Psychiatric Case History

Warning

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

  1. Mood
  2. Psychosis
  3. Anxiety
  4. Substance misuse
  5. Organic
  6. Personality
  7. 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

Last reviewed: 05/07/2023

Next review date: 05/07/2024

Reviewer name(s): NHS GGC MyPsych team.