Psychiatric History

HISTORY-TAKING

Therapeutic & Assessment at the same time

• Make patient feel comfortable; Assure privacy
• Let patient guide somewhat.
• Give undivided attention; Gain pt’s trust
• Empathize with the patient’s complaints; Avoid Belittling
• Avoid premature assurance or conclusions
• Avoid Leading or Close-ended questions; Avoid suggestion
• Notice: Patient’s affect & nonverbal behavior
• Elicit information relevant to known diagnostic criteria

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Outline of Psychiatric History

• I. Identifying data
• II. Chief complaint and Problem
• III. Present illness
  • 1. Onset
  • 2. Precipitating factors (Stresses)
• IV. Past illnesses
  • A. Psychiatric
  • B. Medical
  • C. Alcohol and other substance history
• V. Personal history
  • A. Prenatal and perinatal
  • B. Early childhood (through age 3)
  • C. Middle childhood (ages 3–11)
  • D. Late childhood (puberty through adolescence)
• E. Adulthood
  • 1. Occupational history
  • 2. Marital and relationship history
  • 3. Military history
  • 4. Educational history
  • 5. Religion
  • 6. Social activity
  • 7. Current living situation
  • 8. Legal history
• F. Sexual history
• G. Family history
• H. Fantasies and dreams

Don’t Forget 5 “S”

s for systemic review

• Severity
• Sleep “how much, rolling after waking from sleep, nightmares, walking, talking, on day hours, asr, magrhib” -
• Sex - “raise standard of interview prior asking this question, without any hidden agenda”
• Suicide - “avoid direct question, how’s life, any enjoyment, thoughts, how ajd if acted upon”
• Psychosis - “when you are sleeping, do you hear any sounds, calling your name, do you hear them in morning?”

Start

• smartly
• suitably
• sociably
• step by step