Psychiatric History Taking

Written by: Verity Bradley from Manchester University,

Introduction

The history should be structured and logical. A full psychiatric assessment includes a thorough history and mental state examination.

 

Components of the Psychiatric History

  • Personal details
  • Source, mode and reason for referral
  • Presenting complaint
  • History of presenting complaint
  • Past psychiatric history
  • Past medical history
  • Family history
  • Personal history
  • Social history
  • Drug & Alcohol history
  • Forensic history
  • Premorbid personality

 

Before the interview:

Starting the interview

- Introduce yourself fully. Explain who you are and the purpose of the interview.

- Put patient at ease and build a rapport.

- Inform patient of timings of the interview. How long will it roughly take?

- Need to take notes

- Confidentiality issues.

Personal Details

- Name

- Age

- Occupation

- Lives where & who with.

Presenting Complaint

 

Brief description of the main complaint(s) and the timescale of the problem in the individual's own words.

 

[ Problem; If patient is psychotic this may be difficult. Patient often does not believe a problem exists. In this case, try to comment on the presenting complaint as described by an informant e.g. family member, friend, GP. Clues can also be picked up by observing the patient's actions, body language and speech ]

Past Psychiatric history

- Explore in detail any previous diagnoses or contact with any psychiatric or other mental health services.

- Record (as far as possible): Dates of illness, symptoms, diagnoses, treatments, any hospitalizations, outpatient treatments, any compulsory treatment under the mental health act.

 

Past Medical History

Any medical problems?

 

 

 

Drug & Alcohol history

 - List all current prescription or over the counter medications used.

- Note any drug allergies

- Ask about any drug misuse; type of drug, route of administration, source, cost etc.

- Alcohol use. Record units of alcohol used. Use CAGE questionnaire if necessary.

- Remember to also ask about tobacco.

 

 

Family history

 - Explore family relationships in detail. If helpful, draw a family tree.

- Record; age, health, occupation, quality of relationship, family history of mental illness (incl. Alcoholism, deliberate self harm and suicide) as well as any other serious family illnesses.

Also, record the times of any important family events such as death, divorce, separation and the impact these may have had on the patient.

 

 

Premorbid personality

 

This is the patient's personality before the onset of mental illness. It is often useful to ask partners, family members about this.

 

Things to ask the patient include;

- How they would describe themselves or how others would describe them.

- What is their mood like on MOST occasions.

- Ask about social relationships and support

- Interests and other recreational activites

- Religious or moral beliefs

- Coping mechanisms, emotional reactions, character.

 

 

Useful Links

 

  • Great resource from Bristol medical school. Step by step videos of the psychiatric history

http://www.bristol.ac.uk/medical-school/hippocrates/psychethics/historytaking/