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Psychiatric History-taking
- 1. History Taking –Psychiatric aspects Dr Bhakti Murkey Consulting Psychiatrist (MD)
- 2. Psychiatry – branchof Medicine Biological basis: Neuro-anatomy Neuro-physiology Genetics Neuro-chemical messenger (monoamide) hypothesis Medical Model: Traditional way of thinking about ‘disease’ Extended to diseases of the mind (thoughts, feelings and behaviors) Dramatic response to Rx modalities
- 3. Psychiatric History-taking Medicalprocess Systematic record of data received during interview An account of significant events Compilation and analysis of patient experience Goal: to achieve a succinct summary of relevant information Standardized format: facilitates communication with other professionals Most important diagnostic tool in mental health Elements of subjectivity
- 4. Qualities of atherapist Non-judgemental attitude Warmth and Empathy Communication skills Interpersonal soft skills Patient and active listening Honesty Flexibility Optimism Building trust Allowing patient participation Sensitive (language, culture, sexuality) Scientific approach Ability to say no/ draw boundaries Adequate subject knowledge
- 5. Goals of historytaking Establish Rapport Communicating about confidentiality and professional ethics Collect accurate information about patient’s problems Meaningful interpretations of patient’s version Rule out presence of physical symptoms distinctly from psychological Holistic assessment of person’s psyche and health Being able to formulate a treatment plan Comprehensive documentation and record keeping of the history for future reference or external communication
- 6. Informant Assess Reliability: Age Education Relationship Living with? Intent for the patient Any personal gains? Consistency over time/ multiple interviews
- 7. Outline Demography Identification Presenting complaints Onset and course of illness Negative History Medical/Surgical History Functioning Treatment History Past History Family History Childhood History Perinatal Schooling Socio-economic History Occupational History Religious beliefs Psychosexual History Premorbid Personality
- 8. Demographic Details Name Age Sex Address Occupation Marital status Identification marks Type of admission (if IPD) Significance: Medico-legal cases Avoid inter-change of information in similar cases Communicating on community level Making Rx plan based on background/ practical aspects Research purpose
- 9. Presenting complaints Totalduration of illness Chronological order of symptoms Duration of each symptom When too many? Pick top 5 Make symptom clusters Elaborate each symptom: onset, severity and course Story of illness progression Patient’s narration vs clinical interpretation
- 10. Axis 1 disorders Multi-axial clinical diagnosis: ICD vs DSM How to rule out major Psychiatric diagnoses: Depression Mood Disorder Psychosis SUD OCD Anxiety spectrum
- 11. Medical co-morbidity Organicity Major medical illness: Hypertension Diabetes Tuberculosis Asthma Thyroid Disorders B12 deficiency Any surgical illness/ intervention
- 16. Family History Pedigree Birth order Nuclear vs Joint F/H Psychiatric illness F/H Medical illness/ complications Home environment and relations Support system H/O active stressors
- 17. Childhood Psychiatric Disorders Axial Classification: Axis I – Clinical Diagnosis Axis II – Specific Learning Disability Axis III – General Learning Difficulties Axis IV – Medical Diagnosis Axis V – Psychosocial & Environmental stressors Assess Parenting style Rule out: Autism ADHD Temper tantrums Eating or Feeding problems Emotional issues CSA Academic/ learning problems (SpLD)
- 18. Pre-morbid Personality AxisII presentation Reflection on Axis I Proportion of symptoms expected to respond Managing psycho-social impact and interpersonal relations Prognostic implications (recurrence) Assessment of: Temperament Lifestyle Impulsivity Social interaction Significant others Friendships Emotional communication Habits/ Hobbies Anger management Coping skills Perception of patient’s personality by family/ friends
- 19. Diagnostic Case Formulation Diagnosis alone tells us little about causation of disorder Formulation: Understanding etiological factors Identifying key difficulties in order to guide intervention accordingly Anticipating challenges that may occur during the course of treatment 5 P approach: Presenting problem Predisposing Factor Precipitating Factor Perpetuating Factor Protective Factor
- 20. Diagnostic Case Formulation Summary: Concise description of important aspects Formulation: Comprehensive assessment of the case rather than mere restatement of facts Case formulation: Integrative process Synthesizes how one understands the complex, interacting factors implicated in development of a patient’s presenting problems Discussion on etiology, differentials, prognosis Takes into account the person’s strengths and capacities Helps to identify potentially effective treatment approaches Types: Clinical Diagnostic Psychodynamic Psychotherapeutic Bio-psycho-social
- 21. Diagnostic Classification Normal Abnormal: Organic Functional: Neurosis: Anxiety/ Depression/ Phobia/ OCD Psychosis: Schizophrenia/ Bipolar Disorder/ Delusional Disorder Mixed: Substance Use/ Personality Disorder
- 22. Treatment plan Medicalmanagement: Axis I and IV Intensity, frequency and duration of symptoms Functional impairment Poor sleep/ appetite/ quality of life Psychotherapy: Axis II and III Supportive/ Interventional Make Rx response sustainable Psychosocial management: Axis III Correction of social aspects Vocational aspects Skills building Enhanced self-efficacy Involving significant others
- 23. Take away points Medical model of Psychiatry Significance of History taking Reference to Physical health parameters Assessment of Personality Case Formulation Therapeutic Interventions Holistic health care
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