Psychiatric History taking

History taking…

Why do we take history?

 To obtain information that will establish a criteria-based diagnosis

 To describe adaptive and maladaptive behavior

 To predict course of the illness

 Predict prognosis of the illness

 Helps as initial measure taken towards treatment.

 Cont…

Settings where psychiatric history can be taken:

Psychiatric inpatient units,
Medical non-psychiatric inpatient units,
Emergency rooms,
Outpatient offices,
Nursing homes,
Correctional facilities.
Other residential programs,
General principles in history taking

Agreement as to Process
 Examiner should introduce himself or herself depending on the circumstances

 Examiner should inform the patient and important others why he or she is
speaking with the patient.
 nature of the interaction and the approximate (or specific) amount of time for the
interview should be stated
 Consent from the patient /family/ is important before proceeding to the interview.
 Cont…
Privacy and Confidentiality
 Ensure that the content of the interview cannot be overheard by others

 Interview the patient in a separate room (if not feasible, avoid certain
topics that need privacy and indicate that these issues can be
discussed later)
 indicate that the content of the session(s) will remain confidential
except for what needs to be shared with the referring physician or
treatment team.
 Cont…

 However in some situations patient information might not be kept

confidential.
 For instance:
Forensic evaluation
 disability evaluation
 when other person in a danger
 Cont…

Respect and Consideration

 Respect the patient and be considerate of the circumstances of the
patient’s condition.
 Be aware of potential issues and interact in a manner to decrease, or at
least not increase, patient’s distress.

“The success of the initial interview often depends on the physician’s

ability to allay excessive anxiety”
 Cont…
Rapport and Empathy
 Rapport: harmonious responsiveness of the physician to the patient
and the patient to the physician.
 Empathy: understanding what the patient is thinking and feeling and
ability to be in the patient’s place while at the same time maintaining
objectivity.

Eg. That must have been very difficult for you” or “I’m beginning to
understand how awful that felt”)
 Cont…
Patient–Physician Relationship
 A good doctor-patient relationship is a crucial point in a successful
history taking and management of the patient.
demonstration by physician that he/she understands what the patient
is stating and emoting.
recognition by the patient that the physician cares.

 Boundary should be maintained

 Cont…

 Patient- physician relationship should be maintained genuinely

 For instance:
 Being able to smile in response to a humorous comment,

 admit a mistake, or apologize for an error that inconvenienced the patient

(e.g., being late for or missing an appointment)

 Maintain patient centered approach of relationship

 Cont…

Conscious and unconscious processes

 Unconscious processes must be considered since majority of mental
activity remains outside of conscious awareness.
 Be aware of slip of tongue and mannerism of speech.

E.g phrases such as “to tell you the truth” or “to speak frankly”
suggest that the speaker does not usually tell the truth or speak frankly
 Cont…

 Transference and countertransference are major unconscious processes

encountered during doctor- patient relationship
 Transference is the process of the patient unconsciously and
inappropriately displacing onto individuals in his or her current life
those patterns of behavior and emotional reactions that originated with
significant figures from earlier in life, often childhood.
 Cont…

 Eg. A patient may consider a clinician as her loved one as she

unconsciously relates the clinician with her first boy friend.

 Failure to recognize this process can lead to the clinician

inappropriately reacting to the patient’s behavior as if it is a personal
attack on the clinician.
 Cont…

 Countertransference is the process where the physician

unconsciously displaces onto the patient patterns of behaviors or
emotional reactions as if he or she were a significant figure from
earlier in the physician’s life.
 Eg. A physician might dislike to talk to the patient because the patient
unconsciously reminds him of his abusive uncle.
 Cont…

 The patient is generally unaware of the impact of these feelings,

thinking, or behaviors, which take many different forms including
exaggerated emotional responses, intellectualization, generalization,
missed appointments, or acting out behaviors.
 Countertransference should be handled wisely to provide successful
management of the patient.
 Cont…
Person-Centered Interviews
 the focus should be on understanding the patient and enabling the
patient to tell his or her story
 focus on strengths and assets as well as deficits.

 For example,
 “Tell me about some of the things you do best,”

 “What do you consider your greatest asset?”

 “Tell me about yourself,”
 Cont…
Safety and Comfort

 Safety first!

 During the interview both the patient and examiner should feel safe.

 In hospital or emergency room settings, this may require that other staff be
present or that the door to the room where the interview is conducted be
left open.
 It is generally agreed that the patient and the examiner should be seated
approximately 4 to 6 feet apart.
 Interview techniques

Open ended question

 Helps to interact in a manner that allows the patient to tell his or her
story
 eg. tell me about what initiates you to come here.

 Avoiding predominance of yes/no questions is important in

psychiatric interview to illicit more information from the patient.

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 Cont…

Nonverbal Communication
 Allows examiner to both “read the patient” more effectively and to
send messages to the patient.
 Pay close attention to eye contact, facial expression, posture, head
position and movement such as shaking or nodding, interpersonal
distance, and placement of the arms or legs, such as crossed or
neutral.

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 Cont…

Facilitation

 Nodding of the head ,remaining silent, leaning forward, making eye contact, and

using continuers like “Mm-hmm,” “Go on,” or “I’m listening” all maintain the
flow of the patient’s story.

Echoing

 Simple repetition of the patient’s words encourages the patient to express factual

details.

 Reveal not only the location and severity of the patient’s problem but also its
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meaning to the patient and the clinician.
 Cont…

For instance,
Patient: My heart began to move starting from last month

examiner: move? (Pause)

Patient: Yes, it went to my shoulder and I am going to die (Pause)

examiner: Going to die?

Patient: Yes, I feel that it is moving. The doctors did not know it. They said
it is in its normal place. But they are completely wrong and I am sure that
my heart moves up to my shoulder and I am going to die because of it.

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 Cont…
Empathic response
 Conveying empathy is part of establishing and strengthening rapport
with patients.
 Once you have identified the feelings, respond with understanding
and acceptance.
 Responses may be as simple as “I understand,” “That sounds
upsetting,”
 Empathy may also be nonverbal—for example,
 Offering a tissue to a crying patient or gently placing your hand on
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 Cont…

Reassurance
 When talking with patients who are anxious it is important to reassure
them.
 Take care of immature reassurance.

Eg, “Don’t worry, everything is going to be all right.”

 The first step to effective reassurance is identifying and accepting the
patient’s feelings without offering reassurance at that moment.

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 Cont….
 Summarization

 Giving a capsule summary of the patient’s story in the course of

the interview can have several functions.
 It indicates to the patient that you have been listening carefully.

 lets the patient add other information.

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Common errors in psychiatric interviewing

 Inadequate explanation of psychiatric disorders and treatment options

 Empathic failures by inadvertently shaming or embarrassing the

patient
 Countertransference issues with the patient

 Not exploring in depth safety issues with the patient

 Cont…

 Premature closure and false assumptions about symptoms

 False reassurances about the patient’s condition or prognosis

 Defensiveness with aggressive or arrogant patients

 Omission of significant parts of the interview

 Recommendations for treatment when diagnostic formulation is

incomplete.
Components of psychiatric history

 Identification  Family history

 Personality and Developmental history

 Chief compliant
 Mental state examination
 History of presenting illness  Physical examination

 Past psychiatry history  Case summary

 Diagnosis
 Substance use history
 Formulation
 Past Medical history  Management
 Cont…
Identification

 Brief understanding of client’s background

 includes the patient’s name, age, sex, marital status (or significant

other relationship), address, educational background, religion,

occupation, living circumstances, arrival situation (brought by,
accompanied by…), number of visit, admission, source of
information, source of referral (if any), reliability of information ,etc.
 Cont…
Chief Complaint
 patient’s most recent presenting complaint

 Taken from patient and attendants

 Use the patient’s ‘own’ word, “verbatim”

 Duration of the complaint should be asked.

E.g. the patient may say “I am okay”, “they brought me”……

or ‘I am suffering from head ache since yesterday”

 Cont…
History of presenting illness

 Chronological description of the evolution of the symptoms of the current episode.

 Detailed description of patient’s presenting complaint.

 Details that should be gathered include

 Duration of illness

 Onset and of the illness

 Course and fluctuations in the nature or severity of those symptoms over time

 Psychosocial stressors
 Cont….
 Presenting symptoms should be gathered in detail.

 Use open ended question so that the patient can talk in detail.

 Ask the patient about Vegetative symptoms (sleep, appetite, weight…)

 Ask the patient to specify and characterize each symptoms

 Aggravating and relieving factors

 Impairment due to the illness and duration of impairment.

 Occupational impairment

 Psychosocial impairment

 Help sought: paths to mental health institution.

 Cont…
 Review of systems:
 Anxiety disorders

 Mood disorders (manic, hypomanic and depressive symptoms)

 Psychotic disorders

 Other mental illnesses

 Risk assessment:
 Suicide (ideation, attempt, means of attempt, frequency, reported reason)

 Homicide (ideation, attempt, means of attempt, frequency, reported reason)

 Substance use (type, amount, frequency, duration, reason of initiation, etc…)

 Cont…
 Presence of any medication/drug (prescribed or non prescribed) which
the patient is taking.
 Medical comorbidity assessment:
Make sure every patient is medically evaluated

Screen patients for acute and chronic medical illnesses

NB: do not use medical terms in HPI (eg..delusion, hallucination…)

 Cont…

Past psychiatry History

 Presence of previous mental illness history

 If there is history of mental illness,

 Clinical manifestation of the illness

 Onset, course and duration of illness

 Psychosocial stressor

 Medication

 History of hospitalization (frequency and duration)

 Inter-episodic functioning (with or without medication)

 Cont…

• Risk assessment:
Suicide (ideation, attempt, means of attempt, frequency, reported reason)

Homicide (ideation, attempt, means of attempt, frequency, reported reason)

Substance use
 Cont…

Past medical History:

 History of acute and chronic medical illnesses(DM, HTN, HIV/AIDS,
hyperthyroidism, hypothyroidism, etc)
 History of neurologic illnesses

 History of surgical conditions and hospitalization

 Head trauma

 Medication allergies
 Cont…

Family history:
 Presence of parental figures.

 Number of siblings,

 Family history of mental illness, suicide and homicide

 Family history of substance use

 Neurological illness in family

 Relationship among family members

 Families attitude towards patient’s illness

 Patient’s attitude towards family

 Supportiveness of family
 Cont…

Developmental and personality history

 From prenatal period to present

 Whether the pregnancy was wanted, planned or not.

 Maternal maladaptive behaviors during pregnancy (psychoactive substance use,) and use of
prescribed drugs.
 delivery (means of delivery, place of delivery, birth complications like hemorrhage ,etc.)

 Post natal period (neonatal sepsis, …)

 Developmental milestones
 Cont…

 Early childhood history

 Preschool age (relationships with peers, siblings, etc)

 School age (relationships with peers, teachers, truancy history, school performance)

 Adolescence history (truancy, substance use, conduct disorder)

 Adulthood (love affairs, marriage, military history)

 Sexual history (desire phase, excitement phase, orgasm and resolution)

 Forensic history (legal history, criminal activity, imprisonment, court orders…)

 Premorbid personality (how others describe the patient, how patients describe themselves,
hobbies and future plans)
Mental State Examination

 General Description and appearance  Cognitive and sensorium

 Attitude towards examiner  Alertness

 Orientation
 Psychomotor activities
 Attention and concentration
 Speech
 Memory
 Emotion
 Fund of knowledge
 Thought form  Abstract thinking

 Thought content  Judgment

 Perception  insight
 Cont…

General Appearance
 Posture

 Dressing and hair style

 Personal hygiene (nail, teeth ….)

 Eye contact
 Cont…

Attitude towards examiner

 attitudes like friendly, cooperative/not, interested, hostile….

Psychomotor activities:

 Overt psychomotor behaviors like tics, mannerism, streotypy, posturing, waxy flexibility, agitation, etc…

Speech

 Amount

 Volume

 Tone

 rate
 Cont…

Emotion
 Mood : ‘verbatim’

 Affect:
Quality (eg. sad looking, happy looking, angry looking…)

Range (eg. full range, constricted, blunted, flat)

Stability (eg. stable, labile…)

Appropriateness (eg. appropriate to the setting/to what the patient is talking……

Congruence (eg. Congruent to mood, incongruent to mood…)

 Cont…

Thought
 Thought Form: flight of ideas, tangentiality, circumstantiality, loosening of
association, etc…
 Thought Content:
Delusion

Obsession

Suicide and homicide

Hopelessness

guilty
 Cont…

Perceptions

Hallucinations: auditory, visual, gustatory…

Illusion

Depersonalization

derealization
 Cont…

Cognition and Sensorium

 Alertness

Alert

Stupor

Clouding of consciousness

Comatose
 Cont…

Orientation
 Time-
– Appropriately what time of the day is it?

– Is it morning, afternoon, evening or night?

 Place-
– What place is this?

– Is this a school, office, hospital, restaurant etc.?

 Person
–ability to identify people around the patient

– Identifying of the patient’s relative or family members.

 Cont…
Attention & Concentration
 Tests used-
Digit span test
Serial subtraction
Days or months forward to backward
 Digit span test-
Forward- numbers are given & asked to repeat in the same order
Backward- numbers are given & asked to repeat in opposite order.
 Serial subtraction-
Serial 7 (100-7 …..)
Serial 3 . (20-3,….)
 Days or months may be asked for in backward or forward.
 Cont…

Memory
 Immediate: ask patients to repeat thing after minutes.

 Recent: Asking the patient to recall events in the last 24 hours (then cross-check from family)

 Remote memory: long period of time…. (birth date, marriage,.).(then cross-check)

Fund of Knowledge
 Based on educational status of patients.

Abstract Thinking
 Ask similarities and differences between two things (lemon and orange…)

 proverbs
 Cont…
Judgment
 Social judgment- (by looking at the patient’ s activities like obeying orders, taking medications
appropriately)
 Test judgment- (Eg. What will you do if you find someone’s ID on your way to work? …..why?)

Insight:
 level I : complete denial of illness
 Level II: partial awareness and denial simultaneously
 Level III: blaming on others
 Level Iv: unknown factors or organic factors
 Level V: intellectual insight (patient knows about illness and maladaptive behaviors but doesn’t try to
modify those behaviors)
 Level VI: true emotional insight (patient knows about illness and maladaptive behaviors and take actions
to modify those behaviors)
 Cont…

Physical examination
 Vital signs,:
Blood pressure,

Pulse rate

Temperature etc…

 From HEENT to MSS

 Cont…
Case Summary
 Summarizing positive findings from all components of history by
interpreting problems to medical terms
 Every positive findings should be included
Diagnosis
 Based on criteria of mental illnesses
 Can be more than one disorder based on fulfilled criteria
Differential Diagnosis
 Disorders that are most related to the diagnosis based on their criteria
 All possible differential diagnosis should be included
 Cont…

Biopsychosocial Formulation
 Biological, psychological factors that contribute to the illness and those factors that can protect

from the illness.

 Predisposing factors: longstanding factors that increases the probability of an individual to be

affected by certain mental illness through out his/her lifetime…eg. genetics and temperament

 Precipitating factors: a specific event or trigger that lead to the onset of the current problem.

 Perpetuating factors: factors that maintain the problem once it has become established.

 Protective factors: factors that reduce the severity of problems and promote healthy and adaptive

functioning.( eg. Physical health, good social support…)

 Cont…
Biological Psychological Social

Predisposing factors ___ ___ ___

Precipitating factors ___ ___ ___

Perpetuating factors ___ ___ ___

Protective factors ___ ___ ___

 Cont…

Prognosis
 Prediction of overall prognosis based the patient’s presenting features

(poor prognosis vs good prognosis)

 Identification of factors leading to poor and good prognosis
 Cont…

Management
 Acute phase:
Biological: -lab investigation

- medications

-monitoring patient’s physical condition (eg. Vital signs)

Psychological: - rapport building

- psycho-education for family and patients

Social: - social support

-identification of potential sources of support

 Cont…

 Continuation phase
 Biological: continuing medication or patient monitoring (out patient or inpatient

 Psychological: maintenance of rapport, psycho-education and psychotherapeutic interventions.

 Social: encouragement of social engagement and support

 Maintenance phase: (relapse prevention)

 Biological: minimum effective dose of the medication

 Psychological: Psychotherapeutic intervention

 Social: Encouragement of social support

Thank you!!!!