History taking of anxiety patient in psychiatry
Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Reading File
Finding Sources
Reading File
Reading File
Finding Sources
Based on all the content gathered from Kaplan & Sadock's Synopsis of Psychiatry and Comprehensive Textbook of Psychiatry, here is a structured, comprehensive guide to history taking in an anxiety patient in psychiatry:
History Taking of an Anxiety Patient in Psychiatry
Setting the Stage
Before beginning, create a supportive environment. The patient presenting with anxiety is often already anxious about the interview itself. A warm demeanor, non-verbal reassurance (leaning forward, open posture), and clarifying confidentiality and time available help establish rapport. Begin with an open-ended question:
"Can you tell me in your own words what brings you here today?"
Structure of the Psychiatric History (Table 1-1)
I. Identifying Data
- Name, age, sex, marital status, ethnicity, occupation
- Referral source
II. Source and Reliability
- Who provided the history (patient, family member, records)?
- Clinician's assessment of reliability of the information
III. Chief Complaint (in patient's own words)
- e.g., "I have a lot of anxiety," "I keep having panic attacks," "I can't stop worrying"
IV. History of Present Illness (HPI)
This is the core of the assessment. Use the funnel method: start open-ended, then narrow with closed questions.
Key domains to cover:
| Domain | Questions to Explore |
|---|---|
| Onset | When did the anxiety begin? Was it sudden or gradual? |
| Nature of anxiety | Generalized worry, panic attacks, phobias, obsessions/compulsions, social fears? |
| Severity | How much does it interfere with daily functioning? |
| Duration & course | Constant or episodic? Improving, worsening, or fluctuating? |
| Triggers | Specific situations (social, agoraphobic), objects, thoughts, or unprovoked? |
| Avoidance behaviour | What situations or objects does the patient avoid? |
| Physical symptoms | Palpitations, shortness of breath, sweating, trembling, dizziness, chest tightness, nausea, paraesthesias, hot flushes — especially in panic attacks |
| Cognitive symptoms | Fear of losing control, fear of dying, derealization/depersonalization |
| Worry content | What does the patient worry about? Is it uncontrollable? |
| Compulsions/rituals | Repetitive behaviours or mental acts driven by obsessions? |
| Impact | Work, relationships, social life, sleep |
| Precipitants | Recent stressors — home, work, school, finances, relationships, legal, medical |
| Relieving/aggravating factors | Medications, substances, coping strategies, time of day |
| Why now? | What triggered seeking help at this moment? |
V. Past Psychiatric History
- Previous episodes of anxiety or other psychiatric illness
- Prior diagnoses and treatments (medications, therapy — response, compliance, side effects)
- Previous hospitalisations
- History of suicide attempts or self-harm
VI. Substance Use / Abuse
- Alcohol, caffeine, cannabis, stimulants, benzodiazepines (non-prescribed)
- Caffeine and stimulant use can mimic or exacerbate anxiety
- Alcohol/benzodiazepine withdrawal can cause severe anxiety
VII. Past Medical History
- Medical conditions that mimic anxiety: hyperthyroidism, phaeochromocytoma, cardiac arrhythmias, asthma, hypoglycaemia, epilepsy
- Current and past medications — prescribed, OTC, herbal, supplements (some can cause anxiety as a side effect)
- Ask specifically about compliance: "How many days a week do you actually take this medication?"
- Medication allergies
VIII. Family History
- Family history of anxiety disorders, depression, OCD, PTSD, substance use
- Family history of psychiatric hospitalisations or suicide (significant risk factor)
- Familial medication response (useful for treatment planning)
IX. Developmental and Social History
Obtained chronologically:
- Prenatal/childhood: Home environment, family dynamics, quality of friendships
- School history: Academic performance, learning difficulties, behavioural problems, bullying
- Childhood trauma: Physical or sexual abuse — ask carefully and directly
- Occupational history: Type of work, performance, relationships with supervisors/peers, current employment status
- Relationship/marital history: Partnerships, quality of relationships, losses
- Sexual history: Relevant if anxiety is linked to sexual functioning or trauma
- Current social supports: Who can the patient rely on?
- Financial situation: Economic stressors may contribute
X. Review of Systems
- Anxiety-specific: Sleep disturbance (difficulty falling asleep, early waking), appetite changes, concentration difficulties, fatigue
- Depressive symptoms — comorbidity is very common
- Psychotic symptoms (to exclude secondary causes)
- PTSD screen if trauma history present
XI. Mental Status Examination (MSE)
Though technically objective rather than history, the MSE runs alongside and is inseparable from a good anxiety assessment:
| Domain | Observations in Anxiety |
|---|---|
| Appearance | May appear tense, restless, trembling |
| Behaviour/Psychomotor | Fidgeting, avoidance of eye contact, increased startle response |
| Speech | Rapid, pressured, or hesitant |
| Mood (subjective) | "Nervous," "on edge," "frightened" |
| Affect (objective) | Anxious, fearful, labile |
| Thought content | Worries, fears, obsessions, phobias; assess for suicidal/homicidal ideation (ideation, intent, plan, preparation) |
| Thought process | Usually intact; may be circumstantial if severely anxious |
| Perceptual disturbances | Usually absent; depersonalisation/derealisation may occur in panic |
| Cognition | Usually intact; may have concentration difficulties |
| Insight & Judgement | Usually preserved in anxiety disorders |
Special Considerations
- Comorbidities: Depression and anxiety co-occur very frequently — screen for both
- Safety assessment: Always ask about suicidal ideation — anxiety disorders carry suicide risk, especially with comorbid depression
- Medical masqueraders: Rule out organic causes before attributing symptoms to a primary anxiety disorder
- Collateral history: Especially valuable if the patient minimises symptoms
- Cultural context: Expression of anxiety varies culturally; somatic presentations (chest pain, headache) are common in many cultures
Sources: Kaplan and Sadock's Synopsis of Psychiatry; Kaplan & Sadock's Comprehensive Textbook of Psychiatry
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