History of the Client

Past psychiatric history

The following points are relevant in this section:

 details of previous episodes of illness

 previous psychiatric admissions/treatment
 outpatient/community treatment
 suicide attempts/drug and alcohol abuse
 interval functioning (what is the patient like between episodes/when "well')

By including this sort of information, you will build a picture of the pattern of illness (chronicity,
severity, coping strategies, crisis triggers, etc.), which will contribute toward a complete
discussion of the illness.

Example:

Lucy has a 4-week history of severe headache. Initially, Lucy reported a disturbance in her
vision, saying that she saw "purplish-black color spots" in her vision. This was followed by the
onset of a severe headache located at the right frontal and temporal regions, radiating to the right
occipital area. The headache commenced as mild and dull pain then became severe and
throbbing in nature. It was worsened by straining and coughing. Lucy likened the pain to "being
stabbed and squeezed by someone continuously" and described the headache as the most horrible
she had ever had. Lucy's GP prescribed her Panadol. The medication did not help and Lucy
started to experience nausea, vomiting, and mild photophobia. She also experienced pain at the
nape of her neck.

2 weeks after the headache commenced, Lucy was referred to an ophthalmologist. An angiogram
showed signs of venous blockage in the retinal veins. The headache persisted, and 3 weeks after
it commenced, Lucy was becoming more worried about it. She was experiencing (4) sleep
disturbance, poor appetite and weight loss (she reports losing 5kg over three weeks). At the time,
Lucy resigned from work, thinking that her symptoms were stress-related and she probably
needed a break. Lucy also sought a second opinion from another GP. A CT scan revealed a
tumor in the right frontal lobe, which was causing oedema and a mid-line shift. Lucy was
immediately admitted to MMC for biopsy of the tumor.

Since receiving the diagnosis of neural tumor, Lucy has felt depressed and anxious about her
health. Lucy has experienced two nights of restless sleep. She has lost enthusiasm for her usual
activities, such as going shopping and taking care of her son. She reports having no energy for
maintaining her work or social life. She has also become more irritable and aggressive, which is
putting additional pressure on her family. She admits to being preoccupied with thinking about
her illness and is having trouble concentrating on daily activities. She reports feeling tired but too
scared to sleep for fear that she will not wake in the morning.
In conjunction with her depressive symptoms, Lucy is also experiencing excessive anxiety. Her
anxiety is associated with restlessness, tiredness, irritability, insomnia, and difficulty in
concentrating. Other symptoms include palpitations, tachycardia and flushing. Lucy expresses
concern over the impending biopsy report, due sometime in the next two days, asking, "Am I
going to die? Does the tumor mean cancer?" Lucy also expresses concern over her son's welfare
while she is hospitalized. In the last month, her fiancé and her mother have been looking after
both her and her son.
(428 words)

Writing tip

In reporting past events, your choice of English tense-aspect will allow you to add your
perspective on the current relevance of the patient's symptoms, signs, and experiences.

Incorrect use of tenses and time markers impacts on temporal sequences, which influences the
logical structure of the text and may even influence clinical interpretations of illness.

In the example shown, note how the history is reported chronologically, starting with an account
of most distant past events and culminating in events and circumstances existing in the present
time (i.e. at the time of the interview). Note how the tenses shift through the report.

Present Psychological illness

This should be a detailed account of the patient's central problem that you have already
identified in presenting complaints statement. Put details about the problem and related
symptoms in a chronological order, as this will help with the clarity of your writing.

Identify common psychiatric symptoms

You should make connections between the isolated symptoms that the patient may have revealed
to you somewhat randomly in their interview or presenting complaints by grouping the
symptoms together (i.e. depressive, stress, anxiety). This will help your writing to develop
logical sequences. It may be necessary to comment on relevant negative as well as positive
symptoms.

Note details of previous treatment

Include information on who administered management (when and where), what the treatment
was (and preferably the duration of treatment), and the patient's responses to treatment.

Integrate current problem and psychiatric issues

Consider the relationship between the patient's psychiatric state and concurrent medical
conditions
Example 4:

The patient describes an eight-month history of anxiety symptoms, which began two months
after a car accident. She experiences apprehensiveness when out of her home, inability to cope
with anything out of the ordinary, initial insomnia and irritability, and she has withdrawn
socially. More recently she has had trouble concentrating on her work. Five days ago she was
taken to her local GP after experiencing a typical attack in the supermarket. She has become
housebound since, ruminating that "I'm terrified of suffering a heart attack and dying suddenly
like my mother". She has begun drinking up to a bottle of wine a day in an effort, she says, "to
calm myself down and make things more bearable".

Writing tip 1

You may choose to commence this section of the report with a summary of the key issues that
you will address, as in the example shown.

The central problem is identified promptly in the first sentence, and relevant key symptoms are
outlined immediately in the second sentence. This is important information in an objective
diagnostic work-up.

Information on the impact of illness is placed next, helping to contextualize the patient's
experience of the central problem and related symptoms. This information will contribute toward
a more sophisticated diagnosis that accommodates the patient's experience and response to
illness.

Note that in the example all symptoms (whether present or not) relevant to a diagnosis of anxiety
and the differential diagnosis) have not been included. This is OK for an introduction but not for
the history of presenting complaint.

Writing tip 2

Chronology is established using three techniques.

1. The opening sentence not only identifies the central problem but also informs the reader
of when the problem first started. This establishes a temporal perspective on the patient's
current problem, which is relevant for framing the events when describing the course of
the problem. Remember, in this instance, we are referring to the patient's current problem
or episode, which may or may not be related to an underlying chronic condition. This
means that, having alerted the reader to the fact that this presentation/episode is part of a
longer-standing problem, the current episode is described first and then the remainder of
the illness course beginning with the first onset of symptoms. This would usually be put
in the history of the presenting complaint.
2. Events are placed in chronological order, which is regularly marked by the use of
specific temporal markers, highlighted in the example ( e.g. an eight month history...
began two months after, more recently, five days ago, since). This is preferable to a
specific date (as the reader then has to calculate the duration).
3. Temporal perspectives on actions, events, and states of affairs are marked grammatically
by appropriate use of English verb tense forms.