NIMHANS PROFORMA

HIStORy tAkINg & MSE

1. Chief complaints:
Patients complaints shd b recorded however bizarre they might be

Record in chronological order

Don’t write a long list of complaints

Ask direct questions if they don’t report

Use ur skills for discretion in eliciting the complaints

2. HOPI:
Give a detailed account of symptoms from onset to the time of consultation including their
chronological evolution and course.

 ONSET:
1
Abrupt- developed within few hours

Acute- developed within one week

Sub acute- 1-2 weeks

Gradual- > 2 weeks

2 PRECIPITATION FACTORS:

Physical- febrile illness

Psychological- death, loss

Ascertain whether events clearly proceed or were consequences of illness

 COURSE OF ILLNESS:
3
Episodic- discrete symptomatic periods with intervening periods of normalcy

Continuous

Fluctuating- Periodic exacerbations of a continuous illness. E.g.: Delusions,

hallucinations intense affect may b prominent in initial phase while in later stages
apathy and emotional blunting might b prominent.

Graphic presentation of course of illness can often b very informative.

 ASSOCIATED DISTURBANCES:
4
 Disturbances in sleep, appetite, weight, sexual life, social life, occupation and evidences
of secondary gain.

The specific nature of the disturbance and degree of disability to be noted.

5 CERTAIN HISTORICAL DETAILS:



History of trauma, fever, headache, vomiting, confusion, disorientation, memory

disturbances, physical illnesses like hypertension, diabetes n history of substance abuse.

3. PAST HISTORY:
 Past psychiatric illness: Nature and duration of symptoms and nature of the treatment
received and pattern of response, degree of compliance.

 Past physical illness: Epilepsy, hypertension, diabetes, tuberculosis, head injury, asthma
and any other medical illness.

4. FAMILY HISTORY:
 Description of individual family members, parents and siblings. Whether they are alive
or dead, age, education, occupation, marital status, personality, relationship with the
patient.

 Socioeconomic condition of the family.

 Leader ship pattern.

 Role functions and communications within the family.

 Physical and psychiatric illness in the family.

5. PERSONAL HISTORY:
 BIRTH & EARLY DEVELOPMENT:

Details of prenatal, natal, postnatal periods.

Gestational period, place of birth, complications during delivery.

Physical illness during postnatal period

Developmental milestones.

 BEHAVIOUR DURING CHILDHOOD:

Sleep disturbances

Thumb sucking
 Nail biting

Temper tantrums

Bed wetting

Stammering

Tics and mannerisms

Conduct disturbances in the form of -------

Frequent fights

Truancy

Stealing

Lying and gang activities

Relationship with parents, siblings and peers.

 PHYSICAL ILLNESS DURING CHILDHOOD: Epilepsy, meningitis, encephalitis.

 SCHOOL:

Age of beginning and finishing school

Type of school

Scholastic performance

Attitudes towards peers and teachers.

 OCCUPATION:

Age of starting work

Jobs held in chronological order

Work satisfaction

Competence

Future ambitions

 MENSTRUAL HISTORY:

Age of menarche,

Reaction to menarche

Regularity of periods

Dysmenorrhea

Oligomenorrhoea
 Emotional disturbances in relation to menstrual cycle

 SEXUAL HISTORY:

Age at onset of puberty

Level of knowledge regarding sex and mode of getting the same

Masturbatory practices

Anxiety related to sexual practices

Homosexual and heterosexual inclinations and experiences

Extramarital relationships

 MARITAL HISTORY:

Age at the time of marriage

Arranged or self

Mutual consent of the partners

Age, education, occupation, health and personality of the partner

Quality of marital relationship

Any separation or divorce

No. Of children, their age and health status.

 SUBSTANCE ABUSE:

Smoking, alcohol drinking pattern

Abuse of other substances like cannabis, opiates, barbiturates

6. PREMORBID HISTORY:
Description of the personality prior to the beginning of the mental illness aim at a picture of an
individual, not a type.

Attempt should be made particularly in cases of neurosis or affective disorder to elicit evidence about all
aspects of premorbid personality.

 SOCIAL RELATIONS:

To family

To friends

Groups
 Societies

Clubs

To work and work mates

 INTELLECTUAL ACTIVITIES, HOBBIES, INTERESTS:

Books, plays, pictures preferred

Memory, observation, judgement

 MOOD:

Bright, cheerful / despondent

Worrying / placid

Strung up / calm and relaxed

Optimistic / pessimistic

Self-depreciative / satisfied

Mood stable / unstable

 CHARACTER:

 ATTITUDE TO WORK & RESPONSIBILITY:

Welcomes or worried by responsibility

Makes decisions easily or with difficulty

Haphazard & slapdash / methodical & meticulous

Rigid / flexible

Cautious, foresightful & given to checking / impulsive, slipshod

Persevering & determined / easily bored & discouraged

 INTERPERSONAL RELATIONSHIPS:

Self-confident / Shy & timid

Insensitive / touchy & sensitive to criticisms

Trusting / suspicious & jealous

Emotionally controlled / quick tempered & irritable

Tactful / outspoken

Enjoys / shuns self display

Quiet & restrained / expressive & demonstrative in speech n gestures

 Interests & enthusiasms sustained / evanescent

Tolerant / intolerant of others

Adaptable / unadaptable

 STANDARDS IN MORAL, RELIGIOUS, SOCIAL & HEALTH MATTERS:

Level of aspiration low / high

Perfectionist & self critical / complacent & self approving in relation to own

behavior n achievement

Steadfast in face of difficulties / intolerant of frustration

Self & egoistical / unselfish & altruistic

Given too much / little concern about own health

 ENERGY, INITIATIVE:

Energetic / sluggish

Output sustained / fitful, fatigability

Any regular or irregular fluctuations in energy n output

 FANTASY LIFE: Frequency and content of day dreaming

 HABITS:

Eating

Alcohol & tobacco consumption, Self medication specify amount taken recently and
earlier

Sleeping

Excretory functions
 MENtAL StAtUS EXAMINAtION
A systematically conducted MSE is an important component of case taking.

It is essential to record the observations properly.

Positive findings should be described in detail.

MSE has to be repeated several times during the course of illness to the evolution of
symptoms, effectiveness of treatment…etc…

7. GENERAL BEHAVIOUR:
Observations of ward staff and observations of examiner

The way of spending the day- eating, sleeping

Cleanliness in general – self care, hair, dress

Behaviour towards other patients, doctors, nursing staff.

Patient is looking healthy or not

Is he in touch with surroundings?

Is the patient relaxed / tense n restless ?

Is he slow / hesitant ?

Response to various requirements and situations

Any abnormal responses to external events

Attention can be held / diverted

Is the patient cooperative ?

Adequate rapport can be established

Behaviour suggests he is disoriented

Presence of tics / mannerisms / catatonic phenomenon

Restlessness, winging of hands (aimless, purposeless activity)

8. PSYCHOMOTOR ACTIVITY: Increased / decreased / normal.

9. SPEECH :
Spontaneous / only in response to questions

Amount – little / excessive

Tone – high / low

Tempo – fast / slow

Reaction time – increased / decreased

Prosody – maintained or not

 SPEECH SAMPLE – Mannerisms , twitches, hyperactivity.

1. THOUGHT:
 FORM:

 STREAM:

Flight of ideas

Retardation of thinking

Circumstantiality

Perseveration

Thought blocking

 POSSESSION:

Obsessions – Ideas, doubts, imagery, impulses, phobias

Compulsory acts – checking, counting, washing

Controlling compulsions / yielding compulsions

Thought alienation

 CONTENT:

Over valued ideas and delusions

Delusions single / multiple

Type of delusions

Exact content of delusions

Fleeting / fixed

Well systematized / poorly systematized

Mood congruent / not

Enquire about worries, preoccupations, hypochondriacal, somatic symptoms

Depressive ideation, ideas of worthlessness, guilt, hopelessness and suicidal ideas.

2. MOOD:

Assess subjective report and objective evaluation

Assess both longitudinal (mood) & cross sectional (affect)

Quality of emotion – happiness / sadness

Intensity of emotional expression – flat / blunt / normal

Range of affective responses – full / restricted

Mobility & reactivity – change of emotions in relation to the environmental factors

Diurnal variations

Congruity in relation to the thought process

Appropriateness in relation to the situations

Lability – rapid and extreme changes in emotions

3. PERCEPTION:
Hallucinations

 Modality – vision / hearing / smell / touch / taste /pain / deep sensations

Vestibular sensations & sense of presence.

 Special varieties – functional / reflex / extracampine / synesthesia / autoscopy

 Detailed description of h.

 Auditory h. –

Verbal / non verbal

Continuous / intermittent

Single voice / multiple voices

Familiar voice / unfamiliar voice

First person / sec. Person / third person

Pleasant / unpleasant

If unpleasant – commanding / abusive / threatening

Whether mood congruent

 Distinguish h. From imagery and pseudo hallucinations

Illusions

Heightened perceptions

Dulled perceptions

Depersonalization, derealization experiences

Disturbances in perception of time

4. COGNITIVE FUNCTIONS:
Clinical assessment includes

 Attention & concentration

 Orientation

 Memory

 Intelligence

 Judgement

 ATTENTION & CONCENTRATION:

Tests used in clinical assessment

 Digit span test –

Forward

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Backwards

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Ask the patient to listen carefully and repeat them in the same order after the examiner finishes

Read the digits at the rate of one per second to the patient

The same digit should not be presented more than once

Note whether the immediate response of the patient is correct or incorrect

If d pt. cannot repeat a second trial with same number of digits is given and credit is given if the
response is correct

The digit span is highest number of digits repeated correctly.

 SERIAL SUBTRACTIONS:

Increasingly difficult tests are presented.

The examiner instructs the pt. with an example of how to perform a task.

Note the responses verbatim and note the time taken in seconds

TASK CORRECT RESPONSE AND TIME

LIMIT
20 - 1 20 to 0 reversed in 15 secs
40 – 3 60 secs
100 - 7

 Days or months repeated in forward & backward order

 ORIENTATION:

Three aspects are described to time, place, n person

 TIME :

Approximately what time of the day is it ?

Is it morning / evening / afternoon / night ?

Approximately how long is it since u had ur breakfast / lunch / tea

Approximately how long I have been talking to you ?

What is the date & day is today ?

  PLACE:

What place is this ?

 PERSON:

Orientation of person is tested by asking identity of the pt.

Inquire about the identity of the pt s relatives and family members

 MEMORY:

Assessment includes immediate, recent and remote memory

 Immediate memory: tested by digit span test.

 Recent memory – tested by

i. address test

An address consisting of about 4-5 facts not known to the pt. is slowly read to the pt.
after instructing him to attend to the examiner to engage in the conversation (to avoid
rehearsal) and the response is noted verbatim.

ii. Asking the pt. to recall events in the last 24 hrs. Responses given by the pt. is
crosschecked from the reliable source

 Remote memory –

Information on life events

o Date of birth or age

o No. of children

o Name and no. of family members

o Time since marriage or death of any family members

o Year of completing education

Facts may be asked that are relevant to pt. background

 INTELLIGENCE:
It includes areas of general information, comprehensive arithmetic abstraction

 GENERAL INFORMATION –

Information relevant to the pt's literacy, age, occupation may be asked.

For literates –
 o Names of prime minister, chief minister

o Capitals of countries

o Current events (major)

For illiterates –

o Seasons, crops, and fruits grown in particular seasons

o Prizes of food grains or food items.

o Prizes of land

 COMPREHENSION :

The ability to understand questions asked during an interview is one index.

Questions of increasing difficulty may be asked

o What will you do when you feel cold ?

o What will you do if it rains, when you start for work ?

o What will you do if you miss the bus when you are on journey ?

o Why should be away from bad company ?

 ARITHMETIC :

Following questions may be asked with increasing time units.

o How much is 4 rupees and 5 rupees ?

o I borrowed 6 rupees from a friend and returned 2 rupees , how much do I still owe to
him?

o If a man buys cloth for 12 rupees and gives the shopkeeper 20 rupees, how much
change would he get back ?

o How many pencils do you buy for 2 rupees if one pencil costs 25 ps.

Time limit for 1-3 questions is 15 secs and for 4th is 30 secs.

 ABSTRACTION :

Tested by similarities, differences and Proverbs

Differences being easy task is always presented before similarities.

Differences –

o Stone / potato

o Fly / butterfly
 o Cinema / radio

o Iron / silver

Similarities –

o Orange / banana

o Dog / lion

o Eye / ear

o North / West

o Table / chair

Proverbs –

The patient is asked the following questions whether he knows what a proverb is

An example of proverb and what it means

When the patient had the concept of a proverb the following may be asked

o Slow and steady wins the race

o A barking dog never bites

o As you sow, so shall you reap

o All that glitters is not gold

o Whether there is a will there is a way

The response of the pt. is to be noted verbatim & the answer is judged to be correct
or incorrect.

 JUDGEMENT:
Is accused in three areas – personal, social, test

o Personal judgement is assessed by inquiries about the patients future plans.

o Social judgement is assessed by observing behaviour in social situations.

o Test judgement – two problems are presented in a manner in which he can comprehend

5. INSIGHT:
Test the pt’s level of awareness of his illness.

o Absent – pt. thinks that he is not at all ill

o Partial – pt. recognizes that he is Ill but gives explanation in physical terms.
o Present – pt. fully realizes the emotional nature of his illness and the cause of his
symptoms.