Obtaining the Social and Developmental History

In the days when psychoanalysis was king, the social and developmental history was the psychiatric interview. Residents were instructed to cover everything from breastfeeding to a patient’s first sexual fantasies, a process that could well take several hours. The results were written up and used to develop a psychoanalytic formulation, focusing on Freudian notions of psychosexual conflict.

In our age of psychopharmacology, interviewers sometimes reach the other extreme, asking about little more than their patient’s job and marital status before moving on to the DSM-4 diagnostic questions.

What is the purpose of the social and developmental history in a brief diagnostic interview? How extensive should it be? The social history is useful in two closely related ways: (a) It allows you to get to know the patient as a person rather than as a diagnosis, and (b) you can approach the diagnosis of a personality disorder through the social history (see Chapter 31).

The essential questions take 5 minutes to ask, whereas the extended version takes 10 to 20 minutes and should be reserved for occasions on which you can take two sessions to do the evaluation.

EARLY FAMILY LIFE

Begin with the following introductory question:

Can you tell me a bit about your background, where you grew up, and how you grew up?

Proceed to more specific questions, moving chronologically through the stages of life.

How many siblings did you have, and where were you in the birth order?

Each family configuration has a unique impact on psychological development. Typical scenarios include the loneliness of the only child, the eldest child of a large family who was forced into the role of a parent, the ignored middle child, and the youngest child who grew up as the resented apple of his mother’s eye.

What did your parents do for a living?

Parental employment may have affected the patient’s relationship with her parents. For example, a father who worked as a traveling salesman may not have been home much. This question also gives you a sense of socioeconomic situation: Did the patient grow up amid poverty or affluence?

How did you get along with your parents?

Although there’s not enough time to do this topic justice in the diagnostic interview, these questions will give you an idea of the general flavor of the home. Was it a peaceful, loving environment, or was it angry and chaotic?

What did they do when you disobeyed?

This question can gently introduce the topic of physical or sexual abuse. Depending on the answer, you can follow up with a more explicit question, such as

Were you abused physically or sexually as you grew up?

Were there any other important adults in the home?

Often, another relative was a major factor in the patient’s early life, with either a positive or a negative effect.

How did you get along with your siblings?

A close relationship with siblings can often compensate for a terrible relationship with parents.

Who were you closest to, growing up?

EDUCATION AND WORK

Did you enjoy school?

This question will give you a sense of how the patient managed her first encounter with the social field outside of the family.

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