Psych History Template

PSYCHIATRIC HISTORY 1. Preliminary Identification  Name, age, marital status; sex; occupation; language if other than English; race, nationality, and religion insofar as they are pertinent; previous admissions to a hospital for the same or a different condition; with whom the patient’s lives. There should also be comment on the sources of information and the reliability of history. 2. Chief complaint (s)  exactly why the patient come to the psychiatrist, preferably in the patient’s own words; if information does not come from the patient, note who supplied it. Note that one important function of the chief complaint is to provide possible differential diagnosis based on your description. 3. History of presenting illness  This should be started with a very brief description about the patient’s past psychiatric illness (if applicable) and time of the last discharge, followed by the time when the patient has become ill this time. This is important in order to put your history in context especially for patients with chronic relapsing illnesses like Schizophrenia or Bipolar Disorder.  Next, elaborate the chronological background and development of the symptoms of behavioural changes that culminated in the patient’s seeking assistance; patient’s life circumstances at the time of onset; personality when well: how illness has affected life activities and personal relations –changes in personality, interests, mood, atÝtudes towards others, dress, habits, level of tenseness, irritability, activity, attention, concentration, memory, speech.  Elicit psychophysiological symptoms - nature and details of dysfunction, location, intensity, fluctuation; whether anxieties are generalized and nonspecific (free floating) or specifically related to particular situations, activities, or objects, or object; how anxieties are handled – repeated avoidance of feared situation, use of drugs or other activities for distraction.  This should then be followed by a section highlighting important negatives and ruling out of the other differential diagnosis presumed from the chief complaint. 4. Previous illnesses  Past psychiatric history - Emotional or mental disturbance – extent of incapacity, admissions and type of treatment, names of hospitals, length of illness, effect of treatment. - If there has been several admissions, try to summarize the main events / presentations. There is no need to give a too detailed account of past episodes. Past medical or surgical history- Elaborate when relevant. 5. Systemic Review Keep a brief review of various systems to ensure that you have not missed out any possible organic cause for the patient’s presentation. 6. Family history  Family tree  Elicited from patient and from reliable informants, since quite different description may be given of the same people and events: ethnic, national, and religious traditions  Other people in the home, descriptions of them – personality and intelligence – and what has become of them since patient’s childhood.  Description of different household lived in; present relationships between patient and those who were in family; role of illness in the family; history mental illness. 7. Past Personal History  History (anamnesis) of the patient’s life from infancy to the present to the extent it can be recalled, including age of onset, duration, and impact of significant medical illness on patient; gaps in history as spontaneously related by the patient; emotions associated with those life periods – painful, stressful, conflicting etc. 􀀀 Components: 1. Prenatal history – nature of mother’s pregnancy and delivery: length of pregnancy, spontaneity and normality of delivery, birth trauma, whether patient was planned and wanted, birth defects. 2. Early childhood (through age 3) a. Feeding habits: breast-fed or bottle-fed, eating problem b. Maternal deprivation, early development – language development, motor development, signs of unmet needs, sleep pattern, object constancy, stranger anxiety, separation anxiety. c. Toilet training: age, atÝtude of parents, and feelings about it. d. Symptoms of behaviour problems: thumb sucking, temper tantrums, tics, head banging, rocking, night-terrors, fears, bed wetÝng or bed soiling, nail biting, masturbation. e. Personality as a child: shy, restless, overactive, withdrawn, studious, outgoing, timid, athletic, friendly, patterns of play, reactions to siblings. f. Early or recurrent dreams or fantasies 3. Middle childhood (ages 3 to 11)  early school history – feelings about going to school, early adjustment, gender identification, conscience development, punishment. 4. Later childhood (from pre-puberty through adolescence a. Social relationships: atÝtudes toward siblings and playmates, number and closeness of friends, leader or follower, social popularity, participation in group or gang activities, idealized figures; patterns of aggression,passivity, anxiety, antisocial behavior b. School history: how far the patient went, adjustment to school, relationships with teachers – teacher’s pet or rebellious – favourite subjects of interests, particular abilities or assets, extracurricular activities, sports, hobbies, relationships of problems or symptoms to any school period c. Cognitive and motor development: learning to read and other intellectual and motor skills, minimal cerebral dysfunction, learning disabilities – their management and effects on the child d. Particular adolescent emotional or physical problems: nightmares, phobias, masturbation, bed wetÝng, running away, delinquency, smoking, drug or alcohol use, weight problems, feeling of inferiority e. Psychosexual history i. Early curiosity, infantile masturbation, sex play. ii. Acquiring of sexual knowledge, atÝtude of parents toward sex. iii. Onset of puberty, feelings about it, kind of preparation, feelings about menstruation, development of secondary sexual characteristics iv. Adolescent sexual activity: crushes, parties, dating, petÝng, masturbation, wet dreams and atÝtudes toward them v. AtÝtudes toward opposite sex: timid, shy, aggressive, need to impress, seductive, sexual conquests, anxiety vi. Sexual practices: sexual problems, homosexual experiences, paraphilias, promiscuity F. Religious background: strict, liberal, mixed (possible conflicts), relationship of background to current religious practices 5. Adulthood a. Occupational history: choice of occupation, training, ambitions, conflicts; relations with authority, peers, and subordinates; number of jobs and duration: changes in job status; current job and feelings about it. b. Social activity: does patient have friends; is he or she withdrawn or socializing well; kind of social, intellectual, and physical interests; relationships with same sex and opposite sex; depth, duration, and quality of human relations. c. Adult sexuality i. Premarital or extra – marital sexual relationships ii. Marital history: common-law marriages, legal marriages, description of courtship and role played by each partner, age at marriage, family planning and contraception, names and ages of children, atÝtudes toward the raising of children, problems of any family members, housing difÏculties if important to the marriage, sexual adjustment, areas agreement and disagreement, management of money, role of in-laws. iii. Sexual symptoms: anorgasmia, impotence, premature ejaculation etc. iv. AtÝtudes toward pregnancy and having children; contraceptive practices and feelings about them v. Sexual practices: paraphilias d. Forensic History: any involvement with the law or criminal offences. 8. Current social situation:  Where does patient live - neighborhood and particular residence of the patient; is home crowded; privacy of family members from each other and from other families; sources of family income and difÏculties in obtaining it; public assistance, if any, and atÝtude about it; will patient lose job by remaining in the hospital; who is caring for children. 9. Premorbid Personality  In this description of the personality prior to the beginning of the mental illness, do not be satisfied with a series of adjectives and epithets, but give illustrative anecdotes and detailed statements. Aim at a picture of an individual, not a type. The following is merely a collection of hints, not a scheme. It will not be possible to cover all the items listed in the course of the first interview, but an attempt should be made, particularly in case of neurosis or affective disorder, to elicit evidence about all aspects of pre-morbid personality in the course of explorations extending over a period. Of course, presence of a reliable informant is crucial to get an accurate account of the patient’s Premorbid personality. For the ease of remembering, remember the acronym: C H A R2 M S I F 1. Character    AtÝtude to work and responsibility; welcomes or is worried by responsibility; makes decisionseasily or with difÏculty; haphazard an slapdashor methodical and meticulous; rigid or flexible; cautious, foresightful and given to checking or impulsive and slipshod; persevering and determined or easily bored and discouraged Interpersonal relationships; self-confident or shy and timid; insensitive or touchy and sensitive to criticism; trusting or suspicious and jealous emotionally controlled or quicktempered an irritable; tactful or outspoken; enjoys or shuns self-display; quiet and restrained or expressive and demonstrative in speech and gesture; interest and enthusiasms sustained or evanescent; tolerant or intolerant of others; adaptable or not adaptable. Standards in moral, religious, social and health matters: level of aspiration high or low; perfectionist and self-critical or complacent and self approving in relation to own behaviour and achievement; steadfast in face of difÏculties or intolerant of frustration; selfish and egotistical or unselfish and altruistic; given too much or little concern about own health Energy, initiative: energetic or sluggish; output sustained or fitful. Fatigability: and regular or irregular fluctuations in energy or output. 2. Habits: eating (fads); alcohol consumption; selfmedication with drugs or other medicines. Specify amounts taken recently and earlier. Tobacco consumption; sleeping; excretory function. 3. AtÝtudes: towards self and others – optimistic, pessimistic, stingy, paranoid towards others etc. 4. Relationships: to family (attachment, dependence); to friends, groups; to work and workmates (leader or follower, organizer, aggressive, submissive, ambitious, adjustable, independent) 5. Religion: the patient’s religion, atÝtude towards it, piousness, anxiety and the role of religion as the source of solace in times of stress. 6. Mood: bright and cheerful or despondent; worrying of placid; strung-up or calm and relaxed; optimistic or pessimistic; self-depreciative or satisfied; mood stable of unstable (with or without any occasion) 7. Social activities: these include involvements in social events like feasts, societies or even recreational activities including sports and clubbing. 8. Intellectual activities, hobbies and interests: books, plays, movies preferred; memory, observation, judgment, critical faculty 9. Fantasy life: frequency and content of Daydreaming 10. Events Chart  It is very helpful to provide a summary of events which illustrates the main events of the patient’s history in simple graphic style for easy viewing. The contents of the chart should be concise, precise and striking.  For mood disorder patients especially those with repeated episodes e.g. bipolar disorder on recurrent depressible disorder, a mood chart will also be very helpful. MENTAL STATUS EXAMINATION Mental Status: sum total of the examiner’s observations and impressions derived from the initial interviews. 1. GENERAL APPEARANCE AND BEHAVIOUR:  Posture, state of personal hygiene, abnormal involuntary movements, mannerism, hyper / hypoactivity, physical signs of anxiety, like sweating of hands, wide eyes, frequently changing posture and frequent swallowing or depressive signs like stooped posture, vacant look apathy to surrounding. • AtÝtude (towards the examiner) - co-operative, communicative, Domineering, with drawn, interfering, evasive, guarded, hostile, rapport. 2. SPEECH :  Language, relevance  Amount - Normal / increased / decreased  Volume - Normal / increased / decreased  Speed - Normal / increased / decreased; pressure of speech / poverty of speech  Tone - Normal / monotonous 3. MOOD AND AFFECT  MOOD - A pervasive and sustained emotion that colors the person’s perception of the world - This is a subjective and longitudinal emotional state. - Question : How have you been feeling lately.  AFFECT -Emotional expression in response to a given situation. This is an objective and cross-sectional emotional state. -Affect is characterized in several ways 1. By the type of emotion expressed and observed : anger, sadness elation, etc. 2. By the intensity / depth of emotion expressed : normal, blunted or flat. In flat affect, there is no expression of feeling; the face is immobile and the monotonous. In blunted effect, the expression of feeling is severely reduced. 3. By the range of emotion shown : Broad affect describes the normal condition in which a full range of feelings is expressed. Restricted or constricted affect is when it is limited in expression. 4. By it appropriateness : Inappropriate affect is apparent emotion discordant with accompanying thought or speech (e.g., laughing while telling a story most people would find horrifying). 5. By consistency or liability of emotion : labile affect shifts rapidly between different emotional states such as crying, laughing, and anger. 4. PERCEPTUAL DISTURBANCE a. Definition Hallucination - Sensory perception without an objective stimulus Illusion - Sensory misinterpretation of an objective stimulus b. Types True Pseudo Hallucination Hallucination a. Spatial relationship Objective Subjective space Space b. Sensory modality + + involved c . Clarity + + d. Voluntary Control Absent Present e. Insight Absent Present The most important differentiating point is insight. The rest are fluctuating and unreliable. c. Modalities  Auditory, visual, olfactory,gustatory, tactile. Auditory Hallucination Second person  When the voice addresses the patient directly as “you” or commands him to do things. Third person  When 2 voices converses and refer the patient as third person eg.‘he’, ‘she’ etc.  When a voice gives a running commentary of the patients activities d. Description - Continuous / Intermittent Depersonalization - Sense of unreality pertaining to the self with a quality of “as if”. Derealization - Sense of unreality pertaining to the surrounding with a quality of “as if”. 5. THINKING a. Disorders Of Form  Form refers to the meaningfulness or understandability of the speech. Normally ideas, associations and symbols are connected meaningfully to reach a reality oriented conclusion.  Fantasy thinking – the connections may be meaningful but the conclusions reached are unrealistic.  Autism – may be present as thinking is less responsive to external stimuli  Neologism – presents with highly personalized meaning being attached to newly formed words  Association disturbance  Looseness – may be association / incoherence – inability to logically understand the jumps from one topic to another.  Flight of ideas – it is based on rhyming, punning etc. leading to vague wooly thinking and word salad. Presence of pressure of speech is also necessary (see below).NB: prolixity is flight of ideas without the pressure of speech.  Conceptual thinking – evidence of abnormal overgeneralization / concretization (mainly through proverbs / similarity / differences tests)  Circumstantiality / Tangentiality b. Flow  Productivity and continuity of speech/thought.  Increased productivity (pressure of speech) may give rise to flights of ideas and circumstantiality.  Decreased productivity gives rise to thought retardation Disturbance of continuity produces either perseveration or thought block c. Content If refer to the content of thinking per se. It includes primary delusions, secondary delusions, preoccupations, overvalued ideas and also obsessional or repeated thoughts. d. Possession  Normally the subject experiences his thinking as his own i.e. he has a sense of possession. Disorder of possession means the subject thinks that his thoughts are no longer his own or no more under his control eg. thought insertion, broadcasting, withdrawal and obsessions and compulsions. Note that the disorders of thought possession are also delusions. So, you need to attempt at challenging these believes as well.  Thought Insertion - Do you think other people / force are putÝng their thoughts in to your mind/head against your wish?  Thought broad casting - Do you think others can know your thoughts without you telling so  Thought withdrawal -Do you think somebody / some force snatches your thoughts away against your wish. 6. COGNITION a. Orientation  Time - does patient identify the date correctly; can be approximate date, time of day if he is in a hospital, does he know how long he has been there; does patient behave as if he is oriented to the present?  Place: does patient know where he is?  Person: self and others. Does the patient know the identity of himself and the examiner, does he know the roles or names of the persons with whom he is in contact. b. Attention And Concentration :  Serial Subtraction Test i) 100 - 7 (N - 120 sec.) ii) 40 - 3 (N - 60 sec.) iii) 20 - 1 (N - 15 sec.)  Days of the week and months forward and backward. c. MEMORY:  Efforts made to cope with impairment - denial, confabulation, catastrophic reaction, circumstantiality; whether the process of registration, retention, or recollection of material is involved. (i) Immediate memory - Digit span test  digit forward (DF) & digit backward (DB)  Instruction to the patient with example.  Read digits one per sec.  The following digits may be used 5-7-3 6-3-8-2 1-6-4-9-5 3-8-1-7-9-6 7-2-5-9-4-8-3 4-7-2-9-1-6-8-5 The normal range for DF is 7 ! 2 and DB is 5 ! 2.NB: Avoid using consecutive numbers or numbers with a familiar pattern (e.g. 2,4,6,… or 1,3,5,7,…) in the list. Also, do not use the same set of digits for both DF and DB. (ii) Recent memory:  The past few days; what did patient do yesterday, the day before; what did he have for breakfast, lunch, dinner, object recall test - (2 dissimilar objects, one address - name, house number, street, city) after 3 minutes of distraction. Remote memory: Personal like birthday, dates of graduation, employment, marriage, no. of children, I.C. No. and impersonal like old events like the Independence Day, the May-13 incident, the Agung’s installation. d. INFORMATION AND INTELLIGENCE (i) Comprehension (ii) General Knowledge (iii) Arithmetic (iv) Vocabulary e. ABSTRACT THINKING : 􀀀 disturbances in concept formation; manner in which the patient conceptualizes or handles his ideas; 1. Proverb test - Proverbs known to the patient. 2. Test of similarity - 2 to 3 each 3. Test of difference f. JUDGEMENT  Social judgment: behaviours harmful to self and others and or against all social norms.  Test judgment: patient’s prediction of what he would do in imaginary situations - what he would do if he found a stamped, addressed letter in the street.  Personal judgment: future plans after discharge g. INSIGHT: The awareness of having mental illness and the necessity for the treatment CASE FORMULATION 1. Summary  Demographic details (eg. 28 year old Malay gentleman, single, unemployed, from Pasir Tumbuh  PMH/ PSH/ P. PSY. HX/ F.HX. (with no past medical/ surgical or psychiatric history and no family history of  any mental illnesses……..  Presented with ……….  Characterized by ………  No evidence to indicate organicity/ affective disorder/ anxiety/ substance abuse  No evidence of gross behavioral disturbances or hearing of voices  Mental status examination revealed ………  Physical examination revealed ……… 2. Diagnosis  Provisional and differential diagnoses – with justifications  Diagnostic classification according to the international Classification Of Diseases (World Health Organization) 3. Aetiology  Predisposing factors (bio/psycho/social)  Precipitating factors (bio/psycho/social)  Perpetuating factors (bio/psycho/social) 4. Investigations  Physical Blood tests, urine tests, EEG, CT Scan etc., laboratory tests, tests of other medical conditions, reading comprehension and handwriting tests, tests for aphasia Psychological Psychological tests e.g. personality, intelligence and neuropsychological testing Social Trace old notes, speak to relatives, staffs’ observation, specialized reports 5. ManagementPhysical/ Psychological/ Social  Treatment plan – modalities of treatment recommended, role of medication, inpatient or outpatient treatment, frequency of sessions, probable duration of therapy; individual, group, or family therapy; type of psychotherapy; symptoms or problems to be treated. 6. Prognosis (short-term and long-term)  From own experience  From papers  Dependent also on patient’s  Previous history  Personality                                       Compliance Characters Response to medication Social support Skills and coping mechanisms pertinent : relevant anamnesis : reminiscence temper tantrums : are unpleasant and disruptive behaviors or emotional outbursts. They often occur in response to unmet needs or desires.Tantrums are more likely to occur in younger children or others who cannot express their needs or control their emotions when they are frustrated. Tics ; a habitual spasmodic contraction of the muscle : face ( spasm ) Conscience : an inner feeling or voice as acting a guide to the rightness or wrongness of one behavior . Delinquency : minor crime , especially that commited by the young people . Inferiority : the condition of being lower in status PetÝng : engage in sexually stimulating caressing ans touching Paraphilia: A paraphilia is a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in sexual behavior that is atypical and extreme. is the experience of intense sexual arousal to atypical objects, situations, or individuals.[1] No consensus has been found for any precise border between unusual sexual interests and paraphilic ones. Promiscuous : having or characterized by many transient sexual relationship Liberal : open to mew behavior or opinion and willing to discard traditional values Subordinate : a person under the authoruity or control of another within an organization Courtship : behavior designed to persuade someone to marry or develop a romantic relationship with one Anorgasmia : persistent inability to achieve orgasm despite responding to sexual stimulius ( climax ) Epithet : an adjectives or descriptive phrases expressing a quality or chracteristics of the persons or thing mentioned . Anecdotes : a short and amusing or interesting story about a real incident or person Neurosis : a realtively mild illness that is not caused by organic disease , involving symptoms of stress ( depression , anxiety , obsessive behavior , hypochondria ) but not aradical loss of touch with reality . Haphazard : lacking any obvious principle of organization : random , unplanned Slapdash : done too hurry / carelessly Meticulous : showing great attention to details : very craeful and precise Slipshot : typical a method or a person : chracterised by a lack of care , thought or organization Persevere : continue with course of action Tact: understanding and sensitives Shun : persistent avoid , ignore , or reject ( someone or something ) through antipathy or caution Gesture : a movement of part of body , especially a hand or head , to express an idea or meaning Evanescent : soon passing out of sight , memory , or existence , quickly fading or disappearing Complacent : showing smug or uncritical satisfaction with oneself or one ‘s achievement Steadfast : loyal faithful , resolutely or dutifully firm and unwavering Altruistic : showing a disinterested and selfless concern for the well being of others : unselfish Sluggish : slow moving , inactive Fitful : happening only for short periods , not continuous or regular Fatigability : susceptibility to fatigue Paranoia : mental condition characterized by delusions of persecution, unwarranted jealousy, or exaggerated self-importance, typically elaborated into an organized system. It may be an aspect of chronic personality            disorder, of drug abuse, or of a serious condition such as schizophrenia in which the person loses touch with reality. Submissive : ready to conform to the authority or will of others ( passive , obedient ) Piouness : having or showing a dutiful spirit of reverence for God or an earnest wish to fulfill religious obligations. characterized by a hypocritical concern with virtue or religious devotion; sanctimonious. Solace : comfort or consolation in a time of distress or sadness Despondent : in low spirit from loss of hope or courage Placid : person that not easily excited or upset (calm ) Self- depreciation : is the act of reprimanding oneself by belittling, undervaluing, or disparaging oneself, Dominerring : assess one will in an arrogant way Evasive ; tending to avoid commitment or self- revelation ( not willing to give a clear answer to any question ) Rapport : a close and harmonious , relationship in which the people or groups concerned understand each other ‘ feelings or ideas and communicate well . ( close relationship ) Hostile ; unfriend , antagonistic Discordant : not in agreement , combining with each other things in a way that is strange and unpleasant