History Taking in Psychiatry

Identification Data Personal History

Name Early Childhood (through age 3) Middle Childhood (ages 3 – 11)
Age Prenatal, birth history Friends
Marital Status/ Occupation Developmental milestone School
Address Intrafamilial relationships
Ethnic Abnormal Behaviour, Habits
Religion (Presence of emotional/ functional disorder)
Status (in/ out patient) Sleep problems
Reliability Soiling, bed wetting
Stammering, nail-biting
Chief Complain Tantrum (sudden aggressive behaviours)
Withdrawn for 6 months
Hearing voices for 1 month Personal History (cont.)
Middle, Older
Adolescence Early Adulthood
HOPI Adulthood
Characteristics Puberty Marital, adult relation Family constellation
Duration/ date of onset Psychosexual history Work history Retirement
Mode of onset (acute/ chronic)  Menstrual problems Recreational pursuits Losses
Severity  Attitude towards Aging
Precipitating factors opposite sex
Aggravating/ alleviating factor  Sexual experiences
Accompanying physiological/ psychological symptom  Masturbation
Severity, effects to lifestyles  Fantasies
Support (family, friend, relatives) Dating, peer relations
School performance
Associated Biological Symptoms Drug, alcohol use
Sleep
Appetite Social History
Weight gain/ loss Present social situations
Energy  Accommodation
 Financial status
History of (Direct questioning)  Leisure
Fever  Social relationship
Fits Habits, abuse of drugs
Visual disturbances
Vomiting Premorbid Personality
Headache
Relationship
Use of leisure
Past Medical/ Surgical History Intellectual activities
Admission Predominant mood
Diagnoses Character
Medication/ treatment Attitude toward work, responsibility
Outcome Interpersonal relationship
Precipitants Moral, religious standard
Energy, initiative
Past Psychiatric History (Previous illness) Habits
Diagnoses
Precipitants
Admissions
Medication/ treatment/ compliance
How well between admission
Format
Begin with 1st onset of symptoms
Progress chronologically to current episode

Family History
Family tree
Family personality
Family history of medical/ psychiatric illness
Relationship with patients
Effect from family members, vice versa
Mental Status Examination in Psychiatry

Appearance & Behaviour Thinking

Consciousness (overall level) Stream/ flow
Appearance, state of health Poverty, inhibition of thought (slowed down)
Bodily proportion, posture Pressure of thought (compelled to think)
Dress, self care Thought blocking
Facial expressions, characteristics Form
Social behaviour, rapport Flight of ideas
Appropriateness of manner Circumstantiality
Abnormal behaviour, motor activity Incoherence
Example Looseness of association, derailment
Possession
Thought insertion
Thought withdrawal
Thought broadcasting
Content – Nature/ content of thought
Delusions
Overvalued idea
Obsessive, compulsive phenomena
Phobia
Depersonalisation, derealisation
Speech
Language Formal Thought Disorders (Definitions)
Pattern Circumstantiality
Spontaneity Overinclusion of trivial, irrelevant details that impede the sense of getting to
Comprehendible the point
Quantity Clang association
Rate Thoughts are associated by the sound of words rather than their meaning
Reaction time (through rhyming, assonance)
Tone (normal/ monotonous) Derailment
Breakdown in both logical connection between ideas, overall sense of goal-
Emotional Expression directedness. Words make sentences, but sentences don’t make sense
Mood (subjective) Affect (objective) Flight of ideas
What is your mood like? Emotion at time of interview Succession of multiple associations, so that thought seems to move abruptly
from idea to idea. Often in rapid, pressured speech
Affect
Neologisms
Nature
Invention of new words, phrases, use of concential words in idiosyncratic ways
 Depressed
Perseverance
 Irritable
Repetition out of context of words, phrases, ideas
 Fearful
Tangentiality
Appropriateness
In response to question, gives a reply that is appropriate to general topic
Range
without actually answering the question
 Broad Thought blocking
 Restricted Sudden disruption of thought, break in flow of ideas
Depth
 Normal Cognitive Function
 Blunted Orientation
 Flat Time
Lability Place
 Quick changes of emotion Person
 Sudden unexpected emotional outbursts Attention, Concentration
Attention Concentration
Perceptual Disturbances Ability to focus on matter in hand Ability to sustain that focus
Look for hallucinations, illusions Digit span test 100-7, 40-3, 20-1
Describe type, content, sensory system involved Day of week, months backwards
Content of hallucination Spell WORLD backward
Derogatory Record time taken, no. of mistakes made
Praise Memory
Reaction (attitude) towards hallucination Immediate/
Happy Short term/ Recent Remote
Registration
Sad Digits forward, 5 minutes Long term
Angry backward  Address  Personal events
Confuse
 5 Unrelated  Birthdate
Terrified
items  IC numbers
Perplexed
 Short story
Doesn’t care
Past few days events
 Breakfast
 Lunch
 Dinner
Information, Intelligence
Comprehension
General knowledge
Arithmetic, calculations
Vocabulary
Abstract Reasoning Formulation, Discussion
Similarity, difference testing Summary
Proverb Demographic details (eg. 23 y/o Malay man, single, unemployed, from KB)
Presented with
Judgement Characterized by
Social Mental status examination revealed
Test Physical examination revealed
Personal Diagnosis
Provisional
Insight (Awareness of one’s own illness) Differential Diagnosis
Is the patient aware of phenomena that others have observed? Aetiology (Factors)
(eg. he appear to be unusually talkative) Predisposing Precipitating Perpetuating
Does he recognize that these phenomena as abnormal? From early life that Events occur shortly Prolong the course of
Does he consider that they are caused by mental illness? determine a person’s before the onset of a a disorder after it has
Does he think that he needs treatment? vulnerability to causes disorder, appear to been provoked
(acting close to time of induce it
illness)