Psychiatric History 

Steps of Psychiatric History Taking

1. Put the patient at ease 
2. Introduce yourself and explain your role 
3. Ask to introduce to anyone else accompanying the patient 
4. Inform them about the length of the interview, 
5. And the need to take notes 
6. Ensure confidentiality

 

Demographics

 

Name 

Age 

Sex

Address 

Educational qualifications

Occupation 

 

Informants 

 

Relationship to the patient

Living with the patient

For how long do they know the patient

Reliability

 

Presenting Complaints 

 

Who referred patient and what is their concern/request 

Where is patient being seen? 

Are they voluntarily present or detained under MHA

And which section

If applicable

What is the complaint, in their own words 

 

History of the Present Illness

 

Nature of problem 

Precipitant/trigger 

Course

Onset (when, sudden or insidious)

Time-span

Development of symptoms 

(Improving, worsening)

Fluctuations

Factors that affect the severity

Worsening or improving

Other expected symptoms 

Degree of functional impairment

Level of distress

Effect on others 

Treatments trialled so far, 

Their effectiveness 

Side effects

Adherence

Other current medications 

 

Past History

 

Past medical history 

(Past) history of psychiatric symptoms

Previous diagnoses

Hospitalization

Recovery between episodes 

Previous DSH and suicidal attempts 

Chronological treatment history

Past medications

Which ones were effective 

And which ineffective 

Allergies or adverse reactions

Especially EPS, NMS. 

Depot Injections

Compliance in case of lithium

Electroconvlusive therapies

How many

What was the effect 

Any complications during ect

Any adverse effect on memory 

Other treatments

Including from primary care

Counselling

Psychotherapy

Complementary therapy 

 

Family History

 

Parents

Age (now or at death), 

Occupation, 

Quality of relationship with patient 

Siblings

As above, 

Birth order 

Psychiatric history in family members

Substance use

Suicide

Other familial illnesses. 

Genogram 

 

Personal History

 

Mother’s pregnancy

Birth 

Early development

Illness in childhood 

Separations

Emotional problems 

Relationships with family members, 

Atmosphere at home 

Schooling

Academic performance 

Peer relationships

Bullying

School refusal 

Shyness

Conduct issues

Qualifications

Further education 

Occupation(s) 

Work performance 

Sexual relationships

Marriage

Children 

History of abuse 

Physical

Sexual 

Emotional 

In childhood or adulthood

Alcohol, other substances, tobacco. 

 

Substance Abuse, if positive

 

Pattern of use 

Age at onset 

Relationship to symptoms 

Harmful use 

Psychological dependency 

Physical dependency 

Previous detox 

Patient view 

Risky behaviours

 

Forensic History

 

Record all offences – convicted or not. 

Violence/Anger, sexual offences particularly important 

Persistent offending 

Probation 

Relationship to symptoms

 

Premorbid Personality

Hard to assess at one-off interview and collateral information should be sought. 

Ask patient how others see them/would describe them

Relationships

 

How many friends

Is he/she shy

How stable

Are friends superficial

Relations with elders and boss

Relations at home 

 

Prevailing mood and emotions, character traits

how they get on with people; deal with stress; hobbies; standards. 

 

Impulsive 

Prone to worry 

Strict, fussy 

Seek attention 

Untrusting, resentful 

Irritable 

Sensitive 

Suspicious 

Argumentative 

Lack concern for others 

 

Current Social Circumstances

 

Who they live with 

Current employment 

Stressors 

Social supports 

Typical day 

 

Mental Status Examination

 

Describe what you see 

General appearance and behaviour. 

Striking physical features. 

Posture, Physique, clothing, hair, cleanliness, self-care, posture 

Facial expression (depressed, anxious, wooden) 

Eye contact, rapport 

 

Motor activity:

Agitation

Retardation 

Restlessness

Tremulousness

Stuprose (akinesic and mute)

 

Abnormal Movements

Tics

Tardive Dyskinesia

Chorea

Stereotypy

Catatonic Features

Mannerism

 

Other

Tearfulness 

Distractibility 

Disinhibition 

Appears to hear voices, preoccupied. 

 

Speech and thoughts 

 

Rate

Slow in depression

Pressure of speech in mania

Quantity

Reduced 

(poverty of speech and/or thoughts) 

in depression 

and chronic schizophrenia 

(where it is also called alogia)

Flight of ideas in mania 

(in which quantity of speech is also increased)

Racing thoughts may occur without an increased quantity of speech. 

Volume 

Increased in mania

Reduced in depression

Pattern 

Spontaneity

Coherence 

Rationality

Circumstantiality

(skirts around the topic)

Perseveration 

as in frontal lobe syndrome, 

organic brain syndromes of other types

Neologisms

Puns

clang associations

(word that sounds the same). 

Formal thought disorder

Loosening of associations

Knight’s move thinking, 

Word salad (schizophrenia) 

Thought blocking

arrest of train of thought leading to blankness of mind

Different than losing the train of thought 

 

Mood-Subjective

Patient description

Sad, happy, top of the world, worried 

Depression:

 

Early morning wakening, 

Diurnal variation, 

Anhedonia 

Loss of appetite 

Loss of weight 

Fatigue 

Loss of concentration

Hopelessness

Suicidal thoughts, plans, intent 

 

 

Anxiety

 

Worrying thoughts

Fearfulness

Palpitations

Feeling missed beats

Chest pain

breathlessness

Dry Mouth 

Sweating

Tremor 

 

Elation

 

Over Activity

Excessive Self-Confidence

Increased self esteem

Reduced Sleep 

Distractibility

Increased Libido 

 

Mood-Objective

 

Your objective description of emotion 

Depressed

Anxious 

Fearful 

Irritable

Suspicious

Perplexed

Elated 

Angry 

Fluctuations:

Reactivity, 

Lability (Mania), 

Blunting (Chronic Schizophrenia) 

Consistent with thoughts/behaviour?

Incongruity is seen in schizophrenia

 

Thought content 

 

Preoccupations 

Obsessional thoughts

Compulsive rituals 

Delusions:

Persecution

Infidelity

Grandiose

Hypochondriacal

Love

Guilt

Nihilistic

Poverty 

Reference

Infestation 

Thought Interference 

“loss of boundary with outside world”

usually found in schizophrenia 

Thought withdrawal 

Thought insertion 

Thought broadcasting 

Passivity

Humans usually experience actions, thoughts, feelings as under their control but may (usually in schizophrenia) experience them as being under control of another agency 

 

 

 

Perception

 

Illusions 

Hallucinations

Can occur in any sensory modality. 

Visual, More likely in organic conditions 

Gustatory, unpleasant taste 

Olfactory, TLE

Tactile: 

touched, pricked

insects crawling on skin 

(formication, drug withdrawal/cocaine) 

Deep Sensation:

May be sexual. 

Considered first-rank only when they are interpreted delusionally 

Auditory Hallucinations: 

May be noises, 

whispers,

partially organised 

Thought echo 

echo de pensee

gedankenlautwerden 

 

Cognitions

 

Consciousness 

Alert

Clouding 

Stupor 

Orientation

Time, 

Place 

and person 

(if answers are wrong then ask about the persons own name, occupation, and role in life) 

Attention 

7-Digit span test 

Concentration 

Serial 7’s, 

Spell WORLD in reverse order, mentally 

STM

Name and address with seven items.

Recall after three or five minutes. 

Or three unrelated itmes, 

Recall after five minutes

LTM

Events from the past 

Frontal Lobe

Verbal fluency, 

similarities/differences, 

Luria’s three stage task

General knowledge and intelligence

From interview and PM, events 

Can use screening instruments: MMSE or ACE

 

Insight (GOOD, MODERATE, POOR)

 

Awareness of abnormal state of mind 

Understanding of the cause 

Understanding of benefits of treatment 

Awareness of effects of not having treatment

 

 

Preparing for the interview 

Are there any risks, so that precautions can be taken.

Find what’s already known about the patient's past and current. 

Some recommend avoiding this, to help an unbiased first assessment. 

Precautions 

 

Inform another person 

Emergency call should be available 

No obstruction between you and the door 

No weapons in the room 

High Risk? 

Defer

 

Staring the interview 

 

Greet the patient and companions 

Introduce yourself

Explain the reason for the interview

State the time available

Can the patient be seen alone? 

If yes, do it 

Acknowledge the need to take notes 

Explain the structure of the interview 

Make the patient comfortable 

The chair should be at an angle but the same level 

Keep taking notes 

Agitated or anxious patient? 

Defer notes

Patient-led history 

Invite the patient to tell you about their presenting complaint.

Use general opening questions 

and prompt for further elaboration.

Let the patient do most of the talking

help them tell the story in their own words

Note the major observations in the mental state examination

Doctor-led history 

Clarify the details in the history

Including the nature of diagnostic symptoms 

e.g. are these true hallucinations? 

Is there diurnal mood variation?. 

Explore significant areas not reported spontaneously

Background history 

Complete the history by direct inquiry. 

This is similar to standard medical history-taking, 

With the addition of a closer inquiry into the patient’s personal history.

Summing-up 

Summarise the history back to the patient. 

Ensure there are no omissions 

or important areas uncovered.

Indicate if you would like to obtain other third-party information, 

To help better your understand their problems

and their diagnosis.

 

Techniques of effective interview

 

Be relaxed and unhurried 

Have proper eye contact 

Be alert to cues of distress 

Control over-talkative patients 

 

Personal History-Detailed 

 

Explain to the patient,

now we will talk about your life story and current circumstances 

from before birth until now. 

Acknowledge that it will be detailed 

and educate why it is important 

i.e. we know what kind of illness you have

but we also want to know what has caused this illness in you 

so that we can make a better management plan for you. 

Collateral information will be required

 

Mothers Pregnancy and birth 

 

Preferably from the mother

During the pregnancy before he was born, 

Did you have any health problems, 

Like fever, hypertension, diabetes, fits, or other illness? 

Did his birth occur at home or hospital? 

Were there any birth complications? 

On what month (premature?) was he born? 

Did he cry immediately after birth? 

 

Early Development 

At what age did he started to crawl, sit, stand, walk, talk, achieved sphincter control? 

Childhood 

 

Did he have any prolonged separation from parents in childhood? 

If yes, what was his reaction to this separation? 

Did he develop any serious illness in childhood? 

Did you have any emotional problems in childhood? 

If yes, what was the age at onset, the treatments received, the duration of the problem? 

 

Schooling and higher education 

 

How much are you educated? 

What type of student were you? 

What are your achievements? 

What were your extracurricular activities and interests? 

How were your relations with school friends? 

How were your relations with teachers 

Do you have any experience of bullying others or being bullied by others? 

If yes, nature, duration, impact. 

 

Occupations 

 

What is your present job, tell me the date since you started it, your duties, performance, and satisfaction with this job? 

Did you do any earlier Jobs? [enlist] 

If yes, why did you change jobs? 

 

Relationships and sex 

 

Are you married? 

If yes, for how long are you married? 

How are your relationships with your partner? 

What is the state of health of your partner? 

What is the attitude of the partner to your current illness? 

Did you have any other relationships currently or in the past? 

What was/is the nature of these relationships? 

What is your attitude towards sex? 

Do you have any sexual problems? 

If yes, do these have any relationship to your current illness? 

 

Children 

 

[if the patient is married] Do you have any children? 

If yes, how many children do you have [alive and dead]? and 

What is the physical and mental health of each of your children?

Any abortions, or stillbirths? 

 

Social Circumstances 

 

What is your financial situation? 

Do you live in your own home or a rented one? 

The total number of persons in your home and the number of rooms? 

Who lives in that whom with you? 

What kind of home do you own [closed open, mud concrete]? 

 

Substance use 

Have you used cigarettes, cannabis, naswar, and other illicit drugs? 

If yes, how much and for how long? 

What problems have they caused? 

Forensic History 

Have you been arrested, convicted or imprisoned ever? 

What was the nature of the offenses

Integration and evaluation of information 

 

What is the most likely diagnosis? 

What is the severity? 

What are the possible risks to self and others? 

Suicidal Risk 

Homicidal Risk 

What are the effects on the patient’s life? 

What are the current circumstances of the patient? 

Accommodation 

Interests 

Values 

Relationships 

Finances 

What are the causes of the current condition? 

Predisposing 

Precipitating 

Perpetuating 

Life chart 

Personality 

What are the available treatments? 

What is the prognosis? 

What the patient needs and wants to know? 

 

Questioning techniques

Open-ended vs. closed-ended questions 

An open-ended question does not suggest anything about the possible answers; 

e.g. can you tell me how you are feeling?

Can you tell me what’s on your mind these days?

A closed question expects a limited range of replies. 

e.g. is your mood up or down at the moment?

In general, begin the interview with open questions, turning to more closed questions to clarify details or factual points.

Non-directive vs. leading questions 

A leading question directs a patient towards a suggested answer 

e.g. ‘is your mood usually worse in the mornings?’

instead of ‘is your mood better or worse at any time of day?’

Always try to avoid leading questions.