Psychiatric Interview

and History
CC JANA VICTOR
March 21, 2019
Psychiatric History
● Record of the patient’s life
○ Who the patient is?
○ Where the patient came from? will go in the future?
● Stated in his own words and point of view
○ Other sources or informants (parent or spouse)
○ Allow the patients to tell their stories in their own words
○ What they consider important
● Essential in making a correct diagnosis and formulating a specific and
effective plan

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Psychiatric History
● Concrete and factual data
● Chronological
● Elusive picture of the patient
○ Personality characteristic
○ Strengths and weaknesses
● Insight into the nature of relationships
○ Closest and important to the patient
● From earliest formative years until the present

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 I: identifying data
II: source & reliability
III. Chief complaint

iv: present illness

v. Past psychiatric history
 VI: substance use
vII: past medical history
VIII. Family history

ix. anamnesis
x. Review of systems
 I: identifying data
Demographic summary of the patient
▪ Name
▪ Age
▪ Marital status
▪ Sex
▪ Occupation
▪ Language
▪ Ethnic background
▪ Religion
Kaplan and Sadock’s Synopsis of Psychiatry 11th edition
 II: source & reliability
▪ where the information has come from
○ patient, relatives, or records reviewed

▪ Interviewer’s assessment of how reliable the data are.

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 III. Chief complaint
● Why he or she has come or been brought in for help
○ patient and relative/ companion
● Recorded even if patient is unable to speak, and a
description of the person who provided the information
● Should be recorded no matter how bizarre or irrelevant
● Other individuals present as sources of information
a) Can give their versions
b) Should be noted if the patient is comatose

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

 iv: present illness
● Comprehensive and chronological description of the
evolution of the events and symptoms of the current
episode, leading up to the current moment in the patient’s
life

● Most helpful in making the diagnosis

■ When was the onset of the current episode?
■ What were the immediate precipitating events or triggers?

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 iv: present illness
• Why is the patient seeking help now? Triggering factors?
• What were the life circumstances at the onset of symptom
or behavioral changes?
• How did they affect the patient so that the presenting
disorder manifest?
• Previous and current treatment, how often, if
discontinued-why?

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 v. Past psychiatric history
▪ Past psychiatric illnesses
➢ diagnosis, who diagnosed, when they occurred, how long
they lasted, and the frequency and severity of episodes
▪ Past treatment episodes
➢ medications and other modalities, duration of use, doses,
why stopped, response and side effects, compliance
▪ Violence and homicidality history
▪ Past suicidal ideations, plan and attempts
▪ Non-suicidal self-injurious behaviors
Kaplan and Sadock’s Synopsis of Psychiatry 11th edition
 VI: substance use
● Substances used
○ alcohol, drugs, medications (prescribed or not prescribed to the patient), and
routes of use (oral, snorting, or intravenous)
○ include tobacco and caffeine use, gambling, eating behaviors, and Internet
use, overeating
● Frequency and amount of use
● Tolerance, the need for increasing amounts of use, and any
withdrawal symptoms
○ Impact of use on social interactions, work, school, legal consequences, and
driving while intoxicated (DWI)

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 vII: past medical history
● Major medical illnesses, comorbids and treatments
● Past surgeries
● History of neurological diseases- seizures, head injury, pain disorder
● Patient’s reaction and coping skills to the illnesses
● Prenatal, perinatal and developmental problems
● Women: Reproductive and menstrual history, potential for current or future pregnancy
● Review of all current medications and duration of intake, compliance, effect and side
effects
○ also non-psychiatric medications, over-the counter meds, sleep aids, herbal and
alternative medications
● Allergies

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 VIII. Family history
Any psychiatric or medical illness, hospitalization, and treatment of the patient’s
immediate family members
▪ History of alcohol and other substance abuse or antisocial behavior
▪ Description of personalities and intelligence of persons living in the patient’s
home from childhood to present as well as various households
▪ Role of each person played in patient’s upbringing and current relationship
▪ Psychiatric diagnoses, medications, hospitalizations, substance use disorders,
and lethality history
▪ Medical illnesses eg. Diabetes, hyperlipidemia

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 VIII. Family history
▪ Family’s Ethnic, national and religious traditions, and expectations
▪ Family’s attitude toward, and insight into, the patient’s illness
a) Does the patient feel that the family members are supportive,
indifferent, or destructive?
b) What is the role of illness in the family?
c) What is the patient’s attitude toward his or her parents and
siblings?

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

 ix. Developmental & social history (anamnesis)

●Review of the stages of the patient’s life

●Important tool in determining the context of psychiatric
symptoms and illnesses
●Identify some of the major factors in the evolution of the
disorder
●Reveals psychosocial stressors

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

 ix. Developmental & social history (anamnesis)

PERINATAL HISTORY
▪ Full-term pregnancy or premature?
▪ Vaginal delivery or caesarian?
▪ Drugs taken by mother?
▪ Birth complications?
▪ Defects at birth?

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

 ix. Developmental & social history (anamnesis)

MIDDLE CHILDHOOD (3-11 YEARS OLD)

▪ Early school history
▪ Early adjustment, gender identification
▪ Conscience development, punishment
▪ Social relationships
▪ Attitudes toward siblings and playmates

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

 ix. Developmental & social history (anamnesis)

LATE CHILDHOOD (PUBERTY-ADOLESCENCE)

▪ Peer relationships
▪ School history
▪ Cognitive and motor development
▪ Particular adolescent emotional and physical problems
▪ Psychosexual history
▪ Religious background

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

 ix. Developmental & social history (anamnesis)

ADULTHOOD
• Occupational history • Social activity
• Marital and relationship • Sexual activity
history • Current living situation
• Military history • Legal history
• Education history
• Religion

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

 x. Review of systems
● Capture any current physical or psychological signs and
symptoms not already identified in the present illness.
● Neurological and systemic symptoms (e.g., fatigue or
weakness).
○ might contribute to the presenting complaints or influence
the choice of therapeutic agents should be carefully
considered (e.g., endocrine, hepatic, or renal disorders).

Kaplan and Sadock’s Synopsis of Psychiatry 11th edition

Thank you!

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