History taking in Psychiatry

Dr. M. Subendran
 Objectives
• Basics of a clinical interview
• The components of the history
• The importance of co-lateral information
• The other things to be done during history
taking
 Basics of a clinical interview
• Setting
• Starting the conversation
• Building up rapport with the patient
• Continuing conversation
• Taking notes
• Sum up the information
• Ending the interview
• The purpose of the clinical interview is to;
– Establish a diagnosis or to come to a differential
diagnoses
– Establish the severity of the illness
– Identify the aetiology
– Identify reasons for relapse
– Carry out risk assessment
– Plan on the future interventions suitable to the
patient
 Setting
• Ensure privacy of the patient
• Correct table/chair arrangement
• Quick access to help / escape in case of an
emergency
 Starting the conversation
• Introduce yourself
• Get the consent of the patient
• Give a rough estimate how long the interview
would last
• After obtaining the personal details of the
patient initiate the interview with open ended
questions
• Do not interrupt (allow him to ventilate
emotions)
 Building up rapport
• Be professional
• Be flexible
• Listen to his concerns
• Win the patient’s confidence
• Empathize
• Be alert on sensitive issues get the maximum
without embarrassing the patient or hurting him
or postpone them
• Sum up the relevant details and ensure the
correct information obtained
 Continuing the interview
• Psychiatric interviews could not be carried out in a pre fixed
manner
• Considering the time allowance given to elaborate the
emotional distress faced by the patient, do focus on your
objective getting the maximum information as possible
• Better stick to open ended questions rather than closed
questions; but whenever the patient starts talking out of
topic direct the patient to come back to the topic of your
interest
• Sum up the information gathered then and there
• Make the patient feel free to clarify the questions if not
understood
 Taking notes
• Taking notes while interviewing is of your choice
• Patient’s account might be haphazard
• Better taken in a shortened form
• Many collect relevant information organize it and write
down
• Do not make the patient feel uncomfortable by not
paying enough attention to his story (rather make him
feel that you are more concerned taking down notes)
• If you are a right hander let the patient to be seated
perpendicular to your left hand side and vice versa
 Ending the interview
• List out a problem list
• Identify the risks
• Clarify details not understood by you and let
the patient to clarify his doubts
• Give instructions to the patient regarding your
future management plans
• Thank the patient
 Components of the psychiatric history
• Patients personal details
• Source of referral
• Presenting complaint
• History of the presenting complaint
• Family history
• Personal history
– Sexual & menstrual Hx
– Substance history
– Forensic history
• Past psychiatric history: if relevant here if not below personal
history
• Past medical history
• Pre morbid personality
 Basic information
• Name
• Age
• Sex
• Occupation
• Marital status
• No of children
• Area of residence
• E.g.: I took the history from / I assessed
Mr. K. S, a 54 year technical officer married
and a father of 3 children from Kopay
 Source of referral
• Pathway through the patient accessed the
psychiatric services
• Could have been
– referred by a clinician
– Brought by the family members
– Self referral
– Judicial services
– Brought by the police
 Presenting complaint
• The last component to be incorporated extracting the
salient information from HPC
• Patient’s description of problem
– Important, precise and concise description denoting a DD
• The time duration of the problem
• The period of worsened symptoms
• E.g.:
– Brought by the mother with the c/o
– Pervasive preoccupied worrying thoughts, lack of energy
feeling of guilt and recurrent suicidal ideation of past 3
weeks duration worse for past 2 days.
History of the presenting complaint
• Contains information from the time the patient
was last healthy to the time of evaluation
– If he is a diagnosed patient with a psychiatric illness
start as
• He was a diagnosed patient with a psychiatric illness
(depression) for 9 years. He was followed up at TH Jaffna
with the h/o fairly good clinic follow up record and good drug
adherence. He lost his brother 3/52 back who was the bread
winner of the family since then he had preoccupied thoughts
about his demised brother.
– If the patient presents to the psychiatric services for
the first time start as;
• This was the first contact with the psychiatric services. He
was previously well 3/12 back.
• Description of symptoms:
– Symptom onset sudden or insidious
– Better in the chronological order cluster the symptoms finish
one by one
– Progression of symptoms over time
– Give less weight to negatives;
• Patient doesn’t have …… list of so many negatives!
– Describe the symptom not the sign
• Patient hears voices of his persecutors discussing among themselves
in a derogatory manner
• Not to present as patient has 3rd person auditory hallucinations in the
history
– Give relevant examples;
• patient believes that his neighbours are trying to harm him as he
claims that they are spying him fixing cctv cameras all over his
premises and trying to figure out each and every movement of him.
Aetiological factors;
• Biological, Psychosocial;
– High expressed emotions in the family
– Psychosocial stressors: death of a loved one, financial break
down etc.
– Poor drug adherence
– Relapse despite good drug adherence
– Any other medical conditions and comorbidities
– Any recent usage of medications or psychoactive substances
E.g.: He claimed that his family members were extremely critical
about his illness and express their despair. Thus, he was feeling
lonely and no one to care for.
• Functionality and impact on life
– Activities of daily living
• D – Dressing
• E – Eating
• A – Ambulating
• T – Toileting
• H – Hygiene (Brushing / Bathing)
– House hold activities
• S – Shopping
• H – House keeping
• A – Accounting
• F – Food preparation
• T – Travelling
– Occupational / Educational activities
– Social interaction
– Money spent on illness
E.g.: Patient was able to carry out his ADLs with prompting, however he
was unable to engage in house hold activities. He also refrained attending
to his job for past 10 days as he found increasingly difficult to converse
with others. The family has approached natural healers and spent more
than 50,000/- over the past 2/52.
• Exclude differentials:
– At least try to figure out most probable DDs
– Give positive and negative findings towards each differentials
– Elicit the basis how you are excluding the DD (if possible)
– Some important considerations
• If the current disturbance could be secondary to a psychoactive
substance consider supporting or excluding in the DD
• If the current episode had different sets of symptoms alternatively
worth mentioning. E.g.: Mixed episode of bipolar affective disorder
– The patient was not having a history of recent onset fever, neck stiffness,
photophobia or headache suggestive of a meningo-encephalitis.
– He denied the usage of any psychoactive substances in the recent past
– He didn’t have persistently low mood, lack of interest in previously
pleasurable activities and lack of energy suggestive of a depressive illness
during or preceding this episode
Risks
• History of suicidal thoughts
or thoughts of harming
others during the current
episode
Current Rx
• If the patient had been
admitted to the ward, what
were the treatments given
to the pt
• And the response
 Family history
• Family tree
• Family history of mental illnesses
• History of suicidal deaths in the family
• History of chronic usage of alcohol and other
psychoactive substances in the family
• History of significant medical comorbidities in the
family (may be useful to avoid drugs inducing
metabolic syndrome in case of a strong family history)
• E.g.: the patient denied history of any mental illnesses
suicidal deaths and chronic usage of substances
among her first degree relatives.
 MI

Mother and maternal aunt have a Mental illness. Maternal aunt committed
suicide hanging herself. Father and his younger brother both used to drink
heavily on daily basis. Patient has a strong family history of DM and
hypercholesterolemia.
 Personal history
• Mode of delivery • Relationships
• Perinatal complications • Work history
• Milestones • Marital history
• Children
• Childhood parental discord
and abuses • Earnings
• Savings
• Academic and non –
academic achievements
• Family support
• Sexual history and
• Highest educational menstrual history
qualification • Substance Hx
• Forensic Hx
 Substance history
• Usage of various substances – types
• Day of last consumption
• Level of consumption – occasional / features
of dependence
• Criminal offences – drug dealing / trafficking
• Any arrests by police due to psychoactive
substance usage
 Forensic history
• Any convictions / arrests / imprisonment /
reprimands
• The type of offence
• Any contact with the law enforcement
authorities
 Past psychiatric history
• Diagnosed since when
• Follow up history
• Current medication
• Adherence to prescribed drugs
• Whether achieved full remission in the past/ inter-
episodic functioning
• Relapses, number of hospital admissions and last
hospital admissions
• Effective therapeutics – ECT/ clozapine/ Lithium
carbonate
• Side effects
• Suicidal or homicidal attempts in the past
 Past medical history
• Significant medical comorbidities
– DM, hypercholesterolemia, hypertension etc.
– Hypothyroidism, hyperthyroidism, SLE, Epilepsy
– Parkinson disease
– Allergic history
• Drugs
– Corticosteroids, carbimazole
– Syndopa
 Pre morbid personality
• Pre morbid personality is not just what the
patient says. Its about your judgment on patient’s
probable personality
– Attitude to self – how he sees him and how others see
him
– Nature of significant relationships
– Coping skills including response to illness
– Leisure activities and religious values
• If there are any evidence of personality traits /
disorders
 Importance of co-lateral history
• Psychiatric patients do not have a stable mental
state
• Thus some find it difficult to narrate their stories
as others do
• Some may be mute, some may be paranoid,
some may have LD and some converse
completely in incoherent irrelevant manner
• So co-lateral history from the immediate family
members, guardian, by standers and hospital
staff becomes mandatory
Other things to be done during history
taking
• From the time the patient enters the room
observe the patient start assessing the
patient’s mental state
• Try to formulate patient’s personality from his
behaviour, actions and his conversation