2. Introduction
• Psychiatric history taking is the record of
patient’s past , present history and also various
factors that leads to mental illness.
3. Definition
The psychiatry history is the record of the
patient’s life: it allows a psychiatrist to
understand who the patient is, where the
patient has come from, and where the patient
is likely to go in the future.
4. Importance
• Obtaining a comprehension history from a patient
and if necessary from informed sources are
essential to make a correct diagnosis and
formulation a specific and effective treatment
plan.
5. Purpose
• To describe adaptive and maladaptive behavior.
• To formulate priorities.
• To identify problems.
• To predict probable responses t potential
interventions.
• To analyze the client’s perceptions.
• Helps to develop nursing care plan.
6. Basic principles of history taking
• Introduce yourself
• Explain the purpose
• Ask open ended questions
• Allow the patient to explain things in his/her own words.
• Encourage the patient to elaborate and explain avoid
interrupting
7. Basic principles of history taking
• Guide the interview as necessary
• Avoid asking “why” Questions
• Listen and observe for cues
• You might need an informant.
8. components
1. Identification data
2. Informants
3. Chief complaints
4. History of present illness
5. Treatment history
6. Past history of illness
a) Medical / surgical illness
b) Past psychiatric history
9. Contd…
7. Family history
8. Personal history
a) Perinatal history
b) Childhood history
c) Educational history
d) Play history
e) Emotional problems during adolescence
f) Puberty
g) Obstetrical history
h) Sexual and marital history
i) Premorbid personality
j) Occupational history
13. Informants
• The sources of the information:
Informants name
The reliability of the sources
• Relation to patient to patient:
• Intimacy with patient
• Interest of the patient
• Does the informant live with the present?
• Duration of stay with patient
• Intellectual and observational ability
14. Chief complaints on admission
Presenting complaints and or reasons for
consultation should be recorded.
Both the patient’s and the informant’s version
should be recorded separately.
It should be recorded even if the patient is
unable to speak and the patient explanation
regardless of how bizarre or irrelevant
15. Chief complaints on admission
Patient’s problem or reason for the visit
Recorded as the patient’s own words.
Ask leading questions such as
-”What brings you here today?”
- “How can I help you?”
16. Examples:
• “am having thoughts of wanting to harm
myself”
• “peoples are trying to drive me insane”
• “I feel am going mad”
• “am angry all the time”
18. History of present illness
• Provides a comprehensive and
chronological picture of the events.
• Probably the most helpful in making an
accurate diagnosis.
19. History of present illness
• Duration- Week/months/years
• Mode of onset- Abrupt/acute/subacute /insidious
• Course –(continuous/ episodic /fluctuating/
deteriorating/ improving/unclear)
• Precipitating factors (death/ separation/ loss/
frightening experience/any other)
• Aggravating and reliving factors, if any.
20. History of present illness
• When the patient was well the last time should be noted.
• The time of onset
• When the symptoms are first noticed by the patient or by the
relatives.
• The symptoms of the illness from the earliest time at which a
change was noticed until the present time should be narrated
choronologically, in a coherent manner.
21. History of present illness
• The presenting chief complaint should be expanded.
• Any disturbances in the physiological functions like sleep,
appetite, and sexual functioning
• Always enquire about suicidal ideation
• Important negative history should be recorded(eg. No H/o head
injury)
• Life chart valuable display of course of illness.
27. Past history of illness
a) Past medical / surgical illness
b) Past psychiatric history
28. Past medical/ surgical illness
• History of chronic medical illness and death of medication
received and the duration of illness.
• Hospitalization
• Medical/neurological/ surgical illness
• Head injury/ convulsion/ unconsciousness
• Accidents/ surgical procedure
• DM/HTN/CAD/Visceral/ HIV +ve
29. Past psychiatric history
• Past psychiatric illness
• H/o alcohol/substance abuse/ dependence
• Had the patient suffered from any mental illness
and undergone any psychiatric treatment
• Has the patient been hospitalized earlier for the
treatment of mental illness
• What was the nature of treatment of mental
illness
• Did the patient improve with the treatment
30. Examples
• Any similar or other psychiatric problem in the past?
• Have you ever been admitted to a psychiatric hospital?
• What treatment have you had ?
• Has there ever been a time that you left completely well?
32. FAMILY HISTORY
a) Family structure
b) Family history of illness
• Psychiatric illness –similar/ other
• Major medical illness
• Alcohol/ drug dependence / suicidal attempt
33. Current situation
• Home circumstances
• Per capita income
• Socioeconomic status
• Head of the family-nominal & functional
• Current attitude of the family members towards the patient’s
illness
• Communication pattern in the family
• Cultural & religious values
• social support system available
34. Description of family members
S . No Name Age sex Relationshi
p with
patient
Age / mode
of death
37. Examples
• Are your parents still living? Are they well?
• Do you mind me asking how they died?
• What did your parents do?
• Do you have any brothers or sisters? Are you close to them?
• As far as you know, has anyone in your family ever had
problems with their mental health?
40. a) Perinatal history
Anti natal
Any febrile illness
Physical/Psychiatric illness
Medication/drugs/alcohol use
Trauma to abdomen
Immunization
Birth
Full term/premature/post mature
Wanted /unwanted
42. b) Childhood history
Primary care giver
Whether the patient was brought up by mother/some one else
Feeding
Breast feed/artificial
Age at weaning
Developmental milestones
Normal/delayed
Age & ease of toilet training
44. Examples
• Where were you born?
• Where did you grow up?
• As far as you know, was your mother’s pregnancy and delivery
normal?
• If not, were there any problems around the time of your
birth?
• Did you have any serious illness as a young child?
• Were you walking and talking at the correct times?
45. c) Educational history
Age at beginning & finishing formal education
Academic and extra curricular achievements- if any
Relationship with peers & teachers
School phobia
Truancy, non attendance
Learning disabilities
Reason for termination of studies (if occurs prematurely)
46. Examples
• Which school/ did you go to?
• Did you enjoy school?
• Any lasting memories of school?
• Did you have many friends at school? Still in contact?
• When did you finish school ? Qualification?
• Were you ever in trouble at school? ever expelled or
suspended? Bullied?
47. d) Play history
• Games played
At what age & with whom
Relationship with playmates
48. e) Emotional problems during
adolescence
• Running away from home
• Delinquency
• Smoking
• Drug use
• Any other
49. f) Puberty
• Age at appearance of secondary sexual characteristics
• Anxiety related to puberty changes
• Age at menarche
• Reaction to menarche
• Regularities of cycle & duration of flow
• Abnormalities if any (menorrhagia/dysmenorrhea)
50. g) Obstetrical history
• LMP
• Any abnormalities associated with
pregnancy/delivery/puerperium
• Number of children
• Termination of pregnancy
• Reaction to menopause
51. Occupational history
• Age at starting work
• Jobs held in chronological order
• Reasons for change, if any
• Current job satisfaction (including relationship with authorities
, peers and if applicable, subordinates).
• Whether job is appropriate to clients back ground
52. i) Sexual and marital history
• Type of marriage: self choice / arrange
• Duration of marriage
• Interpersonal relationship with- in-laws: satisfactory/ unsatisfactory
• Details of spouse and children
53. j) Premorbid personality
a) Interpersonal relationships
Interpersonal relationship with family members, friends,
work-mates and superiors
Introverted/ extroverted
Ease of making and keeping social relations.
b) Use of leisure time
Hobbies
Interests
Intellectual activities
Energetic/ sedentary.
54. Contd..
a) Predominant mood
Optimistic/pessimistic
Stable/prone to anxiety
Cheerful/despondent
Reaction to stressful life events.
b) Attitude to self & others
Self-criticism level & self-consciousness
Self- confidence level
Selfish/thoughtful of others
Achievement and failures.
General attitude towards others
55. Contd..
a) Attitude to work and responsibilities
Decision making
Acceptance of responsibility
Flexibility
Foresight
b) Religious beliefs and moral attitudes
c) fantasy life
Day dreams- frequency and contents
