Overdose and Self-Harm History Taking OSCE — Risk Assessment & Sensitive Communication

Why Overdose and Self-Harm History Is Tested in OSCEs

This station tests one of medicine's most important and challenging skills: communicating sensitively about suicide and self-harm while simultaneously performing a rigorous clinical risk assessment. Examiners mark both the quality of information gathered and the quality of communication. Candidates who are either overly clinical (no empathy) or overly gentle (fail to ask direct risk questions) both underperform. The optimal candidate is warm, direct, and thorough.

Before You Begin — Approach and Environment

In an OSCE, acknowledge the setting: "I want to make sure this conversation feels as safe as possible. What we discuss will be confidential, although I have a duty to share information if I'm very concerned about your safety." Ensure privacy. Sit at the same level. Use open, non-judgmental body language.

Structure: Before, During, After

The risk assessment framework for overdose/self-harm should cover three time periods: before the act, during the act, and after the act.

Before — Circumstances and Intent

• Triggers: "Can you tell me what was going on in the days and hours before this happened?"
• Planning vs. impulsivity: "Was this something you had been thinking about for a while, or did it happen suddenly?"
• Suicidal intent: "When you took the tablets, were you hoping to die?" / "What did you think would happen?"
• Precautions against discovery: "Were you alone? Did you take steps so that you wouldn't be found?" (High lethality intent)
• Communication beforehand: Did they tell anyone? Write a note? Give away possessions? (Preparation = higher risk)
• Access to means: "How did you get hold of the tablets/implement?"

During — Details of the Act

For overdose:

• What did they take? (Name, dose, number of tablets)
• Over what time period?
• What else was taken alongside? (Alcohol significantly increases lethality risk)
• Was it prescribed to them or acquired from another source?

For self-harm:

• Method (cutting, burning, ligature — each carries different medical risk)
• Depth, location, number of wounds
• First time or recurrent?

After — Immediate Response

• How were they found? By whom?
• Did they call for help themselves, or did someone else find them?
• How long before help arrived?
• What are their feelings now? "How do you feel about still being alive?" (Critical question — ambivalence vs. relief vs. regret)
• "Do you still feel like harming yourself now?"

Risk Factors Assessment

Use the framework to assess static and dynamic risk factors:

Psychiatric History

• Previous episodes of self-harm or overdose (number, method, medical severity)
• Current psychiatric diagnoses (depression, bipolar, borderline personality disorder, schizophrenia, PTSD, substance use)
• Current mental health treatment and medications
• Contact with community mental health team (CMHT) or crisis team

Mental State Examination (MSE)

Perform a brief MSE, documenting:

• Appearance and behaviour: agitated, psychomotor retardation, poor self-care
• Speech: rate, volume, fluency
• Mood: subjective ("How are you feeling right now?") and objective (your assessment)
• Thoughts: suicidal ideation (current), hopelessness, worthlessness, command hallucinations
• Perceptions: hallucinations (auditory — command type most concerning)
• Cognition: orientation, concentration
• Insight: does the patient understand they are unwell and need help?

Safeguarding

If the patient is under 18, or if there are concerns about children at home, safeguarding must be initiated. If the patient has children: "I have to ask — do you have children at home? Who is looking after them right now?" Parental mental health crises are a trigger for a child protection referral. Document all decisions.

Management Plan — Safe Discharge vs. Admission

Assess capacity for voluntary admission. Discuss:

• Crisis plan: who to call, what to do if feelings escalate before next appointment
• Safety plan: identify warning signs, coping strategies, social supports, emergency contacts
• Means restriction: "Are there tablets at home that you could access? Could someone hold them for you?"
• Follow-up: when, where, with whom
• Mental Health Act: if patient lacks capacity or refuses admission despite high risk, Section 2 or Section 5(2) may be needed (hospital doctors) or Section 136 (police, community)

Paracetamol Overdose — Specific Points

Paracetamol is the most common overdose agent in the UK. Time from ingestion is critical:

• <1 hour: activated charcoal
• 4-hour paracetamol level plotted on the Rumack-Matthew nomogram determines N-acetylcysteine (NAC) treatment
• Check LFTs, INR, U&Es, blood glucose (hepatotoxicity can cause hypoglycaemia)

Frequently Asked Questions

"How do I structure a risk assessment for overdose or self-harm in an OSCE?"

Structure your assessment around three time periods: before, during, and after. Before the act: explore triggers, planning vs. impulsivity, suicidal intent ("Were you hoping to die?"), precautions against discovery, and communication beforehand (note, giving away possessions). During the act: method, dose/amount, duration, alcohol coingestants, access to means. After the act: who found them and how, self-presented vs. found by others, current feelings about survival ("How do you feel about still being alive?"), and current ideation ("Do you still feel like harming yourself?"). Supplement this with a psychiatric history, current MSE, social circumstances, and risk factor assessment. Present your risk stratification to the examiner as low, medium, or high risk with the key factors supporting your classification.

"What is the difference between suicidal ideation, intent, and plan — and why does it matter?"

Suicidal ideation refers to thoughts of suicide without necessarily any intention to act on them. These may be passive ("I wish I wasn't here") or active ("I'm thinking about killing myself"). Intent refers to the strength of the wish to die and the decision to act — "Have you made a decision to end your life?" Plan refers to a specific method, time, place, and preparations — "Have you thought about how you would do it?" A patient with ideation alone is lower risk than one with ideation plus intent plus a plan. The specificity and lethality of the plan are critical: access to a specific lethal method (stockpiled tablets, a ligature, a firearm) dramatically escalates risk. Documenting all three components separately in the notes and to the examiner demonstrates clinical rigour.

"What factors make a self-harm or overdose high risk for completed suicide?"

High-risk features include: planned act (not impulsive), high-lethality method (hanging, drowning, firearms, jumping, rather than cutting), precautions taken to avoid discovery, not seeking help after the act, stating regret at survival, current active suicidal ideation, a detailed future plan with access to means, previous serious attempts (the single strongest predictor of future attempt), psychiatric comorbidity (especially depression, borderline personality disorder, schizophrenia), substance misuse, social isolation, chronic physical illness or pain, recent significant loss, male sex, and age over 45. The Columbia Suicide Severity Rating Scale (C-SSRS) is a validated tool for quantifying risk that is worth mentioning in the OSCE. Low-risk features: impulsive act, low-lethality method, immediate help-seeking, relief at survival, no current ideation, strong social support, intact insight, engagement with treatment.

"How do I ask about suicidal thoughts without making the patient feel worse or more at risk?"

Ask directly but compassionately: "It sounds like things have been incredibly difficult. When things feel that dark, sometimes people have thoughts of ending their life — have you had any thoughts like that?" This phrasing normalises the question, links it to the patient's expressed distress, and avoids the blunt "are you suicidal?" which often elicits denial. If they say yes, explore further: "Can you tell me more about those thoughts? Have you had any thoughts about how you might do it?" Research consistently demonstrates that asking about suicidal thoughts does not increase risk and often provides relief. Avoiding the question out of discomfort is a patient safety failure and a communication mark deduction. After asking, validate: "Thank you for telling me — I know that was difficult to share. It helps me understand how serious things have been."

"What is a safety plan and how does it differ from a crisis plan?"

A safety plan is a collaboratively developed, personalised written document that helps a patient manage a suicidal crisis. It covers: (1) warning signs that a crisis is developing (specific thoughts, feelings, behaviours — e.g., "when I start isolating myself"); (2) internal coping strategies the patient can use alone (breathing exercises, a distraction activity); (3) social contacts to distract from suicidal thoughts (friends or family to talk to about anything); (4) people to contact for support during a crisis (including specific names and contact details); (5) professionals or services to contact if the crisis escalates (crisis team number, Samaritans 116 123, A&E address); and (6) means restriction — removing or restricting access to lethal means. A crisis plan is a simpler version covering only escalation and emergency contacts. Safety planning reduces hospitalisation rates and repeat attempts — mentioning it in the OSCE management plan demonstrates knowledge of evidence-based intervention.

"When would you consider using the Mental Health Act for a patient who has self-harmed?"

The Mental Health Act 1983 (as amended 2007) allows compulsory detention of a patient if they have a mental disorder AND their health or safety or the protection of others requires it AND informal treatment is not appropriate. In the acute setting, Section 5(2) allows a doctor (FY2 or above) to detain an inpatient for up to 72 hours pending full psychiatric assessment. Section 136 allows police to remove a person from a public place to a place of safety for up to 24 hours (was 72 hours before 2017 amendment). Section 2 (28 days, assessment) and Section 3 (6 months, treatment) require two doctors and an Approved Mental Health Professional. In practice, the threshold for formal detention is a patient who lacks capacity to consent to admission AND is at high imminent risk AND refuses voluntary admission. Capacity must be formally assessed — having a mental disorder does not automatically equal lacking capacity. Always document your reasoning carefully.

Related guides: Psychiatric History OSCE · Mental State Examination OSCE · Paracetamol Overdose OSCE · Safeguarding OSCE Guide · Consent and Capacity OSCE