THE PSYCHIATRIC MEDICAL HISTORY

Prof. Paz

García-Portilla

MEDICAL HISTORY (HX)

• Clinical data set gained by a physician by asking specific questions to the patient (or proxy), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient

MEDICAL HISTORY

• The information obtained in this way, together with the physical examination and additional evaluations, if needed, enables the physician to form a diagnosis, prognosis, and treatment plan

• Clinical reasoning based on facts elicited from symptoms and signs in the history-taking and examination has to be tested against basic scientific background and knowledge acquired during medical training

PSYCHIATRIC MEDICAL HISTORY

• A psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

• Mainly symptoms-based

HISTORY-TAKING IN PSYCHIATRY

• Based in the clinical interview

1. Initiation of a therapeutic alliance

2. Diagnotic data collection

3. Understand the views of the patients

4. Share the information

5. Reach agreements

6. Close the interview

HISTORY-TAKING PROCESS: 2. DIAGNOSTICDATA COLLECTION

• Identification and demographics of the patient

• Chief complaint (CC)

• History of the present complaint (HPC)

• Somatic history

• Substance use history

• Previous psychiatric history

• Family psychiatric history

HISTORY-TAKING PROCESS: 2. DIAGNOSTICDATA COLLECTION

• Psychopathological examination

Systematic questioning about the symptoms of the

psychiatric conditions

Observed behavior

Cognitive abilities

Inner experiences

COMPONENTS OF THE PSYCHOPATHOLOGICALEXAMINATION

• ABC STAMP LICKER

Appearance

Behavior

Cooperation

Speech

Thought – Form & Content

Anxiety

Mood

Perception

• ABC STAMP LICKER

Level of consciousness

Insight

Cognitive functioning

Orientation

Memory

Attention & Concentration

Abstract thinking

PsyKophisiology

Endings – suicidal or homicidal ideation

Reliability of informationModified from: Robinson DJ. Brain Calipers. 1997

ABC

• Appearance

• Behavior

Psychomotor

Restlesness

Agitation

Inhibition

Repetitive behaviors

Extrapiramidal Sx (EPS)

Social

……….

• Cooperation with the interview

STAMP

• Speech

Amount

Increased: loquacious, talkative, logorrhea, pressureof speech, …

Decreased: paucity of speech, impoverished, laconic, minimally responsive, mutism, …

Prosody (nonverbal communication)

Intonation, spontaneity/latency, rhythm, inflection

Mutism Pressure

of speech

STAMP

•Thought

Form: circumstantiality1, tangentiality2, flight of ideas3, loose associations4, thought derailment5 / blocking6, word salad7, incoherence, …..

1

2

35

4

6

7

STAMP

• Thought

Content: overvalued ideas, delusions, obsessions, homicidal / suicidal ideas

STAMP

• Anxiety

Psychic: anticipatory worry

Physical

• Mood

Depressed

Disphoric

Irritable

Manic / hipomanic

STAMP

• Perception

Hallucinations

Ilusions

Disturbances of self and environment

Depersonalization

Desrealization

LICKER

• Level of consciousness

• Insight

• Cognitive functioning

Orientation

Memory

Attention & Concentration

Abstract thinking

? ?

LICKER

• PsyKophysiology

Sleep-Wake

Feeding and eating

Sexual functioning

Gender identity

LICKER

• Endings – suicidal or homicidal ideation

• Reliability of information

?

• Demographics

• Medical Hx

• Psychiatric Hx

• Family psychiatric

Hx

• Psysical

examination

• Additional

investigations

(if needed)

Psychopathological

examination

DiagnosisProvisional + Differential dx

Treatment plan

Prognosis

• Additional investigations

Vital signs and Anthropometry

Lab analysis

EEG, EKG

Neuroimaging: CT scan, MRI, PET, SPECT

Psychometric evaluation

HISTORY-TAKING PROCESS: 3. UNDERSTANDTHE VIEWS OF THE PATIENTS

• Determine, acknowledge and appropriately explore

the patient’s

Ideas and concerns

Expectations

How each problem affects the patient’s life

• Encourage expression of the patient’s feelings

CLINICAL INTERVIEW: BASIC SKILLS

• It is not a conversation, but an active period of questioning and observation

• Be alert! Pursue suggestions and insinuations

• Display a neutral, calm, and objective/nonjudgmental manner

• Understand patients and empathize with them. Show an attitude of acceptance

• Be flexible, adjust your tone, vocabulary and type of questions to suit the patient

• At regular intervals, check your understanding of patient’s problems with them