By

Ethel Maureen B. Pagaddu, MD

PSYCHIATRIC HISTORY

 the record of the patient's life

 in the patient's own words from his or her own point of view
 a psychiatrist strives to derive from the history the elusive picture
of a patient's individual personality characteristics, including both
strengths and weaknesses
 provides insight into the nature of relationships with those closest
to the patient and includes all the important persons in his or her
life
 most important technique: allow patients to tell their stories in
their own words in the order that they consider most important
PSYCHIATRIC HISTORY
 Identifying data
 Presenting complaints

 Referral and informants

 History of present illness

 Past illnesses

 Psychiatric

 Medical

 Family medical and psychiatric history

 Personal and social history (anamnesis)
 Prenatal and perinatal
 Early childhood (Birth through age 3)
 Middle childhood (ages 3 to 11)
 Late childhood (puberty through adolescence)
 Adulthood
 Occupational history
 Marital and relationship history

 Military history

 Educational history

 Religion

 Social activity

 Current living situation

 Legal history

 Sexual history
 Fantasies and dreams
 Values
IDENTIFYING DATA

 provide a succinct demographic summary of the

patient
 name, age, marital status, sex, occupation, educational
background, ethnic background, and religion
 whether the current disorder is the first episode for the
patient
 indicate whether the patient came in on his or her own,
was referred by someone else, or was brought in by
someone else.
 a thumbnail sketch of potentially important patient
characteristics that may affect diagnosis,
prognosis, treatment, and compliance.
PRESENTING COMPLAINTS
 states why he or she has come or been brought in for help
 in patient's and informant’s own words (verbatim)
 According to informant/s:
 According to patient:
 should be recorded even if the patient is unable to speak and
the patient's explanation, regardless of how bizarre or irrelevant
it is
REFERRAL AND INFORMANTS

 records all sources of information:

 patient’s relatives or any accompanying person who
could give relevant information about patient’s course
of illness
 may also include social case report, referral notes
from a person or agency
 should indicate name, age, relationship to the
patient, educational attainment, and whether
living with the patient or not
HISTORY OF PRESENT ILLNESS

 provides a comprehensive and chronological

picture of the events leading up to the current
moment in the patient's life
 probably the most helpful in making a
diagnosis
 evolution of the patient's symptoms should be
determined and summarized in an organized
and systematic way
 symptoms not present should also be
delineated
 should answer:
 When was the onset of the current episode?
 What are the immediate precipitating events or
triggers?
 What were the circumstances at the onset of the
symptoms or behavioral changes?
 In what ways has the patient's illness affected his
or her life activities (e.g., work, important
relationships)?
 What is the nature of the dysfunction?
 Are there psychophysiological symptoms?
 How does the patient handle these symptoms?
 Why did the patient come to the doctor at this
time?
PAST ILLNESSES

Past psychiatric history

 Explore in detail previous contact with psychiatric and
other services for mental health problems. Include
dates, diagnoses, treatment and duration of
admissions.
Past medical history
 This is little different from any other discipline but
remember to ask about obstetric complications,
epilepsy, head injury, etc.
FAMILY HISTORY

 obtain the same sort of information about the

family as you did for the patient
 remember to include history of neurological
disorders, suicides, criminal behaviour, abuse,
alcoholism etc.
 a brief statement about any psychiatric illness,
hospitalization, and treatment of the patient's
immediate family members should be placed
PERSONAL HISTORY [ANAMNESIS]
 Prenatal and perinatal
 Full-term pregnancy or premature
 Vaginal delivery or Caesarian
 Drugs taken by mother during pregnancy (prescription and recreational)
 Birth complications
 Defects at birth
 Infancy and early childhood (0 to 3 years)
 Infant-mother relationship
 Problems with feeding and sleep
 Significant milestones
 Other caregivers
 Unusual behaviors (e.g., head-banging)
 Personality as a child
 Middle childhood (3 to 11 years)
 Preschool and school experiences
 Separations from caregivers
 Friendships/play
 Methods of discipline
 Illness, surgery, or trauma
 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)
 Young adulthood
 Meaningful long-term relationship/Marital and Relationship History
 Academic and career decisions
 Military experience
 Work history
 Prison experience
 Intellectual pursuits and leisure activities
 Middle adulthood and old age
 Changing family constellation
 Social activities
 Work and career changes
 Aspirations
 Major losses
 Retirement and aging
CURRENT SOCIAL CIRCUMSTANCES

 describe where he or she lives in terms of the

neighborhood and the residence as well as the
number of rooms, the number of family
members living in the home, and the sleeping
arrangements.
 ask about the sources of family income and any
financial hardships
 ask who is caring for the children at home, who
visits the patient in the hospital, and how
frequently
PRE-MORBID PERSONALITY

 Ask about the character of the patient prior to

the onset of present symptoms
 may be written verbatim or in sentence form on
how the patient describe himself or how the
significant others describe him/her
 INTERVIEWING TECHNIQUES WITH SPECIAL PATIENT
POPULATIONS

 various types of patients fall under the rubric of

special patient populations
 include patients with urgent issues, the severely
mentally ill, patients from different cultural
backgrounds who are unassimilated, those who
cannot communicate well, and patients whose
personality problems make them, difficult,
demanding, uncooperative, or likely to engage in
power struggles
PSYCHOTIC PATIENTS

 psychotic patients have poor or absent reality

testing abilities
 Open-ended questions and long periods of
silence are apt to be disorganizing
 Questions calling for abstract responses or
hypothetical conjectures may be unanswerable
 Thought Disorders
 Disorders of thought can seriously impair effective
communications.
 When derailment is evident, the psychiatrist
typically proceeds with questions calling for short
responses.
 For a patient experiencing thought blocking, the
psychiatrist needs to repeat questions, to remind
the patient of what was already said
 Hallucinations
 false sensory perceptions
 the full phenomenology of the hallucination should
be explored
 for auditory hallucinations, this includes content,
volume, clarity, and circumstances; for visual
hallucinations, this includes content, intensity, the
situations in which they occur, and the patient's
response
 distinguish between true hallucinations, on the one
hand, and illusions, hypnagogic and hypnopompic
hallucinations, and vivid imaginings, on the other.
 Delusions
 fixed, false beliefs not in keeping with the culture
 patients often come to psychiatric evaluation
having had their beliefs dismissed or belittled by
friends and family
 they are on guard for similar reactions from the
examiner
 it is possible to ask questions about delusions
without revealing belief or disbelief (e.g., “Does it
seem that people are intent on hurting you?” rather
than “Do you believe there is a plot to hurt you?”)
SUSPICIOUS PATIENTS

 Some persons have a chronic, deeply ingrained

suspicion that other people want to cause them
harm
 critical and evasive, and are sometimes called
“grievance collectors” because they tend to
blame other people for everything bad in their
lives
 extremely mistrustful and may question
everything the doctor says or does
 the physician should try to maintain a
respectful but somewhat formal and distant
approach
 expressions of warmth often heighten their
suspicions
DEPRESSED AND POTENTIALLY SUICIDAL
PATIENTS
 severely depressed patients may have difficulty
concentrating, thinking clearly, and speaking
spontaneously
 the psychiatrist evaluating a depressed patient
may need to be more forceful and directive
than usual
 Ruminative patients need to be interrupted and
redirected
 All patients must be asked about suicidal
thoughts
 A thorough assessment of suicide potential
addresses intent, plans, means, and perceived
consequences, as well as history of attempts
and family history of suicide
 Asking about suicide does not increase the
risk.
 Intent
 the seriousness of the wish to die
 Some patients report that they wish that they were
dead, but would never intentionally do anything to
take their own lives ( passive suicidal ideation)
 At the most extreme level of determination are the
patients who are the most difficult to help, those
who tell no one about their suicidal plans and
proceed in a deliberate, systematic manner.
 It is useful to ask about restraining influences,
internal and external
 Plans
 Patients with well-formulated plans are generally at
greater risk than patients who do not know what
they would do, but the method of suicide is NOT
always a reliable indication of the risk
 The psychiatrist should also ask about preparatory
actions, such as giving away goods and putting
one's estate in order
 Means
 Askingpatients about the intended means of
suicide is helpful in two ways.
 First,
it clarifies the urgency of the situation.
 Second, the understanding of intent is sharpened by
knowing whether a patient has thought through the steps
necessary to carry out the action
 Perceived Consequences
 Patients who see something desirable resulting
from their deaths are at increased risk for suicide
 On the other hand, some potentially suicidal
patients are restrained by what they see as
negative consequences
 In rare circumstances, the threat of suicide is so
imminent that immediate action must be taken to
hospitalize the patient
SOMATIZING PATIENTS

 Somatizing patients pose a number of

difficulties for the consulting and the treating
psychiatrist because they may be reluctant to
engage in self-reflection and psychological
exploration
 Moreover, somatic distress without physical
findings can lead to diagnostic uncertainty,
which, in turn, makes treatment less certain.
 Many somatizing patients live with the fear that
their symptoms are not being taken seriously
and the parallel fear that something medically
serious may be overlooked.
 Psychiatrists' main task in dealing with these
patients is to acknowledge the suffering
conveyed by the symptoms without necessarily
accepting the patient's explanation for the
symptoms.
 An important goal of treatment is to minimize
the harm caused by aggressive and
unwarranted medical interventions
AGITATED AND POTENTIALLY VIOLENT PATIENTS
 When interviewing potentially violent patients,
the task is to conduct an assessment and to
contain behavior and limit the potential for
harm.
 Several steps can be taken to minimize the
agitation and potential risk.
 The interview should be conducted in a quiet,
nonstimulating environment.
 Sufficient space should be available for the comfort
of the patient and the psychiatrist, with no physical
barrier to leaving the examination room for either of
them.
 During the interview, the psychiatrist should avoid
any behavior that could be misconstrued as
menacing: standing over the patient, staring, or
touching.
 The psychiatrist should ask whether the patient is
carrying weapons and may ask the patient to leave
the weapon with a guard or in a holding area.
 If the patient's agitation continues to increase, the
psychiatrist may need to terminate the interview.
SEDUCTIVE PATIENTS

 Seductiveness can be manifested in a patient's

dress, behavior, and speech
 sex is NOT the only enticement with which
psychiatrists can be seduced
 seductive behavior is discussed and examined
in an effort to understand its meaning
 the psychiatrist should make it clear that what
is being offered will not be accepted, in a way
that preserves good rapport and does not
unnecessarily assault the patient's self-esteem.
 Seductive behavior during an initial psychiatric
assessment must be handled somewhat
differently.
 mild and indirect, it may be best to ignore it
 more explicit propositions call for more direct
responses and may afford the psychiatrist the
chance to explain the nature of the therapeutic
relationship and the need to establish boundaries
DEPENDENT PATIENTS

 seem to need an inordinate amount of

attention and yet never seem reassured
 who are likely to make repeated urgent calls
between scheduled appointments and to
demand special consideration
 be firm in establishing limits when reassuring
the patient that his or her needs are taken
seriously and are treated professionally
DEMANDING PATIENTS

 Some patients have a difficult time delaying

gratification
 easily frustrated and can become petulant or
even angry and hostile
 may impulsively do something self-destructive if
they feel thwarted, and they appear
manipulative and attention seeking
 be firm with these patients from the outset and
must clearly define acceptable and
unacceptable behavior.
NARCISSISTIC PATIENTS

 Narcissistic patients act as though they are

superior to everyone around them
 have a tremendous need to appear perfect and
are contemptuous of others whom they
perceive to be imperfect
 underneath their surface arrogance,
narcissistic patients feel desperately
inadequate and fear that others will see
through them
ISOLATED PATIENTS

 do not appear to need or to want much contact

with other people
 withdrawn, absorbed in a world of fantasy, and
are unable to talk about their feelings
 doctor should treat these patients with as
much respect for their privacy as possible and
should not expect them to respond to the
doctor's concern with openness.
OBSESSIVE PATIENTS

 orderly, punctual, and so concerned with detail

that they often do not see the larger picture
 may appear unemotional, even aloof, especially
when confronted with anything disturbing or
frightening
 physicians should try to include them in their
own care and treatment as much as possible
 should explain in detail what is going on and
what is being planned, allowing the patient to
make choices on his or her own behalf
PATIENTS WHO LIE
 at times, patients lie consciously with the
explicit intent of deceiving the therapist
 purpose may be secondary gain

 an experienced clinician may detect subtle

discrepancies, internal inconsistencies, or
suspiciously atypical symptoms; these can
certainly be queried without necessarily
assuming that the patient is lying
 It may be difficult to catch a practiced liar in an
initial session
 Psychiatrists are trained to detect, to
understand, and to treat psychopathology, not
to function as lie detectors
 a certain level of suspicion is essential to the
practice of psychiatry
PATIENTS WHO DO NOT COOPERATE

 many forms: failure to keep appointments,

refusal to talk or to take the session seriously,
failure to pay for services
 causes of noncooperation:
 manifestations of the patient's underlying pathology
 anger at the psychiatrist

 feelings of being coerced into an evaluation or

treatment against one's will
 manifestations of transference
 Little basis exists for pursuing the meaning of
uncooperative behavior when a psychiatrist is
meeting with a patient for the first time
 For patients who cannot or will not cooperate,
the treatment contract may need to be
renegotiated
 In certain circumstances however, the initial
assessment or therapy has to be terminated
because of a patient's uncooperative behavior
PATIENTS FROM DIFFERENT CULTURES AND
BACKGROUNDS
 Differences in race, nationality, and religion
and other significant cultural differences
between patient and interviewer can impair
communication and can lead to
misunderstandings
 Apart from diagnostic categories, the
vocabulary used to describe emotional distress
varies from culture to culture
 When an interpreter is needed, the person
should be a disinterested third party, unknown
to the patient.
 Translators must be instructed to translate
verbatim what the patient says
 The evaluating psychiatrist must proceed with
humility and respect
EMPATHIC LISTENING

 listening is more than just hearing what the

patient is saying
 must be empathic; the empathic listener is
affected by the sorrow or suffering of the
person being interviewed
 enables the listener to understand emotionally
the experiences of his or her patients
 that empathic listening not be carried too far,
the therapist must be able to step out of the
patient's shoes
 Empathy is an essential characteristic of
psychiatrists, but it is not a universal human
capacity
 an empathic psychiatrist may anticipate what is
felt before it is spoken and can often help
patients articulate what they are feeling
 Whether in an initial diagnostic setting or in an
ongoing therapy, patients draw comfort from
knowing that psychiatrists are not mystified by
their suffering
Thank you!