Reference: Ellen, S., & Selzer, Rob. (2011). Psych-lite. AU.

Contributors: Ajeeta Singh & Isabelle Goh;

Psychiatry History-Taking
1
Diagnostic
Hierarchy Pyramid
Organic
disorders
Patient Details
Psychotic disorders
Full name, age & occupation
Mood disorders
Discuss confidentiality
Are you a voluntary or involuntary Anxiety disorders
patient (i.e. under MHA)?
Personality/behavioural disorders

2
HOPC
Psychosis
Do you hear voices no else hears?
(auditory hallucinations)
Do you think people can hear your thoughts?
(thought broadcasting)
What brings you in today?
Do you think you are not in control of your
Onset & duration of current episode
actions? (thought insertion)
Previous similar episodes
Do you think people are stealing your thoughts?
Triggers or precipitating factors (i.e.
(thought withdrawal)
relationship problems, domestic
Do you believe that you are in danger or being
violence, unemployment)
harmed? (persecutory delusion)
Impact on work, family & social Do you believe you are receiving messages from
relations their environment (e.g. tv)? (referential delusion)

3
Mania
Do you feel happier than usual? (elated mood)
Have you required less sleep than usual?
Differentials (Increased level of activity)
Do you believe you have special powers?
Organic Conditions Screen (grandiose delusion)
Thyroid Have you been engaging in activities you would
Heat/cold intolerance not otherwise (i.e. spending more money than
Changes in weight & appetite usual, risky sexual activities)? (impulsivity)
Changes in bowel movement
Brain/Space-Occupying Lesions Depression
Nausea or vomiting Have you been feeling low in mood?
Early morning in headache Have you been feeling low in energy?
Changes in vision Have you been experiencing poor concentration?
Substance Use/Abuse Enquire about changes in appetite.
Alcohol, recreational drugs Enquire about changes in sleep pattern.

Anxiety
Are you feeling anxious or worried?
Do you actively avoid certain situations (i.e. public speaking)?
Do you experience physical symptoms during your episode of anxiety (i.e. sweating, trembling,
chest pain, dizziness, choking)?
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Psychiatry History-Taking
4
Psychiatric History
8
Forensic History
Past & current psychiatric diagnoses
Any ongoing cases with law enforcement?
Past and current medications
Any past convictions?
Any allergies?
Compliance to medication & appointments?

9
Previous hospital admissions?

5
Medical History
Developmental
History
Past & current medical diagnoses Describe your upbringing

Past and current medications Relationship with parents in childhood

Any allergies? Difficulties at school

Compliance to medication & appointments? Relationships with others (i.e. friends, family)

Hospital admissions?

6 Premorbid
10
Family History Personality
Family history of psychiatric and medical
What was your personality like before your
conditions (include grandparents, parents,
current episode?
siblings & children)

7 11
Social History Next Steps
Employment status Conduct a risk assessment
Financial well-being Perform a mental state examination
Living situation Determine need for admission
Activities and hobbies Determine if patient needs to be admitted
Social support (i.e. family, friends, GP, under the Mental Health Act (MHA)
psychiatrist, social worker) Take a collateral history from family/friend
HEEADSSS assessment (for adolescents)

Reference: Ellen, S., & Selzer, Rob. (2011). Psych-lite. AU.