Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

Taking a psychiatric history

The purpose of the psychiatric history is help with decisions about diagnosis, will increase understanding of the factors that may influence symptoms or problems, and to help determine the most appropriate treatment and management plan. It will be important to inform individuals that the psychiatric history notes belong to the health service and that others with a duty of care or other legitimate role, now or in the future, will have access to the notes. The steps involved in taking a psychiatric history are outlined below.

Identify the individual

1. 1. Name

2. 2. Age and Sex

3. 3. Present address and phone number

4. 4. Marital status

5. 5. Education

6. 6. Occupation

Estimate the reliability of the source. Also include the relationship of the source to the patient and how well the source knows the patient.

Identify the presenting problem

Obtain a brief description of the principal complaint and the time frame of the problem in the individual’s own words. The individuals concerns need to be taken seriously. Respect and empathy will enhance trust. The individual’s description of the problem will also enable the clinician to assess the individual’s insight or perception into his or her situation. Specifically, find out:

1. 1. What is the nature of the problem?

2. 2. Why and precisely how has the individual presented at this time?

3. 3. What events led up to this presentation?

4. 4. Should always be a quotation of the patient’s own complaint, not the relative’s or
doctor’s paraphrase.

5. 5. At the physician’s discretion and as an additional chief complaint that of an informant
other than the patient may be added. The source must be clear. Again, it is a quotation, not a paraphrase.

History of the present illness

The HPI is the most important part of the history. Most of the data which will aid, directly or indirectly in the diagnosis and treatment of the patient’s illness should be included in the—HPI. Most severe psychiatric illnesses are chronic and recurrent and thus the knowledge of longitudinal course is extremely important in assessing the patient and planning treatment. Therefore, although certain phases or manifestations of an illness may have existed for years,

Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

they are reported in the HPI. For example, in the case of a patient admitted to the hospital with affective symptoms, the initial affective episode 20 years ago is described in the HPI. This approach is similar to that taken for other chronic debilitating illnesses in which it is important to have a longitudinal perspective on the illness (eg. asthma, CAD, PVD). Obviously one should not list verbatim everything that has happened to the patient, but rather consolidate and present the pertinent information concisely. In most cases, the data of the HPI are presented chronologically. Occasionally, the complexity of the present illness will require separate consideration of part of the history or separate consideration of one informant’s report. After reading the HPI one should have an impression of the course of the patient‘s illness (e.g. severity, response to treatment, compliance with treatment). When the relevancy of certain data of the more remote history is indeterminate, such data should be included in the past medical or social history as is appropriate. Similarly, certain data about current problems (eg medical illnesses, drug or alcohol use, sexuality) should be included in the HPI only if they are pertinent to the present illness. If they are not, then they should be placed in the appropriate section below. It is improper to employ flippant language. The hospital record is a formal document which may be subject to inspection by courts of law.

An earnest attempt must be made to include all the diagnostic possibilities and to avoid prejudice by presenting data referable to only one of the illnesses which require differential consideration.

The following specific considerations should be observed in writing the HPI:

. a) What was the mode of onset? Was it insidious or abrupt? Was it first apparent to the patient or to others?

. b) How did the evolving illness affect the patient’s usual life functions? Were his marriage, occupation, or\avocations disrupted? Did his relationships with people change? Were there alterations in habits such as those of taking meals or those involving patterns of sleep? If alterations have occurred, when, and how extensively?

. c) What are the specific symptoms which have appeared during the time of the Present Illness? A psychiatric case history, like histories elsewhere in medicine, is based on patterns of symptoms. Signs are listed in the examination section. A diagnosis becomes possible when it is found that a patient has experienced a pattern of symptoms in content and chronology with the natural history of a known illness.

. d) Do not forget to include pertinent negative findings as well as positive findings.

It will be important for the clinician to identify information that is relevant and useful and to bypass information that is not as useful. An important part of history taking involves probing for useful information that the individual does not mention spontaneously. Some individuals (e.g., those who are brought into the centre by others) may deny the existence of a problem. In these circumstances it may be necessary to obtain a history of the illness from a family member or close friend.

Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

You will need to obtain the following information:

1. 1. Identify specific symptoms that are present and their duration.

2. 2. Note time relationships between the onset or exacerbation of symptoms and the
presence of social stressors/physical illness.

3. 3. Note also any disturbance in mood, appetite, sexual drive and sleep.

4. 4. Obtain information about any treatments given by other doctors or specialists for this
problem, and the individual’s response to treatment.

Obviously a great many questions could be asked of each patient, but certain symptoms have proven to be particularly important in psychiatric disorders. These include: symptoms of change in physiologic functions (eating, sleeping, elimination, menses, potency), loss or gain in weight, changes in mood. changes in memory or judgement, changes in behavior suggesting hallucinations or delusions, ideas of sin, guilt, persecution, jealousy or idnfidelity. This list is not complete but representative.

Personal history

The personal history covers many aspects of the individual’s life, from childhood through to adulthood. Obtain infonnation about:

1. 1. infancy (drug treatments during pregnancy; emotions and temperament; level of activity; nourishment; general development). This information is generally only important if the index individual is a child. You will need to obtain this information from the child’s parents or guardians.

2. 2. Childhood and adolescence (emotional adjustment; relationships with peers. siblings and parents; play; trait anxiety; physical illnesses; sleeping behavior; mental and motor development; early loss of close family members; sexual or physical abuse; belonging to a group; relating to peers and adults; school history; extent of sexual activity).

3. 3. Work history (jobs held; reasons for changing jobs; level of satisfaction with employment; ambitions). 9A

4. 4. Marital history (number of marriages; duration; quality of relationships; personality of spouses; reasons for break-up of relationship/s).

5. 5. Relationships with others (intimate or sexual relationships; presence of someone in

6. 6. Children (name; sex; age; mental and physical health).

7. 7. Activities/violence (ask about criminal record and any previous episodes of violence such as pub, حانة brawls, شجارات violence at home, or other acts of aggression).

Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

Previous medical history

Obtain information about any physical, psychological or emotional disorders for which professional help has been obtained. Find out about the response to treatment.

Drug history

Find out about present or previous drug or alcohol use (prescribed medications, self- prescribed, or illegal) and responses to each of these drugs. Are there any adverse (including allergic) drug reactions? Premorbid personality How does the individual describe his or her personality before becoming unwell? Note:

1. 1. Overall mood or temperament

2. 2. Character traits

3. 3. Confidence

4. 4. Religious and moral beliefs

5. 5. Ambitions and aspirations

6. 6. Social relationships with family, friends, workmates

Family history

Ask about the individual’s close family (i.e., spouse, children, parents, siblings). For each member of the immediate family, obtain information about:

1. 1. Age

2. 2. Health

3. 3. Occupation

4. 4. Personality description

5. 5. Quality of relationship with that person

6. 6. Psychiatric and other illnesses (including alcoholism and other substance abuse)
Treatment for these illnesses

7. 7. Response to treatment

It may also be helpful to ask about the presence of psychiatn’c illness in grandparents, aunts, and uncles.

SOCIAL HISTORY

Upbringing (family constellation, socioeconomic status, religion). School and occupational history (grade completed and age when stopped, for what reason, ability, performance. and behavior in school). Types of work and job history, if pertinent. Military service (record and type of discharge. If none, why?). Sexual and marital history (details not only of sexual experience, but also the family dynamics with patient’s role may be of importance. Premorbid personality (personality of patient before the onset of an acute psychiatric illness). Although it is often delineated with difficulty. it is worth assessing a patient’s personality in order to appreciate the changes subsequent to illness. Describe briefly his premorbid activities, interests, general mood and social patterns. Also detail the patient’s drug, alcohol and tobacco history I’f it is not part of the HPl.

Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

REVIEW OF SYSTEMS

The chief function of the ROS in a psychiatric case history is to provide a systematic investigation of symptoms of non-psychiatric illnesses. The ROS does not serve to extend the HPl (i.e. filling in gaps which may have been left in the HPl). Report positive findings here, not usually seen in psychiatric illness (hemoptysis, melena, orthopnea, etc.). It should be noted that when the patient’s psychiatric diagnosis is hysteria. the special symptom review for that illness becomes part of the HPI. Do not report “within normal limits”.

PHYSICAL EXAMINATION

(with complete neurological examination) In both the physical and the mental status exam, be specific with your findings. For instance, don’t simply say that something is “normal” or “within normal limits”, state what you found. Alternatively, say nothing at all if you did not examine an area. Do not state deferred unless that part of the exam is in fact deferred and you intend to complete it later. If you cannot or are unable to do a portion of the physical exam state that it was “not done”. Similarly, in the mental status exam, when you assess memory, you need to state exactly which tests you performed. For example: “three simple items recalled immediately and at five minutes” would be adequate. If you do ‘fund of knowledge’ testing, state what you tested. For example: the current presidency, five large. cities, or other such tests. Also you must spell out specifically the tests used to check each cranial nerve. You cannot state “CN ll-Xll intact”

Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

MENTAL STATUS EXAMINATION

The Mental Status Examination (MSE) is an amplification of the examination of neurological function. As amplified, it is rendered separately and placed after the Physical Examination. As its name and location imply it is an objective statement about signs. Symptom reports have no place in the MSE. Ordinarily the MSE is divided into eight parts:

1. 1. General appearance and behavior (GAB): Does the patient appear his stated age. Describe facial expression as well as condition and dress. Evidence for tatoos should be recorded here or in the dermatological parts of the PE. If motor activity is unusual in any way, describe (overactive, underactive, give evidence of neurologic disturbance). ls patient responsive and alert? ls patient cooperative? calm? agitated? Does he regard the examiner during the interview or are his eyes fixated in space (on an apparent object that is not present?)? Does his mouth move when he is not talking?

2. 2. Speech: This section is concerned only with the mechanics of talking. What is the rate? Is it monotone? What is the rhythm? Is there an increase in latency (normal time to respond is 3-5 secs)? Is the amount of speech increased or decreased (e.g mute, poverty of speech)? What is the level of the vocabulary? Are there neologism (words invented by connecting syllables in a fashion to produce a new word)?

3. 3. Content of Thought (COT) or Thought Content (TC): This section describes what ideas and thoughts the patient is discussing or is occupied by. This is one of the most difficult sections because the examiner must try to distinguish between signs and symptoms. One should not being recording what the patient complains of (“I am seeing things”). Instead when evaluating a patient’s COT one should be probing and examining several aspects of a belief, for example, in order to offer evidence for or against it being a delusion.

• • Phobias and obsessions are included here if patient speaks of these phenomena as occurring at the present time (they are otherwise described in the HPI). A phobia is an intense, unreasonable fear associated with some situation or object; is fear of heights, closed places, etc. An obsession is a recurrent or persistent idea or thought which is recognized as foreign or alien to the individual and which is accompanied by the desire to resist it. A compulsion is a recurrent act recognized as foreign or alien to the individual and which is accompanied by the desire to resist it. As such compulsions should not be placed in COT and if observed should be in GAB and if reported as a symptom in the HPI. However, some do record compulsions here since they are seen with obsessions.

• • Also included are self-deprecatory and self-accusatory.ideas, suicidal or homicidal ideas, and unusual preoccupations or ruminations If they occur at present. Further suicidal or homicidal thoughts should be explored further to delineate ideation from intent from plan and explicitly recorded in the note.

• • Delusions, ideas of reference, feelings of derealization and depersonalization are reported in this section of the mental status examination. They are certainly reported here if they occur at present. Past experiences would be in the HPI. Traditionally hallucinations are also recorded here since they occur frequently with other psychotic phenomena like delusions. However, the elicitable signs of

  

Dr. Hafidh M. Farhan kufa medical college psychiatry

6th stage

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2018-2019 بسم الله الرحمن الرحیم

hallucinations are usually behavioral and should be recorded in GAB. All this said, almost all psychiatrist record hallucinations here.
Hallucinations are false sensory perceptions. Sometimes an attempt is made to distinguish between illusions (the misinterpretation of real sensory stimuli) as opposed to hallucinations which occur in the absence of real, external, sensory stimuli. For practical purposes. one cannot easily distinguish between illusions and hallucinations. It is likely that most patients with delirium are experiencing illusions. Hallucinations can occur in any of the five sensory modalities. Auditory hallucinations are the most common. Visual hallucinations are also common. Tactile hallucinations are sometimes called haptic hallucinations (not to be confused with hypnogogic hallucinations which occur in the state between wakefulness and sleep). Olfactory and gustatory hallucinations may sometimes occur.

A delusion is a fixed firm false belief outside of the norm of society. Persecutory delusions are obviously those of persecution (note that they should NOT be referred to as paranoid). Delusions of megalomania are those of being a great person. One kind of delusion which has its own name because it occurs so frequently is the delusion of passivity. This is the belief that one’s thoughts or one’s motor behavior is under the control of an outside agent. The outside agent may be either animate or inanimate. It may be close at hand or at a distance.
The patient may believe that his mind is being controlled, that thoughts are being put in his mind, taken out of his mind, or somehow molded (thought insertion /withdrawal /broadcasting). He may believe that his body is being controlled, marionette-like. This experience of passivity is often accompanied by a complex array of other delusions and hallucinations so that it can be difficult to determine at what point one pathological phenomenon ends and another begins.
Delusion of reference This term is source of confusion because it covers such a variety of experiences“. Normal people have ideas of reference in embarrassing social situations. On the other hand, patients who are psychotic may experience delusion of reference in a bizarre and pronounced fashion. A delusion of reference is the unwarranted idea based upon a trivial occurrence (e.g. the person at the next table looked at the patient) that a person is’ talking about you, watching you, or noticing you. it also is used to describe the phenomenon where a patient reports that an event was meant as a special message to the patient (e.g. the death of the horse in The Godfather had a hidden message for the patient from God – that horses should be killed because they are the messengers of Satan).
‘Derealiztion’ on’ is the feeling that the world has changed, usually in some alien way. The patient may or may not know that this feeling is abnormal. ‘Depersonalization‘ is’ a similar feeling, however it applies to the patient’s own body. The patient feels that his/her body is somehow changed or that his/her identity has somehow changed or become lost. The patient may or may not believe the feeling is abnormal.
Finally one should be evaluating whether there is any Poverty of Content. This is different than Poverty of Speech which is recorded in the speech section. Poverty of Speech describes a decrease in the amount of words. A patient who only answers yes or no would be an example. Poverty of Content describes a decrease in the informational content. This sign is seen frequently in patients suffering from schizophrenia. A patient may have either, both or neither of these two.

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Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

4. Flow of Thought (FOT): This section describes how each thought is connected to the next When normal one’s thoughts are logical and sequential and goal directed (i.e. one can answer the question put to him). This area of the MSE is difficult and requires constant work. It involves observations about verbal patterns which one does not ordinarily make. This area of the MSE is the least precise but can be done well with the use of verbatim examples from the patient. A general rule of thumb is that if you have to ask the patient to explain himself or if you find yourself saying “I think he means this” then the patient probably has a thought disorder and is having difficulties in explaining himself.

• • Circumstantial speech involves inclusion of too many trivial details. It is logical and sequential thus the connection between ideas is easily understood. In addition if the patient is given enough time he/she will also reach the goal (usually the answer to your question). Circumstantial speech is not necessarily pathological. It tends to be seen more commonly in the elderly (e.g. a patient starting back in 1914 and going through his/her whole life story to tell you why he/she looks both ways when crossing the street.)

• • Tangential speech also appears to be sequential but the patient goes off on a tangent and does not arrive at the goal. This FOT pattern is difficult to distinguish from circumstantiality if the patient’s response is cut off prematurely. This usually is a subtle indication of an abnormality and is probably on a continuum with Loosening of Associations.

• • Loosening of Associations (LOA) is the generic description of thought in which the Iogicality and sequentiality of the ideas breaks down (The association between ideas is beginning to break down and the thread connecting the thoughts is loosening). Some people qualify LOA as mild, moderate or severe. Word salad is used to describe the extreme of LOA where even the associations between the words of a sentence no longer exist.

• • Flight of Ideas describes speech in which one idea is quickly followed by another. Use of this term historically is used to indicate the FOT in a manic and thus one should be careful in it’s use in non-manics least it be misinterpreted by others. In theory there is logicality from one thought to the next. However in practice it may appear as LOA because the examiner cannot follow the Iogicality because the ideas are coming too quickly. Other indicators can be used to help in differentiating the two though. Clanging (choice of words based on their sounds), rhyming, puns may be present.
Other patterns to note include:

1. 1. Echolalia (repeating what is said by others in an echoing fashion).

2. 2. Perseveration (repeating the same word, phrase, or idea over and over again). is little
used now, mainly because it is rarely seen and its import is unclear. It describes a FOT where the patient is describing an idea logically and sequentially then jumps to a parallel track of ideas (derails).



Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

5. 5. Mood: Mood is the patient’s report of his emotional state. Therefore it really is a symptom but it is recorded here in order to allow compan’son to the affect.

6. 6. Affect. There are three basic questions which can be asked about affect.

. a) What is the type of affect? Is it depressed, normal or elevated? What is its range? Can it be evoked with prompting (e.g. laughs after a joke)? An appropriate description of a patient suffering from depression might be: “Affect is depressed and restricted to the lower range though the patient will laugh to jokes.”

. b) Is the patient’s affect labile? Does it remain stable, or does it change noticeably and quickly in response to small changes in the conversation.

. c) Is the patient’s affect appropriate to the conversation? Is it congruent to his stated mood? A patient’s affect may be judged to be inappropriate for a number of reasons. Examples should be given. –

. d) ‘Blunted’ and ‘flat’ affect is used to describe patients in whom the amount of affect is decreased or non-existent. This phenomenon is typically seen in patients with schizophrenia. Usually patients with depression do have affect it is just restricted to the negative emotions. Depressed patients should not be described as blunted/flat.

7. 7. Insight and judgement:
Insight signifies that the patient realizes that he/she is ill and understands something of the nature of his/her illness. In addition it also refers to their ability to recognize their symptoms. It does not refer to etiology or psychodynamic aspects of the illness. Insight may be assessed by evaluating the patient’s responses to the following questions: What kind of problems are you currently having? Are you sick in any way? What sort of sickness? Do you need help? What sort of sickness do people have here? In describing their insight one should be specific about the object of their insight. For example a patient might have good insight into the fact t hat he/she has a major depressive disorder and is having problems with sleep and appetite but has little to no insight into the fact that his/her thoughts about guilt are also symptoms of the illness.
Judgement may be assessed by evaluating the patient’s responses to the following questions: What would you like to do next? What do you plan to do when you leave? Why were you brought here? Again as with insight one must specify precisely the object or symptoms on which one is evaluating the judgement. Questions about mailing a stamped letter, a house on fire, or an idiom offer little in the way of significant information about a patient‘s judgement and really reflect a patient’s intellectual functioning and schooling.

  

Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

8. Sensorium and Intellect:

a. a. Sensorium; Orientation – time (day of month, month, year, day of week, season),
place, person. If not oriented, give patient’s answers and correct information.

b. b. Memory

• • Retention and immediate recall – give a street address, a person’s name and a
color and test in five minutes.

• • Recent memory – date of admission, brought to hospital by whom.

• • Remote memory – when and where born, date of marriage, names and ages of
children.

c. c. Attention

• • Calculations – subtract 7 from 100 and 7 from the answer and each
succeeding answer (average adult has less than four errors and finishes
within 60 seconds). Multiply 7 x 8, 3 x 4, etc. Count from 20 backwards to 1

• • Other – If the patient cannot do the mathematical tasks, try verbal ones like: the ability to spell WORLD backwards, list days of the week backwards, cite
string of numbers forwards and backwards. Say the months of the year in reverse order. One also needs to be cognizant of the patient’s education.

d. d. Intellect

• • In evaluating the following tests of intellectual functioning, factors such as the
patient’s educational level, ability to concentrate, anxiety, and willingness to
cooperate should be considered.

• • General information – name five large cities and the last five presidents.

• • Meaning of proverbs – “Don’t cry over spilled milk”; “All that glitters is not gold”; “A
bird in the hand is worth two in the bush”; “A rolling stone gathers no moss”. Is the patient able to identify the abstractions involved in the proverbs?



Dr. Hafidh M. Farhan kufa medical college psychiatry 2018-2019 بسم الله الرحمن الرحیم 6th stage

LABORATORY DATA

In addition to typical medical tests, one should record the results of any psychometric tests here.

ASSESSMENT AND PLAN

In the majority of cases when one is doing an initial evaluation this section probably will be the longest. On follow-up patients this section can be substantially abbreviated unless a change in Dx or plan is being documented. This is the one section in which people try to skimp and which can lead to unpleasant outcomes (i.e. loss in law suits – – remember no documentation means it didn’t happen, no matter what you say in the courtroom). A separate number should be assigned for each problem. For each one should:

• • Briefly review the pertinent information from the HPl, PMH and Fam Hx as well as the important findings on exam and labs. Assessment of whether the elicited signs indicate pathology should also be done here.

• • A differential diagnosis should offered and the pros/cons for each Dx given and weighed and the most likely explanation highlighted.

• • An appropriate plan should be formulated given the assessment. Justify the patient’s admission. Reasons for doing or not doing certain tests or treatments should be substantiated. For inpatients, include nursing and social work interventions. Be specific (for example: if the patient has been violent and agitated, you need to provide specific interventions for the nursing staff, such as placing patient on assault precautions, provide 1-on-1 coverage, write orders for prn lorazepam, start neuroleptic treatment).

• • Documentation of discussions with the patient should also be done with a notation of the patient’s consent or lack thereof being noted. In addition one must document that the consequences (including side effects and bad outcomes) of following or not following the recommendations have been discussed with the patient.
DIAGNOSTIC FORMULATION
Medicare requires a listing of the five axes for psychiatric patients according to DSM- lll-R. Thus, at the end restate your assessment in this format (Axes l-V) according to DSM criteria . If you do not make a diagnosis in an axis but may possibly do so in the future, state “none formulated” on that axis. Remember, if you happen to state “ruled out, or deferred”. at some point during the hospitalization you must go back to this issue and change it from “deferred” to having a specific diagnosis or “no diagnosis”. Axis I are Clinical Syndromes. Axis II are primarily Personality and Developmental
Disorders. Axis III are physical disorders. Axis IV is for Psychosocial Stressors. Axis V denotes Global Assessment of Functioning.
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