Family Psychiatric History

Screening Questions

Has any blood relative ever had nervousness, a nervous breakdown, depression, mania, psychosis or schizophrenia, alcohol or drug abuse, suicide attempts, or hospitalization for nervousness?
Has any blood relative ever had a medical or neurologic illness, such as heart disease, diabetes, cancer, seizures, or senility?

Recommended time: 2 minutes for bare bones; 5 minutes for genogram.

The family history may be approached in one of two ways. One is the bare-bones approach, which aims to ascertain the patient’s inherited risk of developing a psychiatric or medical disorder. The second approach is more extensive and is a way of beginning the social history part of the interview. I describe both approaches here and let you decide which works best for you.

BARE-BONES APPROACH

Ask the following long, high-yield question, which is adapted from a question suggested by Morrison and Munoz (1991, p. 102):

Has any blood relative ever had nervousness, nervous breakdown, depression, mania, psychosis or schizophrenia, alcohol or drug abuse, suicide attempts, or hospitalization for nervousness?

Because the question is so long, you have to ask it very slowly, pausing after each disorder so that the patient has time to think about it. You should also define blood relative.

By blood relative, I mean parents, brothers, sisters, uncles, aunts, grandparents, and cousins.

TIP

If the patient answers with a definitive “no,” you can move on. If there was a “yes,” you should try to determine exactly what the diagnosis was. Unless your patient is in the mental health field and is familiar with its jargon, this may not be easy. It’s helpful to ask about specific treatments the relative may have received, such as lithium, carbamazepine (Tegretol), divalproex sodium (Depakote) (clues to bipolar disorder), antipsychotics [older examples are haloperidol (Haldol) and chlorpromazine (Thorazine); newer ones are risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify)], electroconvulsive therapy (clue to depression, bipolar disorder, or schizophrenia, depending on when the treatment was administered), antidepressants, and antianxiety agents. Remember that medications were used differently 20 years ago. For example, in its heyday, diazepam (Valium) was given to many patients for depression, whereas now a history of benzodiazepine treatment is a clue for the presence of an anxiety disorder.

To determine a family history of transmissible medical and neurologic problems, ask

Has any blood relative ever had a medical or neurologic illness, such as heart disease, diabetes, cancer, seizures, or senility?

How does it help diagnostically to know that a patient has a first-degree relative with a psychiatric disorder? Table 17.1 lists those psychiatric disorders for which there is significant evidence of familial transmission. The relative risk compares the risk for people with such a family history against the risk of people in the general population, who are assigned a relative risk of 1.0. For example, the relative risk of developing bipolar disorder is 25; this means that if your patient’s father is bipolar, she is 25 times more likely to develop bipolar disorder than the average person. The baseline lifetime prevalence of each disorder is also listed in the table.

Typically, family information is used in conjunction with other clinical information. For example, family history is crucial in deciding whether a patient with new-onset psychosis has schizophrenia or is in the manic phase of bipolar disorder.

TABLE 17.1. Psychiatric disorders with significant evidence of familial transmission

DSM-IV-TR disorder	Lifetime relative risk if first-degree relative has disorder^a	Lifetime prevalence in general population^b
Bipolar disorder	25	1
Schizophrenia	19	1
Bulimia nervosa	10	2^c
Panic disorder	10	4
Alcoholism	7	14
Generalized anxiety disorder	6	5
Anorexia nervosa	5	1^c
Specific phobia	3	11
Social phobia	3	13
Somatization disorder	3	2^d
Major depression	3	17
Obsessive-compulsive disorder	?	3^e
Agoraphobia	3	5
^aRelative risk figures from Reider, R. O., Kaufmann, C. A., et al. (1994). Genetics. In R. E. Hales, S. C. Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American Psychiatric Press. See text for explanation. ^bLifetime prevalence figures from Kessler, R. C, McGonagle, K. A., Zhao, S., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19; and Regier, D. A., Farmer, M. E., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association, 264, 2511-2518. ^cData from Halmi, K. A. (1994). Eating disorders: Anorexia nervosa, bulimia nervosa, and obesity. In R. E. Hales, S. C. Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American Psychiatric Press. ^dData from Martin, R. L, and Yutzy, S. H. (1994). Somatoform disorders. In R. E. Hales, S. C. Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American Psychiatric Press. ^eData from Hollander, E., Simeon, D., et al. (1994). Anxiety disorders. In R. E. Hales, S. C. Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American Psychiatric Press.