Introduction
This section deals with the details of the psychiatric assessment interview, concentrating on history taking. It should be read alongside Part 1, which describes the purpose and approach, and Part 3, which addresses the interview process itself.
It is important in psychiatry that we also obtain an objective account of the patient's presenting problem from other independent sources. This must be cleared with the patient in advance. Often, a family member of the patient's choice, a GP, a close friend, or a work colleague may be a valuable source of additional information about the patient's current health and their views about the presenting problems and, possibly, the underlying causes as they understand them. Family members, a spouse, or parents are particularly useful sources of information about the patient's premorbid personality, habits, relationship issues, and areas such as dependence on drugs or alcohol, financial difficulties, and any forensic history — which a patient may not always disclose to their treating physician.
Often, medical students or Accident & Emergency doctors may not have the opportunity or time to explore the patient's history from other sources, but they must always mention this important aspect of history taking when formulating their case, and highlight the need to do so at a later stage — either themselves or through other health professionals.
Obtaining history from another appropriate source serves several important purposes:
- It gives further insight into the patient's illness, personality, and relevant psychosocial issues.
- It helps the patient psychosocially — knowing that a professional has formally involved members of their family and briefed them about the nature of the illness and proposed treatment (with the patient's consent) can itself be therapeutic.
- From the family's perspective, they are better able to understand the medical reasons for their loved one's behaviour and the expected treatment outcome.
- Members of the family feel involved in the patient's care and thus less burdened by the guilt they often unconsciously carry, blaming themselves for their partner's or child's ill health.
In the author's opinion, we should always aim to include at least one close member of the family, or another person of the patient's choice, when completing the history in psychiatry.
The Standard Schema for History Taking in Psychiatry
1. Personal Details and Reasons for Referral
The following information should be established at the start of every assessment:
- Name
- Date of birth
- Address
- Telephone numbers
- Marital status
- Next of kin — name, address, telephone numbers
- GP details
- Who referred the patient
- Reasons for referral
- Legal status — subject to the Mental Health Act 1983 (and if so, which section) or informal (voluntary)
2. Place of Interview, Interviewer, Date and Time, and Who Else Was Present
- Inpatient (hospital ward, etc.)
- Outpatient
- Home visit
- Other (e.g. police custody, prison, A&E)
Recording who was present is important for medicolegal purposes and for understanding the context in which information was given.
3. History of the Current Problems
This is the heart of the assessment. It covers:
- Key symptoms — described in the patient's own words first, then clarified and elaborated
- Duration — for how long have the symptoms persisted?
- Precipitating factors — what triggered the onset of symptoms? Consider life events (bereavements, relationship breakdown, job loss), physical illness, substance use, changes in medication
- Key life events prior to the onset of symptoms
- Life events since the onset of symptoms
- Alleviating or exacerbating factors
- What help has been offered and its response
- The patient's own view about:
- What they think is wrong with them
- What they believe may be the underlying causes or precipitating factors
- What help they would prefer to have
This last point — eliciting the patient's explanatory model of their illness — is often neglected but is crucial for engagement and for planning treatment the patient will accept.
4. Past Psychiatric History
For each previous episode, establish:
- The nature, duration, and treatment of the episode and its response
- How and by whom was the patient treated:
- GP
- Specialist service (CMHT, CRHTT, EIP, etc.)
- Outpatient or inpatient
- Voluntary (informal) or involuntary (detained under the Mental Health Act)
- Medications, including depot (long-acting injectable) antipsychotics
- Electroconvulsive therapy (ECT)
- Counselling or psychotherapy (type and number of sessions)
- Other treatment methods
Pay particular attention to any previous self-harm or suicide attempts — these are among the strongest predictors of future risk.
5. Past Medical History and Current Status
- The nature, duration, and treatment of physical conditions and their response
- How and by whom was the patient treated
- Current medications, including over-the-counter and herbal preparations
- Known allergies or drug reactions
Physical illness is highly relevant in psychiatry — hypothyroidism can cause depression, corticosteroids can trigger mania, and cardiovascular disease limits choice of antidepressants. Conversely, psychiatric illness significantly increases physical health morbidity and mortality.
6. Family History
- Information about parents and siblings
- Extended family members
- Any significant mental and physical health history in the family
- Family members given treatment for a specific mental health disorder
- History of illicit drug or alcohol misuse, gambling, deaths, suicide, and trouble with the law or forensic history in the family
Many psychiatric conditions — including schizophrenia, bipolar disorder, depression, and anxiety disorders — have significant genetic components, and a positive family history substantially increases an individual's lifetime risk.
7. Personal History
This section is a chronological account of the patient's life. It includes:
- Pregnancy — complications, maternal health, planned or unplanned
- Infancy and childhood — early developmental milestones, significant illnesses, separations
- Developmental issues — any delays in walking, talking, or social development; neurodevelopmental conditions (autism spectrum disorder, ADHD)
- Schooling — age started, schools attended, any special educational needs
- Educational achievements — examinations passed, qualifications obtained
- Social adjustment at school — friendships, bullying (as perpetrator or victim), exclusions
- Interests, habits, and hobbies
- Relationships — quality of peer relationships, romantic relationships, significant losses
- Sexual experiences and sexual health history (asked sensitively and with appropriate context)
- Steady friendships and social network
- Employment history — jobs held, reasons for leaving, current employment status
- Marital history — relationships, cohabitation, marriage, separation, divorce
- Children — ages, health status, any child protection concerns
8. Social History
- Current financial situation — income, debts, benefits
- Housing — owned or rented, stability, condition, living alone or with others
- Social support network — who is available to help in a crisis?
9. Forensic History
This section should be approached sensitively and non-judgementally. Ask about:
- Trouble with the law — arrests, charges, cautions, convictions, imprisonment
- Driving offences
- History of violence or aggression — as perpetrator or victim
- Illicit drug misuse (also relevant to substance history)
- Problem with alcohol (also relevant to substance history)
A forensic history is essential in psychiatry, particularly for risk assessment. The presence of a forensic history does not in itself indicate dangerousness, but it provides important context for understanding the patient's behaviour.
10. Premorbid Personality
Premorbid personality refers to the patient's characteristic way of thinking, feeling, and behaving before the onset of their mental illness. Key traits to explore include:
- Attitudes and opinions
- Religious or spiritual beliefs
- Temperament — shy/quiet/introverted versus extroverted
- Anxious or obsessional traits
- Suspicious or trusting
- Optimistic or pessimistic
- Sociability — easy to mix with others and make friends, or preferring to keep to themselves and avoiding large social events
- Other attributes — impulsivity, perfectionism, emotional sensitivity
- How the patient would describe themselves
- How others would describe them
11. History as Given by Others (Collateral History)
Always record the following about any collateral history obtained:
- Informant — who provided the information
- Relationship with the patient
- Key information obtained
- History as obtained from medical notes and other documents (e.g. GP letters, previous discharge summaries, social services reports)
The process of history taking — including how to conduct the interview — is dealt with in History Taking in Psychiatry – Part 3.
Frequently Asked Questions
Why do we ask about the patient's childhood and personal development in a psychiatric history?
Early life experiences — particularly adverse childhood experiences (ACEs) such as abuse, neglect, or early loss — are strongly associated with increased risk of mental health problems in adulthood. They also shape personality, attachment style, and coping mechanisms, all of which are relevant to understanding the current presentation and planning treatment. For example, a history of childhood trauma may support the use of trauma-focused psychological therapy. Developmental history also helps identify neurodevelopmental conditions (such as autism or ADHD) that may have been undiagnosed and may be contributing to current difficulties.
How do I ask about sexual history sensitively?
Sexual history is relevant in psychiatry for several reasons — sexual dysfunction is a common side effect of psychiatric medications, sexual trauma is a significant risk factor for many conditions, and sexual behaviour can be a feature of manic episodes. Approach the topic by contextualising it: "I'm going to ask you some questions about your personal and sexual history — these are questions I ask all my patients as they help me understand the full picture." Ask open questions first, then more specific ones if needed. Be alert for a history of sexual abuse or coercive control, and be prepared to offer appropriate referral for specialist support.
What is the difference between substance misuse and substance dependence?
Harmful use (or misuse in common parlance) refers to a pattern of substance use that is causing damage to health — physical or psychological — but without the features of dependence. Dependence (ICD-10 criteria) requires three or more of the following in a twelve-month period: strong desire or compulsion to take the substance; difficulty controlling its use; physiological withdrawal; tolerance (needing more to achieve the same effect); progressive neglect of other pleasures or interests; and continued use despite evidence of harm. Dependence is associated with a higher risk of withdrawal complications (particularly with alcohol and benzodiazepines) and typically requires more intensive treatment.
What is the CAGE questionnaire and when should I use it?
The CAGE questionnaire is a four-item validated screen for alcohol misuse: Have you ever felt you needed to Cut down on your drinking? Have people ever Annoyed you by criticising your drinking? Have you ever felt Guilty about drinking? Have you ever needed a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? A score of 2 or more is considered clinically significant and warrants further assessment. CAGE is useful as a brief initial screen, but the AUDIT (Alcohol Use Disorders Identification Test) provides a more comprehensive assessment of quantity, frequency, and alcohol-related harm and is recommended by NICE.
What should I do if a patient refuses to consent to a collateral history?
You should respect the patient's wishes and document that they have declined consent for contact with a third party. Record the limitations this places on the completeness of your assessment. In most circumstances, you should proceed with what information you have from the patient themselves, supplemented by information already in the medical record (to which you have access without the need for specific consent). You can still receive information from a carer or family member who contacts you, but you should not confirm or deny the patient's involvement in services without the patient's consent. If there is an immediate risk to life, the threshold for acting without full consent is lower and you should seek urgent senior advice.
Why is it important to ask about the patient's own view of their illness?
Eliciting the patient's explanatory model — what they think is wrong, what they believe caused it, and what they think would help — is essential for several reasons. It helps build the therapeutic alliance by demonstrating genuine interest in the patient's perspective. It reveals the degree of insight the patient has into their condition. It helps identify cultural or personal beliefs that may affect engagement with treatment (for example, a patient who attributes their symptoms to spiritual causes may need a different explanatory framework for understanding psychiatric treatment). It also helps ensure that the management plan is negotiated with the patient rather than imposed upon them, improving adherence.
For an ST3 interview — how do you approach taking a history from a patient who is psychotic and difficult to interview?
A strong candidate would acknowledge the challenge and demonstrate a structured, flexible approach. Prioritise safety first — ensure the environment is safe for both you and the patient. Establish a calm, unhurried presence and avoid confrontation or challenging delusional beliefs directly. Use simple, open questions and be prepared to tolerate silence. Gather as much information as possible while keeping the patient comfortable and not escalating distress. Accept that a full history may not be possible in a single session, and document clearly what could not be elicited and why. Use collateral sources (family, GP, previous notes) to supplement the history. A full mental state examination may yield more diagnostic information than a detailed history in this situation.
References
- Johnstone EC, et al. Companion to Psychiatric Studies (7th ed). Churchill Livingstone, 2004.
- Gelder M, Harrison P, Cowen P. Shorter Oxford Textbook of Psychiatry (6th ed). Oxford University Press, 2010.
- Semple D, Smyth R. Oxford Handbook of Psychiatry (4th ed). Oxford University Press, 2019.
- Sims A. Symptoms in the Mind: An Introduction to Descriptive Psychopathology (5th ed). Elsevier, 2015.
- World Health Organization. ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, Geneva, 1992.
- Babor TF, et al. AUDIT: The Alcohol Use Disorders Identification Test (2nd ed). WHO, 2001.
- Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252(14):1905–1907.
- NICE. Alcohol Use Disorders: Diagnosis and Management (QS11). NICE, 2011 (updated 2019).