HISTORY TAKING IN

PSYCHIATRY

PRELIMINARY
INFORMATION
-Identifying information
-Referral source
-Sources of information

REFERRAL AND
INFORMANTS
When and where is patient being
seen?
Legal status of admission : voluntary
or detained?
Why are they being seen?
Who was history taken from; patient
or caretaker?

THE SOURCES OF
INFORMATION
Informants 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

CHIEF COMPLAINT
Nature, duration and severity of the
principal difficulties
(chronological events)

PRESENT ILLNESS

Record events chronologically

When did you last feel well?
Duration
Mode of onset acute / insidious
Course continuous/ fluctuating
Precipitating factor
Aggravating and relieving factor If
any

DEPRESSION (SIGECAPS)
Sad or depressed mood
Insomnia
Guilt or worthlessness or hopeless or helpless
with no motivation
Energy decreased
Cognitive problems like concentration,
attention, planning, memory
Anhedonia including Appetite disturbance
with or without weight change and libido
Psychomotor retardation or agitation/
Suicidal thoughts

THOUGHTS OF SELF HARM

How do you feel about the future?

Worthlessness
Thoughts of ending life how
Preparation
Any attempt
Self injurious behaviour

MANIA (DIGFAST)
Distractibility
Irritability and Indiscretion (excessive
pleasurable but risky regrettable in
the future activities)
Grandiosity
Flights of Ideas
Activity increased
Sleep decreased need
Talkativeness (pressured speech)

 Anxiety disorders- GAD/ Panic

attack/ OCD
Delusional disorders
Somatization disorders/ Malingering/
factitious disorder
Post- traumatic stress disorder

ASSOCIATED SYMPTOMS

Other physical symptoms?

Appetite
Weight loss
Lack of motivation
Sleep affected

PSYCHOSIS
Have you been had any thoughts
recently that you now accept as
being strange or that others have
commented on being strange?
Are they any plots against you?
Have people been interfering with
your thoughts (thought insertion) or
are your thoughts being withdrawn
or broadcast (thought alienation)

 Do you ever see or hear things that other

people seem unable to see or hear?
(Hallucination)
If yes, are the voices talking about you
(third person) or to you (second person),
are they commenting on what you are
doing (running commentary) or are they
telling you to do certain things, if so what?
Do you believe the voices and do you do
what they tell you to do?

INSIGHT
Does the patient believe that their abnormal
experiences are symptoms?
Does the patient believe that their
symptoms are attributable to illness?
Do they believe that the illness is
psychiatric?
Do they believe that psychiatric treatment
might benefit them?
Would they be willing to accept advice from
a doctor regarding their treatment?

CLINICAL RATING OF
INSIGHT
1. Complete denial of illness
2. Slight awareness of being sick and needing
help but denying it at the same time
3. Awareness being sick but it is attributed to
external or physical actors.
4. Awareness of being sick, due to something
unknown in self
5. Intellectual insight
6. True emotional insight

Drugs
ECT
Psychotherapy
Rehabilitation

 History of chronic medical illness

and details of medication
received and duration of illness
Hospitalisation
Medical / neurological/ surgical
illness
Head injury / convulsion /
unconsciousness
Accidents/ surgical procedure
DM/ HTN/ Heart disease

PAST PSYCHIATRY HISTORY

Any mental illness

Hospitalisation
Treatment nature (drugs / ECT)
Any improvement
Suicidal/ Homicidal risk assessment
(Severity of past attempts)

 Family structure consanguineous

relationship
Family history of illness
Current social situation
home circumstances
per capita income
socioeconomic status
leader of the family
current attitudes of family members towards
the patients illness

Perinatal history
Antenatal
Any febrile illness
Physical / psychiatric illness
Medications/ drugs/ alcohol use
Immunisation
Birth
Term/ premature
Wanted/ unwanted pregnancy

 Delivery : normal / instrumental /

caesarean
Birth cry : immediate / delay
Birth defects
Postnatal complication : cyanosis /
convulsion/ jaundice
Any other

CHILDHOOD HISTORY

Primary care giver

Feeding
Age at weaning
Developmental milestones : Normal /
delayed
Age and ease of toilet training

BEHAVIOURAL AND EMOTIONAL

PROBLEMS

Thumb sucking
Temper tantrum
Tics, head banging
Night terrors
Fears
Bed wetting
Nail biting
Stuttering/stammering
Enuresis/ encopresis
Somnabulism

EDUCATIONAL HISTORY
Academic and extra curricular
achievements
Relationships with peers and
teachers
School phobia
Truancy
Learning disabilities
Termination of studies (If yes, reason)

PLAY HISTORY
What games were played at what
stage with whom and where
Relationship with peers

OCCUPATIONAL HISTORY

Age at staring work

Jobs held in chronological order
Reason for change if any
Current job satisfaction ( relationship
with peers, authorities)

MARITAL HISTORY
Self choice / arranged
Duration of marriage
Interpersonal relationship with in
laws: satisfactory / unsatisfactory
Details of spouse and children

PREMORBID PERSONALITY
Interpersonal relationship
with family members, friends, work mates
Introverted / extraverted
Ease of making and keeping social relations
Use of leisure time
hobbies
Interests
energetic / sedentary

 Predominant mood
optimistic / pessimistic
Stable / prone to anxiety
cheerful / despondent
reaction to stressful life events

 Attitude to self and others

Self confidence level
Self criticsm and self consciousness
Selfish / thoughtful of others
Self appraisal of abilities
Achievements and failures
General attitude towards others

 Attitude to work and responsibilities

Decision making
Acceptance of responsibility
Flexibility
Foresight
Religious beliefs and moral attitudes
Fantasy life
Day dreams frequency and contents

 Habits
Eating pattern
Elimination
Sleep
Use of drugs/ alcohol/ tobacco