Psychiatric History Taking

by | Oct 3, 2016 | MindFOAM & Psychiatry, Week 1, Year 5 Psychiatry | 0 comments

The Psychiatric History can sometimes seem a little foreign and diffuse at times to medical students and junior medical trainees.  Whilst it is certainly possibly to impose a similar structure to the information gathering, i.e. identifying details, history of presenting complaint, past psychiatric history, past medical history etc… We psychiatrists insist on making matters more difficult by encouraging a more open approach to questioning and “just seeing where it leads us”.

But surely it is impossible to get all the right information if we don’t stick to the script?

The nature of taking a psychiatric history is like anything else in medicine.  It takes time to master and even more longer to become an expert.  It is not uncommon for students to struggle early on between the competing tensions of asking good questions and gathering information from patients in psychiatry and my general advice is to focus on asking good questions.

Why?  Well there are many reasons for this.  But chief amongst these are rapport building as well as the greater likelihood that you get a much more accurate picture of what is going on for the person presenting to you.

Asking questions is a fundamental part of finding information and for subtle (and otherwise) persuasion. There are various types of questions.

Open questions  are those questions which encourage the interviewee to give a long and reflective answer.  It is generally good to commence your psychiatry interview with a few open questionsfor e.g. Could you tell me a little bit about yourself first? OR What would you like to talk about today?. You will be surprised both how much you find out about the person and why they are having concerns but also how effective a few open questions are at establishing rapport and ensuring that the rest of the interview goes well.

As you get further into the interview and the nature of the persons problem or concern becomes more apparent.  You might then try other types of open questionsWhat sort of problems have you been having with your (e.g. mood(? OR. The good old tried, tested and true: Can you tell me more about this problem you have been having with your (e.g. sleep)?.

Closed questions generally elicit yes or no responses or short answers and are better utilized as follow up questions to an open question or series of open questions in order to elicit more specific information about a certain issue or problem.

The combination of open and closed questions is known as funnelling.

 

It is not uncommon for students to struggle early on between the competing tensions of asking good questions and gathering information from patients in psychiatry and my general advice is to focus on asking good questions.

In terms of how you spend your time in the interview the evidence in relation to effective interviewingMead N, Bower P. Patient-centredness: a conceptual
framework and review of the empirical literature. Social Science & Medicine 51 (2000) 1087 -1110. AND Shaw J, Dunn S, Heinrich P. Managing the quality of breaking bad news: an in-depth analysis of doctors’ delivery style. Patient education and counselling. 2012. 87: 186-192.
indicates that a “patient centred” approach is most effective.

Regardless of how much time you have with a patient it is often useful to divide your interview into 3 phases: opening, middle and close.  In all 3 phases a mix of open and closed question types is encouraged, with an emphasis particularly on open questions for the start of the interview.

The concept of a preview as a start for each phase of the interview is a useful one to bear in mind.  The idea here being that you are alerting the patient to the stage of the interview and what will occur.  This is especially useful towards the end of the interview as it can give the patient the indication that the interview is about to end.

Things to cover in each phase of the interview:

Opening

Preview – use open questions and establish empathy, let the patient know your name, role and the amount of time available.
Converse using open questions to establish background information and the presenting complaint

Middle

Preview – indicate to the patient that you are now interested in exploring in more depth some of their key concerns
Converse – using a mixture of open and closed questions, at this stage you are inquiring into symptoms, testing hypotheses, checking and gaining feedback from the patient to ensure you have properly understood their history

As a good tip towards the end of the interview you might try a final open question along the lines of:

Is there anything else you think might be important for me to know?

You will be amazed how helpful patients can be with this sort of line of enquiry, especially if you have been able to establish with them that you are genuinely interested in their problems.

Close

Preview – towards the end of the interview indicate to the patient that you will need to complete the interview soon
Converse – by giving final feedback as to the key points of the history, outline your impressionsAdd a Tooltip Text and go over next steps, check that the patient has understood and thank them for their participating

As a good tip towards the end of the interview you might try a final open question along the lines of:

Is there anything else you think might be important for me to know?

This has been a basic introduction to the Psychiatry History.  You will have noted that we have not touched upon structure or how to compose all this information.  We will tackled this matter in another post.

I will also try to return to the concept of “good questions” at some stage with some additional tips and techniques for how to ask those difficult questions in psychiatry.

Categories

Anthony Llewellyn
I was born on Mouheneenner land in Hobart, Tasmania and I pay my respect to the traditional owners of lands I live and work on and elders past and present. My two most important roles in life are proud husband and father of two boys. I am a psychiatrist and medical educationalist from Newcastle. From 2012 to 2016 I was the (Executive) Medical Director of HETI. I am now currently working in Newcastle in private practice part-time as well as teaching and training medical students, junior doctors and psychiatry trainees. I am also enrolled in a PhD in medical education. I continue to play a role in #FOAMed websites, in particular onthewards and the #ICEBlog.
Anthony Llewellyn
Anthony Llewellyn

Latest posts by Anthony Llewellyn (see all)

Pin It on Pinterest

Shares
Share This