DEFINITION:

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.

IMPORTANCE:

Obtaining a comprehensive history from a patient and if necessary from, from

informed sources are essential to make a correct diagnosis and formulating a
specific and effective treatment plan.

PURPOSE :-

 To describe adaptive and maladaptive behaviour.

 To formulate priorities.
 To identify problems.
 To predict probable responses to potential interventions.
 To analyze the client’s perceptions.
 Helps to develop nursing care plan.

BASIC PRINCIPLES OF HISTORY TAKING:

 Introduce yourself
 Explain the purpose and approximately 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

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  Listen and Observe For Cues
 You might need an informant

COMPONENTS:

1. Identification data

2. Informants

3. Chief complaints

4. History of Present Illness

5. Past history of illness

a) Medical/surgical illness:

b) Past psychiatric history :

6. Family history:

7. Personal history

a. Perinatal history

b. Childhood history

c. Educational history

d. Play history

e. Emotional problems during adolescence

f. Puberty

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g. Obstetrical history

h. Occupational history

i. Sexual and marital history

j. Pre morbid personality

HISTORY COLLECTION FORMAT:

IDENTIFICATION DATA:

Name :

Age :

Sex :

Marital status:

Religion:

Education:

Occupation :

Income:

Address:

Date of admission:

Hospital No :

Psychiatric ward :

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Source of referral:

Informants:

The sources of the information: Relevant/reliable and complete/ incomplete

CHIEF COMPLAINTS ON ADMISSION:

(The complaints should be recorded in a chronological order).

 Presenting complaints and/or reasons for consultation should be recorded.

 Both the patient’s and the informant’s version should be recorded
separately 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 Ask leading questions such as -"What brings you here today?“
-How can I help you?”
 Examples:
 Fearfulness X 4 weeks
 Hearing sounds and seeing things X 3 weeks
 Unable to eat X 2 weeks
 not sleeping properly X 2 weeks

HISTORY OF PRESENT ILLNESS: Provides a comprehensive and

chronological picture of the events. Probably the most helpful in making an
accurate diagnosis.

 Mode of onset-Abrupt/acute/subacute/Insidious
 Abrupt- sudden and unexpected
 Acute-serious or something bad
 Insidious-proceeding in a gradual or harmful way

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  Course-( continuous / episodic/ fluctuating/ deteriorating/ improving/
unclear) Precipitating factors (death/ separation/ loss/ frightening
experience/ any other) Aggravating and relieving factors, if any.
 Episodic- occurring at regular intervals
 Fluctuating- rise and fall irregularly in number or amount
 Associative disturbances- includes present medical problems.

(eg. Loss of appetite, impaired functioning, disturbed sleep pattern etc.)

 Important negative history should be recorded (eg. no h/o head injury)

Example: Mr. X was alright before two years and after that he exhibited
symptoms like loss of appetite, sleeplessness, hallucination and delusions.
He is having auditory hallucination i.e. he says that familiar sounds was
always talking to him. He also has visual hallucination like one person
standing near to him always. He is having delusion of persecution i.e. if at
all he sees a group of persons or his neighbours standing together, he thinks
that they were talking about him and were planning to harm him. He is
also having tangentiality and thought withdrawal and retardation. He is
not maintaining good social and family functioning.

TREATMENT HISTORY:

Drugs- dose/route/side effects/complains

 ECT
 Psychotherapy
 Rehabilitation Year & Month Centre Duration Treatment
 Current medications
 What medications do you take regularly and since when?
 What medications have you had in the past?
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 Example: There is no past treatment history.

PAST HISTORY OF ILLNESS:

a) Past medical/surgical illness

b)Past psychiatric history

Past medical/surgical illness:

History of chronic medical illness and details of medication received and the
duration of illness . Hospitalization . Medical/neurological/surgical illness .
Head injury/ convulsion/ Unconsciousness . Accidents/surgical procedure .
DM/HTN/CAD/Visceral/ HIV +ve .

Example: There is no past medical history.

PAST PSYCHIATRIC HISTORY:

Had the patient suffered from any mental illness and undergone psychiatric
treatment. Has the patient been hospitalized earlier for the treatment of mental
illness. What was the nature of treatment she or he had been getting; drugs or
ECT. Did the patient improve with the treatment Any similar or other
psychiatric problems in the past?

Example: There is no evidence of any psychiatric history.

FAMILY HISTORY:

a. Family structure

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FAMILY HISTORY OF ILLNESS:

Psychiatric illness- similar/other Major medical illness Alcohol/drug

dependence/suicidal attempt.

Example: There is no history of psychiatry illness in his family.

PERSONAL HISTORY:

a. Perinatal history
b. Antinatal Any febrile illness Physical/Psychiatric illness
Medications/drugs/alcohol use Trauma to abdomen Immunization Birth
Full term/premature/post mature .

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 c. Delivery Normal/instrumental/ caesarean Birth cry Immediate/delayed
Birth defects Postnatal complications Cyanosis/convulsion/jaundice Any
others.
Example: His mother underwent her four delivery at the hospital by
normal vaginal delivery. She has not undergone any infections, radiations
during antenatal period. She attended the antenatal visit properly and she
not had any complication during her delivery.

NATAL HISTORY:

 Type of delivery
 Any complications
 Breath and cried at birth
 Neonatal infections
 Mile stones: normal or delayed
Example: He was normal vaginal delivery and does not have any
complications and neonatal infections. He breathed and cried
immediately after birth. He achieved mile stones normally.

BEHAVIOURAL AND EMOTIONAL PROBLEMS:

Thumb – sucking , tempetantrums , tics, head-banging , night terror , fears ,

bed-wetting , nail-biting. Stuttering/stammering , Enuresis/ encopresis ,
Somnambulism.

Example: He had no excessive tempetantrums. He had normal feeding habits

and no excretory disorders. There was no neurotic symptoms.

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ILLNESS DURING CHILDHOOD:

 Look specifically for CNS infection

 Epilepsy
 Neurotic disorders
 Malnutrition
Example: He had no CNS infection, no epilepsy and no nutritional
disorders.

EDUCATIONAL HISTORY :

 Age at beginning & finishing formal education

 Academic and extra curricular achievements- if any
 Relationship with peers &teachers
 School phobia
 Truancy, non-attendance
 Learning disabilities
 Reason for termination of studies(if occurs prematurely)

Emotional problems during adolescence Running away from home delinquency

smoking drug use any others.

Example: He went to the school at the age of 5 years. He showed average

performance in school. He maintained a good relationship with peers and
teachers. His conduct was good.

OCCUPATIONAL HISTORY:

 Age of joining job

 Relationship with superiors, subordinates and colleagues
 Any changes in the job—if any give details
 Reasons for changing jobs
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  Frequent absenteeism

SEXUAL HISTORY:

 Age of attaining puberty (female-menstrual cycles are regular)

 Source and extent of knowledge about sex, and exposures

MARITAL STATUS:

 Spouse
 Age
 Education
 Occupation
 Personality
 Marital life: satisfactory/unsatisfactory
 Sexual adjustment: satisfactory/unsatisfactory

Example: He is married. He is satisfactory in marital life and sexual life.

PREMORBID PERSONALITY:

Personality of a patient consists of those habitual attitudes and patterns of

behaviour which characterize an individual. Personality sometimes changes
after the onset of an illness. Get an description of the personality before the
onset of the illness. Get a description of the personality before the onset of the
illness. Aim to build up a picture of the individual, not a type. Enquire with
respect to the following areas.

ATTITUDE TO OTHERS IN SOCIAL, FAMILY AND SEXUAL

RELATIONSHIP:

Ability to trust other, make and sustain relationship, anxious or secure, leader to
follower, participation, responsibility, capacity to make decision, dominant or

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submissive, friendly and emotionally cold, etc. Difficulty in role taking---
gender, sexual, familial.

Example: He had ability to trust others and to make sustain relationship. He is

very social. He has able to make decisions.

ATTITUDES TO SELF:

Egocentric, selfish, indulgent, dramatizing, critical, depreciatory, over

concerned, self conscious, satisfaction or dissatisfaction with work. Attitudes
towards health and bodily functions. Attitudes to past achievements and failure
and to the future.

Example: He is not an egocentric and selfish. He is self conscious and had

good attitudes towards achievements and failure. He has good attitude towards
health and bodily functions.

MORAL AND RELIGIOUS ATTITUDES AND STANDARDS:

Evidence of rigidity or compliance, permissiveness or over conscientiousness,

conformity or rebellion. Enquire specifically about religious beliefs. Excessive
religiosity.

Example: He believes in God and goes to temple every Friday.

MOOD:

Enquire about stability of mood, mood swings, whether anxious, irritable,

worrying or tense. Whether lively or gloomy. Ability to express and control
feelings of anger, anxiety or depression.

Example: He had mood stability. He not having mood swings. He is having

anxiety.

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LEISURE ACTIVITIES AND HOBBIES:

Interest in reading, play, music, movies etc. Enquire about creative ability.
Whether leisure time is spent alone or with friends. Is the circle of friends large
or small.

Example: He is very interested in leisure time activities. He likes gardening and

reading books.

FANTASY LIFE:

Enquire about content of day dreams and dreams. Amount of time spent in day
dreaming.

Example: His day dream about his children’s and about his daughter’s
marriage. The duration approximately 5to 10 mins.

REACTION PATTERN TO STRESS:

Ability to tolerate frustrations, losses, disappointments and circumstances

arousing anger, anxiety or depression. Evidence for the excessive use of
particular defense mechanisms such as denial, rationalization, projection etc.

Example: He had the ability to tolerate frustration, losses and disappointments.

HABITS:

Eating, sleeping and excretory functions.

EXAMPLE: He is having disturbed sleep pattern, loss of appetite and normal

excretory function.

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 SEMINAR
ON
HISTORY TAKING

SUBMITTED TO

PROF. DR. JAYESTRI KURUSHEV

DEPT OF MHN

MTPG&RIHS

SUBMITTED BYMS. GAYATHRIM.SC I YEAR

SAMPLE OF PSYCHIATRIC NURSING HISTORY

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IDENTIFICATION DATA:

Name : Mr. Kishore

Age :30 years

Sex : Male

Marital status : Unmarried

Religion : Hindu

Education : B.A II year

Occupation : clerk in railways

Income : Rs. 600/-

Address : XI/ 1098 Agra

Date of Admission : 6-8-87

Hospital no : 7866

Source of referral : By relatives

Informant : younger brother staying with the patient since

birth.

Information : relevant/reliable

Complete/incomplete

CHIEF COMPLAINTS: (According to the patient)

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Not interested in doing any work X 9 months

Unable to sleep X 6 months

Headache X 5 months

Pain all over the body X 5 months

Generalized weakness throughout the day X 4 months

According to the patient’s relative:

For 8-9 months the patient has:

 Abnormal behaviour of talking to self

 Talking excessively and irrelevantly
 Laughing without reason
 Doing aggressive and violent behaviour
 Not sleeping properly
 Staring at wall
 Stopped working
 Complaining body pain
 Not maintaining personal hygiene
 Not taking medicines properly
 Smoking excessively

HISTORY OF PRESENT ILLNESS:

The patient was, apparently, well eight months ago when he started beating up
members of his family. This is the fourth episode and the onset was gradual.
The patient had stopped going to duty and when they asked him to do so, he

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started beating them up. There is history of fighting with somebody at his office
one year ago. The cause of fight is not known. No history of any injury or
threatening from him. The patient says that he doesn’t want to go to work as he
feels tried throughout the day and he has pain all over the body. No other
specific reason.

The patient complaints of headache in the frontal region (points his finger to the
forehead). Headache is more early in the morning and decreases in intensity as
the day progresses. He feels relieved of occasional headache but no history of
fall due to dizziness. No history of epileptic fit, blurring of vision. History of
seeing flames in front of eye occasionally, not associated with headache. No
history of weight loss, no history of sleep disturbance. History of not caring for
personal hygiene daily. Takes bath sometimes and sometimes does not. No
history of any delusions or hallucinations.

History of muttering to self, smiles on his own without any reason. History of
smiling while facing the wall. Matter of talk is unknown. No history of any head
injury, epilepsy, fever and ear discharge.

PAST HISTORY:

MEDICAL ILLNESS:

No history of TB, diabetes mellitus, hypertension, jaundice, fever or epilepsy.

SURGICAL ILLNESS:

Nil significant.

PAST PSYCHIATRIC OR MENTAL ILLNESS:

This is the 4th episode of mental illness.

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In 1983: the patient had been admitted to the G.B. pant hospital and was
diagnosed as a case of acute psychotic reaction. He got 7 ECT’s and stayed for
approximately four weeks. He got the following treatments:-

Tab. Largectil 100mg H.S.

Tab. Phenargen 25 mg 2HS

Tab. Nitravet 10 mg

Tab complex forte I BD

The patient was apparently well between the first and second attacks and was on
medication.

In 1985: The patient had a similar illness and was admitted to the Shahdara
Mental hospital. He got 5 ECT’s and was discharged after six months. He was
on Eskazine. No other medicine known.

In 1986: For similar complaints as present now, he was admitted to the Rohtak
Hospital where he stayed for one month. He got 6 ECT’s and doesn’t know
about medicines.

According to history given by the relative, the patient was not well between the
third and fourth episodes but seems to be well between the second and third
episodes.

PERSONAL HISTORY:

INFANCY:

The patient was born full-term normal delivery at home. Normal growth and
development. Milestones were normal.

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CHILDHOOD:

No behavioural disturbances. He started going to school at the age of 6 years.

He was not good at studies. He didn’t like to go to school, and preferred to play.
Was able to mix up with any group easily. Had good relationship with all other
siblings and peer groups.

ADOLESCENCE:

The patient was not good at studies. In class 10th he failed but continued his
studies upto BA II year, till he got a job as a clerk in Railways in place of his
father in 1977.

ADULTHOOD:

He started working as a clerk in Railways earning Rs. 600/- per month, still
unmarried and doesn’t want to marry till he completely recovers from mental
illness. Has good relationship with his colleagues and peer group, he is satisfied
with his job. Before 1983, he used to be regular in his duties but after fighting
with his office colleagues he goes to work occasionally. There is no history of
masturbation or inclination to female sex. The patient is a chain smoker .
sometimes he takes four packets of bidis daily. He says smoking gives him
relief from headache.

FAMILY HISTORY:

Their’s is a joint family, living in Delhi. The patient father’s died of heart attack
11 years ago at the age of 52 years. His grandfather is still alive at 86. He has a
60 year old mother and an illiterate wife. The patient has four sisters and one
brother. All sisters are married and living separately. His younger brother is also
reported as mentally ill. Both brothers are earning a total of Rs.900/- per month.
No similar illness in the family.

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FAMILY TREE:

RELATIONSHIP OF FAMILY MEMBERS WITH THE PATIENT:

The patient has food relationship with members of his family but he often
quarrels with his mother on trifles. His relationship with his grandfather is
good. They are getting a pension of Rs. 900/- all his sisters are married and live
separately. They pull on well with the patient and take care of him.

PREMORBID PERSONALITY:

Before his illness in 1983, the patient was absolutely alright. He used to
socialize, had good interpersonal relations with others i.e. elders, relatives and
friends. He was not much interested in studies but liked to read story books,
magazines etc. He was a very cheerful person. He also used to go to movies
with his friends and play indoor games such as carom, ludo, etc.

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