What are the key points for a perfect history taking in psychiatry?

Key Points for Perfect Psychiatric History Taking

A comprehensive psychiatric history taking should include structured assessment of symptoms, mental status examination, psychosocial factors, and risk assessment, with emphasis on establishing rapport and understanding the patient in their biopsychosocial context.

Establishing Rapport and Setting

• Address each family member in an informal manner consistent with their developmental level 1
• Identify patient's strengths and resources at the outset to build rapport 1
• Create a comfortable environment for the interview with appropriate seating arrangements
• For younger patients, have games or activities available to facilitate rapport and decrease behavioral disruption 1
• Consider addressing the patient's occupation early in the consultation as a rapport-building technique 2

Comprehensive History Components

Current Presenting Complaint

• Define the problem by gathering relevant current and past history 1
• Document duration, severity, and impact of symptoms on functioning 3
• Explore how and when symptoms began and what the patient understands about possible causes 1
• Assess whether symptoms are constant or fluctuating, with exacerbating or relieving factors 1

Psychiatric History

• Document past and current psychiatric diagnoses 3
• Record prior psychiatric hospitalizations and emergency department visits 3
• Document response to past psychiatric treatments including adherence 1
• Note previous similar episodes and their management 3

Substance Use History

• Assess use of tobacco, alcohol, and other substances (marijuana, cocaine, heroin, hallucinogens) 1
• Document any misuse of prescribed or over-the-counter medications or supplements 1
• Note current or recent substance use disorder or change in use patterns 1

Medical History

• Document allergies or drug sensitivities 1
• List all current and recent medications (prescribed, non-prescribed, supplements) 1
• Record past or current medical illnesses and related hospitalizations 1
• Note relevant past or current treatments, including surgeries 1
• Document past or current neurological or neurocognitive disorders 1
• Assess physical trauma history, including head injuries 1
• Include sexual and reproductive history 1

Family History

• Assess family history of psychiatric disorders, especially when relevant to presenting symptoms 1
• Document history of suicidal behaviors in biological relatives (particularly important for patients with current suicidal ideas) 1
• Note history of violent behaviors in biological relatives (for patients with aggressive ideas) 1

Personal and Social History

• Document psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
• Assess trauma history and exposure to violence or aggressive behavior 1
• Note cultural factors related to the patient's social environment 1
• Evaluate personal/cultural beliefs and explanations of psychiatric illness 1
• Assess social support systems and resources 1

Mental Status Examination

• Observe general appearance and nutritional status 1
• Assess coordination, gait, and involuntary movements 1
• Evaluate speech patterns, including fluency and articulation 1
• Document mood (self-reported) and affect (observed) 3
• Assess level of anxiety and anxiety symptoms 3
• Evaluate thought content and thought process 1, 3
• Document perceptual disturbances (hallucinations, illusions) 3
• Assess cognitive function (orientation, memory, attention, concentration) 1, 3
• Screen for hopelessness 1
• Evaluate suicidal or homicidal ideation, plan, intent, access to means, and protective factors 1, 3

Risk Assessment

• Document current suicidal or homicidal ideation, plan, and intent 3
• Assess prior suicide attempts or self-harm behaviors 3
• Evaluate access to suicide methods, especially firearms 1
• Assess patient's intended course of action if current symptoms worsen 1
• Explore possible motivations for suicidal thoughts 1

Observational Elements

• Observe family interactions while gathering history 1
• Note antecedents and consequences of behavioral problems as they may be demonstrated during the session 1
• Use probing questions to understand how events have acquired specific meanings for each family member 1
• Document successful problem resolution strategies the patient/family has used 1

Special Considerations

• For family interviews, expect sessions to take 1-2 hours depending on clinical situation, number of family members, and ages of children 1
• Be prepared to manage acute issues that may arise during history-taking (e.g., suicidal ideation, intense disagreements) 1
• When interviewing children/adolescents, balance confidentiality with parental involvement appropriately 1
• For patients with cognitive or behavioral symptoms, obtain information from reliable informants regarding changes in cognition, activities of daily living, mood, and sensory/motor function 1
• Consider using validated assessment tools to supplement the clinical interview 1

Closing the Interview

• Summarize what you have observed and its relevance to the patient's problems 1
• Ensure all family members/patients feel they have been understood 1
• Convey a sense of hope regarding future adjustment when possible 1
• Discuss next steps in the assessment or treatment process

Common Pitfalls to Avoid

• Overlooking medical causes of psychiatric symptoms 3
• Relying solely on screening tools without clinical judgment 3
• Neglecting cultural factors in symptom presentation 3
• Making assumptions about capacity based on diagnosis alone 3
• Ordering unnecessary laboratory and imaging studies 3
• Probing injudiciously about trauma if history is not forthcoming 1

By following this structured approach to psychiatric history taking, you will be able to gather comprehensive information needed for accurate diagnosis and effective treatment planning while establishing a strong therapeutic alliance with your patients.