Psychiatric history taking format

1. Identification data
a. Name, age, sex, occupation, marital status, race, religion, wad, registration
number, date of admission, date of clerking, live with, previous diagnosis
2. Chief complaint
a. Pt’s own words
3. History of present illness
a. Chronological development of problems-
i. How? “would you like to tell me what happen?”
ii. When?
iii. Why- Precipitating and Perpetuating?
iv. Any changes?
b. Significant Associated problems- sleep pattern, appetite, low, suicidal
ideas/attempts “how do u feel about ur future?”, hallucination, illusion, (other
symptoms that rule in or out DSM diagnosis)
c. Effects of problems-, work, domestic, leisure, social, family, sexual, personal
hygiene
d. Treatment taken so far
e. Record this twice if necessary, eg “history from patient” “history from notes”
4. Past psychiatric history
a. Dates (include hospitalization)
b. Main complaints + symptoms
i. Did u ever lose consciousness? Have a seizure?
c. Diagnosis & treatment – side effect + compliance
d. Cause
e. Socialization/functioning/ personal care in between episodes
f. Deliberate self harm, violence
5. Past medical history (include hospitalization)
a. Side effect of medication
6. Family history
a. How many siblings?
b. Genetics- family history mental illness, drug/ alcohol abuse, suicide, depressed
c. Ages and age of death
d. Occupations, marital status.
e. Dynamics- relationships now and when child
f. Draw a family tree
g. Who you share your problem with?
7. Personal history
a. Birth and early development
i. Birth history – normal delivery / cs / instrumental delivery
ii. “do u know anything abt ur birth? Age of mother & father when born?”
 Older mother (>35) – Down syndrome
 Older father (>45) – damaged sperm schizo
iii. Childhood – friends, habits, behavior
b. Educational history
i. Level achieved
 ii. How was the previous study?
iii. Peer relationships (b4 & after the disease)- bullying etc, reasons
iv. Teacher relationships, inc disciplinary problems
c. Occupational history
i. How many jobs?
ii. Why did they leave?
iii. Problems with peers and with management
d. Relationship history
i. How many relationship b4?
ii. How you are b4 met your gf?
iii. How long they have been together?
iv. How was the relationship b4 break up? / what sort of relationship you
have?
v. Sexual relationship?
vi. Children?
e. Drugs and alcohol history
i. How much? (2 cans of beer/day = safe amount)
ii. Pattern of use, when, how long per day, who with, effects on life, when
started using
iii. If heavy or problematic use ask about the symptoms of dependency
syndrome
f. Forensic history
i. Ever arrested & why
g. Menstrual /obstetrical history
h. Marital history
i. Age at marriage
ii. Attitudes toward children
iii. Extramarital affairs
8. Premorbid personality (From patient and informant if possible)
a. “How would others describe you before this happened?”
b. Personality traits
c. Hobbies
d. Beliefs & attitudes
e. Social relationships
i. Any close friends?
ii. Wide circle of friends?
iii. Reliable?
f. Coping resources
g. Religious beliefs

Mental state examination

1. General appearance & behavior

a. Young or old
b. Body build (schizo on treatment – obese)
c. Looks comfortable/uncomfortable
 d. Eye contact – < normal (depression), normal, > (mania, aggression)
e. Physical health / personal hygiene
f. Self care
g. Dressing – properly dress?
h. Facies –Parkinsonian facies (medication side effect)
i. Gait/posture – parkinson (side effect of antipsychotic), slow (depression)
j. Rapport & Attitudes towards examiner - cooperative, seductive (hysteria),
defensive, hostile, guarded
k. Comprehension
l. Motor activity
i. Increased/decreased
ii. Excitement /stupor
iii. Abnormal involuntary movements – tics (involuntary, spasmodic,
stereotyped movement of small group of muscles, especially prominent
when the person is under stress / anxiety), tremors, stiffness
(medication side effect)
iv. Restlessness/akathisia (side effect of antipsychotic and neuroleptic
medication)
v. Catatonic signs- mannerism (habitual involuntary movement),
stereotypies (continuous mechanical repetition of speech or physical
activities, as in certain forms of schizo)
vi. Posturing, waxy flexibility (cond. in which pt maintain body position into
which they r placed), negativism, ambitendence, echopraxia (involuntary
imitation of movements made by another)
m. Social manner
n. Hallucinatory behaviour
o. Signs of anxiety – moist hand, perspiring forehead 额头出汗, restlessness, tense
posture
2. Speech
a. Rate & quantity
i. present, absent, mute
ii. spontaneous, prompt (give only 1 word answer)
iii. rapid/slow / average
iv. pressure of speech (continuous, fast & uninterruptible, in mania),
poverty of speech
b. Volume & tone – increased (mania)/decreased (depression & anxiety)
c. Flow and rhythm- smooth, hesitent, stuttering, slurring, staccato, block,
circumstantiality, tangentiality, looseness of association, verbigeration, flight of
ideas, clang association (word connection due to phonetics rather than actual
meaning ; often encountered in the manic phase of manic-depressive psychosis)
3. Mood & affect
a. blunted (), restricted, , labile
b. Mood (climate) –depressed, anxious, angry, guilty, anhedonic (loss of interest in
& withdrawal frm all regular & pleasurable activities, in depression), alexithymic
(inability to describe or be aware of one’s emotions or moods, or to elaborate
 the fantasies associated with depression, substance abuse, & PTSD), warmth,
euphoria, elation (mood consisting of feelings of joy, euphoria, triumph &
intense self-satisfaction or optimism, as in mania), exaltation (feeling of intense
elation & grandeur), sad, irritable, despair, shallow
c. Affect (weather)
i. Flat affect (negative symptoms of schizo) – remain expressionless &
monotone even when discussing extremely sad / happy moments in his
life.
ii. Restricted affect – displays some emotion, but not as many as is normal.
iii. Labile affect – abnormally large range of emotions, fluctuate rapidly
between laughter and tears.
iv. Blunted affect - a disturbance in mood seen in schizophrenic patients
manifested by shallowness and a severe reduction in the expression of
feeling
v. Inappropriate affect - a pt. who giggles while telling you that he set his
house on fire & is facing criminal charges
4. Thought
a. Form of thought /stream of thought
i. overlaps with speech
ii. spontaneity
iii. productivity - flight of ideas (jump frm topic to topic very fast, there r
link between topic but links r unusual, as in mania)
iv. continuity of thought and the relevancy - looseness of association
(jumping frm topic to topic, no link betw topics, as in schizo),
tangentiality (point of conversation never reached due to lack of goal-
directed associations between ideas), circumstantiality (point of
conversation is reached after circuitous path), thought block (abrupt
cessation of communication before the idea is finished), perseveration
(pathological repetition of same response to different stimuli, as in
repetition of same verbal response to different question), verbigeration
(constant repetition of meaningless words / phrases, as in
schizophrenia)
v. language impairments – word salad (incoherent collection of words),
clang association, neologisms (new word / phrase whose derivation
cannot be understood)
b. Thought content
i. Poverty of thought vs overabundance – too few vs too many ideas
expressed
ii. Obsessions – repetitive, intrusive thought
iii. Compulsions – repetitive behaviors (link with obsession)
iv. Fears / phobias – persistent, irritational fears
v. Delusions (a fixed belief which is firmly held, on inadequate grounds, is
not affected by rational argument and is not a conventional belief that
the person might be expected to hold given his educational and cultural
 background) - persecution (paranoid schizophrenia), reference (belief
that some event is uniquely related to the individual, eg :” Jesus is
speaking to me through TV character”), grandeur (belief that one has
special powers beyond those of a normal person, eg : “I’m the all-
powerful son of God & I shall bring down my wrath on you if I cannot
have a smoke”), love, jealousy, guilt, nihilism (delusion of nonexistence
of everything, especially of the self or part of the self), poverty,
hypochondriacal 忧郁症, hopelessness + helplessness + worthlessness =
depression
vi. Delusion of control (false belief that a person’s will, thoughts or feelings
are being controlled by external forces), thought insertion (schizo),
thought withdrawal, thought broadcasting (feeling that one’s thoughts
are being broadcast or projected into environment), neologism (made –
up words)
vii. Suicidal & homicidal thoughts
5. Perception
a. Hallucination – perception in the absence of an object : auditory, visual (schizo),
tactile (cocainism, delirium tremens), olfactory (temporal lobe epilepsy),
gustatory.
i. “do u ever hear voices that others cant hear?”
ii. “do u ever see, feel, taste or smell things that others cant?”
iii. “does the voice sound as real as me talking to u?”
iv. “can u make them go away if u want to?”
v. “do u recognize the voice? Male? Female?”
vi. “what kind of things does it say to u?”
vii. “Does it talk directly to u, or does it talk abt u?”
viii. “Does it ever talk abt u to someone else, as if u r not there?”
ix. “does it ever comment on things u r doing, like narrator?”
x. Hypnogogic – occur as pt going to sleep
xi. Hypnopompic – occur as pt waking up normal
b. Illusion (delirium) – inaccurate perception of existing sensory stimuli (“shadow
out of the corner of our eye & believe it to be a person” or “ wall appears as if
it’s moving”)
c. Depersonalization – extreme feelings of detachment frm self
d. Derealization - extreme feelings of detachment frm environment
e. Somatic passivity
6. Cognition
a. Commonly points to organic psychiatric disorders
b. Consciousness – alert, drowsy, lethargic, stuporous, coma
c. Orientation – time, place, person
d. Attention -serial 7’s (100-7-7-…)
e. Concentration -spell WORLD / DUNIA backward
f. Memory-
i. immediate recall – tell 3 objects then ask them repeat immediately & 5
min later
 ii. short term (recent) – what they eat for lunch or breakfast
iii. Episodic / remote (long term memory) – childhood event (where did u
go to school), important event in secondary school
iv. Semantic – DOB, date of wedding
g. Abstract thinking
i. Proverb testing, eg :what is meant by the phrase, “ you cant judge a
book by it’s cover?”
 normal – you cant judge ppl jz by how they look.
 concrete – books have different covers.
ii. Similarities – ability to explain similarities betw objects, eg :”how are an
apple & orange alike?”
 Normal – they r fruits
 Concrete – they r round
iii. Concrete thinking or abstract
iv. Appropriateness
7. Insight
a. Complete denial
b. Slight awareness of being sick but denying it at the same time
c. Awareness of being sick but attributes it to external factors
d. Awareness of being sick due to something unknown in himself
e. Intellectual insight
f. True emotional insight
8. Judgement
a. Ability to understand relations betw facts & to draw conclusion
b. “what is the thing to do if u find an envelope in the street that is sealed,
stamped & addressed?”

Physical examination
• General:
 Blood pressure
 Pulse rate
 Respiratory rate
 Temperature
• Systemic :
 Cardiovascular System
 Respiratory System
 Abdomen
 Central Nervous System
 Musculoskeletal