Psychiatric history
Dr A McLeod

There is a lot of rubbish written about the psychiatric history and the mental state examination. They are NOT the same thing.

Basically:

• History is what has happened
• MSE is what symptoms are occurring NOW [click here for MSE]

---

The presenting complain, history or presenting complaint, past medical history, family history, drug history, allergies, and social history are the same as for a standard medical examination but there are extra areas that need to be asked about. The full psychological history is usually much longer than a normal medical history - in an exam you may have only ten minutes to complete this and it's basically impossible. You can get as close as possible by remembering the extra parts of the psych history: PERFIDY

Premorbid personality, Education / employment, Relationships, Forensic, Illicit Drugs, Development. Then map the Year each occurred.


Premorbid personality

• How the patients personality used to be - giving an idea of how much it has changed
• Extremely useful to get a collateral history
• Difficult to ascertain - there is no single best way to ask questions of this type

Educational / Employment history:

• What sort of school did the patient go to (normal, 'special', boarding etc.)
• What age did they leave?
• What level of qualifications did they get?
• Participation in sports, clubs or other social environments
• Relationship to teachers / other pupils
• Bullying

• Types of jobs held
• Resons for leaving
• Long periods of inemployment and reasons
• Relationship to bosses / workmates
• Bullying

Relationships:
Relationship complications can be a trigger for episodes of mental illness - they can also provide support or indicate people (e.g. young children) who may be at risk.

Who does the patient live with?

• What is their relationship (spouse, friend etc.)
• How well do they get on

Ask specifically about partners, children, siblings and parents.

• How far away do these people live
• How often do the communicate
• What is the relationship like (close, distant etc.)

Ask about past relationships

• Does the patient have trouble maintaning relationships
• Prior marriages

Ask about sexual practices


Forensic history:
Psychiatric patients often come to the attention of the police - this may be for inappropriate or frightening behaviour, drug use, crime to fund drugs, or a host of other problems.

Ask about:

• Has the patient been arrested before
• Has the patient been in prison
• What for
• For how long
• Did they see psych services in prison
• Are the under probation or similar services (who may be able to provde help if the patient should need it).

Illicit drugs:
Some people make it a practice to ask about this is 'normal' medical hsitories but it is ESSENTIAL in the psychiatric history. Many people who use illicit drugs also have mental health problems and some drugs effects may impersonate or precipitate mental illness.

Ask about:

• What drugs are taken
• How often
• How much
• HOW are they taken (smoked, injected etc.)
• When they were last taken
• Where the money comes from for the drugs

If the patient is on methadone then specifically ask if the patient is topping up with heroin. Many are.

Drugs to enquire specifically about are cannabis and amphetamines (can predispose to mental illness), heroin, crack, and cocaine. LSD and 'magic' mushrooms can cause hallucinations. Many patients take benzodiazepines illegally on top of their other drugs. Patients should also be asked about Quat or other 'legal highs' if appropriate.


Development:

• More imprtant in child and adolescent psychiatry - will often require collateral history
• Milestones including walking, talking, social interaction, bowel and bladder training etc.

Years:

• With complicated issues of cause and effect (as well as establishing diagnosis accurately) it is important to establish accurately excatly when significant events occurred - did the drug abuse start before or after the voices - did the depression come after the divorce or was it a causative factor...
• Some psychiatrists advocate a 'life chart' that lists the years of all significant events.

---

---

Created October 2010, Updated February 2012