How to take a history in psychiatry ?

How to take a psychiatric history?

A complete and thorough history as in any other history includes past medical history and also a complete mental state examination.

Remember – Most of the patient’s information that you are going to gather from the interview can be obtained from the appearance and behavior of the patient when he first comes is.

Before taking the history –

1.     Introduce yourself

2.     Make sure it is a comfortable room and free of overt noisy surroundings.

3.     Inform the patient what it is all about and why we are conducting this meeting.

Pillars of taking a psychiatric history

1.     Confidentiality – The utmost priority is to make sure you have ensured confidentiality. Failure to do so can have severe ethical and legal dilemmas. You must tell the patients that everything that they talk amongst themselves is confidential

2.     Presenting illness history- HPI:

a.     When did the complaints start?

b.     How did it start

c.      Is it Worsening or getting better.

d.     What is the effect on your life because of the symptom? What is the effect on your sleep?

3.     Mood:

a.     How is your mood?

b.      Have you noticed any change in your sleep.

c.     Change in appetite?

d.     Change in weight?

e.     Did you experience any weight loss or weight gain.

f.      What is your energy level?

g.     Do you think life is worth living?

h.     Have you thought of harming yourself or anybody else (What, when,

how)?

i.      Are there times when your mood is high?

4.     Psychosis:

a.     Do you see/hear/feel things which others do not?

b.     Did you have any strange experiences? Do you think somebody is putting ideas in your head (thought insertion)?

c.     Do you think your ideas are being broadcasted everywhere/do you think people are after your ideas (thought broadcasting)? Do you think that people, TV, radio, newspaper is talking about you?

d.     Do you hear voices telling you to harm yourself/somebody?

5.     Insight:

a.     Do you think something is wrong with you? Do you think you need help?

6.     Judgment:

a.     What will you do if there is a fire in this room?

b.     What will you do if you find an envelope with a name, ticket, everything?

7.     Cognition: do you know who you are? Where you are and the time?

Past Medical history

a.     Previous hospitalization

b.     Previous medications / current medications

c.     Previous psychiatric problems

d.     Drug and alcohol abuse history

e.     History of problems with law enforcement agencies?

Personal and Social history

a.     What do you work as?

b.     How long have you been in this job?

c.     How much do you socialize?

Forensic history

Visits to courts etc ..

Leave a Reply

Your email address will not be published. Required fields are marked *