Each branch of science uniquely approaches history. The lawyer would approach the case history differently than the medical professional. Each field has its structure for the case history. This provides insight into the current situation, but it also assists us in understanding the variables that have led to the development of those symptoms. This is a life sketch of the individual. The background and etiological elements are collected throughout the case history procedure. While taking the case history, rapport is built. If the interviewer is a good listener, the client is more likely to reveal personal information.
The information is taken concerning the real situation that the user is now facing. The sequence, for this reason, is in the order in which the complaints began. Details about how these symptoms began, how they developed, how long they lasted, and so on are provided. Details regarding the person's developmental years are collected to determine if they experienced difficulties. The individual is questioned about his education and schooling.
The interviewer then inquires about any medical history. As psychologists, we may be unaware of some of the significant medical conditions the client may have suffered from. Physical ailments, as is well known, affect the client's mental state. However, we can assess the psychological influence on the customer. In this element, information focuses on the ailments and treatments that have worked so far for that person. The following topic concerns the person's interest and attitude toward life and other relevant elements. The case history mentions this.
There is a specific format for Case history taking. It is explained below.
It includes −
Name − This is required, although, in some circumstances, we must guarantee them that their name will be kept secret. The customer may refuse to divulge that they are identified at times. Because the clients may come from a well-known or distinguished family, they may be reluctant to reveal their identity.
Sex − This provides a greater cultural perspective on the person. Each gender is allotted a distinct set of duties, which is the significance of this feature.
Age − Knowing the person's age helps the clinician comprehend his developmental stage. A developmental job is assigned to each phase. The age of a person helps us comprehend their development. This indicates that he completed all of the chores on schedule.
Education − Education informs us about a person's exposure to the outside literate world. This is particularly significant because, as clinicians, we may wish to recommend references in the form of reading. Education does not necessarily imply that a person will be sensible, logical, and rational.
School / Institute − School is a person's first social experience. He recognizes that the rules established by the institutions must be followed. In that sense, school-related information is critical.
These are −
Client − Knowing what the client thinks about the situation is critical. Others may see the situation in a different light than the customer does. Because the client is the one who must deal with the situation, his perspective must be shared with the counselor.
Informant − The person accompanying the client provides this information, and he describes his perception of the client's situation. These two may only sometimes complement one other, and these two may have distinct perspectives on the same issue.
Others − In some circumstances, obtaining information on some extra factors is critical.
The current sickness describes how the symptoms of the current episode evolved. Furthermore, the narrative should include any additional changes in the patient's interests, interpersonal connections, behaviors, personal habits, physical health, bio functions, and socio-occupational dysfunction within the same period. The timeline of the patient's symptoms must be followed. The existence or absence of stresses, which may include conditions at home, work, school, legal challenges, medical comorbidities, and interpersonal difficulties, should be determined. Medication, support, coping skills, and time of day are all crucial elements that can reduce or intensify symptoms. What (symptoms), how much (severity), how long, and what connected circumstances are the main questions to be addressed in the history of the current disease.
The doctor should acquire information regarding all psychiatric diseases and their progression over the patient's lifetime, including symptoms and treatment, in the prior psychiatric history. Because comorbidity is the norm rather than the exception, doctors should look for signs and symptoms of other mental illnesses in addition to former bouts of the same illness (e.g., past episodes of depression in an individual with a severe depressive disorder). Past symptoms should be described in terms of when they happened, how long they lasted, and the frequency and intensity of bouts.
Previous therapy should also be thoroughly evaluated. Outpatient treatment such as psychotherapy (individual, group, couple, or family), inpatient treatment (voluntary or involuntary and what caused the need for the higher level of care), support groups, or other types of treatment such as vocational training are examples of these. Medication and other treatment techniques, such as electroconvulsive therapy or alternative therapies, should be thoroughly evaluated. What was tested, how long and at what levels were these used (to determine trial adequacy), and why they were discontinued should all be investigated? Important inquiries must include how the medication/modality was received and whether there were any negative effects. It is also useful to determine if the proposed treatment was followed fairly.
The previous medical history comprises a description of key medical and surgical diseases and ailments and past and contemporary treatments. It is critical to comprehend the patient's reaction to these conditions and the coping techniques adopted. When assessing probable causes of mental illness and comorbid or confounding issues, the prior medical history is an essential component that may determine prospective treatment choices or restrictions. Medical illnesses can cause a psychiatric disorder (for example, depression in an HIV-positive individual), mimic a psychiatric disorder (hyperthyroidism mimicking an anxiety disorder), be caused by a psychiatric disorder or its treatment (a metabolic syndrome in a patient on a second-generation antipsychotic medication), or influence the treatment of a psychiatric disorder (hepatic dysfunction disorder and the use of disulfiram).
Paying close attention to neurological disorders such as seizures, brain injury, and pain is critical. Nonpsychotropic drugs, over-the-counter pharmaceuticals, sleep aids, herbal treatments, and alternative medications should all be considered. All of these can potentially have mental consequences, including side effects or the production of symptoms and potential pharmaceutical interactions.
Birth and Development − The informant is questioned about the birth specifics. We know that delays in reaching developmental milestones are excellent indications of intellectual subnormally. The ordinal position at which a person is born influences the development of their personality.
School History − This is the institution the youngster encounters for the first time in his life. Most of the time, a person's school experience influences their future schooling. It is not necessarily damaging to a person's growth, but it impacts their experience.
Medical History − This is not just to ensure that there is no medical reason for the symptoms but also to understand the person's limitations. Certain symptoms may appear as a result of another medical ailment. For example, if a person experiences an accident and develops a fear of open spaces, this is secondary to the person's medical history.
Social History − A person's social evolution reveals much about them. How closely the customer is tied to the community and reflects his standing in the community. This is also an excellent indicator of the person's social support. Understanding the influence of culture on a person is aided by social development.
Emotional Development − When the counselor proposes it, this component tells us about the person's ability to deal with his situation. This is the foundation of a person's personality. Emotional growth is a process that helps a person to deal with a problem or stress properly. This indicates if the person is acting correctly emotionally.
Premorbid Personality − The patient's premorbid personality typically provides useful insights into his or her symptomatology, diagnosis, and care. Ideally, an individual's premorbid personality should be appraised in the interview with corroborative data. Patients who are ill frequently misreport their premorbid personality, and in circumstances where no informant is available, a review may be necessary once the patient's symptoms have improved.
Substance Use/Abuse and Addictions − The psychiatric interview requires a thorough examination of drug use, misuse, and addictions. Remember that this information may be difficult for the patient to communicate, and a nonjudgmental approach will extract more accurate information. Specific queries may be useful if the patient is unwilling to provide such information.
Alcohol, drugs, medicines (prescription or not prescribed to the patient), and modes of use (oral or intravenous) should all be mentioned in the history of usage. The frequency and amount of usage should be established with the understanding that patients have the propensity to reduce or deny use that is viewed as socially inappropriate. Tobacco and caffeine consumption are two more major drugs and addictions that should be addressed in this area.
Family is an important source of personality and growth, but it is also a cause of frustration in many circumstances. This perspective may differ from the truth in that the parents may not be as bad as the client thinks them, but they may act in good faith. The inverse can also occur, in which a person has a false impression of his parents. In both circumstances, we must validate it with a credible source of information. This is a critical part of family relations. It is critical to consider how family members interact with one another. The client may not be the victim of the dispute, but he may be there when it occurs with other family members. As a result, it is critical to determine how strong the client's emotional bond is with his or her family.
Taking a history is a skill. An excellent interviewer cares about the patient, takes enough time to listen to the patient, can express empathy and develop a solid doctor-patient connection, and keeps focus. To take a good history, the expert should be professionally dressed and groomed, and he or she should set aside at least 45-90 minutes.
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