A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.

Psychologists take a similar history, often referred to as a psychological history.

This article mainly covers the initial assessment history taking of a patient presenting for the first time with a new complaint.

Background

In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions. Some of these questions are quite specific, such as, "How old are you?" and others are more open, such as, "How have you been feeling lately?" Although the structure of the interview may appear disjointed, the result is usually under a set of headings which have a worldwide similarity.

Patient identification

The basic details of who the patient is are collected. This includes their age, sex, educational status, religion, occupation, relationship status, address and contact details. This serves several purposes. Firstly, it is necessary information for administrative purposes and for this reason some of this is often taken by clerks. Secondly, the questions are largely non threatening and provide a gentle introduction into the meeting of patient and clinician. Thirdly, it provides a format for individual introduction suitable to the culture. Thus the clinician may start by introducing themselves and then move on to these questions. This initial structure can provide a sense of familiarity for the patient who is stressed about what is happening. It also helps the clinician understand the patient's social situation. may include screening questions directed at identifying or exploring co-morbid psychiatric illnesses or issues (e.g., SIGECAPS mnemonic or PHQ-9 for depression, Generalized Anxiety Disorder 7 for anxiety, DIGFAST mnemonic for mania, or specific questioning around psychoses or other psychiatric complaints. A full review of systems should attempt to identify and list all of the relevant STRESSORS that may be impacting a patient's function and overall health.

Summary

Having collected this information the clinician usually then considers any other factors that might be relevant to the particular patient and enquires about them. Although the gathering of the information may follow the flow of the patient's thoughts rather than those of the clinician, it is not uncommon for the clinician to record the psychiatric history under headings, such as those above, to make it easier for others who will later read it.

Subsequent history taking on reviews concentrates on changes in the levels of symptoms and responses to treatment, including possible side-effects.

See also

  • Medical history
  • Mental status examination

References

  • PsychSkills.co.uk - The Psychiatric Patient History :