Psychiatric history

taking
Personal information
Name of the individual
Father’s/Husband’s Name
Sociodemographic profile
Age
Sex
Education
Occupation
Socio-economic status
Marital status
Religion
Residence
Language spoken as mother tongue

Address

Source of referral

Identification marks

Type of admission, if admitted

 History of Present illness
Patient’s report of his illness: It should take precedence over the other informants’ report.
Patient should be asked about his version of the illness. Using the patient’s own words gives
insight into his state of mind and how he himself views his symptoms

Informant’s report: Details of all the available informants should be documented first,
including their names, relationship with the patient, acquaintance, length of contact,
consistency of the information. Also mention the reason for seeking help at current point of
time and what do they expect from the treatment they are seeking currently.
acronym of 5Cs: for Reliability
! Contact- between the patient and informant
! Closeness- of realtionship between the patient and informant
! Continuity- of the account given by informant
! Consistency- of the verbatims of the informant
! Coroborativeness- between various sources of information

Adequacy- it refers to the amount of information given by the informant and

assessment that whether this information is sufficient for forming a diagnosis or not.
Chief complaints- The chief complaints, often recorded verbatim states, why he has come or
has been brought in for help. It usually describes present symptoms, including the duration
of
each and an account of the development of the illness. Complaints should be in chronological
order with the earliest complaint first and recent most being last in list.

History of present illness - This provides a comprehensive and chronological

picture of the events leading up to the current moment in the patient’s life. The evolution of
the patient’s symptoms should be determined and summarized in an organised and
systematic
way.

Factors in illness - Predisposing factors , Precipitating factors, Perpetuating factors, Limiting factors, Modifying
factors

Mode of onset: It is assessed as time from being asymptomatic to symptomatic

Abrupt- Sudden appearance of signs and symptoms within 48 hours e.g. delirium
Acute- Rapid onset of signs and symptoms within 2 weeks e.g. ATPD
Insidious- Onset of signs and symptoms takes more than 2 weeks e.g. Schizophrenia
Course of illness
Continuous- Characterised by uninterrupted change without breaks or with steps
infinitely small and thus not detectable e.g. Schizophrenia.
Episodic- An illness can be said episodic when it has an onset and an offset of signs
and symptoms of the disease with periods of recovery inbetween at least for a period
of 2 months e.g. affective illness, non affective remitting psychosis
Fluctuating- When the course is waxing and waning especially under the effect of
treatment. e.g. Obsessive compulsive disorder, Schizophrenia

Progress of illness- To what extend has the patient’s symptomatology represented an

evolution over time
• Improving
• Deteriorating
• Static
Symptom analysis needs to be done at level of each symptom, so as to rule out (as far as
possible) all differential reasons for that particular symptom at that point itself

When explaining a particular compaint or symptom, it should be dealt in with as ABC model,
i.e. assessing the antecent to that behaviour, then the behaviour itself and then the
consequence of that particular behaviour.

Adequate and explanatory examples for each behaviour should be

mentioned, in chorological order. How and when a particular behaviour is noticed and how it
ends, all needs to be explained in the words of the informant, avoiding use of technical
words.

Other symptoms which the examiner expects to be present should be asked for, even if the
informant does not give spontaneous account

Certain symtoms (such as suicidal attempt) should be asked for and ruled out in all cases.
Persistant and pervasive mood during the course of illness should be asked for and
mentioned.

Impact of illness on patient’s attitudes should be noted. This should include mixing with
people, interest in work, self confidence, enthusiasm & optimism, experiencing pleasure in
light of current problems.

Role functioning and biological functions during the period of illness should be asked for

Activities of daily living and personal care & hygiene should be asked for

In the end of HOPI, all relevant histories which were ruled out should be mentioned under the
rubric of negative history.
 Treatment history
It includes details of the treatment obtained in the present episode. It is
noted whether help was sought and if help was sought, following are noted

medication, if any that were prescribed, details should be mentioned including doses,
duration, compliance, response, adverse effects (tabulate details as much as possible); length
of treatment; reason for discontinuing treatments or poor compliance; day treatment/
hospitalization if done, all of these domains should be elaborated.

Compliance- Compliance is defined as the extend to which the patient’s behaviour (in
terms of taking medications, following diets or executing other lifestyle changes)
coincides with medical recommendations
Adherence is defined as the extend to which the patient’s behaviour (in terms of
taking medications, following diets or executing other lifestyle changes) matches medical
recommendations “jointly agreed” between patient and prescriber
 Past history
Past medical history: This includes an account of major medical illness and conditions including
common as well as uncommon chronic childhood illness, conditions leading to frequent
medical consultation and treatment and those requiring emergency department visits,
and those requiring hospitalization.

Past Psychiatric History: Take a detailed history of previous episodes, symptoms, duration,
probable diagnoses, all available treatment details including hospitalization, inter-episodic
functioning, deficits.
 Family history
Parents and siblings: Age now or at death (if dead, the cause), occupation, personality,
quality of relationship with parents, psychiatric and medical history.
A brief statement about any psychiatric illness, hospitalization, and treatment of the patient’s
immediate family members should be placed in the family history part of the report.
Any family history of alcohol or substance abuse or of personality problems should be
Documented

Consanguinity: Relation by blood/descent from a common ancestor within the same family
stock. If present then degree of the consanguinity should be noted

Relationships amongst family members: Patient’s relationship with family members,

interpersonal relationship among family members; family squabbles, attitude of family
towards patient’s illness; family support system should all be noted in family history part.

Genogram: The genogram is a valuable assessment tool for learning about a family’s history
over a period of time.
 Personal history
Birth and Early Development: Antenatal history should start from presence of any illness,
medication, drugs, alcohol use, trauma or bleeding, exposure to X-rays, any physical/
psychiatric illness during pregnancy.

How was the home situation into which the patient was born.

What was the mother’s emotional and physical state at the time of pregnancy as well as
Delivery

Whether the delivery was full term, preterm or postterm? Place (home/ hospital/ other) and
type of delivery (normal/ instrumental/ episiotomy/ caeserian section), any injury at the time
of birth, birth weight, normal or delayed cry should be documented.

Developmental milestones should be probed into.

Presence of chidhood disorders: Comment on presence of hyperactivity, attention deficits and
impulsivity which are usually noticed from age of 2-3 years. Conduct problems during
childhood should be probed into.

Temper tantrums are very common in children; when present, extent and intensity should be
carefully noted. Neurotic traits (nail-biting, thumb sucking, food-faddiness, stammering,
mannersisms, bedwetting, phobias, night-terrors, sleep walking, etc.) during childhood
should be probed into and if present, the details should be mentioned.

Home atmosphere in childhood and adolescence

Scholastic and extracurricular activities

Vocational/Occupational history: Mention the age at which the individual started working
professionally for the first time. Duration at each work place, positions held, reasons for
leaving, relation with work mates and superiors.
Menstrual history

Sexual and marital history

Forensic history: Trouble with police, law; charges and convictions (sections), status of
cases should be adequately mentioned here as per the available information.

General pattern of living

Premorbid personality: It can be viewed as individualised styles of dealing with the

environment that is characteristic to each person prior to the onset of psychiatric disorder. It is
important to elicit details regarding the personality of the individual. Assess from
patient/relatives/others who know the patient well
 Physical Examination
For a psychiatrist, he is a doctor first and then a psychiatrist
For the respect of the medical knowledge, one should be and remain thorough with the skills
of physical examination
For doing physical examination of a female patient, a male doctor needs to have a female
attendant at the time of examination

Results of Investigation, if any available should be noted

Physical findings or diagnosis: Based on detailed physical examination and available

investigations, physical findings or diagnosis or differentials should be reached at.
 Mental Status Examination
Mental Status Examination: It is the part of clinical assessment that describes the sum total of
the examiner’s observation and impressions of a psychiatric patient at the time of the
Interview

It is a process of clinical observation of the patient for evaluation of psychological signs and
symptoms. It is analogous to physical examination in medicine and follows a definite
procedure.

Four assessment techniques are used to take a mental status examination of the patient
• Observation
• Conversation
• Exploration
• Testing
General Appearance: It is the evaluation of the patient’s manner of presentation at the time of
interview. The description should be as avid as possible.

General physical appearance: External attributes need to be examined. Body build, hygiene
and grooming should also be commented upon.

Estimate of age: It should be commented whether the patient appears appropriate to his
stated or real age

Body built: Make a comment on body built of a person

Touch with surroundings: In this we evaluate the patient’s perception of self in respect to his
surroundings.
Present: Patient is oriented; has normal perception of self in respect to surroundings.
Partial: Some aspect of his surroundings or their significance to the patient is lost.
Absent: Patient is unable to orient himself and behaves in a manner inappropriate to
the situation
Eye contact with the examiner

Dress

Facial expression

Posture: Posture and movements also reflect mood.

Attitude towards examiner:

• Co-operative
• Attentive
• Defensive
• Frank
• Hostile
• Guarded
• Evasive
Rapport: It is a bidirectional empathetic relationship, which the examiner shares with the
patient
Easily established: Seen in Normal persons, Mania
Established with difficulty: Seen in Schizophrenia, Dementia and Depression
Not possible: Seen in Paranoid Schizophrenia, Dementia and Depression

Motor Behaviour:
• Retardation
• Hyperactive
• Mannerisms
• Restless
• Stereotypy
• Awkward
• Destructive
• Tics
• Odd posturing
• Rigidity
Speech: This part describes the physical characteristics of speech. Speech can be described in
terms of its intensity, pitch, quality, prosody, reaction time, speed, ease, coherence, relevance,
goal directedness, rate of production, manner of relation and deviations .

Cognitive Functions
Orientation- It is defined as a state of awareness of oneself and one’s surrounding in terms of
time, place and person

Attention- The ability to focus in a sustained manner on a particular stimulus or activity. A

disturbance in attention may be manifested by easy distractibility or difficulty in finishing
tasks or concentrating on work

Concentration- Concentration is the ability to maintain attention to specific stimuli over an

extended period
Memory: Mental process that allows the individual to store information for last recall

Immediate memory- Reproduction, recognition and recall of perceived material within

seconds after presentation. Immediate memory/ recall is used to recall a
memory trace after an interval of few seconds, as in the repetition of series of digits

Recent Memory: Recall of events over the past few days . Recent memory is the
patient’s capacity to remember current day-to-day events. More strictly defined, recent
memory is the ability to learn new material and to retrieve that material after an
interval of minutes, hours or days .

Remote memory: Traditionally refers to the recall of facts or events that occurred
years back, such as the names of teacher and old school friends, birthdates and
historical dates . Recall of events in the distant past .
Abstract Ability: It is the ability to deal with concepts. Patients can have disturbances in the
manner of conceptualizing or handling ideas

Intelligence: It is the ability to think logically, act rationally and deal effectively with
environment.

It has following components:

• Comprehension
• General information
• Vocabulary
• Calculation
Mood and Affect

Mood- Mood is perceived as a persistent and sustained emotion that colours the patient’s
perception of the world.

Affect- Affect can be defined as the patient’s present emotional responsiveness, inferred from
the patient’s facial expression, including the amount and range of expressive behaviour.

Quality of Affect- the label or valence of the affect. Assessed on two criteria.
Subjective evaluation- ‘how do u feel’.
Objective evaluation- based on the observation of interviewer.

The quality of affect can be: Dysphoric, Anxious, Irritable, Depressed, Euphoric, Elated, Exalted,
Ecstatic , Euthymic
Intensity of affect- It is the strength of the emotional expression. It normally varies according to
the situation.
Those with a limited intensity of emotional experience may have-
• Shallow affect- When there is lack of depth in emotion.
• Blunted affect- Greatly diminished emotional response or expressionless face and a uniform
voice, irrespective of the topic of conversation, patient is indifferent to distressing topics.
• Flat affect- When no affect is displayed, it is reported to be flat or absent in emotional
response. Or it may be understood as an absence of appropriate outwardly thoughts

Mobility of affect- It is the ease and speed with which one moves from one type to another
type of emotion

Reactivity- The reactivity is the extent to which affect changes in response to enviormental
stimuli. When patient does not respond to examiner’s provocation in the form of joking, for
instances, the affect is said to be non-reactive.

Range of affect - Full Range or Restricted range

Communicability- The ability of the expression of affect to communicate to another one’s
emotional response to events, interaction, behaviour, and situation.

Appropriateness- It is refers to the congruence or fit between the expressed quality of emotion
and the content of speech, thought, expected degree of intensity and the overall situation
Thought
It is an idea produced by thinking or occurring suddenly in mind or the action or process of
thinking
The division of disorders can be understood, if we compare thought to a flowing river. The
source of water, be it hills, rains or waste from community is equivalent to possesion; the
flow of river is stream; the water content in it is content and the liquid form of water is its
Form.

The abnormality in thoughts can be assessed on following points:

Stream- Flow of thoughts
Volubility Circumstantiality
Acceleration Tangentiality
Pressured Speech Perseveration
Flight of ideas Thought blocking
Prolixity
Retardation
Poverty of speech
Form- Form of thought means “the arrangement of parts”. Disturbance in the form of thought
are disorder in the logical connections between ideas.
Formal thought disorder- Disorder of form of thinking is also called formal thought
disorder. This is disorder of conceptual or abstract thinking, which occur in
Schizophrenia and coarse brain disease

There are two types of formal disorder:

Negative type – the patient looses his previous ability to think and cannot
produce a concept.
Positive type – in this, the patient produces false concept by blending together
incongruous elements

Loosening of association
Derailment
Neologism
Over inclusion
Possession: Normally one experiences one’s thinking as being one’s own, although this sense of
personal possession is never in the foreground of one’s consciousness and is taken for granted

In some psychiatric illnesses there is a loss of control or sense of possession of thinking

Obsession: Persistent and recurrent idea, thought or impulse that cannot be eliminated
from consciousness by logic or reasoning.
essential feature of the obsession are
Own and ego-dystonic
Intrusive
Deemed as irrational or senseless
Appears against the will (involuntary)
Tries to resist
May have temporary relief by yielding to compulsions, but the thoughts recur
Associated with dysfunction
Obsessions can take various forms:

• Obsessional thoughts
• Obsessional images
• Obsessional ruminations
• Obsessional doubts
• Obsessional impulses
• Obsessional phobias
• Obsessional fear of illnesses
• Obsessional slowness
Compulsion- compulsions are in fact merely obsessional motor acts.
The word obsession is usually reserved for the thought and compulsion for the act.
Compulsions may occur in form of acts, rituals or behaviours.
They are accompanied by a subjective sense that the behaviour must be carried out and by an
urge to resist.

Thought alienation

• Thought insertion
• Thought withdrawal
• Thought broadcasting
Content:
• Worry
• Phobia
• Impulse
• Somatic symptoms
• Depressive cognition
• Suicidal ideas
• Death wishes
• Inflated self esteem
• Delusion (Delusion is defined as “a false, unshakeable belief that is out of keeping with the
patient’s social and cultural background)
• Overvalued idea
• Delusion of Reference
• Delusion of Persecution
• Delusional misidentification syndromes
• Delusion of control
• Delusion of infidelity
Perceptual disorders

Sensory distortion
Changes in intensity
Changes in quality
Changes in spatial form

Sensory deception
Hallucination (A false perception which is not a sensory distortion or a
misrepresentation, but which occurs at the same time as real perceptions.)
Hearing- Auditory hallucination
Vision- Visual hallucination
Smell- Olfactory hallucination
Taste- Gustatory hallucination
Touch- Tactile hallucination
Illusion
Imagery
Other psychotic phenomena

Somatic passivity

Made phenomenon
Made act
Made affect
Made impulse

Other phenomena

Depersonalization
Derealization
Body image disturbance
Paramnesia
Judgement
Judgement is a complex mental process whereby a person forms an option, makes a decision,
or plans an action or response after first analysing the issue and comparing choices with
acceptable social behaviour

Social judgement -Here the person’s interaction with the other social members and the
interviewer is assessed. It is usually assessed from the history given by the informants.

Personal judgement - the individual’s personal expectations, plans and attitudes are assessed

Test judgement- It aims to assess the course of action that a person might take in a socially
difficult or disastrous situation
Insight:
It is a patient’s degree of awareness and understanding about being ill .

Insight is rated on a 6-point scale from one to six.

Grade-1 Complete denial of illness.
Grade-2 Slight awareness of being sick and needing help, but denying at the same time.
Grade-3 Awareness of being sick, but it is attributed to external or physical factors.
Grade-4 Awareness of being sick, due to something unknown in self.
Grade-5 Intellectual insight- awareness of being ill and that the symptoms/ failures in
social adjustment are due to own particular irrational feelings/ thoughts; yet doesn’t apply this
knowledge to the current/ future experiences.
Grade-6 True emotional insight- it is different from intellectual insight in that the
awareness leads to significant basic changes in the future behaviour.