This will include the patient‟s narrative, and is therefore subject to revision and embellishment according to the state of mind of the individual and the relationship with the interviewer. The patient may adjust the history according to the interviewer‟s hypothesis and values. History taking is therefore collaborative and therapeutic. It is helping to construct the illness story
Identifying Data
Name, date of interview, age, sex, race, country of birth, occupation, date of hospital admission, marital status
Use as opportunity to put the patient at ease, build rapport
Reasons for and circumstances of referral/admission
Who made the referral, why now, what expectations
List of presenting symptoms and their duration
List each symptom and duration, use patient‟s own words
Is the situation acute or chronic
Suggested questions:
What sort of problems are troubling you/were troubling you when you came to hospital?
What have been the main difficulties
History of Current Illness
Need to know the patient‟s story: patient‟s situation and preceding/precipitating events
Narrative account of development of symptoms
Include medication and compliance
Suggested questions:
When did you last feel well?
What are the worst worries in your life?
Systematic enquiry
Should screen for all these in every patient
Anxiety Symptoms
See Topic: History Taking in Anxiety Disorders
Mood Symptoms
Refers to long-term/sustained emotional state (ie over last week/months) and is subjective experience of the patient
Prevailing mood at the time: quality (eg depressed, sad, angry, irritable, happy, elated, suspicious, perplexed, anhedonia), intensity (ask about extremes), reactivity, duration (when was it last normal)
Persisting or fluctuating: if so what pattern
Aggravating or relieving factors
Associated symptoms
Patient‟s attribution of mood
Psychotic symptoms
= Thought disorder, delusions or hallucinations
Thought disorder = abnormalities in the thinking process – evidenced by disorganised speech, thinking or behaviour
Delusions
= Fixed, false belief, abnormal/bizarre beliefs held with conviction, are without evidence and are culturally inconsistent
Fixedness is key, resisting coercion to change, and preoccupying
Ask about unusual concerns, preoccupations, thoughts that others find strange
Hallucinations = abnormal perceptual phenomena. Ask about visions, sensations, noises that are unusual or not shared by other people
Suicidibility or other dangerous behaviour: See Topic: Suicide Assessment and Management
Cognitive functioning: See Topic Cognition
Neurophysiological changes
Measure severity of primary process
Changed sleep, energy/motivation, concentration, appetite/weight (look for a 5% change over several weeks), sex
Sleep: initial, middle, terminal phases, how much in total, is it restful
Impulse-Control Screen: Screen for gambling (comorbidity of gambling with other pscyh symptoms is common)
Past Psychiatric History
Dates, duration, diagnoses, treatment, response to treatment and outcome
Suggested questions:
Have you had any psychiatric treatment before?
Is the present illness like the previous one?
Medical History: Past serious illnesses, disabilities, current illnesses and medication
Family History
Parents and siblings: age, state of health (mental & physical), occupations, situation, personalities, relationship to patient. May help to draw up a family tree
Get idea of family atmosphere during childhood: personalities of parents and relationships have lasting influence on subsequent relationships. How much care did you get from each parent? How controlling/protective were they?
Ask about grandparents, and parents up brining
Has anyone in the family been treated for nerves, had a breakdown, been admitted to a psych hospital, committed or attempted suicide, had an A & D problem?
Categorise under:
Structure of family
Description of key people
Description of important relationships
Family roles
Family history of psychiatric illness or alcohol abuse
Personal and Social History
Important events and influences in patient‟s life
Start open ended: Tell me a bit about your childhood and background? What are the important things you remember?
Birth: difficulties, parents situation at time
Childhood: family situation, illnesses, injury, nervous symptoms (eg enuresis/bedwetting, fears, phobias, how did they feel going to school, etc). Did you ever have any unpleasant experiences – did anyone ever harm you, hit you, interfere with you sexually?
School: primary to tertiary. Academic, sporting, relationships with peers and teachers
Employment: types of jobs, reason for leaving, work performance & satisfaction, relationships at work
Sexual: age at puberty, sexual orientation, sexual experience (current and past), sexual satisfaction, contraception, sexual abuse, unpleasant or distressing sexual experiences. Introduce when talking about adolescence. Aim is to establish abnormalities or concerns about sexual functioning or relationships
Marital: duration of courtship, age at marriage, age, occupation and health of spouse, marital relationship and problems
Children: pregnancies, ages and names of children, health, personalities, schooling, occupations, difficulties in relationship with parent
Friendships: long-standing friends and confidences
Current living situation
Difficulties with law
Leisure activities and interests
Religion: upbringing, beliefs and practices, changes in religious belief (important to ask, won‟t volunteer)
Premorbid personality
Patient‟s opinions and interviewer‟s impressions of premorbid personality
Personality = enduring characteristics, so requires evaluation over time
Patient’s Attribution of Illness
What the patient thinks is the cause of the illness
Possibility include under „insight‟ in mental state exam
Insert Mental State Exam write-up here
Formulation
Core of the psychiatric assessment: why did this person become ill in this way at this time?
Opinion about what explains the presentation and what treatment may work
Manner in which patient‟s problems are unique. Not a summary of problems but the crucial factors, based on a theoretical knowledge of the aetiology of psychiatric illness. The linkages/connections between different aspects should add something new – all the raw material should have been presented before
Should cover the 4 Ps: Predisposing factors, precipitating factors, perpetuating factors, protective factors
Conceptualise by filling in this table:
Suggest outline (one paragraph per bullet):
Describe problem
Why is this patient at risk of a psychiatric illness, using bio-psycho-social framework
Describe triggers to presentation
Describe relevant prognostic factors, positive and negative
Balanced assessment of risks: especially of suicide and violent behaviour
Diagnosis and Differential Diagnosis
Manner in which patient‟s problems are similar to others (cf formulation which emphasises uniqueness)
Usually presented using DSM-IV or ICD-10.
In differential diagnosis: concisely state evidence for and against each possible diagnosis in order of probability – only include evidence that discriminates between diagnoses
Don‟t forget general medical conditions if there is sufficient evidence
Management Plan
Safety: how will the risks identified be contained or minimised. Is the patient consenting or committed?
Medical: any medical conditions requiring attention
Diagnosis: is it clear? If not, what needs to be done?
Psychiatric Management: can be divided into management of target symptoms and management aimed at underlying disease. Can be considered under bio-psycho-social headings. Divide into timeframes – now, the next day or two, longer term
Always mention family in plan: information and support for them, their role in helping the patient, assistance with the significant stresses the family may face, etc
Experience Interviewing the Patient: difficulties interviewing the patient, reactions/emotions evoked by patient, how you dealt with these
SUMMARY
Reasons for referral
Presenting symptoms and duration
History of Current Illness, any medication and compliance with it
Mental State: appearance and behaviour, speech, mood, affect, thought form, thought content, suicidal ideation, perceptual phenomena, cognition, intelligence, insight and judgement, rapport
Formulation
Diagnosis and Differential Diagnosis
Management Plan
Suicide Assessment:
Trying to assess nature of suicidal ideation and state of current plans
Predisposing factors: family history of suicide, psych illness, or alcohol & drug, personality, childhood and developmental difficulties, suicide exposure, other illness, environment (eg living alone, isolated), age and sex
Precipitating factors (short-term risk factors): major/stressful life event, current mood, thoughts about the future, mental state (eg psychosis, judgement, impulsivity), alcohol and drug use, current plans, expectations of outcome, availability and lethality of method
Protective factors: cognitive flexibility, strong social supports, hopefulness, treatment of disorders, responsibility for children
For screening for psychiatric illness in teenagers
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