THE HEALTH HISTORY

Common or Concerning Symptoms

In Psychiatry

By Prof. PAUV BUNTHOEUN

Khmer Soviet Friendship Hospital
THE HEALTH HISTORY
Common or Concerning Symptoms
- Changes in attention, mood, or speech
- Changes in insight, orientation, or memory
- Anxiety, panic, ritualistic behavior (stereotyped
movements such as picking threads from carpets, flicking pieces of string,
opening and shutting doors)
, and phobias
- Delirium or dementia
Overview.
- As with the General Survey, your assessment of
mental status begins with the patient's first words.

- As you gather the health history, you will quickly

discern(understanding) the patient's level of alertness
and orientation, mood, attention, and memory.

- As the history unfolds(េពលែដល្របវត�ិ្រត�វបានលត្រតដង ), you will

learn about the patient's insight and judgment, as
well as any recurring or unusual thoughts or
perceptions.
For some, you will need to supplement your interview with
specific questions and a more formal evaluation of mental
status. Just as symptoms, blood pressure, and valvular
murmurs help you to distinguish, for example, health from
disease in the cardiovascular system, specific components
of mental function illuminate specific concerns and
conditions( សមាសភាគជាក់លក់ ៃនមុខងរផ�ូវចិត�ក៏នឹងបំភឺព� ីករ្រព�យបារម� និងលក�ខណ�ជាក់លក់ផងែដរ។) .
Many of the terms pertinent ( relating to)to the mental health
history and the mental status examination are familiar to
you from social conversation
. Take the time to learn their precise meanings in the
context of formal evaluation of mental status, as detailed in
the next table.
Attention, Mood, Speech; Insight, Orientation, Memory.
Much of the information about the patient's mental status
becomes evident during the interview.
As you talk with the patient and listen to the patient's
story, assess level of consciousness; general appearance;
mood, including depression or mania; and ability to pay
attention, remember, understand, and speak. By placing
the patient's vocabulary and general fund of information in
the context of his or her cultural and educational
background, you can often make a rough estimate of
intelligence. Likewise, the patient's responses to illness and
life circumstances often tell you about his or her degree of
insight and judgment.
See Table 5-2, Disorders of Mood, p. 160, and Table 17-5,
Disorders of Speech, p. 722.
P.141
- If you suspect a problem in orientation and memory,
you can ask,
“Let's see, your last clinic appointment was
when …?”
“And the date today?”
- The more you can integrate your exploration of mental
status into a sensitive patient history, the less it will seem
like an interrogation.

- Anxiety, Panic, Ritualistic Behavior, Phobias.

If the patient has unusual thoughts,
preoccupations, beliefs, or perceptions, explore
them as they arise during the interview
 . For example, worries persisting over a 6-month
period suggest a possible generalized anxiety disorder, the
most prevalent psychiatric condition in the United States
following substance abuse, with a lifetime prevalence of
approximately 5%.
Over time, you will come to recognize some of its
mimics:
- panic disorder, with its recurrent panic attacks
followed by a period of anxiety about further attacks;
- obsessive-compulsive disorder, with its intrusive
thoughts and ritualistic behaviors;
- posttraumatic stress disorder, characterized by
avoidance, numbing, and hyperarousal; and social phobia,
with its marked anticipatory anxiety in social situations.
 For such patients, you will need to supplement your
interview with questions in specific areas.

You may determine the need to go further and pursue a

formal mental status examination. (The components of the
mental status examination are described in the section on
Techniques of Examination, pp. 145-155) .
See Table 5-3, Anxiety Disorders, p. 161, and Table 5-4,
Psychotic Disorders, p. 162.
Delirium or Dementia.
- All patients with documented or suspected brain lesions,
psychiatric symptoms, or reports from family members of vague
or changed behavioral symptoms need further systematic
assessment.
- Patients may have subtle ( making used of clever and indirect methodes to achive
something ) behavioral changes, difficulty taking medications properly,

problems attending to household chores or paying bills, or loss of

interest in their usual activities.
- Other patients may behave strangely after surgery or
during an acute illness. Each problem should be identified as
expeditiously as possible. Mental function influences the ability to
hold a job and is often important in evaluating disability.
See Table 20-2, Delirium and Dementia, p. 931.
EXAMPLES OF ABNORMALITIES
May be signs of depression or dementia
TABLE 5-3 Anxiety Disorders
Panic Disorder

A panic disorder is defined by recurrent, unexpected panic attacks,

at least one of which has been followed by a month or more of
persistent concern about further attacks, worry over their
implications or consequences, or a significant change in behavior
in relation to the attacks. A panic attack is a discrete period of
intense fear or discomfort that develops abruptly and peaks within
10 minutes. It involves at least four of the following symptoms: (1)
palpitations, pounding heart, or accelerated heart rate; (2)
sweating; (3) trembling or shaking; (4) shortness of breath or a
sense of smothering;
Panic Disorder 2

(5) a feeling of choking; (6) chest pain or discomfort; (7)

nausea or abdominal distress; (8) feeling dizzy, unsteady,
lightheaded, or faint; (9) feelings of unreality or
depersonalization; (10) fear of losing control or going crazy;
(11) fear of dying; (12) paresthesias (numbness or tingling);
(13) chills or hot flushes. Panic disorder may occur with or
without agoraphobia.
Agoraphobia

Agoraphobia is an anxiety about being in places or situations

where escape may be difficult or embarrassing or help
unavailable. Such situations are avoided, require a companion, or
cause marked anxiety.

Specific Phobia
A specific phobia is a marked, persistent, and excessive or
unreasonable fear that is cued by the presence or anticipation of a
specific object or situation, such as dogs, injections, or flying. The
person recognizes the fear as excessive or unreasonable, but
exposure to the cue provokes immediate anxiety. Avoidance or
fear impairs the person's normal routine, occupational or
academic functioning, or social activities or relationships.
Social Phobia
A social phobia is a marked, persistent fear of one or more
social or performance situations that involve exposure to
unfamiliar people or to scrutiny by others. Those afflicted
fear that they will act in embarrassing or humiliating ways,
as by showing their anxiety. Exposure creates anxiety and
possibly a panic attack, and the person avoids precipitating
situations. He or she recognizes the fear as excessive or
unreasonable. Normal routines, occupational or academic
functioning, or social activities or relationships are
impaired.
Obsessive-Compulsive Disorder
This disorder involves obsessions or compulsions that cause
marked anxiety or distress. Although they are recognized at some
point as excessive or unreasonable, they are very time consuming
and interfere with the person's normal routine, occupational
functioning, or social activities or relationships.

Acute Stress Disorder

The person has been exposed to a traumatic event that involved
actual or threatened death or serious injury to self or others and
responded with intense fear, helplessness, or horror. During or
immediately after this event, the person has at least three of
these dissociative symptoms:
Acute Stress Disorder( continue )
(1) a subjective sense of numbing, detachment, or absence
of emotional responsiveness; (2) a reduced awareness of
surroundings, as in a daze; (3) feelings of unreality; (4)
feelings of depersonalization; and (5) amnesia for an
important part of the event. The event is persistently
reexperienced, as in thoughts, images, dreams, illusions,
and flashbacks, or distress from reminders of the event.
The person is very anxious or shows increased arousal and
tries to avoid stimuli that evoke memories of the event.
The disturbance causes marked distress or impairs social,
occupational, or other important functions. The symptoms
occur within 4 weeks of the event and last from 2 days to 4
weeks.
Posttraumatic Stress Disorder
The event, the fearful response, and the persistent
reexperiencing of the traumatic event resemble those in
acute stress disorder. Hallucinations may occur. The person
has increased arousal, tries to avoid stimuli related to the
trauma, and has numbing of general responsiveness. The
disturbance causes marked distress, impairs social,
occupational, or other important functions, and lasts for
more than a month.
Generalized Anxiety Disorder
This disorder lacks a specific traumatic event or focus for
concern. Excessive anxiety and worry, which the person
finds hard to control, are about a number of events or
activities. At least three of the following symptoms are
associated: (1) feeling restless, keyed up, or on edge; (2)
being easily fatigued; (3) difficulty in concentrating or mind
going blank; (4) irritability; (5) muscle tension; (6) difficulty
in falling or staying asleep, or restless, unsatisfying sleep.
The disturbance causes significant distress or impairs
social, occupational, or other important functions
TABLE 5-4 Psychotic Disorders

Psychotic disorders involve grossly impaired reality testing.

Specific diagnoses depend on the nature and duration of the
symptoms and on a cause when it can be identified. Seven
disorders are outlined below.

Schizophrenia
Schizophrenia impairs major functioning, as at work or school or in
interpersonal relations or self-care. For this diagnosis,
performance of one or more of these functions must have
decreased for a significant time to a level markedly below prior
achievement. In addition, the person must manifest at least two of
the following for a significant part of 1 month:
Schizophrenia (Continue)
Schizophrenia impairs major functioning, as at work or school or in
interpersonal relations or self-care. For this diagnosis,
performance of one or more of these functions must have
decreased for a significant time to a level markedly below prior
achievement. In addition, the person must manifest at least two of
the following for a significant part of 1 month: (1) delusions; (2)
hallucinations; (3) disorganized speech; (4) grossly disorganized or
catatonic behavior;* and (5) negative symptoms such as a flat
affect, alogia (lack of content in speech), or avolition (lack of
interest, drive, and ability to set and pursue goals). Continuous
signs of the disturbance must persist for at least 6 months
Subtypes of this disorder include paranoid, disorganized, and
catatonic schizophrenia.
Schizophreniform Disorder
A schizophreniform disorder has symptoms similar to those of
schizophrenia, but they last less than 6 months, and the functional
impairment seen in schizophrenia need not be present.

Schizoaffective Disorder
A schizoaffective disorder has features of both a major mood
disturbance and schizophrenia. The mood disturbance
(depressive, manic, or mixed) is present during most of the illness
and must, for a time, be concurrent with symptoms of
schizophrenia (listed above). During the same period of time,
there must also be delusions or hallucinations for at least 2 weeks
without prominent mood symptoms
Delusional Disorder
A delusional disorder is characterized by nonbizarre delusions that
involve situations in real life, such as having a disease or being
deceived by a lover. The delusion has persisted for at least a
month, but the person's functioning is not markedly impaired, and
behavior is not obviously odd or bizarre. The symptoms of
schizophrenia, except for tactile and olfactory hallucinations
related to the delusion, have not been present.

Brief Psychotic Disorder

In this disorder, at least one of the following psychotic symptoms
must be present: delusions, hallucinations, disordered speech
such as frequent derailment or incoherence, or grossly
disorganized or catatonic behavior. The disturbance lasts at least 1
day but less than 1 month, and the person returns to his or her
prior functional level.
Psychotic Disorder Due to a General Medical Condition
Prominent hallucinations or delusions may be experienced
during a medical illness. For this diagnosis, they should not
occur exclusively during the course of delirium. The
medical condition should be documented and judged to be
causally related to the symptoms.

Substance-Induced Psychotic Disorder

Prominent hallucinations or delusions may be induced by
intoxication or withdrawal from a substance such as
alcohol, cocaine, or opioids. For this diagnosis, these
symptoms should not occur exclusively during the course
of delirium. The substance should be judged to be causally
related to the symptoms.
Reference:
Lynn S. Bickley MD, Bates' Guide to Physical Examination and History Taking, 10th Edition, School of Medicine Texas
Tech University Health Sciences Center Lubbock, Texas. Copyright ©2009 Lippincott Williams & Wilkins
Thank you