This document provides an overview of the components of a psychiatric history taking and examination. It describes collecting personal data, the patient's complaint, history of present illness, past medical and psychiatric history, personal history including development, relationships, and sexual history. It also includes obtaining a family psychiatric and medical history. The examination involves a mental status exam assessing appearance, behavior, mood, affect, speech, thought content and process, perception, and insight. The goal is to chronologically understand the patient's life and current symptoms from their perspective and an informant to make an accurate diagnosis.

1. Psychiatry History Taking
and Examination
By
Soheir H. ElGhonemy
Assistant Professor of Psychiatry,
MD in Psychiatry, Arab Board in Psychiatry
Member of International Society of Addiction Medicine (ISAM)

2. The psychiatric history is the chronological story
of the patient’s life from birth to present
Personal data:
Name, age, sex, marital status, religion,
address, occupation, education.
n.b.; source of referral could be mentioned
here if the patient can’t cooperate

3. Complaint:
In the patients own words.
Informant complaint; ( reliable informant)

4. History of the present illness:
Onset, duration of illness,
Development of symptoms and relation of
events, stressors,
Change from previous level of functioning,
medication taken with the reported response and
compliance,
Previous hospitalization and their duration
and level of improvement.

5. Past History: Includes both psychiatric and medical ;
neurological illnesses.
Personal History:
Developmental history ; prenatal, natal, postnatal.
Childhood,
Adolescence,
Adulthood; work history, marital history, children,
level of education, finance, military history…etc.
Premorbid personality.
Sexual History; sexual development, masturbation,
sexual dysfunction.

6. Family History:
Psychiatric and medical histories.
Name, age, occupation of the family members
(father, mother, siblings), order of birth of the
patient, and the relationships between the family
members as reported by the patients.

7. Examination
* Mental state examination:
‫٭‬General appearance; appearance, grooming, gait,
posture, facial expression.
‫٭‬Level of activity; retarded, agitated, tics, tremors,
…etc.
‫٭‬Attitude; cooperative, hostile, eye to eye
contact….etc.
‫٭‬Level of consciousness; orientation to time, place,
and person, attention and concentration.
‫٭‬Memory; immediate, recent, remote

8. Mood:
Patient’s expression of his own feeling (subjective
description)
Affect:
Examiner’s expression of the patient’s feeling and its
appropriateness to the situation (objective description).
Speech:
Description of the patient’s speech; slow, fast,
spontaneous, fast, slurred…etc.

9. * Thought Examination:
*Form; off pointing, thought block, tangential,
circumstantial, loose association, neologism,
incoherence.
*Stream; fast, pressure of thoughts, flights…etc.
*Content; delusions, obsessions, phobias…etc.
*Control; broadcasting, insertion, withdrawal,
reading.
*Abstraction and judgment.

10.  Perceptual Examination:
Illusions; misinterpretation of stimulus.
Hallucination; perception with No stimulus
Examine : type (visual, gastatory, olfactory, tactile or
auditory), timing, content, frequency and reaction of
the patient
 Insight; for illness, symptoms, need for
treatment and compliance.

11. Good luck