Archive for November, 2010

Past Psychiatric History

There are many things you can ask but here is a minimalistic list of informative data:

1. How many visits to a psychiatric ER?

Too many to count“: usually indicates a severe Axis  I disorder (psychotic or affective), personality disorder, moderate (or more) panic disorder, somatization disorder, or secondary gain (which can also be part of a personality disorder). Very few or none (esp. in an older patient) usually rule out Axis II.

2. How many of the above (ER visits) were followed by hospitalization?

Most of them“. Balance tilts toward Axis I. Most of them were not: balance tilts toward Axis II.

3. How many psychiatric hospitalizations total?

Too many to count: reserved prognosis (due to chronicity, dual diagnosis or Axis II comorbidity). Consider non-compliance and dual diagnosis. Just a few/none: good prognosis.

4. What was the chief complaint/reason for most of the hospitalizations/ER visits?

Great screening question. Voices or paranoia versus depression with suicidal ideation will greatly focus further inquiry.

5. What was the longest hospitalization?

I started to appreciate this question after one patient told me his been hospitalized only twice before. I was puzzled and had a difficult time understanding the mismatch between his level of dysfunction (which was pretty significant) and the very low number of hospitalizations. It turned out that his second hospitalization was 12 years long, in one of the state forensic facilities. So, while the total number of hospitalizations is informative, what really matters (when it comes to prognosis and understanding dysfunction is the total duration of the time one spend inpatient).

6. What medication(s) worked the best/was the worst?

Good question to further narrow the differential. Also, it will save you time to cross off the list ineffective/poorly tolerated medications. Futher, usually there is no need to reinvent the wheel: if a specific intervention worked once, change is that it will work again (the exceptions here is a medication tachyphylaxis reaction, more commonly known as “poop out” phenomenon, where a medication that is effective stops working)

7. Is there a history of noncompliance? Why?

Two benefits: 1. Gives a good measure of the patient’s insight. 2. Places the patient on the stages of change continuum and thus allows you to tailor your intervention accordingly.

8. Were you using drugs around the times when you got hospitalized?

If the answer is”yes, time and again” you should re-asses what’s primary versus secondary.

9. Tell me what’s the most violent you’d ever been.

Open ended increases the chance to get a valid answer.

10.  Did you ever find yourself wishing to be dead?

Suicidality is a sensitive topic. Go straight for a past history of attempts you might put the patient off. Also, your range is too narrow. Start with a broad question and follow up with more specific questions (use a concentric approach) and you will get more honest and comprehensive (thus also more valid) answers.

A few nursing students followed me for rounds today.

It turned out that, as part of their rotation requirements, they are supposed to complete a psychiatric interview. As they never talked to a psychiatric patient before they wanted to know about the do’s and dont’s… After talking further it became clear that their image of a psychiatric patient was the too common stereotype of a highly volatile, potentially dangerous, explosive, out of control, unpredictable person.

Instead of answering their question I asked them what was the most striking and unexpected aspect of the rounds they just saw. “It was very casual”, they said. “The way you interacted  – it was all very “normal”.” “The patients knew about their symptoms and treatments.”

Yes, most of them do.

There are always “normal” and “healthy” parts of the self that survive even the most damaging mental and emotional storms. Your expertise is to find these islands, terra firma amidst on ocean of otherwise overwhelming feelings and thoughts. That is where you want to meet your patient. As that will be the safe harbor, the heaven from where you’ll journey together to chart and explore and bring “back to civilisation” the unruly oceans of raw experience.

When terra firma is where you will meet you only need to remember that you are nowtwo equally good beings: terra firma to terra firma, human being to human being. The only difference is that you are there to offer (not force) help, out of caring for the other.

Remember this: respectful offering of help – and you will have no troubles approaching any psychiatric patient. Or, even more, approaching anyone, anywhere, for that matter.

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