HISTORY TAKING Ali Pk

Clinical Psychologist
MIND WEAVERS
YOUR THOUGHTS?

Why we need case history

How do we collect case history
From whom we collect case history
PERSONAL DETAILS

➤ NAME OF THE INDIVIDUAL : Primary identification of the individual.

➤ FATHERS/GUARDIAN’S NAME :Documentation/ SOS
SOCIODEMOGRAPHIC DETAILS
➤ Demographic variables (age, sex, education, status, religion area residence) should be adequately and
correctly noted. These factors have a role to play in onset, course, treatment and prognosis various
mental health conditions
➤ AGE
➤ SEX
➤ EDUCATION
➤ OCCUPATION
➤ SOCIO ECONOMIC STATUS
➤ MARITAL STATUS
➤ RELIGION
➤ RESIDENCE & MOTHER TONGUE
➤ SOURCE OF REFERRAL & IDENTIFICATION MARKS
HISTORY OF PRESENT ILLNESS
➤ PATIENT’S REPORT
➤ INFORMANT’S REPORT
➤ NAME & RELATIONSHIP
➤ RELIABILITY
➤ Contact - between pt and informant
➤ Closeness - of relationship between pt and informant
➤ Continuity - of account given by informant
➤ Consistency - of verbatim of the informant
➤ Coroborativeness - between various sources of information
➤ ADEQUACY - it refers to the amount of information given by the informant and
assessment that whether this information is sufficient for forming a diagnosis or not.
 CHIEF COMPLAINTS/ PRESENTING COMPLAINTS
➤ How do we write it..?

➤ Possible chief complaints of a patient with MDD

➤ Note down all possible complaints
➤ Which one you will write first?
➤ How many C/C you will write?
CHIEF COMPLAINTS/ PRESENTING COMPLAINTS
➤ The chief complaints, often recorded verbatim states, why he has come on has been
brought in for help. It usually describes present symptoms, including the duration of
each and an account of the development of the illness. Complaints should be in
chronological order with the earliest complaint first and recent most being last in
list.
➤ Patients verbatim
➤ Chronological order
➤ Duration of each
➤ No technical terms
CHIEF COMPLAINTS/ PRESENTING COMPLAINTS
➤ EXAMPLE - DEPRESSION

➤ Low mood - since last 3 months

➤ Lack of confidence
➤ Lack of interest in activities since last 2 months
➤ Not interested to engage with others
➤ Thoughts about ending own life - last 5 days
HOPI

➤ PREDISPOSING FACTORS - Factors operating from early life that determines a

person's vulnerability to develop a disorder or likelihood that person will develop
certain symptoms under given stress conditions.
➤ Biological (delayed milestones, head injury, family history of psychiatric illness)
➤ Psychological (impaired premorbid personality)
➤ Social (home atmosphere in childhood, neglect, abuse, low education level)
➤ PRECIPITATING FACTORS - Events that occur shortly before the onset of a
disorder and act as physical or psychosocial stressors and lead to the onset of
disorder in a person who may be predisposed to develop the disorder
➤ Biological (fever, accident, onset of severe medical illness)
➤ Psychological (stress intolerance, poor impulse control)
➤ Social (trauma, loss of job/partner)
➤ PERPETUATING FACTORS - Factors due to which the disorder is maintained or
aggravated.
➤ Biological (chronic medical illness, substance use)
➤ Psychological factors (poor insight, poor impulse control, low intelligence)
➤ Social (social isolation, unemployment, ongoing expressed emotions in family)
➤ MODE OF ONSET : It is assessed as time from being asymptomatic to symptomatic
➤ Abrupt- Sudden appearance of signs and symptoms within 48 hours eg. delirium
➤ Acute-Rapid onset of signs and symptoms within 2 weeks e.g. ATPD
➤ Insidious-Onset of signs and symptoms takes more than 2 weeks e.g.
Schizophrenia
➤ COURSE OF ILLNESS
➤ Continuous- Characterised by uninterrupted change without breaks or with steps
infinitely small and thus not detectable e.g. Schizophrenia.
➤ Episodic- An illness can be said episodic when it has an onset and an offset of
signs and symptoms of the disease with period of recovery in between at least for
a period of 2 months e.g. affective illness
➤ Fluctuating. When the course is waxing and waning especially under the effect of
treatment, o.f. Obsessive compulsive disorder, Schizophrenia
➤ PROGRESS OF ILLNESS - To what extend has the patient's symptomatology
represented an evolution over time
➤ Improving- Improving from the date of onset e.g. Depression (with treatment)
➤ Deteriorating-Condition is getting worse by time eg. Schizophrenia
➤ Static-Condition remains same no change happens e.g. Dysthymia
HOPI…

➤ LOW MOOD
➤ Index patient was maintaining well 3 months back. The he started to feel low at
times. When he is at home he doesn’t feel like doing anything, he sit alone and
aloof, when he is asked about this he gets irritated. He used to talk with family
members 3 months back and engage in free talks, but currently he finds it very
difficult.
➤ ABC MODEL
➤ Antecedents
➤ Behavior
➤ Consequence
➤ Index patient was maintaining well 3 months back. When he is at home he
doesn’t feel like doing anything, he sit alone and aloof. He started to feel low at
times., when he is asked about this he gets irritated. He used to talk with family
members 3 months back and engage in free talks, but currently he finds it very
difficult
➤ ABC MODEL
➤ Antecedents
➤ Behavior
➤ Consequence
➤ Index patient was maintaining well 3 months back. He is having anger outbursts
when he is asked to do his homework and also when he is not given much time to
play in mobile phone, When he become angry he would shout at mother and
younger brother, he would throw anything he gets his hands on. Last week he
threw a glass and mother was injured.
➤ Biological functioning (Intact, Impaired, Partially impaired)
➤ Sleep
➤ Appetite
➤ Libido
➤ Role functioning (Intact, Impaired, Partially impaired)
➤ Negative History (Ruling out relevant possible histories)
➤ No history of significant head injury/Family mental illness/substance abuse/
epilepsy
TREATMENT HISTORY
➤ It includes details of the treatment obtained in the present episode. When was the first
contact; whether treatment was voluntary/ involuntary, who saw the patient and for how
long (Psychiatrist/Psychologist/Physician/Faith healer Traditional practitioner); the nature
of the treatment (Pharmacological/Psychotherapy/faith healing/traditional): modality that
was helpful (psychopharmacological interventions, individual group therapy); medication,
if any that were prescribed, details should be mentioned including doses, duration,
compliance, response, adverse effects (tabulate details as much as possible): length of
treatment reason for discontinuing treatment or poor compliance; day treatment
hospitalization if done, all of these domains should be collaborated.

➤ Compliance is defined as the extend to which the patient's behaviour (in terms of taking
medications, following diets or executing other lifestyle changes) coincides with medical
recommendations.
TREATMENT HISTORY - EXAMPLE
Sl
DATE Treatment From Treatment Compliance
NO
PAST HISTORY
➤ Past Medical Illness - This includes an account of major medical illness and
conditions, including common as well as uncommon chronic childhood illness,
conditions leading to frequent medical consultation and treatment and those
requiring emergency department visits, and those requiring hospitalization.
➤ Past Psychiatric Illness - Take a detailed history of previous episodes, symptoms,
duration, probable diagnoses, all available treatment details including
hospitalization, inter-episodic functioning, deficits.
➤ Mood Graph
FAMILY HISTORY
➤ Parents and siblings: Age now or at death (if dead, the cause), occupation,
personality, quality of relationship with parents, psychiatric and medical history.
➤ A brief statement about any psychiatric illness, hospitalization, and treatment of the
patient's immediate family members should be placed in the family history part of
the report.
➤ Any family history of alcohol or substance abuse or of personality problems should
be documented.
➤ Consanguinity
FAMILY HISTORY
➤ Genogram: The genogram is a valuable assessment tool for learning about a family's
history over a period of time. Based upon the concept of a family tree, it usually
includes data about three or more generations of the family, which provides a
longitudinal perspective. The genogram provides a graphic picture of family
genealogy, including significant life events (birth, marriage, separation, divorce,
illness, death)
PERSONAL HISTORY
➤ It comprises of a chronological account of the person's personal experiences starting with his birth and birth
details. The personal history is usually divided into perinatal, early childhood late childhood and adulthood.
➤ Birth and Early Development:
➤ Presence of any illness medication, drugs, alcohol use, trauma or bleeding, any physical/ psychiatric
illness during pregnancy.
➤ Term of delivery (Full term/ pre-term/post-term)
➤ Place (Hospital/home/other)
➤ Type of delivery (Normal/Caesarian/ Instrumental)
➤ Birth cry ( Present/Absent)
➤ Birth Weight
➤ Any complication
➤ Developmental Milestones
➤ Presence of childhood disorders:
➤ Comment on presence of hyperactivity, attention deficits and impulsivity which are
usually noticed from age of 2-3 years.
➤ Conduct problems during childhood should be probed into and will include
disobedience, lying, stealing, truancy (running away from school) cruelty towards
animals, bossy attitude towards younger children, not obeying rules while playing.
➤ Temper tantrums are very common in children; when present, extent and intensity
should be carefully noted. Neurotic traits (nail-biting, thumb sucking, stammering,
mannerisms, bedwetting, phobias, night-terrors, sleep walking, etc.) during childhood
should be probed into and if present, the details should be mentioned
➤ A comment on social relation with peers, elderly and authority figures and younger
children should be made.
➤ Home atmosphere in childhood and adolescence:
➤ A comment should be made on emotional environment at home in formative years
(disturbed/congenial any abnormality of family situation, desertion by a parent,
broken home, step-parents, adopted sibs etc. and also patients attitude towards
parents)
➤ Scholastic and extracurricular activities:
➤ Comment on age and class of entry in school, type of school, scholastic performance
and progress in studies, regularity in school, failures if any, disciplinary problems/
actions if any, relational problems with peers/authorities, any discontinuity or
change in school/college with reasons, involvement in games and extra curricular
activities. Also mention special interests in games if any during childhood.
➤ Vocational Occupational history:
➤ Mention the age at which the individual started working professionally for the
first time. Duration at each work place, positions held, reasons for leaving,
relation with work mates and superiors, promotion (in comparison to colleagues)
should be commented upon. Impact of illness on occupation will form a part of
history of presenting illness itself.
➤ Menstrual history:
➤ Age of menarche should be asked. Regularity and duration of usual cycle, whether
associated with psychological and physical change (pain or any other). Date of last
menstruation.
➤ Sexual and marital history:
➤ How and when sexual information and knowledge was first obtained and of what
kind, masturbatory history (fantasy and activity), sex play if any.
➤ adolescent sexual activity, premarital and extramarital sexual relationship if any,
sexual disorders, Also probe for any history of childhood sexual abuse.
➤ Marital history includes all enduring intimate relationships. Ask for age at
marriage and parental consent for marriage. The spouse's age, occupation,
personality and state of health are relevant to the patient's circumstances should
be documented. Also ask for role allocation, sharing of responsibilities and
decision making. perceived adequacy of sexual relation.
➤ Forensic history:
➤ Trouble with police, law; charges and convictions (sections), status of cases
should be adequately mentioned here as per the available information.
➤ General pattern of living:
➤ Physical environment of the individual should be mentioned here
(accommodation, number of rooms, ownership). Also make a comment on ways
of handling adversity in home environment
PREMORBID PERSONALITY
➤ Individuals way of dealing with environment prior to onset of psychiatric illness. Assess
from patient/relative/others who knows person well. Mention source and reliability
➤ Social Relation (Independent, dependent, aggressive, submissive, organiser, leader,
follower, adjustable, ambitious)
➤ Intellectual activities, hobbies
➤ Predominant Mood (Cheerful, optimistic, pessimistic, relaxed, worrying, unstable)
➤ Character - Attitude to self/ others/ work/ moral standards
➤ Habits
➤ Euthymic mood
➤ IMPRESSION (Well adjusted/ Not well adjusted)
ASSIGNMENT
➤ 1. Read the Case History
➤ 2. Develop your DEMO case
➤ 3. Developmental Milestones
➤ 4. National Mental Health Survey
➤ Submission: 08.05.2021 (09:00 PM)
THANK YOU

ALI PK

CLINICAL PSYCHOLOGIST

MIND WEAVERS

alipkpsy@gmail.com

9656293940

www.mindweavers.in