Mastering the HPI – Beyond Checklists, Into the Mind
Case 1, Episode 2
“It started around the time I moved off campus. I stopped going to class. I couldn’t focus. I started hearing things. I thought it was just stress. But now I’m not so sure.”
In Episode 1, we met Sarah—a 22-year-old college senior unraveling.
Paranoia. Intrusive thoughts. Isolation. Whispering voices.
Our task: Understand her. Help her. Find clarity.
But we can’t do that with a rushed or rigid approach.
That’s why we begin with the most powerful tool in your psychiatric toolkit:
The HPI—the History of Present Illness.
And not just any HPI[1].
Today, we explore how to turn a chaotic story into a clear, compassionate clinical narrative that honors both symptom and soul.
The Purpose of the HPI
The HPI[2] isn’t just a story—it’s your clinical compass.
Done well, it helps you:
Understand what the patient is experiencing
Map the timeline and trajectory of symptoms
Clarify triggers, coping mechanisms, and functional impact
Begin distinguishing between different diagnostic pathways
Reveal the patient’s insight, meaning-making, and inner logic
Most importantly, it invites the patient into a process of self-reflection, which is in itself therapeutic.
The Framework: Five Anchoring Questions
Here’s how we structure the HPI[3] for depth and clarity. These five domains form a clinical rhythm for your assessment:
When did this begin?
Symptoms without a timeline are like puzzle pieces without edges.
Sarah: “It started around the time I moved off campus. Maybe two, three months ago?”
Key takeaway: We now know the onset was acute, not lifelong.What changed around that time?
Context provides causality—or at least correlation.
“I was living alone for the first time. I thought I’d love the independence, but I started staying up late, not eating, feeling weird.”
Here, we uncover potential triggers: Isolation, sleep dysregulation, role transition.How have the symptoms progressed?
Is it episodic? Gradual? Sudden? Escalating?
“At first it was just noise at night. Then I started hearing whispers. Then… I started thinking my roommates were talking about me. Even when they weren’t home.”
This helps you determine intensity, pattern, and level of impairment.How has this affected your daily functioning?
This anchors the symptoms in real-world consequences.
“I stopped going to class. I missed two exams. I don’t talk to anyone. I’m scared to go outside.”
We’re now looking at major functional decline, especially academic and social.What do you think is going on?
Insight is gold.
“At first, I thought I was just anxious or stressed. But now I don’t know. Maybe something’s wrong with my brain.”
This gives you a glimpse into Sarah’s awareness, capacity for reflection, and potential engagement in treatment.
Now Step Back: What’s Emerging?
From this single structured conversation, here’s what we now know:
Timeline: ~2–3 months
Triggers: Isolation, sleep disruption, stimulant use
Symptoms: Paranoia, auditory hallucinations, thought alienation
Function: Marked decline in academic and social roles
Insight: Uncertain, but not entirely absent
We don’t yet have a diagnosis.
But we have a clinical story.
And that story is our map.
The Art Part: Tone, Timing, Trust
Clinical skill matters—but relational skill matters more.
Be curious, not clinical.
Instead of “When did your psychotic symptoms begin?” try:
“When did things first start to feel strange or unfamiliar?”
Mirror their language, then gently translate.
If they say, “I feel like I’m unraveling,” say:
“That sounds overwhelming—let’s walk through what unraveling has felt like.”
Normalize without minimizing.
“Many people struggle with feeling detached when under stress. That doesn’t make you weak. It makes you human. Let’s figure this out together.”
Trust builds clarity.
Clarity builds the path to healing.
Coming Up Next: Episode 3 – The Full Psychiatric Assessment
We’ve heard Sarah’s story. Next, we widen the lens.
In Episode 3, we’ll walk through:
The biopsychosocial formulation
Her developmental stage (Is this identity vs. role confusion?)
Cultural, trauma, and social determinants
Maslow’s hierarchy of needs—what’s unmet, and what must be addressed first?
Reflective Prompt for You
What’s one question you always ask when something “just doesn’t make sense” in a case?
Share your go-to phrases, your guiding instincts, or your biggest challenges in building a strong HPI.
Drop them in the comments or share this article with a colleague—it’s time to elevate how we teach and practice psychiatric care.
References:
[1] Adler, Herhert M. "The history of the present illness as treatment: who's listening, and why does it matter?." The Journal of the American Board of Family Practice 10.1 (1997): 28-35.
[2] Redelmeier, Donald A., et al. "Problems for clinical judgement: 1. Eliciting an insightful history of present illness." Cmaj 164.5 (2001): 647-651.
[3] Aronson, Louise. A history of the present illness: Stories. Bloomsbury Publishing, 2013.