National Conference for
Postgraduates in Psychiatry
TIPPS CLINICAL NOTES
Authored by: Dr Rishikesh V Behere, Dr Naren P Rao, Dr
Girish Babu N, Dr Sugnyani Devi Patil
Supported by educational grant from
,Training Initiative for Psychiatry Postgraduates (TIPPS ) www.tipps.co.in
Psychiatric history taking and mental status examination
HISTORY:
Socio demographic details:
(Ask for name, age, gender, socio-economic status and average family annual income,
marital status, occupational status)
Informant: (Record who is the informant – name and relationship to patient)
✓ Reliability of information (Is the information consistent, corroborative, and
continuous?)
✓ Adequacy of information (Is the information adequate to come to a provisional
diagnosis?)
Presenting complaints: (present the main 3-4 complaints preferably in patients words
avoid technical terms and arrange in chronological order)
Onset: (The time period between when symptoms started and reached maximum intensity.
Abrupt – within 48 hours, acute – within 2weeks, insidious – gradual)
Course: continuous/fluctuating/episodic
Precipitating factor: (Record significant events – biological or psychosocial which may be
deemed to be associated as a triggering factor with the onset of illness).
History of presenting illness:
Elaborate the presenting complaints in a descriptive manner to elicit all information
pertaining to the symptoms. The flow of description should be such that at the end of history
the listener should be able to make a fair estimation of possible diagnosis. One way is to
think of differential diagnosis for your complaints and arrange your information including and
excluding possible diagnosis.
In psychiatric history it is easy to get carried away by describing only contextual factors and
stressors reported by over anxious informants. While they are important they do not help in
diagnosis and decision making. It may be necessary for interviewer to filter information and
focus on eliciting symptoms.
Thumb rules to follow:
✓ Elaborate each presenting complaints for onset, duration, progression,
✓ Ask for and cover symptoms in all 3 domains of thought/emotions/behavior
✓ Describe the Socio-occupational dysfunction caused by the symptoms
✓ A good way to do this is to describe a typical day of the patient and activities over a
24 hour period
✓ Describe Biological functions – Sleep/appetite/sexual activity
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,Training Initiative for Psychiatry Postgraduates (TIPPS ) www.tipps.co.in
✓ Describe associated stressors
✓ Check for history of substance use
✓ Always check for risk of harm to self or others (Suicidal
ideation/attempts/aggression)
✓ Check for potential legal issues
✓ Start negative history with:
▪ Symptoms of likely diagnosis which are not present in this patient
▪ Other psychiatric symptoms which are absent to rule out differential
diagnosis
▪ Neurological and Medical symptoms/conditions that may be associated with
the likely diagnosis
Treatment history: (Details of past treatment – Drug given. Duration of treatment,
compliance, and adverse effects if any, and if there was any response)
Past history: (Details of past illness. Typically in episodic illness, only current episode is
described in HOPI and details of past episodes come here)
Family history: Record following information
✓ 3 generation genogram
✓ Family history of medical or psychiatric disorder (Psychosis, bipolar disorder,
depression, suicide, substance use, dementia). The diagnosis may not be clear,
describe the symptoms and behavioral disturbances, and record their treatment
history if available (for e.g. family history of response to lithium may predict good
response to lithium in this patient also).
✓ Record current living arrangement and who is primary care giver
✓ Record family understanding of illness and attitude towards the patient also record
any family stressors, interpersonal difficulties
Personal history:
✓ Antenatal history and birth complications
✓ Developmental milestones
✓ Childhood history for enuresis, nail biting, school refusal, truancy, conduct symptoms,
ADHD, temper tantrums
✓ Schooling history: record average academic performance, last class studied,
grades/marks in 10th and 12th standard and reasons for drop out
✓ Occupational history: Jobs held, performance, reason for loss of job. Ask specifically
for any frequent job changes, impersistence in work etc.
✓ Marital history: Record for duration of Married life, nature of marital and sexual
relations, marital discord if any, details of family of procreation.
✓ Sexual history: Check for sexual misconceptions, high risk sexual behavior
✓ Menstrual history in female patients
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Premorbid personality:
Ask about the individual’s attitude to work/family, ability to take responsibility, coping when
faced with stress, hobbies and interests prior to onset of illness.
In young adults/adolescents temperamental history needs to be taken.
Interviewing patients in Psychiatry:
History taking is the first step and interviewing skills are the most important tool to a
psychiatrist. Given the nature of the discipline, most clinical diagnosis are made based on
the available information. Hence eliciting adequate information, analyzing and organizing it
to reach a conclusion is a very important skill.
To be able to elicit important information the interviewer needs to know certain specific skills
1. To be able to establish a rapport
2. Empathy and listening skills
3. Interview technique
Few things to remember are:
✓ History taking is a Clinical interview, the focus of which is to obtain adequate
information in order to arrive at a clinical diagnosis. There may be a lot of contextual
information related to circumstances, events and psychosocial stressors which may
be important to understand the person’s reaction and significance of the event but
may not be relevant for clinical diagnosis. Hence the interviewer may need to filter
these out.
✓ While analyzing and organizing the information collected the principle of ‘atheoretical’
nature of psychiatric diagnosis needs to be kept in mind.
✓ The interviewer should be non-judgemental and empathetic in approach to the
interview
✓ Certain questions may need to be asked in a specific set manner to elicit correct
information and eliminate subjectivity in interview techniques and make the process
of eliciting information reproducible.
Establishing rapport
Establishing rapport is probably the most important step in history taking. Especially
when interviewing psychotic patients with poor insight, eliciting personal information like
interpersonal issues, sexual history, sexual abuse etc.
✓ Introduce yourself and set the agenda of the interview by stating that you would be
asking questions to understand reason for consultation/admission.
✓ Address the patient by name – this is a useful to gain the trust of the patient
✓ Ensure confidentiality by making explicit statement that information discussed with
not be revealed without consent
✓ Always interview the patient first and get her version of the history. This is also vital in
cases where patients have poor insight and psychopathology involving the
informants
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