Psychiatric history
Encyclopedia
A psychiatric history is the result of a medical process where a clinician working in the field of mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...

 (usually a psychiatrist
Psychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...

) systematically records the content of an interview with a patient. This is then combined with the mental status examination
Mental status examination
The mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessment process in psychiatric practice...

 to produce a "psychiatric formulation" of the person being examined.

Psychologist
Psychologist
Psychologist is a professional or academic title used by individuals who are either:* Clinical professionals who work with patients in a variety of therapeutic contexts .* Scientists conducting psychological research or teaching psychology in a college...

s 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
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

 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. 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.

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
Alcohol abuse
Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...

 or seemingly unrelated, such as panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...

 and premature ejaculation
Premature ejaculation
Premature ejaculation is a condition in which a man ejaculates earlier than he or his partner would like him to. Premature ejaculation is also known as rapid ejaculation, rapid climax, premature climax, or early ejaculation....

. The patient is unlikely to present a diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...

 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
Hypothesis
A hypothesis is a proposed explanation for a phenomenon. The term derives from the Greek, ὑποτιθέναι – hypotithenai meaning "to put under" or "to suppose". For a hypothesis to be put forward as a scientific hypothesis, the scientific method requires that one can test it...

 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
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

 or sexual difficulties.

Past history

This is divided into the psychiatric past history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. The past substance (drug) history included data about patterns of use (age of onset, frequency, amount, last use, medical or psychological complications) for alcohol, tobacco, and illicit drugs. The medical past history documents significant illnesses, both past and current, and significant medical events such as head injury
Head injury
Head injury refers to trauma of the head. This may or may not include injury to the brain. However, the terms traumatic brain injury and head injury are often used interchangeably in medical literature....

, seizures, major surgeries, and major illnesses. 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
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...

 have a genetic
Genetics
Genetics , a discipline of biology, is the science of genes, heredity, and variation in living organisms....

 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
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...

 whose mother also suffered from the same disorder and responded well to fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...

 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
Alcohol abuse
Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...

 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. Ideally it starts with pre-natal factors such as maternal illnesses or complications with the pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

, 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
Abuse
Abuse is the improper usage or treatment for a bad purpose, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, sexual assault, violation, rape, unjust practices; wrongful practice or custom; offense; crime, or otherwise...

, education
Education
Education in its broadest, general sense is the means through which the aims and habits of a group of people lives on from one generation to the next. Generally, it occurs through any experience that has a formative effect on the way one thinks, feels, or acts...

, 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.

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
Adverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...

.

External links

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