Psychiatric History-Taking
Presenting Complaint
Low Mood
SADAFACES
Poor Sleep
Anhedonia
Lack of enjoyment of previously enjoyed activities
Dysthymia
Low mood
Poor Appetite
Fatigue
Agitation
Poor Concentration
Poor Self Esteem
Suicidality
High Mood
FIDGET
Flight of ideas
Insomnia
Distractibility
Grandiosity
Grandiosity
Energy
Talkativeness
Suicidality
SADPERSONS
Sex
Age
Depression
Past attempts
Excessive alcohol / substances
Rational thinking loss
Social supports
Organised plan
No support
Sickness
Self-Harm
Triggers, type of self-harm, severity of harm
Delusions
Fixed false beliefs held involuntarily
Hallucinations
Incorrect sensory experience
Thought Disorders
Derailment, tangientiality, neologisms
Negative Symptoms of Psychosis
Amotivation, social withdrawal, blunt affect
Catatonia
Involuntary psychomotor abnormalities
Medical Complaint
As interpreted by the patient e.g. pain
Past Psychiatric History
Psychiatric Illness
Diagnosis, symptoms, severity, management
Mood Disorders
Depression, bipolar affective disorder
Anxiety Disorders
GAD, PTSD, OCD, phobias, panic disorder
Eating Disorders
Anorexia nervosa, bulimia nervosa, pica
Psychotic Disorders
Schizophrenia, drug-induced psychosis
Personality Disorders
Autism
Intellectual Disability
Psychiatric Drugs
Which drugs, who prescribes them, effect
Admissions
When, why, length of stay, treatment received
Impact
On work and relationships
Forensic History
Aggressive behaviour
Circumstances, context, injury sustained
Criminal Charges / Convictions
Probation, jail time, fines
Past Medical History
Systems Review
Medical issues may mimic psych problems
Past Medical Issues
Especially chronic disease
Medications
Psychiatric Medications
Click for a summary of important drugs
Medications
May affect mood / limit psychiatric treatment
Family History
Mental Illness
Psychiatric treatment, self-harm, suicide
Deceased Family Members
Circumstances, patient's response, effect
Substance History
Have an index of suspicion; find out longitudinal and specific information with details and examples
Substances Used
Alcohol, marijuana, amphetamine, opioids, others
Amount Consumed
Period & pattern of abuse
Tolerance
Amount needed to reach the desired effect
Withdrawal Symptoms
What symptoms, severity
Attempts to Cut Down
Level of success, length of abstinence
Salience of Abuse
Time spent obtaining, using or recovering from
Complications
Physical / psychological
Impact on Work / Relationships
Regrets, extreme situations
Developmental History
Pregnancy, Delivery
Known complications
Childhood
Milestones, neglect / abuse / trauma
Schooling
Where, what level reached
Separations / Losses
And their consequences
Social History
Relationships and Support
Family, friends
Coping Strategies
Response to stress and adversity
Work history
Current and past jobs
Marital / Relationship History
Current and past relationships
Current interests
Level of continued enjoyment
