Archive for the ‘Educational material’ Category

The psychiatric history

Saturday, May 17th, 2008

I’m doing some more nights shifts at the moment.  As regular readers of this blog will know, for me this involves a lot of grumbling, but it also involves seeing a lot of patients who are having problems with their mental health at times when most people are asleep.

Whenever I see a patient for the first time I interview them and ask a set of particular questions.  These questions add up to a ‘psychiatric history’.  The aim of the psychiatric history is to establish in a systematic way the problems that the patient is having, their chronicity, i.e. how long these problems have been going on, and any other influencing factors. 

If you ever fancy taking a psychiatric history from one of your friends then here’s how to go about it. 

Write the date and time a the top of the page and say who you are.  In my case ‘Psychiaty doctor on call’.  In general try and write down everything that you think is important.  This not just for when others may be reading the notes later, but also from a legal standpoint if there is no record in the notes then something will be considered not to have happened. 

The first part of the history is called the history of the presenting complaint (HPC).  It involves recent events which have lead to this particular visit to hospital.  These events could be over a few weeks or months or over a few days or hours. With a cooperative patient I often start with a list of the things that are bothering them.  This can be very illuminating and provide a guide as to the help the patient would like to receive.  I also find that this is a useful way of not medicalising a patient’s problems.  It is not unusual for a patient to be referred to me for depression, but to say to me that their problems are housing related, and that their husband keeps hitting them and to not mention any psychiatric symptoms at all.

An important thing to establish here is what brought the patient to hospital.  They may have been sent by their GP, or have been brought in by a family member, or have come in of their own volition.  They may also have been brought in by the police or an ambulance.  Although your patient is your primary ‘witness’ so to speak, don’t be shy of asking other people details like this.  This called taking a ‘collateral history’. 

The next section to cover is the past psychiatric history.  Here we must establish for how long the patient has had problems with their mental health.  This usually covers doctors seen, medications taken and admissions to hospital. 

Mental illness often runs in families, and it is important to probe about this.  This is called the family psychiatric history. If we know that there is mental illness already in someone’s family then this may lend weight to any diagnosis we may make, but it will also give us information about a patient’s background.  For instance if an adolescent is living with a depressed parent then this will make a big difference to their home environment. 

Some psychiatric problems may be caused by or interact with physical problems.  So the next section concerns medical history.  I usually split this up into family medical history and patient’s medical history.  It is far from unheard of for a psychiatric problem to actually be the result of an undiagnosed physical problem so psychiatrists have to be awake to this possibility.

One of the reasons that working in mental health is so interesting is that someone’s mental health is often very tied up with their social situation and the experiences they have had up to the point of presenting.  This is why a personal history is taken.  This will include details of childhood, with important questions about developmental delay, schooling, employment and relationships.  If time is short this is part of the history that can be left to a later time.

Drug use and particularly alcoholism is rife in our society and a careful drug and alcohol history is important.  I’m always amazed by how reluctant people are to tell me how much they drink.  The usual conversation: Me: how much alcohol do you drink?  Patient: not much.  Me: how much is not much?  Patient: much less than I used to.  Me: how much is that? Patient: one or two. Me: one or two what? Patient: well I don’t drink every night of the week…..  Cannabis use is also linked to the development of psychotic illness.

If writer’s cramp is holding off, then a forensic history, detailing brushes with the law and time spent in prison can be taken, and it is also useful to ask about premorbid personality whereby the patient or their relatives tell you how they used to be can give an idea as to how out of character a patients actions are and how sick they may be.

There are quite thick books written on the subject of the psychiatric interview and so I can’t hope but provide anything but a taster here.  Sometimes the patient is able to give you all the information you might need.  Sometimes they might be so disturbed that the entire history is from a a collateral source.  Often psychiatrists need to talk to several people.  At the same time as the history is being taken information for the mental state examination is also being noted – this is a posting for another day.

PS I have a theory that if someone without the appropriate qualifications, but with a bit of guile and a crash course in the right things to say, decided to pose as a psychiatrist then it would be quite some time before they were found out.  If anyone is interested in giving this a go, then take careful note, as the ability to take a ’psychiatric history’ will be an important part of your subterfuge

Psychiatry Podcasts

Thursday, January 17th, 2008

I’m revising for MRCpsych papers 1 and 2 this week and have been listening to the psychiatry podcasts that are available online.


The best is the British Journal of Psychiatry podcast available from the Royal College of psychiatry website.  TV doctor Raj Persaud is the host and discusses papers in the most recent journal with their authors.  There are two podcasts available – one is for the ‘public’ and the other a longer CPD version.  The discussion is usually rather matey (about 50% of the authors work at the IoP and would be known to Dr Persaud), but Dr Persaud does often put his guests on the spot by challenging them with possible alternative interpretations for their results.  Highly recommended.

The American Journal of Psychiatry also provides a lacklustre podcast or, as they call it, ‘audio digest‘.  I have never managed to get through an entire episode as its format involves a monotonic American reading out an abbreviated AJP papers.  Unlike the BJP there is no illuminating discussion.  The Mindhacks blog describes it as being ‘like an excessively thorough lecture given by a voice synthesiser’, which is a nice summary.

Also featuring Dr Persaud, but aimed at the general public is the BBC’s ‘All in the Mind‘.  This has more of a magazine format, but is often very interesting, and does not shy away from controversial topics.  All the episodes from the series broadcast since 2005 are available to ‘listen again’. on the BBC’s All in the Mind webpage.

The Institute of Psychiatry also offers podcasts.  Their website says that they wish to put online all the public lectures and debates at the institute.  These are a mixed bag, but included in amongst them are recordings of Maudsley debates going back some time as well as lectures on a wide variety of other topics.  A sort of lucky dip by the looks of things…

Bad Science blogger Ben Goldacre has started podcasting.  It’s a fledgling initiative, judging by there only being one download available, but it’s pretty interesting, and I hope adds more soon.

The ‘My Three Shrinks’ podcast is by blogger ‘Shrink Rap‘ and friends.  I’ve not listened to this yet, but it looks informal and interesting.  There are 42 downloads available

Another podcast I’ve not yet listened to are psychiatry podcasts by the Peerview Press.  Here’s a link to their stuff on podcastdirectory.com

If you are aware of any worthy psychiatry podcasts not on this list, please let me know.