2.

01 The Psychiatric History

Dr. Luis Sundiang | September 25, 2017
PSYCHIATRY

OUTLINE  Help patient cope with his situation

 Suggest changes to improve prognosis and minimize future
I. Functions of a Medical Interview risks
A. Assess Nature of the Problem
B. Develop and Maintain a Therapeutic D.MENTAL STATE EXAMINATION (from University of Bristol
Relationship Website: http://www.bristol.ac.uk/medical-
C. Communicate Information and Implement a school/hippocrates/psychiatry/mse_etc/ )
Treatment Plan This part is for the next lesson but the lecturer included it in ppt
D. Mental State Examination
II. Psychiatry history taking - Enables you to understand what your patient is
A. Introduction and Presenting Complaint experiencing.
B. Past Psychiatric history - Involves the following:
C. Past Medical history
D. Family history 1. Appearance and Behavior
E. Personal history o Involves objective observation your patient from
F. Premorbid personality
G. Difficult questions the first meeting and record the observations
H. Risk assessment accurately in less than 30 words
III. Components of Psychiatric History o Physical Appearance
A. Identifying data  body build, (nutritional state)
B. Chief Complaint  significant distinguishing features
C. Source and Reliability  cleanliness (hair, teeth, nails)
D. History of Present Illness
 Quality, style and state of clothing
E. Past Medical and Psychiatric History
F. Family history o General Attitude
G. Social History  rapport
H. Anamnesis/Personal History  attitude towards interview
IV. Quiz  eye contact
o Motor Behavior
LEGEND  restless, fidgety or apathetic, retarded
2. Speech
Remember Textbook Trans Editor Previous Trans
o Volume and speed
   
 pressure of talk <-> retardation
o Construction
OBJECTIVES:
 flight of ideas, rhyming, punning,
1. Know the functions and purpose of psychiatric interview and
incoherence
examination
o Enunciation
2. Learn the content and process of taking a psychiatric history
 dysarthria, stammer
3. Integrate psychiatric history taking in your medical/ surgical
3. Mood or Affective State
interview and examination
o Subjective experience (ask!)
o objective impression
I. FUNCTIONS OF A MEDICAL INTERVIEW
 elevated, euthymic, low, angry, cheerful,
A. ASSESS NATURE OF THE PROBLEM
distraught, despondent, resentful
 Diagnose o congruity with speech content
 Determine appropriate diagnostic procedures if warranted o stability
 Formulate and propose management o emotional reactivity
 Provide information on course and outcome o suicidal ideation or intent
4. Thoughts
B. DEVELOP AND MAINTAIN A THERAPEUTIC RELATIONSHIP o Content
(Establishing a Therapeutic Relationship)  preoccupations?
 Facilitate patient’s collaboration in diagnostic and treatment  ideas of reference?
activities  delusions?
 Maintain flow of information exchange  recurring, pervasive theme,
 Relieve patient’s distress and suffering  depressive ruminations
 Provide satisfaction for patient and doctor  grandiose ideas
 self-referential ideation
C. COMMUNICATE INFORMATION AND IMPLEMENT A o obsessional thoughts
TREATMENT PLAN  How to probe for obsessional thoughts (+
 Help patient understand illness, diagnostic procedures, compulsive rituals): “Some people find
treatments, risks and outcome they have unpleasant and unwanted
 Establish and maintain consensus with patient and facilitate thoughts or images coming into their
informed consent
GROUP #1: Eleazar M., Elefante, Elgar, Esperanza, Espinosa
EDITOR/S: Surname (Cellphone#) 1 of 5
 mind, which can’t be resisted. Has that
been a problem?”
o objective signs of thought disorder
o subjective experience of thought disorder
 Probing questions: “Can you think quite
clearly, or does there seem to be some
kind of interference with your thoughts?”
 Thought withdrawal: “Are your thoughts
actually taken out or sent out of your
mind? Do they actually feel like that? So
that they are outside your head?”
 Thought insertion: “Do there seem to be
thoughts in your mind which are not your
own; which seem to come from
somewhere else?”
 Thought broadcasting: “Do your thoughts
seem to be somehow public; not private
to yourself, so that others can know what
you are thinking?”
5. Perceptions
o defined as the ability to perceive the outside world
that could be related to a complex,
neuropsychological process which involves the
ability of the sense organs to detect and modulate
the raw data of our senses (sight, smell, noise),
and the ability of the brain to decode that
information and produce an internal neuronal
representation of the outside world.
o to the person experiencing a hallucination, the
perception is real
o Auditory hallucinations:
 Get an exact description!!
 Familiar or unfamiliar voices?
 2nd or 3rd person?
 Do the voices give commands?
 If so, how does the patient react?
o How to probe for auditory hallucinations:
 “We ask this question routinely of
everyone, because sometimes people
under stress seem to hear noises or
voices when there is nobody around and
no ordinary explanation is possible. Has
anything like this ever happened to you?”
o Loud thoughts (Gedankenlautwerden)
 “Do your thoughts seem to sound aloud
in your head, almost as if somebody
standing near you could hear them?”
o Thought echo (Écho de la pensées)
 "Does a thought in your mind seem to be
repeated over again, like an echo?”
6. Delusions
o defined as a false, unshakable idea or belief which
is out of keeping with the patient's educational,
cultural and social background; it is held with
extraordinary conviction and subjective certainty
o can be:
 primary: ideas that arise are fully formed
 secondary: attempt by the patient to
make sense of their experiences
o How to probe for delusions:
 “Have you had the feeling that something
odd is going on that you can’t explain?”
[PYSCH] 2.01 The Psychiatric History
 “Do you feel puzzled by strange
happenings that are difficult to account
for?”
 “Do familiar surroundings seem
strange?”
7. Cognition
o Level of consciousness
o Orientation
 Time, Place, Personal Identity
o Attention and concentration
 Test: Serial Sevens, months in reverse
o Memory
 immediate recall: digit span
 recent: address
 remote: Personal History!
o General knowledge + intelligence
8. Insight
o Attitude towards illness
 “How do you see your difficulties?”
 “Do you feel there is something wrong
with your nerves?”
o Attitude towards treatment
 “What sort of treatment do you feel is
needed?”
 “How do you feel about: being in hospital
/ taking tablets?”
II. PSYCHIATRY HISTORY TAKING
(from University of Bristol Website: http://www.bristol.ac.uk/medical-
school/hippocrates/psychiatry/mse_etc/ )
It is a clinical history in itself but with an in depth coverage of social
and developmental history.
A. Introduction, Presenting Complaint and its History
 Keep it short and simple
 If appropriate, use patients own word
 List relevant event leading up to the present problem
 Knowledge of specific disorders required
B. Past Psychiatric and Medical History
 This includes treatment and admissions
 Either informal or under section
 Ask any previous episodes of deliberate self harm
 If very long, summarize
C. Family History
 Use genograms
 Ask about their occupations and social status
 Ask if there are family members with mental health problems
 Ask if there are any suicides and suicide attempts among
family members
D. Personal History I
 Early Child Hood
o Place and circumstances of birth
o Early milestone and development
o Family atmosphere and moves
 Education
o Schools Attended
o Attitudes to school
o Regularity of attendance
o Exams passed, age at leaving
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  Occupational History
o Details of jobs
o Reasons for finding another job if applicable
E. Personal History II
 Psychosexual Development
o Tailor to what’s appropriate and needed
o Orientation
o Relationships
o Family attitudes and instruction
o First experiences
 Present Social Circumstances
o Own or rented accommodations
o Financial problems, debts
 Drug History
o Prescribed
 Asked for the dose and duration
 Compliance and check for side effects
o Illicit drug and alcohol use
 Useful screening tool
 Be prepared to explore all features of
dependency if necessary
 Forensic History
o We live in the age of risk assessment
o “Have you ever had any trouble with the police?”
o History of violence
 Get all the details, if present
 Distinguish between violence against
property or people
F. Premorbid Personality
“When you are well, …”
 Volition
o “…how (what kind of person would you
describe yourself?”
 Mood
o “… what’s your usual mood like?”
 Social
o “… how do you get on with other people?”
 Cognitive
o (intellectual capacity) general knowledge
 Reaction patterns to stress
o “… how do you react to stress?”
G. Risk Assessment
 Risk of suicide
o Symptoms of depression
o Ask if they are attempting suicide
o If there is risk of suicide, arrange appointment
o Manage the course of suicide
o Treat depression
o Can be cause by substance abuse and alcohol
abuse
o Consider patient’s situation (marital problem,
financial problem, and others)
 Risk of self-harm
o Common (30%)
o Use as a way to regulate their emotions
o Develop collaborative relationship and find an
alternative way like being mindfulness by
encouraging them to express their emotional
feelings
 Risk of violence
o Not common
o Check if there is a history of violence
o Ask if they carry a weapon and ask them not to
come to the hospital with weapons
o Paranoid delusion (misinterpretation of innocent
gesture as threatening; belief that they are in
danger and being threatened; delusional voices
that tells them to hurt another person)
o Jealousy – very powerful emotion that can lead to
violence
III. COMPONENTS OF THE PSYCHIATRIC HISTORY
(this part is as presented by Dr. Sundiang in his lecture ppt)
 The patient history is based on the subjective report of the
patient and in some cases the report of collaterals including
other health care providers, family and other caregivers
(Kaplan & Sadock).
Notes:
Below are the parts of the Initial Psychiatric Interview (in the
book it is called initial psychiatric interview while Dr. Sundiang
called it psychiatric history) based on Kaplan and Sadock:
I. Identifying data
II. Source and reliability
III. Chief Complaint
IV. Present Illness
V. Past psychiatric history
VI. Substance use/abuse
VII. Past medical History
VIII. Family history
IX. Developmental and Social history
X. Review of Systems
XI. Mental status examination
XII. Physical Examination
XIII. Formulation
XIV. DSM-5 diagnoses
XV. Treatment plan
A. Identifying Data
 This includes patient’s name, age, marital status, sex,
handedness, occupation, nationality, birth order, religion,
educational attainment and living conditions
 Ask also if this is the patient’s first admission or if the patient
has past admissions already
B. Chief Complaint
 Verbatim: in the patient’s own words
 Why he or she has come or been brought in for consult
 Must be brief
C. Source and Reliability
 The other individuals present as collateral sources of
information
 Write reliability of the sources as well
 Patient’s pre-morbid and morbid personality
D. History of Present Illness
 Comprehensive and chronological picture of the events
leading up to the current moment in the patient's life
 The account should include any other changes that have
occurred during this same time period in the patient’s

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 interests, interpersonal relationships, behaviors, personal
habits and physical health
 Include all significant symptomatology, precipitating factors,
significant modifiers of the illness
o Possible organic factors, drug, and alcohol abuse
 Pertinent positive and negative symptoms
 “Can you tell me in your own words what brings you here
today?”
E. Past Medical and Psychiatric History 
 Past Medical History
o Any medical, surgical, or obstetric problems the
patient has or had
 Medications (with doses) currently being
taken
 Treatments must also be included
o Hospitalizations
o Allergies to food and drugs
o 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.
o Medical illness can precipitate a psychiatric
disorder
 Past Psychiatric History
o Psychiatric diagnosis
 Past suicide attempts
o Psychiatric treatment
 When was the medication given?
Duration? Dose? Therapeutic and
adverse effects?
 Psychotherapy, ECT
 Admission at an in-patient facility? OPD
consult? Rehab center?
 Consult with other mental health
professionals (psychologist, social
worker, counselors)
o Written records from institutions and past
caregivers may be considered
F. Family History
 Because many psychiatric illnesses are familial and a
significant number of those have a genetic predisposition, if
not cause, a careful review of family history is an essential
part of the psychiatric assessment.
 A genogram is often useful for clarity
o To look for similar conditions in other family
members, as well as their treatment and
responses
 Medical, psychiatric, and substance abuse
o Suicide attempts or completed suicide in the family
 List the psychotropic medications
o Which ones are effective vs not effective
 Family dynamics must also be taken into account
o Who are the members living together?
o Quality of relationship
 Who is closest to the patient? Who is in
conflict with the patient?
 How the family members interact with
one other
o Reactions to illness, support given
[PYSCH] 2.01 The Psychiatric History
E. Social History
 Substance abuse – history should include which substances
have been used, including alcohol, drugs, medications
(prescribed or not prescribed to the patient), and routes of
use. The frequency and amount of use should be
determined, keeping in mind the tendency for patients to
minimize or deny use that may be perceived as socially
unacceptable
o Smoking, alcohol, illicit drug use
 Smoking: in pack-years
 Alcohol: type of alcohol, how frequent, shared
among friends, CAGE criteria
 Drugs: First use? Who influenced the patient
to use drugs? How often? How much? Effects
(anong klaseng “tama”), when was the last
use?
G. Anamnesis/Personal History 
 In Kaplan and Sadock, this part is under developmental and
social history
 It is an important tool in determining the context of
psychiatric symptoms and illness and may, in fact, identify
some of the major factors in the evolution of the disorder
 Outline of a developmental History
o Prenatal and Perinatal – developmental
milestones should be noted
 Full-term pregnancy or premature
 Vaginal delivery or caesarean
 Drugs taken by mother during pregnancy
(prescription and recreational)
 Birth complications
 Defects at birth
 Wanted/Unwanted and Planned/Unplanned
Pregnancy
o Infancy and Early Childhood
 Birth – 3 years
 Infant-mother relationship
 Problems with feeding and sleep
 Significant milestones
 Standing/walking
 First words/two-word sentences
 Bowel and bladder control
 Other caregivers
 Unusual behaviors (e.g., head-banging)
o Middle childhood (3-11yrs)
 Preschool and school experiences
 Separations from caregivers
 Friendships/play
 Methods of discipline
 Illness, surgery, or trauma
o Late Childhood and Adolescence
 Onset of puberty
 Academic achievement
 Organized activities (sports, clubs)
 Areas of special interest
 Romantic involvements and sexual
experience
 Work experience
 Drug/alcohol use
 Symptoms (moodiness, irregularity of
sleeping or eating, fights and arguments)
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 o Young adulthood
 Meaningful long-term relationships
 Marital history
 Sexual history
 Academic and career decisions
 Military experience
 Work history
 Prison/ Legal experience
 Intellectual pursuits and leisure activities
 Religion
 Fantasies and Dreams
o Middle adulthood and old age
 Changing family constellation
 Social activities
 Work and career changes
 Aspirations
 Major losses
 Retirement and aging

REFERENCES
 Lecture slides
 Synopsis of Psychiatry 11th Ed. Kaplan and Sadock
 http://www.bristol.ac.uk/medical-
school/hippocrates/psychiatry/mse_etc/

MINI-QUIZ
1. Which of the following statements is TRUE regarding psychiatric
interview?
a. The interview is the most important element in the
evaluation and care of persons with mental illness
b. A well conducted interview results in an understanding of
the neurobiological elements of the disorder
c. The results of which is usually confirmed by laboratory
testing and imaging
d. All of the above
2. Which of the following is NOT included in the identifying data?
Previous medications
b. Marital status
c. Occupation
d. Number of consults
3. Which of the following is FALSE regarding the chief complaint?
a. Recording should be done in a verbatim manner
b. Usually obtained only from the patient
c. It is the patient’s primary concern for consult
d. All of the above statements are true regarding chief
complaint
4. Anamnesis refers to:
a. Family history
b. Sexual history
c. Personal history
5. The purpose of the interview in history taking is
a. To gather information that will enable the examiner to
make a diagnosis and plan for treatment accordingly
b. To help the physician decide if the patient should be
admitted or sent home
c. To be able to know the latest events in the patient’s life
d. To be able to comfort and allow the patient to ventilate his
frustrations in life

ANSWERS: AABCA

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