back to the basics history taking in psychiatry

1. PSYCHIATRY HISTORY TAKING
DR CHIKONDE.

2. History Taking/ Information Gathering
• Psychiatry hx is record of pts life allowing clinician to understand
• who pt is,
• Where pt has come from
• Where pt is likely to go
• Pt is allowed to narrate in own words , manner they deem important
• However on reporting chronology needs to be followed leading up to
the current state of the patient.

3. Outline
• Demographic data/ identifying information/ Social Demographic
details
• Home address
• Telephone number
• Relatives
• Friends
• Emergency contact when pt is in need i.e. discharge, injury etc.
• Where patient was referred from and why

4. Presenting problems
• Allegations
• What exactly is the patient complaining about
• Duration of the complaint

5. History of presenting complaint
• In patients own words they are allowed to say when this started and
how this complaint progressed.
• Has there been any added complaints to this one illness
• When the problem gets worse
• Gets better and why and how
• Alleviation of symptoms
• Guided however if losing track of events

6. Hx Presenting complaints
• Screening questions can however be used
• Depression
• Anxiety
• obsession
• Suicidal
• psychoses

7. Past Psychiatry History
• If there has been any previous episode and missed during previous history,
this needs to be known
• Drug history
• Current medication or drug history can be highlighted in this section
• Past medical history
• can be highlighted also in this section
• Family hx
• In relation with Psychiatric history, family history can be of importance
• Where the relatives are
• Their state of health
• Family tree
• Relationships

8. Personal history
• Infancy
• Adolescence
• Education
• Handedness
• Occupation
• Relationships
• Sexual history
• marriage

9. Present Social circumstances
• How is the patient living their life
• Where
• With who
• Is it conforming to normal
• Socioeconomic status
• What has led to all these challenges

10. Premorbid Personality
• Attitude to self, since when
• Attitude towards others
• Moral and religious attitudes
• Leisure activities

11. Forensic history
• Perceptions on crime
• In trouble, answering charges, aggression, violence
• Why
• risk

12. Systemic review for physical illness
• Ask related systemic questions
• Rule out physical illness
• Examples

13. Mental State Examination
• Note that appearance and behaviour are key to examination
• Appearance
• Behaviour
• Speech
• mood- subjective/ objective/affect
• Thoughts- form and content
• Perception
• Cognition
• insight

14. Appearance
• Apparent age
• Race
• Dressing
• Kempt
• Self neglect
• Dirty
• Prominent physical characteristics
• Posture and movement
• Tearfulness/ anxious/ perplexed/ angry

15. Behaviour
• Cooperation
• Irritable
• Distractibility
• Hostile
• Over familiarity
• Sexual inappropriateness
• Aggression
• Violence
• Risk

16. Speech
• Rate/ pressure/ otherwise
• Tone
• Volume
• Relevance
• Coherence
• Language / new language/ neologisms

17. Mood
• Subjective predominant mood- pts own words
• Objective/ appraisal / euthymic/ dysthymic/ angry
• Congruence

18. Affect
• Objective examination
• Mood variations
• Labile
• Flat
• Blunt
• Reactiveness
• Incongruent/ congruent

19. Thought process
• Poverty of thought
• Rapid thinking
• Flight of ideas
• Good directed thinking
• Response relevance
• Loose associations- unrelated/ idiosyncratically connected
• Thought blocking- sudden stop
• Tangentiality- looses thread of conversation/ word salad/ incoherent
connections of thought/ neologisms
• Circumstantiality-brings in irrelevant details
• Clang associations/rhythmic punning/ association by double meaning

20. Form of thought/ content
• Delusions
• Preoccupations
• Compulsions
• Phobias
• Homicidal ideation
• Passivity phenomenon

21. Perceptions
• Illusions
• Hallucinations
• Depersonalization
• Derealisation

22. Cognition
• Orientation
• Attention
• Concentration
• Memory/ deficit
• MMSE
• Lob testing

23. Insight
• Recognition and attribution of illness
• Do they think they need hospitalization
• Treatment
• What type of treatment
• Capacity- retain, reproduce and chose
• Aware of treatment

24. G/E
• Stigmata/ signs
• Oedema
• Erythema
• Drug marks
• withdrawal symptoms
• Airway
• Circulation
• May require systemic examination depending on findings

25. Summary/ Formulation
• Few sentences 3- 4
• Descriptive
• Demographics/ age / sex etc.
• Referral
• Positive findings from all headings/ negative findings

26. Aetiological formulation
• Predisposing factors
• Perpetuating factors
• Maintaining factors
• Biological factors
• Psychological factors
• Social factors

27. Differential diagnosis
• Preferred diagnosis
• ICD/ DSM
• Points favouring
• Other considerations
• Co morbidity

28. Management
• Investigation to rule out or confirm or follow performance of
management
• Tx
• Mgt of risks
• Immediate/ short term or long term
• Consider prognosis by all models of mental illness
• Adopt biophysical social approach