Psychiatric History
Taking
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General Principles of History Taking
• Aim to understand problems/symptoms and effect on life
• To put presenting problems into context by enquiring about background
history and previous treatment.
• This is followed by MSE
• Enables formulation to be reached
• Is therapeutic in itself
N/B
• Hx Will vary according to setting (in-pt v A&E v OPD)
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Preparing The Setting
• Safety
• Privacy
• Try to avoid interruptions
• Arrange seating so sitting at angle to patient
• Writing materials
• Box of tissues.
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• The ideal interview room has two doors, one for you and one for the
patient.
• If this is not available sit so that the patient is not between you and the door.
• Remove all potential weapons from the interview room.
• Familiarize yourself with the ward's setting
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Starting the Interview
• Before interviewing a patient, particularly for the first time, consider: who you
are interviewing, where you are interviewing, and with whom.
• If possible, review the patient's records noting previous symptomatology and
episodes of previous violence (the best predictor of future violence).
• A number of factors will increase the risk of violence including:
• previous history of violence,
• psychotic illness,
• intoxication with alcohol or drugs,
• frustration,
• feeling of threat (which may be delusional or relate to real world
concerns).
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Introductions
• Observe the normal social forms when meeting someone for the first time.
• Introduce yourself and any accompanying staff members by name and
status.
• Ensure that you know the names and relationships of any people
accompanying the patient (and ask the patient if they wish these persons
to be present during the interview).
• It is best to introduce yourself by title and surname and refer to the patient
by title and surname.
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• Put the patient at ease
• Inform them about the length of the interview
• Need to take notes
• Confidentiality
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Interview Style
• Relaxed even if under time pressure
• Appropriate eye contact, appear interested
• Begin with a general question e.g. “tell me about your problem”
• Have a systematic but flexible plan – at beginning can be helpful to take a
list of headings as prompt
• Keep in control. May need to interrupt “I’m sorry but I need to move on to
other things” “We can come back to this if we have time later”
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Interviewing techniques
• Open-ended questions: ‘Can you tell me why you were admitted?’
• Open-ended questions are often used in the initial phase of the
interview to produce spontaneous responses from the patient, which
are potentially what feels most important to the patient.
• They convey a sense of genuine interest to the patient.
• Closed-ended Questions: ’Did you attempt to end your life prior to
admission?’
• Closed-ended questions often follow open-ended questions to
efficiently elicit specific details.
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Summation
• This refers to the brief summary of what the person has said so far and is done
periodically to ensure the interviewer understands the person correctly.
• E.g. ‘I would like to make sure that I understand you correctly so far.
• You are saying that you do not think your experience is part of schizophrenia
based on your own readings (in a man who does not believe that he suffers
from schizophrenia and wants to seek a second opinion)’
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• Transition is a useful technique to gently inform the person that the interview is
going on to another topic.
• Empathic statements convey the message that the psychiatrist finds the
patient’s concern important and acknowledge the patient’s sufferings.
• E.g. ‘I can imagine that you were terrified when you realized that you could
not move half of your body (to a man suffering from post-stroke
depression)
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Interview Techniques
• Encourage the patient by leaning forward, nodding, saying “go on” “tell me more
about…..”
• Help them talk about painful or embarrassing subjects by being non-judgmental,
acknowledging distress, and explaining why you are asking, e.g. “I can see this is
difficult to talk about…”
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Interview Techniques
• Summarise key points to check understanding
• As experience grows, start to select questions according to emerging
diagnostic possibilities and management options.
• This becomes more important when time is limited or the patient
uncooperative
• Don’t take words at face value e.g. “paranoid”
• Watch experienced clinicians and get them to watch you!
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Interviewing Informants
• Pick up non-verbal cues
• Always useful and more so if the patient is cognitively impaired, the patient is
concealing information
• Gain patient consent
• Often best to see the patient alone first and then the informant
• Establish confidentiality
• Ascertain the informant’s concerns as well as gain information.
• May need to help informant if stressed carer (carer assessment)
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Records
• Good notes are vital
• Record for you, aids formulation
• Record for others so history taking does not have to be repeated, as a
record of presentation for future clinicians
• Patients may request access to them
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Establish a therapeutic relationship
• Aim to listen more than you speak (especially initially).
• Show respect for the patient as an individual (e.g. establish their preferred
mode of address, ask permission for anyone else to be present at the
interview).
• Explicitly make your actions for the benefit of the patient.
• Do not argue (agree to disagree) if consensus cannot be reached.
• Accept that in some patients trust may take time to develop.
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The History
• Identification information and demographics
• Presenting Complaints/ allegations
• History of presenting complaint
• Past Psychiatric History
• Past Medical/Surgical History
• Personal History
• Family History
• Substance Use
• Drug History
• Forensic History
• Premorbid Personality
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Introduction
• Purpose
• Before you start the interview, ensure the person understands the purpose
and make that there is no hearing impairment
• Demonstration
• “Hello, my name is ……….. Has anyone told you about the nature of this
interview? Let me explain…”
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1. Identifying Information and demographics
• Key demographic data include:
• Full name.
• Age.
• Gender.
• Marital status: married, divorced, single, widow.
• Occupation (if the person is unemployed, the interviewer should explore
previous job and duration of unemployment; if the person is a housewife,
explore her spouse or partner’s occupation.
• Current living arrangement: living alone, homeless, with family.
• Current status: inpatient or outpatient
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Demonstration
• “Before we start the interview, it is important for me to ensure that I got your
name right…” “May I know your current age?”
• Example for presentation:
• Mr. Bob is a 36-year-old taxi driver, married and stays with his family in a 3-
room flat. He is currently an inpatient in ward 6, at this facility/ Mathari
teaching and Referral Hospital.
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2. Presenting complaint/allegations
• The presenting compliant can be part of a first episode of illness or as one
of a series of episodes.
• For patients who are hospitalized, it is important to enquire whether this
admission is voluntary or involuntary.
• Seek the person’s view in his or her own words about the admission.
• List the symptoms in lay term in the order of decreasing severity and state
the duration during presentation
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Demonstration
• “What have brought you here to this hospital/clinic?
• Can you tell me what has happened before that?”
• Example for presentation:
• ‘Mr. Bob presents with an intention to end his life, hopelessness, low
mood, poor sleep, poor appetite and poor concentration for 3 months.’
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3. History of present illness
• Enquire about the precipitating factors, symptoms severity, duration, and
context of the current episode in chronological order.
• Enquire about maintaining and protective factors.
• Assess the impact on relationships and functioning.
• Enquire about significant negatives (e.g. psychotic symptoms in severe
depression).
• Seek his or her views towards previous psychiatric treatments, assess the
efficacy, and explore previous side effects.
• Assess for common psychiatric comorbidity and differential diagnosis
associated with the history of the present illness
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Demonstration
• Start with allowing the person to talk freely for 5 minutes and demonstrate
an eagerness to hear the person’s concerns.
• Questions like “What made you seek treatment this time?” may reveal
current stressors; and “What are the problems that your illness has caused
you?” assesses functional impairments.
• “What do you think may have caused you to feel like this?” may reveal the
patient’s perception of symptoms
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4. Past psychiatric history
• Enquire past psychiatric diagnoses, past treatments (medication, psychotherapy
or ECT); side effects associated with psychotropic medications, adherence to
treatment, previous hospitalizations (including involuntary admissions) and
treatment outcomes.
• History of suicide, self-harm, violence and homicide attempts is essential to
predict future risk.
• It is important to identify the precipitating and maintaining factors of each
episode, as this would provide important information in formulation.
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Demonstration
• Example for presentation:
• ‘This current episode is in the context of 20- year history of depressive
illness.
• 20 years ago, Mr. Bob first consulted a psychiatrist in private practice
because of low mood, poor sleep and loss of interest for 6 months.
• The psychiatrist prescribed a tricyclic antidepressant (amitriptyline).
• Mr. Bob complained of dry mouth and constipation.
• Due to financial constraint, he consulted a psychiatrist at the MTRH for
…………………..
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5. Past medical/surgical history
• Enquire past and current medical problems and physical symptoms, in particular
pain (e.g. migraine), seizures (e.g. temporal lobe epilepsy), stroke, head injury,
endocrine disorders and heart diseases.
• Indicate medications that the patient has been prescribed for the above
problems.
• Enquire past surgical problems and surgery received.
• Explore drug allergy (especially to psychotropic medication and clarify the
allergic reactions)
• The physical problems may be due to the medication effect (e.g. prolonged QTc
resulted from antipsychotics)
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Demonstration
• Example for presentations,
• ‘Mr. Bob suffers from hypertension and hyperlipidemia.
• The doctor has prescribed atenolol 50mg OM and simvastatin 40mg nocte.
• Mr. Bob has no past history of surgery.
• He has no past history of drug allergies.
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6. History of substance use
• Enquire about type (alcohol, benzodiazepine, and recreational drugs),
amount, frequency, the onset of, and past treatment for substance misuse.
• Explore biological (e.g. delirium tremens/ head injury) and psychosocial
complications (e.g. drunk driving, domestic violence) associated with
substance misuse.
• Explore the use of tobacco (quantity and frequency).
• Look for dual diagnosis e.g. depression with alcohol misuse.
• Explore the financial aspect (i.e. the funding of substance misuse).
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Demonstration
• Maintaining a non-judgmental attitude is essential in enquiring about substance
misuse.
• Normalize the experience of substance misuse, “When people are under stress,
they may use recreational drugs.
• I would like to find out from you whether you have such experience.”
• Avoid a direct question like, “Do you use drugs?” which may prompt the person
to deny any drug use
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7. Family history
• Enquire about the family’s psychiatric and medical histories.
• Look for substance misuse (e.g. alcohol) among family members.
• Look for early and unnatural deaths which may indicate suicide.
• Briefly assess the quality of interpersonal relationships in the family
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Demonstration
• Demonstrate empathy if a close family member suffers from severe
psychiatric illness.
• Identify the etiology of psychiatric illness in family members.
• E.g. “What made you think that your mother may suffer from depression?”
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8. Personal history
• Developmental history: birth, childhood development, relationship with
parents and siblings, history of physical/sexual abuse, prolonged separation,
unhappy childhood.
• Education history: details of schooling, age that schooling began and stopped.
• If education is stopped prematurely, enquire the reasons.
• Education background affects performance of the Mini Mental State
Examination (MMSE).
• Relationship or marital history (current and past);
• wellbeing of children (e.g. child protection issues);
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• psychosexual history (sexual orientation, STDs if relevant, issues related to
infertility, for women, candidate needs to explore the last menstrual period,
possibility of pregnancy, and method contraception);
• social history; current living situation, level of expressed emotion, past
employment, and religion.
• occupation
• Enquire details about the current occupation: e.g. working hours, interpersonal
relationships in the workplace, and stress level.
• Enquire about reasons for changing jobs (e.g. interpersonal problems which
reflect the patient’s personality) Look for potential risks associated with an
occupation (e.g. alcohol misuse in a man working in a bar).
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Demonstration
• Seek permission from the patient to explore the sensitive issue, ‘It is
important for me to explore the following aspect as it may be relevant to
your case.
• Some of the issues are sensitive. Would it be all right with you? May I know
your sexual orientation?’
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Forensic history
• history of offenses,
• the nature of offenses,
• current status (convicted or pending court case),
• previous imprisonment
• Any remorse toward the victim
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Premorbid personality
• Ask the person to describe his or her character, habits, interests, attitude to
self or others, and coping mechanisms.
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Questions to assess premorbid personality
• How would you describe your character?
• How do you think your friends or relatives would describe you?
• Has your character changed since you became unwell?
• Can you tell me your attitude towards other people like colleagues,
supervisors, and the society?
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End
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