Psychiatric history collection is the most vital step to ensure appropriate evaluation and care of person with mental illness. A proper history collection led to in depth understanding of biopsychosocial factors responsible for mental disorder. This process also help in predicting the illness course, diagnosing the illness and making prognosis. A good rapport between interviewer and patient is the fundamental element for collecting reliable and complete history.
General Principles of History Collection
- Take consent before interviewing patient
- Purpose of the interview should be clearly explained
- Make every attempt to ensure confidentiality of patient information
- Be non judgemental
- Build good rapport with patient
- The interview should be patient centred
- Ensure safety of both patient and yourself.
- Follow techniques of therapeutic communication like asking open ended questions.
Elements of psychiatric history collection
It involves mental profile which includes the following:
- Basic identification data
- Chief complaints
- Present health history
- Past health history
- Family history
- Personal history
Identification Data
Name:
Age:
Sex:
IPD No:
Educational status
Occupation:
Religion:
Marital status:
Address:
Date of admission:
Patient was admitted by: family member/ police/ self-admission
Reason for consultation: mention specifically the chief complaint for which patient seek treatment.
Provisional diagnosis/ diagnosis of patient:
Chief Complaints
Mention specifically the present duration of problems since when it started to appear in patient.
In patient’s own words
Write patient’s history or problem in his own stated words
In informant’s own words
Write patient’s history or problem in informant’s own stated words
Informant Details:
Name-
Relationship-
Acquaintance-
Adequacy of information-
Reliability of information-
The information given by psychiatric patient is not reliable hence the data is validated by informant. Details of informant like his acquaintance with patient etc. is to be asked to make sure that the information is correct and can be trusted.
History of present illness
It includes the chronological description of appearance of symptoms and evolution of illness. special focus should be given to any deviation in patients behaviour, interest and interpersonal relationships during same time period. Notes should be taken regarding the length of time of present symptoms, fluctuation in severity of symptoms, presence of any stressors and factors that alleviate symptoms like medication, etc.
It is important to collect past medical history which includes an account of both past and present major medical illness, their course and treatment. Any past surgical history should be reviewed. Past medical history is vital to determine potential causes for mental illness as medical illness can precipitate mental illness.
Family History
This history is important because many mental illnesses are due to genetic predisposition. Careful review of family history also provide information regarding patient’s psychosocial background. The following should be asked while taking family history
a) Type of family-
b) Support system- obtain patient’s family member’s attitude towards patient’s disease condition and their support and care towards patient.
c) Genogram/ family tree: In family tree three generation should be included with specific mention of mental illness in family members.
d) History of illness in family
Write specifically about the medical and surgical history of family. Specifically mention family history of any mental illness in family
Personal History
It involves a review of patients developmental stages and his social behavior. The following details should be obtained.
Birth and early development
Collect history about- Place of delivery, type of delivery, any instrument used during delivery or not (eg- forceps and ventouse), history of delayed crying after birth or any other significant problem, history of hospitalization after birth or poor feeding, history of developmental delay or delayed achievement of developmental milestones.
Parental lack
Rule out presence of loss of parents during childhood.
Behavior during childhood
Collect history about patient’s behavior during childhood. History of any childhood behavioral problem should be asked like tics, temper tantrums, nail biting, nocturnal enuresis and encopresis, autistic behavior, etc.
Physical illness during childhood
Collect specific history about presence of any surgical or medical illness during childhood like meningitis, jaundice, head injury, encephalitis, seizure or epilepsy, etc.
School History
Collect history about-
Age of starting and finishing formal education, reason for terminating education, academic and extracurricular performance in school, history of learning disability,behavior with peer group and teachers, history of problem in conduct like stealing, lying, bullying, etc.
Puberty
collect data regarding age at menarche, reaction to menarche, premenstrual mood changes and problems related to menstruation
Emotional problems during adoloscence
Ask about the emotional problems faced by patient during adoloscence and ways of coping. Specifically rule out history of running away from home, deliquent behavior and substance use.
Occupational History
Collect history about-
Ask the chronological sequence of jobs, mention age at starting first job, specific reasons for changing jobs (if any), patient’s present occupation, when he started present job, his average earning, his behavior with his colleague at office, any stressor present in his job, satisfaction with job, etc.
Sexual and marital history
Collect history about-
Ask about patient’s view regarding his sexual identity, his sexual orientation, at what age patient got acquaint with the knowledge regarding sexual relationship, mention the source from where he got information about sex (eg- by watching porn, through his friends or others etc), any sexual practices and fantasies he prefer, etc.
Mention the type of marriage whether it is arranged by parents or is self choice, duration of marriage, satisfaction in interpersonal relationship with in-law’s, number of children, marital problems and satisfaction, sexual life and satisfaction.
Use of substance
Collect history about the type of substance patient used, at what age he started and why he started, duration of substance use and frequency of substance use in a day and quantity of substance used in one sitting or in a single day.
Premorbid Personality
Interpersonal Relationship- Collect history of patient’s behaviour with others before illness, mention his personality feature like introvert or extrovert, ask about his communication with neighbours and family members.
Use of leisure time- Ask patient’s way of using free time before illness, specific mention of hobbies and interest to be addressed.
Predominant mood- Specify the premorbid mood state like anxious, cheerful, sad, etc.
Attitude to self and others- Collect information regarding patient’s attitude toward self whether he was optimistic,self confident or was pessimistic and self critical. Ask his general attitude towards others.
Religious and moral beliefs- This information include patient’s religious beliefs, religious practices, moral values and patient’s overall value system.
Attitude towards work and responsiblity- Collect history whether patient have positive or negative attitude towards any responsiblity assigned to him.
