experiences some people have, especially when they're going through very difficult times..." This reduces shame and improves disclosure.
Mental State Examination (MSE)
The MSE is observed throughout the consultation, not asked about separately. Structure your documentation (or presentation to the examiner) using these domains:
| Domain | What to observe | Examples |
|---|---|---|
| Appearance | Dress, hygiene, age vs apparent age | "Well-kempt, appropriately dressed, appears younger than stated age" |
| Behaviour | Eye contact, psychomotor, rapport | "Good eye contact, psychomotor retardation noted, cooperative" |
| Speech | Rate, rhythm, volume, quantity | "Slow rate, low volume, decreased spontaneity" |
| Mood | Subjective (what patient reports) | "Patient reports feeling 'empty'" |
| Affect | Objective (what you observe) | "Flat affect, tearful at times, congruent with mood" |
| Thought form | Logical, tangential, pressured, flight of ideas | "Linear and logical, no formal thought disorder" |
| Thought content | Themes, preoccupations, delusions | "Preoccupied with hopelessness; no delusional beliefs elicited" |
| Perceptions | Hallucinations in any modality | "No hallucinations elicited" |
| Cognition | Orientation, memory, attention | "Oriented in time, place, person; concentration impaired" |
| Insight | Patient's understanding of their illness | "Partial insight — acknowledges feeling unwell but attributes symptoms to external stress" |
Risk Assessment — Never Skip This
Risk assessment is an explicit mark in all psychiatric OSCE stations. It should be done sensitively but directly.
⚠️ Red Flag
Risk assessment is not optional. Avoiding it because you feel awkward will cost you marks and represents genuine patient safety risk. Practise saying these phrases until they feel natural.
Suicidal Ideation — Graduated Approach
- 1"Have you ever felt that life wasn't worth living?"
- 2"Have you had any thoughts of harming yourself?"
- 3"Have you had thoughts of ending your life?" (active suicidal ideation)
- 4If yes: "Have you thought about how you might do this?" (plan)
- 5"Have you made any preparations?"
- 6"Have you ever acted on these thoughts before?" (previous attempts — strongest predictor of future attempt)
Risk of Harm to Others
- "Have you had any thoughts about harming anyone else?"
Risk Factors to Screen
- Static: previous attempts, male sex, single, unemployment, chronic physical illness, substance misuse
- Dynamic: acute psychosis, hopelessness, recent loss, intoxication
- Protective: social support, children, religious beliefs, therapeutic alliance
💎 Clinical Pearl
After the risk assessment, always explicitly acknowledge and validate: "Thank you for being so open with me — I know that wasn't easy. What you've shared is really important and I want to make sure you have the right support."
Closing a Psychiatric Consultation
"Thank you for telling me all of this — I appreciate how much trust that takes. Based on everything you've shared, I'd like to arrange for you to be seen by the team who specialize in these kinds of difficulties. In the meantime, if things feel overwhelming or you feel unsafe, I want you to know you can contact the crisis team at any time."