History Taking and Psychiatric Interview

8/3/2019 History Taking and Psychiatric Interview

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HISTORY TAKING ANDPSYCHIATRIC INTERVIEW

MING,WANG YAN


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PSYCHIATRIC HISTORY I.Identifying data

II.Chief complaint III.History of present illness A.Onset B.Precipitating factors IV.Past illiness A.Psychiatric B.Medical C.Alcohol and other substance history

V.Family historyVI.Personal history(anamnesis)

A.Prenatal and perinatal

B.Early childhood(Birth through age 3)C.Middle childhood(age 3-11)D.Late childhood (puberty through adolescence)


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PSYCHIATRIC HISTORY

E.Adulthood 1.Occupational history 2.Marital and relationship history 3.Military history

4.Educational history 5.Religion 6.Social activity 7.Current Living situation 8.Legal history

F.Sexual history G.Fantasies and dreams H.Values


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Identifying DataThe identifying data provide a succinct demographic

summary of the patient by name, age, marital status, sex.occupation, language (if other than English), ethnicbackground, and religion, insofar as they are pertinent,and the patients current living circumstances.

Chief ComplaintThe chief complaint, in the patients own words, stateswhy he or she has come or been brought in for help. Itshould be recorded even if the patient is unable to speak,

and the patients explanation, regardless of how bizarreor irrelevant it is, should be recorded verbatim in thesection on the chief complaint.


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History of Present Illness

The history of present illness provides a comprehensiveand chronological picture of the events leading up to thecurrent moment in the patients life.

Knowing the previously well patients personality also

helps give perspective on the currently ill patient. The evolution of the patients symptoms should be deter

mine and summarized in an organized and systematicway .Symptom not present should also be delineated .

The more detailed the history of the present illness .Themore likely the clinician is to make an accurate diagnosis.


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Past Illness The past illness section of the psychiatric history is a

transition between the story of the present illness andthe patients personal history (also called anamnesis).Past episodes of both psychiatric and medical illness aredescribed.

Ideally, a detailed account of the patients preexistingand underlying psychological and biological substrates isgiven at this point, and important clues to, and evidenceof , vulnerable areas in the patients functioning are

provided.


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Family History

A brief statement about any psychiatric

illness, hospitalization, and treatment ofthe patients immediate family membersshould be placed in the family history partof the report.


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.Personal history(anamnesis)A.Prenatal and perinatal

The psychiatrist considers the home situation into which the patientwas born and whether the patient was planned and wanted.

B.Early childhood(Birth through age 3)The early childhood period consists of the first 3 years of thepatients life.

C.Middle childhood(age 3-11)In addressing the middle childhood, the psychiatrist focuses on suchimportant subjects as gender identification, punishments used in thehome, and the persons who provided the discipline and influencedearly conscience formation.

D.Late childhood(puberty through adolescence)During late childhood, persons begin to develop independence fromtheir parents through relationships with peers and group activities.


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E.Adulthood 1.Occupational history The psychiatrist should describe the patients choice of

occupation, the requisite training and preparation, any work-relatedconflicts, and the long-term ambitions and goals.

2.Marital and relationship history The psychiatrist elicits a history of each marriage, legal or

common law. 3.Military history The psychiatrist should inquire about the patients general

adjustment to the military, whether he or she saw combat orsustained an injury, and the nature of the discharge.

4.Educational history The psychiatrist needs to have a clear picture of the patients

educational background .


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5.Religion The psychiatrist determines the religious

background of both parents and the details of thepatients religious instruction.

6.Social activity The psychiatrist elicits information about the

patients social life and the nature of friendships, with anemphasis on the depth, duration, and quality of humanrelationships.

7.Current Living situation

Ask the patient to describe where he or she lives interms of the neighborhood and the residence as well asthe number of rooms, the number of family membersliving in the home , and the sleeping arrangements.


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8.Legal history An extensive legal history, as well as the patients attitude

toward it, may indicate antisocial trends or a litigious personality. Anextensive history of violence may alert the psychiatrist to thepotential for violence in the future.

F.Sexual history Much of the history of infantile sexuality is not recoverable,

although many patients can recall curiosities and sexual gamesplayed from the ages of 3 to 6 years. The psychiatrist should askhow the patient learned about sex and what he or she felt wereparents attitudes about sexual development.

G.Fantasies and dreams Freud stated that dreams are the royal road to the unconscious.

Repetitive dreams have particular value. H.Values The psychiatrist may inquire about the patients system of

values both social and moral including values about work,money , play, children, parents, friends, sex, community concerns,and cultural issues.


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PSYCHIATRIC INTERVIEW


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AREAS OF FOCUS IN THEPSYCHIATRIC INTERVIEW

Patients psychological makeup How the patient relates to his or her environment Significant social, religious, and cultural influences on the patients

life Conscious and unconscious motivations for the patients behavior

Patients ego strengths and weaknesses Coping strategies used by the patient Defense mechanisms that are predominant and under what

conditions Available support systems and networks for the patient Patients points of vulnerability Patients aptitude and achievement


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INITIAL STEPS OF THEPSYCHIATRIC INTERVIEW

BACK GROUND INFORMATION

Reason for call Location of patient How caller can be reached Presenting complaints Referral sources name and telephone number

Treatment history Concurrent medical conditions What patient hopes to gain Determination of urgency Primary physicians name and phone number

EXPECTATIONS

Time for assessment Cost of evaluation Purpose of assessment Psychiatrists availability for treatment


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PHASES OF THE PSYCHIATRIC INTERVIEW

(CONCLUDING)

Time remaining Important areas not covered Patients questions Sharing clinical impressions Permission to obtain records

Permission to speak with others Treatment plan and patients reaction


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Doctor-patient Relationship

A good doctor-patient relationship ischaracterized by a sense of trust, respect,and honesty between the two parties.

The better the doctor-patient relationship,the less chance for misunderstandingleading to litigation. Studies have shownthat, when a medical error or adverseevent occurs within the context of a gooddoctor-patient relationship, litigation is rare.


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Doctor-patient Relationship

In surveys of patients, almost 100 percentdesire that doctors report and discussmedical errors with them.

Acknowledging medical error, minor ormajor, may actually reduce the risk ofmalpractice action


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THANK YOU

Documents

History Taking and Psychiatric Interview