2.

1
August 8, 2013
Doc Los Baños Psychiatric
“Learn  from  your  history,  but  don’t  live  in  it.”    
                                                                                                               -­‐Steve  Maraboli   History
 
OUTLINE PAGE PSYCHIATRIC INTERVIEW
I. Psychiatric History 1 • Time management
II. Psychiatric Interview 1 • Arrangement of seating
III. Psychiatric History (CONTENTS) • Taking of notes
A. Identifying Data 3 • Follow-up interviews
B. Chief Complaint 3 • Interviewing variations
C. History of Present Illness 3
D. Past Illnesses 3 *from upper batch trans: (2D_2015) =also in the book
E. Family History 3
F. Personal History (Anamnesis) 4 PRACTICAL ASPECTS OF PSYCHIATRIC INTERVIEW:
1. Prenatal and Perinatal History 4
2. Early Childhood History 4
SESSION LENGTH
3. Middle Childhood History 4
• Initial interview: 30 mins to 1 hour depending on the
4. Late Childhood History 4
circumstances
5. Adulthood 5
(Marital, Education, Religion, Social, Current, Legal)
• Initial interviews to evaluate patients for pharmacotherapy
6. Sexual History 5 or psychotherapy tend to be longer
7. Fantasies and Dreams 5 • Second visits vary in length
IV. Pre-Morbid Personality Circumstances 6 • PATIENT’S MANAGEMENT OF APPOINTMENT TIMES
V. Outline of Developmental History 6 - Reveals important aspects of personality and coping
o Anxious patient may arrive as much as 30 minutes
PSYCHIATRIC HISTORY early before the appointment
• Record of the patient's life o A patient who states, “I forgot all about the
• Allows a psychiatrist to understand: appointment,” → clue that there is something
o who the patient is about going to the doctor that makes that patient
o where the patient has come from anxious or uncomfortable → should be explored
o where the patient is likely to go in the future. further by the physician
• Patient's life story told to the psychiatrist in the patient's • PSYCHIATRIST'S HANDLING OF TIME - also an important
own words from his or her own point of view. factor in the interview
• Also includes information about the patient obtained from o Carelessness about time → lack of concern for the
other sources, such as a parent or spouse. patient
• Must be comprehensive to make a correct diagnosis and o If unavoidably detained for an interview →express
formulating a specific and effective treatment plan. regret at having kept the patient waiting
SEATING AND ARRANGEMENT OF OFFICE
PSYCHIATRIC HISTORY vs. MEDICAL HISTORY • Both chairs should be of approximately equal height, so
Gather concrete and factual data related to the chronology of that neither person looks down on the other
symptom formation and to the psychiatric and medical history • If the room contains several chairs, psychiatrist indicates
In contrast to medical history, psychiatric history provides the his chair and allows the patient to choose the chair in
following: which he or she will feel most comfortable.
ü Elusive picture of patient's individual personality • Should protect both parties (doctor is usually closer to the
characteristics, including both strengths and weaknesses. door/exit and there should be another person near the
ü Insight into the nature of relationships with those closest area like a secretary)
to the patient and includes all the important persons in • Comfortable room with pleasant lighting
his or her life. • Don’t make the office too stacky→ objects that can be
ü A reasonably comprehensive picture can be elicited of the used against you by the px or can distract the px
patient's development from the earliest formative years • Normally there is a “barrier” between px and psychiatrist
until the present. just to be safe
NOTE TAKING
• Most important technique for obtaining a psychiatric • For legal and medical reasons, an adequate written record
history: of each px’s treatment must be maintained
o Allow patients to tell their stories in their own words in • Careful not to take notes extensively as that may cut
the order that they consider most important. down on the ability to listen
o As patients relate their stories, recognize the points at • Some pxs may be offended by note-taking whereas others
which relevant questions about the areas described in may feel that their thoughts aren’t important if the doctor
the outline of the history and mental status is not taking them down (Solution: explore such feelings).
examination can be introduced. FOLLOW-UP INTERVIEW
• Allow patients to correct any misinformation provided in
• NOTE: not intended to be a rigid plan for interviewing the first meeting
• For additional questions that were not asked or weren’t
*from upper batch trans: (2D_2015) clear during the initial interview.
Diagnosis of psychiatric patients differ from diagnosis of INTERVIEWING VARIATIONS
patients with physical disease in that: • Should be in control of the situation
• Most psychiatric disorders remain primitive and incomplete o Depressed and potentially suicidal patients
thus diagnosis based on etiology is not likely o Aggressive patients
• Psychiatry has no external validating criteria

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  1  of  6  

 
 Psychiatric History

 
  • JUDGMENTAL
D: Have you been using any
ENDING THE INTERVIEW
drugs?
• Psychiatrist must give the patient his impressions and
P: Well besides drinking, I smoke a
suggestions, even if they are preliminary
little grass on weekends
• Prepare the patient for follow-up
D: Do you not know that marijuana
• Handling patients well increases the likelihood of helping
can cause serious problems with
the patient
motivation over the long term?
• Give persons who have become emotionally distraught a
few minutes to collect themselves before they are asked
• NONVERBAL FACIAL
to leave the office.
EXPRESSION, BODY POSTURE,
CONCEPT OF NEUTRALITY
AND BEHAVIOR that indicate lack
• In psychoanalytic psychiatry, the psychiatrist does not
of interest or inattentiveness, such
take sides in the patient's intrapsychic conflicts
as yawning, or checking one's
• Does not mean the clinician is a nonresponding robot.
watch. The doctor who shows no
emotional reaction to what a
TYPES OF INTERVENTIONS
patient is saying usually conveys a
• Psychiatrist provides feedback and information, offer
sense of not listening or being
• reassurances and responds to what the px is saying
uninterested
• May be SUPPORTIVE or OBSTRUCTIVE, depending on
STRESS INTERVIEW
the extent to which they increase the flow of information
• To decrease anxiety of patients = provide reassurance
and enhance or diminish rapport.
• Monotonously repetitious or patients w/ insufficient
emotion for motivation (apathetic, indifferent, &
SUPPORTIVE OBSTRUCTIVE
emotionally blunted) = not conducive to discussion of
personality problems
• ACKNOWLEDGING • COMPOUND QUESTIONS • Stimulation of emotions can be constructive = may require
EMOTIONS D: Do you take a vacation every probing, challenging, or confrontation to arouse feelings
D: Even after all year, and are you able to relax? that will promote progress in furthering understanding.
these years, talking
about your mother • TRAPPING THE PATIENT IN HIS
PSYCHIATRIC HISTORY (CONTENTS)
brings tears to your OR HER OWN WORDS
A. IDENTIFYING DATA
eyes D: When I asked you before, you
• Includes: demographic summary of the patient
said nothing had gone well over
• Example:
the last year, and now you are
Mr. John Jones is a 25-year-old single, white,
• ENCOURAGEMENT telling me you got a raise and have
Protestant male who works as a department store
P: I've never been been exercising more.
clerk. He is a college graduate living with his parents.
very good at
He was referred by his internist for psychiatric
putting things into • WHY QUESTIONS
evaluation.
words D: Why do you keep waking up so
• Other contents:
D: I think you've early in the morning?
o Place/situation in which the interview took place
described the
o source(s) of the information
situation well in a • DISMISSAL/MINIMIZATION
o reliability of the source(s)
way that helps me P: Over the last month I have had
o Is the current disorder the first episode for the px
understand what trouble with sex.
o Indicate whether the patient came in on his or her own,
you have been D: That happens from time to time
was referred by someone else, or was brought in by
going through
someone else.
• PREMATURE ADVICE
• Meant to provide a thumbnail sketch of potentially
P: Ever since my girlfriend and I
important patient characteristics that may affect diagnosis,
• REASSURANCE split up last year, I cannot seem to
prognosis, treatment, and compliance.
D: The meet anyone new
hopelessness you D: Why not try spending time in
B CHIEF COMPLAINT
feel right now bookstores and coffee houses?
seems There are usually lots of single • In the patient's own words
overwhelming. I people in those places • States why he or she has come or been brought in for help.
think it is very likely • Should be recorded verbatim, regardless of how bizarre or
with the proper • NOT FOLLOWING THE irrelevant it is.
treatment you can PATIENT'S LEAD • Should be recorded even if the patient is unable to speak.
get back to feeling D: How long have you been feeling • If Px is comatose/mute = that should be noted in the chief
yourself (pero so sad? complaint as such.
bawal mag falsely P: Over 6 months. Nothing is • Other individuals present as sources of information
reassure ng px!) getting better. I am starting to can then give their versions of the presenting events in the
wonder if it is worth it. section on the history of the present illness.
D: Do you have trouble sleeping • Examples of chief complaints follow:
• NONVERBAL through the night? I am having thoughts of wanting to harm myself.
FACIAL (The better response would be, People are trying to drive me insane.
EXPRESSION AND ‘you are wondering if what is worth I feel I am going mad.
BODY POSTURE it? – basta explore the patient’s I am angry all the time.
that convey thoughts and feelings)
interest, concern,
and attentiveness

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  2  of  6    

 
 Psychiatric History

 
C. HISTORY OF PRESENT ILLNESS ASK  and  take  note  of  THE  PRESENCE  OF  THE  FF:  
Doc’s PPT: ü Episodes  of  craniocerebral  trauma  
• Blow by blow account of events that lead to day of ü Neurological  illness,  tumors,  and  seizure  disorders  
admission. ü History  of  testing  positive  for  HIV  or  having  (AIDS).    
• Chronological, Detailed, Comprehensive and Concise ü Seizure   disorder,   episodes   of   loss   of   consciousness,   changes   in   usual  
headache  patterns,  changes  in  vision,  and  episodes  of  confusion  and  
Kaplan: disorientation.    
• Comprehensive and chronological picture of the events ü History  of  infection  (e.g.  syphilis)  
leading up to the current moment in the patient's life. ü Causes,  complications,  and  treatment  of  any  illness  and  the  effects  of  
• Evolution of the patient's symptoms should be determined the  illness  on  the  patient  
and summarized in an organized and systematic way. ü Psychosomatic  disorders  
• THE MORE DETAILED THE HPI, THE MORE LIKELY ü Alcohol  and  other  substances  used  (quantity  and  frequency)  
THE CLINICIAN IS TO MAKE AN ACCURATE ü Included  in  this  category  are  hay  fever,  rheumatoid  arthritis,  ulcerative  
DIAGNOSIS. colitis,   asthma,   hyperthyroidism,   gastrointestinal   upsets,   recurrent  
o Onset of the current episode? colds,  and  skin  conditions.  
o Immediate precipitating events or triggers?
o Effect on patient’s life activities o The importance of a thorough, accurate medical history
§ (e.g., work, important relationships)? cannot be overstated.
o Nature of the dysfunction o Many medical conditions and their treatments cause
§ (e.g., details about changes in such factors as psychiatric symptoms that without an attentive medical
personality, memory, speech)? history may be mistaken for a primary psychiatric
o Psychophysiological symptoms? disorder.
§ (describe in terms of location, intensity, and Treatment  with  
fluctuation.) Endocrinopathies   corOcosteroids  can  
(hypothyroidism  or   may  manifest  with  
depression   precipitate  manic  
o Patient's current anxieties? Addison's  disease)     and  psychoOc  
§ (whether they are generalized and nonspecific (free symptoms  
floating) or are specifically related to particular • Patient's medical status
situations, is helpful. How does the patient handle o Will also guide psychiatric treatment decisions.
these anxieties? ) o A depressed patient with cardiac conduction
• Relatively open-ended question (e.g. How did this all abnormalities will not be treated (at least initially) with
begin?) leads to an adequate unfolding of the history of a tricyclic antidepressant.
the present illness. o A bipolar disorder patient with kidney disease will
WELL-ORGANIZED PX DISORGANIZED PATIENT(PX) receive an anticonvulsant mood stabilizer rather
• Generally able to • Difficult to interview than lithium.
present a chronological • Chronology of events is confused o The names and dosing schedules for all currently
account of the history • In such cases, contact other prescribed nonpsychiatric drugs should be obtained to
informants, such as family avoid adverse interactions with prescribed psychiatric
members and friends, to aid in medication.
clarifying the patient's story
E. FAMILY HISTORY
D. PAST ILLNESSES • Brief statement about any psychiatric illness,
hospitalization, and treatment of the patient's immediate
• Transition between the story of the present illness and
family members.
the patient's personal history.
• Family history of alcohol and other substance abuse or
• Include past episodes of PSYCHIATRIC AND MEDICAL
of antisocial behavior
ILLNESSES.
• Family ethnic, national, and religious traditions
• Ideally, this section provides detailed account of the
• Define the role each person played in the patient's
patient's preexisting and underlying psychological and
upbringing and this person's current relationship with the
biological substrates, and important clues to, and evidence
patient.
of, vulnerable areas in the patient's functioning.
• In the written record, cite the Informants/source other than
• The following are explored and recorded chronologically:
the patient who contribute to the family history.
o Patient's symptoms and extent of incapacity
• Various members of the family often give different
o Names of hospitals and Length of each illness
descriptions of the same persons and events.
o Type and effects of treatment received
• The psychiatrist should determine the family's attitude
o Effects of previous treatments
toward, and insight into, the patient's illness.
o Degree of compliance
o Does the patient feel that the family members are
• FIRST EPISODES OF SYMPTOMS
supportive, indifferent, or destructive?
o Should be paid particular attention
o What is the role of illness in the family?
o Signaled the onset of illness
• Other questions that provide useful information in
o Can often provide crucial data about precipitating
this section include the following:
events, diagnostic possibilities, and coping capabilities.
o What is the patient's attitude toward his or her
• MEDICAL HISTORY
parents and siblings?
o Medical review of symptoms
o Describe each family member. Who is mentioned
o Major medical/surgical illnesses/ traumas,
first? Who is left out? What does each parent do for a
particularly those requiring hospitalization.
living? What do the siblings do? How do the siblings'
occupations compare with the patient's work? How
does the patient feel about it? Who does the patient
feel most similar to in the family and why?

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  3  of  6    

 
 Psychiatric History

 
F. PERSONAL HISTORY (ANAMNESIS) 3. MIDDLE CHILDHOOD (Age 3 to 11 years)
• PERSONAL HISTORY = ANAMNESIS • The psychiatrist focuses on the ff. important subjects:
• The psychiatrist needs a thorough understanding of the o gender identification
patient's past and its relation to the present emotional o punishments used in the home
problem. o persons who provided discipline and influenced early
• Note predominant emotions associated with the different conscience formation.
life periods (e.g., painful, stressful, conflictual). • Data about the patient’s earliest friendships and
personal relationships are valuable.
1. PRENATAL AND PERINATAL • The psychiatrist should:
• Considers the home situation into which the patient was o Determine Number and closeness of the patient’s
born and whether the patient was planned and wanted. friends
• QUESTIONS THAT NEED TO BE ANSWERED: o Describe whether the patient took the role of a leader
o Were there any problems with the mother’s pregnancy or a follower
and delivery? o Describe the patient’s social popularity and
o What was the mother’s emotional and physical state at participation in group/gang activities.
the time of the patient’s birth? • Early patterns of assertion, impulsiveness, aggression,
o Were there any maternal health problems during passivity, anxiety, or antisocial behavior emerge in
pregnancy? the context of school relationships.
o Was the mother abusing alcohol or any other • History of the patient’s learning to read and developing
substances during her pregnancy? other intellectual and motor skills
• Explore the presence of nightmares, phobias, bed-wetting,
2. EARLY CHILDHOOD (Birth to 3 years of age) fire-setting, cruelty to animals, and excessive masturbation.
• IMPORTANT: Quality of the mother-child interaction • QUESTION THAT NEEDS TO BE ANSWERED:
during feeding and toilet training. o Was the child able to cooperate with peers, to be fair,
• Early disturbances in sleeping patterns, including to understand, and comply with rules, and to develop
episodes of head banging, and body rocking provide an early conscience?
clues about possible maternal deprivation or developmental
disability. 4. LATE CHILDHOOD (Puberty through adolescence)
• The psychiatrist should: • The psychiatrist should attempt to ascertain the values of
o Obtain a history of human constancy and the patient’s social groups and to determine who the
attachments during the first 3 years. patient’s idealized figures were.
o Explore the patient’s siblings and the details of his or • Provides useful clues about the PATIENT’S EMERGING
her relationship with them. SELF-IMAGE
• It is helpful to explore the patient’s school history,
• Topic of crucial importance: EMERGING PERSONALITY relationships with teachers, and favorite studies and
OF THE CHILD interests, both in school and in extracurricular areas.
• Seek the child’s ability to concentrate, to tolerate
frustration, and to postpone gratification. • QUESTIONS THAT NEED TO BE ANSWERED:
o What was the patient’s sense of personal identity?
• FEEDING HABITS o How extensive was the use of alcohol and other
o breastfed or bottle-fed, eating problems substances?
o Was the patient sexually-active, and what was the
• EARLY DEVELOPMENT quality of sexual relationships?
o Walking, talking, teething, language development, o Was the patient interactive and involved with school
motor development, signs of unmet needs, sleep and peers, or was he or she isolated, withdrawn and
pattern, object constancy, stranger anxiety, maternal perceived as odd by others?
deprivation, separation anxiety, other caretakers in the o Did the patient have a generally intact self-esteem, or
home. was there any evidence of inferiority complex?
• TOILET TRAINING o What was the patient’s body image?
o Age, attitude of parents, feelings about it. o Were there suicidal episodes?
o Were there problems in school, including excessive
• SYMPTOMS OF BEHAVIOR PROBLEM: truancy?
o Thumb-sucking, temper tantrums, tics, head-bumping, o How did the patient use private time?
rocking, night terrors, fears, bed-wetting or bed- o What was the relationship with the parents?
soiling, nail-biting, excessive masturbation. o What were the feelings about development of
secondary sexual characteristic?
• QUESTIONS: o What was the response to menarche?
o Were any psychiatric or medical illnesses present in the o What were the attitudes about dating, petting, crushes,
parents that may have interfered with parent-child parties and sex games?
interactions?
o Did persons other than the mother care for the patient? • SOCIAL RELATIONSHIPS
o Did the patient exhibit problems at an early period such o Attitude towards sibling(s) and playmates
as severe stranger anxiety or separation anxiety? o Social popularity, number and closeness of friends
o Was the child shy, restless, overactive, withdrawn, o Leader or follower, participation on groups or gang
studious, outgoing, timid, athletic, friendly? activities
o What were the child’s favorite games or toys? o Idealized figures
o Did the child prefer to play alone, with others, or not at o Patterns of aggression, passivity, anxiety, antisocial
all? behavior.

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  4  of  6    

 
 Psychiatric History

 
o QUESTIONS: how far the other members of the
• SCHOOL HISTORY patient's family go in school, how they compare with
o How far the patient progressed? the patient's progress, and patient's attitude toward
o Adjustments to school academic achievement?
o Relationships with teachers (teacher’s pet vs. rebel)
o Favorite studies or interests Examples.    
o Particular abilities or assets • A   patient   from   an   economically   deprived   background   who  
o Extracurricular activities, sports, hobbies, relations of never   had   the   opportunity   to   attend   the   best   schools   and  
problems or symptoms to any social period. whose  parents  never  graduated  from  high  school  shows  strength  
of   character,   intelligence,   and   tremendous   motivation   by  
• COGNITIVE AND MOTOR DEVELOPMENT graduating  from  college.  
o Learning to read and other intellectual and motor skills  
o Minimal cerebral dysfunction, • A   patient   who   dropped   out   of   high   school   because   of   violence  
o Learning disabilities- their management and effects on and   substance   use   displays   creativity   and   determination   by  
the child. going  to  school  at  night  to  obtain  a  high  school  diploma  while  
working  during  the  day  as  a  drug  counselor.  
• EMOTIONAL AND PHYSICAL PROBLEMS
o Nightmares, Phobias, Bed-wetting, running away, • RELIGION
delinquency, smoking, alcohol or other substance use, o Religious background of both parents and the details of
anorexia, bulimia, weight problems, feelings of the patient's religious instruction
inferiority, depression, suicidal ideas and acts. o Family’s attitude toward religion(strict or permissive)
o Conflicts between the parents over the child's religious
5. ADULTHOOD education
• OCCUPATIONAL HISTORY o Evolution of the patient's adolescent religious practices
o Describe the patient’s choice of occupation, the to present beliefs and activities.
requisite training and preparation, any work- • SOCIAL ACTIVITY
related conflicts, and the long term ambitions and o Social life and the nature of friendships (depth,
goals. duration, and quality of human relationships)
o Explore the patient’s feelings about his or her o Social, intellectual, and physical interests shared with
current job and relationships at work and friends, relationships with persons of the same sex and
describe the job history. the opposite sex.
o QUESTION: o QUESTIONS THAT NEED TO BE ANSWERED:
§ What would the person do for work if he or she § Does the patient prefer isolation, or is the patient
could choose freely? isolated because of anxieties and fears about other
• MARITAL AND RELATIONSHIP HISTORY people? Who visits the patient in the hospital and
o History of each marriage, legal or common law. how frequently?
o Significant relationship with persons with whom the • CURRENT LIVING SITUATION
patient has lived for a protracted period. o Where he or she lives in terms of:
o Areas of agreement and disagreement: § The neighborhood and the residence
§ money management, housing difficulties, the roles of § The number of rooms
in-laws, and attitudes toward raising children, should § The number of family members living in the home,
be described. and the sleeping arrangements
o QUESTIONS: o How issues of privacy is handled (parental and sibling
§ Is the patient currently in a long-term relationship? nudity and bathroom arrangements)
§ How long is the longest relationship that the patient o Sources of family income and any financial hardships.
has had? • LEGAL HISTORY
§ What is the quality of the patient’s sexual o arrest (for what?), jail time, probation, history of
relationship? assault or violence, attitude towards arrest or prison
§ What does the patient look for in a partner? term
§ Can the patient initiate a relationship or approach
someone with whom he or she feels attracted? 6. SEXUAL HISTORY
§ How does the patient perceive failures of past • Infantile sexuality is not recoverable
relationships in terms of understanding what went • Many patients can recall curiosities and sexual games
wrong and who was or was not to blame? played from the ages of 3 to 6 years
• MILITARY HISTORY • Questions to be asked:
o Inquire about the patient’s general adjustment to the o How the patient learned about sex and what he or she
military, whether he/she saw combat or sustained an felt were parents' attitudes about sexual development
injury, and the nature of the discharge. • Sexual abuse in childhood
o QUESTIONS: • Onset of puberty and feelings about this milestone
§ Was the patient ever referred for psychiatric • Adolescent masturbatory history
consultation, and did he/she incur any disciplinary o including the nature of the patient's fantasies and
action during the period of service? feelings about them
• EDUCATION HISTORY • Attitudes toward sex:
o Educational background, highest grade or graduate o Should be described in detail: (shy, timid, aggressive)
level attained, what patient liked to study, level of o Does the patient need to impress others and boast of
academic performance sexual conquests? Did the patient experience anxiety in
o Can provide clues about the patient's social and the sexual setting?
cultural background, intelligence, motivation, and any o Was there promiscuity?
obstacles to achievement. o What is the patient's sexual orientation?

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  5  of  6    

 
 Psychiatric History

 
Should include any sexual symptoms, such as
o VALUES
anorgasmia, vaginismus, erectile disorder • Social & moral values about work, money, play, children,
(impotence), premature or retarded ejaculation, parents, friends, sex, community concerns, and cultural
lack of sexual desire, and paraphillias (e.g., issues
sexual sadism, fetishism, voyeurism). • Ex. Are children a burden or a joy? Is work a necessary
o Attitudes toward fellatio, cunnilingus, and coital evil, an unavoidable chore, or an opportunity? What is the
techniques patient's concept of right and wrong?  
• Sexual adjustment
o how sexual activity is usually initiated, the frequency of PRE-MORBID PERSONALITY CIRCUMSTANCES
sexual relations, and sexual preferences, variations, • Characteristics, Temperament, Peculiarities, Daily routine,
and techniques Work-employment, Social Milieu
• Extramarital relationships (circumstances and if spouse
knew of affair) *from to upper batch trans (2D_2015)
o The reasons underlying an extramarital affair are just =this is part of HPI
as important as understanding its effect on the =Condition before the illness– so we can return to
marriage. BASELINE!
• Attitudes toward contraception and family planning are =Madalas daw kasing nalilimutan to sabi ni Doc. Dapat
important. Issues involved in safe sex, STD, HIV. hindi ka magaaspire na sobrang umayos nung pasyente
SEXUAL  HISTORY  CONTENTS:  (From  Kaplan)   kung ang baseline nya ay di naman maayos talaga. Hiwalay
1. Screening  questions     na yung additional improvement na yun.
a. Are  you  sexually  active?    
b. Have  you  noticed  any  changes  or  problems  with  sex  recently?   *Additional notes from lecture:
2. Developmental     =You should not change the patient to someone he is not. As
a. Acquisition  of  sexual  knowledge     psychiatrist, your goal is to listen to the patient and help him
b. Onset  of  puberty/menarche     live a better life, not an “ideal” life.
c. Development  of  sexual  identity  and  orientation    
d. First  sexual  experiences     OUTLINE  OF  DEVELOPMENTAL  HISTORY  FROM  KAPLAN  
e. Sex  in  romantic  relationship     A. Prenatal and perinatal
f. Changing  experiences  or  preferences  over  time     1. Full-term pregnancy or premature
g. Sex  and  advancing  age     2. Vaginal delivery or caesarian
3. Drugs taken by mother during pregnancy
h. Clarification  of  sexual  problems    
(prescription and recreational)
i. Desire  phase   4. Birth complications
                   Presence  of  sexual  thoughts  or  fantasies   5. Defects at birth
                   When  do  they  occur  and  what  is  their  object?   B. Infancy and early childhood
                   Who  initiates  sex  and  how?     1. Infant–mother relationship
j. Excitement  phase   2. Problems with feeding and sleep
3. Significant milestones
                     Difficulty  in  sexual  arousal  (achieving  or  maintaining  erections,  
a. Standing/walking
                     lubrication),  during  foreplay  and  preceding  orgasm     b. First words/two-word sentences
k. Orgasm  phase   c. Bowel and bladder control
                     Does  orgasm  occur?   4. Other caregivers
                     Does  it  occur  too  soon  or  too  late?   5. Unusual behaviors (e.g., head-banging)
                     How  often  and  under  what  circumstances  does  orgasm  occur?   C. Middle childhood
                     If  orgasm  does  not  occur,  is  it  because  of  not  being  excited  or     1. Preschool and school experiences
2. Separations from caregivers
                     lack  of  orgasm  despite  being  aroused?    
3. Friendships/play
l. Resolution  phase   4. Methods of discipline
                   What  happens  after  sex  is  over  (e.g.,  contentment,  frustration,   5. Illness, surgery, or trauma
                   continued  arousal)?   D. Adolescence
1. Onset of puberty
7. FANTASIES AND DREAMS 2. Academic achievement
3. Organized activities (sports, clubs)
• FREUD: Dreams are the royal road to the unconscious. 4. Areas of special interest
• Repetitive dreams have particular value. 5. Romantic involvements and sexual experience
o Repetitive themes of nightmares 6. Work experience
o Most common dream themes: 7. Drug/alcohol use
§ food, examinations, sex, helplessness, and feelings 8. Symptoms (moodiness, irregularity of sleeping or
of impotence eating, fights and arguments)
E. Young adulthood
• Fantasies, daydreams à valuable source of unconscious
1. Meaningful long-term relationship
material 2. Academic and career decisions
3. Military experience
• QUESTIONS: 4. Work history
o What are the patient's fantasies about the future? 5. Prison experience
o If the patient could make any change in his or her life, 6. Intellectual pursuits and leisure activities
what would it be? F. Middle adulthood and old age
1. Changing family constellation
o What are the patient's most common or favorite
2. Social activities
current fantasies? 3. Work and career changes
o Does the patient experience daydreams? 4. Aspirations
o Are the patient's fantasies grounded in reality, or is the 5. Major losses
patient unable to tell the difference between fantasy 6. Retirement and aging  
and reality? *J END of TRANS J*

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  6  of  6