As with any patient, aim for an open, empathic and judgemental approach and try to maintain non-threatening eye contact (for example, looking at the lower half of the face) as much as possible. Start with open questions, avoid loaded questions, encourage patients to tell their story in their own words and follow the approaches for general history taking detailed in Chapter 1. Another way of questioning
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up in the morning or to focus on problems, but if none are volunteered a systematic inquiry is essential.
Thus, in a patient presenting with depression, inquire about other symptoms in the depressive syndrome (Box 8.2) such as concentration, memory, things not enjoyed (anhedonia) and social withdrawal. Taking patients through a typical 24-hour day in terms of sleep, waking, what they do and how they feel can be very helpful. Anxiety and depression frequently coexist and so either presentation should lead to a systematic inquiry about symptoms of the other.
Somatic and psychic symptoms of anxiety are outlined in Boxes 8.3 and 8.4. An acute onset of these will generate what is known as a panic attack.
Biological symptoms are important in all mental disorders, so inquiry should always be made about sleep, appetite, weight and energy levels. Particular note should be taken of any abrupt change to sleep pattern, as this is more significant in diagnosis than a chronic sleep problem. Inquire about sleep onset.
Delay in getting to sleep is described as initial insomnia, and initial insomnia of 1 or 2 hours or more is pathological. It is often due to intrusive anxiety, perceptual experiences such as voices (see below) or pain. Inquire about waking in the night, since this is a pattern sometimes seen in anxiety.
Waking regularly in the early hours (e.g. 3 or 4 in the morning) and being unable to get back to sleep is a pattern described as ‘early morning wakening’
and is indicative of a depressive disorder. Sometimes patients have a shifted sleep phase (sleep lag syndrome, just like jet lag) so, although they do not get off to sleep until late into the night and will complain about this, they will sleep on until later in the morning, say midday.
recorded as the basis for your interview. If the patient is being formally held on any section of the Mental Health Act, this must be recorded. If the patient cannot define a problem, then telling him what others have reported and why they are concerned can open up the conversation and allow him a chance to give his version of events.
History of presenting complaint (HPC)
Obtain a detailed description of how symptoms began (e.g., ‘when did you last feel well?’), inquiring about the relationship to any life events that might have kicked things off. Establishing if the symptoms are new, that there has been a change in their condition or they are longer lasting helps to clarify if the current presentation is part of, for example, long-standing personality traits or due to the acute onset of a psychiatric disorder. The nature and persistence of symptoms and their impact on day-to-day functioning should be clarified. In order to fulfill diagnostic criteria for a psychiatric disorder, symptoms should persist across different circumstances and be severe enough to have an impact on a patient’s functioning in daily life.
For example, with low mood it is important to establish whether the low mood is a brief fluctuation or whether it has persisted for a period of time. (The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision – ICD-10 specifies 2 weeks of low mood for a formal diagnosis of depression.) How reactive is it to circumstances?
Moods unreactive to day-to-day events are generally indicative of a greater severity of depression. The evolution of symptoms over time, any help sought or given and any treatment received should all be clearly noted.
Patients may volunteer symptoms associated with the presentation, for example, finding it hard to get
Box 8.1 Suggested order for psychiatric history
■ Presenting complaint (C/O)
■ History of presenting complaint (HPC)
■ Previous medical history – psychiatric and physical (PMH)
■ Current medication/treatment
■ Family history
■ Personal history – Childhood – Schooling – Occupation
– Psychosexual history including relationships and marriage
– Reproductive history (in women) – Children
– Present social circumstances – Social support
– Forensic history (if relevant)
■ Premorbid personality
Box 8.2 Features supporting a diagnosis of depression
■ Persistent/pervasive low mood, often tearfulness
■ Diurnal variation of mood, typically worse in the morning
■ Loss of motivation/interest
■ Anhedonia, i.e. inability to experience pleasure in things
■ Irritability and/or poor concentration
■ Lethargy, fatigue and lack of energy
■ Sleep disturbance, usually early-morning waking
■ Appetite and weight loss (increased in atypical depression)
■ Constipation and/or loss of libido
■ Ideas of hopelessness, worthlessness, guilt, persecution, nihilism
■ Loss of confidence and social withdrawal
■ More severe depression
■ Self-deprecation and/or self-neglect
■ Motor retardation, leading to depressive stupor
■ Retardation of speech, or muteness
■ Paradoxical agitation
■ Psychotic symptoms with mood
■ Congruent delusions and auditory hallucinations
Psychiatric assessment 103 important to inquire into changes in weight in relation to starting psychotropic medication. Many psycho-tropic medications (e.g. some antidepressants, antipsychotics and anticonvulsants) tend to cause weight gain. This should not be ignored and considera-tion should be given to stopping the relevant drugs as well as to clear dietary advice.
History of psychiatric disorder
Inquiry should be made about the lifelong history of mental health problems. The questions need to be asked in terms the patient will understand. For example, you could ask ‘Have you ever had any problems with your nerves or mental health in the past?’ or ‘Have you ever suffered with a very low mood or with worrying too much or had any kind of nervous breakdown?’ Ask about previous contact with mental health, counselling or psychology services.
In women who have had children, inquire as to whether they experienced any mental health problems during or after pregnancy. Ask about previous use of psychotropic medication: ‘Have you ever been pre-scribed any medication for your nerves or mental health, for example, taken an antidepressant, sedative or sleeping tablet?’ Establish what previous medication has been effective in similar episodes or any medica-tion to which they have reacted adversely. Establish whether the patient is currently in contact with any mental health professionals.
Past medical history
Inquire about any current or previous physical health problems, including operations. Note childhood operations or chronic childhood illness, which can be pointers to a tendency to somatise (i.e. to experi-ence physical symptoms when anxious or distressed).
Any chronic debilitating conditions or acute life-threatening events, such as a myocardial infarction, are important risk factors for depressive and anxiety disorders. A number of neurological illnesses have important psychiatric manifestations. Ask about all contacts with health services. Frequent consultations with many different specialists for a variety of symptoms in the absence of a definite medical diagnosis indicate a distinct somatoform disorder.
Current medication
Record all the medication a patient is currently taking (including over-the-counter medications, any recently
‘borrowed medications’ and herbal products). Overuse of some over-the-counter medications can exacerbate a problem (e.g. analgesic overuse headache). Record any allergies clearly.
Family history
Ask about parents: their ages, whether they are alive and, if so, whether they have any physical or mental health problems, where they live and the nature of the patient’s current relationship with them. Inquire If there is a distinct sleep problem, you should ask
about sleep-related behaviours (e.g. bedtime routines, if children share the bed) or phenomena such as sleepwalking or hypnagogic hallucinations (see below).
Establish if sleep is refreshing. Chronic fatigue patients describe unrefreshing sleep and waking still tired, but this is also seen in patients with anxiety. Even so, most patients underestimate how much sleep they actually get.
Ask if the patient’s appetite has changed. In typical depression appetite is poor, but in atypical depression there may be an increase in appetite and a craving for carbohydrate-rich foods. Some patients without depression will describe eating to cope with brief episodes of low mood or to cope with upsetting events. Ask if the patient’s weight has changed.
Significant weight loss (more than 5%) in a depressed patient indicates moderate to severe depression.
Weight increases can indicate a major problem of mood-related eating or bulimia (impulsive eating and self-induced vomiting), while very low weight may indicate anorexia nervosa (morbid fear of weight gain and severe weight loss).
Cycling of weight gain and loss can occur in eating disorders, such as bulimia and anorexia. It is also very
Box 8.3 Somatic symptoms of anxiety
■ Headaches and other muscular aches and pains
■ Palpitations
■ Breathlessness (typically feel unable to get breath in)
■ Tachypnoea
■ Chest pain
■ Urinary frequency
■ Faintness and light-headedness, dizziness
■ Blurred vision, dry mouth
■ Fatigue
■ Pins and needles, tremor
■ Diarrhoea
■ Abdominal discomfort, ‘butterflies in stomach’
■ Nausea and vomiting
■ Flushes or pallor, sweating
■ Insomnia, classically difficulty getting off to sleep
Box 8.4 Psychic symptoms of anxiety
■ Feelings of anxiety
■ Irritability
■ Inability to relax
■ Inability to concentrate
■ Worry/anxious rumination
■ Feeling of impending doom
■ Depersonalisation
■ Panic episodes (sudden onset of panic, sense of doom, fears of dying/collapsing/having a heart attack, with pounding heart and/or shortness of breath and hyperventilation, with an urge to flee one’s situation)
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and relationships with parents or alternative caregivers such as grandparents or foster carers. It is important to note any periods of separation from parents and the quality of alternative caregivers. Inquire about and record any loss of parents or other caring figures through death, separation or divorce. These factors are important in understanding whether there has been any early disruption of attachment bonds for the individual. Childhood health is important. Ask about operations, hospitalisation or chronic illness in childhood and about family attitudes to any illness.
Asking how much time was missed off school due to illness is a good indicator of childhood health, whether organic or non-organic. A happy childhood can be covered quickly, with more time spent explor-ing causes of an unhappy childhood experience.
Specifically ask about physical or sexual abuse. This may seem difficult at first as these feel like taboo topics. Make sure the questions are in an appropriate context (i.e. when inquiring about the patient’s experience of childhood). Then you can ask, in a matter of fact though sensitive way, questions such as the following:
■ Did you ever have any experience of being badly treated as a child?
■ Were you ever neglected and not provided with adequate physical care?
■ Was anyone persistently mean or cruel to you in what they said?
■ Were you ever hit?
■ Were you ever physically abused in any way?
■ Were you ever sexually abused by anyone as a child?
If the rapport with a patient is poor for any reason, or if you are seeing a very psychotic disorganised patient, just asking a general question and deferring exploration may be better. Sometimes patients will indicate that they did experience abuse, in which case it is important to test out sensitively how much to explore this in an initial interview. It is usually best not to do so, but useful to ascertain if this is the first time abuse has been disclosed.
A patient who has undergone a period of therapy, for example, and has discussed abusive experiences at length beforehand may be comfortable recounting such experiences at a first interview. A patient however who has never disclosed such abuse before may find it difficult to discuss it at all, and an agreement to talk more about this subsequently may be more appropriate. Patients should never feel coerced, either overtly or covertly, by the whole context of the interview to talk about issues which cause pain or distress. If they do, the interview itself can feel like an abusive experience.
Schooling
A person’s experience of school can be very important in terms of understanding the development of their peer relationships and indicating whether there were any behaviour problems as well as finding out about the parents’ occupations and personalities and
the patient’s relationship with them during childhood.
Establish if the parents are separated or divorced and, if so, how old the patient was at the time. If the parents have died, inquire into when they died, their age at death, the circumstances of their death, how old the patient was at the time and how the patient has coped with the grieving process.
Establish how many siblings there are, whether full or half siblings, and the patient’s order in the family.
As for the parents, inquire into any siblings’ mental and physical health, place of living, marital status, occupation, personality and the patient’s relationship with them.
Some family structures can be very complicated, with parental separations, remarriages or re-partnerships and half- or stepsiblings from different parental relationships. In this situation, it can be helpful to draw a family tree and annotate it with the above information. Circles are used for women, squares for men; a line through the symbol denotes death. Marriage or permanent liaisons are indicated by a line connecting the symbols and divorce or permanent separation by two oblique lines through the connecting line.
Considerable information can emerge about relation-ships with parents, siblings, etc. while taking the family history, which can be explored further in the personal history. Specifically inquire whether there is any family history of mental health or psychological problems. When considering the heritable component of a condition, obviously you are only interested in first-degree relatives and not in relatives by marriage.
Personal history
Birth and early developmental milestones (in most patients only a brief outline is required) This begins with inquiry about the patient’s birth.
Was it a normal delivery or were there any medical interventions or birth complications requiring special-ist care? This is relevant to assess the possibility of any early brain injury. It can also be relevant if there were problems in early maternal bonding. Were developmental milestones reached within the normal range (see Ch. 6). Patients may not have any knowl-edge about their birth and milestones. If a patient tells you about some problem surrounding their birth and early milestones, this may be significant and is worth recording. If no problems are identified, it is possible that the patient just does not know. Clearly an informant, such as the patient’s mother, may have more accurate information.
Family milieu, childhood health and early relationships with caregivers
Start with an open question such as ‘How do you remember your childhood?’ ‘Was it a happy or unhappy time of life?’ Cover the family atmosphere during early upbringing, relationships between parents
Psychiatric assessment 105 and personality. Ask about his current job (if the patient is employed) such as the hours worked, what it involves and if it is enjoyable as well as any particular current work stressors. If a patient is unemployed, establish when he last worked and the reasons for not working (e.g. illness, redundancy).
Psychosexual history, including marital/
relationship history and children
The psychosexual history can be a source of embar-rassment for students and patients, but this is unneces-sary if handled in a straightforward way. If there is a problem, patients may even be relieved to be asked about this, since they may have been afraid to mention such a topic. Many psychotropic drugs have psycho-sexual side effects (e.g. erectile dysfunction or loss of libido with some antidepressants), but patients often do not mention such side effects unless asked.
How much detail is needed will vary depending on the presenting complaint. Obviously, if the patient is complaining of marital or psychosexual difficulties, a full history of this area is relevant. The level of detail outlined in Box 8.5 is usually not necessary, but you should routinely gather basic details of the psychosexual history. In the relationship history, do not make an assumption about sexual orientation.
Ask about sexual orientation in an open non-judgemental way. Look for patterns that may be indicative of relationship problems (lots of brief what educational level has been attained. Inquire
about both primary and secondary school, what sort of schools were attended, whether school was enjoyable and any experience of bullying. Likewise, things enjoyed, peer relationships, ease of friendships and whether friends from school are still part of the friendship group should be inquired about.
Truancy, school refusal, exclusions from school and referral to any children’s service are all important to clarify.
Truancy refers to a child missing school deliberately, usually without parental knowledge, and doing something else such as working or playing with other truants. School refusal describes a situation in which a child stays at home refusing to go to school despite persuasion from parents, usually due to an anxiety disorder. Sometimes parents keep children at home due to the parent’s health or practical needs (the parent may need practical help due to physical illness or with looking after other children).
Establish the patient’s level of academic achieve-ment (qualifications attained). Ask about further education or training on leaving school and their experience of this (college or university). Further education is an important point in a person’s devel-opmental trajectory as it is often the point at which an individual starts to live independently. How successfully this major milestone is negotiated is an important indicator of psychological health and can reveal information about emotional attachments and functioning. Inquire specifically about the transition from home to living independently, even if not for further education, or whether the patient still lives in the parental home.
Time may not allow all aspects of schooling to be covered but always record age at start and end of full-time education, any problems encountered and the highest level of qualifications attained.
This information can be important in evaluation of cognitive state.
Occupational history
Take a history of the first job patients have had after their education, what other jobs they have had, how long they have stayed in those and the reasons for leaving. It is not necessary to go into exhaustive detail, but it is important to establish if the individual is able to sustain long-term periods of employment.
Use a shortened approach by asking about total number of jobs, longest period of employment and highest level of employment, longest period of unemployment, difficulties at work and relationships at work. If a pattern emerges of frequent job switches after brief periods of employment, it is important to establish the reason for this pattern: is there a pattern of repeated behaviour (e.g. getting bored) or a par-ticular problem (e.g. difficulty with authority figures or other problems in interpersonal relationships).
This can give important information about ability
Box 8.5 The psychosexual history
■ Women: age at menarche, menstrual history, sex education at home/school
■ Men: puberty, sex education at home/school
■ For both sexes, a full sexual history would also cover sexual fantasies, masturbation and deviant sexual
■ For both sexes, a full sexual history would also cover sexual fantasies, masturbation and deviant sexual