Psychiatric history taking


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Psychiatric history taking

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  2. 2.  Name Age Sex Marital Status Religion Occupation Socio-economic status Address Informant Information (Relevant or not) adequate or
  3. 3.  – In patient’s own words & in information’sown words.Eg: - Sleeplessness X 3 weeks- Loss of appetite & hearing voices X 2 weeks- talking to self X 2
  4. 4.  Onset - Acute (within a few hours)-Subacute (within a few days)- Gradual (within a few weeks) Duration – days, weeks or months Intensity / same / increasing or decreasing Precipitating factors – yes / no (if yes explain) History of current episode (explain in detail regarding thepresenting complaints) Associated disturbances – include present medicalproblems(eg: Disturbance in sleep, appetite, IPR & socialfunctioning, occupation etc)
  5. 5.  Number of episode with onset & course Complete or incomplete remission Duration of each episode Treatment details & its side effects if any Treatment outcomes Detail if any precipitating factors if
  6. 6. a) Past Medical History:b) Past Surgical Historyc) Obstetrical History (Female)
  7. 7.  Family genogram – 3 generations include onlygrandparents. But if there is a family history include the
  8. 8.  Pre-natal history – Maternal infection- Exposure to radiation etc.– Check ups– Any complications Natal history: - Types of delivery-Any complications-Breath & cried at birth Mile Stones: - Normal or
  9. 9.  Behaviour during childhood:- Excessive temper tantrums- Feeding habit- Neurotic symptoms- Pica- Habit disorders- Excretory disorders etc. Illness during childhood- Look specifically for CNS infections- Epilepsy-Neurotic disorder
  10. 10.  Schooling- Age of going to school- Performance in the school-Relationship with teachers(Specifically look for learning disability & attention deficit)- Look for conduct disorders Eg. Truancy, stealing Occupational history- Age of joining job- Relationship with superiors, subordinates & colleagues- Any changes in the job – if any give detail- Reasons for changing
  11. 11.  Sexual history- Age of attaining puberty (female-menstrualcycles are regular)-Source & extent of knowledge about sex, anyexposures- Marital status: with
  12. 12. (Personality of a patient consistsof those habitual attitudes & patterns of behaviourwhich characterize an individual. Personalitysometimes changes after the onset of an illness.Get a description of the personality before theonset of the illness. Aim to build up a picture ofthe individual, not a type. Enquire with respect tothe following areas)
  13. 13. 1. Attitude to others in social, family & sexualrelationship:Ability to trust other, make & sustainrelationship, anxious or secure, leader orfollower, participation, responsibility, capacity to makedecision, dominant or submissive, friendly or emotionallycold, etc. difficulty in role taking –gender, sexual, familial.2. Attitudes to self:Egocentric, selfish, indulgent, dramatizing, critical, depreciatory, over concerned, self conscious, satisfaction ordissatisfaction with work. Attitudes towards health &bodily functions. Attitudes to past achievements &failure, & to the
  14. 14. 3. Moral & religious attitudes & standards:Evidence of rigidity orcompliance, permissiveness or overconsciousness, conformity, or rebellion. Enquire specificallyabout religious beliefs.4. Mood:Enquire about stability of mood, mood swing, whetheranxious, irritable; worrying or tense. Whether lively orgloomy. Ability to express & control feelings oranger, anxiety, or depression.5. Leisure activities & hobbies:Interest in reading, play, music, movies etc. enquireabout creative ability. Whether leisure time is spent along orwith friends. Is the circle of friends large or small?
  15. 15. 6. Fantasy life:Enquire about content of day dreams & dreams.Amount of time spent in day dreaming.7. Reaction pattern to stress:Ability to toleratefrustrations, losses, disappointments, & circumstancesarousing anger, anxiety or depression. Evidence for theexcessive use of particular defense mechanism such asdenial, rationalization, projection, etc.8. Habits:Eating, sleeping & excretory
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