1.
7
Psychiatric History
Personality
Dr. Los Baños Theories
PSYCHIATRIC HISTORY
 Record of the patient's life
 Allows a psychiatrist to understand:
o who the patient is
o where the patient has come from
o where the patient is likely to go in the future.
 Patient's life story told to the psychiatrist in the patient's
own words from his or her own point of view.
 Also includes information about the patient obtained from
other sources, such as a parent or spouse.
 Must be comprehensive to make a correct diagnosis and
formulating a specific and effective treatment plan.
PSYCHIATRIC HISTORY vs. MEDICAL HISTORY
Gather concrete and factual data related to the chronology of
symptom formation and to the psychiatric and medical
history
In contrast to medical history, psychiatric history provides the
following:
 Elusive picture of patient's individual personality
characteristics, including both strengths and weaknesses.
 Insight into the nature of relationships with those closest
to the patient
 A reasonably comprehensive picture can be elicited of the
patient's development from the earliest formative years
until the present.
 Most important technique for obtaining a psychiatric
history:
o Allow patients to tell their stories in their own words
o As patients relate their stories, recognize the points at
which relevant questions about the areas described in
the outline of the history and mental status
examination can be introduced.
Diagnosis of psychiatric patients differ from diagnosis of
patients with physical disease in that:
 Diagnosis based on etiology is not likely
 Psychiatry has no external validating criteria
PSYCHIATRIC INTERVIEW
 Time management
 Arrangement of seating
 Taking of notes
 Follow-up interviews
 Interviewing variations
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PLM CM
PRACTICAL ASPECTS OF PSYCHIATRIC INTERVIEW:
SESSION LENGTH
 Initial interview: 30 mins to 1 hour depending on the
circumstances
 Initial interviews to evaluate patients for pharmacotherapy
or psychotherapy tend to be longer
 Second visits vary in length
 PATIENT’S MANAGEMENT OF APPOINTMENT TIMES
- Reveals important aspects of personality and coping
o Anxious patient may arrive as much as 30 minutes
early before the appointment
o A patient who states, “I forgot all about the
appointment,” → clue that there is something
about going to the doctor that makes that patient
anxious or uncomfortable → should be explored
further by the physician
 PSYCHIATRIST'S HANDLING OF TIME - also an important
factor in the interview
o Carelessness about time → lack of concern for the
patient
o If unavoidably detained for an interview →express
regret at having kept the patient waiting
SEATING AND ARRANGEMENT OF OFFICE
 Both chairs should be of approximately equal height, so
that neither person looks down on the other
 If the room contains several chairs, psychiatrist indicates
his chair and allows the patient to choose where he or she
will feel most comfortable.
 Should protect both parties
 Comfortable room with pleasant lighting
 Don’t make the office too stacky→ objects that can be
used against you by the px or can distract the px
 Normally there is a “barrier” between px and psychiatrist
just to be safe
 Distance is important to maintain
NOTE TAKING
 For legal and medical reasons, an adequate written record
of each px’s treatment must be maintained
 Careful not to take notes extensively as that may cut
down on the ability to listen
 Some pxs may be offended by note-taking whereas others
may feel that their thoughts aren’t important if the doctor
is not taking them down (Solution: explore such feelings).
FOLLOW-UP INTERVIEW
 Allow patients to correct any misinformation provided in
the first meeting
 For additional questions that were not asked or weren’t
clear during the initial interview.
INTERVIEWING VARIATIONS
 Should be in control of the situation
o Depressed and potentially suicidal patients
o Aggressive patients
ENDING THE INTERVIEW
 Psychiatrist must give the patient his impressions and
suggestions, even if they are preliminary
 Prepare the patient for follow-up
 Handling patients well increases the likelihood of helping
the patient
 Give persons who have become emotionally distraught a
few minutes to collect themselves before they are asked
to leave the office.
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 2.1
Psychiatic History August 7, 2014

CONCEPT OF NEUTRALITY AND BEHAVIOR that indicate lack

 In psychoanalytic psychiatry, the psychiatrist does not of interest or inattentiveness, such
take sides in the patient's intrapsychic conflicts as yawning, or checking one's
 Does not mean the clinician is a nonresponding robot. watch. The doctor who shows no
emotional reaction to what a
TYPES OF INTERVENTIONS patient is saying usually conveys a
 Psychiatrist provides feedback and information, offer sense of not listening or being
 reassurances and responds to what the px is saying uninterested
 May be SUPPORTIVE or OBSTRUCTIVE, depending on
the extent to which they increase the flow of information
and enhance or diminish rapport.

SUPPORTIVE OBSTRUCTIVE

 ACKNOWLEDGING  COMPOUND QUESTIONS

EMOTIONS D: Do you take a vacation every
D: Even after all year, and are you able to relax?
these years, talking
about your mother  TRAPPING THE PATIENT IN
brings tears to your HIS OR HER OWN WORDS STRESS INTERVIEW
eyes D: When I asked you before, you  To decrease anxiety of patients = provide reassurance
said nothing had gone well over  Monotonously repetitious or patients w/ insufficient
the last year, and now you are emotion for motivation (apathetic, indifferent, &
 ENCOURAGEMENT telling me you got a raise and have emotionally blunted) = not conducive to discussion of
P: I've never been been exercising more. personality problems
very good at  Stimulation of emotions can be constructive = may
putting things into  WHY QUESTIONS require probing, challenging, or confrontation to arouse
words D: Why do you keep waking up so feelings that will promote progress in furthering
D: I think you've early in the morning? understanding.
described the TIPS:
situation well in a  DISMISSAL/MINIMIZATION In interviewing patient’s, it’s better to probe feelings
way that helps me P: Over the last month I have had shown outwardly by the patient in order to deeply unravel
understand what trouble with sex. such underlying causes of this kind of maladaptation.
you have been D: That happens from time to time
going through PSYCHIATRIC HISTORY (CONTENTS)
 PREMATURE ADVICE A. IDENTIFYING DATA
P: Ever since my girlfriend and I  Includes: demographic summary of the patient
 REASSURANCE split up last year, I cannot seem to  Example:
D: The meet anyone new Mr. John Jones is a 25-year-old single, white,
hopelessness you D: Why not try spending time in Protestant male who works as a department store
feel right now bookstores and coffee houses? clerk. He is a college graduate living with his parents.
seems There are usually lots of single He was referred by his internist for psychiatric
overwhelming. I people in those places evaluation.
think it is very likely  Other contents:
with the proper  NOT FOLLOWING THE o Place/situation in which the interview took place
treatment you can PATIENT'S LEAD o source(s) of the information
get back to feeling D: How long have you been feeling o reliability of the source(s)
yourself (pero so sad? o Is the current disorder the first episode for the px
bawal mag falsely P: Over 6 months. Nothing is o Indicate whether the patient came in on his or her own,
reassure ng px!) getting better. I am starting to was referred by someone else, or was brought in by
wonder if it is worth it. someone else.
D: Do you have trouble sleeping
 NONVERBAL through the night?
FACIAL B CHIEF COMPLAINT
EXPRESSION AND  JUDGMENTAL  In the patient's own words
BODY POSTURE D: Have you been using any  Should be recorded verbatim, regardless of how bizarre or
that convey drugs? irrelevant it is.
interest, concern, P: Well besides drinking, I smoke a  Should be recorded even if the patient is unable to speak.
and attentiveness little grass on weekends  Other individuals present as sources of information
D: Do you not know that can then give their versions of the presenting events in the
marijuana can cause serious section on the history of the present illness.
problems with motivation over the  Examples of chief complaints follow:
long term? I am having thoughts of wanting to harm myself. •
People are trying to drive me insane. •
 NONVERBAL FACIAL I feel I am going mad. •
EXPRESSION, BODY POSTURE, I am angry all the time. •

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Psychiatic History
C. HISTORY OF PRESENT ILLNESS
 Blow by blow account of events that lead to day of
admission.
 Chronological, Detailed, Comprehensive and Concise
 Comprehensive and chronological picture of the
events leading up to the current moment in the
patient's life.
 Evolution of the patient's symptoms should be determined
and summarized in an organized and systematic way.
 THE MORE DETAILED THE HPI, THE MORE LIKELY
THE CLINICIAN IS TO MAKE AN ACCURATE
DIAGNOSIS.
o Onset of episode?
o Triggers
o Effect on patient’s life activities
 (e.g., work, important relationships)?
o Nature of the dysfunction
 (e.g., details about changes in such factors as
personality, memory, speech)?
o Psychophysiological symptoms?
 (describe in terms of location, intensity, and
fluctuation.)
o Patient's current anxieties?
 (whether they are generalized and nonspecific (free
floating) or are specifically related to particular
situations, is helpful. How does the patient handle
these anxieties? )
 Relatively open-ended question (e.g. How did this all
begin?) leads to an adequate unfolding of the history
WELL-ORGANIZED PX DISORGANIZED PATIENT(PX)
 Generally able to  Difficult to interview
present a  Chronology of events is confused
chronological account  In such cases, contact other
of the history informants, such as family
members and friends, to aid in
clarifying the patient's story
D. PAST ILLNESSES
 Transition between the story of the present illness and
the patient's personal history.
 Include past episodes of PSYCHIATRIC AND MEDICAL
ILLNESSES.
 This section provides detailed account of the patient's
preexisting and underlying psychological and biological
substrates, and important clues to, and evidence of,
vulnerable areas in the patient's functioning.
 The following are explored and recorded chronologically:
o Patient's symptoms and extent of incapacity
o Names of hospitals and Length of each illness
o Type and effects of treatment received
o Effects of previous treatments
o Degree of compliance
 FIRST EPISODES OF SYMPTOMS
o Signaled the onset of illness
o Can often provide crucial data about precipitating
events, diagnostic possibilities, and coping capabilities.
 MEDICAL HISTORY
o Medical review of symptoms
o Major medical/surgical illnesses/ traumas,
particularly those requiring hospitalization.
ASK and take note of THE PRESENCE OF THE FF:
 Episodes of craniocerebral trauma
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August 7, 2014
 Neurological illness, tumors, and seizure disorders
 History of testing positive for HIV or having (AIDS).
 Seizure disorder, episodes of loss of consciousness, changes in
usual headache patterns, changes in vision, and episodes of
confusion and disorientation.
 History of infection (e.g. syphilis)
 Causes, complications, and treatment of any illness and the effects
of the illness on the patient
 Psychosomatic disorders
 Alcohol and other substances used (quantity and frequency)
 Included in this category are hay fever, rheumatoid arthritis,
ulcerative colitis, asthma, hyperthyroidism, gastrointestinal upsets,
recurrent colds, and skin conditions.
o The importance of a thorough, accurate medical history
cannot be overstated.
o Many medical conditions and their treatments cause
psychiatric symptoms that without an attentive medical
history may be mistaken for a primary psychiatric
disorder.
Treatment with
Endocrinopathies
corticosteroids can
(hypothyroidism may manifest with
or Addison's depression
precipitate manic
and psychotic
disease)
symptoms
 Patient's medical status
o A depressed patient with cardiac conduction
abnormalities will not be treated (at least initially) with
a tricyclic antidepressant.
o A bipolar disorder patient with kidney disease will
receive an anticonvulsant mood stabilizer rather
than lithium.
o The names and dosing schedules for all currently
prescribed nonpsychiatric drugs should be obtained to
avoid adverse interactions with prescribed psychiatric
medication.
E. FAMILY HISTORY
 Brief statement about any psychiatric illness,
hospitalization, and treatment of the patient's immediate
family members.
 Family history of alcohol and other substance abuse or
of antisocial behavior
 Family ethnic, national, and religious traditions
 Define the role each person played in the patient's
upbringing and this person's current relationship with the
patient.
 The psychiatrist should determine the family's attitude
toward, and insight into, the patient's illness.
o Does the patient feel that the family members are
supportive, indifferent, or destructive?
o What is the role of illness in the family?
 Other questions that provide useful information in
this section include the following:
o What is the patient's attitude toward his or her
parents and siblings?
o Describe each family member. Who is mentioned
first? Who is left out? What does each parent do for a
living? What do the siblings do? How do the siblings'
occupations compare with the patient's work? How
does the patient feel about it? Who does the patient
feel most similar to in the family and why?
F. PERSONAL HISTORY (ANAMNESIS)
 PERSONAL HISTORY = ANAMNESIS
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Psychiatic History
 The psychiatrist needs a thorough understanding of the
patient's past and its relation to the present emotional
problem.
 Note predominant emotions associated with the different
life periods (e.g., painful, stressful, conflictual).
1. PRENATAL AND PERINATAL
 Considers the home situation into which the patient was
born and whether the patient was planned and wanted.
 QUESTIONS THAT NEED TO BE ANSWERED:
o Were there any problems with the mother’s pregnancy
and delivery?
o What was the mother’s emotional and physical state at
the time of the patient’s birth?
o Were there any maternal health problems during
pregnancy?
o Was the mother abusing alcohol or any other
substances during her pregnancy?
2. EARLY CHILDHOOD (Birth to 3 years of age)
 IMPORTANT: Quality of the mother-child interaction
during feeding and toilet training.
 Early disturbances in sleeping patterns, including
episodes of head banging, and body rocking provide
clues about possible maternal deprivation or developmental
disability.
 The psychiatrist should:
o Obtain a history of human constancy and
attachments during the first 3 years.
o Explore the patient’s siblings and the details of his or
her relationship with them.
 Topic of crucial importance: EMERGING PERSONALITY
OF THE CHILD
 Seek the child’s ability to concentrate, to tolerate
frustration, and to postpone gratification.
 FEEDING HABITS
o breastfed or bottle-fed, eating problems
 EARLY DEVELOPMENT
o Walking, talking, teething, language development,
motor development, signs of unmet needs, sleep
pattern, object constancy, stranger anxiety, maternal
deprivation, separation anxiety, other caretakers in the
home.
 TOILET TRAINING
o Age, attitude of parents, feelings about it.
 SYMPTOMS OF BEHAVIOR PROBLEM:
o Thumb-sucking, temper tantrums, tics, head-bumping,
rocking, night terrors, fears, bed-wetting or bed-
soiling, nail-biting, excessive masturbation.
 QUESTIONS:
o Were any psychiatric or medical illnesses present in the
parents that may have interfered with parent-child
interactions?
o Did persons other than the mother care for the
patient?
o Did the patient exhibit problems at an early period
such as severe stranger anxiety or separation anxiety?
o Was the child shy, restless, overactive, withdrawn,
studious, outgoing, timid, athletic, friendly?
o What were the child’s favorite games or toys?
o Did the child prefer to play alone, with others, or not at
all?
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August 7, 2014
3. MIDDLE CHILDHOOD (Age 3 to 11 years)
 The psychiatrist focuses on the ff. important subjects:
o gender identification
o punishments used in the home
o persons who provided discipline and influenced early
conscience formation.
 Data about the patient’s earliest friendships and
personal relationships are valuable.
 The psychiatrist should:
o Determine Number and closeness of the patient’s
friends
o Describe whether the patient took the role of a leader
or a follower
o Describe the patient’s social popularity and
participation in group/gang activities.
 Early patterns of assertion, impulsiveness, aggression,
passivity, anxiety, or antisocial behavior emerge in
the context of school relationships.
 History of the patient’s learning to read and developing
other intellectual and motor skills
 Explore the presence of nightmares, phobias, bed-wetting,
fire-setting, cruelty to animals, and excessive
masturbation.
 QUESTION THAT NEEDS TO BE ANSWERED:
o Was the child able to cooperate with peers, to be fair,
to understand, and comply with rules, and to develop
an early conscience?
4. LATE CHILDHOOD (Puberty through adolescence)
 To ascertain the values of the patient’s social groups and to
determine who the patient’s idealized figures were.
 Provides useful clues about the PATIENT’S EMERGING
SELF-IMAGE
 It is helpful to explore the patient’s school history,
relationships with teachers, and favorite studies and
interests, both in school and in extracurricular areas.
 QUESTIONS THAT NEED TO BE ANSWERED:
o What was the patient’s sense of personal identity?
o How extensive was the use of alcohol and other
substances?
o Was the patient sexually-active, and what was the
quality of sexual relationships?
o Was the patient interactive and involved with school
and peers, or was he or she isolated, withdrawn and
perceived as odd by others?
o Did the patient have a generally intact self-esteem, or
was there any evidence of inferiority complex?
o What was the patient’s body image?
o Were there suicidal episodes?
o Were there problems in school, including excessive
truancy?
o How did the patient use private time?
o What was the relationship with the parents?
o What were the feelings about development of
secondary sexual characteristic?
o What was the response to menarche?
o What were the attitudes about dating, petting, crushes,
parties and sex games?
 SOCIAL RELATIONSHIPS
o Attitude towards sibling(s) and playmates
o Social popularity, number and closeness of friends
o Leader or follower, participation on groups or gang
activities
o Idealized figures
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Psychiatic History
o Patterns of aggression, passivity, anxiety, antisocial
behavior.
 SCHOOL HISTORY
o How far the patient progressed?
o Adjustments to school
o Relationships with teachers (teacher’s pet vs. rebel)
o Favorite studies or interests
o Particular abilities or assets
o Extracurricular activities, sports, hobbies, relations of
problems or symptoms to any social period.
 COGNITIVE AND MOTOR DEVELOPMENT
o Learning to read and other intellectual and motor skills
o Minimal cerebral dysfunction,
o Learning disabilities- their management and effects on
the child.
 EMOTIONAL AND PHYSICAL PROBLEMS
o Nightmares, Phobias, Bed-wetting, running away,
delinquency, smoking, alcohol or other substance use,
anorexia, bulimia, weight problems, feelings of
inferiority, depression, suicidal ideas and acts.
5. ADULTHOOD
 OCCUPATIONAL HISTORY
o Describe the patient’s choice of occupation, the
requisite training and preparation, any work-
related conflicts, and the long term ambitions and
goals.
o Explore the patient’s feelings about his or her
current job and relationships at work and
describe the job history.
o QUESTION:
 What would the person do for work if he or she
could choose freely?
 MARITAL AND RELATIONSHIP HISTORY
o History of each marriage, legal or common law.
o Significant relationship with persons with whom the
patient has lived for a protracted period.
o Areas of agreement and disagreement:
 money management, housing difficulties, the roles of
in-laws, and attitudes toward raising children, should
be described.
o QUESTIONS:
 Is the patient currently in a long-term relationship?
 How long is the longest relationship that the
patient has had?
 What is the quality of the patient’s sexual
relationship?
 What does the patient look for in a partner?
 Can the patient initiate a relationship or approach
someone with whom he or she feels attracted?
 How does the patient perceive failures of past
relationships in terms of understanding what went
wrong and who was or was not to blame?
 MILITARY HISTORY
o Inquire about the patient’s general adjustment to the
military, whether he/she saw combat or sustained an
injury, and the nature of the discharge.
o QUESTIONS:
 Was the patient ever referred for psychiatric
consultation, and did he/she incur any disciplinary
action during the period of service?
 EDUCATION HISTORY
o Educational background, highest grade or graduate
level attained, what patient liked to study, level of
academic performance
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August 7, 2014
o Can provide clues about the patient's social and
cultural background, intelligence, motivation, and any
obstacles to achievement.
o QUESTIONS: how far the other members of the
patient's family go in school, how they compare with
the patient's progress, and patient's attitude toward
academic achievement?
Examples.
 A patient from an economically deprived background who
never had the opportunity to attend the best schools and
whose parents never graduated from high school shows
strength of character, intelligence, and tremendous motivation
by graduating from college.
 A patient who dropped out of high school because of violence
and substance use displays creativity and determination by
going to school at night to obtain a high school diploma
while working during the day as a drug counselor.
 RELIGION
o Religious background of both parents and the details of
the patient's religious instruction
o Family’s attitude toward religion(strict or permissive)
o Conflicts between the parents over the child's religious
education
o Evolution of the patient's adolescent religious practices
to present beliefs and activities.
 SOCIAL ACTIVITY
o Social life and the nature of friendships (depth,
duration, and quality of human relationships)
o Social, intellectual, and physical interests shared with
friends, relationships with persons of the same sex and
the opposite sex.
o QUESTIONS THAT NEED TO BE ANSWERED:
 Does the patient prefer isolation, or is the patient
isolated because of anxieties and fears about other
people? Who visits the patient in the hospital and
how frequently?
 CURRENT LIVING SITUATION
o Where he or she lives in terms of:
 The neighborhood and the residence
 The number of rooms
 The number of family members living in the home,
and the sleeping arrangements
o How issues of privacy is handled (parental and sibling
nudity and bathroom arrangements)
o Sources of family income and any financial hardships.
 LEGAL HISTORY
o arrest (for what?), jail time, probation, history of
assault or violence, attitude towards arrest or prison
term
6. SEXUAL HISTORY
TIPS:
To properly extract valuable info in this section of the
interview, you must take note of the following
 Your own comfort in asking this questions
 Is the patient comfortable with this topic
 Location where you are talking about this
 Infantile sexuality is not recoverable
 Many patients can recall curiosities and sexual games
played from the ages of 3 to 6 years
 Questions to be asked:
o How the patient learned about sex and what he or she
felt were parents' attitudes about sexual development
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Psychiatic History August 7, 2014

 Sexual abuse in childhood  Repetitive dreams have particular value. Includes

 Onset of puberty and feelings about this milestone Fantasies, daydreams (Dream journals are helpful)
 Adolescent masturbatory history o Repetitive themes of nightmares
o including the nature of the patient's fantasies and o Most common dream themes:
feelings about them  food, examinations, sex, helplessness, and feelings
 Attitudes toward sex: of impotence
o Should be described in detail: (shy, timid, aggressive)  QUESTIONS:
o Does the patient need to impress others and boast of o What are the patient's fantasies about the future?
sexual conquests? Did the patient experience anxiety in o If the patient could make any change in his or her life,
the sexual setting? what would it be?
o Was there promiscuity? o What are the patient's most common or favorite
o What is the patient's sexual orientation? current fantasies?
o Does the patient experience daydreams?
o Should include any sexual symptoms, such as o Are the patient's fantasies grounded in reality, or is the
anorgasmia, vaginismus, erectile disorder patient unable to tell the difference between fantasy
(impotence), premature or retarded ejaculation, and reality?
lack of sexual desire, and paraphillias (e.g.,
sexual sadism, fetishism, voyeurism). VALUES
o Attitudes toward fellatio, cunnilingus, and coital  Social & moral values about work, money, play, children,
techniques parents, friends, sex, community concerns, and cultural
 Sexual adjustment issues
o how sexual activity is usually initiated, the frequency of Ex. Are children a burden or a joy? Is work a necessary
sexual relations, and sexual preferences, variations, evil, an unavoidable chore, or an opportunity? What is the
and techniques patient's concept of right and wrong?
 Extramarital relationships (circumstances and if spouse
knew of affair) PRE-MORBID PERSONALITY CIRCUMSTANCES
o The reasons underlying an extramarital affair are just  Characteristics, Temperament, Peculiarities, Daily routine,
as important as understanding its effect on the Work-employment, Social Milieu
marriage.
 Attitudes toward contraception and family planning are *from to upper batch trans (2D_2015)
important. Issues involved in safe sex, STD, HIV. =this is part of HPI
SEXUAL HISTORY CONTENTS: (From Kaplan) =Condition before the illness– so we can return to
1. Screening questions BASELINE!
a. Are you sexually active? =Madalas daw kasing nalilimutan to sabi ni Doc. Dapat
b. Have you noticed any changes or problems with sex recently? hindi ka magaaspire na sobrang umayos nung pasyente
2. Developmental kung ang baseline nya ay di naman maayos talaga. Hiwalay
a. Acquisition of sexual knowledge na yung additional improvement na yun.
b. Onset of puberty/menarche
c. Development of sexual identity and orientation *Additional notes from lecture:
d. First sexual experiences =You should not change the patient to someone he is not. As
e. Sex in romantic relationship psychiatrist, your goal is to listen to the patient and help him
f. Changing experiences or preferences over time live a better life, not an “ideal” life.
g. Sex and advancing age
h. Clarification of sexual problems
i. Desire phase
Presence of sexual thoughts or fantasies
When do they occur and what is their object?
Who initiates sex and how?
j. Excitement phase
Difficulty in sexual arousal (achieving or maintaining
erections,
lubrication), during foreplay and preceding orgasm
k. Orgasm phase
Does orgasm occur?
Does it occur too soon or too late?
How often and under what circumstances does orgasm
occur?
If orgasm does not occur, is it because of not being excited
or
lack of orgasm despite being aroused?
l. Resolution phase
What happens after sex is over (e.g., contentment,
frustration,
continued arousal)?

7. FANTASIES AND DREAMS

 FREUD: Dreams are the royal road to the unconscious.

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