A Guide to Psychiatric History Taking

Psychiatric history taking is a crucial component of mental health assessment and diagnosis. It involves gathering information about a person’s mental health status and symptoms, past medical history, family history, lifestyle and social circumstances, and personal experiences.

The process enables mental health professionals to gain a comprehensive understanding of the individual and helps in forming an accurate diagnosis and appropriate treatment plan. The information gathered during psychiatric history taking also forms the basis for ongoing monitoring and management of the individual’s mental health.

By gathering a thorough psychiatric history, mental health professionals can improve the quality of care they provide and support individuals in their journey toward recovery.

01. Particulars of the patient

• Name,
• age,
• sex,
• religion,
• education,
• occupation,
• marital status,
• address etc.

02. Chief complaints

Statement from the patient: Sometimes patient denies illness & gives insufficient information.

Then information from reliable (Relatives or others) informants is required.

03. History of present illness

Elaboration of chief complaints as well as observation of patient’s mode of answer & behavior. Describe the obtaining treatment with impact (if any) including other than medical treatment.

04. Family history:

• Father: Alive/dead, education, occupation, relationship, attitude, etc.
• Mother: Alive/dead, education, occupation, relationship, attitude, etc.
• Siblings: Number, birth order of the patient, education, occupation, relationship, attitude, etc. \
• Social Position: Higher/Middle/Lower. Consanguinity: Present/Absent.
• Family history of psychiatric illness: Present/Absent. If present, then, 1st degree/2nd degree.
• Type of illness, treatment history, outcome.

05. Personal history:

• Birth history: Any complications.
• Early development: Normal/delayed.
• Childhood: Personality trait.
• Schooling & Education:
• Age of schooling, level of education.
• Occupational history: Frequent change of job, and relationship with colleagues.
• Marital history: Age of marriage, multiple marriages.
• Sexual history: Age of first sexual exposure, extramarital relationship.
• Menstrual history: Regular/irregular/painful etc.
• Obstetrical history: Number of children, normal delivery or cesarean section
• Children: Number, education, relationship, etc.
• Family type & environment: Nuclear/joint, healthy/unhealthy.
• Forensic history: Nature of offenses, arrests, convictions, imprisonment.
• Social circumstances: Housing, finances, stress, etc.

06. Past history of psychiatric illness:

• Type of illness,
• duration of illness,
• treatment history,
• outcome.

07. Past history of medical illness

• Type of illness,
• accident,
• drug treatment,
• operations,
• outcome.

08. History of substance abuse:

• Types of substances,
• duration,
• impact etc.

09. History of premorbid personality:

• Relationship, character,
• predominant mood,
• attitudes,
• leisure activities,
• habits,
• hobbies etc.

10. General examination:

Positive findings if any

11. Systemic examinations :

Especially nervous system

12. MSE (Mental State Examination)

A. Appearance & Behavior

General appearance: Physical health (ill-looking, underweight, overweight), dressing (dirty, bright color, the oddity of dress, etc.),

Hygiene (self-neglected, unkempt, over kempt, etc).

Facial appearance:

• Depressed (corner of the mouth is turned downward, increase vertical furrow between eyebrows),
• anxious (wide palpebral fissure, pupil widely dilated, increase transverse furrow of forehead), blunted (reduced expression of the face),
• flattened (expressionless face),
• labile (frequent change of expression),
• euphoric (excessive pleasure or smiling face) etc.

Rapport: Not established/established but not maintained/well established & maintained.

Posture & Movement: Stupor, mannerism, stereotypes, posturing, echopraxia, waxy flexibilities, etc.

Social behavior: Avoidant, withdrawn, over-familiar, anxious, etc.

Motor behavior: Excessive (agitation), reduced (retardation)

The oddity of behavior: Aggressive, hostile, unresponsive, etc.

B. speech

Incoherent or irrelevant speech, rapid or pressure of speech, slow or poverty of speech, echolalia, mute or no speech.

C. Mood & Affect

Euthymic or normal, depressed (How you are feeling?, do you feel depressed? do you feel pleasure with pleasurable activities?),

• anxious (do you feel worried?, are you unable to concentrate?, are you able to relax?),
• bunted (reduced expression, insufficient answer),
• flattened (expressionless),
• labile ( frequent changes of quality of mood),
• elated (how you are feeling?, do you think that you have special power or ability?).

D. Thoughts

Stream of thoughts: Pressure of thought, poverty of thought, thought blocking.

• Form of thought: Flight of ideas, loosening of association, perseveration, etc.
• Possession of thought: Do you think that your thoughts are being broadcast to others? do you think that your thoughts are stolen or withdrawn by an alien force?
• Content of thought: Delusions (do you think that someone try to harm you?, do you think that people are fun with you? etc.), obsessions (are you trying to resist the thoughts or activities),
• homicidal/suicidal thoughts ( do you want to kill someone?, do you want to die?).

E. Hallucination

Are you hearing voices without the presence of any person? are you hearing voices of conspiracy without the existence of persons? do you feel the movement of insects under the skin? etc.

F. Cognition

• Consciousness: Stupor (unresponsive, immobile & mute though the patient is apparently conscious).
• Orientation: Time, place & person.
• Attention & concentration: DOWB (days of the week from backward), MOYB (Months of the year from backward),
• subtraction of 7 from 100 or 3 from 20 depending upon the intelligence & educational level of the patient.
• Memory: Immediate (name three things & ask to recall after 5 minutes, give a telephone number & ask to recall after 5 minutes, etc.), recent ( ask the address of the patient, ask the items in breakfast, ask important headline of daily newspaper of that day, etc.), remote ( ask the birthday, marriage day of the patient, independent day, victory day, etc.)
• Intelligence: Indirect evidence from the conversation, an IQ test.
• Judgment: What will you do when you get a letter with an address? what will your duty be if set fire to a neighbor’s house?
• Abstract thought: Ask about similarities (difference between apple & pear, bus & train, etc)., ask the meaning of the proverb (unity is strength, a rolling stone gathers no moss, etc.)

G. Insight

• Are you ill? if yes, then ask, are you suffering from mental illness? if yes, then ask, is treatment required.
• If the first answer is no then insight is completely lost.
• If the subsequent answer is no then insight is partially lost.

13. Differential diagnosis.

14. Provisional diagnosis.

15. Investigations:

Depending upon the individual patient m Psychological • Laboratory

16. Confirm the diagnosis.

17. Treatment.

18. Follow up.

Conclusion

In conclusion, psychiatric history taking is a crucial aspect of mental health assessments. A thorough and accurate history can aid in the diagnosis of mental health conditions and help in determining the best course of treatment. Mental health professionals should approach history-taking with empathy, open-mindedness, and a non-judgmental attitude to build trust with their patients. It is important to be mindful of the power dynamics in the therapeutic relationship and to respect the privacy and confidentiality of the patient.

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