Hi everyone. Welcome to another psych student video.
Today we're thinking about how you would go about taking a history within the specific context of Psychiatry, and what things you might need to consider in addition to your normal history taking process.
So, when we go about taking a history usually, we start with thinking about the presenting complaint. So, what have they come in for? What's the main problem? and then we go more into the history of presenting complaint. So how did this problem come about? How long has it been present for? Are there any kind of, additional symptoms or problems that are going on at the same time? Adding to that you would then consider past medical history and think about any medication that they're taking. Any kind of, social circumstances that are of relevance and also thinking about any family history, and that would all form part of your usual history process.
In Psychiatry however, we add to that. So early on we add past psychiatric history as well as past medical history and thinking about social history. We expand that more to consider the personal history and developmental history. And within drugs we focus a bit more than you maybe usually would do on substance misuse and getting a real understanding of that area particularly. We then add completely separate areas such as forensic history, which you might not consider at all in your usual medical history and premorbid personality is also an important factor for us. So here we're going to focus on each of those areas highlighted in pink that are specific to Psychiatry.
So, when we think about past psychiatric history, there's lots of different factors we want to consider within that. So, part of that is thinking about any diagnoses they might have had in the past. So, if they've been diagnosed with depression by their GP, for example. We would think about any medication that they're tried in the past and this is particularly important when you're thinking about what medication you might want to try in the future so we know that for example, if you want to try clozapine, they have to have had two other trials of antipsychotics that have been unsuccessful first. So, when taking a history, it's really important to know what's already happened.
Any past admissions are really going to be relevant. When they were, how long they were for, and in particular, what legislation they were under. Were they under the mental health act or were they informal? Did they come in voluntarily for a period of treatment?
Talking therapies and ECT, much like much like with the past meds, it's useful to know what treatments they have already had. And for each of those things we want to know did they work? And if they have any side effects? So, we know whether we can avoid those or use those again.
When we think specifically about substance misuse. This is a really important area in Psychiatry. It feeds into both our mental health as a whole and our well-being but also our risk assessments. We think about this in terms of alcohol and drugs. So, when we're thinking about alcohol, for example, we want to know exactly how much, that might be in kind of units and you might need to work that out from a percentage. We want to know how often they're drinking of this every day or is it been drinking at the weekends? What's the pattern of use? CAGE and AUDIT are two different questionnaires which might be able to help you to get an idea of this. CAGE is quite short, and AUDIT is a longer form. For these problems we want to know if they're causing any physical health problems if there's any withdrawal symptoms or any social problems is interacting with how they are in their work environments, for example. So when we're thinking about drugs as well, it's a similar kind of concept. We're thinking about what kind, how often, the cost is a good idea of how much if they're not sure, and the method of use, is it injected? Is it inhaled? Or are they taking it as a tablet? And again, physical problems, withdrawal, and social problems are really important here. Always ask if there is anything else. They might say “I drink three beers a day”, ask about anything else any spirits they might say, “okay actually yeah a couple of shots of vodka, too”. And think about any dependence or tolerance and how that might feed into our diagnosis as well.
For a forensic history, we're looking specifically at any overlap with the criminal justice system. So a good way to screen for any problems here is ask them if they've ever been in any trouble with the police, or more specifically if they've got any cautions or convictions, and if you're really needing to dig into this more you can sometimes liaise with the police in order to look at history there. But you have to consider that within kind of, need to know information, and confidentiality. It's important to know if there's a history of carrying or any access to weapons. But that may not always come up in a history initially.
Personal history is when we're thinking more about a kind of really advanced social history. So, everything that's really happened to them since their birth up to now and what has been kind of, the most impactful. I find the easiest way to think about this is to look at the main kind of headings so school and family life and track that through from the beginning. So how was school when they were young? And how was it later on? Did they get good grades? Were they bullied? Did they have any problems with kind of, teachers? Attendance? Those kinds of things. (Brief interruption here from my cat meowing – sorry!). Did they move schools often? And then later on the same kind of things with work. Did they have lots of jobs. Did they get on well? Did they get fired a lot? What kind of employment.
Family and relationships, you can ask about siblings, parents, any kind of, difficulties through life with maybe kind of, frequent relationships that have broken down often with partners. And across this time if there's any trauma any delayed milestones. So, thinking about that developmental history, if you're worried about perhaps learning disabilities and IQ. And any moving, where were they born and did, they kind of, move accommodation often, was this disruptive to them?
Premorbid personality is really helpful when we're thinking about getting more kind of collateral information about what they were like before. So, it might be that when unwell people aren't able to really tell us what they were like before. It might seem like their whole life has had this kind of dark cloud over it but maybe in the past they were someone who was quite active and the life of the party. You just don't really know until you dig in. And then we can see what baseline we are trying to get back to.
So, putting that all together at the end you would be then documenting the history, putting that together with a mental state examination and a risk assessment and then we’d really recommend giving a kind of overall impression. It might not be that everyone kind of agrees with you later down the line, but it's good to know what you felt and what you thought at that time because it gives a really helpful overview of what your plan is then, and the plan for management going forward.
So, thank you very much for watching this video. Please do like, subscribe and share if you enjoyed and found this helpful.