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Psychiatry
The Importance of a Proper Psychiatric History
Knowing the person you are treating.
Posted December 3, 2012
Someone coming to a psychologist or a psychiatrist for treatment can readily be assigned to one diagnostic category or another on the basis of his/her symptoms; but that label does not say all there is to say about that person. Indeed, not uncommonly, more than one label may reasonably apply since the symptoms a person has may suggest more than one disorder. Someone can be phobic and compulsive at the same time, possibly paranoid also. Even when inserted into a number of such categories, human beings are still not well described. They are more than the sum of the labels attached to them. Each of us is a particular human being with a particular point of view that transcends these narrow characterizations. How we think, or feel, or behave grows out of our past. In order to understand a new patient, therefore, a psychiatric or psychological history must be taken. To understand that person in the present we must struggle to understand him/her in terms of the past.
Medical doctors take a medical history when the patient comes for the first time into the doctor’s office. It includes, naturally, a statement of the patient’s present complaints and an account of how they began and developed. The patient tells this story in his/her own words. Then the doctor asks relevant questions, and then asks, also, about various parts of the body. This is called a review of systems: the cardiac system, the gastrointestinal system, the neurological system, and so forth. The patient may have forgotten to mention something relevant to his/her condition, or to mention other illnesses the patient may have. A psychiatrist does something similar. I think it might be helpful for patients to understand the thinking behind the questions asked during this examination. If the clinician neglects to take a proper history, the patient will not be really understood; and treatment may be inadequate.
The following is an outline of a psychiatric history. It is the way I was taught to examine psychiatric patients; and it was what I expected from psychiatric residents who were presenting cases to me many years later, when I was the Director of Psychiatric Training. It is one such model. There are others.
The Chief Complaint: A statement in the patient’s own words of what brings him or her to treatment. For example: “I feel depressed all the time.” Or, “I worry about getting cancer.” Or, “I’m upset since I got divorced.” Or any of the myriad other worries or discomforts that trouble people.
History of the Present Illness: An account of when the symptoms began and how they progressed. How long have you felt this way? How bad did it get? Have you been taking medicine for it? As the patient tells this story, the likelihood that he/she is suffering from one or another particular illness becomes more apparent. The ability of the clinician to elicit a full account of the History of the Present Illness is dependent on his knowledge of the various conditions that may be present.
Past History: This account includes not only other conditions that may be relevant to understanding the present illness, but as much as possible of the patient’s past life in general. It is a picture of who that person is. It is what a friend or family member would say if asked to write a biography of that person. There Is no obligatory way of getting this information, but the model described here is the way I proceed. To some extent this information is provided spontaneously by the patient. I fill in the gaps by asking specific questions:
Family History: Parents. I ask about each parent separately. How old are they --or were, when they died. What sort of people are/were they? What sort of relationship do/did you have with them? What kind of work did they do? How often do you see them? Siblings. I want to know the names and ages of all siblings—and where they live, and how often my patient speaks to them and sees them. I ask about their personalities and circumstances: nature of their work, marriages, children. What sort of relationship do you have with them?
Early Memories: I ask the patient to tell me four or five early memories. They don’t have to seem to be important to the patient. Just the first things that come to mind. There are two reasons why these memories are important: 1. They are often screen memories, that is, each memory sums up a number of similar events and may reflect an emotional state that characterized childhood.
For example: “I remember falling and hurting my hand, and everyone laughed.” Such a memory suggests that the patient grew up feeling un-cared for. Incidentally, the memories people report of childhood may very well not have happened. Memory is unreliable and subject to different influences. The meaning of the memory may still be valid.
2. The memories that come to mind first in a psychiatrist’s office reflect to some extent the patient’s current mood and are, therefore, another clue to understanding the patient.
Past medical history: Dating back to childhood.
Religion: which religion and how religious.
School: Staring in grade school. Three questions: Did you like school? How well did you do academically?Did you make friends? Do you still have friends?
The same questions are asked about high school. Other features of the patient’s reaction to school and activities are elicited here.
Sex: If the patient is a woman, I ask if she remembers her first period. (Menarche) Almost all women remember this event; and the emotional reactions that are reported to me vary greatly. Some women (few) report it in bland, unemotional terms. Some were pleased, especially if they were the last among their friends to menstruate. Some were frightened, particularly if they were unprepared by other family members. Some were ashamed or disgusted. I think these responses give hints to that girl’s—soon to become woman’s—reaction to sex and to growing up, in general.
First dating experiences: What age? And did they work out okay?
First sexual experiences: Usually interpreted by the patient as the first time he/she had intercourse. But earlier experiences may be reported. What was that like? Have you had—or do you have—sexual problems? Have you had sexual problems while taking anti-depressants?
First important romantic relationship: Who and When and What happened?
College: Which one, and did you like it?
After College: Work and Marriage. Not an exhaustive account of either, but at least the details of the beginning of the marital relationship. What did you like about that person? (Surprisingly, over the years about 20% if patients have told me that initially they did not like the person they ended up marrying. One of the most common qualities that women report they did like about their future spouses was a sense of humor.) I ask how the marriage has worked out so far. I ask about current work? Do you like it? What are your work plans?
Children: How many? Their names and sexes. How are they doing?
Mental Status: The mental status is not part of a formal history. It corresponds to a physical examination in a doctor’s office. It is a statement about the way the patient presents himself/herself—usually divided into five parts: Appearance, attitude and behavior, Affective state (emotional tone—including mood, and emotional responsiveness) Thought: Including evidence in speech of a thought disorder such as flight of ideas or loosening of associations which are ways that a patient may communicate, indicating one sort of pscychotic disorder or another. Certain fixed ideas or abnormal perceptions: such as obsessions or delusions or hallucinations. Cognition: This category includes memory defects, or defects of attention or concentration (usually affected in Alzheimer’s Disease, or in delirium.) The mental status, like a physical examination, is reflective of the clinician’s knowledge of disease processes. It is not usually recorded in the records of someone coming to psychotherapy unless some obvious abnormality is present. It is relevant mostly in the severe psychiatric conditions that lead to hospitalization.
Usually, I am able to take a history during the first two—sometimes three—visits. If the patient is overwhelmingly preoccupied with one problem or another, taking a full history may need to be postponed for a while. But it is important to take a history. The patient is not simply a collection of symptoms; he/she is a particular human being, and everything about that person is connected and explained by everything else.
I make this point now because the practice of psychiatry is changing—for the worse. Psychiatrists used to do psychotherapy. My teachers (a very long time ago) were embarrassed by knowing something about drugs. As residents, we learned about drugs from more senior residents, and there weren’t very many drugs and there wasn’t much to know. Psychotherapy, particularly psychoanalysis, was thought to be a more definitive treatment. That was one extreme; and now we are at another. Psychiatrists are expected to give drugs. Sometimes I have to explain to a referring psychologist that I do not think that particular patient needs drugs. Some patients need drugs, and some do not. In particular, some patients who are depressed need drugs, and some do not. Psychotherapy and the use of drugs are both important; and they do not substitute for each other.
There are certain conditions, such as attention deficit disorder, which seem to be so narrow in scope that they exist apart from the rest of that individual’s psychological life and so can be treated without taking a full history. That way, psychiatrists can see more patients in less and less time. That sort of practice is lucrative, but as far as I can tell, not very interesting. And, of course, if the patients need more help, they will not get it. The patients tend to think of the doctors as selling prescriptions. It seems to me often that they are right.(c) Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog
