Psychiatry History

 

Psychiatric history

• Basic structure

  Standard history – presenting complaint, drug history, past medical history etc. – plus PSYCH extras:

  • Pre-morbid personality: "how would friends and family describe you before you were unwell?". Ask about previous hobbies and habits.
  • Substance use, including alcohol. Ask about frequency, volume, location and situation, and if relevant, administration route and needle sharing.
  • Youth: personal history.
  • Crime: forensic history.
  • Harm risk i.e. risk assessment. SO CRAP: Risk to Self, Risk to Others, Chronic physical health problems, Relapse risk, Medication Adherence, Protective factors.

  Standard history components

  Presenting complaint:

  • "What's been happening with you lately?". Put their own words in quotations as the presenting complaint.
  • If anxious, reassure: "we don't have to talk about anything you don't want to discuss".
  • Think about 4 key components of the episode, in a causal sequence: (1) triggers and life circumstances → (2) thoughts and emotions → (3) behavioural and physical symptoms, including functional impairments → (4) impacts on family, work, and physical health.
  • Make sure to cover the onset, duration, and pattern of symptoms, and factors that perpetuate, exacerbate, or relieve them.
  • Get their ideas, concerns, and expectations: what do they think is going on?
  • Ask about specific psych symptoms – e.g. delusions – as part of the mental state exam.

  Past psychiatric and medical history:

  • Use of mental health services.
  • Sectioning
  • Self-harm

  Drug history:

  • Prescribed meds, including psychiatric drugs. Ask about adherence and side effects.
  • Over the counter drugs.

  Family history:

  • Psychiatric disease.
  • Neurological disease.
  • Crime
  • Alcoholism

  Personal history

  Childhood:

  • Birth and development: "any difficulties in pregnancy or labour?", "did anybody say if you were slow to walk or talk?".
  • "Anything particularly traumatic or significant happen to you as a child?"
  • "Were you at home with parents and siblings?"
  • "Any trouble at school including making friends/bullying/suspension?"
  • "Any problems with schoolwork including special educational needs?"

  Later life, including detailed current social history:

  • Life events: "any particularly stressful events in your life?".
  • Work and finances: problems may be a cause and/or consequence of mental health problems.
  • Relationships and sex: relationship status, sexual orientation, impact of mental illness (i.e. libido).
  • Housing: where, what type (private or social), and who are they with.
  • Children: names, ages, and any social service contact.

  Risk assessement

  Types of risk:

  • Risk to self: deliberate harm or neglect. Includes poor medication adherence – psychiatric and medical – and substance misuse.
  • Risk to others: deliberate harm or neglect.
  • Risk from others: victimization or exploitation.

  Questions about harming self:

  • "Have you ever wished you just weren't here?"
  • "Have you ever felt so low that you thought about harming yourself?"

  Factors suggesting serious suicidal intent, some of which may only be relevant after an attempt has been made, PLAN:

  • Planned suicide attempt over time and not spontaneous. Researched techniques and got kit. Made a suicide note and got affairs in order including a will and funeral plan.
  • Location and Lethality. Made sure they wouldn't be found in terms of location and timing, and made sure the method was sufficiently lethal and untreatable.
  • Feelings Afterwards. Did not seek help after attempt. Did not regret attempt.
  • Narcotics, alcohol, and other drugs. Where they intoxicated during attempt? Suggests weaker intent, but also a risk in so far as it continues.

  Risk and protective factors:

  • Ask about social isolation.
  • "What stops/stopped you from hurting yourself (more)?"

  Risk of harm to others, including through neglect:

  • People they care for e.g. children, elderly relative.
  • Voices telling them to harm.
  • Persecutory delusions leading to violent 'defence'.
  • History of violence.

  Issues and solutions

  • Allow silences, especially in depression.
  • Assure confidentiality but don't overpromise as need to breech it if they or others are in danger.
  • Dealing with overfamiliarity and an interest in you: "today we need to focus on you and get to the bottom of your problems, so we shouldn't get bogged down with my issues".
  • Rambling: "we'll maybe get back to that later, but first we need to focus on…"

• Psychiatric formulation

  Definition of formulation:

  • Frustratingly, there is no clear agreement on what this term means.
  • Most commonly, it is a case summary which includes: key features of history and MSE, differential diagnosis, etiology, management, and prognosis.
  • Other definitions focus on elaborating the etiology in detail, using the 3 x 3 matrix of the bio-psycho-social features of the predisposing (risk factors), precipitating (triggers), and perpetuating factors. This could also be included in the 'case summary' version of the formulation. Remember that in an acute episode of disease, an underlying disease is considered a predisposing factor e.g. in a patient with a manic episode, a history of bipolar disease is a predisposing factor.

  Giving a differential:

  • For any presentation, it can be useful to give a psychotic, affective, and organic differential, though this is not always appropriate.
  • For the likely diagnosis, describe the stage of illness e.g. manic episode as part of bipolar disorder, schizophrenia currently in remission.

  Summarizing management:

  • Discuss treatment using the bio-psycho-social model. Psychological treatment should often start with psychoeducation. Social treatment can involve lifestyle, housing, family, and work.
  • As always, take an MDT approach, involving community psychiatric nurse (CPN), social worker, occupational therapist (OT), and GP.
  • Hospital admissions should be avoided if possible. Relapses of illness should ideally be treated by the community mental health team (CMHT) or crisis team.
  • Inpatients can be discharged to the CMHT, or their GP if they are very well. Those needing a couple of weeks of intense monitoring can first be discharged to the crisis team.
  • CMHT patients all have a care-coordinator – a social worker, CPN, or OT – and will have their medical care from a CPN or psychiatrist. This can be delivered though home visits or outpatient clinics.