Psychiatric Case History
MyPsych App
Presenting complaint
- Patient’s name
- Age
- Demographic information
- Reason for referral and by whom.
History of presenting complaint
- This is an account of the patient’s history in their own words.
- Explore thoroughly what they presented with, for example, low mood, hearing voices, etc.
- Explore for other symptoms – mood, psychosis, anxiety
- Always think about risk – to health, safety or welfare to self or others
Past psychiatric history
- Diagnosis
- When first referred to psychiatry
- Treatment by GP for mental illness
- Current input – ?attends outpatient clinic, CPN, psychology, occupational therapy, 3rd sector support,
- Previous treatments, dates given, and what helpful
- Previous hospital admission
- Previous detentions under the Mental Health Act
- Previous deliberate self harm
Past medical history
- Any significant past or current medical history
Drug history
- Current medication
- Compliance
- Side effects
- Over the counter medication
- Drug allergies
If appropriate, then past medication history
Family history
- First ask a broad question to establish if anyone in the patient’s family has suffered from mental illness.
- In cases of adoption or step-parents note information regarding biological and social family.
- For all first degree relatives – mother, father, siblings, children – age, age of death (if deceased) and cause of death, history of mental illness, history of physical illness, occupation, quality of relationship with patient in childhood and thereafter
Social history
- Housing – type of accommodation, any issues
- Employment, source of income
- Money worries – debt, money lenders, catalogues, loan sharks, gambling problems, etc
- Smoking
- Alcohol – amount, features of harmful use or dependency
- Drugs – what substances used, amount, features of dependency
Personal history
- History of birth trauma, place of birth
- Family circumstances in childhood
- Early (pre-school) childhood – developmental difficulties, bedwetting, temper tantrums,
- History of physical or sexual abuse
- Primary school – educational achievement, enjoyed/didn’t enjoy, friends, trouble, suspension, expulsion, truancy
- Secondary school - educational achievement, enjoyed/didn’t enjoy, friends, trouble, suspension, expulsion, truancy, qualifications achieved, age of leaving school
- Further education – adjustment, qualifications
- Employment history – chronological list of jobs, how they were, relationships with colleagues, why they ended
- Current employment – how is it
- Relationships – past and present significant, how long did they last, how were they, why did they end
- Friendships – supportive, confiding?
- Hobbies/interests
- Religion
Forensic history
- Past and pending charges
- Previous convictions
- Previous imprisonment
- History of physical aggression, even if not charged
Premorbid personality
- Ask the patient to describe what they were like before they were ill
- How would their friends describe them
- Relationships – shy or makes friends easily, lasting or superficial friendships, few or many
- Prevailing mood – generally cheerful or gloomy, changes in mood
- Hobbies and interests
- How would they usually respond to stress
Mental state Examination
Appearance and Behaviour
Comment on dress, self care, movements (agitation, slowing, abnormal movements), rapport, appropriateness
Mood
Subjective – the patient’s impression of their mood
Objective - elated, flat, euthymic, irritable, fearful, anxious etc. Congruent or incongruent.
Speech
Comment on rate, rhythm, tone and volume
Thought
Thought Content – particular concerns, worries, delusions, preoccupations
Thought form – any evidence of formal thought disorder e.g. thoughts pressured, thought-blocking, tangentiality, perseveration
Perceptual Abnormalities
Abnormal beliefs –overvalued ideas, delusions
Abnormal experiences – hallucinations (auditory, visual, tactile, olfactory). Also passivity, depersonalisation, derealisation
Cognition
Orientation – time place and person
Attention and concentration
Memory
Language
Fluency
Visuospatial
Insight
Does the patient think they are unwell?
Does the patient feel that treatment is needed?
Summary
2 sentences summarizing patient’s name, age, demographics, significant clinical information, significant social information, anything else important in history
Differential diagnosis
- Mood
- Psychosis
- Anxiety
- Substance misuse
- Organic
- Personality
- No mental illness
Aetiology
- Predisposing factors
- Precipitating factors
- Perpetuating factors
Investigations
- Biological/psychological/social
Management
- Physical treatment
- Psychological treatment
- Social treatment
Prognosis
The psychiatric case history may seem long in comparison with other histories. The student should to try and empathise, i.e. ‘feel oneself into’ the patient’s internal experience. Sometimes it is better to complete a case history over several shorter sessions rather than over one long one.
Patients may struggle to answer questions for many reasons - for example, they may be responding to auditory hallucinations which are far more compelling to the patient that what a student or doctor is saying, they may have persecutory delusions which cause them to be guarded or hostile, or they may be confused and disorientated. It is important to try to formulate such difficulties as giving valuable information about a patient’s mental state rather as a ‘problem’ because they don’t give a ‘good history’. It is often helpful to get a collateral history from a friend or relative of the patient.
Dr Angela Cogan
Consultant Psychiatrist, Hospital Sub Dean for Psychiatry
14 August 2013