Psychiatry History Taking

I. Psychiatry History Taking

A) Introduction:To establish Rapport

Patient’s name (How patient wants to be addressed?)

Age

Living environment (Where do you live;who do you live with; since when;any changes in family structure and function)

Referral?

Who brought the patient to hospital?

B) Chief Complain/s:Reason for the visit in“patient’s own words”

C) History of Presenting Illness:Revolve around the chief complain/s

D) Past Medical History:

Psychiatric-

- Similar episode in the past?

- Anyway different to current episode (manic/ hypomanic episodes in particular in the past; anxiety; false perceptions and beliefs)

- Context (precipitating/ predisposing/ perpetuating factors)

- First episode (when and its nature)

- Duration/ Progression/ Remission/ Relapse

- Suicidal/ Homicidal risk assessment (Severity of past attempts; Availability of means at present)

-Any treatments (Medications in a chronological order with dose and duration; which works and which does not/ adherence to medication/ overdosing on any medications); Inpatient hospitalization highlights previous severity (Name of the hospital/duration/outcome/ECT- ask if you may get information from there)/Outpatient care (for how long; How the patient feel about the treatment offered? Any missed appointments)

- Any allergies from any medications? If yes, nature and outcome?

- Any psychiatric diagnosis? Patients insight on own diagnosis and state of mental health?

Physical -

- Any medical diagnosis/ surgery (hospitalizations/ medications)?Ask self care and management of physical illness. Inquire chronic pain/ Narcotics?

- Substance Abuse (temporal relation to symptomatology) - if yes, head trauma, blackouts, seizures, intoxication, withdrawal etc.

Also inquire about IV drugs (needle sharing?), amount, duration, frequency, first use, last use, longest sobriety, and anydrug rehab programs. Ask about Legal issues(conviction, incarceration)

- Any psychiatric symptoms when sober (at the prison or during probation or at rehab)

- Socio- occupational problems due to illness?

E) Personal/ Family/ Social Histories:

-Siblings and parents (alive and dead)/ single orboth parents/ Parents occupations/ Relationship with parents and siblings/ Mother drug use / Birth history (mode of delivery/ preterm/ LWB/ congenital problems)

-How was life while growing up / Relationship with friends, teachers and others / Neighborhood/ Foster care/ Physical, sexual abuse or emotional neglect(if yes, age of onset, characters of perpetrator/s, duration, episodic or continual, help seeking (if yes what was the result, if not what stopped)/ Witnessed any violence.

-Status of siblings and current relationship and support

-Highest educational level attended/ Any special classes / Reason for not being able to continue school/ First job / First emotional relationship (sex of the partner, duration)/

-Married/ single [duration/ times/ separated or divorced/ (reasons for separation)]

-Children ( Planned or Unplanned; Who they live with; Any stressors; Extra responsibilities; status of father/s)

-Sexual activeness/ orientation/ protections/ Ever tested for STDs

-Employment? Do you enjoy the work that you do? Longest job, types of job, numbers of job?

-Interests/ hobbies?

-Anyone in the family has any mental illness (If yes what medications they take)

-Anyone in the family has any medical problems

-Anyone in the family committed/ attempted suicide/ homicide (Witnessed or unwitnessed)

-Anyone in the family with substance abuse

-What do you think what kind of person you are? who you think knows and understands you better (What does he/ she says about you)

-Any source of motivation in life; How do you cope with stress; Spirituality

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II. Evaluations:

A) Mental state Examination-“It is common that people in stress have problem with memory and concentration. To test your memory, I am going to ask you few questions, some are very easy to answer and some may be a little difficult.”

  1. Level of Consciousness- normal/ Alert, clouded,delirium,Obtundation, Stupor, coma
  1. Appearance and general behavior: Age, sex, ethnicity, build; Appearance [dress (subdued/riotous), grooming (immaculate/unkempt), hygiene];Attitude [Postural orientation to examiner, Eye Contact (direct/furtive), engage with examiner, cooperation, seductive/ defensive/hostile/paranoid/ vague]
  1. Speech:nature: Quality- Rate ( rapid/ pressured); rhythm ( flow or hesitancy); volume (hypo/hyperphonia); tone (Manner of expression in speech pitch, melody interval and duration in diatonic) vocabulary, word choice, dysprosody, neologisms
  1. Motor activity: gait, position, posture (erect/kyphotic), tics, gestures, dyskinesia, akathesia
  1. Affect and mood: Affect is the patient's immediate expression of emotion; mood refers to the more sustained emotional makeup of the patient's personality. Patients display a range of affect that may be described as broad, restricted, labile, or flat. Affect is inappropriate when there is no consonance between what the patient is experiencing or describing and the emotion he is showing at the same time (e.g., laughing when relating the recent death of a loved one). Both affect and mood can be described as dysphoric (depression, anxiety, guilt), euthymic (normal), or euphoric (implying a pathologically elevated sense of well-being). Affect must be judged in the context of the setting and those observations that have gone before. Affect { a. Expression of emotions: range( full/ constricted), change of pattern ( labile, monotonous, fluid, appropriate) b. Intensity of expression; c. connection with interviewer}
  1. Thought and perception: tendencies toward somatization or may be troubled with intrusive thoughts and obsessive ideas. “Have you ever seen or heard things that other people could not see or hear? Have you ever seen or heard things that later turned out not to be there?" Process (quantity, speed, connection, abstraction) content ( anxiety, psychosis, safety) perceptions ( hallucination, illusion, depersonalization, derealization) Intelligence
  1. Insight / Judgment The patient's attitude is the emotional tone displayed toward the examiner, other individuals, or his illness. It may convey a sense of hostility, anger, helplessness, pessimism, overdramatization, self-centeredness, or passivity. Likewise, the patient's attitude toward the illness is an important variable. Is the patient a help-rejecting complainer? Does the patient view the illness as psychiatric or nonpsychiatric? Does the patient look for improvement or is he or she resigned to suffer in silence?
  1. Examiner's reaction to the patient: The feelings aroused in the examiner by the patient are often a source of very useful information. These data are sometimes subtle and easily overlooked as the examiner, in an attempt to remain objective, fails to note how he or she is responding to the patient.A developing sense of dysphoria in the examiner may be the first clue that the physician is dealing with a depressed patient. Frustration may be the response to the help-rejecting complainer while a feeling of being off-balance and slightly out of touch with the conversation may be an early indication that one is dealing with a schizophrenic patient.
  1. Cognitive abilities (MMSE): Attention (concentration on simple task, placing minimal demand on language function, motor response, or spatial conception. It is a state of wakefulness: let patient tap each time most frequently occurring letter comes); Language Basic examination of language function should include an assessment of spontaneous speech (Look for disorders of articulation, abnormalities of content, disorders of output, and paraphasic errors. Phonemic errors are mistakes in pronunciation; semantic errors are errors in the meaning of words; neologisms are meaningless nonwords that have a specific meaning for the patient), comprehension of spoken commands (tested with several levels of responses. First the patient is asked complex yes and no questions such as, "Do you take off your clothes before taking a shower?" thereby minimizing the need for motoric and speech acts. Second, questions where gesture alone can be an adequate response are asked, for example, "Point to where people may sit down in this room." finally, the patient is asked to follow a command with a motor response: "Squeeze my fingers.", Word-finding disability may be suspected when spontaneous speech is halting in nature as the patient searches for the proper word. To test this ability, the patient is asked to name a number of objects of several categories ranging from the everyday to the more unusual. To stress this ability further the naming of parts of objects, for example, the crystal of a watch, the lead of a pencil, is also tested. Word fluency is more specifically tested by having the patient generate as many words in a given category as he or she is able in a fixed time period. Standard tests ask for such things as "items found in a supermarket" or "words beginning with the letters F, then A, then S."); reading ability and reading comprehension (“Close your eyes”), writing, and repetition ("That's what she said to them yesterday," and "No ifs, ands, or buts.");Memory and Orientation: Three subunits: immediate recall ( Tell me what 3 things I say to you), short-term memory ( After 5 minutes), and long-term storage (Who is the president? And who was before him?) Constructional Ability and Praxis: Ideomotor aprexia "use an imaginary scissors," Ideatory aprexia “take this paper in your left hand, fold into half, and give it back to my right hand”. Constructional inability: “draw this picture/ draw a clock at 8:30”Abstract Reasoning(Insight/ Judgment/ problem solving):Best assessed by probing into how the patient functions on the job, in community affairs, and social situations by proxy interview as well as by patient interview.Some elements can be formally tested by having the patient perform calculations (complex as well as rote tables), interpret proverbs, and describe similarities between ordered pairs, for example, "How is a tree like a banana?" "How is praise similar to criticism?"

- Diagnostic criteria pyramid:SymptomsSyndrome (Axis I) > Pathology- Psychological(Axis II) or Physiological(Axis III) > Etiology

- Axis I- V

-Axis II: It is too early for me to make a personality disorder diagnosis from 30 minutes interview. However, the patient has following personality traits, which demand consideration because these traits impact the formulation and treatment plan. (Talk relationship/ conflicts with people)

I also noticed the use of following defense mechanisms which the patient used at the context of a conflict around…………………………..

Narcissistic: distortion, denial, delusion, projection

Immature: Acting out, undoing, splitting, projection, introjections, blocking, regression, hypochondriasis, somatization, passive- aggressive, schizoid fantasy

Neurotic: Intellectualization, Rationalization, reaction formation, isolation of affect, displacement, repression

Mature: Altruism, Humor, Sublimation, suppression

  1. Suicide

Questions That May Be Helpful in Inquiring About Specific Aspects of Suicidal Thoughts, Plans, and Behaviors

Begin with questions that address the patient’s feelings about living

Have you ever felt that life was not worth living?

Did you ever wish you could go to sleep and just not wake up?

Follow up with specific questions that ask about thoughts of death, self-harm, or suicide

Is death something you’ve thought about recently?

Have things ever reached the point that you’ve thought of harming yourself?

For individuals who have thoughts of self-harm or suicide

When did you first notice such thoughts?

What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)?

How often have those thoughts occurred (including frequency, obsession quality, and controllability)?

How close have you come to acting on those thoughts?

How likely do you think it is that you will act on them in the future?

Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?

What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, and reactions of others)?

Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)

Do you have guns or other weapons available to you?

Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?

Have you spoken to anyone about your plans?

How does the future look to you?

What things would lead you to feel more (or less) hopeful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)?

What things would make it more (or less) likely that you would try to kill yourself?

What things in your life would lead you to want to escape from life or be dead?

What things in your life make you want to go on living?

If you began to have thoughts of harming or killing yourself again, what would you do?

For individuals who have attempted suicide or engaged in self-damaging action(s), parallel questions to those in the previous section can address the prior attempt(s).

Additional questions can be asked in general terms or can refer to the specific method used and may include:

Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?

What thoughts were you having beforehand that led up to the attempt?

What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)?

Were other people present at the time?

Did you seek help afterward yourself, or did someone get help for you?

Had you planned to be discovered, or were you found accidentally?

How did you feel afterward (e.g., relief versus regret at being alive)?

Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)?

Has your view of things changed, or is anything different for you since the attempt?

Are there other times in the past when you’ve tried to harm (or kill) yourself?

For individuals with repeated suicidal thoughts or attempts

About how often have you tried to harm (or kill) yourself?

When was the most recent time?

Can you describe your thoughts at the time that you were thinking most seriously about suicide?

When was your most serious attempt at harming or killing yourself?

What led up to it, and what happened afterward?

In short, evaluate followings related to suicide attempt:

Circumstances

  • Isolation- somebody present/ somebody nearby or in contact (as by phone)/ no one nearby or in contact.
  • Timing- timed so that intervention is probable/ not likely/ highly unlikely
  • Precautions against discovery and/or intervention- no precautions/ passive precautions, e.g. avoiding others but doing nothing to prevent their intervention (alone in room, door unlocked)/ active prevention, such as locking doors
  • Acting to gain Help during or after the attempt- notified potential helper/ contacted but did not specifically notify potential helper regarding/ did not contact or notify potential helper
  • Final acts in Anticipation of death- none/ partial preparation or ideations/ definite plans made (e.g. changes in will, taking out insurance)
  • Suicide Note- none/ none written but torn up/ present

Self report

  • Patient's statement of Lethality- thought what he had done would not kill him/ unsure whether what he had done would kill him/ very sure
  • Stated Intent- did not want to die/ uncertain or did not care if he lived or died/ did want to die
  • Action plan - impulsive, no premeditation/ considered for < 1 hour/ considered for < 1 day/ considered for > 1 day
  • Reaction to the act- patient is glad he has recovered/ patient is uncertain whether he is glad or sorry/ patient sorry he has recovered

Actual risk

  • Predictable Outcome in terms of lethality of patient's act and circumstances known to him- survival certain/ death unlikely/ death likely or certain
  • Would death have occurred without medical Intervention- no/ uncertain/yes
  1. For individuals with psychosis, ask specifically about hallucinations and delusions
  • Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus non recognizable)?
  • What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples.)
  • How do you cope with (or respond to) the voices?
  • Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?)
  • Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?)
  • Are you worried about having a serious illness or that your body is rotting?
  • Are you concerned about your financial situation even when others tell you there’s nothing to worry about?
  • Are there things that you’ve been feeling guilty about or blaming yourself for?
  1. Consider assessing the patient’s potential to harm others in addition to him- or herself
  • Are there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them?
  • Are there other people you would want to die with you?
  • Are there others who you think would be unable to go on without you?

Competency Assessment

a. Initial Assessment

  • General perspective or specific (Psychiatric hospitalization, ECT)
  • Find out the best language of communication
  • Determine if patient has adequate information on which to base a decision
  • MMSE: attention, concentration, memory
  • Inform the patient about the nature of the disorder, AND the risk and benefit of the PROPOSED treatment, and of ALTERNATIVE treatments or of NO treatment
  • Repeat information number of times and in different ways.
  • Let the patient paraphrase or restate the understanding.
  • Evaluate nature of questions that patient asks regarding treatment plan
  • If patient has “severe deficit” in understanding information-incompetentArrange a process for “ a substitute decision maker”
  • Periodical REassessment of competency ( if any change in clinical conditions, mental status or any modifications in treatment plan)
  • To be competent to consent to “treatment”, 4 criteria must be satisfied in a patient: (Appelbaum PS et al NEJM, 1988 and Tancredi L et al International journal of law and Psychiatry 1982)
  1. able to communicate a choice
  2. to understand relevant information about the PROPOSED treatment and treatment OPTIONS
  3. to appreciate own clinical situation (insight) ( if a patient is in denial of illness, s/he will not be considered competent)
  4. to rationally manipulate (reasonable; sensible; sound judgment)

(Periodical reassessment)