Obtaining the History of Present Illness

WHAT IS THE HISTORY OF PRESENT ILLNESS?

The HPI is probably the most important part of the psychiatric interview, and yet there is disagreement on exactly what it should entail. Even experienced clinicians differ in how they approach the HPI. Some think of it as the “history of present crisis” and focus on the preceding few weeks. Such clinicians begin their interviews with questions such as, “What has been going on recently that brings you into the clinic today?” Others begin by eliciting the entire history of the patient’s primary syndrome: “Tell me about your depression. How old were you when you first felt depressed?” These clinicians work forward to the present episode.

Each of these approaches may be useful, depending on the clinical situation. If a patient has a relatively uncomplicated and brief psychiatric history, it might make sense to explore that first and then move to the HPI. If the psychiatric history is long, with many hospitalizations and caregivers, starting at the beginning may bring you too far from the present problem.

The most common pitfall for beginners is spending too much time on the HPI. It’s easy to do, because this is the time for your patient to share the most difficult and painful part of his story, and cutting your patient off as time begins to pass may seem unempathic. Thus, it is vital that you keep in mind the advice offered in Section I about asking questions and changing topics sensitively. Use these techniques to gently but persistently bring the patient back to the HPI.

In the following sections, I describe techniques for the two major approaches to the HPI; you should decide which to use for a given patient.

The History of Present Crisis Approach

The American Heritage Dictionary defines crisis as “A crucial point or situation in the course of anything; a turning point.” As you begin the interview, ask yourself, “Why now? Why is this a crucial point in this person’s life? What has been happening recently to bring her into my office?” Often, psychiatric crises occur over a 1- to 4-week period, so focus your initial questions on this period.

What has been happening over the past week or two that has brought you into the clinic?

Tell me about some of the stressors you’ve dealt with over the past couple of weeks.

History of the Syndrome Approach

Alternatively, you can begin your questioning by ascertaining when the patient first remembers signs of the illness.

When did you first begin having these kinds of problems?

When was the last time you remember feeling perfectly well?

Ensuing questions track the course of the illness through months or years, arriving eventually at the present.

Now let’s talk about this current episode. When did it start?

One nice thing about this approach to the HPI is that most case write-ups are organized in this format—they often begin, “The patient was without any psychiatric problems until age 18, when she became depressed…”

TIP: MAKING THE INTERVIEW ELEGANT, OR, THE “BARBARA WALTERS APPROACH”

At its best, a well-conducted interview resembles a dance in which the give and take between clinician and patient flow effortlessly throughout the hour, giving the patient the sense
that he just participated in a fascinating conversation about his life rather than a “psychiatric” interview. One way to set the stage for this type of experience is to begin the interview by showing genuine interest and curiosity about the patient’s job, hobbies, or life situation, and to allow the patient to steer the discussion toward clinical topics. Imagine that you are Barbara Walters interviewing a celebrity, bringing that same intense curiosity to your patient:

Interviewer: I see from your intake sheet that you work for the IRS. What do you do with them?

Patient: I’m in their call center, but it’s only seasonal.

Interviewer: So when I call the IRS to ask for a form, you might answer?

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