Psychiatric history

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A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.

Contents

Psychologists take a similar history, often referred to as a psychological history.

This article mainly covers the initial assessment history taking of a patient presenting for the first time with a new complaint.

Background

In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions. Some of these questions are quite specific, such as, "How old are you?" and others are more open, such as, "How have you been feeling lately?" Although the structure of the interview may appear disjointed, the end result is usually under a set of headings which have a worldwide similarity.

Patient identification

The basic details of who the patient is are collected. [1] [2] This includes their age, sex, educational status, religion, occupation, relationship status, address and contact details. This serves several purposes. Firstly, it is necessary information for administrative purposes and for this reason some of this is often taken by clerks. Secondly, the questions are largely non threatening and provide a gentle introduction into the meeting of patient and clinician. Thirdly, it provides a format for individual introduction suitable to the culture. Thus the clinician may start by introducing themselves and then move on to these questions. This initial structure can provide a sense of familiarity for the patient who is stressed about what is happening. It also helps the clinician understand the patient's social situation. [2]

Source and method of presentation

The next step is to determine why the patient is there. How did they get to be in the interview? Were they referred by someone (such as another clinician, a relative or friend, or by the police or the courts) or did they come looking for help? If they were referred by someone then what was that person's reason for the referral. Often such information is provided in a referral letter or by an earlier phone call.

The main (chief) complaints

The clinician next tries to clarify what are the main problems that have brought the patient to be there. Some of this may have already been achieved in the previous section. The patient may have more than one problem and these may be related, such as posttraumatic stress disorder and alcohol abuse or seemingly unrelated, such as panic disorder and premature ejaculation. The patient is unlikely to present a diagnosis and is more likely to describe the nature of their problems in common language.

History of the presenting complaints (present illness)

The clinician then attempts to obtain a clear description of these problems. When did they start? How did they start, suddenly, slowly or in fits and starts? Have they fluctuated over time? What does the patient describe as the essential features of the complaints? Having developed a hypothesis of what may be the diagnosis, the clinician next looks at symptoms that might confirm this hypothesis or lead them to consider another possibility. Much of the mental process for the clinician is involved in this process of hypothesis testing to arrive at a diagnostic formulation that will form the basis of a management plan. The severity of each complaint is assessed and this may include probing questions on sensitive issues such as suicidal thoughts or sexual difficulties.

History

This is divided into the psychiatric history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. [2] The substance (drug) history includes data about patterns of use (mode of administration, age of onset, frequency, amount, last use, medical or psychological complications, history of attempting to quit) for alcohol, tobacco, and illicit drugs. [2] The medical history documents significant illnesses, both past and current, and significant medical events such as head injury, seizures, major surgeries, and major illnesses. [2] A separate sexual history gathers data about sexual orientation and sexual activity. Finally a history of abuse, including physical, emotional, and sexual abuse is obtained from the patient and collateral sources (family members or close family friends) as trauma might not be directly remembered by the patient.

Family history

Many psychiatric disorders have a genetic component and the biological family history is thus relevant. Clinical experience also suggests that a response to treatment may have a genetic component as well. Thus a patient who presents with clinical depression whose mother also suffered from the same disorder and responded well to fluoxetine would indicate that this drug would be more likely to help in the patient's disorder.

Apart from the genetic factors, research has shown that illnesses in the parents such as depression and alcohol abuse are associated with a higher rate of some conditions in the children growing up in that environment. Similar effects are seen with the death of a parent from a protracted illness.

Developmental history

This documents the significant events in the patient's life. [2] Ideally it starts with pre-natal factors such as maternal illnesses or complications with the pregnancy, then documents delivery and early childhood illnesses or problems. It then looks at significant events in the patient's life such as parental separation, abuse, education, psychosexual development, peer relationships, behavioural aspects and any legal complications. It flows then into adulthood with relationship and occupational histories. The aim is to get an overview of who the patient is and what they have experienced in life, both good and bad. Major stresses and transitions such as marriage, parenthood, retirement, death or loss of a partner, and financial success and failure are all important, as is how the patient has dealt with them. Sexual adjustment and problems can be relevant and are often questioned.

Social history

If the information has not already been obtained, the clinician then documents the social circumstances of the patient looking at factors such as finances, housing, relationships, drug and alcohol use, and problems with the law or other authorities. This is also a time to document racial or cultural issues that are relevant to the presenting complaint.

Review of Systems

A psychiatric review of systems [3] may include screening questions directed at identifying or exploring co-morbid psychiatric illnesses or issues (e.g., SIGECAPS mnemonic or PHQ-9 for depression, Generalized Anxiety Disorder 7 for anxiety, DIGFAST mnemonic for mania, or specific questioning around psychoses or other psychiatric complaints. A full review of systems should attempt to identify and list all of the relevant STRESSORS that may be impacting a patient's function and overall health.

Summary

Having collected this information the clinician usually then considers any other factors that might be relevant to the particular patient and enquires about them. Although the gathering of the information may follow the flow of the patient's thoughts rather than those of the clinician, it is not uncommon for the clinician to record the psychiatric history under headings, such as those above, to make it easier for others who will later read it.

Subsequent history taking on reviews concentrates on changes in the levels of symptoms and responses to treatment, including possible side-effects.

See also

Related Research Articles

A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior. It is usually associated with distress or impairment in important areas of functioning. There are many different types of mental disorders. Mental disorders may also be referred to as mental health conditions. Such features may be persistent, relapsing and remitting, or occur as single episodes. Many disorders have been described, with signs and symptoms that vary widely between specific disorders. Such disorders may be diagnosed by a mental health professional, usually a clinical psychologist or psychiatrist.

<span class="mw-page-title-main">Causes of mental disorders</span> Etiology of psychopathology

A mental disorder is an impairment of the mind disrupting normal thinking, feeling, mood, behavior, or social interactions, and accompanied by significant distress or dysfunction. The causes of mental disorders are very complex and vary depending on the particular disorder and the individual. Although the causes of most mental disorders are not fully understood, researchers have identified a variety of biological, psychological, and environmental factors that can contribute to the development or progression of mental disorders. Most mental disorders result in a combination of several different factors rather than just a single factor.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.

<span class="mw-page-title-main">Somatization disorder</span> Mental disorder consisting of clinically significant somatic symptoms

Somatization disorder was a mental and behavioral disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms. It was recognized in the DSM-IV-TR classification system, but in the latest version DSM-5, it was combined with undifferentiated somatoform disorder to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms. ICD-10, the latest version of the International Statistical Classification of Diseases and Related Health Problems, still includes somatization syndrome.

Self-medication is a human behavior in which an individual uses a substance or any exogenous influence to self-administer treatment for physical or psychological conditions: for example headaches or fatigue.

Sexual medicine or Psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

Drugs and prostitution have been documented to have a direct correlation.

The medical history, case history, or anamnesis of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to him, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.

Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has developed within the individual from psychoactive substance consumption that results in the experience of withdrawal and that necessitates the re-consumption of the drug. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

<span class="mw-page-title-main">Emergency psychiatry</span> Clinical application of psychiatry in emergency settings

Emergency psychiatry is the clinical application of psychiatry in emergency settings. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behavior.

<span class="mw-page-title-main">Suicidal ideation</span> Thoughts, ideas, or ruminations about the possibility of ending ones life

Suicidal ideation, or suicidal thoughts, is the thought process of having ideas, or ruminations about the possibility of ending one's own life. It is not a diagnosis but is a symptom of some mental disorders, use of certain psychoactive drugs, and can also occur in response to adverse life events without the presence of a mental disorder.

The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is used in a broad range of helping professions in health and social care settings as well as by medical and social science researchers.

The trauma model of mental disorders, or trauma model of psychopathology, emphasises the effects of physical, sexual and psychological trauma as key causal factors in the development of psychiatric disorders, including depression and anxiety as well as psychosis, whether the trauma is experienced in childhood or adulthood. It conceptualises people as having understandable reactions to traumatic events rather than suffering from mental illness.

Dual diagnosis is the condition of having a mental illness and a comorbid substance use disorder. There is considerable debate surrounding the appropriateness of using a single category for a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression and alcohol use disorder, or it can be restricted to specify severe mental illness and substance use disorder, or a person who has a milder mental illness and a drug dependency, such as panic disorder or generalized anxiety disorder and is dependent on opioids. Diagnosing a primary psychiatric illness in people who use substances is challenging as substance use disorder itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.

A psychiatric assessment, or psychological screening, is the process of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist, but it can be a multi-disciplinary process involving nurses, psychologists, occupational therapist, social workers, and licensed professional counselors.

In a medical encounter, a past medical history, is the total sum of a patient's health status prior to the presenting problem.

Somatic symptom disorder, also known as somatoform disorder, is defined by one or more chronic physical symptoms that coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symptoms. The symptoms are not purposefully produced or feigned, and they may or may not coexist with a known medical ailment.

<span class="mw-page-title-main">Homelessness and mental health</span>

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency. It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless have a mental illness. In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question and how homelessness is defined, the consensus estimate as of 2014 was that, at minimum, 25% of the American homeless—140,000 individuals—were seriously mentally ill at any given point in time. 45% percent of the homeless—250,000 individuals—had any mental illness. More would be labeled homeless if these were annual counts rather than point-in-time counts. Being chronically homeless also means that people with mental illnesses are more likely to experience catastrophic health crises requiring medical intervention or resulting in institutionalization within the criminal justice system. Majority of the homeless population do not have a mental illness. Although there is no correlation between homelessness and mental health, those who are dealing with homelessness are struggling with psychological and emotional distress. The Substance Abuse and Mental Health Services Administration conducted a study and found that in 2010, 26.2 percent of sheltered homeless people had a severe mental illness.

People in prison are more likely than the general United States population to have received a mental disorder diagnosis, and women in prison have higher rates of mental illness and mental health treatment than do men in prison. Furthermore, women in prisons are three times more likely than the general population to report poor physical and mental health. Women are the fastest growing demographic of the United States prison population. As of 2019, there are about 222,500 women incarcerated in state and federal prisons in the United States. Women comprise roughly 8% of all inmates in the United States.

References

  1. "UIC, Dept. of Psychiatry". Archived from the original on 2009-09-19. Retrieved 2009-11-10.
  2. 1 2 3 4 5 6 "The Psychiatric Interview". PsychDB. Retrieved 2023-10-26.
  3. "Am Fam Physician 1998 Nov 1;58(7):1617-1624" . Retrieved 2016-02-10.