1 and
The method of psychiatric history taking is somewhat different from the standard medical interview. The psychiatric interview aims to be therapeutic as well as diagnostic. In the course of the interview it is hoped that the patient will be able to talk about his or her problems and their context. In doing so, patients will gain some relief from their distress by airing their problems. For this to take place, the clinician’s attitude needs to be unhurried, patient and understanding. The psychiatric history also aims to gain an understanding of how the patient’s problem arose from a biological, interpersonal, social and psychological perspective, so that the best management plan can be worked out.
Obtaining the history
The clinician taking a psychiatric history wants the patient to tell his or her story in his or her own words. In this way the patient will be more likely to report the most important aspects of the illness. This is best achieved using a non-directive approach with open-ended questions. Open-ended questions are those to which the patient will respond with narrative (or a description about what has been happening) rather than a simple factual response. They give the patient an opportunity to talk about his or her problems. Closed questions are more likely to elicit ‘yes’ or ‘no’ responses. For example, in the assessment of a patient with depression, a closed question would be: ‘Have you been depressed?’ An open-ended question would be: ‘Tell me about how you have been feeling.’ At first glance it might appear that the open-ended question is less efficient, as it could take a longer time to find out about a range of symptoms. However, with a careful and judicious approach, open-ended questioning—by permitting the patient to tell the story—will enable the clinician to get a comprehensive history efficiently. This is not to say that targeted, more-closed questions must not be used—they are necessary to elicit certain symptoms.
While the patient is telling his or her story, the clinician should begin to formulate hypotheses about the problem or diagnosis. These hypotheses are tested by asking more-focused questions later in the interview, at which point a diagnostic hypothesis can be rejected or pursued further. For example, a patient may describe tiredness and lethargy, an inability to concentrate and loss of appetite. These symptoms will suggest a diagnosis of depression. Follow-up questions should focus on this possibility. The clinician should ask questions about other symptoms of depression such as: ‘How have you been feeling in yourself?’, ‘What has your mood been like?’ and ‘How have you been sleeping?’
Introductory questions
The psychiatric interview should start off with non-threatening questions. After introducing yourself, it can be useful to begin by asking about basic demographic information (age, marital state, occupation, whom the patient lives with) and then making the patient feel at ease by discussing some neutral topic.
History of the presenting illness
In assessing the history of the presenting illness, one needs to cover a number of areas.
1. The problem
Find out the nature of the patient’s problem, and the patient’s perception of his or her difficulties. This can, of course, be difficult if the patient is psychotic and does not believe a problem exists at all. In these cases a corroborative history must be taken. For example, a manic patient may consider that there is nothing wrong and that his or her behaviour is reasonable, whereas his or her partner is able to recognise that ordering an expensive new sports car when the family is impoverished is a problem.
A range of symptoms commonly found in psychiatric disorders needs to be reviewed in the course of assessing the history of the present illness. These include mood change, anxiety, worry, sleep pattern, appetite, hallucinations and delusions. A set of simple screening questions for each of the major diagnoses is listed within
TABLE 12.1 The common psychiatric disorders
MOOD (AFFECTIVE) DISORDERS | |
Mood disorders have a pathological disturbance in mood (depression or mania) as the predominant feature. They are distinguished from ‘normal’ mood changes by their persistence, duration and severity, together with the presence of other symptoms and impairment of functioning. | |
1. Manic-depressive illness—bipolar disorder | |
Bipolar disorder is a broad term to describe a recurrent illness characterised by episodes of either mania or depression, with a return to normal functioning between episodes of illness. | |
a. Mania A disorder demonstrated by change in mood (elation), thought form (grandiosity) and behaviour disturbance (increased energy and disinhibition). | Questions box 12.1 |
Questions to ask the patient with possible mania | |
b. Depression A disorder characterised by depressed mood (or loss of pleasure) and the presence of somatic (sleep disturbance, change in appetite, fatigue and weight), psychological (low self-esteem, worry- anxiety, guilt, suicidal ideation), affective (sadness, irritability, loss of pleasure and interest in activities) and psychomotor (retardation or agitation) symptoms. | Questions box 12.2 |
Questions to ask the patient with possible depression | |
ANXIETY DISORDERS | |
Anxiety disorders are those in which the person experiences excessive levels of anxiety. Anxiety may be somatic (palpitations, difficulty breathing, dry mouth, nausea, frequency of micturition, dizziness, muscular tension, sweating, abdominal churning, tremor, cold skin) or psychological (feelings of dread and threat, irritability, panic, anxious anticipation, inner [psychic] tension, worrying over trivia, difficulty concentrating, initial insomnia, inability to relax). | |
1. Generalised anxiety disorder (GAD) | Questions box 12.3 |
Questions to ask the patient with possible anxiety | |
2. Panic disorder A disorder characterised by episodes of panic occurring spontaneously in situations where most people would not be afraid. A panic attack is characterised by the presence of physical symptoms (palpitations, chest pain, a choking feeling, a churning stomach, dizziness, feelings of unreality) or fear of some disaster (losing control or going mad, heart attack, sudden death). They begin suddenly, build up rapidly, and may last only a few minutes. | Questions box 12.4 |
Questions to ask the patient with possible panic disorder | |
3. Agoraphobia (phobic anxiety) | Questions box 12.5 |
Questions to ask the patient with possible phobic anxiety | |
4. Obsessive–compulsive disorder | Questions box 12.6 |
Questions to ask the patient with possible obsessive–compulsive disorder | |
STRESS-RELATED DISORDERS | |
1. Acute stress disorders | Questions box 12.7 |
Questions to ask the patient with possible acute stress disorder | |
2. Post-traumatic stress disorder (PTSD) Onset of persistent problems within 6 months of a traumatic event of exceptional severity. The individual experiences repetitive and intrusive re-enactments of the trauma in images, dreams or flashbacks. Sleep, concentration, memory, mood and attention may be disturbed. Individuals may feel emotionally detached and avoid things that act as reminders of the traumatic event. | Questions box 12.8 |
Questions to ask the patient with possible PTSD | |
SCHIZOPHRENIA AND DELUSIONAL DISORDERS | |
A disorder characterised by disorders of content (presence of delusions), thought form (shown by difficulty understanding the connections between the patient’s thoughts), perception (hallucinations—predominantly auditory), behaviour (erratic or bizarre) and/or volition (apathy and withdrawal). | Questions box 12.9 |
Questions to ask the patient with possible schizophrenia | |
ORGANIC BRAIN DISORDERS | |
These are disorders in which there is brain dysfunction manifested by cognitive disturbances such as memory loss or disorientation; there may be behavioural disturbance as well. | |
1. Delirium (acute brain syndrome) A disorder characterised by the acute onset of disturbed consciousness plus changes in cognition that are not due to a pre-existing dementia. It is a direct physiological consequence of a general medical condition (substance intoxication or withdrawal, use of a medication, exposure to a toxin, or a combination of these factors). Delirium is characterised by confusion and clouding of consciousness. This may be accompanied by poor memory, disorientation, inattention, agitation, emotional upset, hallucinations, visions or illusions, suspiciousness and disturbed sleep (reversal of sleep pattern).
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