Psychiatric History

Psychiatric History •is the record of the patient’s life that allows the psychiatrist to understand who the patient is, where the patient has come from, and where the patient is likely to go in the future. •to gather the concrete and factual data related to the chronology of symptom formation, psychiatric and medical history •it provides insight to the nature of the relationships with those closest to the patients and includes all the important people in their past and present lives. •the patient’s life is told tot he psychiatrist in the patient’s own words from his or her own point of view.

Identifying Data Chief Complaint • states why the patient has come or been brought in for help, and should be recorded verbatim. • If the patient is unable to speak, a person who is close to him is being interviewed and a description of the person who provided the information should be included

History of Present Illness • provides comprehensive and chronological picture of the events leading up to the current moment in the patient’s life • helpful in making diagnosis • knowing what the personality was of the previously well patient also helps give perspective on the currently ill patient • the more detailed the history of the present illness, the more likely the clinician is to make an accurate diagnosis. • If there is relation between physical and psychological symptoms, it should be noted

Previous Illness • a transition between the story of the present illness and patient’s personal history • past episodes of both psychiatric and medical illnesses are described • psychiatrist should obtain a medical review of symptoms and note any major medical or surgical illnesses and major traumas • causes, complications, and treatment of any illness and the effect of illness on the patient should be noted • questions about psychosomatic disorders should be asked and noted

Personal History: Prenatal & Perinatal History • • • • •

Nature of the home situation Problems with pregnancy & delivery Mother’s physical & emotional state Evidence of defects or injuries Maternal health problems during pregnancy

Early Childhood (birth through 3 y.o.) • • • • • • • • •

Quality of mother-child interaction Early disturbances in sleep patterns & unmet needs History of human constancy Parental psychiatric or medical illness Play behavior Feeding habits, Toilet training Symptoms of behavior problems Personality as a child Early or recurrent dreams or fantasies

Middle Childhood (3 to 11 y.o.) • • • • • •

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Gender identification Punishment, discipline, conscience formation Early school experiences, learning experiences, disabilities Earliest friendships & personal relationships Social behavior patterns Other significant behavior

Late Childhood (puberty through adolescence) Values of patient’s social groups Identify patient’s idealized figures Social relationships School history Cognitive & motor development Emotional & Physical Problems Sexuality

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Adulthood

Occupational history Marital & Relationship history Military History Educational History Religion Social Activity Current Living Situation Legal History

Psychosexual History • • • • • • • • •

Infantile sexuality: curiosities & sexual games played (3 to 6 y.o.) Parental attitudes about sexual development Sexual abuse Adolescent sexuality Sexual activity Attitudes toward sex Sexual orientation Sexual functioning, symptoms, sexually-transmitted diseases Sexual adjustment

Family History • Psychiatric illnesses, hospitalizations, treatments of immediate family • Family history of alcohol or substance abuse or of anti-social behavior • Intelligence & personalities of people living at home – Role in patient’s upbringing & current relationship with patient

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Family’s ethnic, national & religious traditions Family’s attitude & insight into the patient’s illness Role of illness in the family Patient’s attitudes toward parents & siblings Patient’s role in the family

Dreams, Fantasies, and Values

Manifest details & attendant feelings Repetitive themes Possible meanings Nightmares Fantasies & daydreams Patient’s system of social & moral values

– Concerning work, money, play, children, parents, friends, sex, community concerns, cultural issues