Basic principles, interview style, various components and their significance, how to take history of present illness, past history,family and personal history, substance history, premorbid personality

1. HISTORY TAKING IN PSYCHIATRY
BY DR. MANISH KUMAR GOYAL
RESIDENT
UNDER GUIDANCE OF
DR. R.K. SOLANKI
SMS MEDICAL COLLEGE
JAIPUR

2. BASIC PRINCIPLES OF HISTORY TAKING
• Introduce yourself
• Explain the purpose and approx how long it
will take
• Ask open ended questions
• Allow the patient to explain things in his/her
own words

3. • Encourage the patient to elaborate and
explain
• Avoid interrupting
• Guide the interview as necessary
• Avoid asking “why?” questions
• Listen and observe for cues
• You might need an informant

4. • Aim to understand problems/symptoms and effect
on life
• To put presenting problems into context by enquiring
about background history and previous treatment
• Is followed by MSE
• Enables formulation to be reached
• Is therapeutic in itself

5. Preparing The Setting
• Safety
• Privacy
• Try to avoid interruptions
• Arrange seating so sitting at angle to patient
• Writing materials.

6. Starting the Interview
• Rapport: It is a bidirectional empathetic relationship, which the
examiner shares with the patient. The development of rapport
as encompassing six strategies:
1. Putting patients and interviewers at ease.
2. Finding patients' pain and expressing compassion.
3. Evaluating patients' insight and becoming an ally.
4. Showing expertise.
5. Establishing authority as physicians and therapists.
6. Balancing the roles of empathic listener, expert, and
authority.
• Introduce yourself and explain role
• Introduce to anyone who is accompanying patient
• Inform them about the length of interview
• Need to take notes
• Confidentiality

7. Interview Style
• Relaxed even if under time pressure
• Appropriate eye contact, appear interested
• Begin with a general question eg “tell me about your
problem”
• Have a systematic but flexible plan – at beginning can
be helpful to take a list of headings as prompt
• Keep in control. May need to interrupt “I’m sorry but
I need to move on to other things” “We can come
back to this if we have time later”

8. Interview Techniques
• Use of open questions where possible,
especially at beginning eg “ how is your
appetite?”
• Closed questions are useful if time is short eg
“is your appetite good?”
• Avoid leading questions eg “You have a poor
appetite, don’t you?”

9. Interview Techniques
• Encourage patient by leaning forward,
nodding, saying “go on” “tell me more
about…..”
• Help them talk about painful or embarrassing
subjects by being non-judgmental,
acknowledging distress and explaining why
you are asking, eg “I can see this is difficult to
talk about…”

10. Open versus closed questions:
• Closed questions • Opened questions
A closed question can be answered
with either a single word
(yes/no) or a short phrase.
• Thus 'How old are you?' and
'Where do you live?' are closed
questions.
• Thus 'Are you happy?' and 'Is that
a book I see before me?' are
closed questions, whilst 'How are
you? Is not.
Using closed questions:
• They give you facts.
• They are easy to answer.
• They are quick to answer.
• They keep control of the
conversation with the questioner.
An open question is likely to receive a
long answer.
• Although any question can
receive a long answer, open
questions deliberately seek
longer answers, and are the
opposite of closed questions.
Using open questions:
• Open questions have the
following characteristics:
• They ask the respondent to think
and reflect.
• They will give you opinions and
feelings.
• They hand control of the
conversation to the respondent.

11. • Closed questions • Opened questions
 closed questions are more useful
in patients with marked loosening
of associations.
 Closed questions are also useful in
patients with organic brain
conditions (learning difficulties,
delirium or dementia) who can
loose track of longer answers.
 Closed questions have a lot of
disadvantages: they don’t build
rapport or allow the patient to
open up, who can feel grilled. From
the point of view of the doctor, you
can collect the facts but miss the
person. It’s also easy to fall in to
the trap of asking another question
when you don’t know what to do.
 Are often more useful in
therapeutic work with patients
than closed questions.
 Open-ended questions develop
trust, are perceived as less
threatening, allow an
unrestrained or free response.
 Can be time-consuming, may
result in unnecessary
information, and may require
more effort on the part of the
user.

12. Records
• Good notes are vital
• Record for you, aids formulation
• Record for others so history taking does not
have to be repeated, as a record of
presentation for future clinicians
• Patients may request access to them
• Life charts may be therapeutic way of
recording information together

13. COMPONENTS
1. Identification data
2. Informants
3. Chief complaints
4. H/o present illness
5. Treatment history
6. Past history of illness
a) medical/surgical illness
b) past psychiatric history
7. Family history

14. COMPONENTS
8. Personal history
a. Perinatal history
b. Childhood history
c. Education history
d. Play history
e. Emotional problem during adolescence
f. Puberty
g. Obstetrical history
h. Occupational history
i. Sexual and marital history
j. Premorbid personality

15. IDENTIFICATION DATA
• Name : Occupation:
• Age: Income:
• Sex: Address:
• Marital status: Date of admission:
• Religion: Identification marks:
• Education: Type of admission:

16. •Identification - The identification establishes the
basic demographics of the patient.
• It should be adequately and correctly noted as all of these
factors have a role to play in onset, course, presentation,
treatment and prognosis of various illnesses.
•Age: Age should be noted and further corroborated while
asking duration of illness and age at onset of illness. Various
mental as well as physical illnesses have a particular age of
onset.
•Sex: Certain disorders are common in one sex than the other.
Certain socio cultural factors might have more importance for
one sex than the other.
•Education: It would help in assessing the overall knowledge of
the patient. Signs and symptoms can also vary according to
educational background of the patient. In intervention,
especially non pharmacological methods, the modality should
be adjusted according to the educational level of the patient.

17. • Occupation: Knowing the past as well as current occupation of the
patient is important as it will have direct implication in socio-
economic status of the patient. Impact of illness on occupation
can be assessed only if we know what the patient used to do
before illness.
• Socio-economic status: One needs to know the SES of the patient
to be aware how much one can afford to spend on treatment and
required investigations.
• Marital status: It is an important prognostic factor. It also helps us
to get an information on social support of the individual.
• Religion: Customs vary from one religion to other significantly.
• Residence: Customs and beliefs are significantly different for
rural/urban population. One should also know how far from the
patient is coming, so that to formulate the frequency of follow up
visits accordingly.

18. • Address: Proper address (both permanent as well as present)
needs to be noted along with Phone no and email id, so that any
postal/electronic/telephonic contact can be made with the patient
or the guardians as per need in the future.
• Type of admission, if admitted: It needs to be mentioned as it has
legal implications as per Mental Health Act, 1987
• Identification marks: They have role in identifying the patient and
have medico-legal importance. Traceable and permanent marks
should be mentioned. Common moles should be avoided. Proper
anatomical location should be mentioned.

19. INFORMANTS
• Informant’s Name
• Reliability
Relation to patient
Intimacy with the patient
Interest of the patient
Does the informant live the patient?
Duration of stay with the patient
Intellectual and observational ability

20. CHIEF COMPLAINTS ON ADMISSION
• Presenting complaints and/or reason for consultation should
be recorded.
• Both the patient’s and the informant’s version should be
recorded separately.
• It should be recorded even if the patient is unable to speak
and the patient explanation regardless of how bizarre or
irrelevant.
• Recorded as the patient’s own words.
• Ask leading questions such as
-what brings you here today?
-how can I help you?

21. HISTORY OF PRESENTING ILLNESS
• Provides a comprehensive and chronological picture of the
events.
• Probably the most helpful in making an accurate diagnosis.
• Duration: weeks/months/years
• Mode of onset: abrupt/acute/insidious
• Course and progress:
continuous/episodic/fluctuating/deteriorating/improving/
unclear
• Factors in illness: Predisposing factors/Precipitating
factors/Perpetuating factors/Limiting factors/Modifying
factors

22.  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 in
between 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

23.  Progress of illness- To what extend has the patient’s
symptomatology represented an evolution over time
• Improving- Improving from the date of onset e.g. Depression (with
treatment)
• Deteriorating-Condition is getting worse by time e.g. Schizophrenia
• Static- Condition remains same no change happens e.g. Dysthymia
 Predisposing factors- Factors operating from early life that
determines a person’s vulnerability to develop a disorder or
likelihood that person will develop certain symptoms under given
stress conditions.
• Biological (delayed milestones, head injury, family history of
psychiatric illness)
• Psychological (impaired premorbid personality)
• Social (home atmosphere in childhood, neglect, abuse, low
education level)

24.  Precipitating factors- Events that occur shortly before the onset of
a disorder and act as physical or psychosocial stressors and lead to
the onset of disorder in a person who may be predisposed to
develop the disorder.
• Biological (fever, accident, onset of severe medical illness)
• Psychological (stress intolerance, poor impulse control)
• Social (trauma, loss of job/partner)
 Perpetuating factors- Factors due to which the disorder is
maintained or aggravated.
• Biological (chronic medical illness, substance use)
• Psychological factors (poor insight, poor impulse control, low
intelligence)
• Social (social isolation, unemployment, ongoing expressed
emotions in family)

25.  Limiting factors- Factors which limit the illness from an extensive
progress and may include factors such as good social support or
treatment during the course of illness.
 Modifying factors- Factors which modify natural or expected
course of the illness. This includes factors such as use of substance
by a patient with Schizophrenia which may lead to affective
colouring of illness, use of antidepressants causing a manic switch
in patient with depressive illness.

26. The History of Present Crisis Approach
•The American Heritage Dictionary defines crisis as “A crucial
point or situation in the course of anything; a turning point.” As
you begin the interview, ask yourself, “Why now? Why is this a
crucial point in this person's life? What has been happening
recently to bring her into my office?” Often, psychiatric crises
occur over a 1-to 4-week period, so focus your initial questions
on this period.
• What has been happening over the past week or
two that has brought you into the clinic?
• Tell me about some of the stressors you've dealt
with over the past couple of weeks.

27. History of the Syndrome Approach
•Alternatively, you can begin your questioning by ascertaining
when the patient first remembers signs of the illness.
When did you first begin having these kinds of
problems?
When was the last time you remember feeling
perfectly well?
•Ensuing questions track the course of the illness through
months or years, arriving eventually at the present.
Now let's talk about this current episode. When did
it start?

28. WHAT IS THE HISTORY OF PRESENT ILLNESS?
•The HOPI is probably the most important part of the psychiatric
interview, and yet there is disagreement on exactly what it should
entail. Even experienced clinicians differ in how they approach the
HOPI.
•Some think of it as the “history of present crisis” and focus on
the preceding few weeks. Such clinicians begin their interviews
with questions such as, “What has been going on recently that
brings you into the clinic today?”
•Others begin by eliciting the entire history of the patient's
primary syndrome: “Tell me about your depression. How old were
you when you first felt depressed?” These clinicians work forward
to the present episode.

29. •Each of these approaches may be useful, depending on the
clinical situation. If a patient has a relatively uncomplicated and
brief psychiatric history, it might make sense to explore that first
and then move to the HOPI.
•If the psychiatric history is long, with many hospitalizations and
caregivers, starting at the beginning may bring you too far from
the present problem.

30. • The evolution of the patient’s symptoms should be
determined and summarized in an organised and systematic
way.
• 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 complain or symptom, it should
be dealt in with as ABC model, i.e. assessing the antecedent
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.

31. • Other symptoms which the examiner expects to be present
should be asked for, even if the informant does not give
spontaneous account.
• Certain symptoms (such as suicidal attempt) should be asked
for and ruled out in all cases. Any such relevant symptom,
thus present, should be adequately mentioned.
• One also needs to rule out all other major psychiatric illness,
which can be thought of as possible differentials or co-morbid
illnesses.
• Presence or absence of fever or other physical illness,
endocrinal disorder, drug (which can cause psychiatric illness
for example antimalarial, steroids etc.) intake, significant head
injury, substance use disorder, epilepsy should be enquired
about.

32. • When mental disorder is thought secondary to these
enumerated causes, the decision to classify a clinical
syndrome as organic/induced is supported by the following
a) Evidence that the cause in question is known to be
associated with one of the mental disorder
b) A temporal relationship (weeks or a few months)
between the development of the underlying cause and
the onset of the mental disorder
c) Recovery from the mental disorder following removal or
improvement of the underlying presumed cause
d) Absence of evidence to suggest an alternative cause of
the mental disorder (such as a strong family history or
precipitating stress)
• Conditions (a) and (b) justify a provisional diagnosis; if all four
are present, the certainty of diagnostic classification is
significantly increased.

33. • 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.
• Role functioning refers to any pattern of behaviour involving
certain rights, obligation, duties which an individual is
expected, trained and indeed encouraged to perform in a
social situation. This would include duties such as studies (in
case of a student), occupation (in case of a working adult),
taking care of children or household duties.
• Biological functions are considered in this section because
they are subjective phenomena appropriately considered with
other subjective symptomatology. These include bowel and
bladder control, sleep, appetite, weight and libido.

34. • Activities of daily living and personal care & hygiene should be
asked for. This would include activities such as brushing teeth,
taking bath, taking care of bowel and bladder habits, having
food and water.
• The characteristics of symptoms should be described in detail;
frequency, duration and impact . small distinctions may be
diagnostically useful. Stating that a patient suffers from
insomnia is less useful than describing the insomnia. Difficulty
in falling asleep, difficulty in maintaining sleep, and a
decreased need for sleep are each associated with different
disorders.
• Whether the patient has been in treatment, has been taking
any psychotropic medication, and has (or has not) been
compliant are essential elements of the history of the present
illness.

35. • If a patient has stopped taking a prescribed medication the
reasons should be determined. Noncompliance is a symptom
that needs to be investigated and not simply dismissed as poor
judgment or character weakness.
• Noncompliance has many possible causes: unpleasant adverse
effects, failure to understand the necessity for chronic
medication despite symptomatic improvement, insufficiently
treated symptoms such as the fear of being poisoned by
medication, a reluctance to see oneself as psychiatrically
impaired, or simply lacking the transportation and money to
get a prescription refilled.
• In the end of HOPI, all relevant histories which were ruled out
should be mentioned under the rubric of negative history.

36. TREATMENT HISTORY
• It includes details of the treatment obtained in the present
episode.
• When was the first contact;
• whether treatment was voluntary/ involuntary.
• who saw the patient and for how long
(Psychiatrist/Psychologist/Physician/Faith healer/Traditional
practitioner).
• the nature of the treatment
(Pharmacological/Psychotherapy/faith healing/traditional).
• modality that was helpful (psychopharmacological
interventions, individual/ group therapy).

37. • 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.

38. PAST HISTORY OF ILLNESS
• A) Past medical/surgical illness
• B) Past psychiatric history

39. PAST MEDICAL/SURGICAL ILLNESS
• History of chronic medical illness and detail of medication
received and the duration of illness.
• Hospitalization
• Medical/ neurological/ surgical illness
• Head injury/ convulsion/ unconsciousness
• Accident/ surgical procedure
• DM/ HTN/ CAD/ HIV +ve

40. • The occurrence of major illness or surgery is likely to be of
considerable significance in a person's life and may be the
precipitant of psychiatric disturbance.
• For example, in response to having a heart attack, a middle-
aged man might develop anxiety, depression, and a fear of
sex.
• In addition, many medical conditions and their treatments
cause psychiatric symptoms that are clinically
indistinguishable from primary psychiatric disorders.
Hypoglycaemia can cause panic and anxiety; hypercalcemia-
depression and lethargy; and Acute porphyria- psychotic
symptoms

41. • Moreover, the presence of underlying medical conditions will
inform treatment decisions: tricyclic antidepressants will be
avoided in patients with cardiac conduction abnormalities, and
bipolar I disorder patients with a history of renal disease are
more likely to be treated with an anticonvulsant than with
lithium.
• The names and dosing schedules for all currently prescribed
nonpsychiatric drugs should be obtained to avoid possible
adverse interactions with any new prescription.

42. • Aspects of the clinical history may also suggest the need for
medical investigation: abrupt onset of symptoms in an older
adult with no prior psychiatric history, symptoms atypical for
purely psychiatric disorders (e.g., vomiting and diarrhoea or
shaking chills), or a history of recent illness or treatment.
• In addition, abnormalities of the sensorium section of the
mental status examination are most typical of delirium and
dementia and indicate the need to look for underlying
medical conditions.

43. PAST PSYCHIATRIC HISTORY
• Past psychiatric illness
• H/O alcohol and other substance abuse/ dependence

44. Past Psychiatric illness
• History of similar or other symptoms in past
• Previous diagnosis
• History of treatment – include from primary care, counselling,
CAMHS, complementary therapy as well as mental health
services
• Previous hospitalization, medications, ECT.
• Recovery between episodes
• Complete relief or not from past treatment.
• Compliance of previous treatment

45. • The past psychiatric history describes all previous episodes
and symptoms whether treated or not. The history should
begin with the first onset of symptoms and progress
chronologically to the current episode.
• It describes symptoms in detail and clearly delineates their
longitudinal progress. Disorders that are chronic and
relapsing are distinguished from isolated episodes of
disturbance. It is particularly important to obtain the fullest
possible information on prior treatments.

46. • The best predictor of treatment response is past experience. If
a person has taken psychiatric medication before, it is essential
to determine not only which drug, but the dosage and length
of treatment, to distinguish non-response from a sub-
therapeutic drug trial.
• Therapeutic benefits and adverse effects should be noted.
Similarly, if a patient has received psychotherapy it is
important to establish which modality of therapy, at what
frequency, for what length of time, and with what benefit.

47.  Clinical course indicators- Different task forces have come up with
definitions for course indicators in different psychiatric illnesses.
 MacArthur Foundation Research Network task force proposed
following definitions for unipolar depressive disorder.
• Remission- Treatment of a depressive episode, if successful, would
lead to a significant reduction of symptoms (“response”) and ideally
to “remission,” a state of minimal or no symptoms.
• Relapse- If symptoms re-emerged following remission, this would
be considered a “relapse” within the index episode.
• Recovery- If remission were stable over a number of months (i.e.
there was no relapse or sub- syndromal symptomatic
exacerbations), then recovery would result. “Recovery” essentially
meant that the index depressive episode had ended at both the
clinical and neurobiological levels.
• Recurrence- After recovery, a subsequent emergence of symptoms
would be regarded as a “recurrence,” or a new depressive episode.

48.  Work-group of experts in bipolar disorder developed these
consensus operational definitions.
• Response- A 50% reduction in a score from a standard rating
scale of symptomatology from an appropriate baseline,
regardless of index episode type (manic, depressed, or mixed)
is defined as response. In addition, the other pole cannot be
significantly worsened during response.
• Remission was defined as absence or minimal symptoms of
both Mania and Depression for at least 1 week. Sustained
remission requires at least eight consecutive weeks of
remission, and perhaps as many as 12 weeks.
• A relapse/recurrence was defined as a return to the full
syndrome criteria of an episode of mania, mixed episode, or
depression following a remission of any duration.
• Roughening was defined as a return of symptoms at a
subsyndromal level, perhaps representing a prodrome of an
impending episode.

49. Substance Use
• Alcohol, tobacco, ganja, bhang, opioid, cocaine and other
substances.
• Pattern of use
• Age at onset
• Relationship to symptoms
• Harmful use
• Psychological dependency
• Physical dependency
• Previous detoxification
• Patient view

50. • For each substance the interviewer gathers basic information
about age of onset, pattern of use over time, current
frequency, and level of use and consequences of use (physical,
mental, social, and legal).
• These facts help to identify problematic current or past
patterns of use. Inquiry about tobacco use and problem
gambling should be a part of the addictive behaviour
inventory.
• The interviewer should identify periods of abstinence and
determine what helped the patient achieve control of use
including any specialized treatment for substance use with
details about the setting, nature of and response to
treatment, as well as engagements with peer support
engagement such as Alcoholics and Narcotics Anonymous.

51. FAMILY HISTORY
• Family members share their genes, as well as their
environment, lifestyles and habits.
• Parents, siblings, spouse, children, other relatives
– age; age and cause of death; health status; important
diseases
• Occurence of
– Diabetes
– Hypertension, heart diseases, stroke
– Infective diseases
– Malignant diseases
– Coagulation disorders
– Psychiatric diseases, alcoholism, drug addiction
– Symptoms like those the patient

52. • Many psychiatric disorders are familial, and many of those
appear to have a genetic component to the cause. Knowing
who is in the patient's family and which, if any, psychiatric
disorders have been diagnosed may help in diagnosis and
treatment planning.
• Family history can clearly show who is in the family, who is
available for support, who may be exacerbating symptoms,
whether a general vulnerability to psychiatric disorders exists,
and what stresses have been caused by a family member's
illness.
• Any family history of alcohol or substance abuse or of
personality problems should be documented. In addition, the
family history should provide a description of the
personalities and intelligence of the various households in
which the patient lived.

53. • Consanguinity: Relation by blood/descent from a common
ancestor within the same family stock. If present than 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. Based
upon the concept of a family tree, it usually includes data
about three or more generations of the family, which provides
a longitudinal perspective. The genogram provides a graphic
picture of family geneology, including significant life events
(birth, marriage, separation, divorce, illness, death);

54. PERSONAL HISTORY
• It comprises of a chronological account of the person’s
personal experiences starting with his birth and birth details.
• The personal history is usually divided into perinatal, early
childhood, late childhood and adulthood.
• The predominant emotions associated with the different life
periods (e.g. painful, stressful and conflictual) should be
noted.
• The personal history may contain information helpful in
making a prognosis as well as diagnosis. For example, a good
premorbid adjustment reflected in school and work history
indicates a good prognosis in patients diagnosed with
schizoaffective disorder.
• The personal history also helps identify key events that may
have helped precipitate current symptoms: divorce, loss of
work, death of a family member, serious financial setbacks.

55. 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.
• Illness can include infectious disease which can present as
fever with or without rash, sexually transmitted diseases,
diabetes, hypertension, jaundice etc. For medications used in
pregnancy, one should be aware of teratogenic effects of
common drugs.
• Whether he/she was wanted? Whether it was a planned or
unplanned conception? Whether a failed abortion attempt
was made?
• Whether the delivery was full term, preterm or postterm?

56. • 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.
• Any other complication during delivery such as abnormal
presentation, cord around neck, prolapsed cord, multiple
pregnancy or congenital anomaly noticed immediately after
birth and presence of neonatal jaundice or cyanosis and its
extent should be enquired about.
• Mode of feeding after birth, any problems associated with
feeding, age at weaning, recurrent infections, significant
injury, convulsions in period immediate after birth and early
childhood should be reported.
• Any delay in developmental milestones should be
documented.

57. Presence of childhood disorders:
• Comment on presence of hyperactivity, attention deficits and
impulsivity.
• Conduct problems during childhood should be probed into
and will include disobedience, lying, stealing, truancy (running
away from school), cruelty towards animals, bossy attitude
towards younger children, not obeying rules while playing etc.
If these symptoms are found in childhood, do make a attempt
to look for dissocial personality traits in adolescent period.
• Temper tantrums are very common in children; when present,
extent and intensity should be carefully noted.
• Neurotic traits (nail-biting, thumb sucking, stammering,
mannerisms, bedwetting, phobias, night-terrors, sleep
walking, etc.) during childhood should be probed into and if
present, the details should be mentioned.

58. Scholastic and extracurricular activities:
• Comment on age and class of entry in school, type of school,
scholastic performance and progress in studies, regularity in
school, failures if any, disciplinary problems/actions if any,
relational problems with peers/authorities, any discontinuity
or change in school/college with reasons, involvement in
games and extracurricular activities. Also mention special
interests in games if any during childhood.
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, promotion (in comparison to colleagues)
should be commented upon.

59. Menstrual history:
• Age of menarche should be asked. What was the reaction of
patient towards it and also information and attitude towards
mensuration subsequently? Regularly and duration of usual
cycle, whether associated with psychological and physical
change (pain or any other). Date of last menstruation,
duration and reasons of amenorrhea, if any.
Sexual and marital history:
• How and when sexual information and knowledge was first
obtained and of what kind, masturbatory history (fantasy and
activity), sex play if any, adolescent sexual activity, premarital
and extramarital sexual relationship if any, sexual disorders
(normal and abnormal), presence of any gender identity
disorder are areas to inquire about. Also probe for any history
of childhood sexual abuse.

60. • Ask for age at marriage and parental consent for marriage.
The spouse’s age, occupation, personality and state of health
are relevant to the patient’s circumstances should be
documented. Also ask for role allocation, sharing of
responsibilities and decision making, perceived adequacy of
sexual relation. Knowledge and use of contraception should
be documented.
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:
• Physical environment of the individual should be mentioned
here (accommodation, number of rooms, ownership). Also
make a comment on ways of handling adversity in home
environment.

61. PREMORBID PERSONALITY
• It is 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. Mention source of information and its reliability.
• Describe as under:
1. Social relations: How were his relation to family (attachment,
dependence); to friends, groups, societies, clubs; to work
and work-mates (leader or follower, aggressive or
submissive, organizer, ambitious, adjustable, independent)

62. 2. Intellectual activities, hobbies and use of leisure time:
Comment on books, plays, pictures preferred; memory,
observation, judgement, critical faculty.
3. Predominant Mood: What used to be persistent mood like, was it
cheerful or despondent; worrying or placid; strung up or
relaxed; optimistic or pessimistic; self-depreciative or satisfied?
Was mood changeable- could he express feelings of love, anger,
frustration or sadness, did he loses control over feelings, had he
been violent? Was mood stable or unstable (with or without any
reason).
4. Character:
a. Attitude to Self: How does patient describe self? What were his
strengths and abilities, shortcomings, ability to plan ahead,
resilience in face of adversity, hopes and ambitions? Was the
level of aspiration high or low? Was he self critical and perfectionist
or self approving and complacent in relation to own behaviour and
achievements? Was he steadfast in face of difficulties or intolerant
to frustration? Were his interests sustained or evanescent?

63. b. Attitude to Work & Responsibility: Did he welcome
responsibility or was worried by it; made decisions easily or
with difficulty? Was he methodological or haphazard in his
approach? Was he flexible or rigid? Was he cautious,
foresightful and given to checking or impulsive & slipshod?
Was he determined towards goal or used to get bored or
discouraged easily?
c. Interpersonal relationships: Was he insensitive or sensitive
to criticism? Was he trusting or suspicious and jealous? Was
he selfish and egotistical or unselfish and altruistic? Was he
emotionally controlled or irritable and quick tempered? Was
he quiet and restrained or expressive and demonstrative in
speech and gesture? Was he tolerant or intolerant to others?
Was he adaptable or unadaptable? Did he use to prefer
company or solitude? Was he shy or used to make friends
easily, were relationships close and lasting? How he used to
handle others’ mistakes, did he always want to be centre of
attention? How was the relation with work-mates or
superiors, any affiliations to any society?

64. d. Standards in moral, religious and health matters: What were
his religious and moral attitudes? Was he given to much or
little concern about own health?
e. Energy, initiative: Was he energetic or sluggish? Was output
sustained or fitful? Did he used to get easily fatigued? Were
there regular or irregular fluctuations in energy or work
output?
5. Fantasy life: What was the frequency and content of day
dreaming?
6. Habits: Use of alcohol, drugs, tobacco; comment on food and
sleep pattern