Obtaining the Psychiatric History

The past psychiatric history (PPH) risks becoming a tedious exercise in documentation. You can avoid this by realizing how vital the PPH is to your twin goals of establishing a diagnosis and formulating a treatment plan.

Specific psychiatric disorders have specific natural histories, with characteristic risk factors, prodromal signs, ages at onset, and prognoses. Obtaining a detailed PPH for a particular patient allows you to compare the course of her illness with the textbook’s version of the course of illness, increasing the likelihood that you will make a correct diagnosis.

Often, patients will come to you after having been treated for many years. One reason such patients are eventually referred to an expert consultant is that experts are great at eliciting a detailed history of prior treatments. They can determine exactly what has been tried in the past and whether past treatment trials have been adequate. From this information, they can present informed recommendations about what should be tried next. And they can do all this in one or two 50-minute sessions.

Potential pitfalls in obtaining the PPH are similar to those lurking during the HPI. At one end of the continuum, some interviewers become so caught up in the intricacies of the
PPH that they spend most of the evaluation time on it, to the detriment of, for example, the PROS. At the other end, the PPH can become a rote exercise and may be obtained too superficially, depriving the interviewer of information necessary to make a firm diagnosis.

OBTAIN THE SYNDROMAL HISTORY

Generally speaking, the HPI will take between 5 and 10 minutes, at the end of which you should have a few provisional diagnoses in mind. Your next job is to obtain the history of these syndromes. Specifically, you want to learn age at onset, premorbid functioning, and history of subsequent episodes up to the present.

Age at Onset

How old were you when you first had your symptoms?

Knowing the age at onset may help you to decide between potential diagnoses, although the most recent epidemiologic data indicate that ages of onset for disorders are less distinct than previously thought (Table 15.1).

Premorbid Functioning or Baseline Functioning

See Chapter 14 for a discussion of premorbid functioning/baseline functioning.

TABLE 15.1. Median age at onset of major psychiatric disorders

Disorder	Age (yr)
Schizophrenia	21 (men), 27 (women)
Major depression	25
Bipolar disorder	19
Panic disorder	24
Obsessive-compulsive disorder	23
Drug abuse/dependence	18
Alcohol abuse/dependence	21
Adapted from Burke, J. D., and Regier, D. A. (1994). Epidemiology of mental disorders. In R. E. Hales, S. C. Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American Psychiatric Press, 19.

History and Precipitants of Subsequent Episodes up to Present

Include questions about the severity of episodes and exacerbations, as well as the duration of episodes. Often, this information comes out when you are obtaining the treatment history. For example, episodes of mania or exacerbations of schizophrenia often correspond with hospitalizations.

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