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?’

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

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)

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)

Questions box 12.10 Questions to ask the patient with possible delirium

Mental state examination (page 416) 2. Dementia (chronic brain syndrome)

Questions box 12.11 Questions to ask the patient with possible dementia

Mental state examination (page 416) OTHER DISORDERS There are a number of other psychiatric disorders which may present with physical problems, or may be seen in an emergency department with some complication (particularly after attempted suicide). A. Eating disorders (anorexia nervosa and bulimia nervosa) Here the sufferer (generally female) has a disturbed body image with an unreasonable fear of being fat, and makes extensive efforts to lose weight (strict dieting, vomiting, use of purgatives, excessive exercise). She may deny that weight or eating habits are problems. Questions box 12.12 Questions to ask the patient with a possible eating disorder

Bulimia nervosa is characterised by binge eating followed by vomiting or purging. Anorexia nervosa is characterised by excessive dieting, but there may also be binges followed by vomiting or purging. Anorexic patients will be grossly underweight and may show signs of malnutrition. Amenorrhoea is generally present.   B. Somataform disorders 1. Somatisation disorder

Questions box 12.13 Questions to ask the patient with possible somatoform disorder

2. Hypochondriacal disorder

Questions box 12.14 Questions to ask the patient with possible hypochondriacal disorder^†

3. Conversion disorder (hysteria)

Questions box 12.15 Questions to ask the patient with possible conversion disorder.

SUBSTANCE MISUSE This category includes the misuse of alcohol, illegal drugs and prescription medications. PERSONALITY DISORDERS In these disorders the individual, while not having specific symptoms, has behavioural disturbances and problems with impulse control, interpersonal relationships and mood. Individuals who repeatedly attempt suicide often have a personality disorder. They may also have stormy illnesses, causing frequent problems for staff. Questions box 12.16 Questions to ask the patient with a possible personality disorder

NEURASTHENIA (CHRONIC FATIGUE SYNDROME) This is a somewhat controversial inclusion in the current WHO classification of psychiatric disorders. PUERPERAL MENTAL DISORDERS This category includes post-partum depression and psychosis.

^* Based on the WHO International Classification of Disease 10th ed (ICD-10). ICD-II will be published in 2014.

^† Alfons Jakob (1884–1931), professor of neurology in Hamburg from 1924, had over 200 cases of neurosyphilis on his ward at a time; he died of osteomyelitis. Jakob described this cerebral atrophy in 1920 and before Hans Creutzeld (1885–1933).

TABLE 12.2 Symptoms of psychiatric illness

Affect	The observable behaviour by which a person’s internal emotional state is judged.
Agitation (psychomotor agitation)	Excessive motor activity associated with a feeling of inner tension. The activity is usually non-productive and repetitious and consists of such behaviour as pacing, fidgeting, wringing the hands, pulling the clothes and inability to sit still.
Anxiety	The apprehensive anticipation of future danger or misfortune. It is associated with feelings of tension and symptoms of autonomic arousal.
Conversion symptom (hysteria)	A loss of, or alteration in, motor or sensory function.
	Psychological factors are judged to be associated with the development of the symptom, which is not fully explained by anatomical or pathological conditions. The symptom is the result of unconscious conflict and is not feigned.
Delusion	A false unshakable idea or belief that is out of keeping with the patient’s educational, cultural and social background.
Depersonalisation	An alteration in the awareness of the self—the individual feels as if he or she is unreal.
Derealisation	An alteration in the perception or experience of the external world so that it seems unreal.
Disorientation	Confusion about the time of day, date or season (time), where one is (place) or who one is (person).
Flight of ideas	A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When severe, speech may be disorganised or incoherent.
Grandiosity	An inflated appraisal of one’s worth, power, knowledge, importance or identity. When extreme, grandiosity may be of delusional proportions.
Hallucination	A sensory perception that seems real, but occurs without external stimulation of the relevant sensory organ. The term hallucination is not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep (hypnagogic) or when awakening (hypnopompic).
Ideas of reference	The feeling that casual incidents and external events have a particular significance and unusual meaning that is specific to the person.
Illusion	A misperception or misinterpretation of a real external stimulus.
Mood	A pervasive and sustained emotion that colours the perception of the world.
Overvalued idea	An unreasonable belief that is held, but not as strongly as a delusion (i.e. the person is able to acknowledge the possibility that the belief may not be true). The belief is not one that is ordinarily accepted by other members of the person’s culture or subculture.
Personality	Enduring patterns of perceiving, relating to, and thinking about the environment and oneself.
Phobia	A persistent irrational fear of a specific object, activity or situation (the phobic stimulus) that results in a compelling desire to avoid it.
Pressured speech	Speech that is increased in amount, accelerated, and difficult or impossible to interrupt. Usually it is also loud and emphatic. Frequently the person talks without any social stimulation and may continue to talk even though no one is listening.
Psychomotor retardation	Visible generalised slowing of movements and speech.
Psychotic	Psychotic can be used to mean a loss of contact with reality, but is generally used to imply the presence of delusions or hallucinations.

Based on DSM-IV, APA 1994.²

2. Precipitating events

Psychiatric illness rarely occurs for no reason and there is generally an event that has precipitated the illness. Such events include a range of experiences which may have affected the patient, or a member of the patient’s social network. Events such as physical illness, drug treatment or treatment non-compliance may be implicated as precipitants. The last-mentioned is important, as patients with psychiatric illness are often non-compliant, a major contribution to relapse.

3. Risk

An assessment of the patient’s risk of harm, either to others or to him- or herself, is essential: this will indicate whether the patient needs to be treated involuntarily. Patients with psychotic illness may, in some circumstances, need to be treated involuntarily under the Mental Health Act. While the exact details for involuntary treatment are different under individual mental health acts, the essential features are generally that: (a) a person has a mental illness; and (b) the person is a danger to self or to others. Assessment of danger to others is difficult, with the best predictor being a history of past threat or harm to others. It is best to err on the side of caution in such cases. Assessment of suicide risk needs to be made with sensitivity and using a direct approach, as shown in Table 12.3.

TABLE 12.3 Assessment of suicide risk

Suicide may be the unfortunate outcome of psychiatric illness but loss of job, family disruption, alcoholism and self-mutilation can also be the distressing result. Assessing the risk of suicide is an essential part of the psychiatric interview. Asking about this does not increase the risk or put the idea into the patient’s head. It may reduce the risk, as the patient may feel relief in talking about his or her fears. The risk of suicide is assessed by asking directly whether the person has ever contemplated it.

Have you thought that life was not worth living?

Or

Have you felt so bad that you have considered ending it all?

If ‘yes’…

Have you thought of killing yourself?

Have you thought how you might do this?

Have you made any plans for doing this?

The past history and treatment history

Both the past psychiatric and medical history should be assessed. The past medical history should be evaluated in the same way as the general medical history. An assessment should be made of stresses that may have contributed to past episodes of illness, and that may have led to relapse. For the past psychiatric history, it is important to obtain not only the diagnosis but also the treatment the patient has had, and its outcome.

Ask about previous non-drug treatment including counselling, psychotherapy and electroconvulsive therapy (ECT), and whether the patient thought the treatment was effective. Was the patient ever admitted to a psychiatric unit, and for how long?

Find out what drug treatment has been tried—the class (Table 12.4) of psychiatric medication, its effectiveness and any side-effects. The antipsychotic drugs in particular have common long term side-effects (Table 12.5).

TABLE 12.4 Classes of psychiatric drugs and their major indications

1 Anti-anxiety e.g. benzodiazepines, beta-blockers (control somatic symptoms)	For anxiety disorders, insomnia, alcohol withdrawal
2 Antipsychotic e.g. phenothiazine, major tranquillisers	For schizophrenia, mania, delirium
3 Antidepressants e.g. tricyclics, selective serotonin reuptake inhibitors (SSRIs)	For depression, obsessive-compulsive disorder
4 Mood-stabilising e.g. lithium, carbamazepine	For prevention of manic depression or treatment of mania

TABLE 12.5 Common side effects of the antipsychotic drugs

1 Anti-cholinergic—dry mouth, blurred vision, urinary retention, erectile dysfunction

2 Hypersensitivity reactions—photosensitivity dermatitis, cholestatic jaundice, neutrophilia (clozapine)

3 Effects due to dopamine blockade—Parkinsonianism, motor restlessness (akathisia), tardive dyskinesia, dystonia, gynaecomastia, malignant neuroleptic syndrome

The family history

There is a familial component in many psychiatric disorders. Two aspects must be assessed in the family history.

First, the patient should be asked tactfully if anyone in the family has had any psychiatric or mental illness or has committed suicide. He or she should also be asked if anyone in the family has had any treatment for psychological problems, such as anxiety, depression, agoraphobia,^a eating disorders or drug and alcohol problems (these last few areas are often not considered by patients to be psychiatric or mental illnesses).

Second, one should try to determine what sort of family the patient grew up in. Drawing up a family tree is a useful way of finding this out. Factual details about each family member can be included in this family tree (age, mental state, health). In the psychiatric history we also need to know about what type of person each family member is, and how family members get on with each other. It is worth exploring how much care (or neglect) the patient received from each parent, and how controlling or protective each was. These two factors have been shown to be important in contributing to psychiatric illness. One needs to ask about the quality of the parental relationship and the general family atmosphere.

Childhood abuse (physical or sexual)³ may be an important predisposing event for many illnesses, and should be inquired about. This can be elicited by saying something like ‘Sometimes children can have had some unpleasant experiences—I wonder if you had any? Did anyone ever harm you? … or hit you? … How about interfering with you sexually? … Could you tell me more about that and what happened?’

Taking a detailed family history in this way sets the scene for the patient’s developmental history, which should be taken next.

The social and personal history

Open-ended questions are again the best way to obtain the personal and social history. Ask the patient something like ‘Could you tell me a bit about your background, your development, what sort of childhood you had, what are the important things you remember from your childhood?’, and then allow the patient to tell his or her own story. During the course of this narrative, the patient may require some prompting to add information about important issues such as the birth history (schizophrenia is known to be associated with perinatal morbidity) and early development, and whether there were significant problems in early childhood, such as head injuries or serious infections. How did the patient cope with early separations, particularly when starting primary school and going on to secondary school (difficulty in separation may be a risk factor for panic disorder or abnormal illness behaviour). The patient should be asked about peer relationships, friendships, school, academic ability, adolescence and teenage relationships. The adult history should focus predominantly on the quality of intimate relationships and the social support network, especially whether there are people in whom the patient can confide.

The patient’s living circumstances should be asked about in the same way as for a medical history. There should also be a focus on the patient’s occupation: not only on the type of job but also on how he or she copes with work or, if he or she does not work, how that is coped with.

The mental state examination

While assessing the patient, one should carefully make observations about appearance, behaviour, patterns of speech, attitude to the examiner and ways of interacting. These observations are brought together in a systematic fashion in the mental state examination. This is not something that is ‘done’ at the conclusion of taking a history; it is an essential part of the total process of assessing the patient.⁴

However, there are a number of tests that need to be conducted in a formalised way as part of the mental state examination. These include assessing the cognitive state (orientation, memory, attention, registration) and inquiring about perceptual disturbances and, in some cases, disorders of thought. The mental state examination provides valuable diagnostic information; with some disorders, it is this examination which gives most of the diagnostic clues.

The headings under which the mental state is recorded are shown in Table 12.6, together with some simple bedside tests for assessing cognitive function. Also shown in Table 12.6 are some abnormal features of the mental state examination that are commonly found in psychiatric disorders.

When cognitive dysfunction is suspected, as in patients with dementia,⁵ a more detailed examination of cognitive function should be carried out. A widely used tool for doing this is the mini-mental state examination,⁶ which assesses aspects of orientation, memory and concentration. Details of this examination are shown in Table 12.7. Some of the common causes of delirium and dementia are listed in Tables 12.8 and 12.9.

TABLE 12.8 Common causes of delirium

Drug intoxication	Alcohol
	Anxiolytics
	Digoxin
	L-dopa
	‘Street drugs’
Withdrawal states	Alcohol (delirium tremens)
	Anxiolytic sedatives
Metabolic disturbance	Uraemia
	Liver failure
	Anoxia
	Cardiac failure
	Electrolyte imbalance
	Postoperative states
Endocrine disturbance	Diabetic ketosis
	Hypoglycaemia
Systemic infections	Pneumonia
	Urinary tract infection
	Septicaemia
	Viral infections
Intracranial infection	Encephalitis
	Meningitis
Other intracranial causes	Space-occupying lesions
	Raised intracranial pressure
Head injury	Subdural haemorrhage
	Cerebral contusion
	Concussion
Nutritional and vitamin deficiency	Thiamine (Wernicke’ encephalopathy)
	Vitamin B12
	Nicotinic acid
Epilepsy	Status epilepticus
	Post-ictal states

TABLE 12.9 Common causes of dementia

Degenerative type	Senile dementia of Alzheimer’s
	Front temporal dementia*
	Huntington’s chorea
	Parkinson’s disease
	Normal-pressure hydrocephalus
	Multiple sclerosis
Hereditable Alzheimer’	Mutation of presenilin-1
Intracranial space-occupying lesions	Tumour
	Subdural haematomas
Traumatic	Head injuries
	Boxing encephalopathy
Infections and related conditions	Encephalitis
	Neurosyphilis
	HIV (AIDS dementia)
	Jacob-Creutzfeldt disease
Vascular	Multi-infarct dementia
	Carotid artery occlusion
Metabolic	Uraemia
	Hepatic failure
Toxic	Alcoholic dementia
	Heavy-metal poisoning
Anoxia	Anaemia
	Carbon monoxide poisoning
	Cardiac arrest
	Chronic respiratory failure
Vitamin deficiency	Vitamin B12
	Folic acid
	Thiamine (Wernicke–Korsakoff’s syndrome)
Endocrine	Myxoedema
	Addison’s disease

^* Slowing of thought, relative sensory presentation.

The diagnosis

At the conclusion of the psychiatric history, which should include a general physical examination, a provisional diagnosis and formulation should be made. Essentially, the diagnostic formulation is a means of pulling together, in a succinct yet comprehensive manner, your understanding of the patient’s problem.

Psychiatric disorders generally arise through a combination of biological, psychological and psychosocial factors, and each of these needs to be considered when a patient’s problem is being assessed (a biopsychosocial approach). The patient’s problem needs to be understood longitudinally, by defining biophysical factors that may have predisposed to the illness and, more immediately, may have precipitated the illness, and factors that may be contributing to the person remaining ill (perpetuating factors). A simple grid can be used for assessing the patient in this manner (Table 12.10). Here biological, psychological or psychosocial factors that predispose to, precipitate or perpetuate the psychiatric illness are identified. Perpetuating factors are very important, particularly among medically ill patients, as it may be the medical or physical illness that maintains the patient’s psychiatric problem. By the same token, psychological factors may perpetuate a patient’s medical illness.

An example of such a formulation grid is shown in Table 12.11 for a 53-year-old man who becomes depressed after a myocardial infarction. He has a family history of depression (a genetic predisposing factor) and chronic low self-esteem (a psychological predisposing factor), which he coped with by succeeding in business. He has few friends and his marriage is unsatisfactory (a psychosocial factor). He had his infarct one week after he heard that he would not be promoted at work (a psychological factor) and his job was at risk (a psychosocial precipitant). His insecurity about work and his failing marriage, together with his low self-esteem, is maintaining his illness, as are the biological changes to the neurotransmitter system.

Understanding the patient in this manner helps one to plan an effective management approach that will focus on all the relevant factors, so that, for the patient in this example, a combination of antidepressants, marital counselling and assertiveness training (to build self-esteem) can be organised.

A good psychiatric history will provide a comprehensive understanding of the patient and will permit appropriate management to be planned. This is immensely rewarding for the clinician, and will also be of considerable benefit to the patient.