What are some of the skills required when interviewing patients? What information is required when taking a patient history or completing a mental state examination? These are just some of the questions you'll seek answers to as you work through the course material. Mental health is an important public issue across the world, and the role of the psychiatrist is crucial in helping to address these. This course aims to give you a more nuanced understanding of the role of a psychiatrist, developing clinical skills and therapeutic relationships. Understanding the impact of mental illness in society and ethics in medicine are some of the key themes central to this course. This course is designed to provide essential background knowledge and practical skills that apply to any mental health clinical setting.
Taking a Psychiatric History
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Do curso por The University of Melbourne
Foundations of International Psychiatry
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Clinical skills
Welcome to the Clinical Skills module. The focus of this week's learning will on skills and concepts that come in useful when documenting a psychiatric patient history.
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Greg ShieldsDr.
Department of Psychiatry
Mahesh JayaramDr
Department of Psychiatry
In the last section, you looked at the communication skills needed to
engage patients and build a therapeutic relationship.
These skills are essential to obtaining a thorough and accurate psychiatric history.
Here is an outline of the psychiatric history: You'll notice that it covers
the recent circumstances that led to the person being seen by mental health services,
as well as many aspects of their background history.
This represents a lot of information.
Sometimes a full history is obtained directly from the patient over one or two sessions.
However, in many cases,
it is obtained over a period of time and from several sources.
These might include the medical notes,
conversations with carers and
health professionals and records from institutions such as schools,
police or social services.
When interviewing a patient it is important
to keep the structure in the back of your mind,
but not to let it dominate the interview.
It's important to allow time for the patient to speak freely.
It's okay to gently interrupt them to clarify something,
or to guide them back to your questions if they stray too far,
but avoid going through the history like a checklist.
Make sure that you use open questions and avoid closed questions,
at least at the beginning of the interview.
Here are some examples of open and closed questions:
You can see from the examples that closed questions
guide the patient to give short, factual responses.
Whereas, open questions encourage them to answer in their own way,
which is often richer and far more informative.
Closed questions are useful when you want to clarify
something or when you need to ascertain specific facts.
The key to taking a good history is to allow the patient to talk
about their experiences and prompt them when you need to know more,
or move onto something else.
That way you will gain much more useful information.
At the end of the interview, you can obtain
any information that's missing by asking closed questions,
but it's helpful to warn the patient that you're going to do so.
Patients don't always tell their story in a straightforward way.
The information you obtain in an interview may need to be restructured so that it
makes sense chronologically and fits within the traditional format of the psychiatric history.
This occurs after the interview when we document our findings.
Another tip is to use direct quotes from the patient when you document the history.
This will help express their experience more authentically.
Now, take a look at the structure of the psychiatric history and some clinical examples.
Circumstances of admission or circumstances of referral is a brief paragraph or
sentence that includes some basic demographic information
to allow you to identify the patient,
along with a one line description of
how or why they were referred to mental health services.
Have a look at these examples of patients seen in
two very different settings: An emergency department,
and an outpatient clinic.
We will hear more about their histories as we go through this video.
John Smith is a 46 year old man with schizophrenia,
who was brought to the emergency department by passers by,
after he was found climbing on a railway bridge.
Or, Gloria Ramos is a 62 year old woman from the Philippines,
who has recently completed treatment for breast cancer.
She was referred to the psychiatry team by her oncologist due to longstanding depression.
Let's move on to the history of presenting illness. The history of
presenting illness describes what happened to
the patient leading up to the current presentation.
In acute cases, it might only cover a few days,
for instance, someone presenting with
manic symptoms one week after stopping their mood stabilizer medication.
On the other hand, if the patient's condition has developed over a long time,
the history of presenting illness may go back over many years.
Say for example, someone presenting with anxiety since they lost their job three years ago.
In patients with chronic conditions that relapse and remit,
only the period leading up to the current presentation is included.
You might want to consider what precipitating and
perpetuating factors have led to the current episode.
Precipitating factors are very recent triggers that
might have contributed to a deterioration in the patient's mental health,
for example, stopping medications.
Perpetuating factors are chronic or recurring things that
maintain the patient's poor mental health or prevent them from recovering.
Like for example, using drugs of abuse.
Let's go back to Mrs. Ramos.
Mrs. Ramos describes persistent low mood
for three years beginning with the death of her husband in 2013.
She feels that she never recovered and although she has some good days,
most of the time she feels sad and tired.
She doesn't enjoy anything she used to do such as cooking or going out with friends.
As a result, she has become very isolated and spends all of her time by herself.
She has trouble sleeping and feels negative about her life.
She said that this is not her usual self as she used to be cheerful and outgoing.
She says that these feelings have got worse since her breast cancer diagnosis in 2016.
She has very little interest in food or
activities and she often thinks that life's not worth living.
She mentioned this to her cancer nurse who
arranged for a referral to the psychiatry clinic.
The precipitating factors in this case include her diagnosis and treatment of breast cancer,
as well as the death of her husband.
The perpetuating factors might include her poor physical health and social isolation.
Now let's move on to her past psychiatric history.
The past psychiatric history briefly describes all previous: diagnoses,
episodes of mental illness including symptoms suffered at that time and
significant risk events like suicide attempts or
aggressive behavior, admissions to hospital,
relationships with outpatient mental health services, medications,
efficacy of treatment and side effects,
psychological therapy and other treatments,
for example, electroconvulsive therapy.
These are usually presented in chronological order
with the most recent episodes listed first.
Let's go back to Mr. Smith now.
Mr. Smith has had a diagnosis of paranoid schizophrenia since 2004,
and was diagnosed with depression following a suicide attempt in 2012.
From 2012-2016, Mr. Smith was stable
in the community on a long acting injection of haloperidol, 50 milligrams monthly.
He regularly attended the North London community team to receive his injections.
He complained of some mild stiffness but no serious side effects.
From July to November 2012,
Mr. Smith was admitted to an acute ward following an overdose of paracetamol.
He was not actively psychotic at the time but presented
with depressive symptoms and was treated with fluoxetene,
20 milligrams, in addition to his depo haloperidol injection.
This seemed to improve his mood and he was discharged home.
He was referred for psychological therapy but did not attend his assessment.
Mr. Smith was diagnosed with schizophrenia in
2004 after suffering from auditory hallucinations for 12 months.
He was smoking cannabis at the time but symptoms persisted following cessation.
He was referred for assessment by his family who were worried about
his mental state and seen by a psychiatrist of the local community team.
He was prescribed oral haloperidol but due to difficulties remembering to take tablets,
he agreed to start a long acting injection.
He's been looked after by the community team since that time.
Mr. Smith has not required any admissions against
his will and he's not previously being treated with ECT.
Now record the past medical history.
Any history of physical illness or current medical conditions should be listed here.
Document the medications.
List any current medications or treatment under the medication section;
doses, frequency and drug allergies should also be included.
Now, let's come on to the substance misuse section,
which is sometimes just called drug and alcohol. List
any drugs of abuse as well as tobacco and alcohol here,
and try to estimate the frequency and quantity.
Alcohol is usually quantified as the number of
standard drinks per day and number of drinking days per week.
Tobacco is expressed as the number of cigarettes per day.
Other drugs can be quantified by weight or cost.
For example, one gram per week or $40 per fortnight.
Moving on to the family history, in the family history,
include any history of mental illness,
relevant physical illnesses,
genetic conditions or suicide in members of the immediate or extended family.
Now we come to the social history,
which describes the patient's current circumstances, this
includes where they live and what sort of accommodation it is,
who they live with,
their social network including friends and family,
finances,
employment and how they manage their activities of daily living which includes cooking,
cleaning, dressing and toileting.
Let's take a look at Mr. Smith again.
Mr. Smith lives alone in government housing,
he has a one bedroom apartment in a large block close to where his parents reside,
he sees his parents on a daily basis and has
a couple of friends who he sees at the pub on weekends.
He receives government financial assistance and is
employed as a volunteer at a local charity shop.
He's not in any debt.
He cooks for himself most days and he's
independent in all of his activities of daily living,
although the house is often not cleaned for several months.
Now let's move onto the personal history, understanding
a patient's childhood and broader life experience is helpful in formulating their diagnosis.
The personal history describes the patient's life since birth,
including the details of their childhood,
schooling, employment, family, social life, relationships and interests.
A good personal history will give some sense of their personality and their values,
and offer some insight into how these things have changed since they became unwell.
Let's find out more about Mrs. Ramos.
She was born in the Philippines and was the eldest of five children.
She doesn't recall having any health problems as
a child and thinks that her development was normal.
Her siblings, mother, father and grandfather lived in the house.
After her grandfather died,
they moved to the USA when she was eight years old
so that her father could further his studies as an engineer.
She has lived in California since then.
She attended primary school and junior high school
where she was considered an average student.
But there were no disciplinary problems as far as she remembers.
She dropped out of high school to work as a secretary when she was 16.
She continued working in administration until retirement at the age of 55.
She met her husband George when she was 23
and they had three children Gracie, Julia and Peter.
George passed away from a heart attack three years ago,
but she has a good relationship with her children who live nearby.
Her brothers and sisters live in the Philippines but
travel to the USA regularly to see her.
Mrs. Ramos always had a big group of
friends and enjoyed playing sports and cooking for them.
She was previously very outgoing and bubbly and
always remembered being the center of attention when she was at school.
However, since George died,
she feels like she's no longer herself and she isn't very good company.
She would like to feel a bit more like me.
Meaning, that she wants to be more outgoing and motivated to socialise with more energy.
Now document the forensic history, include
any history of criminal behavior or contact with police or courts.
This includes any arrests or charges for violent or anti-social behaviour,
convictions or sentences for committing a crime,
special conditions placed by the courts, for example,
an order preventing the patient from contacting or visiting
another person or current criminal proceedings.
Let's come onto the risk history,
documenting risk is an extremely important part of the psychiatric history.
In this section record any history of: harming or attempting to harm themselves,
harming or attempting to harm others,
threatening to harm themselves or others,
aggressive or intimidating behaviour.
You should also include other aspects of their lifestyle
and their behaviour that could put themselves or others at risk.
This might include: neglecting their personal hygiene,
physical health or nutrition,
becoming homeless, stopping psychotropic medications,
neglecting care of their children,
engaging in dangerous behaviour such as reckless driving,
promiscuous sex, drug use,
criminal behaviour or prostitution,
behaviour that may provoke others to harm them, for example,
shouting at strangers, or behaviours that make themselves
vulnerable to exploitation by others.
Let's take a look at Mr. Smith's risk history.
Mr. Smith has a history of attempted suicide in
2012 and it's frequently reported thoughts of harming himself.
He's also vulnerable to financial exploitation by gang members who live in
his block and frequently pressure him into giving them money.
He has been threatening towards others during previous psychotic episodes,
though not for many years,
and he has never intentionally harmed anyone else.
He has struggled with compliance with
his oral medications but regularly attends for his anti-psychotic injections.
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