Dr.

Zebunnisa Sohail (IHO) 2013

History taken in a
psychiatric case is
an amalgamation
of the patients and
the informants
version.
Demographics
Use SOCRATES as applicable.
Depending on the presenting complaint, ask for associated
symptoms of:-
- psychosis (hallucinations Auditory/visual, thought disturbance
insertion, withdrawal, broadcast, suicidality)
- depression (guilty, worthless or hopeless? ever self harm? other physical
Sx? appetite reduced, any weight loss, lack of motivation, sleep effected?)
- anxiety (general anxiety, panic attacks, phobias)
Have these symptoms caused you any problems at work or at
home?
Predisposing factors? Potential triggers? Maintaining factors?
Presenting complaint & History of presenting complaint
Past History (M,S,P)
Medical and surgical history
-History of head trauma, seizures, meningitis?

Past psychiatric illness
Use/abuse of drugs (type, age, Rx)
Alcohol consumption (type, amount, CAGE)
Personal and Family History
Development (childhood, school)
Education
Occupational history
Sexual history, and personal relationships
Pre-morbid personality (according to the patient, and
family/friend/guardian)

Family history Illness, SES, supportive? Genogram.
Non verbal communication
General appearance
Degree of cooperation
Level of consciousness
Speech - (tone, rate, articulation,
volume). E.g. augmented qualities
could indicate mania or aggressive
behavior. Whereas reduced
qualities could indicate impaired
consciousness, depression, social
withdrawal.
Thought
a. Form the way the patient speaks to us.
i. Normal. (e.g. I'm hungry->its too early for dinner->Ill have a snack
instead.
ii. Flight of ideas rapid flow with logical connection between thoughts,
but deviating from the main point. (e.g. Im hungry->Hungarys a place
in Europe->Ill go on holiday soon.)
iii. Loosening of associations loss of logical connections between
thoughts. (e.g. Im hungry->whats on TV?->Its getting dark.)
iv. Thought block (e.g. Im hungry->its too early for lunch.)
b. Content what they're telling us.
i. Phobias
ii. Obsessions
iii. Compulsions
iv. Delusions persecutory, reference, grandiose.
Cognition
Orientation (name, place, time)
Memory
Concentration and attention
Mood - patients subjective emotional state. E.g. anxious,
elated, depressed, irritable, angry.
Affect - how the patient expresses his/her mood. E.g
reactive, restricted, blunt, flat.
Insight patients awareness of his own mental state. (stages
pre-contemplation, contemplation, preparation, action &
maintenance)
Judgment patients response to a given situation.

Assess risk factors for suicide.
Male sex
Age > 45 years
Unemployed
Divorced, widowed or single
Physical illness
Psychiatric illness
Substance misuse
Previous suicide attempts
Family history of depression, substance misuse or suicide
Perception
Hallucinations auditory, visual, tactile, olfactory.
Illusions

Axis
I Major mental illness
II Personality disorders and developmental disorder (e.g.
intellectual disorder)
III Medical illness
IV Psychosocial stressors (divorce, job loss, death..)
V Global Assessment of functioning (0-100)
Code Description of Functioning
91 -
100
Person has no problems OR has superior functioning in several areas OR
is admired and sought after by others due to positive qualities
81 - 90 Person has few or no symptoms. Good functioning in several areas. No
more than "everyday" problems or concerns.
71 - 80 Person has symptoms/problems, but they are temporary, expectable
reactions to stressors. There is no more than slight impairment in any
area of psychological functioning.
61 - 70 Mild symptoms in one area OR difficulty in one of the following: social,
occupational, or school functioning. BUT, the person is generally
functioning pretty well and has some meaningful interpersonal
relationships.
51 - 60 Moderate symptoms OR moderate difficulty in one of the following: social,
occupational, or school functioning.
41 - 50 Serious symptoms OR serious impairment in one of the following: social,
occupational, or school functioning.
31 - 40 Some impairment in reality testing OR impairment in speech and
communication OR serious impairment in several of the following:
occupational or school functioning, interpersonal relationships, judgment,
thinking, or mood.
21 - 30 Presence of hallucinations or delusions which influence behavior OR
serious impairment in ability to communicate with others OR serious
impairment in judgment OR inability to function in almost all areas.
11 - 20 There is some danger of harm to self or others OR occasional failure to
maintain personal hygiene OR the person is virtually unable to
communicate with others due to being incoherent or mute.
1 - 10 Persistent danger of harming self or others OR persistent inability to
maintain personal hygiene OR person has made a serious attempt at
suicide.

References
1. Elsevier Psychiatry an illustrated text.
2. Step up 2 ck guide
3. http://depts.washington.edu/washinst/Resources/CGAS/GAF%20
Index.htm
4. Peanuts comic strip 1959
Thank you