Hey everyone! Just wanted to update you all that I am doing well here in Blackburn.
Last week I had been rotating with the Crisis Response and Home Treatment Team (CRHTT), so all of the psych patients I saw last week had been house visits. This is something you don’t really get to experience in the states. Over here in the UK, before getting sent to the wards, patients are assessed to see if they are eligible to be treated at home with their family. Some patients (not all of course) fare better when treated in an environment their comfortable with, and this can free up some hospital beds to those who really need it. This service is all paid for by the government here. I felt the home visits were a great experience because it really gave me a perspective on where these patients were coming from, and how their illnesses were affecting the people they live with. I got a glimpse at what the patients’ wives, husbands, children, parents, and siblings go through everyday, and it’s often very sad to see.
I saw a previously normal patient who developed an anxiety disorder after a certain event happened in her life. She was tremulous and would cry at everything and anything that we said to her, and she was not able to step out of the house. When we visited her at her home, her husband expressed that all he wanted is to be able to take an evening walk around the neighborhood with his wife again, like they used to. As a husband and a human being, I could relate to him, and I’d be so sad if something like this ever happened to Irene.
This week, in the inpatient psychiatric ward in the hospital, I have begun taking psych patient histories. It is very similar to the histories we learned to take in ICM, but has certain aspects geared towards Psychiatry. For each encounter we also do a Mental Status Exam, equivalent to the Physical examination in other fields in medicine, and sometimes a Mini Mental Status Examination as well to probe into the patient’s present cognitive abilities. Both of these we learned how to do in ICM and Behavioral Science, but now we actually get to do it with real patients. So far most of the patients I’ve seen here have either Schizophrenia or Depression. Some are very easy to talk to. Others, not so much. It’s the ability to extract information from patients (even from difficult ones) and interpret them and find an appropriate treatment for the situation that makes a good psychiatrist.
A good doctor would also have to be able to see through malingering, which is when a patient feigns his or her illness to get financial benefits. We had a patient who complained of suicide ideation and came to the hospital to seek help. On further examination and history taking, it was shown he had no other typical symptoms of depression, and that he came to the hospital right after he was kicked out of his friend’s house after a big argument. He did not have a home of his own and was crashing at his friend’s place. He admitted to one of the nurses that he came to the hospital because he just wanted somewhere to stay. Turns out that this patient had a history of misusing social services, and the doctors, who have years of clinical experience with real patients, could see through his malingering.
Like with all fields of medicine, a patient’s life situation is of utmost importance in Psych. Making a diagnosis or even starting a certain drug may not be something one decides lightly. I learned that sometimes even the decision as to whether or not to diagnose someone should be considered carefully, as getting labeled with a mental illness may often stigmatize a patient in his or her family, culture, or society for life, and for some may prove more harm than help. For example, if the patient is a youth, diagnosing them too hastily (or misdiagnosing them) will permanently label them, leading to difficulty in finding a job in the future. All possibilities and interventions must be considered before giving someone a diagnosis. Often times, it may be better to seek non-pharmaceutical interventions to see if the patient can improve first before labeling somebody with an illness and start on medications, which have side effects. It all depends on the patient’s specific situation, and it is the doctor’s intuition, ability to see the big picture, and plan that I am learning here in clinicals, stuff that you can’t really learn from just reading books or sitting in a classroom.
Anyway, here’s some stuff I learned about taking psychiatric histories for you to enjoy!
PSYCHIATRIC HISTORY
- Setting the Stage
- Make sure you’re in a safe position,
- Introduce yourself
- Figure out the chief complaint and all the other complaints the patient wants to talk about.
- Set the agenda.
- Ask for verbal consent for the interview.
- Identifying Info
- Get information on their sex, age, occupation, who they live with, where they live.
- History of Present Illness
- Ask about the circumstances that led to the hospital admission. In your head, keep asking yourself if this is abnormal.
- For each current complaint, ask about onset, duration, severity, progress, aggravating/relieving factors. Keep in mind whether or not the patient’s complaints are qualitatively and quantitatively normal.
- Keep in your mind a differential diagnosis, and then ask questions that would key in on a working diagnosis.
- Ask if there are any self harm thoughts, self harm attempts. If there have been attempts, ask about the nature and degree.
- Ask how the patient has progressed, and ask how the illness has affected the patient’s life.
- Past Psychiatric History
- Ask about other psych problems that the patient may have had in the past.
- For each one, ask about symptoms, onset, severity, how it has affected the patient’s life, whether or not the patient was admitted to the hospital, and whether it was voluntary or involuntary.
- For each episode, ask how the patient was treated (medication, therapy, care coordinator), and the results. Ask what helped and what did not help.
- Ask if the patient had self harm or harm to others at the time.
- Link the episodes together — is the patient getting worse? better? Patients with schizophrenia often gets worse over time, whereas patients with depression may appear normal between episodes.
- Past Medical History
- Ask about past medical problems and their treatments. Events like getting cancer and surgery can often lead to depression. Conditions like Cushing’s disease and hypothyroidism can also have psychiatric effects. Some viruses can even effect the brain, causing psych problems. Medical problems can have both direct and indirect consequences in behavior.
- Ask about current medical problems and the treatments that the patient currently takes.
- Ask about allergies, illnesses, hospitalizations, etc.
- Family Medical History
- Ask about the patient’s family — how many siblings? children? parents still alive? if deceased, how? divorced/separated?
- Ask if there is anyone else in the family with mental health problems, self-harm/suicide, or alcohol/drug abuse.
- Ask if there has been any crime in the family.
- Personal Social Background
- Birth — was the patient full term? preterm? natural? c-section? asphyxiation during birth? any problems during birth (i.e. placenta previa)? Was the patient’s mother’s pregnancy OK? did the mother take drugs, drink alcohol, get xray/radiation, or get a TORCH infection during pregnancy? How was the patient’s APGAR score when born? Problems during birth and fetal development can be associated with behavioral problems in the future.
- Milestones — did the patient develop normally through childhood? how was upbringing at home? how did patient’s development compare with peers/friends?
- School — did the patient go to a mainstream school? special school? did the patient have learning disabilities? how were peer relationships? did the patient complete school? did the patient go to college?
- Jobs — what jobs did the patient have? what was the longest job? what was the last job and when? why did it terminate? Was there a frequent change of jobs because the patient can’d do the task? Can they cope with challenges of the job?
- Relationships — First relationship? longest relationship? last relationship? what happened? does the patient still have feelings for the relationship? current relationships? children/dependents? children can affect relationships. Was there a frequent change in relationships?
- Current Social Situation — how is current relationship w/ significant others or family? any friends? any stresses? any support?
- Sexual History — don’t underestimate the importance of this.
- Finances — can be a source of stress
- Values/Beliefs — can affect how they think or act or see the world. Could also be a source of support. Need to differentiate between beliefs that is aligned to their culture vs. beliefs that are delusional.
- Self-Sustainability — can patient care for him/herself? IMPORTANT TO ASK!
- Any other significant events in the patient’s life?
- Substance Use History
- Alcohol? Smoking? Drugs?
- Amount? Frequency? Duration? Look for any addictions.
- Effects — Physical, mental, social, forensic (i.e. has the patient been arrested for alcohol or drugs?). Long-term cannabis use has effect on brain/behavior, especially when people are genetically predisposed to psychiatric illnesses.
- was there an environmental stressor that started the substance use?
- Premorbid Personality
- Ask patient and family/friends what the patient was like before the illness. Ask what is it like now.
- How has personality changed?
- How does patient feel about personality now?
- Forensics
- Has the patient been in trouble with the law before?
- Risk Assessment
- Risk of harming self? Risk of harming others? Risk of getting worse?
MENTAL STATUS EXAMINATION
Gives a general observation every time you see a patient. This has the equivalency to a physical exam for Psychiatry.
- Appearance — Eye contact? Rapport (friendly? cooperative?), abnormal movements? alert?
- Speech — rate? variability in tone? volume? sparse speech? lots of speech? word salad?
- Mood — Euthymic? Reactive? Congruent or Incongruent? variability in emotion?
- Subjective — how does the patient describe his/her mood? high? low?
- Objective/Affect — how do you see the patient’s mood as? How does the patient express his/her mood? blunted? flat? appropriate? inappropriate?
- Thought
- Content — delusions of grandeur? paranoia? reference? self?
- Possession — thought withdrawal? insertion? broadcast?
- Formal thought disorder — negative? positive?
- Perception
- Illusions — false interpretation of real things
- Hallucination — sensing something that is not there. Auditory/visual/olfactory/gustatory/tactile hallucinations?
- Are illusions/hallucinations mood congruent or incongruent? Psychosis in depression is often mood-congruent. Psychosis in schizophrenia is often mood-incongruent.
- Cognitive — this is done more in the Mini Mental State Examination (MMSE)
- Orientation — to person, place, time.
- Memory — see if patient can register (repeat something you just said), recall (repeat something you said 5 minutes ago), remember recent events (past few days), and remote events (i.e. memories from childhood).
- Attention/Concentration — see if patient can spell “world” backwards, but first know if he/she can spell “world” forwards correctly. Subtract serial 7′s from 100. If that’s too difficult see if the patient can count backwards from 100.
- Knowledge — who is the queen/president? Name three large cities in the world.
- Reading/Writing — see if patient can read something, or write something you say.
- Abstract Thinking — i.e. what’s does an apple and orange have in common? patients who are capable for abstract thinking will say “they are both fruits.” Those who are not capable, like in some schizophrenia patients, may say “they are both round.”
- Insight
- How does patient think about his/her illness?
- Does patient think it’s a physical or mental problem?
- Does the patient think he/she needs treatment? Does the patient think it will help?
- Does the patient want help?
- Does the patient have poor, partial, or full insight?
