PSYCHIATRIC HISTORY
The reason for referral, the complaints and the history of the presenting illness should be given first.
The chronological sequence of each symptom should be determined at interview.
The psychiatric history should ideally be brought together from both the patient and sources of further information (see the section on Investigations later in this chapter).
Reason for referral
Briefly state how and why the patient was referred.
Complaints
These are the patient’s complaints given in his or her own words. The length of time each complaint has lasted should also be given.
History of presenting illness
A chronological account should be given of the development of each symptom, together with any precipitating factors. Associated impairments should also be given. For example, for a depressive episode biological and cognitive symptoms of depression (Ch. 6) should be included. The effects of the patient’s condition on social functioning should be noted.
Family history
Give details of parents and siblings, including their:
• Current ages or ages at death
• Occupations
• Health
• Relationship with the patient.
The timing of parental separation and/or divorce, if relevant, should also be stated.
Family psychiatric history
Any positive family psychiatric history should be recorded, including dates and types of treatment received and the diagnoses made, if available. Enquiries should also be made about any suicide attempts.
Personal history
Childhood
This should include details of:
• Date of birth
• Place of birth
• Abnormalities prior to or at birth and whether the birth was premature
• Early developmental milestones
• Childhood health, including any history of ‘nervous problems’
• Any early emotional stresses, including separation (e.g. due to death) from close relatives such as siblings or parents.
Education
• Types of school attended
• Relationship with peers and teachers
• Any history of truancy or other trouble or difficulties at school
• Qualifications achieved
• Age on leaving school
• Higher education.
Occupational history
Summarize the occupational history, giving details of promotion/demotion. Reasons for being sacked repeatedly (e.g. problem drinking) should be explored. Any other difficulties at work should be given.
Psychosexual history
For women, give the age of menarche, any menstrual abnormalities, history of pregnancies and the age of menopause, if relevant. The sexual orientation (heterosexual or homosexual) should also be given. Any history of sexual or physical abuse should be detailed. Sexual and marital history (including any history of infidelity) and any sexual difficulties should be noted.
Children
Details of any children should be given, including any disturbances they suffer from.
Current social situation
Give the patient’s current:
• Social situation, including with whom they live
• Marital status
• Occupation and financial status
• Nature and suitability of accommodation
• Hobbies and social interests.
Past medical history
Give a chronological account of the past medical history, including the nature of physical disorders and injuries, where they were treated and the types of treatment administered. Any medication, and its side effects, should also be enquired about, as should any history of hypersensitivity to drugs. Medication taken should include details of any recent immunizations and over-the-counter medicines such as ‘herbal remedies’.
Past psychiatric history
Give details of the:
• Nature of the illness(es)
• Duration of the illness(es)
• Hospital(s) and outpatient department(s) attended
• Treatment(s) received
• Any current psychotropic medication being taken, and any side effects from this.
Psychoactive substance use
Alcohol
Details should be obtained about the amount of alcohol the patient is currently drinking and the amount drunk in the past, including a history of any withdrawal symptoms (Ch. 4) being suffered from either at present or in the past. Also, look for any evidence of primacy of drinking over other activities, a compulsion to drink or a narrowing of the drinking repertoire.
The CAGE Questionnaire (Ch. 4) should be routinely administered to patients to screen for alcohol problems; positive answers to two or more of the four CAGE questions are indicative of problem drinking:
C Have you ever felt you should Cut down on your drinking?
A Have people Annoyed you by criticizing your drinking?
G Have you ever felt Guilty about your drinking?
E Have you ever had a drink first thing in the morning (an Eye-opener) to steady your nerves or get rid of a hangover?
Any history of physical illness, injury (e.g. road traffic accidents), legal problems (e.g. driving offences) or employment difficulties (e.g. being late regularly for work resulting in being sacked) as a result of alcohol intake.
Tobacco
If the patient smokes, the type and number of nicotine-containing products smoked and any previous history of smoking.
Other psychoactive substance abuse
Misuse of drugs both currently and in the past, including the types of drug, the quantities taken, the methods of administration and the consequences. These should include any use of:
• Opioids
• Cannabinoids
• Sedatives
• Hypnotics
• Cocaine – including crack cocaine
• Amphetamine and related psychostimulants
• Hallucinogens
• Lysergic acid diethylamide (LSD)
• N,N-dimethyltryptamine (DMT)
• Mescaline
• Magic mushrooms (psilocybin)
• Phencyclidine (PCP)
• Ketamine
• 3, 4-methylenedioxymethamphetamine (Ecstasy or MDMA)
• Volatile substances
• Solvents
• Adhesives
• Petrol
• Butane gas
• Paint
• Paint thinners
• Correction fluid
• Spray-can propellants.
Colloquial names for the illicit drugs are given in Chapter 4.
Premorbid personality
The patient’s personality consists of his/her lifelong persistent and enduring characteristics and attitudes, including way of thinking (cognition), feeling (affectivity) and behaving (impulse control and ways of relating to others and handling interpersonal situations). If the patient’s personality has changed after the onset of psychiatric disorder, then details of his/her personality prior to the disorder should be obtained from interviewing both the patient and other informants. Summarize the patient’s personality prior to the onset of the psychiatric illness under the following headings:
• Attitudes to others in social, family and sexual relationships
• Attitude to self and character
• Moral and religious beliefs and standards
• Predominant mood
• Leisure activities and interests
• Fantasy life – daydreams and nightmares
• Reaction pattern to stress – including defence mechanisms.
MENTAL-STATE EXAMINATION
The mental-state examination (MSE) is an important part of the psychiatric examination and should be practised repeatedly after carefully observing how trained psychiatrists carry it out. It covers the psychiatric symptomatology (‘signs’ of illness) exhibited at the time of the interview. In addition to recording information obtained from the interview itself, the mental-state examination should also use information obtained by others, such as the observations of nursing staff in the case of an inpatient. This is important because the patient may not always be forthcoming about his/her symptomatology. Thus, for example, a patient who is observed by the nursing staff to be responding to auditory hallucinations may during a formal interview deny experiencing perceptual abnormalities.
The main areas that must be covered during the mental-state examination are detailed in this section. Some of these areas need to be expanded, according to the diagnosis. For example:
• In depression: expand on mood
• In schizophrenia: expand on mood, abnormal beliefs and abnormal experiences
• In obsessive–compulsive disorder: expand on mood and thought abnormalities
• In dementia: expand on mood and cognitive state.
Appearance and behaviour
General appearance
The patient’s general appearance should be described, with particular reference to any features that may be consistent with a psychiatric disorder (Ch. 2).
Facial appearance
The facial appearance can also give clues to the diagnosis, particularly with respect to organic disorders such as endocrinopathies (Ch. 2).
Posture, movements and social behaviour
The patient’s posture, movements (including underactivity or overactivity) and social behaviour at interview should be noted. These are often abnormal in psychiatric disorders (Ch. 2).
Rapport
The level of eye contact and the degree of rapport established should also be recorded. A positive rapport aids the formation of a constructive, therapeutic doctor–patient relationship. A negative rapport may occur, for example, in the case of patients admitted compulsorily against their will and in some personality disorders (Ch. 10). The rapport can be indicative of both the transference and the countertransference (Ch. 2) and should be borne in mind when considering the underlying psychodynamics of the doctor’s relationship with the patient and the latter’s response to various types of treatment (such as individual psychotherapy).
Psychodynamic aspects
The psychodynamic aspects of movements should not be overlooked. For example, a married or engaged woman may play with her wedding or engagement ring during the interview because she has anxieties about her relationship; if she takes the ring off completely this may be indicative of an unconscious desire to end the relationship with her partner.
Speech
Note the following aspects of the patient’s speech:
• Rate
• Quantity
• Articulation
• Form.
The form, i.e. the way the patient speaks, is noted; the content is considered under ‘thought content’ below. If a disorder in the form of speech (including the presence of any neologisms –Ch. 2) is suspected or found it is useful to record a sample of the patient’s speech that shows this.
Mood
Objective assessment
An objective assessment should be made of the quality of the patient’s mood based on:
Subjective assessment
A subjective assessment of the quality of the mood as described by the patient can be obtained by asking a question such as:
Affect and anxiety
The patient’s affect (Ch. 2) should also be noted, as should the presence of any signs of anxiety.
Thought content
Preoccupations
Any morbid thoughts, preoccupations and worries the patient has are noted. Suitable screening questions include:
• ‘What are your main worries and preoccupations?’
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