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©Department of Psychiatric Nursing, Mar Baselios College of Nursing, Kothamangalam |

Format No: Psy/1

MAR BASELIOS COLLEGE OF NURSING, KOTHAMANGALAMDEPARTMENT OF PSYCHIATRIC/ MENTAL HEALTH NURSING

Scheme for Taking Psychiatric History

Format overview:1. Socio demographic data2. Informant3. Presenting chief complaints4. History of present illness

Negative history5. Past psychiatric/ Medical illness

Life chart*6. Family h/o Psychiatric/ Medical illness

Genogram**7. Personal history8. Pre-morbid personality9. Summary

*Life chart is mandatory if the course of illness is episodic or if the present admission is after anotherepisode of mental illness**Genogram should be drawn with three retrospective generation starting from the patient including bothparents’ side.

1. Socio demographic data• Name:• Father's / spouse name:• Address:• Age:• Sex:• Languages known:• Can speak Can write Can read• Mother tongue:• Other languages:• Marital status:• Education:• Occupation:• Income (annual): Self - Family -• Religion:• Reasons for consultation/admission:• Source of referral and reasons for referral

2. Informant• Name/ Relationship/ Acquaintance/ Adequacy of information/ Reliability of the information

provided

3. Presenting chief complaints• Record the complaints in a chronological order. Do not write a long list of complaints (4-6

Nos.).

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©Department of Psychiatric Nursing, Mar Baselios College of Nursing, Kothamangalam |

• Present the salient disturbances in the different areas of functioning, while some patients/relatives may present an elaborate list of their complaints, others might not spontaneously reporttheir difficulties unless more direct questions are posed.

4. History of present illness• Give a detailed and coherent account of the symptoms from the onset to the time of consultation

including their chronological evolution of and course. Specific attention must be paid to thefollowing;

• Onset: Abrupt (<48 hrs), Acute (within few hours to 2wks), Sub acute (Few Wks) orInsidious (few weeks - months).

• Precipitating factors: This could be physical (febrile illness) or psychological in nature(death/ loss). Ascertain whether the events clearly proceeded the illness or wereconsequences of the illness (Job loss following the onset of schizophrenia)

• Course: Continuous or fluctuating/ Episodic (discrete symptomatic episodes withintervals of normalcy) /Unclear (Fluctuating /Deteriorating /Improving).

• Associated disturbances: impairment in other areas of functioning; these includedisturbances in sleep, appetite, weight changes, sexual life, social life, & occupation. Thespecific nature of disturbances & the degree of impairment should be recorded.

• Negative history: Organic etiology (History of trauma, fever, headache, vomiting,confusion, memory disturbances) Substance misuse & Pervasive mood changes etc.

5. Past psychiatric/ Medical illness• Life chartPrecipitating causes if any………………………….. Interval period……………………---------------------------------------Line of Normalcy---------------------------------------------Symptoms of each episodes (duration)……….....Symptoms of each episodes (duration)

• Treatment history: adequacy (Medication, dosage & duration), compliance (presence ofside effects & regular follow ups), resistant to treatments?

6. Family h/o Psychiatric/ Medical illness• Genogram : Draw the tree for three generations on both sides in cases of genetic importance• Type of family : (Nuclear / Joint / Others)• SES : (Upper / Middle / Lower)Leadership pattern:• Role functions :• Communication within the family and others:• Child rearing practices:• Interpersonal relationships:• Social position :• Social support system:• History of illness in family:• Psychiatric: similar illness, other illness, other major behavioral problems like delinquency,

personality problems, suicide, and substance use, epilepsy, mental retardation.• Medical: (Especially hereditary)

7. Personal history• Birth & early development: Record the details of prenatal, natal & post natal periods. Was that

full term delivery? Whether delivered in the hospital or at home? Any complications duringdelivery? Any physical illnesses in the postnatal period? Ascertain whether milestones ofdevelopment were normal or delayed?

• Behavior during childhood: Normal/ Abnormal/ Trauma/ Fever/ Convulsions/ Any other illness.o Behavioral and emotional problems: (Nail biting, thumb sucking, sleep disturbances, tics,

mannerisms, Enuresis, Sleep walking, Temper tantrums, stammering. Look for conductdisturbances like frequent fights, truancy, stealing, gang activities and relationship withparents, siblings and peers)

o Home atmosphere during childhood: Satisfactory / Unsatisfactoryo Parental lack: Yes / No (Dead/ separated for more than one year/ habitually absent from

home)

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©Department of Psychiatric Nursing, Mar Baselios College of Nursing, Kothamangalam |

o Anomalous family situation: Yes / No (Step parent, adoption status)• Physical illness during childhood: Record physical illness suffered during childhood. Enquire

specially regarding epilepsy, meningitis, and encephalitis.• School: Age of beginning/ Age of finishing, Relationship with teachers, Relationship with

schoolmates, Position in class: (Top / Middle / Low), Special abilities (if any), Activeparticipation in games/other extracurricular activities.

• Occupation: Work record: Satisfactory / Unsatisfactory/ Frequent changes of jobs? Age at thetime of starting to work/ Jobs held in the past (in chronological order, reasons for change),Present job with duration: Satisfied with work? (Reasons for dissatisfaction)

• Sexual & Marital history; Information about sex: (How acquired, of what kind, how received,adequacy of knowledge, attitude towards opposite sex),

• Masturbation: Age of starting: Frequency: (Guilt/ attitude if any), Sexual experience:(Homo/ Hetero/ Pre and extra marital / preferences)

• Any complaints including Dhat syndrome.• Menstrual history: (Age at menarche / how regarded / regularity / duration / cycle / amount /

physical / emotional problems)/ Menopause: (Age / climacteric symptoms)• Use of substances (if present): Eating fads / patterns, Sleeping patterns, Excretory functions,

Alcohol consumption, Tobacco consumption, Self-medication with drugs

8. Pre-morbid personalityIn this description, the personality prior to the beginning of the mental illness which should beillustrated with anecdotes and detailed statements. Aim at a picture of the individual, not a type.

• Social relations: The family (attachment, dependence), to friends, groups, societies, clubs, to workand workmates (leader or follower, organizer, aggressive, submissiveness, ambitious, adjustable,independent

• Intellectual activities: Hobbies & interests, books, plays, pictures, memory observations, criticalfaculty

• Mood: Bright & cheerful or despondent. Worrying or placid, stung or calm or relaxed. Optimistic orpessimistic. Self depreciative or satisfied. Mood stable or unstable

• Character• Attitude to work & responsibility: welcomes or worried by responsibility. Makes decisions easily or

with difficulty. Haphazard & slapdash or methodological and meticulous. Right or flexible, cautious,foresightful/ impulsive & slipshod, preserving & determined or easily bored & discouraged.

• Interpersonal relationships: self confident/shy and timid. Insensitive/ touchy and sensitive tocriticism. Trusting /suspicious and jealous. Emotionally controlled/quick tempered and irritable.Tactful /outspoken. Tolerant /intolerant. Adaptive / rigid.

• Energy & imitativeness: Lethargic or sluggish. Irregular fluctuations in output and energy levels.• Fantasy life: Frequency & content of day dreaming• Habits

9. Summary