Psychiatric history Guide

Brief introduction - demographics

Presenting complaint - agree a problem list if necessary

History of presenting complaint

- Open question - How are you? What has been happening to you? Can you tell me
more about this?

- Onset - When did this start?

- Progression - Has it gotten worse?

- Triggers - May anything have caused it to start?

- Description - Who, what, where, when, why?

- Symptoms

- Severity - I can see this is really troubling you. How is it affecting your life?

ICE - Ideas, Concerns, Expectations

- What do you think is going on?, Do you have any concerns?, Is there anything you
would like to discuss?

Diagnostic questions - discussed below

Rest of the history

■ Past Psychiatric history

– Sections

– Self-harm

– Use of mental health services

■ Past Medical/Surgical history

■ Drug history

– Including psychiatric drugs

– Compliance/Side effects

– Allergies
 ■ Family history

– Psychiatric disease

– Neurological disease

– Crime

– Alcoholism

■ Personal history

– Birth and development - difficulties with labour/pregnancy? Slow

development?

– Childhood - traumatic/significant life events? At home with parents and

siblings? Trouble during school - trouble with school work, bullying, suspension,
problem with making friends?

– Later life

■ Stressful life events? Work and finance issues? Relationship and sexual
issues? Housing? Do they have any children?

■ Social history

■ Forensic history

■ Risk assessment - risk to self, to others and from others. Are they safe?

Diagnostic questions - Low mood

HPC:

2 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 ■ Core symptoms of depression

– Low mood - How have you been feeling recently? Felt low in yourself? How
long for?

– Lack of pleasure (anhedonia) - Have you felt little interest or pleasure in doing
things?

– Low energy - Have you energy levels been low or have you been more tired?

■ Other symptoms

– Sleep - Are you getting enough sleep? Do you wake up early?

– Appetite - Has your appetite changed? Has your weight changed?

– Focus - Are you able to concentrate when doing a task?

– Effect on work, hobbies, relationships, libido?

– Preoccupied with guilt, regret, worthlessness, hopelessness?

– Previous episodes and triggers

■ Co-morbid disorders

– Anxiety, Mania (elated mood and energy, thought disorder and

psychosis)/Hypomania (milder but little functional impairment and no psychosis)
, Psychosis (hallucinations.delusions)

Diagnostic questions – Anxiety

HPC:

■ Description

3 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 – What are your worries or anxieties or phobias? Are you always anxious or does
it happen at certain times/attacks?

– Duration, Onset, Frequency, Triggers/Causes

– Severity - How has it affected your life?

– How do you manage it?

■ Mood and thought

– Tense, agitated, fear of loss of control, dread, irritability, decreased

concentration, depersonalisation and derealisation, obsessions and compulsions

– Depression screen

■ Panic attacks

– Have you had any previous attacks? Can you describe these for me please?

– How long does it last for?

– Physical symptoms

■ Sweating, tremor, palpitations, dry mouth, pain, dizziness, breathlessness,

headache, insomnia, GI symptoms - nausea and vomiting, bowel and
urinary changes, decreased appetite, globus, hyperventilation

Diagnostic questions – Psychosis

HPC:

■ Have you seen or heard things that you could not explain?

■ Have you had any strange or unusual experiences?

4 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 ■ When did you first notice this? How has it progressed? How has it impacted your life?

■ Any prodrome symptoms - poor self care, decrease in function (work or studies)

■ Thoughts

– Do you feel as if thoughts are being put into your head (insertion)/taken out of
your head (withdrawal)/overheard by others (broadcasting)?

– Does the patient stop in their thoughts/when speaking? (Blocking)

■ Delusions (false beliefs unchanged by evidence)

– Do you feel as if someone is out to get you/spying on you? (Persecutory)

– Do you feel as if your skin is infested? (Infestation)

– Do you feel that the TV/radio/newspaper talk about you? (Reference)

– Do you feel your own thoughts/feelings/actions are controlled by others?

(Control/Passivity)

– Do you feel as if you have special powers/abilities that others don’t have?
(Grandiose)

– Do you feel as if your rotting away? (Nihilistic)

■ Hallucinations (sensation without stimulus)

– Auditory - Do you hear voices?

■ What do they say?

■ Inside or outside your head? (Pseudohallucinations or Hallucinations)

■ Do they talk to you or about you? (2nd or 3rd person)

■ Do they ask you to do thing or is it a running commentary? (3rd person)

– Visual - Do you see things others cannot?

■ Describe it.

■ When did you first notice?

■ How has it progressed?

– Gustatory/Olfactory - Have you noticed strange tastes or smells that you

cannot explain?

■ When did you notice this?

5 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 ■ How has it progressed?

■ Other symptoms

– Low mood, self-neglect, loss of interest, social withdrawal

Diagnostic questions - Memory loss

HPC:

■ How long has it been since she started to forget things?

■ How has it progressed? When was it first noticed? When did she notice?

■ Cognition

6 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 – Short term memory - Do you have any difficulty remembering names,
appointments, dates?

– Long-term memory – Can you remember when you got married? What was
your first job?

– Visuospatial difficulties – Do you have any difficulty recognising places, people

or items?

– Language – Does she struggle to find the right words when talking?

■ Changes – Have you noticed any changes in your behaviour or personality?

– Behaviours – irritability, sexual disinhibition, wandering and social withdrawal

– Personality – violence/outbursts, verbal/physical aggression

■ Other psychiatric diagnoses

– Depression – How has your mood been recently?

– Anxiety – Have you been feeling upset/anxious recently?

– Psychosis – Have you seen or heard things that you could not explain?

■ Drug history

– Do you take any medication? Do you remember to take them every day?

■ Family history- Dementia?

■ Collateral Hx is required and assess cognitive function (e.g. MMSE)

7 References: Focused history taking (Master pass), NICE CKS, OSCE stop
Diagnostic questions – Mania
HPC:

■ How have things been recently?

■ Elevated/unstable mood

– How is your mood on a scale of 1-10? (Euphoria, irritability, lability, periods of

elevated and low mood)

■ Elevated energy levels/activity

– How are you energy levels? (Extravagance, rapid speech, pressure of speech,
increased libido, decreased sleep, poor appetite)

– Do you feel you have special powers that other people do not have?
(Grandiosity) - Risk assess

■ Thought disorder

– Is the patient very talkative, switching topics mid-conversation etc (flight of

ideas, poor concentration, confusion)

8 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 ■ Psychosis

– Grandiose delusions and decreased insight. Hallucinations seen in 15% of

patients

■ Hypomania = milder form of all the features mentioned above without the psychosis
and little functional impairment

Diagnostic questions - Substance/Alcohol misuse

Substance/Alcohol misuse:

■ What, how much, when, where, alone, progression?

■ Dependency (3 or more of WANTIN)

– Physical Withdrawal symptoms

– Persisting despite Adverse effects

– Neglect of other things

– Tolerance: need more to get the same effects

– Intense desire (craving)

– No control over use in terms of starting, stopping or amount

■ Harmful use - physical or mental health damage

■ Acute intoxication - acutely altered consciousness, behaviour, perception, affect,

cognition

9 References: Focused history taking (Master pass), NICE CKS, OSCE stop
Alcohol misuse :

■ CAGE questionnaire

– Cut down - Have you ever felt you should cut down on your drinking

– Annoy - Do people annoy you by criticising your drinking?

– Guilty - Do you feel guilty about your drinking?

– Eye-opener - Do you drink first thing in the morning?

Substance/Alcohol misuse:

■ Affect on life? Relationships, work, family, friends? Driving?

■ Have they come into problems with the law?

■ Mood? Psychosis? Infestation?

10 References: Focused history taking (Master pass), NICE CKS, OSCE stop
Diagnostic questions - Eating disorder
HPC:

■ Can you tell me a bit more about your eating? Why are other people worried?

■ Typical day - Can you describe what you eat on a particular day?

■ Bingeing - Do you ever binge on food? How do you feel afterwards?

■ Onset - How long has this been going on for?

■ Trigger - Did anything bring it on?

■ Home environment - how is everything at home?

■ Physical symptoms - urinary and bowel habits, pains, bleeding?

SCOFF questions:

■ Do you make yourself Sick?

■ Do you worry you have lost Control?

■ Have you put on One stone/6kg in last 3 months?

■ Do you believe you are Fat even when other thing you are thin?

■ Does Food dominate your life?

WAIF questions:

■ Weight - I know this is personal, but can I ask how much you weight?

11 References: Focused history taking (Master pass), NICE CKS, OSCE stop
 ■ Amenorrhoea - Are your periods regular?

■ Induced vomiting - Have you ever made yourself throw up after eating?

■ Fear of fatness - How would you feel if you gained weight?

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Diagnostic questions - Self-harm/suicide attempt
HPC:

■ How are you feeling today? I am really sorry it got this bad for you that you felt there
was no other way out

■ Before

– Prior events/mood - If you don’t mind me asking, what happened before that
made you feel like you had to harm yourself/end your life? How long have you
been feeling like this?

– Plan - What plans did you make and how long for?

– Not to be caught - Did you try make sure you would not get caught?

– Preparation?

– Did you tell anyone before or seek help afterwards?

■ During

– Can you tell me exactly what happened?

– Expectations - did you expect to die?

– Alcohol/drug use - Were you taking drugs/alcohol at the time? Under the
influence?

■ After

– Discovery - How were you discovered? Did you tell someone?

– Anger/regret - How do you feel about what happened?

– Lingering thoughts - Do you have any thoughts about doing something like this
again?

Mental State Assessment

13 References: Focused history taking (Master pass), NICE CKS, OSCE stop
14 References: Focused history taking (Master pass), NICE CKS, OSCE stop