2.

01 The Psychiatric History

Dr. Luis Sundiang | September 25, 2017
PSYCHIATRY

OUTLINE  Help patient cope with his situation

 Suggest changes to improve prognosis and minimize future
I. Functions of a Medical Interview risks
A. Assess Nature of the Problem
B. Develop and Maintain a Therapeutic D.MENTAL STATE EXAMINATION (from University of Bristol
Relationship Website: http://www.bristol.ac.uk/medical-
C. Communicate Information and Implement a school/hippocrates/psychiatry/mse_etc/ )
Treatment Plan This part is for the next lesson but the lecturer included it in ppt
D. Mental State Examination
II. Psychiatry history taking - Enables you to understand what your patient is
A. Introduction and Presenting Complaint experiencing.
B. Past Psychiatric history - Involves the following:
C. Past Medical history
D. Family history 1. Appearance and Behavior
E. Personal history o Involves objective observation your patient from
F. Premorbid personality
G. Difficult questions the first meeting and record the observations
H. Risk assessment accurately in less than 30 words
III. Components of Psychiatric History o Physical Appearance
A. Identifying data  body build, (nutritional state)
B. Chief Complaint  significant distinguishing features
C. Source and Reliability  cleanliness (hair, teeth, nails)
D. History of Present Illness
 Quality, style and state of clothing
E. Past Medical and Psychiatric History
F. Family history o General Attitude
G. Social History  rapport
H. Anamnesis/Personal History  attitude towards interview
IV. Quiz  eye contact
o Motor Behavior
LEGEND  restless, fidgety or apathetic, retarded
2. Speech
Remember Textbook Trans Editor Previous Trans
o Volume and speed
   
 pressure of talk <-> retardation
o Construction
OBJECTIVES:
 flight of ideas, rhyming, punning,
1. Know the functions and purpose of psychiatric interview and
incoherence
examination
o Enunciation
2. Learn the content and process of taking a psychiatric history
 dysarthria, stammer
3. Integrate psychiatric history taking in your medical/ surgical
3. Mood or Affective State
interview and examination
o Subjective experience (ask!)
o objective impression
I. FUNCTIONS OF A MEDICAL INTERVIEW
 elevated, euthymic, low, angry, cheerful,
A. ASSESS NATURE OF THE PROBLEM
distraught, despondent, resentful
 Diagnose o congruity with speech content
 Determine appropriate diagnostic procedures if warranted o stability
 Formulate and propose management o emotional reactivity
 Provide information on course and outcome o suicidal ideation or intent
4. Thoughts
B. DEVELOP AND MAINTAIN A THERAPEUTIC RELATIONSHIP o Content
(Establishing a Therapeutic Relationship)  preoccupations?
 Facilitate patient’s collaboration in diagnostic and treatment  ideas of reference?
activities  delusions?
 Maintain flow of information exchange  recurring, pervasive theme,
 Relieve patient’s distress and suffering  depressive ruminations
 Provide satisfaction for patient and doctor  grandiose ideas
 self-referential ideation
C. COMMUNICATE INFORMATION AND IMPLEMENT A o obsessional thoughts
TREATMENT PLAN  How to probe for obsessional thoughts (+
 Help patient understand illness, diagnostic procedures, compulsive rituals): “Some people find
treatments, risks and outcome they have unpleasant and unwanted
 Establish and maintain consensus with patient and facilitate thoughts or images coming into their
informed consent
GROUP #1: Eleazar M., Elefante, Elgar, Esperanza, Espinosa
EDITOR/S: Surname (Cellphone#) 1 of 5
 mind, which can’t be resisted. Has that  “Do you feel puzzled by strange
been a problem?” happenings that are difficult to account
o objective signs of thought disorder for?”
o subjective experience of thought disorder  “Do familiar surroundings seem
 Probing questions: “Can you think quite strange?”
clearly, or does there seem to be some 7. Cognition
kind of interference with your thoughts?” o Level of consciousness
 Thought withdrawal: “Are your thoughts o Orientation
actually taken out or sent out of your  Time, Place, Personal Identity
mind? Do they actually feel like that? So o Attention and concentration
that they are outside your head?”  Test: Serial Sevens, months in reverse
 Thought insertion: “Do there seem to be o Memory
thoughts in your mind which are not your  immediate recall: digit span
own; which seem to come from  recent: address
somewhere else?”  remote: Personal History!
 Thought broadcasting: “Do your thoughts o General knowledge + intelligence
seem to be somehow public; not private 8. Insight
to yourself, so that others can know what o Attitude towards illness
you are thinking?”  “How do you see your difficulties?”
5. Perceptions  “Do you feel there is something wrong
o defined as the ability to perceive the outside world with your nerves?”
that could be related to a complex, o Attitude towards treatment
neuropsychological process which involves the  “What sort of treatment do you feel is
ability of the sense organs to detect and modulate needed?”
the raw data of our senses (sight, smell, noise),  “How do you feel about: being in hospital
and the ability of the brain to decode that / taking tablets?”
information and produce an internal neuronal
representation of the outside world. II. PSYCHIATRY HISTORY TAKING
o to the person experiencing a hallucination, the (from University of Bristol Website: http://www.bristol.ac.uk/medical-
perception is real school/hippocrates/psychiatry/mse_etc/ )
o Auditory hallucinations: It is a clinical history in itself but with an in depth coverage of social
 Get an exact description!! and developmental history.
 Familiar or unfamiliar voices?
 2nd or 3rd person? A. Introduction, Presenting Complaint and its History
 Do the voices give commands?  Keep it short and simple
 If so, how does the patient react?  If appropriate, use patients own word
o How to probe for auditory hallucinations:  List relevant event leading up to the present problem
 “We ask this question routinely of  Knowledge of specific disorders required
everyone, because sometimes people
under stress seem to hear noises or B. Past Psychiatric and Medical History
voices when there is nobody around and
 This includes treatment and admissions
no ordinary explanation is possible. Has
 Either informal or under section
anything like this ever happened to you?”
o Loud thoughts (Gedankenlautwerden)  Ask any previous episodes of deliberate self harm
 “Do your thoughts seem to sound aloud  If very long, summarize
in your head, almost as if somebody
standing near you could hear them?” C. Family History
o Thought echo (Écho de la pensées)  Use genograms
 "Does a thought in your mind seem to be  Ask about their occupations and social status
repeated over again, like an echo?”  Ask if there are family members with mental health problems
6. Delusions  Ask if there are any suicides and suicide attempts among
o defined as a false, unshakable idea or belief which family members
is out of keeping with the patient's educational,
cultural and social background; it is held with D. Personal History I
extraordinary conviction and subjective certainty  Early Child Hood
o can be: o Place and circumstances of birth
 primary: ideas that arise are fully formed o Early milestone and development
 secondary: attempt by the patient to o Family atmosphere and moves
make sense of their experiences  Education
o How to probe for delusions: o Schools Attended
 “Have you had the feeling that something o Attitudes to school
odd is going on that you can’t explain?” o Regularity of attendance
o Exams passed, age at leaving

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  Occupational History  Risk of violence
o Details of jobs o Not common
o Reasons for finding another job if applicable o Check if there is a history of violence
o Ask if they carry a weapon and ask them not to
E. Personal History II come to the hospital with weapons
 Psychosexual Development o Paranoid delusion (misinterpretation of innocent
o Tailor to what’s appropriate and needed gesture as threatening; belief that they are in
o Orientation danger and being threatened; delusional voices
o Relationships that tells them to hurt another person)
o Family attitudes and instruction o Jealousy – very powerful emotion that can lead to
o First experiences violence
 Present Social Circumstances
o Own or rented accommodations III. COMPONENTS OF THE PSYCHIATRIC HISTORY
o Financial problems, debts (this part is as presented by Dr. Sundiang in his lecture ppt)
 Drug History  The patient history is based on the subjective report of the
o Prescribed patient and in some cases the report of collaterals including
 Asked for the dose and duration other health care providers, family and other caregivers
 Compliance and check for side effects (Kaplan & Sadock).
o Illicit drug and alcohol use Notes:
 Useful screening tool Below are the parts of the Initial Psychiatric Interview (in the
 Be prepared to explore all features of book it is called initial psychiatric interview while Dr. Sundiang
dependency if necessary called it psychiatric history) based on Kaplan and Sadock:
 Forensic History I. Identifying data
o We live in the age of risk assessment II. Source and reliability
o “Have you ever had any trouble with the police?” III. Chief Complaint
o History of violence IV. Present Illness
 Get all the details, if present V. Past psychiatric history
 Distinguish between violence against VI. Substance use/abuse
property or people VII. Past medical History
VIII. Family history
F. Premorbid Personality IX. Developmental and Social history
“When you are well, …” X. Review of Systems
 Volition XI. Mental status examination
o “…how (what kind of person would you XII. Physical Examination
describe yourself?” XIII. Formulation
 Mood XIV. DSM-5 diagnoses
o “… what’s your usual mood like?” XV. Treatment plan
 Social
o “… how do you get on with other people?” A. Identifying Data
 Cognitive  This includes patient’s name, age, marital status, sex,
o (intellectual capacity) general knowledge handedness, occupation, nationality, birth order, religion,
 Reaction patterns to stress educational attainment and living conditions
o “… how do you react to stress?”  Ask also if this is the patient’s first admission or if the patient
has past admissions already
G. Risk Assessment
 Risk of suicide B. Chief Complaint
o Symptoms of depression  Verbatim: in the patient’s own words
o Ask if they are attempting suicide
 Why he or she has come or been brought in for consult
o If there is risk of suicide, arrange appointment
 Must be brief
o Manage the course of suicide
o Treat depression
C. Source and Reliability
o Can be cause by substance abuse and alcohol
abuse  The other individuals present as collateral sources of
o Consider patient’s situation (marital problem, information
financial problem, and others)  Write reliability of the sources as well
 Risk of self-harm  Patient’s pre-morbid and morbid personality
o Common (30%) D. History of Present Illness
o Use as a way to regulate their emotions  Comprehensive and chronological picture of the events
o Develop collaborative relationship and find an leading up to the current moment in the patient's life
alternative way like being mindfulness by  The account should include any other changes that have
encouraging them to express their emotional occurred during this same time period in the patient’s
feelings

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 interests, interpersonal relationships, behaviors, personal
habits and physical health E. Social History
 Include all significant symptomatology, precipitating factors,  Substance abuse – history should include which substances
significant modifiers of the illness have been used, including alcohol, drugs, medications
o Possible organic factors, drug, and alcohol abuse (prescribed or not prescribed to the patient), and routes of
 Pertinent positive and negative symptoms use. The frequency and amount of use should be
 “Can you tell me in your own words what brings you here determined, keeping in mind the tendency for patients to
today?” minimize or deny use that may be perceived as socially
unacceptable
E. Past Medical and Psychiatric History  o Smoking, alcohol, illicit drug use
 Past Medical History  Smoking: in pack-years
o Any medical, surgical, or obstetric problems the  Alcohol: type of alcohol, how frequent, shared
patient has or had among friends, CAGE criteria
 Medications (with doses) currently being  Drugs: First use? Who influenced the patient
taken to use drugs? How often? How much? Effects
 Treatments must also be included (anong klaseng “tama”), when was the last
o Hospitalizations use?
o Allergies to food and drugs G. Anamnesis/Personal History 
o Past medical history is an important consideration  In Kaplan and Sadock, this part is under developmental and
when determining potential causes of mental social history
illness as well as comorbid or confounding factors  It is an important tool in determining the context of
and may dictate potential treatment options or psychiatric symptoms and illness and may, in fact, identify
limitations. some of the major factors in the evolution of the disorder
o Medical illness can precipitate a psychiatric  Outline of a developmental History
disorder o Prenatal and Perinatal – developmental
 Past Psychiatric History milestones should be noted
o Psychiatric diagnosis  Full-term pregnancy or premature
 Past suicide attempts  Vaginal delivery or caesarean
o Psychiatric treatment  Drugs taken by mother during pregnancy
 When was the medication given? (prescription and recreational)
Duration? Dose? Therapeutic and  Birth complications
adverse effects?  Defects at birth
 Psychotherapy, ECT  Wanted/Unwanted and Planned/Unplanned
 Admission at an in-patient facility? OPD Pregnancy
consult? Rehab center? o Infancy and Early Childhood
 Consult with other mental health  Birth – 3 years
professionals (psychologist, social  Infant-mother relationship
worker, counselors)  Problems with feeding and sleep
o Written records from institutions and past  Significant milestones
caregivers may be considered  Standing/walking
 First words/two-word sentences
F. Family History  Bowel and bladder control
 Because many psychiatric illnesses are familial and a  Other caregivers
significant number of those have a genetic predisposition, if  Unusual behaviors (e.g., head-banging)
not cause, a careful review of family history is an essential o Middle childhood (3-11yrs)
part of the psychiatric assessment.  Preschool and school experiences
 A genogram is often useful for clarity  Separations from caregivers
o To look for similar conditions in other family  Friendships/play
members, as well as their treatment and  Methods of discipline
responses  Illness, surgery, or trauma
 Medical, psychiatric, and substance abuse o Late Childhood and Adolescence
o Suicide attempts or completed suicide in the family  Onset of puberty
 List the psychotropic medications  Academic achievement
o Which ones are effective vs not effective  Organized activities (sports, clubs)
 Family dynamics must also be taken into account  Areas of special interest
o Who are the members living together?  Romantic involvements and sexual
o Quality of relationship experience
 Who is closest to the patient? Who is in  Work experience
conflict with the patient?  Drug/alcohol use
 How the family members interact with  Symptoms (moodiness, irregularity of
one other sleeping or eating, fights and arguments)
o Reactions to illness, support given

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 o Young adulthood
 Meaningful long-term relationships
 Marital history
 Sexual history
 Academic and career decisions
 Military experience
 Work history
 Prison/ Legal experience
 Intellectual pursuits and leisure activities
 Religion
 Fantasies and Dreams
o Middle adulthood and old age
 Changing family constellation
 Social activities
 Work and career changes
 Aspirations
 Major losses
 Retirement and aging

REFERENCES
 Lecture slides
 Synopsis of Psychiatry 11th Ed. Kaplan and Sadock
 http://www.bristol.ac.uk/medical-
school/hippocrates/psychiatry/mse_etc/

MINI-QUIZ
1. Which of the following statements is TRUE regarding psychiatric
interview?
a. The interview is the most important element in the
evaluation and care of persons with mental illness
b. A well conducted interview results in an understanding of
the neurobiological elements of the disorder
c. The results of which is usually confirmed by laboratory
testing and imaging
d. All of the above
2. Which of the following is NOT included in the identifying data?
Previous medications
b. Marital status
c. Occupation
d. Number of consults
3. Which of the following is FALSE regarding the chief complaint?
a. Recording should be done in a verbatim manner
b. Usually obtained only from the patient
c. It is the patient’s primary concern for consult
d. All of the above statements are true regarding chief
complaint
4. Anamnesis refers to:
a. Family history
b. Sexual history
c. Personal history
5. The purpose of the interview in history taking is
a. To gather information that will enable the examiner to
make a diagnosis and plan for treatment accordingly
b. To help the physician decide if the patient should be
admitted or sent home
c. To be able to know the latest events in the patient’s life
d. To be able to comfort and allow the patient to ventilate his
frustrations in life

ANSWERS: AABCA

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