Rural Emergency Medicine

A good history is a fundamental part of any diagnosis. There are some areas like Psychiatry however, where taking a good and thorough history can be more of a challenge for a medical student. The purpose of taking a Psychiatric History can split into three main things;
  • Diagnostic
  • To gain a biopsychosocial understanding of the patient’s problem
  • Therapeutic & psycho-educational
Although while taking a history the structure may appear disjointed, the end result is usually under a set of headings which have a worldwide similarity.

The basic components of a Psychiatric History that I'll use here are;
  • Identification
  • History of Presenting Complaint
  • Systems Review
  • Past Psychiatric History
  • Past Medical History
  • Family History
  • Personal History
    • Childhood 
    • Occupational
    • Psycho-sexual
    • Drug & Alcohol
    • Forensic
  • Pre-morbid Personality

The key to psychiatric assessment is a comprehensive history & mental state examination.
A Primer of Clinical Psychiatry.

Please note this guide does not include everything that you should ask in a  Psychiatric History, but rather some components that I feel are key. It is also assumed that you are familiar with taking history's in general, and this post just highlights the salient features of a Psychiatric History. A typical psychiatric interview can take 40 minutes or more.

Name, age, occupation, marital status, etc
Refereral: By Who, Why, When

HPC - History of Presenting Complaint
(in patients own words – including duration)
  • How are you? How long have you been here? 
  • Why are you here? Why did you seek help?
  • Current Symptoms: onset, stressors, duration & course
  • Sleep: currently, changes over time?
  • Appetite: normal / increased / decreased?
  • Memory & concentration changes?
  • Current Mood: 
    • Rate from 1-10. 
    • Classify: Anxious? Depressed? Obsessional? Psychotic?
  • Screen for relevant events: e.g. recent death of a loved one, back from a war, etc
  • Details of any help-seeking behaviour.

SR – Other Psychiatric Symptoms
Much like doing a Systems Review for organic causes of disease, it is important to go through a check-list of other Psychiatric Symptoms, noting the positive & negative findings.

For example, a patient with an exacerbation of psychotic symptoms could also have depression in conjunction, and possibly suicidal ideologies. 

It can also be useful to ask your standard Systems Review questions to rule out any organic causes of the patient’s presentation.

PΨHx - Past Psychiatric History
Full details are required of past psychiatric illnesses (e.g. depression, anxiety, etc)
Things to particularly ask about;
  • Admissions: How many? What for? How long?
  • Self-harm/Suicide attempts
  • Treatments: medication, psychotherapy, etc
  • Adverse reactions or events due to treatments
  • Support:  regular GP/Psychologist

PMHx – Past Medical History
Past medical history is useful to ascertain the general health of the patient. In particular, chronic medical conditions can often cause a decrease in the quality of life for that individual, which can manifest as psychiatric symptoms. Other points of interest;
  • Hospitalisations
  • Surgeries
  • Allergies, medication sensitivities and current medication (note those with psychiatric side-effects)

FHx – Family History
Many psychiatric disorders have a genetic component and the biological family history is thus relevant. It can also be useful in guiding treatment and management. It can be useful to draw a genogram with the patient.

Collecting information from other family members can sometimes allow you to develop a clearer picture.

Personal History
When taking a personal history it helps to map out the patient’s life in a longitudinal manner.

Childhood: Birth, development (e.g. motor, verbal & social milestones), family atmosphere? Happy or Sad childhood?

School: Enjoyed? Got on well with others? Other schooling? Truancy? Academic/sporting endeavours?
 Drug & alcohol use during these years?

Occupation: Level of education completed? Jobs? How long? Why did they leave? Unemployment?

Psychosexual: Puberty (attitude towards & onset)? Sexual orientation? First experience? Relationships (past & current)? Marriage? Pregnancies?

It is also important to get a good grasp of the individual’s current life situation.

Drug & Alcohol History
Although Drug and Alcohol history can be considered part of Personal History, it requires special consideration as patients will often avoid discussing this topic. It is important to ask about alcohol, tobacco and common recreational drugs (e.g. marijuana).

Investigate: first exposure, patterns of use, effects, withdrawal symptoms, impacts on life, failed treatments or quitting attempts.

A common non-threatening screening tool for assessing alcohol abuse is the CAGE Questionnaire. It can also be adapted for other drugs.

Two "yes" responses indicate that the respondent should be investigated further. The questionnaire asks the following questions:
  • Have you ever felt you needed to Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt Guilty about drinking?
  • Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Forensic History 
Forensic history should be obtained in a non-threatening way (e.g. have you ever been in trouble with the law?). A history of any misdemeanours and any consequences (e.g. prison) should be attained.

Premorbid Personality
Premorbid Personality may assist in diagnostic clarification and provides insight into what strengths/reserves the person may have. A good lead into this is, “What sort of person were you before you developed X?” 

Other aspects to investigate:
  • Attitudes to others (social, family, etc) and to self.
  • Predominant mood
  • Hobbies & interests
  • Reactions to stress
  • A Primer of Clinical Psychiartry (2010) by David Castle & Darryl Bassett 
  • Oxford handbook of Psychiatry (2005) by David Semple, Roger Smyth & Jonathan Burns 
  • Ewing, John A. "Detecting Alcoholism: The CAGE Questionnaire" JAMA 252: 1905-1907, 1984

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