Psychiatric History

Identifying Data

"what sort of things led up to this?"

reason for seeking help that day
current symptoms: onset, duration, and course
stressors, supports, functional status, relevant associated symptoms
can also get information from collateral sources: family, friends, police, charts

It is very important to screen people quickly for other potentialities...

mood: depressed, manic
anxiety: worries, obsessions, compulsions, panic attacks, phobias
substance abuse
psychosis: hallucinations, delusions, thought form disorders
- screening question: "do you have thoughts that other people don't share?"
suicide/homicide ideation/plans/attempts
delerium, dementia

to save time: "is what's happening similar or different from what's happened in the past"
past hospitalizations: first time, with diagnosis, last time, with diagnosis
all previous diagnoses
contact with psychiatrists and other therapists
treatments: what's been helpful, any bad reactions
past suicide attempts, substance abuse, legal problems

"anything medical we should know about you?"

"any problems with your heart, blood pressure..."

family personalities
relationships with parents/siblings
past or current psychiatric conditions, substance abuse, suicide, depression, history of "nervous breakdown" or "bad nerves"
past treatment with therapy

prenatal and perinatal history: desired pregnancy or not, maternal and fetal health, delivery complications, domestic violence, maternal substance use
early childhood: milestones, activity/attention level, family stability, attachment figures
middle childhood: academic performance, peers, fire-setting, stealing
late childhood: drugs and alcohol, peer and family relationships
adulthood: education, occupations, relationships
psychosexual:
personality before now; changes

General: Weight, Fatigue, General well-being, Fever, Chills, Sweats
Current Health: Sleep, Diet

"we all have our blue days. Do you ever feel this way?"

"We're all human, and sometimes we talk to ourselves. Sometimes it might seem like there are voices talking to us. Does this ever happen to you?"

Learn symptoms for systems.

Make sure to ask about delirium, dementia, and substance abuse; these very common things are important and easily missed!

Have the courage to go into uncomfortable areas with people. If someone has an acute abdomen, you gotta palpate to find where the problem is.

You can ask anyone anything if: a) it is a logical thing b) they know you will treat them with respect

Care about the person. Don't try to be the nice doctor. When people get anxious or uncomfortable, you know you're on the right track.

Go after the anxiety-provoking factors; don't just try to figure out what pill will work for what.

People won't talk with you if they are: