Clinical History

By London Deanery | August 23, 2018

This section only contains some brief notes that may help you take a psychiatric history. To develop your history taking skills beyond competency will require further self- directed learning, practice and supervision.

This assessment will look at your ability to gather relevant information from a patient presenting with a common psychiatric disorder. You will not be expected to demonstrate a sophisticated clinical interview but be able to sensibly collect information on the relevant areas to allow for an accurate clinical picture of the patient’s presentation.
You will be asked to take a history from a patient. You may be assessed by interviewing a patient or alternatively you may be assessed by role-play with your trainer.

You may want to include questioning in the following main areas:

History Structure:

  • Name, age, occupation
  • The presenting complaint/reason for referral
  • The history of the presenting complaint
  • Family history
  • Personal and developmental history including social history
  • Psychiatric history
  • Medical history
  • Drug and alcohol history
  • Forensic history
  • Brief assessment of personality

Don’t forget to:

  • Introduce yourself and explain the purpose of the interview
  • Bear in mind partners, carers and dependents of the patient
  • Have empathy with the patient

Resources:

A suggested scheme for taking a comprehensive psychiatric history is given to highlight key important areas of questioning to consider. You will not need to ask all the questions covered but should be able to demonstrate that you have covered the main relevant areas.

Remember a full psychiatric assessment requires a full history and a full mental state examination. Although some of the questions may overlap, generally the history aims to find out what has been going on recently (leading up to this point), while the mental state examination aims to assess the patient’s mood, thoughts etc. at the time of assessment. When eliciting a psychiatric history, try and understand the narrative of the patient rather than compartmentalizing the interview.

1. REFERRAL AND INFORMANTS

Prior to starting the interview, consider the following:

  • The patient’s details and demographics.
  • When and where your patient is being seen? (e.g. on the ward, in A & E or in Section 136 suite)
  • Legal status of patient: voluntary or detained.
  • Why are they being seen?
  • Who was history taken from: patient or carer?

2. Introduction

As with any clinical assessment you must start with an introduction. You may want to include the following:

  • Who you are and the purpose of the interview
  • How long you have to interview the patient.
  • Consent, confidentiality and permission to take notes.
  • Ask about demographics, name, date of birth, occupation and marital status.
  • Other information regarding ethnicity, culture and language.

3. PRESENTING COMPLAINT

Ask the patient to tell you in their own words, what the chief complaints are by the client as you would in any clinical history before commencing the history of presenting complaint.

4. HISTORY OF PRESENTING COMPLAINT

You now want to find out more about the symptoms including:

  • Duration and mode of onset.
  • Time relations between symptoms and any physical disorder or psychological or social problems.
  • Nature and duration of any difficulty.
  • Any treatment received.

You may find it useful to use SOCRATES - The mnemonic for taking a history of a pain: Site (where/when the problems cause most difficulty), Onset (when it started) Character, Radiation (e.g. what other areas of life are impacted), Alleviating factors, Time course (e.g. pervasive, episodic), Exacerbating and precipitating factors, Severity.

Use open and closed questions to clarify further then vary depending on the specific problem that the patient has presented with:

a. DEPRESSION

Treat feelings of low mood in the same way you would treat pain, find out everything about the depression before moving on to ask about other features/associated symptoms.

How has mood been? How long has mood been low for? Is mood always low? Is it worse in the mornings? (Diurnal variation in mood where mood is worse in the morning is a sign of more severe depression). Can you do anything to lift your mood? Do you ever look forward to anything? Are you ever tearful? Do you ever feel guilty, worthless or hopeless? Do you ever self- harm? Have you ever thought of ending it all? If yes, have you made plans to end it all (or kill yourself)?

Ask about associated symptoms: Is the patient experiencing other physical symptoms? Is appetite reduced? Any weight loss? Lack of motivation? Any sleep changes (trouble getting to sleep can be a sign of depression, or is there early morning waking - a sign of more severe depression)? Any other physical symptoms: lethargy, aches and pains? Has sex drive/libido changed? Has concentration waned? Have these symptoms caused problems at work or at home?

If your patient is presenting with self- harm e.g. an overdose or other suicidal behaviour, be sure to get full history of the self-harm (see risk assessment: competency 4)

b. PSYCHOSIS:

It may be difficult to work out what symptoms a patient with psychosis is experiencing as they are unlikely to tell you they are suffering from delusions etc. Some questions you could ask include:

  • Have you had any unusual thoughts recently or have others commented on you being strange/different?
  • Do you feel like any individual or group are against you?
  • Are your thoughts in your head your own? Are the thoughts clear?
  • Have people been interfering with your thoughts: putting thoughts into your head (thought insertion) or are your thoughts being withdrawn (thought deletion/removal) or broadcast.
  • Do you ever see or hear things that other people seem unable to see or hear? (e.g. auditory hallucinations). If yes, are the voices talking about you (third person) or to you (second person); are they commenting on what you are doing (running commentary) or are they telling you to do certain things (command), if so what? Do the voices ever tell you to do things you don’t want do?
  • Do you believe the voices and do you do what they tell you to do? Try to get an idea of how long these problems have been going on and how they have changed over time and what the patient’s understanding of the experience is.

When screening for schizophrenia ask about Schneider’s first-rank symptoms of schizophrenia symptoms. These symptoms, if present, are strongly suggestive of schizophrenia. These include:

  • Auditory hallucinations:
    • hearing thoughts spoken aloud
    • hearing voices referring to himself / herself, made in the third person
    • auditory hallucinations in the form of a commentary
  • Thought withdrawal, insertion and interruption
  • Thought broadcasting
  • Somatic hallucinations
  • Delusional perception
  • Feelings or actions experienced as made or influenced by external agents

c. ANXIETY

Depending on the presenting complaint you may want to ask about the following: * Generalised anxiety; general feelings of anxiousness, feeling on edge, worry, irritable, unable to relax. * Panic attacks; hyperventilation, breathlessness, chest pain/ palpitations, sweating, tremor. Ask how long do attacks last and what brings them on. * Phobias; any fears that may be considered to be excessive. * Obsessions and Compulsions I MPORTANT TO ASK WITH ALL PATIENTS: * What does patient think the cause is? * Are there any recent events that have precipitated the presenting complaint? These events may be negative (separation, death in family) or may appear positive (promotion at work but has led to increased stress). * What is the present social situation and what is the impact of the illness on their life?

5 . FAMILY MEDICAL AND PSYCHIATRIC HISTORY

You may want to draw a genogram.

Genogram

  • Is there a family history of psychiatric or relevant medical illnesses?
  • You may wish to specifically enquire about neurological disorders, dementia, suicides, criminal behaviour or alcoholism?
  • What is the family structure and relationships? Identify carers and dependents also.

6. PERSONAL HISTORY

Here you want to collect information about the patient from birth to present day. Some areas that you may want to include are:

  • Pregnancy and birth of the patient
  • Developmental history e.g. milestones and delay in motor, verbal, toileting and social domains
  • Childhood trauma e.g. separation from parents, abuse
  • Schooling and further training e.g. relationships at school, bullying (either victim or perpetrator), academic achievement
  • Occupational history
  • Sexual History including menstrual history
  • Relationship history and children
  • Current social circumstances: accommodation, benefits, finances

7. PSYCHIATRIC HISTORY

You may want to include the following:

  • All psychiatric history including past contact with psychiatric or mental health services.
  • Dates, diagnosis, treatment, duration, legal status of any admissions
  • Always ask about a history of self- harm or suicide attempts.
  • What has triggered problems/relapses in the past?

8. MEDICAL HISTORY

As with any clinical history take a full medical and surgical history.

Due to related psychiatric co- morbidity you may want to specifically ask about:

  • Head injury
  • Meningitis /encephalitis
  • Epilepsy
  • Developmental problems

9. MEDICATION / TREATMENT HISTORY

You may want to ask about all current medications, prescribed, over the counter and street drugs. It may be relevant to enquire about:

  • Treatments that have been already tried/used in the past and did they work?
  • Does the patient have any problems with any medications, do any medications have any side effects, does patient find it easy to comply with treatment, what are the patient’s thoughts towards treatments e.g. do they feel they need medication?

Do not forget PERSONALITY, FORENSIC and DRUG History

10. DRUG & ALCOHOL HISTORY 11. FORENSIC HISTORY 12. PERSONALITY
How much? How often? What types of drink/drugs? Any withdrawal symptoms? Remember the mnemonic CAGE and screen for dependency? Questions about arrests, convictions and imprisonments.The nature of offences and their dangerousness should be clarified. An assessment of personality may include questions on relationships, friendships, leisure activities, prevailing mood, character, attitudes and habits including drugs and alcohol.

Form to sign off the Competency

Note: You can either fill this PDF form on a computer (preferably together with your assessor) and print it out for the assessor to sign, or you can just print the page and fill it out by hand together with the assessor. In any case after the form is signed, you will need to scan it to upload to your portfolio, just like you would with any paper-based evidence form. If you fill the form on your computer you need to SAVE it with a different name - so that the text you typed into the form gets preserved. A form filled on a computer probably, will be easier to read.

If the form opens directly in your browser you probably will not be able to type in the form fields - for that you need to open the form with your system PDF viewer - which likely will be Adobe Reader.

comments powered by Disqus