History taking in Psychiatry & Mental StateExamination
Dr. Janaka Pushpakumara Department of Psychiatry FMAS/RUSL

History taking in Psychiatry

Illness
Healthy person Patient
Home Hospital

Heath Care System
Healthy person Patient
R
Home x Hospital

R
x
Process of Management
?
Ex

In Psychiatry
Most of the diagnostic information coming from the History and Observation of patients’ appearance and behaviour.
Very Important

History taking in Psychiatry

1. Personal Data:
   Name, age, marital status, occupation, address.
2. Informant:
   Name, relationship to patient and your impression of the informant’s reliability History taking in Psychiatry Cont.
3. Reason for referral :
   the immediate reason which caused the patient to seek treatment /be brought to hospital History taking in Psychiatry Cont.
4. Presenting complaints and duration: The Symptoms (in brief) and
   their duration History taking in Psychiatry Cont.
5. History of presenting complaints:
   • A description of the symptoms and their duration, including:
   • how the symptoms began, and how the symptoms changed with time (e.g. Increasing gradually or stepwise /remained the same/episodic in nature) History taking in Psychiatry Cont.
6. History of presenting comp.
   • Changes in biological functions (e.g. Sleep, appetite, weight)
   • affect of symptoms on patient’s relationships, day to day activity and work
   • association between symptoms and any stressors or life events
   • Any other relevant information History taking in Psychiatry Cont.
7. Stressors :
   Psychological or Physical History taking in Psychiatry Cont.
8. Family history:
   • age and occupations of parents and the parent’s relationship with one another
   • general information about siblings • the patient’s relationship with his
   parents and siblings
   • social standing of the family
   • history of psychiatric illness, suicide or
   substance misuse in the family • Any other relevant information History taking in Psychiatry
9. Personal history:
   • Antenatal and birth history • Early developmental history • Health in childhood
   • Occupational history
   • Marital history
   • Sexual history
   Cont. History taking in Psychiatry Cont.
10. Substance use:
    • History of substance use : alcohol, nicotine, cannabis, other drugs of use
    • Duration of use : amount used at present and frequency of use
    • Associated problems (e.g. legal/financial/social problems secondary to substance misuse) History taking in Psychiatry Cont.
11. Past medical/surgical history: History taking in Psychiatry Cont.
12. Past psychiatric history:
    • Does the patient have a past history of psychiatric illness? When?
    • Was the illness episodic? Or was the patient continuously unwell?
    • Nature of treatment received, and response to treatment? why ?
    • Drug adherence? History taking in Psychiatry Cont.
13. Forensic history: History taking in Psychiatry Cont.
14. Premorbid personality:
    • This is an attempt to get an idea about what sort of a person the patient was before he fell ill. History taking in Psychiatry Cont.
15. Premorbid personality: Cont.
    Inquiry about the following features
    • Relationships:
    • Leisure activities:
    • Character:
    • Attitudes and standards: • Prevailing mood: Mental State Examination History taking in Psychiatry Cont.
16. Appearance and behavior:
    • General appearance
    • Posture and movement
    • Attitude towards examiner History taking in Psychiatry
17. Speech:
    • Rate of speech
    • Flow of speech
    • Content of Speech • Volume
    Cont. History taking in Psychiatry
18. Mood:
    • Anxious
    • Depressed • Elated
    • Irritable
    • Angry
    Cont. History taking in Psychiatry Cont.
19. Content of Thought:
    • Pre occupations and/or worries?
    • Ideas and plans of suicide?
    • Ideas and plans of suicide?
    • Obsessional ideas/impulses/images
    and compulsive rituals?
    • Delusions/overvalued ideas? History taking in Psychiatry Cont.
20. Disorders of Perception:
    • Hallucinations – auditory, visual, olfactory, gustatory, tactile
    • Illusions History taking in Psychiatry Cont.
21. Cognitive Functions:
    • Level of Consciousness
    • Orientation in time, place and person • Attention and concentration
    • Memory – short term and long term
    • Intelligence History taking in Psychiatry Cont.
22. Patient understands of illness/Insight: Thank You..!