History Taking · Intermediate · Psychiatry

Unusual Beliefs and Perceptual Disturbances

Practise this PLAB 2 history taking station on Psychotic Episode. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Segun Danso, a 35-year-old man, has come to see you after his neighbour expressed concern about his strange behaviour. Please take a focused psychiatric history, assessing for psychotic symptoms, and establish risk.

Background notes: PMH: Nil, Anxiety in university (undiagnosed)

What this station tests

  • Engaging a guarded patient before formal symptom assessment: rapport first, then targeted questions
  • Not confronting delusions: asking about experiences rather than challenging beliefs
  • Risk assessment: self-harm, risk to others, vulnerability, substance use
  • Early intervention in psychosis (EIP) referral for first episode: not starting antipsychotics in primary care
  • Excluding organic psychosis: TFTs, glucose, drug screen, CT/MRI if indicated

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

A patient presenting with paranoid beliefs and possible hallucinations requires careful risk assessment alongside empathic engagement. The candidate must not confront delusions but must assess for risk to self and others. Mr Danso is 35, brought by a concerned neighbour after strange behaviour. He is guarded. Open with: 'Mr Danso, your neighbour was worried about you and I would like to understand how you have been feeling. Can you tell me what has been going on?'

Core approach

Engage before assessing. He is guarded and suspicious. Build rapport before asking about specific psychotic symptoms. Start with open questions about how he has been, sleep, appetite, daily activities. Then explore: 'Have you noticed anything unusual happening around you?' 'Have you heard or seen anything that others might not?' Do not challenge his beliefs.

Assess psychotic symptoms. Delusions: paranoid beliefs (neighbours monitoring him, being followed). Hallucinations: auditory (hearing voices, second or third person, commanding or commenting). Thought disorder: disorganised thinking, tangential speech. Negative symptoms: withdrawal, flat affect, self-neglect.

Risk assessment is critical. Risk to self: suicidal ideation (voices may command self-harm), self-neglect. Risk to others: does he feel threatened? Any plans to act on paranoid beliefs? Risk from others: is he vulnerable? Substance use: cannabis, stimulants can trigger psychosis. Recent stressors: relationship breakdown 4 months ago.

Closing and safety netting

This needs urgent psychiatric assessment. If he is willing to engage: urgent referral to crisis resolution and home treatment team (CRHTT) or early intervention in psychosis (EIP) team. If he is unwilling and at immediate risk: consider Mental Health Act assessment. Do not start antipsychotics in primary care without specialist input (first episode psychosis needs specialist assessment and investigation).

Investigations to exclude organic causes: bloods (TFTs, glucose, U&E, LFTs, FBC, calcium), urine drug screen, CT/MRI if indicated. Communicate with care: 'I can see you are going through a difficult time. I would like you to see a specialist who can help.' Safety net: if his behaviour escalates or he feels at risk, 999 or crisis line. Involve his neighbour (with consent) as a community support.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for psychotic episode. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Psychotic symptoms elicited without confrontation. Risk assessment completed (self, others, vulnerability). Substance use screened. Organic causes considered. Stressors identified.

Costs marks: Confronting delusions. No risk assessment. Not screening substances. Not considering organic causes.

Domain 2 (Primary focus)

Scores well: Urgent psychiatric referral (CRHTT or EIP). Not starting antipsychotics. Organic screen bloods. MHA considered if needed. Crisis line safety netting.

Costs marks: Starting antipsychotics. No psychiatric referral. No organic screen.

Domain 3 (Primary focus)

Scores well: Empathic engagement with a guarded patient. Not confronting beliefs. Building trust. Acknowledging his distress. Involving neighbour with consent.

Costs marks: Confrontational. Dismissive of his experiences. Cold or clinical. Not involving any support.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Confronting delusions: telling him 'nobody is following you' will destroy rapport and may escalate the situation
  2. Starting antipsychotics in primary care: first episode psychosis needs specialist assessment and investigation before treatment
  3. Not assessing risk: a psychotic patient may be at risk of self-harm, harm to others, or vulnerability

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a psychotic episode history in PLAB 2?

A patient presenting with paranoid beliefs and possible hallucinations requires careful risk assessment alongside empathic engagement. The candidate must not confront delusions but must assess for risk to self and others. Mr Danso is 35, brought by a concerned neighbour after strange behaviour.

Where are marks won and lost in this psychotic episode station?

Examiners reward: Psychotic symptoms elicited without confrontation. Risk assessment completed (self, others, vulnerability). Substance use screened. Organic causes considered. Stressors identified. Candidates are penalised for: Confronting delusions. No risk assessment. Not screening substances. Not considering organic causes.

Where do candidates most often go wrong in this station?

Confronting delusions: telling him 'nobody is following you' will destroy rapport and may escalate the situation.

Can I do well in this station without real-world experience of psychotic episode?

Structure beats experience here. Focus on not confronting delusions: asking about experiences rather than challenging beliefs. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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