Psychiatric History Taking

Introduction:
Name, Role and Consent: Hi, my name is Aemun Reza and I’m a 5 th year medical student, the doctor
has just asked me to come and ask you a few questions about why you are here, would that be
okay?
Confirm Name and DOB: Can I start with confirming your name and date of birth?
What is your occupation? What do you do for a living?
Explain the need to take notes and confidentiality: Would it be okay if I took some notes whilst we
talk? I’ll assure you that these notes and what you say here will remain confidential and will only be
passed on to people involved in your care
The examiner will act as my chaperone.
Are you here under a MHA section or are you hear voluntarily?

Presenting Complaint:

 What led you to coming to the hospital/GP?

 What problems brought you here?
 Have you been having any problems recently? Can you tell me about them?
 How are you feeling today?
 How has your mood been?

History of Presenting Complaint:

 NOTEPAD
o Nature of the Problem
 The form the problem takes
 A worry, mood, delusion, hallucination, physical ailment, social problem
o Onset
 How long have you had –this problem- for?
 When did –this problem- start?
 Can you remember when it last happened?
 These ‘weird feelings’ can you remember a recent one?
 When were you last your normal self?
o Triggers
 Do you feel there was anything that triggered –this problem-?
 Did any event precede –this problem-?
o Exacerbating/Relieving factors
o Frequency
 How often does this problem happen?
o Progression
 Improving, worsening or staying the same
 Intermittent of continuous
 Do you feel –this problem- has been getting worse over time?
 How do you feel now compared to when you last felt like yourself?
o Associated Symptoms
 Depression – anhedonia, poor concentration, feelings of guilt, hopelessness,
suicidal ideation, disturbed sleep, loss of appetite, diurnal mood variation,
decreased energy, low mood, insomnia, early morning wakening, loss of
libido
 Becks triad
o Loss of confidence, negative view of the world,
hopelessness, guilty, negative view of the future,
worthlessness
 Mania – high energy levels, can’t sleep - too much energy, spending,
gambling, feeling irritable, restlessness, difficulty concentrating, increased
sexual energy, reckless/impulsive behaviour, disinhibited, increases self-
esteem
o Disability (effect on life)
 What are you doing to try and deal with it?
 How are things at home?
 How are you coping?
 What effect does –this problem- have on your day to day life?
 How would you compare this to previous functioning?
 Describe a typical day and whether it is different from before?
 Have you ever sort any help for this before?
 What is your interest like?’
 ‘How much are you able to enjoy things compared with how you used to
do?’
 Risk
 Screen for abuse
 Safeguarding – do you have any children
 Anyone treating you inappropriately
 Domestic abuse, old age abuse
 RISK TO SELF (suicidality)
o Screen for any other problems
 Low mood
 Changes in energy
 Delusional or obsessional thoughts – always remain neutral on topic
 Has anything been worrying you lately?
 What been on your mind?
 Has anything odd been happening to you lately that others find
difficult to believe?
 ‘Do you ever hear noises or voices that seem to come from nowhere
or when there’s no one around?’
 Do you ever feel something strange is going on?
 Have you had any unusual experiences?
 Have you felt suspicious about things recently?
 Is there any plot or conspiracy going on?
 Do you ever feel that you are being watched or followed?
 Do you ever feel that people are trying to harm you or hurt you?
 Ideas of references
o Do you ever feel that people in the newspaper/on TV is
taking about you/is about you?
 Thought interference
o Do you ever feel that your thoughts are being interfered
with?
 Thought broadcasting
o Do you ever feel other people can read your mind or that
your thoughts are available to others?
 Thought withdrawal
o Have you ever felt as if thoughts are being taken out of your
head?
 Thought insertion
o Do you ever feel that people are putting thoughts into your
head?
 Passivity
o Do you ever feel that you are being controlled in some way,
like a puppet?
 Delusional Perceptions
o How did these thoughts come about?
o Was there any event/defining moment?
 Thought echo
o Do you ever hear your own thoughts spoken aloud?
 What do the delusions mean to the patient and how they came to
that conclusion – find abnormal reasoning behind their beliefs
 Try offering alternative explanations to try and explain to see how
fixed their belief is
 ‘Are you absolutely sure that x is true, or is it possible that you might
be mistaken?’
 ‘If somebody else said that to you, what would you make of it?’
 If yes
o Can you tell me more about what you hear?
o What do they say?
o Is there one voice or more than one voice?
o Do they seem to talk you, like how I’m talking to you now or
do they seem to be talking about you, as if you’re not there?
o Where do they seem to be coming from?
o Do they seem to be coming from inside or outside your
head?
o How much of the time are they there?
o Do you hear them in certain situations?
o How do they affect you?
 o Do the voices ever tell you to do anything?
 What do they instruct you to do?
 Do they ever tell you to do bad things, for example
hurt yourself or others?
 Do you feel you have to act on them?
 Look into insight – do they know it’s not normal
 How is this affecting your life?
 What do you intend to do about it?
 Unusual perceptions
 Hallucinations
o Has anything unusual happened to you recently?
o Did you hear voices which no one else can hear?
o Did you ever see things which are strange or that other
people cannot see?
o Describe experiences - the voices heard, how many, who
was talking and what they were saying
o What do the experiences mean to the patient
o Are they real or arise in patient’s own mind
o How has this been affecting your daily life?
 Other unusual experiences
 Suicidality
 Do you still get pleasure out of life?
 Do you still feel hopeful from day to day?/ Do you think things will
turn out well?
 Are you able to face each day?/ Do you ever wish you would not
wake up?
 ‘Given how depressed you’ve felt recently have you felt so bad that
you thought life wasn’t worth living?
 Do you feel life is a burden? Do you wish it would all end?
 Have you ever thought about ending your life? At the moment is
there anything to live for?
 ‘How do you see the future?’
 ‘Do you feel hopeless?’
 ‘Do you ever feel as if you don’t want to carry on?’
 ‘Do you sometimes feel like you don’t want to wake up in the
morning?’
 Have you ever felt so low that you don't want to live?
 Have you ever made any plans to end your life?
 What were these plans?
 If yes
o Are you able to resist the thought of suicide?
o Have you ever thought about the method of suicide?
o Have you ever tried anything?
o How close have you come?
 o What has stopped you doing anything?
o Have you ever tried to harm yourself?
o What particular thoughts went through your mind?
 Self-harm
 Have you ever intentionally hurt yourself?
 Changes in social contact – social withdrawal?
 Sleep problems
 Do you have difficulty falling asleep?
 Do you find that you are waking up much earlier than usual?
 Anxiety
 Generalised - Worried, irritable, restless
 Panic attack – fear of threat/panic that is beyond appropriate
response and is beyond voluntary control
 ‘Do you ever get sudden bouts of anxiety?’
 ‘Could you describe a typical panic attack?’
 ‘When you get the panics do you ever feel that something awful is
about to happen to you?’
 ‘When you panic and experience the chest pain, do you ever feel like
something bad is going to happen to you, like a heart attack?’
 ‘Has the anxiety stopped you doing things you normally do?’
 PTSD
 Do you re-experience the accident?’
 Do you ever get very vivid images of the (attack/ incident) as if you
were almost back there?’
o Any informants? Collateral history
 Anyone else that we could talk to who has been with you?

Past Psychiatric History:

 Has anything like this ever happened before?

 Have you had any stress-related or mental health problems before?
 Have you ever seen a psychiatrist in the past?
o Record details of past episodes, things treated by GP, hospitalisations, when, how
long they lasted or whether they were sectioned under the Mental Health Act
o Note past diagnoses and treatments, which treatments helped
o Check for previous behaviour of self-harm, suicide attempts or violence
o Ask about state of health and level of functioning between episodes, check whether
patient was able to return to normal life between periods of illness

Past Medical History and Drug History

 Do you currently have any serious illnesses?

 Have you had any major illnesses, accidents or surgery?
 What is your physical health like at the moment?
o Screen for current physical symptomatology
  Breathlessness, constipation, dizziness
 Screen for:
o Head injury
o Epilepsy
o Heart disease
o Strokes
o Diabetes
o Hypertension
o Jaundice (as a result of hepatitis)
 What medication are you currently taking?
o Both prescribed and over the counter/self-prescribed
o Drug allergies?

Family History

 Can I ask you about your family?

 How is your relationship with your family? How is your relationship with your parents?
 Do you have any siblings? What is your relationship like with your siblings?
 Has anyone in your family suffered from stress or had to see a doctor for mental health
problems?
 Is there any history of mental health disorder in your family?
 Is there anyone in your family that has trouble with drug or alcohol misuse?
 Any periods of separation from parents, what is family dynamic, how does the family get on
 Name, age, occupation, mental/physical illness, age and cause of death – put in genogram

Social History:

 I’d like to ask you about how and where you live now
o Housing
 Type of housing
 Rented, owned, shared accommodation, council flat
 State of house
 No heating, dangerous stairs, not accessible for wheelchairs
 Other people in accommodation and relationship to them
 Who do you live with?
o Social support
 Friends, relatives, neighbours
 Voluntary organisations
 Daily activities
 Ask patient to describe a typical day
 Ask about social activities, interests or hobbies
 Do they drive?
 Current employment
 Identify any problems with social living
o Finances
  Do you manage your own finances? If not, who does?
 Do you have any financial worries or debts?
 What benefits are you currently receiving?

Personal History:

 I’d like to know a bit more about you, can I ask you questions about your past?
o Childhood
 Where were you born and raised?
 Do you know if there were any problems with your mother’s pregnancy and
your birth?
 Prematurity, labour complications, birth trauma, interventions e.g.
C-section, time in special care/did not go home immediately, need
for paediatric follow up
 As far as you know, did you walk and talk at the normal age?
 Did you reach all your developmental milestones at appropriate ages?
 Any early trauma, illnesses?
 What were things like growing up? Any significant events that stand out?
 What was your childhood like?
 Any deaths, illnesses, divorce, separation from family, neglect or
abuse
 What were your parents and siblings like? How did you get on with them?
 Was early childhood a happy or difficult time?
o School Life
 What was school like for you? What were things like at school?
 Did you have any problems at school?
 Check for bullying, truancy, school refusal
 Were you bullied or did anything traumatic happen?
 Were you ever in trouble for things like bullying or truancy?
 Relationships with peers and teachers
 What were your friendships like?
 Did you get on with teachers?
 Were you near the top, middle or bottom of class?
 Were you shy or outgoing?
o Occupation
 List each job, duration of employment and reasons for leaving
 Note any periods of unemployment
 Did you enjoy working?
o Psychosexual/relationships
 Are you currently in a relationship?
 When did it start, quality of relationship, sexual problems
 Children? Are they trying to have kids? Male/Female
 Age of first intercourse and number of sexual partners
 Past relationships
  Long term or brief relationships, how or why they ended – divorce,
separation, death
 Monogamous or not
 Heterosexual/homosexual/bisexual
 Quality of relationships – abusive or supportive
 Marriages or civil partnership or divorce
 Age of first period/puberty
 First sexual experience
 Any episodes of sexual abuse
 If your childhood, did you ever have any inappropriate sexual
experiences?
 Have you ever had any inappropriate sexual experiences?
 Current or previous sexual difficulties – loss of libido, impotence
o Personality
 ‘How do you see yourself compared with others?’
 ‘How would other people who know you describe you?’
 Can you trust people easily?
 ‘How do you generally get on with others?’
 ‘How do you cope with stress?’
 Do you get angry easily?
 Do you have to do things perfectly?

Substance Misuse:

 Do you smoke? Do you drink alcohol?

o How long for, how many/much a day, regular
o CAGE questionnaire
 Have you ever felt like you should cut down on your drinking?
 Has anyone ever annoyed you by commenting on your drinking?
 Have you ever felt guilty about the amount you drink?
 Do you ever have a drink first thing in the morning? (Eye opener)
 Do you take any drugs which the doctor has not prescribed?
o When first used, route, amount used, increased use over time
o Attempts of abstinence or formal detoxification
o Heaviest level of use
o Withdrawal symptoms
o Physiological or social impact
 Effect on life? Is it still ongoing?

Forensic History:

 Have you ever been in trouble with the police? Have you done anything which could have
got you in trouble with the police?
o Record all offences, seriousness, convictions and sentences
o Violent or sexual offences
 o Offences committed when unwell?
o Broke the law without being caught?

Premorbid Personality

 What the person was like before they became unwell

 Before this all happened, what kind of person were you?
 How would your friends describe you?
 How do you cope under pressure/with stress?
 Do you have any strong religious or moral views?

Finishing off:

 Summarise in the patient’s own words their presenting complaint

 You’ve told me a lot today, is there anything else we’ve not covered that you think I should
know
 Do you have any questions for me? Is there anything else you wish to tell me?
 Thank you for letting me talk to you
 Thank you for letting me talk to this lady/gentlemen of ____ many years old.
 To complete my examination I would do an MSE, MMSE, physical examination including a
neurological examination and bloods including FBC and TFTs
Mental State Examination
ASEPTIC
 Appearance, Speech, E(A)ffect, Perception, Thought, Insight,
Cognition
 (and Risk assessment)
Appearance and behaviour

 General appearance
o Age, sex, build, ethnicity
o Physical problems
o Hair/make-up
o Scarfs, piercings, tattoos
o Self-care  well-kept/cleanliness or self-neglecting or self-harm
o Clothing
 Appropriate/inappropriate
 Striking in some way
 Dark clothes in depression; bright clothes in mania
 Very loose clothes  weight loss
 Tight clothes  weight gain
 Body language
o Facial expression
 Smiling, scowling, fearful, blank
o Eye contract
 Responsive/appropriate
 Staring/downcast
 Avoidant/distracted
o Posture
 Hunched shoulders in depression
o Activity level
 Over or under active
o Describe what they are doing
 Pacing restlessly around the room
o Movements may seem slowed (motor retardation) in depression or speeded up in
mania
 Other movements
o Extra-pyramidal effects are caused by anti-psychotics
 o Akathisia – unpleasant restlessness causing agitation
o Parkinsonism – shuffling gait, ‘pill rolling’ tremor, slowed movements, rigidity
o Tardive dyskinesia – rhythmic involuntary movements of the face, limbs, trunk
 Grimacing, chewing,
o Repeated movements
 Mannerisms appear goal directed
 Sterotypies e.g. not-goal directed
 Tics – purposeless, involuntary movements involving a group of muscles e.g.
blinking
 Compulsions – rituals the patient feels compelled to undertake
o Catatonic symptoms
 Rapport
o Withdrawn or cold? Polite or friendly?
o Rude or guarded (suspicious or deliberately withholding information)
o Disinhibited
 Other
o Responding to hallucinations e.g. watching ‘nothing’ or talking to an unseen
companion
o Smells e.g. body odour, urine, alcohol

Speech

 Speed
o Pressure of speech – quick, uninterruptible – hypomania
o Poverty of speech – retarded
o Thought block - stop without warning
 Volume
o Low voice when depressed
o High volume in hypomania
 Tone
o Emotional quality of the speech
o Sarcastic, angry, calm, glum, monotonous
 Quantity
o Do they say too much or too little
 Dysarthria - impaired articulation
 Dysphasia – impaired ability to comprehend or generate speech
 Clang associations – rhyming connections e.g. bang, sang
 Punning – playing on words with the same sounds but different meanings
 Neologisms – made up words
 Content
o Obscene words – tourette’s, intoxicated, delirium
o Poor fluency
 Poor education or shyness – you can understand what they are trying to say
but they cannot say it well
  Thought disorder– you cannot understand what the patient is trying to say
 Circumstantiality – go off on long tangents with excessive detail
 Flight of ideas – keep jumping from one topic to another though these trains
of thoughts are connected from one to the other
 Receptive dysphasia – words are appropriate and sentences are formed but
sentences do not make sense because patient does not understand what is
being said to them and by them
 Echolalalia – patient repeats what is said to him
 Preservation – inability to shift topic in response to a change in question
 Loosening of associations – thoughts become disconnected, vagueness
results in disjointed speech that seems senseless

Affect

 Type of affect – anxious, sad, happy, angry, disgusted, ashamed, detached

 What they are like to you at that moment – what you see - current
 Intensity – mild or intense emotion
 Stability – either in degree of intensity e.g. blunted or labile or in variability of type e.g.
changeable or restricted
o Blunted (flat) – normal variability of range of affect – reaction to either good or bad
news does not occur or occurs in a limited way
o Labile – this is when affect changes quickly from one extreme to the other in a very
short time, often in reaction to other minor events (e.g. whilst crying at the loss of a
relative they may suddenly laugh at the sight of someone)
 Appropriateness
o Observed emotion is appropriate to the situation or not
o Inappropriate affect is to be found in conversion disorder
o Mask-like expression
 Congruity
o Whether or not other observations tally with the observed affect
o Reaction to some event is opposite of what is expected e.g. laughing when bad
news is given
o Check what the patient thinks as sometimes people laugh to avoid showing the
expected emotion
 Mixed affect states
o Occur where there are simultaneous signs and symptoms of both elation and
depression

Mood

 Subjective – how the patient says they are feeling, recorded in their own words
 Objective – what you think about the patients emotional state
 Type of mood
o Depression
o Hypomania and mania
 o Irritability
o Anxiety
o Alexithymia – inability to feel or describe any sort of mood
o Euthymic – normal mood
 Intensity
 Chronicity
 Stability – problem changeable or not over time

Thought

 Preoccupations and worries

o What kind of things do you worry about?
o What’s on your mind?
 Delusions
o Grandiose delusions
 Exaggerated beliefs of being special or important
 E.g. being rich and famous
o Persecutory (paranoid) delusions
 Beliefs that others are trying to persecute or cause harm
 E.g. people are spying on the patient
o Nihilistic delusions
 Beliefs regarding the absence of something vitals important
 E.g. the patient is dead, homeless or their organs are rotting
o Delusions of reference
 Beliefs that ordinary objects, events or other people’s actions have a special
meaning or significance for the patient
 E.g. news reports relate to them, objects are arranged as ‘signs’
o Delusions of control
 Beliefs that outside forces control the patient in some way
 Passivity – the belief that movement, sensation, emotion or impulse are
controlled by an outside force e.g. as if someone has a remote control for
the patients actions
 Delusions of thought interference – these occur against the person’s will and
feel like an invasion of privacy
 Thought withdrawal: the belief that someone/something is
removing thoughts from the patients head
 Thought insertion: the belief that thoughts are being placed into the
patient’s mind, so that they are thinking someone else’s thoughts
 Thought broadcasting: the belief that thoughts are broadcast to
others
o Delusions of jealousy  delusions of infidelity
o Amorous (erotomanic) delusions – belief that someone is in love with the patient
o Delusions of guilt – the belief of having committed an awful sin or crime
o Hypochondriacal delusions – the patient believes that they have an illness
 o Delusions of infestation (Ekbom’s syndrome) – patient think that insects or animals
are infesting the skin or body
o Misidentification (Capgras syndrome) – patient thinks other person is not the real
person but has been replaced by a close substitute
 Partial delusions
o Like delusions but not held quite as firmly – there is a little doubt (partial conviction).
These include beliefs that are ‘nearly’ delusional on the way to a psychotic episode
and delusions that are weakening with recovery. Under close questioning, someone
with a partial delusion would agree that it was possible their belief could be wrong
e.g. due to their imagination playing tricks on them
 Over-valued ideas
o Reasonable ideas pursued beyond the bounds of reason
o Patients life revolves around the idea to the point that it causes distress to them or
others
 Obsessions
o Recurrent, unwanted, intrusive thoughts, images or impulses which enter the
patients mind, despite attempts to resist them
o Deep down, patient knows that the thought is irrational
o They recognise the thought as their own
o Do you ever find that you have to think certain thoughts or do certain things over
and over again?’
o ‘Do you find that you are checking a lot?’
o ‘Do you wash your hands over and over again?’
o If you try and resist these thoughts (or rituals), do you worry something bad might
happen?’
 Compulsions
o Repeated, stereotyped and seemingly purposeful rituals that the patient feels
compelled to carry out
o They may also be resisted, since the patient feels that they are senseless
o Can be actions or thoughts
o Do you have thoughts that keep coming into your head even though you try to block
them out?
o Some people have rituals that they feel they need to do in a very exact way. Do you
do anything like that?
 Thoughts of harm
o Harm to self
o Harm to others
o Any plans or preparations? Intended method or timing?
 Perceptions
o Relates to the patients sensory world
o Illusions
 Misperception of a stimulus
o Hallucinations
 Perception in the absence of a stimulus
  Feel as real as any other perception
 Auditory
 Can occur with neurological and systemic conditions
 Delirium, strokes, tumours of CNS, epilepsy, migraine
 Visual
 Brain tumours – especially of visual pathway or occipital lobe
 Delirium, eye disease, migraine, epilepsy or Parkinson’s disease
treatment e.g. L-DOPA, lewy-body dementia or drug induced
 Olfactory
 Always do full neurological assessment
 Gustatory e.g. tasting ‘poison’ in food
 Touch
 Tactile – superficial feelings on surface
 Deep sensation – internal feelings
 Voices may be in second person
 Addressing patient directly as ‘you’
 Voices may be in third person
 Said as ‘he/she’
 Thought echo
 Says the patients thoughts aloud
 Commentary
 Voice/voices talking about the patients action before, during or after
they have happened
 Depersonalization and derealisation
o Depersonalization – the person feels unreal; detached, numb or emotionally distant
 Do you ever feel as if you aren’t quite real?
o Derealisation – the world feels unreal
 Do you ever feel as if the world around you is not quite real?

Insight

 How much the patient is aware of their illness

 Is the patient aware that there is anything wrong
 Is the problem within the patient or external
 Is there anything, wrong, does the patient think it is as a result of the illness
 If an illness is it physical or psychological
 Is the patient willing to accept help, if so what help will they accept?
 Do you think you are ill?
 Is it psychiatric?
 Do you need treatment?

Finish off with: is there anything else you need to tell me?

 Depression: may be treated with CBT, IPT and brief psychoanalytic therapy
 Anxiety Disorders: are best treated with CBT
 Post-traumatic Stress Disorder: is treated most effectively with CBT
 Somatic Complaints: most evidence for CBT
 Eating Disorders: CBT, IPT, Systemic Therapy
 Personality Disorders: Dialectical Behaviour Therapy, Psycho-analytic day hospital
programme

 NICE recommends family therapy for:

o Childhood depression
o Eating disorders
o Child behaviour problems
o Psychosis
o Substance misuse