The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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HISTORY TAKING IN PSYCHIATRY – 2

Introduction

This section deals with the details of Psychiatric Assessment Interview, concentrating only on the history taking.

It is important in psychiatry that we also obtain an objective account of the patient’s presenting problem from other independent sources. However, this must be cleared with the patient in advance. Often, a family member of patient’s choice, a GP, a close friend or a work colleague may be a good source to obtain additional information about the patient’s current health issues as well as their views about the current presenting problems and possibly, the underlying causes as they understand it. Family members, spouse or parents are a good source of information about the patient’s pre-morbid personality, habits, relationship issues and other areas such as dependency on drugs, alcohol, financial difficulties and any current or past forensic history, which a patient may not always disclose to the treating physician.

Often, medical students or Accident & Emergency doctors may not have the opportunity or time to explore the patient’s history from other sources, but they must always mention this important aspect of history taking while formulating their case and highlight the need to do so at a later stage by themselves or through other health professionals.

Obtaining history from another appropriate source serves very many important purposes.

1. Firstly, it gives further insight into the patient’s illness and personality and other relevant psychosocial issues.


2. It helps the patient psychosocially by knowing that a professional has formally involved members of his family and briefed them about the nature of his illness and the proposed treatment – of course, with the patient’s consent.


3. From the family’s point of view, they now understand the medical reasons for their loved one’s somewhat abnormal behaviour and the expected treatment outcome.


4. Furthermore, members of the family feel involved in patient’s care and thus not so guilt ridden as they often unconsciously feel and blame themselves for their partner’s or child’s ill health.

In my opinion, we should always aim to include at least one close member of the family, or another person of patient’s choice, to complete the history taking in psychiatry.

Following is the standard schema for history taking in psychiatry:

1. Personal Details and Reasons for Referral:

• Name
• Date of Birth
• Address
• Telephone Numbers
• Marital Status
• Next of Kin – Name, Address, Telephone Numbers
• GP Details
• Who referred the patient
• Reasons for referral
• Legal Status – subject to the Mental Health Act (1983) or Informal

2. Place of interview, by whom, date and time, and who else was present

• In-patient (Hospital ward, etc)
• Out-patient
• Home Visit
• Other

3. History of the current problems

• Key symptoms
• For how long have the symptoms have persisted
• Precipitating factors
• Key life-events prior to the onset of the symptoms
• Life-events since the onset of symptoms
• Alleviating or exacerbating factors
• What help has been offered and its response
• What is the patient’s view about:
  1. What is wrong with the patient
  2. What may be the underlying causes or precipitating factors
  3. What help would the patient prefer to have

4. Past Psychiatric History

• The nature, duration and treatment and its response
• How and by whom was the patient treated:
  1. GP
  2. Specialist Service
  3. Out-patient or in-patient
  4. Voluntary/involuntary treatment
  5. Medications/Depo
  6. ECT
  7. Counselling/Psychotherapy
  8. Other Treatment Methods

5. Past Medical History and Current Status

• The nature, duration and treatment and its response
• How and by whom was the patient treated

6. Family History

• Information about parents and siblings
• Extended family members
• Any significant mental and physical health history
• Given treatment for any specific mental health disorder
• History of illicit drug abuse, alcoholism, gambling, deaths, suicide, and trouble with the Law and forensic history

7. Personal History

• Pregnancy
• Infancy and childhood
• Development issues, if any
• Schooling
• Educational achievements
• Social adjustments
• Interests, habits, hobbies
• Relationships
• Sexual experiences
• Steady friends
• Employment history
• Marital history
• Children, ages, health status, etc

8. Social History

• Financial, Housing, and social support network

9. Forensic History

• Trouble with the Law
• Driving Offences
• Illicit Drug Abuse
• Problem with Alcohol

10. Pre-morbid Personality

• Attitudes
• Opinions
• Religious/Spiritualism
• Shy/quiet/introvert
• Extrovert
• Anxious/Obsessional
• Suspicious/Trusting
• Optimistic/Pessimistic
• Easy to mix and made friends/Sociable
• Kept to himself/avoid big social events
• Other attributes
• How he will describe himself
• How others will describe him

11. History as given by others

• Informant
• Relationship with the patient
• Key information obtained/history
• History as obtained from medical notes and other documents

The Process of History Taking is dealt with in the next section:
History Taking in Psychiatry – 3

Author:
Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent

References:

1. Companion to Psychiatric Studies, Eve C Johnstone, et al, 1998
2. Shorter Oxford Textbook of Psychiatry, Fifth Edition, M Gelder et al, 2006

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