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Psychiatric History

This document outlines the areas to cover when taking a psychiatric history. It includes sections to document the presenting complaint, history of the presenting complaint, past psychiatric history, past and current medical history, family history, personal history, social history, substance use history, forensic history, and premorbid personality. The goal is to gather a comprehensive history on the patient's mental health, medical issues, social support systems, substance use, legal issues, and personality before any deterioration occurred.

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Thomas
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81 views

Psychiatric History

This document outlines the areas to cover when taking a psychiatric history. It includes sections to document the presenting complaint, history of the presenting complaint, past psychiatric history, past and current medical history, family history, personal history, social history, substance use history, forensic history, and premorbid personality. The goal is to gather a comprehensive history on the patient's mental health, medical issues, social support systems, substance use, legal issues, and personality before any deterioration occurred.

Uploaded by

Thomas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Psychiatric History

Presenting Complaint
▪ Admission – hospital / ambulance? Outpatient clinic? GP? A&E? Other?
▪ Multiple complaints?

History of Presenting Complaint


❖ Duration (when did the problem start?)
❖ Development (how did the problem start?)
❖ Mode of onset (sudden or gradual)
❖ Course (constantly present, intermittent, progressively worsening)
❖ Severity (to what extent is the problem affecting the patient’s functioning?)
❖ Associated symptoms (suicidal ideation, illicit substances)
Precipitating factors – stressors, bereavement, employment, relationships

• Previous episodes
• Features of:
o Depression
o Psychotic symptoms – delusions, perceptual disturb, thought alienation,
o Anxiety disorder – chest tight, hyperventilation, tingling sensation
= generalised vs situation specific

Past Psychiatric History


• Known to mental health services – when? • Insight / aware of diagnosis?
• Community MH service involvement? • Care coordinator or social worker?
• Previous hosp admissions – when, where, how long? Voluntary or detained (MH act)?
➢ Previous medications / treatments / counselling – successful? Side effects?
➢ Self-harm hx – when, how, why?
➢ Previous suicide attempts – impulsive? Planned? Circumstances?

Past Medical History

• Medical conditions – cardiac, diabetes, stroke, epilepsy, renal, liver, endocrine?


• Major head trauma? Acquired brain injury → personality changes?
• Major surgery?

Current Medication
 Name, dose, route, frequency
 Drug allergies – what happens?  Psychotropic specific?
 OTC – St Johns Wort?
Family History
• Mental health disorder? • Alcoholism or illicit substance? • Suicide?
• Diabetes, MI, CVD?
• Parent’s still alive – relationship? • Siblings – relationship?

Personal History
❖ Mother’s pregnancy → modern day
○ Premature? Traumatic birth?
○ Developmental delay – walk / talk? Childhood illnesses?
○ Aggressive child? Abuse – physical, emotional, sexual, neglect?
○ Schooling – mainstream, bullying, friendships, truancy, expulsion qualifications / age left?
○ College or uni?
○ Employment history – fired?
○ Relationships – past & current? Abusive?
○ Children – age, relationship, in care, social services, in contact?

Social History

• Accommodation – flat, house, owned, rent, council? • Lives alone?


• Social support – friends, family, carers? • Employed? • On benefits or incurred debts?

Substance Use History


➢ Smoking history
➢ Alcohol consumption – age started, harmful use, preferred drink, intake change
➢ Illicit substances – what, how, duration?
o Motivation – self-medication, anxiety, boredom, peer/partner pressure, trauma?
o Dependency? Under drug/alcohol services? AA or NA?
o Substitution program (methadone or buprenorphine)?

Forensic History
 Previous Convictions – violence, sexual, weaponry?  Age when committed?
 Prison sentence – length?  Probation service – length?  Court appearances – when?

Premorbid Personality
❖ Before deterioration
❖ What do others / family / carers say about them?
❖ Insight – how do they view their personality change or impact?

** summarise – chunk and check – thank patient **

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