This document outlines the components of a psychiatric history taking. It includes gathering demographic data, chief complaints, history of presenting issues, past psychiatric and medical history, family history, substance use, social circumstances, personal history, and assessment of premorbid personality. The goal is to obtain a holistic understanding of the patient's condition, including precipitating stressors, through interviews of the patient and other informants while establishing rapport. Thorough evaluation of personal and family history helps identify any prior conditions or vulnerabilities.

1. PSYCHIATRIC
HISTORY TAKING
Dr. Mubarek Abera
Faculty of Medical Sciences
Jimma University
Mubarek.Abera@ju.edu.et

2. Plan of Presentation
• Demographic Data
• Chief compliant/ main Presenting complaint
• History of presenting complaint
• Past psychiatric history
• Current medication
• Past medical history
• Family history
• Alcohol and substance use
• Social circumstances
• Personal history
• Premorbid personality

3.  Presence of disturbances in thinking and
behavior.
 Patient may not be cooperative
 May lack insight.
 May have poor judgement.
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4.  Information from significant others.
 Give importance to Personal history and pre-
morbid personality.
 Give importance to observation of patient.
 Establish good rapport.
 More importance to elicit information
regarding stressors.
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5. I. DEMOGRAPHIC DATA:
• Name
• Age
• Sex
• Marital Status
• Religion
• Occupation
• Socio-economic status
• Address
• Informant
• Information (Relevant or not) adequate or not

6. II. CHIEF COMPLAINTS’S / PRESENT
COMPLAINTS (LIST WITH DURATION)
• – In patient’s own words & in information’s own
words.
Eg: - Sleeplessness / 3 weeks
- Loss of appetite & hearing voices / 2 weeks
- talking to self / 2 weeks

7. III.
PRESENT PSYCHIATRIC HISTORY /
NA
TURE OF THE CURRENT EPISODE
• 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 the presenting complaints)
• Associated disturbances – include present medical
problems
(eg: Disturbance in sleep, appetite, inter personal
relation & social functioning, occupation etc).

8. IV. PAST PSYCHIATRIC HISTORY
• 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 present

9. V.
a) Past Medical History:
b) Past Surgical History
c) Obstetrical History (Female)

10. VI. FAMILY HISTORY
• Family genogram – 3 generations include only
grandparents.
• But if there is a family history include the
particular generation

11. VII.PERSONAL HISTORY:
• Pre-natal history – Maternal infection
- Exposure to radiation etc.
– Check ups / ANC
– Any complications
• Natal history: - Types of delivery
-Any complications
-Breath & cried at birth
• Mile Stones: - Normal or delayed

12. Count…
• Behaviour during childhood:
- Excessive temper tantrums
- Feeding habit
- Neurotic symptoms
- Pica / craving to each non food item
- Habit disorders
- Elimination disorders etc.
• Illness during childhood
- Look specifically for CNS infections
- Epilepsy
-Neurotic disorder
• Malnutrition

13. Cou
nt…
• 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 jobs

14. Count…
• Sexual history
-Age of attaining puberty (female-
menstrual cycles are regular)
• -Source & extent of knowledge about sex, any exposures
-Marital status: with genogram.

15. VIII.PRE MORBID PERSONALITY
(Personality of a patient consists
of those habitual attitudes & patterns of
behaviour which characterize an individual.
Personality sometimes changes
after the onset of an illness.
Get a description of the
personality before the onset of the illness.
Aim to build up a picture of the
individual.
Enquire with respect to the
following areas)

16. 1. Attitude to others in social, family & sexual
relationship:
Ability to trust other, make & sustain relationship, anxious
or secure, leader or follower, participation, responsibility,
capacity to make decision, dominant or submissive,
friendly or emotionally cold, etc. difficulty in role taking
– gender, sexual, familial.
2. Attitudes to self:
Egocentric, selfish, kind, dramatizing, critical, over
concerned, self conscious, satisfaction or dissatisfaction
with work.
Attitudes towards health & bodily functions.
Attitudes to past achievements & failure, & to the future.

17. 3. Moral & religious attitudes & standards:
Evidence of rigidity or compliance, permissiveness or over
consciousness, conformity, or rebellion.
Enquire specifically about religious beliefs.
4. Mood:
Enquire about stability of mood, mood swing, whether
anxious, irritable; worrying or tense.
Whether lively or gloomy.
Ability to express & control feelings or anger, anxiety, or
depression.
5. Leisure activities & hobbies:
Interest in reading, play, music, movies etc.
Enquire about creative ability.
Whether leisure time is spent along or with friends.
Is the circle of friends large or small?

18. Count
…
6. Fantasy life:
Enquire about content of day dreams & dreams.
Amount of time spent in day dreaming.
7. Reaction pattern to stress:
Ability to tolerate frustrations, losses,
disappointments, & circumstances arousing
anger, anxiety or depression.
Evidence for the excessive use of particular
defense mechanism such as denial,
rationalization, projection, etc.
8. Habits:
Eating, sleeping

19. IX. SUMMARY
• Demographic Data
• Presenting complaint
• History of presenting complaint
• Past psychiatric history
• Current medication
• Past medical history
• Family history
• Alcohol and substance use
• Social circumstances
• Personal history
• Premorbid personality