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11/13/24, 8\:12 PM Guide | Psychiatric history

Psychiatric history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
It is important to try to establish rapport with the patient early in the consultation. Explain that some of the questions you ask
may be di
them or another person, e.g. a child at home).
“ A n y t h i n g s a i d h e r e t o d a y w i l l b e c o n
s h a r e s o m e i n f o r m a t i o n . I a p p r e c i a t e t h a t s o m e q u e s t i o n s m a y b e d i
a n s w e r r i g h t n o w , w e c a n c o m e b a c k t o i t a n o t h e r t i m e . D o e s t h a t a l l s o u n d o k ?”
When taking a full psychiatric history, it can also be helpful to explain (signpost) that you will be covering many areas,
including their life story, family background etc, as patients don't necessarily know that these are important parts of a
psychiatric assessment. It can also be good to establish how much time you have and that because there are many areas to
cover, you may need to interrupt to move on to another area if you have enough information.
Ask the patient if they’d be happy to talk with you about their current issues.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centered and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills that apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Detention under the Mental Health Act

In inpatient settings, patients can be admitted on an informal basis or detained under the Mental Health Act.
When taking a history from a patient in psychiatry, it can be useful to establish the status of their admission before speaking to
them, as this may give you information regarding their current mental state and help you consider any risk that may be present.
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Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?”
Once the patient has
complaints, work with them to establish a shared agenda for the rest of the consultation.
Depending on the setting (inpatient vs. outpatient) and the patient's current mental state, some information may need to be
gathered from a collateral history. A collateral history is particularly important if a patient has been detained under the Mental
Health Act, as it will help to provide information about the patient's background and what prompted the assessment and
admission.
Open vs. closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

You should then explore the presenting complaint in more detail. Patients can present with a wide range of symptoms, ranging
from mania, low mood, hallucinations, anxiety, delusions, and memory loss.
An overview of common symptoms in psychiatry is below, with links to our OSCE guides for speci
Key psychiatric symptoms/presentations
Low mood (depression)
Self-harm/suicidal ideation
Elevated mood and energy (hypomania and mania)
Anxiety, panic attacks, or phobias (anxiety disorders)
Delusions and hallucinations (psychosis)
Obsessions or compulsions
Alcohol or substance abuse
Issues around food or weight (eating disorders)
When exploring symptoms, you can use the acronym NOTEPAD\:
Nature
Onset
Triggers
Exacerbating/relieving factors
Progression
Associated symptoms
Disability
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Depression

When taking a history from a patient presenting with low mood, it is important to explore the core symptoms of depression
and the associated biological and somatic symptoms.
The three core symptoms of depression are low mood, lack of pleasure (anhedonia), and low energy levels.
" H o w h a s y o u r m o o d b e e n r e c e n t l y ?"
" H a v e y o u f e l t l o w i n y o u r s e l f ?"
" H a v e y o u f e l t l i t t l e i n t e r e s t o r p l e a s u r e i n d o i n g t h i n g s ?"
" H a v e y o u r e n e r g y l e v e l s b e e n l o w e r t h a n n o r m a l ?"
" H a v e y o u b e e n f e e l i n g m o r e t i r e d t h a n n o r m a l ?"
Associated symptoms to ask about in depression include\:
Disturbed sleep (this may be increased or decreased)
Change in appetite and/or weight (this may be increased or decreased)
Agitation or slowing down of movements and thoughts
Poor concentration
Lack of hope for the future
Feelings of worthlessness
Feelings of excessive or inappropriate guilt
Reduced libido
Thoughts of self-harm
Thoughts of death or suicide
In any patient presenting with low mood, it is essential to carry out a risk assessment.
When exploring negative thoughts in depression, it can be helpful to start with self-esteem, con
hopelessness and suicidal thoughts. This structure makes it easier to explore sensitive themes. It also allows you to use the
normalisation technique before asking about suicidal thoughts\:
" I t i s n o t u n c o m m o n t h a t p e o p l e w h o h a v e b e e n f e e l i n g a n d t h i n k i n g i n t h i s w a y s t a r t t h i n k i n g a b o u t s u i c i d e . s i m i l a r t h o u g h t s ?"
H a v e y o u h a d a n y
It is also important to remember that patients with depression may not present with low mood but can present with non-
speci
cognitive decline.

Hypomania/mania

Episodes of mania and hypomania are part of the diagnostic criteria for bipolar disorder, and patients will present with an
elevated mood and increased activity and energy.
Several characteristic symptoms are common to both hypomania and mania, but the time frame, speci
impact on function will help you to di
" H a v e y o u n o t i c e d a n y c h a n g e i n y o u r m o o d o r e n e r gy l e v e l s r e c e n t l y ?"
" C a n y o u d e s c r i b e t h e c h a n g e ?"
" H a v e y o u f e l t m o r e i r r i t a b l e o r i m p a t i e n t t h a n u s u a l ?"
" A r e y o u h a v i n g a n y p r o b l e m s i n y o u r j o b / r e l a t i o n s h i p s ?"
" H o w a r e y o u s l e e p i n g a t t h e m o m e n t ? I s i t m o r e o r l e s s t h a n n o r m a l ?"
" H o w i s y o u r a p p e t i t e ?"
" W h a t i s o n y o u r m i n d a t t h e m o m e n t ?"
" C a n y o u d o t h i n g s t h a t o t h e r p e o p l e m i gh t
Other symptoms associated with mania/hypomania may include\:
Increased self-esteem
Reduced social inhibitions
Over-familiarity
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Reduced attention
Spending recklessly
Inappropriate sexual encounters
Preoccupation with extravagant or impractical plans
Persecutory delusions
Incomprehensible speech
Self-neglect
Loss of insight
episode.
Depending on the severity of symptoms, it can be very challenging to take a history from a patient experiencing a manic
They may not be able to concentrate enough on the assessment to give complete answers. However, if this is the case, then a
signimental state examination. In this situation, returning later to
complete the history may be appropriate.
A collateral history is also extremely useful when assessing a patient with mania/hypomania as they will often be able to give
a much clearer description of the changes in behaviour and impact on functioning.

Anxiety disorders

Anxiety is an unpleasant physical and psychological set of symptoms that occur in response to a potential/uncertain threat.
Its basis as a survival mechanism means it can be very disabling and di
There are several anxiety disorders, including generalised anxiety disorder, speci
many psychological and physical symptoms associated with them all that you should ask about.
" H a v e y o u b e e n w o r r y i n g a l o t a b o u t t h i n g s r e c e n t l y ?"
" W h a t s o r t o f t h i n g s h a v e y o u b e e n w o r r y i n g a b o u t ?"
" D o y o u f e e l w o u n d u p o r t e n s e ?"
" A r e y o u a l w a y s a n x i o u s o r d o e s i t h a p p e n a t c e r t a i n t i m e s ?"
" D o y o u g e t s u d d e n ' a t t a c k s' o f a n x i e t y ?"
" A r e y o u a b l e t o p u t y o u r w o r r i e s o u t o f y o u r m i n d ?"
" D o y o u a v o i d d o i n g t h i n g s b e c a u s e o f y o u r w o r r i e s ?"
" H a v e y o u e v e r f e l t d e t a c h e d f r o m y o u r s e l f o r y o u r s u r r o u n d i n gs ?"
Physical symptoms that may be associated with anxiety disorders include\:
Palpitations
Chest tightness
Breathlessness
Sweating
Dizziness
Dry mouth
Nausea and vomiting
Insomnia/di
Paraesthesia
It is important to screen for co-existing depression in patients presenting with anxiety.

Psychosis

Psychosis occurs when a patient has lost touch with reality, so assessing them can be challenging and daunting. It is useful to
have some standard screening questions for common symptoms found in psychotic disorders.
“ I h a v e t o a s k y o u s o m e q u e s t i o n s t h a t m a y s e e m a l i t t l e b i z a r r e a n d m a y n o t m a k e s e n s e . T h e s e a r e q u e s t i o n s w e a s k o f
e v e r y o n e . W o u l d t h a t b e o k ?”
Symptoms of psychosis generally include hallucinations, thought abnormalities, and delusions. These symptoms are
included within the , but they can be found in other disorders.
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Hallucinations
Hallucinations can take the form of any sensory modality, and di
disorders. For example, schizophrenia is generally associated with auditory hallucinations, whereas Lewy-body dementia is
more associated with visual hallucinations.
“ D o y o u e v e r h e a r n o i s e s o r v o i c e s w h e n t h e r e i s n o b o d y e l s e t h e r e ?”
“ D o y o u e v e r f e e l t h a t s o m e o n e o r s o m e t h i n g i s t o u c h i n g y o u w h e n t h e r e i s n o b o d y t h e r e ?”
“ H a v e y o u e v e r f e l t l i k e y o u’ v e b e e n a s s a u l t e d d e s p i t e n o b o d y b e i n g p r e s e n t ?”
“ H a v e y o u e v e r f e l t l i k e i n s e c t s a r e c r a w l i n g b e n e a t h y o u r s k i n ?”
Delusions
contradictory evidence.
Delusions are
Whilst it may be necessary to gently challenge a delusional belief to establish if it is
so as not to cause too much distress to the patient, which may result in a breakdown of rapport.
A common delusion is a persecutory delusion, in which the patient believes another individual or group is trying to harm them.
“ D o y o u s o m e t i m e s h a v e t h o u g h t s t h a t o t h e r s t e l l y o u a r e f a l s e ?”
“ D o y o u h a v e a n y b e l i e f s t h a t a r e n’ t s h a r e d b y o t h e r s y o u k n o w ?”
Disorders of thought content can also be considered as delusions. These include thought withdrawal (the belief that thoughts
can be removed from their mind), thought insertion (the belief that thoughts can be inserted into their mind), and thought
broadcasting (the belief that others can hear their thoughts). Formal thought disorder, such as thought blocking (sudden
cessation of thought), should be covered in the MSE.
“ I s t h e r e a n y o n e o r a n y t h i n g t a k i n g t h o u gh t s o u t o f y o u r h e a d ?”
“ A r e y o u r t h o u g h t s y o u r o w n ?”
“ I s t h e r e a n y o n e / a n y t h i n g p u t t i n g t h o u gh t s i n t o y o u r h e a d t h a t y o u k n o w a r e n o t y o u r o w n ?”
“ C a n a n y o n e h e a r y o u r t h o u g h t s ? F o r e x a m p l e , c a n I h e a r w h a t y o u a r e t h i n k i n g r i gh t n o w ?”
“ D o y o u e v e r h e a r y o u r o w n t h o u g h t s e c h o e d o r r e p e a t e d ?”

Obsessions and compulsions

Obsessions are thoughts, images, or impulses that are recurrent and intrusive. They enter the mind despite resistance and are
recognised by the patient as their own thoughts (i.e. not as a result of thought insertion). They are generally extremely
distressing for the patient, and they tend to remain aware that these thoughts are irrational but still feel they have no control
over them.
Compulsions are repetitive mental processes or physical acts a patient feels compelled to perform due to an obsession or
rule. They are carried out in an attempt to reduce the distress and anxiety associated with the obsessions - even though they
are not linked to the speci
to an obsessive fear of bacteria or dirt).
These two symptoms are characteristic of obsessive-compulsive disorder (OCD) but can also occur in other illnesses, such as
depression, personality disorders, and health anxiety disorder.
" D o y o u g e t r e p e a t e d u n p l e a s a n t t h o u gh t s o r i m a ge s c o m i n g i n t o y o u r m i n d ?"
" D o y o u g e t t h e s e t h o u g h t s e n t e r i n g y o u r m i n d d e s p i t e t r y i n g t o k e e p t h e m o u t ?"
" D o y o u e v e r f e e l t h a t y o u n e e d t o r e p e a t e d l y c h e c k t h i n g s y o u h a v e a l r e a d y d o n e ?"
" D o y o u e v e r f e e l t h a t y o u n e e d t o a r r a n ge , t o u c h , o r c o u n t t h i n gs r e p e a t e d l y ?"
" D o y o u t r y t o r e s i s t t h e t h o u g h t s o r t h e u r ge t o r e s p o n d t o t h e m ?"

Alcohol or substance abuse

The use of alcohol and/or recreational drugs is common, and they may represent a trigger for another psychiatric condition, an
attempt to manage the symptoms of an undiagnosed psychiatric condition, or a substance misuse disorder in their own right.
There are several screening questions for alcohol use, for example,
"CAGE"
\:
" H a v e y o u e v e r f e l t y o u o u g h t t o C u t d o w n o n y o u r d r i n k i n g ?"
" H a v e p e o p l e A n n o y e d y o u b y c r i t i c i s i n g y o u r d r i n k i n g ?"
" H a v e y o u e v e r f e l t G u i l t y a b o u t d r i n k i n g ?"
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" H a v e y o u e v e r f e l t y o u n e e d e d a d r i n k
h a n g o v e r ?"
If the answer to two of these questions is yes, it is worth taking a full alcohol history.
Questionnaires such as AUDIT-C can help to quantify the amount of alcohol consumed, but generally, it is important to
establish what is drunk and when, the presence of physical withdrawal symptoms, tolerance, whether they have had adverse
e
before
The same types of questions should be asked regarding the use of recreational drugs. However, it is important to remember
that non-illicit drugs, such as opioid analgesics, can be misused.
For recreational drugs, the amount of money spent tends to be a good guide to intake, and it is important to consider the route
of administration - if needles are used, are they shared? And has the patient been tested for blood-borne viruses?
There are a few potential questions that you can ask to screen for dependence on any substance\:
" D o y o u f e e l a s t r o n g d e s i r e o r c o m p u l s i o n t o t a k e ___?"
" D o y o u o f t e n t a k e m o r e t h a n i n t e n d e d ?"
" H a v e y o u e v e r e x p e r i e n c e d w i t h d r a w a l s y m p t o m s ?"
" D o y o u
" H a s y o u r u s e o f ____ m a d e y o u g i v e u p i m p o r t a n t o b l i g a t i o n s ?"
" H a s t h e u s e c a u s e d a n y p h y s i c a l o r m e n t a l h e a l t h p r o b l e m s ?"
" H a v e y o u c o n t i n u e d t o u s e , e v e n t h o u g h y o u k n e w y o u h a d p r o b l e m s ?"

Eating disorders

In an eating disorder, the patient uses the control of food to cope with feelings and/or other situations. They generally involve
eating too little or too much, purging behaviours, or worrying excessively about body weight or shape.
The most common eating disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. Patients may self-
present with concerns about an eating disorder or present as a result of concerns from family and friends.
" C a n y o u d e s c r i b e a t y p i c a l d a y' s f o o d i n t a k e ?"
" A r e y o u o n a d i e t a t t h e m o m e n t ?"
" W h a t h a s y o u r w e i g h t b e e n l i k e i n t h e p a s t ?"
" H o w o f t e n d o y o u w e i g h y o u r s e l f ?"
" H o w d o y o u f e e l a b o u t y o u r b o d y ?"
" W h a t d o o t h e r p e o p l e s a y a b o u t y o u r b o d y ?"
These questions will build a picture of the patient's weight history, beliefs around eating and eating behaviours.
After this, it is important to ask about any adaptive behaviours. These adaptive behaviours can include exercise (what sort of
exercise, and how much?), purging behaviours (vomiting, medication use, and insulin abuse if diabetic), and binge eating (what
do they eat in a binge, are there any triggers and how do they feel after?).
Physical signs and symptoms are extremely important to explore in eating disorders, as these disorders can cause signi
disturbances to normal homeostatic function, and patients may require admission to the hospital to manage these\:
Amenorrhoea
Fatigue
Constipation
Dizziness
Haematemesis (due to oesophageal tears)
Seizures

Ideas, concerns and expectations

A key component of history taking involves exploring a patient's ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
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The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Past psychiatric history

After exploring the patient's presenting complaint, you should explore other areas of the history. A past psychiatric history is
extremely important, as it may help with reaching a diagnosis.
Ask the patient about their past psychiatric history\:
" H a v e y o u e v e r e x p e r i e n c e d s y m p t o m s l i k e t h i s b e f o r e ?"
" H a v e y o u e v e r h a d a n y p r o b l e m s w i t h y o u r m e n t a l h e a l t h b e f o r e ?"
" H a v e y o u e v e r b e e n d i a g n o s e d w i t h a m e n t a l h e a l t h p r o b l e m ?"
" H a v e y o u e v e r h a d a n y t r e a t m e n t f o r y o u r m e n t a l h e a l t h b e f o r e ?"
" H a v e y o u e v e r h a d a n y c o n t a c t w i t h m e n t a l h e a l t h s e r v i c e s b e f o r e ?"
" H a v e y o u e v e r b e e n a d m i t t e d t o h o s p i t a l d u e t o y o u r m e n t a l h e a l t h b e f o r e ?"
Any relevant past psychiatric history from these questions should then be explored in more detail.

Existing psychiatric diagnosis

If a patient has an existing psychiatric diagnosis, it is important to
The current presentation could be a relapse of an existing condition, or it may lead to a change in diagnosis. For example, a
patient presenting with low mood may receive a diagnosis of bipolar disorder if they have previously experienced
mania/hypomania.

Previous treatments

You should explore any previous treatments the patient may have received, particularly in those with complex histories.
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The e
experiences. If they have been treated for mental health problems before, it is also worth asking if they have received
electroconvulsive therapy (ECT) in the past - as this may signify that they are relatively resistant to treatment.

Past contact with mental health services

For previous contact with mental health services, you should explore whether this has been through primary care, the
community mental health team, or the crisis team/home treatment team.
Some areas may also have speci
determine if the patient is under the care of a mental health team and who they see. For example, if they have a community
psychiatric nurse or care coordinator, these professionals should be able to provide more background information.
If they have previously been admitted to the hospital due to their mental health, then you should clarify\:
The number of admissions
The dates (if known, otherwise the rough length of stay)
If they were informal admissions or under a section of the mental health act
If they have ever been admitted to a psychiatric intensive care unit (PICU).

Forensic history

A forensic history helps to formulate a risk assessment and may give clues to help with diagnosis.
" H a v e y o u e v e r h a d a n y c o n t a c t w i t h t h e p o l i c e ?"
" I f y e s , w h a t h a p p e n e d ? W e r e y o u c h a r ge d ?"
" H a v e y o u s p e n t a n y t i m e i n p r i s o n ?"
Document all past and pending charges. Episodes of violent or aggressive behaviour may be associated with previous
episodes of mental illness, but even if not, it will still impact your risk assessment and management.
It is also useful to
easier to

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
" H a v e y o u e v e r h a d a n y o p e r a t i o n s ?"
The past medical history will generally be the same as in any patient history. There can be signi
and physical health, and it is always important to exclude physical causes for the patient's symptoms. For example,
hypothyroidism may present as low mood, or encephalitis can present as psychosis.
Some medical conditions are also risk factors for mental health disorders, such as chronic illness (e.g. chronic pain or cancer), a
major risk factor for depression.
Additionally, some medical conditions will a
are often contraindications for psychiatric medication.
A new psychiatric diagnosis may also mean a patient's physical health needs to be managed di
with bipolar disorder who has co-existing asthma or in
avoid or reduce the use of steroids.
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Drug history

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Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication
name, dose, frequency, form and route.
Ask speci
Ask about recent medication changes, as dose changes may precipitate new issues. For example, an anti-psychotic
medication dose reduction may trigger a relapse of symptoms, or the metabolism of medication may be aenzyme
inhibitors and inducers.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
Commonly prescribed psychiatric medications
Anti-depressants
Selective serotonin reuptake inhibitors (SSRIs)\: sertraline, citalopram, escitalopram,
Serotonin-noradrenaline reuptake inhibitors (SNRIs)\: venlafaxine, duloxetine
Mirtazapine
Tricyclic antidepressants (TCAs)\: amitryptiline, nortriptyline
Mood stabilisers
Lithium
Sodium valproate
Carbamazepine
First-generation (typical) antipsychotics
Chlorpromazine
Flupentixol
Haloperidol
Levomepromazine
Zuclopenthixol
Second-generation (atypical) antipsychotics
Amisulpride
Aripiprazole
Clozapine
Olanzapine
Quetiapine

Family history

Ask the patient if there is any family history of psychiatric or physical disease\:
“ H a v e a n y o f y o u r p a r e n t s o r s i b l i n g s h a d p r o b l e m s w i t h t h e i r m e n t a l h e a l t h i n t h e p a s t ?”
“ D o y o u k n o w w h a t t y p e o f m e n t a l h e a l t h p r o b l e m s t h e y h a d ?”
" D o a n y m e d i c a l p r o b l e m s r u n i n t h e f a m i l y ?"
For physical health problems, it is important to ask about diabetes, cardiovascular conditions, or any genetic conditions.
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Personal history

In the personal history, you are aiming to get an understanding of the patient's life experiences and the impact they may have
had on them. It may be easiest to structure this chronologically, starting in childhood and moving on to education and
employment.

Childhood

Ask the patient about their childhood\:
" D o y o u k n o w i f t h e r e w e r e a n y p r o b l e m s d u r i n g y o u r m o t h e r' s p r e gn a n c y w i t h y o u ?"
" A r e y o u a w a r e o f a n y p r o b l e m s a r o u n d y o u r b i r t h ?"
" A s f a r a s y o u k n o w , d i d y o u m e e t t h e n o r m a l m i l e s t o n e s g r o w i n g u p ?"
" H o w w o u l d y o u d e s c r i b e y o u r c h i l d h o o d ?"
The environment someone grows up in signi
in particular, is associated with most psychiatric disorders.
If they report di
discuss.

School and education

Ask about schooling and education\:
" D i d y o u e n j o y s c h o o l ?"
" D i d y o u h a v e a l o t o f f r i e n d s a t s c h o o l ?"
" D i d y o u h a v e a n y p r o b l e m s w i t h b u l l i e s a t s c h o o l ?"
" A t w h a t a g e d i d y o u l e a v e s c h o o l ?"
" W h a t q u a l i
Explore whether they enjoyed primary and secondary school. If they didn't, was it because of di
something else in the school environment, such as relationships with teachers or bullying.
If the patient attended college and university, you should also ask about that experience and what they studied. How they
coped at university can be very informative, as it may be the
managing things like

Occupation

Ask the patient about their occupation and employment history\:
" A r e y o u e m p l o y e d a t t h e m o m e n t ?"
" H o w l o n g h a v e y o u b e e n a t y o u r c u r r e n t j o b s ?"
" W h a t j o b s h a v e y o u h a d i n t h e p a s t ?"
" W h y d i d y o u l e a v e y o u r p r e v i o u s j o b s ?"
" H a v e y o u e v e r b e e n d i s m i s s e d f r o m a p r e v i o u s j o b ?"
An employment history can give a surprising amount of relevant information in the psychiatric history.
If a patient is currently employed, how they cope at work gives a good indication of their current level of function. For example,
mania is more likely to impact a person's work than hypomania.
If a patient has had multiple short-term episodes of employment or has been unable to maintain any period of employment, it
suggests a signi

Relationships

Try to establish the patient's current and previous interpersonal relationships, and make sure to ask about relationships with
family and friends and those of a romantic nature\:
" H o w d o y o u g e t o n w i t h y o u r f a m i l y ?"
" D o y o u
" D o y o u f e e l l i k e y o u h a v e a g o o d s o c i a l s u p p o r t s y s t e m ?"
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" A r e y o u i n a r o m a n t i c r e l a t i o n s h i p a t t h e m o m e n t ?"
" W h a t h a v e y o u r p r e v i o u s r o m a n t i c r e l a t i o n s h i p s b e e n l i k e ?"
" H a v e y o u r c u r r e n t p r o b l e m s a
When asking about family, you should establish who is in their immediate family, their childhood circumstances, and how they
would describe their relationship with their family, both in the past and now. It is also worth asking about any recent signi
events in the family, as this may have triggered the patient's presentation.
The patient's relationship history can give clues to a diagnosis, and their current relationships will be relevant to their ongoing
management (for example, having a supportive partner tends to contribute to better outcomes). A longstanding pattern of
multiple turbulent relationships may suggest borderline personality disorder, or a pattern of gradual social withdrawal may
suggest an illness like schizophrenia.
Although it can be challenging to ask about and discuss, it is also important to screen for any experience of sexual abuse at
some point during a psychiatric assessment. However, particularly sensitive discussions may be better left until a later stage
when rapport has been established unless it is signi

Pre-morbid personality

Asking about pre-morbid personality helps understand how the patient's personality and behaviour patterns have changed
over time - from asking the patient directly and from a collateral history. It's an extremely important part of a psychiatric history
and should not be overlooked, as it will signi
" H o w w o u l d y o u d e s c r i b e y o u r s e l f ?"
" H o w w o u l d o t h e r s d e s c r i b e y o u ?"
" D o y o u t h i n k t h i s w o u l d h a v e c h a n ge d a t a l l r e c e n t l y ?"
" D o y o u h a v e a n y h o b b i e s o r i n t e r e s t s ?"
" A r e y o u r e l i g i o u s ?"
After some initial open questions asking the patient to describe themselves, you should conduct a structured enquiry about
di
Emotional traits\: would they describe themselves as happy or sad? Do they experience mood swings? How do they manage
anger?
Cognitive traits\: how is their self-esteem? Are they a con
Are they naturally suspicious of others? How do they cope with decision-making?
Behavioural traits\: would they describe themselves as an introvert or extrovert? Would they say they are impulsive? Do they
enjoy socialising?

Social history

The social history is arguably one of the most important parts of a psychiatric history, as social circumstances are often
signi

Living circumstances

You should ask about the patient's current living circumstances\:
" W h e r e d o y o u l i v e c u r r e n t l y ?"
" D o y o u l i v e w i t h a n y o n e e l s e ?"
" A r e t h e r e a n y c h i l d r e n a t h o m e ?"
Homelessness
If a patient discloses that they are currently homeless, you should
homeless (e.g. a problem with
sleeping on the streets?
45% of homeless people in England have been diagnosed with a mental health condition, and there is a much higher
2
prevalence of mental health problems in the homeless population compared to the rest of the population .
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Homelessness can both be caused by and cause mental health problems, so it is essential to include accommodation in
your assessment and management plan.
You also need to ask about any children at home to ensure they are still being cared for and in case any safeguarding issues
arise from the assessment.

Activities of daily living

Asking about how a patient is managing their activities of daily living helps to assess the impact of an illness and will a
types of treatment o
" H o w a r e y o u c o p i n g a t h o m e a t t h e m o m e n t ?"
" D o y o u f e e l a b l e t o l o o k a f t e r y o u r s e l f ?"
" D o y o u h a v e a n y w o r r i e s a t t h e m o m e n t ?"
If not already covered elsewhere in the history, you should ask about diet and what they are eating now, whether they are
managing to maintain personal hygiene, or having di

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history-taking guide for more information.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use

Insight

Insight refers to the ability of a patient to understand that they have a mental health problem and that what they’re
experiencing is abnormal. Patients with severe depression may demonstrate a loss of insight into their illness.
Some examples of questions which can be used to assess insight include\:
“ W h a t d o y o u t h i n k t h e c a u s e o f t h e p r o b l e m i s ?”
“ D o y o u t h i n k y o u h a v e a p r o b l e m a t t h e m o m e n t ?”
“ D o y o u f e e l y o u n e e d h e l p w i t h y o u r p r o b l e m ?”

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Mohammed Abbas
Consultant Psychiatrist
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References

1. Mind. Mental Health Facts and Statistics. Published 2017. Available from\: [LINK]
2. Mental Health Foundation. Homelessness\: statistics. Published 2016. Available from\: [LINK]
3. Gulati G, Lynall M, Saunders K. Psychiatry Lecture Notes. 11th Ed. Wiley Blackwell. Published 2014.
Source\: geekymedics.com
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