PSYCHIATRY HISTORY TAKING

_________________________________________________________________________________
Demographics:
• Name, age, DOB, patient number
• Race, gender, religion
• Marital status, employment/ grants
• Address, who are they staying with?
• Level of education
• Handedness, language
• MHCA status: voluntary/ assisted/ involuntary
• Name and contact details of relative/ friend
• Contact details of patient

Referral Data
• Who referred the patient - Self/ family/ GP/ traditional healer/ base hospital?
• Due to family/ other pressure?

Presenting complaint
• Reason for referral/ admission
• Duration of main complaints
• Why admitted now?

History of presenting complaint

• Time course: from earliest time a change was noted to admission
• Onset, precipitants
• Duration
• Evolution of symptoms
• Aggravating & relieving factors

Systemic enquiry
Psychotic cluster
Positive symptoms:
1. Voices:
® How many voices are there?
® Is it a familiar voice? Who’s voice is it?
® Is it a male/ female voice?
® When did it start?
® Are they talking to you or to each other?
® Is the voice in your ear or in your head?
® Are they commanding you to do anything?

2.Visual: Are you seeing things that other people can’t see?
3.Tactile: Do you feel like something is crawling on your skin?
4.Taste: Can you taste something that is not there?
5.Delusions:
® Do you sometimes have thoughts that others tell you are false?
® Do you have beliefs that aren’t shared by others you know?
® Persecution: is anyone trying to harm you? Are people talking behind your back? Are you
constantly being watched?
® Referential: when you watch the TV/ listen to the radio, do you feel that the stories are referring
to you or something that you have done?
® Religious: has God ever spoken to you or given you a task?

1
 ® Grandeur: Do you have special powers/ special person/ extremely wealthy or famous?
® Erotomanic: Do you think that someone (of a higher stature) is in love with you?
® Jealousy: do you believe your partner is unfaithful? Why?
® Control:
o Thought broadcasting: Can anyone hear your thoughts? Do you ever your own thoughts
echoed/repeated?
o Thought insertion: Is there anyone/ anything putting thoughts that are not your own in your
head? Where do these come from?
o Thought blocking: Do you feel able to think clearly? Do you ever experience your thoughts
stopping as though there were none left?
o Thought withdrawal: Is there anyone/ anything taking thoughts out of your head?

Negative symptoms:
1. Do you have feel like you aren’t able to think or process things as well as you used to?
2. Do you lack energy ?
3. Do you feel like you don’t have the motivation to do things that you enjoyed before?
4. Do you find it difficult to find interest in pleasure in the things that you used to before?
5. Lack of interest in social interactions
6. Do you find it difficult to take care of yourself?

Mood cluster
Mania:
1. Do you feel like you need less sleep than usual?
2. Do you have more energy than previously?
3. Do you feel happier/ more excited than usual? Or more irritable?
4. Do you feel very confident in yourself?
5. Are you more talkative than usual? Or do you feel pressured to keep talking?
6. Do you feel like your thoughts are racing?
7. Are you easily distracted?

Depressive episode:
1. Do you ever feel depressed/ sad? (>6/12)
2. Did you loose interest in anything recently?
3. Have you lost/gained weight?
4. Do you have insomnia or problems sleeping?
5. Do you feel excessively tired?
6. Have you ever thought about death or dying?
7. Have you every tried to commit suicide?
8. Has there been a change in your appetite? (incr or dec)
9. Do you ever feel worthless or excessively guilty?
10. Have you noticed changes in your menstrual cycle?

Anxiety cluster
Generalised Anxiety Disorder:
1. What are you worried about? (>6/12)
2. Is the worry difficult to control?
3. Does this affect your work/ social life?
4. Do you have any physical symptoms?

2
 On edge/ restless, easily fatigued, difficulty concentrating, irritability, muscle tension, unable to
sleep.
Panic Attack:
1. Unexpected surge of intense fear within minutes with ≥ 4 other symptoms
® Palpitations
® Sweating
® Trembling
® Shaking
® SOB
® Feeling of choking
® Chest pain/discomfort
® Nausea/ abdo tenderness
® Dizzy, lightheaded, faint
® Chills/heat
® Numbness or tingling
® Derealization/ depersonalization
® Fear of loss of control
® Fear of dying
Panic disorder
Recurrent panic attacks. Atleast 1 attack followed by 1/12 of worrying about another attack of changing
behaviour related to attack.

Trauma and stressor - related disorders

PTSD: 1 from 1-4 + 1 from 5-9+ 10 +
1. Did you ever have or witness a near death experience or threatened with death or seriously
injured?
2. Did you ever experience or witness sexual violence?
3. Has anyone close to you experienced the above events?
4. Were you repeated exposed to this? (not related to media)
5. Recurrent, involuntary, intrusive distressing memories from the event?
6. Recurrent dreams/ nightmares of the event?
7. Do you ever have flashbacks where you feel that this is happening again?
8. If you come across something that reminds you of this event, is it distressing, worrying,
traumatic?
9. Do you have a physical reaction to this?
10. Do you avoid things associated with the event? Internal (thoughts, feelings, memories) or
external (people, places, activities, objects, situations)
11. Has thing impacted the way that you think? Have you noticed a change since this occurred?
Unable to remember, negative thoughts about yourself or the world,
12. Do you ever have persistent thoughts about the cause or result of this event? Do you blame
yourself for this?
13. Do you have persistent feelings of fear, horror, anger, guilt or shame
14. Do you feel that you are not interested in things that you used to enjoyed or do not do these
activities anymore?
15. Do you detached or estranged from others?
16. Do you think that you are able to feel happy, satisfied or loved?

3
 17. Did you notice any changes with arousal and reactivity associated with this event or mad worse
by this event? (irritability, anger, reckless or self destructive behaviour, hypervigilance,
exaggerated startle response, problems concentrating, sleep disturbances.
Cognitive cluster
1. Do you feel that you are unable to focus or maintain focus?
2. Are you less aware of your environment?
3. Do you feel disorientated?
4. Do you have problems remembering things?
5. Is it difficult to understand language?
6. Are these problems the same throughout the day or does it vary during the day?
7. Are you able to do your everyday activities by yourself?
8. Is this a change from normal?

Past psychiatric history

• First illness episode
• First contact with psychiatry/ psychology/ traditional healer
• Previous psychiatric diagnosis
• Number & details of previous illness episodes:
o precipitants, duration, severity, response to treatment, duration of remission
• Number and details of admissions:
o MCHA status, duration, treatments, date of most recent admission
• Previous response to treatment
o pharmacological, psychological, social, previous ECT)
• Adherence
• Details of previous suicide attempts & self-harm
• Clinic attendance & outpatient treatment
Family history
• Parents, siblings:
o Age, DOB, name, marital status, occupation
o Age at time of death, Cause of death, Patient’s reaction to death
o Mental illness
o Medical illnesses: NB epilepsy
o Substance related disorders
o Nature of relationships past and present
• If parents are divorced: when? Why? Did they live in separate homes and who did patient live
with? how did this impact patient?
• Other relatives who had an impact on the patient’s personality, emotional, educational
development?
• Social and financial position of family?
• Family religious status?

Personal history
• Pregnancy: planned vs unplanned, mother’s mental state, substance abuse, maternal infection
• Birth: location, mode of delivery, complications of labor
• Post-partum: complications, length of hospital stay after birth
• Milestones: walking, talking, toilet training

• Childhood health:
o Illness, convulsions
o Bed-wetting, night terrors, sleepwalking, thumb sucking, nail biting
o Physical trauma/ abuse/ neglect

4
 o Parental separation, parental violence
o Traumatic events
• School:
o Type of schooling: mainstream vs specialized
o Age in grade 1
o Primary school
o Secondary school
o Age @ completion of school
o Did you ever repeat a grade?
o Tertiary education
o Problems: failures, learning difficulties/ unable to cope with work, bullying, truancy, anti-
social behaviour
o Protective factors: friends, sport, hobbies, enjoyment of school

• Occupation history
o First job
o Number and duration of jobs – chronological order
o Reasons for leaving
o Most recent job + problems/ job satisfaction
o Ambition
o Do you receive any grants?
o
• Current social circumstances:
o Accommodation: lights, water, sanitation, overcrowding
o Functioning: ADLs
o Support: family, friends, colleagues, religious organisations, hobbies
o Current income
o Premorbid personality: Self-description, hobbies, interests, coping skills, reaction to
stress, religious affiliation, spiritual beliefs

• Religious attitudes: actively religious? Was a traditional healer consulted & result?
• Cultural influences: how long have they lived in an urban/ rural area? Do they think illness is due
to witchcraft/ sorcery?

Sexual and marital history

• Sexual history:
o Coitarche
o number of partners
o currently sexually active, frequency of coitus/ sexual satisfaction
o sexual dysfunction (desire/ excitement/ orgasm/ vaginismus/ dyspareunia)
o Sexual orientation
o Previous sexual trauma
• Relationship history
o Married/ current relationship?
o Duration of courtship/ engagement prior to getting married?
o Partner: age, occupation, personality, compatibility
o Previous relationships: chronological order, reasons for ending
o Domestic violence/ abuse within relationship
• Children/ obstetric history
o No. of pregnancies
o Chronological order
o Age, name, DOB, birth issues

5
 o Problems or anxieties surrounding children

Habits
• Cigarettes, Alcohol, Cannabis, other drugs, Caffeine, OTC and prescription medication
• Environmental or occupational exposure
• NB amount and pattern of usage and effects
• Features of abuse and dependence, attempts to stop
• For each drug:
1. Onset: When did they start taking the drug?
2. Precipitants: Do they take it regularly or is there a trigger?
3. Amount: How much do you take now? How much did you take when you first started?
4. Effect: How does it make you feel? What does it do to you? How does it make you behave?
5. Timing: How often do you take it?
6. Dependence: Do you feel like you need to take it to get through the day? How long can you
go without taking the substance? Do you feel like you need a drink in the morning before
starting the day? How long have you gone without it & how did you feel during this time? Are
you able to stop taking the substance after you start?
7. Do you want to stop? Have you ever tried to stop? Do you feel guilty for using the
substance?
8. Has been harmed because of your substance use?
• Withdrawal features:
® Cigarettes:
® Alcohol: restlessness, irritability, agitation, tremor, sweating, anxiety, loss of appetite,
nauseam vomiting, insomnia, poor concentration, impaired memory and judgement.
Complicated: hallucinations, delusions, grand mal seizures, hyperthermia. Features of
delirium: Confusion, clouding of consciousness, tremors, paranoid delusions, agitation,
sleeplessness, sweating, fever (hours after last drink)
® Cannabis: (Mild)- agitation, tremor, insomnia, flashbacks
® Amphetamines (Tik): Same as cocaine
® Caffeine:
® Cocaine: Early: agitation, anorexia, depression, severe craving, exhaustion, insomnia
with desire to sleep. Late: hypersomnia, hyperfagia.
® Madrax: anxiety, restlessness, nausea, vomiting, abdominal cramps, poor appetite,
headaches, insomnia, tremors, weakness and seizures. (Start 12-24 hours after last
dose)
® Opiods (sugar/ woonga/ morphine/ heroine/ codeine):
Symptoms: Abdominal cramps, anxiety, craving, irritability, dysphoria, fatigue, hot and
cold flushes, muscle aches, nausea, sweating, restlessness, yawning, diarrhoea,
sweating, muscle spasms, vomiting, fever

Past medical history

• Comorbidities: epilepsy, DM, HPT, HIV, TB, syphilis, thyroid disease, GERD, asthma, liver
disease, cardiac disease, renal failure
• CNS history: Head trauma, delirium, CNS infections, headaches
• Previous surgeries
• Allergies
• Drug history
• Gynae history:
o LNMP
o Menarche
o How many days they bleed for? Regular? How heavy?
o Pap smear?

6
 o Contraception history?
o Previous STIs?

Forensic history
• Cautions, charges, convictions, prison sentences, pending court cases, screen for antisocial
behaviour

Premorbid personality

• self-description, hobbies, interests, religious affiliation, spiritual beliefs, cultural influences,

coping skills, reaction to stress

7
MENTAL STATE EXAM
_________________________________________________________________________________
Appearance and behavior
• Appearance:
o Self-care: grooming, dressing (including cosmetics, accessories), hygiene, nutrition
o Do they look ill?
o Are they in touch with their surroundings/ orientated?
• Behavior:
o Attitude towards the examiner: co-operative, hostile, defensive, seductive, evasive,
guarded
o Eye contact
o Level of distress
o Demeanor
• Psychomotor activity
o Involuntary/ abnormal movements – tics, mannerisms, gestures, grimaces, abnormal
behavior or movements
o Look for EPSE
o Are they increased, decreased or normal?
o Do activities have an evident purpose/ meaning?
Speech
• Rate
o Rapid: mania
o Pressure of speech: mania
o Slow: depression
o Short, monosyllabic answers (poverty of speech)
o Scarce content (poverty of content of speech): depression, negative symptoms of
schizophrenia
o Slow à ?poverty of speech
• Tone: Dull, monotonous or Normal
• Volume: loud, soft
• Fluency and rhythm: whispered, slurred, staccato or mumbled
• Language

Mood
• Subjective: ask patient how they feel
• Are they experiencing insomnia or reduced appetite? Variation in mood?
• Objective: how do they appear to be feeling

Affect
• Range: normal, restricted, blunted, flat
• Stability: normal, labile
• Appropriate?

Thoughts
• Syntax and grammar - are words used appropriately, neologisms, echolalia
• Comment on flow of thoughts/ ideas: loosening of associations, flights of ideas, irrelevant

• What has been on your mind?

• Assess fears/ anxiety: have you been worried about anything?
• Delusions:

8
 o Persecution: Do you think anyone is trying to harm you? Are people talking behind your
back?
o Grandeur: do you believe you have special powers/ that you are a special person?
o Religious: Do you think you have special powers/ given a task by God? Has God spoken
to you?
o Jealousy: do you believe your partner is unfaithful and why?
o Control: do you believe your body or mind is controlled by an outside agency?
• Obsessions:
o Do you have intrusive thoughts or images that you can't get out of your head?
• Phobias:
o Do you have an irrational or excessive fear of something?
• Suicidality:
o Do you ever feel that life is not worth living?
o Have you ever thought about cutting yourself?
o Have you ever thought about killing yourself? If so, how would you do it?
• Homicidality:
o Have you ever thought about killing others or getting even with those who have wronged
you?

Perception
• Do you see things that upset you?
• Do you ever see/feel/hear/smell/taste things that are not really there? If so, when does it occur?
• Have you had any strange sensations in your body that others do not seem to have?

Sensorium and Cognition

Attention Is attention easily obtained & held throughout interview

Concentration Name days of the week in reverse order
Or
Spell ‘world’ forward and backward
Or
Subtract serial sevens from 100
Or
Digit span: give patient digits to repeat forwards & other to repeat backwards
Orientation Person: own name and identity
Place
Time: time of day, day of week, month, year
Memory Immediate: ask patient to repeat a sentence/ digits/ name and address
immediately
Short term: what did he have for breakfast. Can ask patient to recall address 5
minutes later.
Long term: compare patient’s account of life with that given by others. Assess
for gaps/ inconsistencies
Language Naming, reading, writing
Visuospatial ability Copying a figure; drawing the face of a clock
Abstract reasoning Explaining proverbs; describing similarities (e.g., comparing an apple to a pear)
Executive functions List making (e.g., name as many animals [or fruits or vegetables] as you can in
one minute); drawing the face of a clock
General intellectual Identify the previous five presidents; physician must take into account the
level/fund of patient's education level and socioeconomic status; screen for mental
knowledge retardation

9
Insight
• Why have you been admitted?
• What is your understanding of your problems?
• Do you think your thoughts and moods are abnormal?

Judgement
• Patient's recognition of consequences of actions
• Ask an appropriate question

10