history collection in psychiatric setting

1. 1
Psychiatric history collection
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.
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
 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:
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
1. Identification data
 Name
 Age
 Sex
 Marital status
 Religion
 Education
 Occupation
 Income
 Address
 Date of admission
 Hospital No
2. Informants
 The sources of the information
 Informant’s name
 The reliability of the sources

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o 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
3. 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
o it should be recorded even if the patient is unable to speak and the patient explanation regardless
of how bizarre or irrelevant
 Patient's problem or reason for the visit
 Recorded as the patient's own words
o 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 Ask leading questions such as -"What
brings you here today?“ -How can I help you?”
4. History of present illness
Provides a comprehensive and chronological picture of the events. Probably the most helpful in making an
accurate diagnosis.
 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.
 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.
 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
5. Treatment history
Year & Month Centre Duration Treatment
 Drugs- dose/route/side effects/complains
 ECT
 Psychotherapy
 Rehabilitation
Current medications
 What medications do you take regularly and since when?
 What medications have you had in the past?
6. Past history past history
a) Past medical/surgical illness
 History of chronic medical illness and details of medication received and the duration of illness
o Hospitalization
o Medical/neurological/surgical illness
o Head injury/ convulsion/ Unconsciousness
o Accidents/surgical procedure
o DM/HTN/CAD/Visceral/ HIV +ve
b) Past psychiatric history
 H/o alcohol/substance abuse/dependence
 history of Past psychiatric illness
o Had the patient suffered from any mental illness and undergone psychiatric treatment
o Has the patient been hospitalized earlier for the treatment of mental illness

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o What was the nature of treatment she or he had been getting; drugs or ECT and its detail
o Did the patient improve with the treatment
o Has there ever been a time that you felt completely well?
7. Family history
 Family structure
 Family history of illness
o Psychiatric illness- similar/other
o Major medical illness
o Alcohol/drug dependence/suicidal attempt
 Current social situation
o Home circumstances , Per capita income, Socioeconomic status, Head of the family-nominal
& functional,
o Current attitude of the family members towards the patient’s illness
o Communication pattern in the family , Social support system available
o Cultural &religious values
8. Personal history
a. Perinatal history
o Antinatal - Any febrile illness, Physical/Psychiatric illness, Medications/drugs/alcohol use,
Trauma to abdomen, Immunization
o Birth -Full term/premature/postmature, Wanted/unwanted
o Delivery Normal/instrumental/ ceserean
o Birth cry Immediate/delayed
o Birth defects
o Postnatal complications Cyanosis/convulsion/jaundice
o Any other
b. Childhood history
o Primary care giver,
o Feeding breast feed/artificial , age at weaning
o Developmental milestones normal/delayed, age & ease of toilet training
o Behavioural and emotional problems - thumb sucking, temper tantrums, tics, head-banging,
night terror, fears, bed-wetting, nail-biting.stuttering/stammering, enuresis/ encopresis,
somnambulism

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c. Educational history
o Age at begining&finishing formal education
o Academic and extra curricular achievements- if any
o Relationship with peers &teachers
o School phobia, truancy, non-attendance, learning disabilities, reason for termination of
studies(if occures prematurely)
d. Play history
o Games played at what age &with whom relationships with playmates
e. Emotional problems during adolescence
o Running away from home delinquency smoking drug use anyother
f. Puberty
o Age at appearance of secondary sexual characteristics
o Anxiety related to puberty changes
o Age at menarche. Reaction to menarche
o Regularities of cycle & duration of flow
o Abnormalities if any(menorragia/dysmenorrea)
g. Obstetrical history
o LMP
o Any abnormalities associated with pregnancy/ delivery/ puerperium
o Number of children
o Termination of pregnancy
o Reaction to menopause
h. Occupational history
o Age at starting work
o Jobs held in chronological order
o Reasons for change, if any
o Current job satisfaction (including relationship with authorities ,peers and if applicable
,subordinates).
o Whether job is appropriate to client’s back ground
i. Sexual and marital history
o Type of marriage: self choice/ arranged
o Duration of marriage
o Interpersonal relationship with in-laws: satisfactory/ unsatisfactory
o Details of spouse and children
j. Premorbid personality
o Interpersonal relationships
 Interpersonal relationship with family members, friends, work-mates and superiors.
Introverted/extraverted. ease of making and keeping social relations.
o Use of leisure time – Hobbies, Interests, Intellectual activities, energetic/sedentary.
o Predominant mood - Optimistic/pessimistic, Stable/prone to anxiety, Cheerful/despondent,
Reaction to stressful life events.
o Attitude to self & others
o Attitude to work and responsibilities
o Religious beliefs and moral attitudes,
o Fantasy life - Day dreams –frequency and contents
o Habits
 Eating pattern: regular/ irregular
 Elimination: regular/ irregular
 Sleep: regular/ irregular
 Use of drugs/alcohol/tobacco
Chandni Narayan
11.4.2021