The Psychiatric History (trans 1)

Question 1

Functions of a Medical Interview

Answer 1

 Assess nature of the problem
 Develop and maintain a therapeutic relationship
 Communicate information and implement a treatment plan

Question 2

Functions of a Medical Interview - Assess Nature of the Problem

Answer 2

 Diagnose
 Determine appropriate diagnostic procedures if warranted
 Formulate and propose management
 Provide information on course and outcome

Question 3

Functions of a Medical Interview - Establish and Maintain a Therapeutic Relationship

Answer 3

 Facilitate patient’s collaboration in diagnostic and treatment activities
 Maintain flow of information exchange
 Relieve patient’s distress and suffering
 Provide satisfaction for patient and doctor

Question 4

Functions of a Medical Interview - Communicate Information and Implement Treatment Plan

Answer 4

 Help patient understand illness, diagnostic procedures, treatments, risks and outcome
 Establish and maintain consensus with patient and facilitate informed consent
 Help patient cope with his situation
 Suggest changes to improve prognosis and minimize the risks
 Provide the right information to be able to choose the right course of action that will help them best
*Correct assessment, history, and physical exam will help lead to the correct diagnosis

Question 5

Part I of Psychiatric History Taking:
Taking a psychiatric history has things in common with any clinical history you take. The major difference is in the social and developmental history, which we cover in more depth
**
1.  Chief complaint
2. Past psychiatric history
3. Past medical history
4. Medications

Answer 5

The parts which need to be covered in a psychiatric history taking are the following:
 Chief complaint
 Past psychiatric history
 Past medical history
 Medications
 Family history
 Family psychiatric history
 Personal history
o Birth and early life
o School and qualifications
o Higher education
o Employment
o Psychosexual history
o Forensic history
o Substance use
 Premorbid personality

Question 6

REMEMBER
Don’t always ask all the questions. Leave some gaps to be filled in later especially if the patient is paranoid, suspicious or acutely distressed

Answer 6

**Start with open-ended questions and gradually focus on areas of interest wherein it is better to use close-ended questions. This gives the patient a chance to talk about their experiences and concerns while allowing the interviewer to get the information needed.

Question 7

Part I of Psychiatric History Taking:
Chief Complaint and History of Present Illness
**The chief complaint, in the patient’s own words, states why he or she has come or been brought in for help. This should be recorded, after which another informant present may give their version of presenting events in the section on the history of the present illness

Answer 7

• *The history of present illness provides a comprehensive and chronological picture of the events leading up to the current moment in the patient’s life. This part of the psychiatric history is probably the most helpful in making a diagnosis
• *The chief complaint and history of present illness may be difficult to separate especially in complicated cases. The important thing is that the interviewer must get a good account of what is troubling the patient and thoroughly investigate any associated symptoms.

Question 8

Part I of Psychiatric History Taking:

Past Psychiatric History

Answer 8

Remember that the patient’s understanding of their illness may be different from the formal diagnosis. In cases like this, using previous notes would be helpful. Also, get the basic facts such as rough dates and length of admissions, treatment given and follow-up arrangements.

Question 9

Part I of Psychiatric History Taking:

Medication

Answer 9

The patient’s belief about their medication may provide useful insight into what they believe is wrong with them. Make sure to ask about side effects and compliance while bearing in mind possible drug interactions.

Question 10

Part II of Psychiatric History Taking

Answer 10

1. Family History
2. Personal History
3. Premorbid Personality

Question 11

Part II of Psychiatric History Taking:
Family History
Family history would give a good indication about an individual’s family relationships. Find out which persons the patient is close to. Conflicts within the family should be asked. Remember the possible roles of genetics and social and psychological risk factors in mental illness. Lastly, ask about family psychiatric history.

Answer 11

 This includes any previous psychiatric illness, hospitalizations and treatment of patient’s immediate family members
 This includes history of substance abuse (alcohol and/or drugs), addictions, and antisocial behaviors exhibited by family members
 A description of the personality and intelligence of each person living in the patient’s home from childhood up to the present.
 It also includes family dynamics, ethnic, national and religious beliefs, patient’s primary support group inside the family
 It will be helpful if the information can be gathered from other family members as well.
 Identify the role of patient’s illness to the family
 This should also include the patient’s current feelings: like if their family members are supportive, different, or destructive of him/her.

Question 12

Part II of Psychiatric History Taking:
Personal History
- Personal history is important because it helps the interviewer understand what led the patient into becoming the person they are.
**The personal history highlights any predominant emotions and events of major significance in the different periods of the patient’s life. There are major aspects that include early childhood friendships, educational attainment, romantic involvements, work history, and leisure activities of the patient. It in includes the development of the patient’s personality and functional capacity. How the patient is able to cope with different life events (Ex. Death of family member, or failing a test). It will help identify key events in the patients past that may have precipitated current symptoms

Answer 12

Things that need to be asked are the following:
 Family of origin
 Early experiences
 Schooling
 Friendships
 Qualifications
 Further or higher education
 Employment history
 Interests and current friendships
 Significant relationships, marriage and children
 Psychosexual history
 Forensic history
 Use of alcohol and illicit drugs

Question 13

Part II of Psychiatric History Taking:
Premorbid Personality
- In asking about premorbid personality, the information from a third party or informant can be particularly helpful. Think about the patient’s coping styles, interests and activities and how the patient usually relates to other people.
 The patient’s personality is often left out because people aren’t sure what questions to ask
 It will be difficult until you understand what your patient is usually like, and thus, hard to completely comprehend how their illness has affected them.
 When asking about a patient’s premorbid personality, it is helpful to get key information from a third party or involvement from them (Ex. parents or siblings)

Answer 13

Some useful questions to ask include the following:

• “I’d like to get an idea about what sort of person you are when you’re well? Firstly, how do you cope with stress?”
• “Are you a genuinely cheerful person, or do things get you down easily?”
• “How do you think your friends describe you? Do you agree with that?”
• “How do you cope when things get difficult?”

Question 14

Risk Assessment (together with MSE)
 There will be certain occasions where in you'll be required to see a patient who is intoxicated or aggressive. When approaching these kinds of patients, you need to be mindful of your personal safety as well as that of other people
 Risk assessment is done with every patient you see and meet, you need to make an assessment of the risk they pose to both themselves and to the people around them

Answer 14

The main risks you should be looking for when we’re taking a patient’s history are:
 Risk of suicide
 Risk of self-harm
 Risk of violence

Question 15

Immediate Management vs Long Term Management
Immediate Management
- What do you do when you think that someone is about to take his/her life? You can intervene and prevent that person from taking their life, physical restraint is common. However, it is important to try and implement other forms of interventions such as: crisis team, seeing your patient in a week’s time, arranging an appointment with a GP, etc

Answer 15

Long-term Management
You can never take the risk from them way completely. It is important that you try and manage whatever is the cause of their suicidal risk.

Question 16

REMEMBER
Remember that suicidal ideas or self-harm is not a diagnosis.
- It is possible that it may be caused by depression which in this case, you should treat the depression.
- It may also be caused by a psychiatric illness (such as schizophrenia), in this case should first recognize and then treat this condition.
- Another example is that it may be caused by their alcohol dependency or substance abuse and thus, you need to assess and recommend proper management.

Answer 16

You need to consider the context and circumstances, such as financial problems or other factors that may affect the patient’s self-harm.

Question 17

Repeated Self-harm
 Repetition of self-harm is common. There will be patients that repeat self-harm within a year and some people whom would repeat 5 or more times of self-harm within a year.
 The way to manage repeated self-harm might be on a case-to-case basis, like an individual who self-harms in response to an episode of depression.

Answer 17

 There will be some patients who use self-harm as a way of regulating their emotions. You need to develop a collaborative relationship and look at ways of finding alternatives to self-harm such as using psychological techniques such as mindfulness to management of difficult emotions, encouraging them to express emotion feelings rather than to act by self-harm.

Question 18

Risk of Violence
 This is important but is uncommon. Fortunately, people with mental illness rather choose to be victims of violence rather than perpetrate violence.
 Background information regarding episodes of previous violence should be investigated using medical records instead of over reliance on patient interview (patient may be lying or in denial)

Answer 18

 Management: ask patients if they regularly carry weapons. If yes, ask them to leave those weapons at home. If you sense there is an imminent danger the patient may inflict harm on another person, you as a doctor have the responsibility to inform the police

Question 19

Risk Factors in Mental State Examination
 Individuals with persecutory delusions or paranoid delusions are of concern – individuals who believe that they are in danger, being threatened, misinterpreting apparently innocent gestures being threatening, or they may have command hallucinations (voices that telling them to act violently towards another individual)

Answer 19

 Morbid jealousy - a belief that your partner is having affair is by all evidence contrary. Jealousy is a very powerful emotion and if held with delusional intensity can result in violence.

Question 20

Doing a Risk Assessment

Answer 20

 Remember that risks are dynamic instead of static. They may change overtime
 Calls for the need to make periodical risk

Question 21

Which belongs to the first part of psychiatric history taking?

a. Risk Assessment
b. Management
c. Medications
d. Personal history

Answer 21

c. Medications

Question 22

In taking the patient’s history during the interview, you usually start with:

a. Open ended questions
b. Assumptions
c. Close-ended questions

Answer 22

a. Open ended questions

Question 23

This provides a comprehensive and chronological picture of the events leading up to the current moment in the patient’s life:

a. Medications
b. Chief Complaint
c. History of Present Illness
d. Past Psychiatric History

Answer 23

c. History of Present Illness