Psychiatric History PDF

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PSYCHIATRIC HISTORY TAKING Is a state of well-being in which every individual realizes his or her own potential, can cope with the normal MENTAL HEALTH stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. THE PSYCHIATRIC INTERVIEW IS THE MOST IMPORTANT ELEMENT IN THE EVALUATION AND CARE OF PERSONS WITH MENTAL - Build rapport. ILLNESS. - Collect data about the patient's current dif culties, past psychiatric history and medical history, as well as relevant developmental, interpersonal and social history. CAUSE THERE IS NO DECISIVE INVESTIGATIONS - Diagnose the mental health disorder(s). to make a psychiatric diagnosis, we depend on: 1/ THE GOALS OF THE PSYCHIATRIC what the pateint is saying 2/ our observation 3/ MSE INTERVIEW ARE - Understand the patient's personality structure, use of defense mechanisms and coping strategies. Open-ended question versus Closed-ended questions. - Improve the patient's insight. In taking a psychiatric history the clinician must ask both speci c and open- - Create a foundation for a therapeutic plan. ended questions. The relative proportions vary from one interview to another, - Foster healing and quality of life. depending on many factors, the most important being the mental state of the patient. It is not possible to give strict rules. Facilitation. Doctors help patients continue in the interview by providing both verbal and nonverbal cues. (e.g., “Tell me more about it”. Or by eye contact) Silence give the pt space to talk and don’t interrupt the pt Clari cation In clari cation, doctors attempt to get details from patients about what they have already said. In Opening Phase (5 to 10 Minutes) The interviewer and patient are Interpretation TECHNIQUES introduced, and the purposes and procedures of the interview are set. The technique of interpretation is most often used when a doctor states something about a patient's behavior or thinking that a patient may not be The typical interview comprises an opening, Body Body of the Interview (30 to 40 Minutes) aware of. PHASES OF THE INTERVIEW of the Interview, and closing consists of assessing the major issues in the case and ling in enough detail phase to answer the salient questions and construct a working formulation. Transition The technique of transition allows doctors to convey the idea that enough In the Closing Phase (5 to 10 Minutes) of the interview information has been obtained on one subject; the doctor's words encourage The interviewer shares his/her conclusions with the patient, makes treatment patients to continue on to another subject. recommendations. Explanation Doctors explain treatment plans to patients in easily understandable language 1. Name and allow patients to respond and ask questions 2. Age 3. Religion Normalizing questions 4. Race Sometimes when people feel depressed they do think of ending their life. Have 5. Marital Status you ever felt like this? 6. Occupation and Employment Status- employed, unemployed, pensioner 7. Children Identifying Data 8. Education - The patient is greeted in the waiting room by the psychiatrist who, with a friendly face, introduces himself 9. the source(s) of the information, the reliability of the source(s) or herself, extends a hand, and, if the patient reciprocates, gives a rm hand shake. The psychiatrist should indicate whether the patient came in on his or her - If the patient does not extend his or her hand, it is probably best not to comment at that point but warmly own, was referred by someone else, or was brought in by someone else. indicate the way to the interview room. It is important to clarify where the information has come from, especially if others - Upon entering the interview room, the psychiatrist then indicates where the patient can sit. have provided information or records reviewed, and the interviewer's assessment of how reliable the data are. - Psychiatrists can convey interest and support by exhibiting a warm, friendly face and other nonverbal Source and Reliability communications such as leaning forward in their chair. If the source isn't reliable, you have to ask for another one either any family member who living with the patient or any one that aware of the patient's condition - It is generally useful for the psychiatrist to indicate how much time is available for the interview. - The patient may have some questions about what will happen during this time, con dentiality, and other - the chief complaint, in the patient's own words (you can use Arabic), states why he or she has come or been brought issues, and these questions should be answered directly by the psychiatrist. The psychiatrist can then continue in for help. It should be recorded with the patient's explanation, regardless of how bizarre or irrelevant it is, and should be with an open-ended inquiry recorded verbatim in the section on the chief complaint. INITIATION OF THE INTERVIEW Rapport, the sense of mutual trust and understanding that helps people work together. - The other individuals present as sources of information can then give their versions of the presenting events in the section - Watch your patient’s demeanor. If it’s depressed, you will naturally feel like movinga little closer for support. If on the history of the present illness. angry or hostile (or euphoric), you’ll want to back off to give each of you more personal space. Chief Complaint ✓ Examples of chief complaints follow: - Monitor your own demeanor. Maintain eye contact and nod your head to show that you are listening. Patients who , ,I am having thoughts of wanting to harm myself. , perceive that you like and respect them will return the favor. , ,People are trying to drive me insane. , Building Rapport , ,I am angry all the time - You might do better to express interest and compassion: “I’ve never experienced [that situation], so I can only imagine how horrible you feel.” “I can see that it upset you ✓ “The chief complains should be written in chronological order where the complaint which has appeared rst should be terribly.” “You must have felt miserable.” written.” - Follow up on material that is obviously important to the patient. That may seem hard to do early in training, - Once you’ve identi ed some of the major problem areas you need to explore, start Digging when just thinking up the next question is an effort. But if instead you strive for a relaxed conversation that won’t yield everything you want to know, both of you may have a more productive experience. You can always return to the - The present illness is a chronological description of the evolution of the symptoms of the patient later for details that you overlooked the rst time. current episode. In addition, the account should also include any other changes that have occurred during this same time period in the patient's interests, interpersonal relationships, behaviors, personal habits, and physical health. - This is the most important part in psychiatric interview - Mode of onset: suddenly or over a period of time? - Course: are symptoms constant, progressively worsening or intermittent? - Duration: when did the problems start? - Severity: how much is the patient suffering? To what extent are symptoms affecting the patient’s social and occupationalfunctioning? - Full description of all the symptoms in chronological order of occurrence, and in literature English language. All data are put in one or two paragraphs. - Then you have to ask and verify the presence of any other related symptoms. - All symptoms should be mentioned either present or not. Establishing a timeline is vital: - Patients and their relatives may confuse the chronology of illnesses, mixing up the consequences of early illness with potential causes. - The most useful tool for a historian here is to constantly clarify and use xed time markers, e.g. birthdays, annual holidays such as national day, to identify symptom onset and progression. Acute: the time between the start of symptoms till the full blown picture of the illness ranges from few hours to few days (not more than a week). In psychiatric disorders this occurs in: - Severe psychic trauma - Organic brain disorders as: Encephalitis, Substance-induced psychosis, Onset Epilepsy. Gradual (insidious): the time between the start of symptoms till the full blown picture of the illness ranges from weeks to months or even years. This is the common presentation in psychiatric disorders. Episodic course: the patient experience distinct attacks of the symptoms. In between attacks he is completely free of symptoms. - This usually occurs in affective disorders and anxiety disorders. Remission and exacerbation course: the patient does not go back to the base line before the start of the illness. In between attacks the patient still has some residual symptoms. This usually occurs in cases of different psychotic disorders specially schizophrenia. Course History of the presenting complaint Stable course: since the onset of the illness the patient does not improve and the symptoms exist in the same intensity. This occurs in some cases of schizophrenia. Deteriorating course: since the onset of the illness, the symptoms continue to increase in intensity, and the condition persists. This occurs in some cases of schizophrenia. Interpersonal. Has the patient avoided or fought with friends, been avoided by relatives? Marital and love relationships. Has there been serious discord, even separation or divorce? Legal. Ask: “Have you ever had any police or legal dif culties?” Follow up positive answers with In what ways has the patient's illness affected his or “Have you ever been arrested? How many times?” “Have you been in jail? For a total of how her life activities (e.g., work, important relationships)? long?” And of course, “What were the charges?” Employment. Has your patient missed work, quit a job, or red as a result of illness? Personal interests. Sleep. Many patients complain of insomnia. ❑ terminal (or late, usually associated with severe depression or melancholia); ❑ interval, in which patients awaken during the night (especially found in heavy drinkers and those who have PTSD); ❑ early (experienced from time to time by normal adults who have problems of living). Some patients sleep too much when they are ill (especially true of depression in younger people). Appetite and weight. Was weight change intentional? Classically, appetite and weight decrease with severe depression, but they increase even in some patients with mood disorder. Energy level. Is constant fatigue a change? Has it interfered with normal activities Vegetative symptoms Daily mood variation. How people feel can vary with time of day. Some depressed patients feel worse upon arising but improve throughout the day; others experience the opposite pattern. Sexual interest and performance. Interest in sex is often an early casualty of mental disorder, so explore whether your patient’s frequency, ability, and enjoyment of sex have changed. For most mental disorders, the direction will be down; for mania, libido may increase. - Avoid attempts to refute or discon rm delusions. Often it can be helpful to include a psychiatric review of systems in conjunction with the history of - Af rm that the belief is important to the person and express a desire to understand, without “going along with” the present illness to help rule in or out psychiatric diagnoses wit pertinent positives and negatives. delusional ideas - Every patient requires an evaluation of suicide potential - Rather than commenting on the actual content of the delusion, try to connect in terms of the feelings that the Tips for Interacting with The paranoid and - Some beginning interviewers worry that they’ll suggest suicide to a patient, but anyone with a potential for person appears to be experiencing. Delusional Patient self-harm will have already considered it. - Let the person know that you are here to help, not harm him/her. Suicide and violence - The real risk is in asking too late. You can gently approach the issue: “Have you ever had desperate thoughts, such as wanting to be dead?” - Avoid rapid, unexpected, or unexplained/ unannounced movements that may be misinterpreted due to paranoia. PARTS OF THE INITIAL PSYCHIATRIC - Explore any risk of violence. A history of domestic quarrels or legal dif culties can ease you in to this line of - Provide enough personal space and Keep your hands visible INTERVIEW questioning. Otherwise, you’ll need to ask whether the patient has ever been involved in ghts, harmed others, or - Agitation is a sign of many different types of mental disorders as well as a part of normal temperament variation. Extreme degrees, been concerned about controlling impulses leading to violence, are a common reason for psychiatric as well as legal interventions. SPECIAL PROBLEMS IN A detailed account of all the previous psychiatric disorders before the present The Violent, Agitated Patient INTERVIEWING - The clinical interview requires, rst of all, that a safe environment be established. No helpful intervention can be made in an episode should be described. atmosphere of fear and uncertainty. Adequate resources such as additional people, physical restraint, seclusion, or distance must be If it is a continuous illness then whole of the history should be described in used in order to obtain an appropriate assessment the history of presenting complain. - Talking to a profoundly depressed patient can drain the energy of the interviewer. The patient will often have the classic symptom of prolonged latency of response; You’ll need to learn details of prior episodes: - When did they occur? - A great deal of patience is required when evaluating someone very depressed. V. Past Psychiatric History And if the illness is an episodic one , then that episode is required to be - What were the symptoms? The diagnosis? described in H/O presenting illness, rest of the previous episodes should be - What were the social consequences? The Depressed Patient described in the past history. - If hospitalized, how many times and for how long? - Another dif cult aspect of dealing with a very depressed person is the emotional drain. The pessimism, hopelessness, and helplessness of these patients can be somewhat infectious. - What treatments were tried? Which worked best? Was recovery complete? For how long? - Was there a period of time that the patient remained well without prophylactic treatment? - Crying is a frequently encountered affect in the interview of a depressed patient, which issometimes problematic. At times, the patient must be For previous medications, besides such basic information as name, dose, frequency, told of this dif culty and the importance of completing the assessment in a timely manner in order to reduce his/her pain. duration of use, and effects (both wanted and unwanted), learn how well the patient cooperated with treatment. People often resist admitting to poor compliance, so ask: “Have you ever had trouble following your doctor’s advice?” “What sort of dif culty have you had?” History of use should include: ❑ Which substances have been used, including alcohol, drugs, medications (prescribed or not prescribed to the patient), ❑ Routes of use (oral, snorting, or intravenous). VI. Substance Abuse, and Addictions ❑ The frequency and amount of use should be determined. ❑ Tolerance, the need for increasing amounts of use, ❑ Any withdrawal symptoms ❑ Impact of use on social interactions, work, school, legal consequences, and driving while intoxicated (DWI) should be covered. The past medical history includes an account of major medical illnesses and conditions as well as treatments, both past and present. Any past surgeries should be also reviewed. It is important to understand the patient's reaction to these illnesses and the coping skills employed. The past medical history is an important consideration when determining potential causes of mental illness as well as comorbid or confounding factors and may dictate potential treatment options or limitations. Medical illnesses can: VII. Past Medical History