Psych History is midbrain only to Pain
not an original work
. Which principles guide the organization and presentation of clinical data?
After you have done the initial interview(s), performed the mental status exam, and gathered the results of various tests, you are left with the task of organizing and presenting the data coherently. This task often is daunting. Keep in mind that your primary goal is to be able to tell a concise yet sufficiently detailed story about the patient’s current state so that (1) you have at least a few working hypotheses about the patient’s problems, and (2) a person hearing (or reading) about the patient has enough information to arrive at his or her own hypotheses. The success of any effort toward organization and presentation of information is founded on the clearest presentation of the most relevant facts.
2. Where do I start?
The psychiatric presentation differs little from the standard way of presenting a medical patient, and often is organized in the following order:
a. Chief complaint f. Family psychiatric history
b. History of present illness g. Physical exam
c. Past psychiatric history h. Mental status exam
d. Past medical history i. Assessment and plan
e. Psychosocial history
3. How do the write-ups for a patient with schizophrenia and a patient with diabetes differ?
In theory, nothing is different; in practice, however, psychiatrists tend to work more effectively when they have even a rudimentary grasp of who the patient is as a person, and not just as the vehicle for an array of signs and symptoms. Of course, this could be said to be true for all physicians, not just psychiatrists. However, because psychiatrists deal with disturbances in patients’ behaviors, thoughts, moods, and feelings, a vivid and lifelike description of the patient’s history can be especially helpful in diagnosis and treatment.
4. What does assessing the patient “as a person” mean in practice?
Compare these two hypothetical histories of present illness:
Mr. Jones is a 54-year-old married white man who was in his usual state of health until 3 weeks prior to admission, when he lost his job. He then noted subacute onset of early-morning awakening, weight loss, fatigue, decreased concentration, and depressed mood. His wife, noticing that he had suicidal ideation, brought him to the hospital.
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Mr. Jones is a 54-year-old married white man who derived much of his sense of self-esteem and accomplishment from his job as an accountant, which he held for over 30 years. Three weeks ago, when he was laid off (due to cutbacks in the firm where he worked), he felt that “The rug was pulled out from under me.” He had always made his job the center of his life, and was left with nothing to do at home. His wife was overwhelmed as well. He says that he began to feel that “Nothing made sense any more … I felt all washed up,” and gradually lost his appetite as well as his interest in and energy for the few hobbies he had. He developed insomnia with early-morning awakening, and after a while began to tell his wife that “I’m no use to anyone anymore.” When he asked his wife if she’d miss him “if he were gone,” she brought him to the hospital.
Although both histories give a clear picture of someone developing an episode of major depression, the second one conveys a more detailed and useful assessment of the patient as a person, as well as of the circumstances leading up to the hospital admission. It presents at least the beginning of an understanding of the patient’s personality and home life. The use of direct quotations greatly contributes to the sense of vividness and immediacy, and begins to help the listener empathize with the patient’s suffering. When reading or hearing such a presentation, important questions readily come to mind: Had Mr. Jones seen the cutbacks coming but failed to plan for them? Why was the job the center of his life? Why couldn’t his wife have been more of a support? Why does he frame his anguish in terms of his not being any “use” to anyone?—and so forth.
The essential point is to make the history of present illness as vivid and richly detailed as possible, making use of direct patient quotations when applicable and useful, and minimizing use of standard “boiler-plate” jargon about symptoms and behavior.
5. What sort of boiler-plate jargon should be avoided?
The kind that describes symptoms in concise but impoverished ways that lack important complexity. For example, rather than saying:
“The patient demonstrated intense affect when faced with his illness.”
Consider saying instead:
“The patient became tearful and sad when discussing the isolation caused by his psychotic thinking.”
Rather than saying:
“The patient exhibited agitated and threatening behavior in her relationship.”
Consider saying:
“The patient shouted angrily and shook her fist at her boyfriend.”
Once again, the more successful you are at depicting a clear, detailed, and evocative history, the greater the chances will be of reaching a more accurate assessment that leads directly to a rational treatment plan. Avoid clinical clichés!
6. How should the past psychiatric history be incorporated?
This part of the presentation should document not only what prior treatment the patient has received, but also the circumstances and outcome of such treatment. Outlining untreated episodes of illness also can be helpful, as can describing the initial onset of symptoms.
Hospitalizations:
Note precipitating factors, length of stay, success/failure of different treatments used, working diagnoses.
Somatic treatments:
Note dosage of medication, duration, usefulness, and side effects. If appropriate, mention whether electroconvulsive therapy has been used.
Therapy:
Note session length, frequency, duration, focus (e.g., supportive, exploratory, behavioral, cognitive), and usefulness.
Suicidality/homicidality:
Note stressors, prior attempts (in detail), and treatment measures that proved effective. Classifying prior attempts in terms of relative risk and rescue potential can be particularly helpful. For example: the patient who lightly lacerated a wrist in full view of a family member would be considered a low-risk/high-rescue attempt; taking an overdose of acetaminophen behind a locked bathroom door would be high-risk/low-rescue.
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14
Remember: eliminate vagueness! Saying “The patient failed a lithium trial” is less helpful than saying “A two-month trial of lithium at therapeutic plasma levels resulted in intolerable tremor and polyuria.” Direct patient quotations can be quite useful, as well.
7. Is taking a past medical history in a psychiatric setting different than in a nonpsychiatric setting?
Not substantially. Clearly, any illness with possible psychiatric complications (e.g., Parkinson’s disease, multiple sclerosis, stroke, Lyme disease, hyopthyroidism) should be explored in some detail. Given the protean psychiatric manifestations of several different types of seizures, the presence or absence of a seizure disorder is especially important to determine. Mood disorders, hallucinations, delusions, and unusual character traits may be sequelae of a seizure focus, usually in the temporolimbic area. Because these symptoms may represent ictal manifestations of a nonconvulsive seizure, a patient’s seizures may have gone undiagnosed. Therefore, inquire about any history of head trauma, particularly if it led to loss of consciousness.
8. Describe some key points of the psychosocial history.
Given the importance of early relationships to personality development and coping skills, a few essential facts about the patient’s upbringing can shed light on his or her current functioning. A brief outline of the structure of the patient’s family is essential, and should include the place of the patient in the birth order, whether or not the parents were ever married or remain married, and whether either parent is deceased. Patients often fail to spontaneously mention losses of other family members; therefore, ask whether any siblings or grandparents were lost to the patient either recently or in childhood.
Physical and sexual abuse—two obviously sensitive subjects—should be mentioned tactfully but candidly if they are clinically relevant. Clearly, taking a history of abuse must be done with care, with special attention to the patient’s clinical condition and whether or not discussion of such events could be traumatizing or intrusive.
Information about the patient’s work history and relationships is invaluable for an accurate assessment of personality functioning. How does the patient respond to the responsibility of a job? How does he or she deal with interpersonal conflict and intimacy? Similarly, even a brief history of how the patient performed in school can convey a sense of early social relationships as well as any possible learning difficulties that may have gone undetected.
Substance abuse often is presented in this section. The same overall suggestions for detail and richness apply, e.g.: “The patient typically drinks alone, on weekends only, consuming ‘anything I can get my hands on’ until he passes out. He has never had seizures or DTs, and does not like Alcoholics Anonymous because ‘it’s hard to be around so many strangers.’” This description is so much more evocative than “Patient is alcohol-dependent.”
The patient’s religion and whether it is important also should be mentioned, especially if the patient is struggling with suicidal impulses.
Finally, any military and legal elements are important and should not be neglected.
9. What about the family psychiatric history?
A careful exploration of the family’s history of mental illness frequently offers helpful data. Not uncommonly, patients remember that a family member was psychiatrically ill but don’t know the diagnosis. Certain facts can be revealing: The patient’s mother was “nervous a lot” and was hospitalized five times for “shock treatments.” The patient’s uncle was “always hyper,” “drank too much,” and was arrested three times for passing bad checks.
Not surprisingly, such details often are more revealing than the “diagnosis” remembered by the patient.
10. What are the pitfalls in presenting the mental status exam?
This is where boiler-plate jargon can easily get out of hand (see Question 5). “Patient has auditory hallucinations” can be true, if the examiner was careful, or quite false, if the exam was cursory. Be specific! If a patient mentions hearing voices, you need to ask: How many voices? Are they there
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15
all the time? Do they comment on the patient? Are they perceived as coming from inside or outside the head? Do they tell the patient to do anything? Are they threatening or comforting? Don’t just mention the symptom—describe it. Describe the patient’s appearance, interpersonal style, and mannerisms or idiosyncrasies. This principle applies to all portions of the mental status exam, including cognitive testing.
11. How is everything pulled together in the formulation (or assessment) section?
Remarkably little consensus exists about what it means to formulate a case. A common belief is that formulation involves an esoteric and sophisticated explanation of the patient’s difficulties that displays the examiner’s ability to extrapolate more from details of the case than meets the eye. Rather, perhaps the essence of formulation is that it arranges facts in such a way as to suggest a differential diagnosis and a treatment plan. A focus on basic psychiatric knowledge, common sense, and a willingness to think in terms of hypotheses rather than conclusions usually lead to a clarifying and useful formulation.
12. Give some examples of successful formulations.
One main function of the formulation is to summarize known pertinent clinical facts, emphasizing the stressors and sequence of events that led to the patient seeking help. Features essential to any formulation are:
• An indication of baseline functioning (no prior psychosis)
• A description of a likely stressor (the loss of the job)
• A response to that stressor (humiliation, followed by cocaine use)
• A summary of the salient symptomatic phenomenology (e.g., grandiosity, irritability)
• A differential diagnosis
The following is a simple but useful formulation:
In summary, Ms. Smith is a 19-year-old woman with the new onset of a psychotic disorder that has developed over the past 3 weeks. The symptoms appeared to begin fairly abruptly after she was fired from her job and began using cocaine daily to avoid her feelings of shame and disappointment. Her grandiosity, irritability, sleeplessness, and pressured speech all suggest the diagnosis of bipolar disorder, manic phase; however, given the amount of cocaine that she has been using, it is worth considering the possibility of a substance-induced mood disorder with manic features, secondary to cocaine.
The hypothesis that the patient used cocaine to avoid the pain of her loss is clearly based more on common sense and empathy rather than on any formula concerning human behavior. Here is a more complex formulation (referring to the patient in Question 4):
In summary, Mr. Jones is a man without prior psychiatric history whose self-esteem is closely tied to his ability to be an effective worker and to provide for his family. The loss of his job is a tremendous blow to his self-image and quickly has led to his feeling worthless, guilty, and hopeless. He has developed all the signs of a major depressive episode. His suicidal state may be the outcome of his hopelessness and his inward-turned rage about the layoff.
13. The previous formulation indicates that the patient is turning his rage onto himself. Explain.
That is a hypothesis based on psychodynamic theory, which holds that human behavior is, to a large extent, governed by hidden (or, more specifically, unconscious) meanings and forces within the mind. Psychodynamic principles can be useful tools for probing and unraveling patients’ difficulties; these principles are most helpful when used to generate hypotheses, which then require further data to be confirmed or refuted. In this case, for example, further discussions with this patient while he was recovering clinically might reveal the rage (perhaps directed against a harsh and over-demanding father) masked by the acute symptoms. Exploration and venting of the rage might lead to further improvement and reduced vulnerability to future depression.
14. Are there other hypotheses that can be used as tools in case formulation?
Three other sets of hypotheses, which are well-summarized by Lazare, are the sociocultural, the behavioral, and the biologic/syndromal. Although a complete description of each of these is
--------------------------------------------------------------------------------
16
beyond the scope of this chapter, some familiarity with each can greatly enhance a clinician’s skill in reaching an accurate and thorough formulation. The biologic/syndromal approach underlies the classification system contained in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association, which is the prevailing diagnostic system within American psychiatry.
15. What if the formulation is wrong?
Revise it. The value of a formulation is that it provides a starting point for an informed understanding and discussion of the case. It is less important to be “right” than to be flexible. Think of the initial formulation as leading to a working diagnosis that will guide the initial work-up and treatment and may be modified as you become more familiar with the patient. In summary:
• Emphasize clinical detail.
• Avoid clinical clichés and boiler-plate jargon.
• Quote the patient where applicable.
• Describe symptoms rather than label them.
• Use the formulation to summarize the facts, generate hypotheses, and arrive at a working
. Which principles guide the organization and presentation of clinical data?
After you have done the initial interview(s), performed the mental status exam, and gathered the results of various tests, you are left with the task of organizing and presenting the data coherently. This task often is daunting. Keep in mind that your primary goal is to be able to tell a concise yet sufficiently detailed story about the patient’s current state so that (1) you have at least a few working hypotheses about the patient’s problems, and (2) a person hearing (or reading) about the patient has enough information to arrive at his or her own hypotheses. The success of any effort toward organization and presentation of information is founded on the clearest presentation of the most relevant facts.
2. Where do I start?
The psychiatric presentation differs little from the standard way of presenting a medical patient, and often is organized in the following order:
a. Chief complaint f. Family psychiatric history
b. History of present illness g. Physical exam
c. Past psychiatric history h. Mental status exam
d. Past medical history i. Assessment and plan
e. Psychosocial history
3. How do the write-ups for a patient with schizophrenia and a patient with diabetes differ?
In theory, nothing is different; in practice, however, psychiatrists tend to work more effectively when they have even a rudimentary grasp of who the patient is as a person, and not just as the vehicle for an array of signs and symptoms. Of course, this could be said to be true for all physicians, not just psychiatrists. However, because psychiatrists deal with disturbances in patients’ behaviors, thoughts, moods, and feelings, a vivid and lifelike description of the patient’s history can be especially helpful in diagnosis and treatment.
4. What does assessing the patient “as a person” mean in practice?
Compare these two hypothetical histories of present illness:
Mr. Jones is a 54-year-old married white man who was in his usual state of health until 3 weeks prior to admission, when he lost his job. He then noted subacute onset of early-morning awakening, weight loss, fatigue, decreased concentration, and depressed mood. His wife, noticing that he had suicidal ideation, brought him to the hospital.
--------------------------------------------------------------------------------
13
Mr. Jones is a 54-year-old married white man who derived much of his sense of self-esteem and accomplishment from his job as an accountant, which he held for over 30 years. Three weeks ago, when he was laid off (due to cutbacks in the firm where he worked), he felt that “The rug was pulled out from under me.” He had always made his job the center of his life, and was left with nothing to do at home. His wife was overwhelmed as well. He says that he began to feel that “Nothing made sense any more … I felt all washed up,” and gradually lost his appetite as well as his interest in and energy for the few hobbies he had. He developed insomnia with early-morning awakening, and after a while began to tell his wife that “I’m no use to anyone anymore.” When he asked his wife if she’d miss him “if he were gone,” she brought him to the hospital.
Although both histories give a clear picture of someone developing an episode of major depression, the second one conveys a more detailed and useful assessment of the patient as a person, as well as of the circumstances leading up to the hospital admission. It presents at least the beginning of an understanding of the patient’s personality and home life. The use of direct quotations greatly contributes to the sense of vividness and immediacy, and begins to help the listener empathize with the patient’s suffering. When reading or hearing such a presentation, important questions readily come to mind: Had Mr. Jones seen the cutbacks coming but failed to plan for them? Why was the job the center of his life? Why couldn’t his wife have been more of a support? Why does he frame his anguish in terms of his not being any “use” to anyone?—and so forth.
The essential point is to make the history of present illness as vivid and richly detailed as possible, making use of direct patient quotations when applicable and useful, and minimizing use of standard “boiler-plate” jargon about symptoms and behavior.
5. What sort of boiler-plate jargon should be avoided?
The kind that describes symptoms in concise but impoverished ways that lack important complexity. For example, rather than saying:
“The patient demonstrated intense affect when faced with his illness.”
Consider saying instead:
“The patient became tearful and sad when discussing the isolation caused by his psychotic thinking.”
Rather than saying:
“The patient exhibited agitated and threatening behavior in her relationship.”
Consider saying:
“The patient shouted angrily and shook her fist at her boyfriend.”
Once again, the more successful you are at depicting a clear, detailed, and evocative history, the greater the chances will be of reaching a more accurate assessment that leads directly to a rational treatment plan. Avoid clinical clichés!
6. How should the past psychiatric history be incorporated?
This part of the presentation should document not only what prior treatment the patient has received, but also the circumstances and outcome of such treatment. Outlining untreated episodes of illness also can be helpful, as can describing the initial onset of symptoms.
Hospitalizations:
Note precipitating factors, length of stay, success/failure of different treatments used, working diagnoses.
Somatic treatments:
Note dosage of medication, duration, usefulness, and side effects. If appropriate, mention whether electroconvulsive therapy has been used.
Therapy:
Note session length, frequency, duration, focus (e.g., supportive, exploratory, behavioral, cognitive), and usefulness.
Suicidality/homicidality:
Note stressors, prior attempts (in detail), and treatment measures that proved effective. Classifying prior attempts in terms of relative risk and rescue potential can be particularly helpful. For example: the patient who lightly lacerated a wrist in full view of a family member would be considered a low-risk/high-rescue attempt; taking an overdose of acetaminophen behind a locked bathroom door would be high-risk/low-rescue.
--------------------------------------------------------------------------------
14
Remember: eliminate vagueness! Saying “The patient failed a lithium trial” is less helpful than saying “A two-month trial of lithium at therapeutic plasma levels resulted in intolerable tremor and polyuria.” Direct patient quotations can be quite useful, as well.
7. Is taking a past medical history in a psychiatric setting different than in a nonpsychiatric setting?
Not substantially. Clearly, any illness with possible psychiatric complications (e.g., Parkinson’s disease, multiple sclerosis, stroke, Lyme disease, hyopthyroidism) should be explored in some detail. Given the protean psychiatric manifestations of several different types of seizures, the presence or absence of a seizure disorder is especially important to determine. Mood disorders, hallucinations, delusions, and unusual character traits may be sequelae of a seizure focus, usually in the temporolimbic area. Because these symptoms may represent ictal manifestations of a nonconvulsive seizure, a patient’s seizures may have gone undiagnosed. Therefore, inquire about any history of head trauma, particularly if it led to loss of consciousness.
8. Describe some key points of the psychosocial history.
Given the importance of early relationships to personality development and coping skills, a few essential facts about the patient’s upbringing can shed light on his or her current functioning. A brief outline of the structure of the patient’s family is essential, and should include the place of the patient in the birth order, whether or not the parents were ever married or remain married, and whether either parent is deceased. Patients often fail to spontaneously mention losses of other family members; therefore, ask whether any siblings or grandparents were lost to the patient either recently or in childhood.
Physical and sexual abuse—two obviously sensitive subjects—should be mentioned tactfully but candidly if they are clinically relevant. Clearly, taking a history of abuse must be done with care, with special attention to the patient’s clinical condition and whether or not discussion of such events could be traumatizing or intrusive.
Information about the patient’s work history and relationships is invaluable for an accurate assessment of personality functioning. How does the patient respond to the responsibility of a job? How does he or she deal with interpersonal conflict and intimacy? Similarly, even a brief history of how the patient performed in school can convey a sense of early social relationships as well as any possible learning difficulties that may have gone undetected.
Substance abuse often is presented in this section. The same overall suggestions for detail and richness apply, e.g.: “The patient typically drinks alone, on weekends only, consuming ‘anything I can get my hands on’ until he passes out. He has never had seizures or DTs, and does not like Alcoholics Anonymous because ‘it’s hard to be around so many strangers.’” This description is so much more evocative than “Patient is alcohol-dependent.”
The patient’s religion and whether it is important also should be mentioned, especially if the patient is struggling with suicidal impulses.
Finally, any military and legal elements are important and should not be neglected.
9. What about the family psychiatric history?
A careful exploration of the family’s history of mental illness frequently offers helpful data. Not uncommonly, patients remember that a family member was psychiatrically ill but don’t know the diagnosis. Certain facts can be revealing: The patient’s mother was “nervous a lot” and was hospitalized five times for “shock treatments.” The patient’s uncle was “always hyper,” “drank too much,” and was arrested three times for passing bad checks.
Not surprisingly, such details often are more revealing than the “diagnosis” remembered by the patient.
10. What are the pitfalls in presenting the mental status exam?
This is where boiler-plate jargon can easily get out of hand (see Question 5). “Patient has auditory hallucinations” can be true, if the examiner was careful, or quite false, if the exam was cursory. Be specific! If a patient mentions hearing voices, you need to ask: How many voices? Are they there
--------------------------------------------------------------------------------
15
all the time? Do they comment on the patient? Are they perceived as coming from inside or outside the head? Do they tell the patient to do anything? Are they threatening or comforting? Don’t just mention the symptom—describe it. Describe the patient’s appearance, interpersonal style, and mannerisms or idiosyncrasies. This principle applies to all portions of the mental status exam, including cognitive testing.
11. How is everything pulled together in the formulation (or assessment) section?
Remarkably little consensus exists about what it means to formulate a case. A common belief is that formulation involves an esoteric and sophisticated explanation of the patient’s difficulties that displays the examiner’s ability to extrapolate more from details of the case than meets the eye. Rather, perhaps the essence of formulation is that it arranges facts in such a way as to suggest a differential diagnosis and a treatment plan. A focus on basic psychiatric knowledge, common sense, and a willingness to think in terms of hypotheses rather than conclusions usually lead to a clarifying and useful formulation.
12. Give some examples of successful formulations.
One main function of the formulation is to summarize known pertinent clinical facts, emphasizing the stressors and sequence of events that led to the patient seeking help. Features essential to any formulation are:
• An indication of baseline functioning (no prior psychosis)
• A description of a likely stressor (the loss of the job)
• A response to that stressor (humiliation, followed by cocaine use)
• A summary of the salient symptomatic phenomenology (e.g., grandiosity, irritability)
• A differential diagnosis
The following is a simple but useful formulation:
In summary, Ms. Smith is a 19-year-old woman with the new onset of a psychotic disorder that has developed over the past 3 weeks. The symptoms appeared to begin fairly abruptly after she was fired from her job and began using cocaine daily to avoid her feelings of shame and disappointment. Her grandiosity, irritability, sleeplessness, and pressured speech all suggest the diagnosis of bipolar disorder, manic phase; however, given the amount of cocaine that she has been using, it is worth considering the possibility of a substance-induced mood disorder with manic features, secondary to cocaine.
The hypothesis that the patient used cocaine to avoid the pain of her loss is clearly based more on common sense and empathy rather than on any formula concerning human behavior. Here is a more complex formulation (referring to the patient in Question 4):
In summary, Mr. Jones is a man without prior psychiatric history whose self-esteem is closely tied to his ability to be an effective worker and to provide for his family. The loss of his job is a tremendous blow to his self-image and quickly has led to his feeling worthless, guilty, and hopeless. He has developed all the signs of a major depressive episode. His suicidal state may be the outcome of his hopelessness and his inward-turned rage about the layoff.
13. The previous formulation indicates that the patient is turning his rage onto himself. Explain.
That is a hypothesis based on psychodynamic theory, which holds that human behavior is, to a large extent, governed by hidden (or, more specifically, unconscious) meanings and forces within the mind. Psychodynamic principles can be useful tools for probing and unraveling patients’ difficulties; these principles are most helpful when used to generate hypotheses, which then require further data to be confirmed or refuted. In this case, for example, further discussions with this patient while he was recovering clinically might reveal the rage (perhaps directed against a harsh and over-demanding father) masked by the acute symptoms. Exploration and venting of the rage might lead to further improvement and reduced vulnerability to future depression.
14. Are there other hypotheses that can be used as tools in case formulation?
Three other sets of hypotheses, which are well-summarized by Lazare, are the sociocultural, the behavioral, and the biologic/syndromal. Although a complete description of each of these is
--------------------------------------------------------------------------------
16
beyond the scope of this chapter, some familiarity with each can greatly enhance a clinician’s skill in reaching an accurate and thorough formulation. The biologic/syndromal approach underlies the classification system contained in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association, which is the prevailing diagnostic system within American psychiatry.
15. What if the formulation is wrong?
Revise it. The value of a formulation is that it provides a starting point for an informed understanding and discussion of the case. It is less important to be “right” than to be flexible. Think of the initial formulation as leading to a working diagnosis that will guide the initial work-up and treatment and may be modified as you become more familiar with the patient. In summary:
• Emphasize clinical detail.
• Avoid clinical clichés and boiler-plate jargon.
• Quote the patient where applicable.
• Describe symptoms rather than label them.
• Use the formulation to summarize the facts, generate hypotheses, and arrive at a working
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