History and aetiology

The standard sections covered by the psychiatric history are shown in Figure 1. An important thing to note is how similar these are to those covered by the standard medical history. As you are probably already familiar with medical history-taking, you will already have many of the skills necessary for taking a psychiatric history.

Fig. 1 The psychiatric history.

The most important difference with the psychiatric history is the amount of background information you need to collect. This is because it is meaningless to consider psychiatric disorders outside the context in which they occur, as exemplified in Figure 2. Because of this, the psychiatric history includes two sections (personal history and premorbid personality) which are not used in other medical specialities. For the same reason, social circumstances are particularly important in psychiatry and should be recorded in detail. As well as giving you a better understanding of the patient and their problems, this background information will help you understand the aetiology of the patient’s problems.

Fig. 2 The symptoms are the same but the clinical picture is completely different.

Aetiology of psychiatric disorders

Psychiatric aetiology should be split into three components:

predisposing factors

precipitating factors

maintaining factors.

In other words: why is this patient vulnerable to developing this disorder, what caused them to develop it now, and what is stopping them getting better? Possible aetiological factors are shown in Figure 3. Identifying these factors is important for several reasons.

Fig. 3 Aetiological factors in psychiatric illness.

If you can explain why a particular patient has developed a particular disorder, then you will feel much more confident about the diagnosis. For instance, a diagnosis of angina is much more likely in a 60-year-old male smoker than in a 30-year-old healthy female non-smoker. A knowledge of the aetiology of ischaemic heart disease, therefore, helps you make a diagnosis. This process is important in all areas of medicine but particularly so in psychiatry. This is because there are no tests available to confirm most psychiatric diagnoses and so aetiology provides a useful way of assessing the likelihood of the diagnoses you are considering for a particular patient.

Aetiology is important for other reasons. Firstly, many patients find it helpful to know why they have developed an illness. Secondly, identifying what has precipitated a disorder, or what is preventing recovery, will influence the treatment a patient receives. Finally, it is often necessary to understand the aetiology of a patient’s problems in order to make accurate predictions about their prognosis.

The psychiatric history

Presenting complaint

This part of the psychiatric history is very similar to that in other medical specialities. The basic principles are laid out in Figure 4. The reasons for presentation are determined and then clarified by further questioning. Questions are then asked about other symptoms that will help clarify the diagnosis.

Fig. 4 Taking the history of presenting complaint.

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