Psychiatric History

•is the record of the patient’s life that allows the

psychiatrist to understand who the patient is, where
the patient has come from, and where the patient is
likely to go in the future.
•to gather the concrete and factual data related to the
chronology of symptom formation, psychiatric and
medical history
•it provides insight to the nature of the relationships
with those closest to the patients and includes all the
important people in their past and present lives.
•the patient’s life is told tot he psychiatrist in the
patient’s own words from his or her own point of view.
 Identifying Data

Chief Complaint
• states why the patient has come or been brought in for
help, and should be recorded verbatim.
• If the patient is unable to speak, a person who is close to
him is being interviewed and a description of the person
who provided the information should be included
History of Present Illness
• provides comprehensive and chronological picture of the
events leading up to the current moment in the patient’s life
• helpful in making diagnosis
• knowing what the personality was of the previously well
patient also helps give perspective on the currently ill patient
• the more detailed the history of the present illness, the more
likely the clinician is to make an accurate diagnosis.
• If there is relation between physical and psychological
symptoms, it should be noted
 Previous Illness
• a transition between the story of the present illness and
patient’s personal history
• past episodes of both psychiatric and medical illnesses
are described
• psychiatrist should obtain a medical review of symptoms
and note any major medical or surgical illnesses and
major traumas
• causes, complications, and treatment of any illness and
the effect of illness on the patient should be noted
• questions about psychosomatic disorders should be asked
and noted
 Personal History:
Prenatal & Perinatal History
• Nature of the home situation
• Problems with pregnancy & delivery
• Mother’s physical & emotional state
• Evidence of defects or injuries
• Maternal health problems during pregnancy

Early Childhood (birth through 3 y.o.)

• Quality of mother-child interaction
• Early disturbances in sleep patterns & unmet needs
• History of human constancy
• Parental psychiatric or medical illness
• Play behavior
• Feeding habits, Toilet training
• Symptoms of behavior problems
• Personality as a child
• Early or recurrent dreams or fantasies
 Middle Childhood (3 to 11 y.o.)
• Gender identification
• Punishment, discipline, conscience formation
• Early school experiences, learning experiences, disabilities
• Earliest friendships & personal relationships
• Social behavior patterns
• Other significant behavior

Late Childhood (puberty through

•
adolescence)
Values of patient’s social groups
• Identify patient’s idealized figures
• Social relationships
• School history
• Cognitive & motor development
• Emotional & Physical Problems
• Sexuality
 Adulthood
• Occupational history
• Marital & Relationship history
• Military History
• Educational History
• Religion
• Social Activity
• Current Living Situation
• Legal History
Psychosexual History
• Infantile sexuality: curiosities & sexual games played (3 to 6 y.o.)
• Parental attitudes about sexual development
• Sexual abuse
• Adolescent sexuality
• Sexual activity
• Attitudes toward sex
• Sexual orientation
• Sexual functioning, symptoms, sexually-transmitted diseases
• Sexual adjustment
 Family History
• Psychiatric illnesses, hospitalizations, treatments of immediate family
• Family history of alcohol or substance abuse or of anti-social behavior
• Intelligence & personalities of people living at home
– Role in patient’s upbringing & current relationship with patient
• Family’s ethnic, national & religious traditions
• Family’s attitude & insight into the patient’s illness
• Role of illness in the family
• Patient’s attitudes toward parents & siblings
• Patient’s role in the family

Dreams, Fantasies, and Values

• Manifest details & attendant feelings
• Repetitive themes
• Possible meanings
• Nightmares
• Fantasies & daydreams
• Patient’s system of social & moral values
– Concerning work, money, play, children, parents, friends, sex, community
concerns, cultural issues