Conceptual understanding and outline for basic history taking in Psychiatric disorders, formulating a diagnosis based on the information and planning appropriate management for the same.

1. History Taking – Psychiatric aspects
Dr Bhakti Murkey
Consulting Psychiatrist (MD)

2. Psychiatry – branch of Medicine
 Biological basis:
 Neuro-anatomy
 Neuro-physiology
 Genetics
 Neuro-chemical messenger (monoamide) hypothesis
 Medical Model:
 Traditional way of thinking about ‘disease’
 Extended to diseases of the mind (thoughts, feelings and behaviors)
 Dramatic response to Rx modalities

3. Psychiatric History-taking
 Medical process
 Systematic record of data received during interview
 An account of significant events
 Compilation and analysis of patient experience
 Goal: to achieve a succinct summary of relevant information
 Standardized format: facilitates communication with other
professionals
 Most important diagnostic tool in mental health
 Elements of subjectivity

4. Qualities of a therapist
 Non-judgemental attitude
 Warmth and Empathy
 Communication skills
 Interpersonal soft skills
 Patient and active listening
 Honesty
 Flexibility
 Optimism
 Building trust
 Allowing patient participation
 Sensitive (language, culture,
sexuality)
 Scientific approach
 Ability to say no/ draw
boundaries
 Adequate subject knowledge

5. Goals of history taking
 Establish Rapport
 Communicating about confidentiality and professional ethics
 Collect accurate information about patient’s problems
 Meaningful interpretations of patient’s version
 Rule out presence of physical symptoms distinctly from
psychological
 Holistic assessment of person’s psyche and health
 Being able to formulate a treatment plan
 Comprehensive documentation and record keeping of the history for
future reference or external communication

6. Informant
 Assess Reliability:
 Age
 Education
 Relationship
 Living with?
 Intent for the patient
 Any personal gains?
 Consistency over time/ multiple interviews

7. Outline
 Demography
 Identification
 Presenting complaints
 Onset and course of illness
 Negative History
 Medical/Surgical History
 Functioning
 Treatment History
 Past History
 Family History
 Childhood History
 Perinatal
 Schooling
 Socio-economic History
 Occupational History
 Religious beliefs
 Psychosexual History
 Premorbid Personality

8. Demographic Details
 Name
 Age
 Sex
 Address
 Occupation
 Marital status
 Identification marks
 Type of admission (if IPD)
 Significance:
 Medico-legal cases
 Avoid inter-change of information
in similar cases
 Communicating on community
level
 Making Rx plan based on
background/ practical aspects
 Research purpose

9. Presenting complaints
 Total duration of illness
 Chronological order of symptoms
 Duration of each symptom
 When too many?
 Pick top 5
 Make symptom clusters
 Elaborate each symptom: onset, severity and course
 Story of illness progression
 Patient’s narration vs clinical interpretation

10. Axis 1 disorders
 Multi-axial clinical diagnosis: ICD vs DSM
 How to rule out major Psychiatric diagnoses:
 Depression
 Mood Disorder
 Psychosis
 SUD
 OCD
 Anxiety spectrum

11. Medical co-morbidity
 Organicity
 Major medical illness:
 Hypertension
 Diabetes
 Tuberculosis
 Asthma
 Thyroid Disorders
 B12 deficiency
 Any surgical illness/ intervention

16. Family History
 Pedigree
 Birth order
 Nuclear vs Joint
 F/H Psychiatric illness
 F/H Medical illness/ complications
 Home environment and relations
 Support system
 H/O active stressors

17. Childhood Psychiatric Disorders
 Axial Classification:
 Axis I – Clinical Diagnosis
 Axis II – Specific Learning
Disability
 Axis III – General Learning
Difficulties
 Axis IV – Medical Diagnosis
 Axis V – Psychosocial &
Environmental stressors
 Assess Parenting style
 Rule out:
 Autism
 ADHD
 Temper tantrums
 Eating or Feeding problems
 Emotional issues
 CSA
 Academic/ learning problems
(SpLD)

18. Pre-morbid Personality
 Axis II presentation
 Reflection on Axis I
 Proportion of symptoms
expected to respond
 Managing psycho-social impact
and interpersonal relations
 Prognostic implications
(recurrence)
 Assessment of:
 Temperament
 Lifestyle
 Impulsivity
 Social interaction
 Significant others
 Friendships
 Emotional communication
 Habits/ Hobbies
 Anger management
 Coping skills
 Perception of patient’s personality
by family/ friends

19. Diagnostic Case Formulation
 Diagnosis alone tells us little about causation of disorder
 Formulation:
 Understanding etiological factors
 Identifying key difficulties in order to guide intervention accordingly
 Anticipating challenges that may occur during the course of treatment
 5 P approach:
 Presenting problem
 Predisposing Factor
 Precipitating Factor
 Perpetuating Factor
 Protective Factor

20. Diagnostic Case Formulation
 Summary: Concise description of
important aspects
 Formulation: Comprehensive
assessment of the case rather than
mere restatement of facts
 Case formulation:
 Integrative process
 Synthesizes how one
understands the complex,
interacting factors implicated in
development of a patient’s
presenting problems
 Discussion on etiology,
differentials, prognosis
 Takes into account the person’s
strengths and capacities
 Helps to identify potentially
effective treatment approaches
 Types:
 Clinical
 Diagnostic
 Psychodynamic
 Psychotherapeutic
 Bio-psycho-social

21. Diagnostic Classification
 Normal
 Abnormal:
 Organic
 Functional:
 Neurosis:
 Anxiety/ Depression/ Phobia/ OCD
 Psychosis:
 Schizophrenia/ Bipolar Disorder/ Delusional Disorder
 Mixed:
 Substance Use/ Personality Disorder

22. Treatment plan
 Medical management:
 Axis I and IV
 Intensity, frequency and
duration of symptoms
 Functional impairment
 Poor sleep/ appetite/ quality
of life
 Psychotherapy:
 Axis II and III
 Supportive/ Interventional
 Make Rx response
sustainable
 Psychosocial management:
 Axis III
 Correction of social aspects
 Vocational aspects
 Skills building
 Enhanced self-efficacy
 Involving significant others

23. Take away points
 Medical model of Psychiatry
 Significance of History taking
 Reference to Physical health parameters
 Assessment of Personality
 Case Formulation
 Therapeutic Interventions
 Holistic health care

24. Questions