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Summary psychiatry history taking
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history taking in psychiatry for medical students
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Class notes Introduction to business Oxford Handbook of Psychiatry
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Chapter 3Psychiatric History
13
, Chapter 3: Psychiatric History
Background
The psychiatric history aims to gather information in order to capture a patient’s story, elicit signs and symptoms
of the presenting disorder and to derive the necessary information for diagnosis and management.
Each of the individual sections of a psychiatric history should come together to give a complete picture of a
patient’s life and current situation.
The success of a psychiatric interview depends on how well the doctor communicates with the patient.
Components of a psychiatric history (each of these components are discussed in more detail below)
Introduction.
Presenting difficulty.
History of presenting difficulty.
Past psychiatric history.
Family history.
o Parental history.
o Siblings.
o Family psychiatric history.
Past medical and surgical history.
Alcohol and substance misuse history.
Current medications.
Personal history.
o Birth and development.
o Childhood and adolescence.
o Education and literacy.
o Occupational history.
o Relationship history.
o Psychosocial history.
Forensic history.
Premorbid personality.
1. Introduction
Give the patient’s initials, age, gender, marital status, occupation, location (name of hospital or outpatient
clinic) and the date of the patient’s presentation to the hospital or outpatient clinic.
Example A: Ms BW is a 38 year old single unemployed lady with two children, who presented to St Kevin’s
Hospital Emergency Department on 1st October 2020.
Example B: Mr AB is a 56 year old married father of three children receiving disability benefit, who was
admitted to St Theresa’s Hospital on 4th December 2020.
Example C: Ms SF is a 30 year old single nulliparous woman working as a secretary, who presented to St
Joseph’s Psychiatry Outpatient Clinic for a review on 6th January 2021.
2. Presenting difficulty
A concise statement giving the patient’s reason for presentation.
Example A: Ms BW presented to the emergency department following an overdose of her prescription
medication which was precipitated by multiple psychosocial stressors on a background history of recurrent
depressive disorder since the age of 22 years.
Example B: Mr AB was admitted to St Theresa’s Hospital due to a relapse of psychosis on a background
history of paranoid schizophrenia since the age of 20 years.
Example C: Ms SF presented to St Joseph’s Psychiatry Outpatient Clinic for a review with worsening
generalised anxiety associated with panic attacks on a background history of post-traumatic stress disorder of
one year duration.
3. History of presenting difficulty
This is an expansion of the presenting difficulty.
o Why has the patient presented now?
o What were the major symptoms leading up to the current presentation?
If the patient presented with depression or other psychiatric illness, consider if each of the ICD-10
criteria for depression or other relevant condition are present or absent.
Also consider co-morbid symptoms (e.g. depression, psychosis, agoraphobia, social phobia or
generalised anxiety disorder) by looking at the relevant ICD-10 criteria of the conditions and
determining if the symptoms are present or absent.
It is important to clearly describe the features of mental illness and for the main diagnosis to be obvious
to someone else who reads the history of presenting difficulty. The presenting difficulty is your
‘argument’ for naming the first diagnosis in your differential diagnosis as your preferred diagnosis.
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