PSYCHIATRIC HISTORY COLLECTION

Ms. Meril Manuel
Lecturer
VINE

IntroductIon
Psychiatry History Taking :
 It is the record of the Patient‘s life
It allows to understand
o who the patient is
o where the patient has come from
o where the patient is likely to go in the future.

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.

IMPORTANCE
• Obtaining a comprehensive history from a
patient and if necessary from, from informed
sources are essential to make a correct
diagnosis and formulating a specific and
effective treatment plan.

PurPose :-
To describe adaptive and maladaptive behavior.
To formulate priorities.
To identify problems.
To predict probable responses to potential
interventions.
To analyze the client’s perceptions.
Helps to develop nursing care plan.

BASIC PRINCIPLES OF HISTORY TAKING
• Introduce yourself
• Explain the purpose and approx how long it will
take
• Ask Open Ended Questions
• Allow the patient to Explain Things In his/her
Own Words

BASIC PRINCIPLES OF HISTORY TAKING
•Encourage the patient to Elaborate and explain
• Avoid Interrupting
• Guide the Interview As Necessary
• Avoid Asking “Why?” Questions
• Listen and Observe For Cues
• You might need an informant

Components
1. Identification data
2. Informants
3. Chief complaints
4. H/o Present Illness
5. Treatment history
6. Past history of illness
a) Medical/surgical illness:
b) Past psychiatric history :
7 Family history:

Components
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. Occupational history
i. Sexual and marital history
j. Premorbid personality

IdentIfIcatIon data:
Name :
Age :
Sex :
Marital status:
Religion:
Education:
Occupation :
Income
Address:
Date of admission:
Hospital No :
Psychiatric ward :
♣marital status♣

II Informants:
The sources of the information:
Informant’s name
The reliability of the sources
• Relation to Patient:
• Intimacy with the patient
• Interest of the patient’
• Does the Informant live with the patient?
• Duration of stay with the patient
• Intellectual and observational ability

III 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

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?”

• 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 “

Present
Illness
Present
Illness

4. HISTORY OF PRESENT ILLNESS
Provides a comprehensive and chronological
picture of the events.
Probably the most helpful in making an accurate
diagnosis.

History of present illness
 Duration- Weeks/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 relieving factors, if any.

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 chronolo-gically, in a coherent
manner.

HISTORY OF PRESENT ILLNESS
 The presenting chief complaints 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 chrt-valuable display of course of illness

V. TREATMENT HISTORY
• Drugs- dose/route/side effects/complains
• ECT
• Psychotherapy
• Rehabilitation
Year &
Month
Centre Duration Treatment

Current medications
• What medications do you take regularly and
since when?
• What medications have you had in the past?

VI. PAST HISTORY OF ILLNESS
a) Past medical/surgical illness:
b)Past psychiatric history

Past medical/surgical illness:
History of chronic medical illness and details 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

Past psychiatric history
• Past psychiatric illness
• H/o alcohol/substance abuse/dependence

Past psychiatric history
–Had the patient suffered from any mental
illness and undergone psychiatric treatment
–Has the patient been hospitalized earlier for
the treatment of mental illness
–What was the nature of treatment she or
he had been getting; drugs or ECT
–Did the patient improve with the treatment

?
• Any similar or other psychiatric problems
in the past?
• Have you ever been admitted to a
psychiatric hospital?
• What treatments have you had?
• Has there ever been a time that you felt
completely well?

VII FAMILY HISTORY
a. Family structure
b. Family history of illness
o Psychiatric illness- similar/other
o Major medical illness
o Alcohol/drug dependence/suicidal
attempt

c. Current social situation
o Home circumstances
o Per capita income
o Socioeconomic status
o Head of the family-nominal & functional
o Current attitude of the family members
towards the patient’s illness
o Communication pattern in the family
o Cultural &religious values
o Social support system available

S NO NAME AGE SEX RELATIONSHIP
WITH PATEINT
AGE/ MODE OF
DEATH
Description of family members

?
• 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?

PERSONAL HISTORY
a. Perinatal history
Antinatal
Any febrile illness
Physical/Psychiatric illness
Medications/drugs/alcohol use
Trauma to abdomen
Immunization
Birth
-Full term/premature/postmature
Wanted/unwanted

 Delivery
Normal/instrumental/ ceserean
Birth cry
Immediate/delayed
Birth defects
Postnatal complications
Cyanosis/convulsion/jaundice
Any other

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

Behavioural and emotional problems
Thumb – sucking
 temper tantrums
 tics, head-banging
 night terror
 fears
 bed-wetting
nail-biting.
Stuttering/stammering
Enuresis/ encopresis
Somnambulism

?
• 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 illnesses as a young
child?
• Were you walking and talking at the correct
times?

c. Educational history
Age at begining&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 occures
prematurely)

?• Which school/s 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 ? Qualifications?
• Were you ever in trouble at school? ever
expelled or suspended? Bullied?

d. Play history
 Games played
At what age &with whom
Relationships with playmates

e. Emotional problems during adolescence
Running away from home
delinquency
smoking
drug use
anyother

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(menorragia/dysmenorrea)

g. Obstetrical history
LMP
Any abnormalities associated with pregnancy/
delivery/ puerperium
Number of children
Termination of pregnancy
Reaction to menopause

h. 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 client’s back
ground

i. Sexual and marital history
• Type of marriage: self choice/ arranged
• Duration of marriage
• Interpersonal relationship with in-laws:
satisfactory/ unsatisfactory
• Details of spouse and children

J. Premorbid personality
a.Interpersonal relationships
 Interpersonal relationship with family members,
friends, work-mates and superiors
 Introverted/extraverted
 ease of making and keeping social relations.
a.Use of leisure time
o Hobbies
o Interests
o Intellectual activities
o energetic/sedentary.

a. Predominant mood
o Optimistic/pessimistic
o Stable/prone to anxiety
o Cheerful/despondent
o Reaction to stressful life events.
a. Attitude to self & others
o Self-confidence level
o self-criticism & self-consciousness
o selfish/thoughtful of others
o self-appraisal of abilities,
o achievements and failures.
o General attitude towards others

a. Attitude to work and responsibilities
b. Decision making
c. acceptance of responsibility
d. flexibility
e. foresight.
f. Religious beliefs and moral attitudes
g. Fantasy life
Day dreams –frequency and contents

a. Habits
• Eating pattern: regular/ irregular
• Elimination: regular/ irregular
• Sleep: regular/ irregular
• Use of drugs/alcohol/tobacco

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