How do you take a psychiatric history?

How to Take a Psychiatric History

A comprehensive psychiatric evaluation must include assessment of the patient's psychiatric symptoms, psychiatric history, substance use, medical history, family history, personal and social history, and mental status examination to ensure proper diagnosis and treatment planning.1

Initial Approach and Setting

• Conduct the interview in a comfortable, private setting large enough to accommodate all participants, with minimal distractions 1
• Begin by establishing rapport with the patient, addressing each person in a manner consistent with their developmental level 1
• Explain confidentiality limits at the outset, particularly when interviewing adolescents 1
• Consider interviewing patients and caregivers both together and separately to obtain more comprehensive information 1

Chief Complaint and History of Present Illness

• Document the reason for evaluation and presenting symptoms 1
• Establish a clear timeline of symptoms including:
  • Age at onset of symptoms 1
  • Predominant early symptoms (behavior, language, memory, mood) 1
  • Relationship to life events (interpersonal conflicts, psychosocial stressors) 1
  • Progression over time (insidious onset with progression vs. abrupt onset or fluctuating course) 1
• Assess current psychiatric symptoms including:
  • Anxiety symptoms and panic attacks 1
  • Sleep abnormalities 1
  • Impulsivity 1
  • Mood, level of anxiety, thought content and process, perception and cognition 1

Psychiatric History

• Document past and current psychiatric diagnoses 1
• Review history of psychiatric hospitalizations and emergency department visits 1
• Assess past psychiatric treatments (type, duration, and doses) 1
• Evaluate response to past psychiatric treatments 1
• Document adherence to past and current treatments 1
• Assess history of suicidal ideation, plans, and attempts, including details of each attempt (context, method, damage, potential lethality, intent) 1
• Document history of self-injury without suicidal intent 1
• Evaluate history of aggressive ideas or behaviors 1

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
• Evaluate for current or recent substance use disorders 1
• Note any recent changes in use of alcohol or other substances 1

Medical History

• Document allergies or drug sensitivities 1
• List all current and recent medications, including side effects 1
• Assess relationship with primary care provider 1
• Document past or current medical illnesses and related hospitalizations 1
• Review relevant past or current treatments (surgeries, procedures, complementary treatments) 1
• Assess for neurological or neurocognitive disorders or symptoms 1
• Document history of physical trauma, especially head injuries 1
• Review sexual and reproductive history 1
• Consider assessment of cardiopulmonary status, endocrine disease, infectious diseases, and pain conditions 1

Family History

• Document family psychiatric history, especially when relevant to patient's presentation 1
• Assess history of suicidal behaviors in biological relatives (particularly for patients with current suicidal ideas) 1
• Document history of violent behaviors in biological relatives (for patients with aggressive ideas) 1
• Consider using a demographic family history form to gather data on psychiatric disorders, family development, and family structure 1

Personal and Social History

• Assess psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
• Document trauma history 1
• Evaluate exposure to violence or aggressive behavior 1
• Document legal consequences of past aggressive behaviors 1
• Assess cultural factors related to the patient's social environment 1
• Determine need for interpreter services 1
• Consider assessment of personal/cultural beliefs and explanations of psychiatric illness 1

Mental Status Examination

• Document general appearance and nutritional status 1
• Assess coordination and gait 1
• Note any involuntary movements or abnormalities of motor tone 1
• Evaluate sight and hearing 1
• Assess speech, including fluency and articulation 1
• Document mood, level of anxiety, thought content and process, perception and cognition 1
• Assess for hopelessness 1
• Evaluate current suicidal ideas, plans, and attempts 1
• Consider assessment of height, weight, BMI, vital signs, and skin examination 1

Special Considerations

• For child/adolescent evaluations, observe parent-child interactions to assess family structure and problem-solving abilities 1
• When evaluating for possible medical causes of psychiatric symptoms, perform a focused medical assessment based on history and physical examination findings rather than routine testing 1
• For patients with suicidal ideation or after self-injury, consider implementing safety measures (personal searches, hospital attire, safe environment, close supervision) 1
• When screening for bipolar disorder, obtain detailed psychiatric history including family history of suicide, bipolar disorder, and depression 2

Documentation and Formulation

• Summarize observations and their relevance to the patient's problems 1
• Discuss the potential role family members may play in subsequent treatments 1
• Ensure all family members feel understood and convey hope for future adjustment when appropriate 1