How to take psychiatric history of patients or client?

To take psychiatric history and mental state examination (MMSE) are key clinical skills.  The purpose of this article is make-able to take psychiatry history of their clients.

Taking history of psychiatric is just like you take any clinical history. But, the difference is social and developmental history while you taking psychiatric history. You must cover these areas that are mentioned below:

1.  presenting complaint/history of presenting complaint

2.  Past psychiatric history

3.  Past medical history

4.  Medication

5.  Family history

6.  Family psychiatric history

7.  Personal history (birth & early life, school & qualifications, higher/further, education, employment, psychosexual history, forensic history, substance)

8.  Premorbid personality

            Remember it that This is not always appropriate to ask all of the questions all of the time. it may better to leave gaps for next session, especially if your client is particularly suspicious and paranoid, or in distressed.

            Must Start from open questions but keep focus on necessary questions. It gives the patient a chance to talk about their experiences and this will good to report buildings.

Psychiatric History

presenting complaint/history of presenting complaint

            Ask to patient/client describe problems using questions e.g., what’s brought you here in hospital. Presenting complaints should be in verbatim form. For example, any individual with anxiety seeks help only when he/she begins suffer from having panic attacks so, in this case, panic attacks are the presenting problem. Sleep low or decrees, appetite issues etc.

Past psychiatric history

            In this history you can ask to client or patient about his psychiatric history like onset of this disease. medication if he/she is using, using of medication as inpatient or outpatient. Even therapies as well for example; group therapy couple, individual session all you can ask with dates. Ask he/she to medicine response and compliance and dosage also.       

Past medical history

            In medical history you can ask client or patient about his medical history like onset of this medical disease. About disease like, Blood Presser, Sugar, HIV, Hepatitis B or C, TB etc.     

Medication

            Ask if he/she is using medication for any disease. If he/she is using medicine then how means that inpatient or outpatient. Dosage of medicine and how long duration of medicine he/she is using. 

Family history

            In psychiatric history family history is also important. From it you can know about the Heritable illness (its illness is inherent by his/her family. Current family health status Psychosocial disorders Interactional and relationship data.

Family psychiatric history

            While taking psychiatric history family psychiatry history is also have importance. So, you may ask about the family psychiatry history from them. As you know Environmental, loneliness, stresses and life event, can cause mental illness. Family history of mental illness has great chance of developing mental illness in these situations. Mind it that it’s not means that will definitely develop a mental illness.

Personal Psychiatric History

Personal history

In personal history start from

Birth: Birth is normal or by operate color at time of birth weep or not.

Early life: That how it was in struggle/abusive or good.

Schooling/higher education: Schooling was good, average, below average and environment of school any specific event in school and after schooling education ask about college life if he/she has and special events and relationship with teachers and friends.

Employment: If he/she is working then ask about work experience, stress of job, job satisfaction, relationship with the people and if any point out his/her a particular behavior.    

Psychosexual history: Psychosexual history is also important to know because it may also cause mantel stress that leads to mantel illnesses. You can ask his/her about psychosexual history that if he/she has been involved in sexual relationship in any stage of life and its impact on his/her life.

Forensic History: In this history ask about any crime in which he/she involved. If yes then why he/she done this crime and has he/she been caught by police or law enforcement department.

Substance Abuse: has she/she ever involved in using substance. If yes then type of substance, time duration and quantity of it because this will help you.    

Important Part of History

Premorbid personality

Premorbid personality in psychological history are traits which exists in any individuals prior to illness or injury. These are the evidence that lifelong traits persist even after traumatic experience or brain injuries.

In premorbid personality psychologist ask to client about his/her pre disease history like,

Mood: mood was happy or not.  

Social Relationship: how’s relationship with other people and family members.

Moral Values: how’s believe in moral values like, offer prayers, kind person, gratitude etc.

Smoking: smoking history if any quantity, and duration of smoking.

Attitude: ask about behavior towards the people, person and events.

Stress Reaction: psychologist should ask about stress reaction in particular situation like, silent, abusive, weeping and aggressive (verbal and physical).   

Hobbies: ask about hobbies because, it will help you during treatment.

Abnormal Traits: any abnormal traits ask them.

Others: at the end ask any other specific event things which you want to know about your clients.

Here is history taking Performa in pdf link is below