History Taking in Psychiatry – Part 1

Introduction

The purpose of history taking in psychiatry — sometimes called the Assessment Interview — is to gather factual information, elicit the signs and symptoms of the presenting disorder along with the patient's feelings and emotions, and, most importantly, to establish a rapport and therapeutic alliance with the patient. The therapeutic alliance refers to the collaborative working relationship between clinician and patient; it is one of the strongest predictors of treatment engagement and outcome across all psychiatric conditions.

The success of a psychiatric assessment interview depends on how well the doctor communicates with the patient, how readily the doctor can relax their own manner and thus help to relax the patient. Despite the time constraints of NHS practice, the skilled clinician makes the patient feel that they have all the time in the world and that the patient is the most important person in that moment.

Whereas certain specific question sets must be asked of almost every patient, the interview must not be followed in a rigid manner. Ultimately, a successful session leaves the patient feeling satisfied, with some hope for recovery and trust in their treating physician.

In medicine and especially in psychiatry, the quality of communication between patient and doctor is positively correlated with the accuracy of the diagnosis made, the patient's understanding of the information given, and adherence to the prescribed treatment. A patient's dissatisfaction with their consultation often results in a poor clinical outcome and, for some, prompts the start of litigation against the doctor. Essentially, a patient must always leave the consulting room feeling better than when they arrived.

This article is written primarily for medical students who are increasingly encouraged to interview as many patients as possible during their clinical years of training. It is good practice to observe accomplished physicians' style and to learn the art of eliciting key signs and symptoms — and, more importantly, how they respond verbally and non-verbally to patients' complaints, feelings, and expressed emotions during the interview.

How Psychiatric History Taking Differs from a Standard Medical Clerking

In most branches of medicine, history taking focuses primarily on biological symptoms — onset, duration, character, associated features, aggravating and relieving factors, and systemic review. In psychiatry, all of these remain important, but several additional dimensions are central:

• Life events and psychosocial context — psychiatric symptoms are often precipitated, perpetuated, or shaped by life circumstances. Understanding these is essential to both diagnosis and management.
• Developmental and personal history — childhood experiences, education, relationships, and occupational history provide crucial context for understanding a person's vulnerabilities and strengths.
• Premorbid personality — understanding how a person was before they became unwell helps to establish what the treatment target should be (i.e. recovery to their premorbid level) and informs management.
• Collateral history — independent accounts from family members, carers, or other professionals are often essential in psychiatry, where insight (the patient's awareness of their own illness) may be impaired.
• Continuous mental state observation — unlike a standard examination that follows history taking, the mental state examination in psychiatry begins the moment you see the patient and continues throughout the interview. Your observations during history taking are a fundamental part of the assessment.

Key Points in History Taking

From here on, this article deals with the key headings of history taking. The art of the interview itself is described in Part 3 of this series.

As in any other branch of medicine, we are essentially concerned with the history of the presenting problems and arriving at a working clinical diagnosis. This is followed by relevant investigations to confirm the most likely diagnosis and exclude other possibilities, then by treatment appropriate to the disorder.

In psychiatry, the presenting symptoms are often influenced by various life events, current social circumstances, support networks, and relationships with parents, siblings, partners, and children. As elsewhere in medicine, family history and past medical history are important not only in making the diagnosis but also in planning management.

Most significantly, the patient's developmental and personal history, cultural background, and family and religious values will influence and modify the presenting symptoms and how those factors are perceived by the patient and their family and caregivers. Lastly, it is the patient's attitude and premorbid personality that will determine what is required in a given situation and what help and support they will be willing to seek.

Thus, in psychiatry it is relevant to spend a good portion of the available time covering all the essential historical life events in some order.

It is also important to remember that while going through the process of history taking, we will naturally evoke certain behaviours, emotions, and responses from the patient, and gain some understanding of how the patient thinks, perceives, and believes. These observations form an essential part of the Mental State Examination, which is described in separate articles in this series.

Experienced clinicians move backwards and forwards during history taking, asking relevant questions about the patient's history or mental state as opportunities arise. There is a structured approach to a psychiatric assessment interview, but this structure is known to the physician — not to the patient. Sometimes a patient will be eager to talk about their hallucinations within the first few minutes of the interview and may not see any relevance in their personal development or employment history. Hence, it is reasonable to focus first on what the patient is most concerned about, and then follow the structured format to complete the history and Mental State Examination. Quiet, attentive listening on the part of the physician forms a very essential part of a psychiatric interview.

The Eight Key Headings of a Psychiatric History

The following are the key headings under which we expect to complete history taking in psychiatry. Each is explored in detail in Part 2 of this series:

1. Presenting problems — the symptoms and concerns that have brought the patient to assessment, in their own words and in clinical terms.
2. Past psychiatric history — previous episodes of mental illness, treatments received (including voluntary and involuntary admissions, medications, ECT, and psychotherapy), and response to treatment.
3. Past medical history — physical health conditions, both current and historical, as well as current medications and allergies. Physical illness can cause, mimic, or exacerbate psychiatric conditions.
4. Family history — mental and physical health in parents, siblings, and extended family members. There is a significant hereditary component to many psychiatric disorders, including schizophrenia, bipolar disorder, and depression.
5. Personal history — birth and early development, childhood, education, occupational history, relationships, sexual history, and reproductive history.
6. Current social circumstances — housing, finances, social support, and relationships in the present day.
7. Forensic history — contact with the criminal justice system, including arrests, charges, convictions, and any history of violence or aggression.
8. Premorbid personality — the patient's characteristic way of thinking, feeling, and behaving before the onset of the current illness. This is best understood through both the patient's own self-description and an informant's account.

History Taking in Psychiatry continues in Part 2 — The Schema.