Psychiatry

1. History Taking in Psychiatry
Moderator
Dr. (Major) Rakesh Saxena Sir
Presenter
Dr. Robin Baghla
Junior Resident 1
Department of Psychiatry, HIMS

2. Roadmap
• History taking
 Purpose
 General principles
 Interview room
 Questioning
 Basic details
 HOPI
 Past history
 Personal history
 Family history
 Pre morbid personality
• Techniques

3. History taking
• Most important in evaluation and care of persons with mental
illness.
• Purpose-
Establish diagnosis.
Prediction of course of illness & prognosis.
Treatment decisions.
Shapes patient-physician relationship
• Psychiatry interview takes place in – Psychiatric IPD, Non-
Psychiatry IPD, Emergency Room, OPD, Nursing homes etc.

4. General principles
• Agreement to the process-
 Introducing
 Voluntary/ Involuntary patient
• Privacy & Confidentiality-
 Very essential
 Assure patient of confidentiality
 Legal obligation
• Respect & Consideration-
 Patient should be treated with respect.
 It helps in allaying anxiety of patient
• Rapport/ Empathy-
 Harmonious responsiveness of physician to patient and vice versa
 Understanding what the patient is thinking and feeling by putting in
patient’s place
 Verbal & Non verbal responses
 Retaining Objectivity(Not to get carried away)

5. • Patient-Physician relationship-
 Patient’s willingness to share depends upon verbal and nonverbal behaviour of
physician,
 The sharing is reinforced by nonjudgmental behaviour of Physician
 there are 2 essential ingredients-
1) Demonstration by physician that he understood what patient is stating and
emoting.
2) Recognition by patient that the physician cares.
 Increases trust & therapeutic alliance
• Patient –centerd and Disorder based Interview-
 A Psychiatric interview should be patient centered.
 A patient centered approach focuses on strengths and assests as well as deficits.
• Safety and Comfort- Patient should feel safe and comfortable.
 If patient feels threatened, medical staff should reassure the patient.
 If the patient is threatening or agitated, Interview should be shortened or terminated.
 Open-ended questions should be asked to make patient comfortable
 If patient is distracted, then closed end question should be asked
• Time and Number of Sessions- mostly 45-90 minutes.
 If patient is in distress or psychosis then 20-30 minutes or less
 Either number of brief sessions or atleast more than one session is required for accurate
evaluation

6. Interview room
• Relatively soundproof
• Décor- pleasant, non distracting
• Chair of patient - Patient should be given choice of chair
• Distance b/w Psychiatrist and Patient - Approx 4 to 6 feet apart
• Distractions should be kept minimum
• Doctor should be dressed professionally and well groomed
• No telephone or beeper interruption should be kept in the room

7. Questioning
• Open ended and Closed ended
• Open ended- They identify an area, provide minimal structure
as to how to respond. E.g- Tell me about your problem?
• Closed ended - Provide structure and narrow the field of
responses. Mostly yes or no. E.g - Is sleep your problem?
• The interview should not be a single funnel of open-ended
questions in the beginning and closed-ended questions at the
end of the interview but rather a series of funnels, each of
which begins with open-ended questions

8. Parts of Initial Psychiatric Interview
• Identifying data
• Source & reliability
• Chief complaints
• HOPI
• Past history (Psychiatric and Medical)
• Family history
• Personal history
• Pre Morbid Personality

9. Basic details
• Identifying data-
 Sociodemographic profile i.e. Patient’s name, age, sex, religion, occupation,
marital status, education, occupation, socioeconomic status, & residence should
be noted adequately and correctly as these factors have a role to play in onset,
course, presentation, treatment and prognosis of various illnesses. It also helps in
legal matters and research purpose
• Source & reliability-
 From whom the information came & how reliable is the data.
 Essentials for Reliability, 5 C’s-
 Contact
 Closeness
 Continuity
 Consistency
 Coroborativeness
 Adequacy- Data should be sufficient for forming a diagnosis.
• Chief complaints-
 In patient’s own words e.g. “I am depressed.”
 Noted chronologically.. It should include onset, course and total duration of illness.

10. HOPI- History Of Present Illness
• It forms the backbone of Psychiatric case work up.
• Chronologic description of the evolution of symptoms of the
current episode.
• Onset (Sudden/Acute/Insidious/Chronic), duration and course
of illness (Continous/Episodic/Fluctuating).
• Basic information of specific chief complaints- duration,
intensity etc..,
• Essential questions to be answered in HOPI includes “What”,
“how much”, “how long” and associated factors.
• Details of Predisposing factor, Precipitating factors and
Perpetuating factors
• Any Treatment history for current episode and its complaince
should also be mentioned.

11. Past history
• Includes- Psychiatric & Medical. Past history.
• Past Medical history- Medical illness can precipitate a psychiatric disorder( e.g.
Axienty disorder in newly diagnosed Cancer patient) , mimic a psychiatric
disorder (e.g. Hyperthyroidism resembling in anxiety disorder). Medical illness
can be precipitated by long use of Antipsychotic medicines. Any past history of
Surgery, head injury, seizure disorder, pulmonary TB
• Information about past psychiatric illnesses, course including symptoms &
treatment.
• Description of past symptoms should include when, how long they
lasted, frequency and severity of episodes.
• Any history of suicidal attempts, voilence, homicidal history or non-
suicidal self injurious behaviour like cutting, burning, banging head.
• Treatment details should be reviewed in detail like- pharmacotherapy,
psychotherapy, ECT. what was tried , how long and at what doses they were used , and
why they were stopped, response to the medication or modality and whether there were
side effects.
• It is also important to ask about the complaince.

12. Family history
• Genogram is a valuable assessment tool for learning about a family’s
history over a period of time.
• Psychiatric illnesses are familial and a significant number of those
have a genetic predisposition.
• Family history of psychiatric illness- details regarding the same.
• Medical illnesses present in family history like Diabetes etc. may also
be important in both the diagnosis and the treatment of the patient.
• Family traditions, beliefs, and expectations may also play a significant
role in the development, expression, or course of the illness.
• Family history is important in identifying potential support as well as
stresses for the patient

13. Personal history
• Birth & early development
• Presence of childhood disorders
• Home atmosphere in childhood and
Adolescence.
• Scholastic and extracurricular activities
• Occupation history
• Menstrual history
• Sexual and Marital history
• Forensic history

14. Pre morbid personality
• Prior to the beginning of mental illness
• Details like-
Social Relation
 Predominant Mood
 Intellectual activities, hobbies & interests
 Character
a) Attitude to self
b) Attitude to work and responsibility
c) Interpersonal relationship
d) Standard in Moral, Religious and health matters
e) Energy , Initiative
Fantasy life
Habits

15. Techniques
Facilitating Interventions- effective in continuing patient to share his/her story. It develops Positive
Patient –Doctor relationship
 Reinforcement - A brief phrase such as "I see," "Go on," "Yes," "Tell me more" "Hmm" or "Uh-
huh" all convey the interviewer's inter' ' est in the patient continuing.
 Reflection - By using the patient's words, the psychiatrist indicates that he or she has heard what
the patient is saying and conveys an interest in hearing more.
 Summarizing- Periodically during the interview it is helpful to summarize what has been identified
about a certain topic. This provides the opportunity for the patient to clarify or modify.
 Education- Educate the patient about the Interview process.
 Reassurance- Reassure the patient e.g. Accurate information about course of illness can decrease
anxiety.
 Encourangement - encourage the patient to engage in the interview.
 Acknowledgement of Emotion- Interviewer should acknowledge the expression of emotion of the
patient.
 Humor- Patient may make a humorous comment or tell a brief joke. It can be very helpful if the
psychiatrist smiles, laughs, or even, when appropriate, add another punch line. This sharing of
humor can decrease tension and anxiety and reinforce the interviewer's genuineness.
 Silence - Careful use of silence can facilitate the progression of the interview. The patient may need
time to think about what has been said or to experience a feeling that has arisen in the interview

16. Nonverbal communication-
Nodding of the head, body posture including leaning toward the patient, body
positioning becoming more open, moving the chair closer to the patient, putting
down the pen and folder, and facial expressions including arching of eyebrows all
indicate that the psychiatrist is concerned, listening attentively, and engaged in the
interview.
Expanding Intervention- used to expand the focus of the interview
 Clarifying- At times carefully clarifying what the patient has said can lead to
unrecognized issues
 Association- As the patient describes his or her symptoms, there are other
areas that are related to a symptom that should be explored.
 Leading - Often, continuing the story can be facilitated by asking a "what,"
"when," "where," or "who" question.
 Probing- Gently encouraging the patient to talk more about this issue
 Redirecting - to redirect the focus of patient from nonproductive area.

17. Obstructive interventions
• unclear, unconnected, poorly timed, and not responsive to the patient's issues or concerns.
 Closed - ended Questions- A series of closed-ended questions early in the interview can
retard the natural flow of the patient's story .
 Compound Questions- Some questions are difficult for patients to respond to because
more than one answer is being sought.
 Judgmental Questions or Statements- generally nonproductive for the issue at hand
and also inhibit the patient from sharing even more private or sensitive material.
 Minimizing Patient’s concern- patient may feel that the psychiatrist does not
understand what he or she is trying to express.
 Premature Advice- Advice given too early is often bad advice because the interviewer
does not yet know all of the variables.
 Premature Interpretation- patient may respond defensively and feel misunderstood.
 Nonverbal Communications-repeatedly looks at a watch, turns away from the patient,
yawns, or refreshes the computer screen conveys boredom, disinterest, or annoyance..
This can quickly shatter the interview,

18. Closing the Interview
• The last 5-10 minutes of the interview are crucial
• It is essential to alert the patient to the remaining
time.
• It can also be useful to allow the patient to ask a
question.
• If this interview was to be a single evaluative session,
then a summary of the diagnosis and options for
treatment should generally be shared with the patient.

19. Medical Record
• Most Psychiatrists take notes throughout the interview.
• Usually a form is used that covers the basic elements of
Psychiatric evaluation.
• Sometimes patients have concerns with their confidentiality
while taking notes. This concern can be dealt with discussion
about how important is it to take notes.
• Eye contact must be made while taking notes otherwise
interviewer can miss non-verbal communication.
• These days computerised methods (EHR’s)are used that can
be useful but also disruptive for smooth ongoing interview.

20. Interviewing the difficult patient
• Patient with Psychosis=
 Patients with psychotic illnesses are often frightened and guarded. They
may be actively hallucinating during interview causing them to be
inattentive and distracted.
 The interviewer may need to alter the usual format and adapt the
Interview to match the capacity and tolerance of the patient.
 Many patients will not interpret their experiences as hallucinations, and it
is useful to begin with a more general question: "Do you ever hear
someone talking to you when no one else is there”? The patient should be
asked about the content of the hallucinations, the clarity, and the
situations in which they occur Other perceptual disturbances should be
explored including visual, olfactory, and tactile hallucinations.
 For patients with paranoid thoughts and behaviors it is important to
maintain a respectful distance Harry Stack Sullivan recommended that
rather than sitting face to face with the patient who is paranoid, the
psychiatrist might sit more side by side,

21. Depressed and Potentially Suicidal patients.
 The depressed patient may have particular difficulty during the
interview as he or she may have cognitive deficits as a result of the
depressive symptoms.
 impaired motivation and feelings of hopelessness may contribute
to a lack of engagement.
 A suicide assessment should be performed for all patients
including prior history, family history of suicide attempts and
completed suicides, and current ideation, plan, and intent.
 The intent of the psychiatric interview is to build rapport and
gather information for treatment and diagnosis, the patient's safety
must be the first priority. If the patient is viewed to be at imminent
risk, then an interview may need to be terminated and the
interviewer must take action to secure the safety of the patient.

22. Hostile, Agitated and Potentially violent Patients
 Safety for the patient and the psychiatrist is the priority when interviewing
agitated patients.
 Hostile patients are often interviewed in emergency settings, but angry and
agitated patients can present in any setting.
 As increased stimulation can be agitating for a hostile patient, care should be
taken to decrease excess stimulation as much as feasible. The psychiatrist
should be aware of his or her own body position and avoid postures that could
be seen as threatening, including clenched hands or hands behind the back.
 The psychiatrist should approach the interview in a calm, direct manner and
take care not to bargain or promise to elicit cooperation in the interview.
 Depending on the patient history, the psychiatrist may decide to prescribe or
increase antipsychotic medication, recommend hospitalization, and perhaps,
depending on the jurisdiction, notify the threatened victim.

23. Deceptive Patients
 Patients lie or deceive their psychiatrists for many different
reasons. Some are motivated by secondary gain (e.g., for financial
resources, absence from work, or for a supply of medication).
Some patients may deceive, not for an external advantage, but for
the psychological benefits of assuming a sick role.
 It may be useful to gather collateral information regarding the
patient. This allows the psychiatrist to have a more broad
understanding of the patient outside the interview setting, and
discrepancies in symptoms severity between self-report and
collateral information may suggest deception.