NOBLE WOMENS COLLEGE

(Affiliated To University Of Calicut & Recognized By Kerala)

MANJERI

DEPARTMENT OF PSYCHOLOGY

INTERNSHIP REPORT

YEAR: 2019-2021

NAME: REEMA K.V

CLASS: IV SEM MSC PSYCHOLOGY

REG NO: NWATMPY015

 BONAFIDE CERTIFICATE

This is to certify that the reports of online clinical practicum is the bonafide

record of work done by REEMA.K.V under the guidance and supervision

of qualified clinical psychologists at TRUST CENTER FOR MINDFUL

LIVING during the 4th semester for fulfilling the requirements of MSc

Psychology Degree, University Of Calicut.

REG NO: NWASMPY015

PLACE: MANJERI FORWARDED TO:

DATE: Ms. ANUPAMA. S. R

HOD, Department of

Psychology

Noble women`s college,

Manjei
INTERNSHIP REPORT
 An internship is an opportunity that employers offer to students interested

in gaining work experience in particular industries. It is the best way to

understand about the skills and qualifications required in a professional

setting. Internships are required to become a licensed psychologist and can

give students an invaluable experience. It is an excellent way to determine, if

the industry and the profession is the best career option to pursue. It helps an

individual to understand more about the field by combining the theory and

practical work experience. Lightner Witmer is generally considered to have

founded clinical psychology in 1896 (Pomerants, 2011).

The term clinical psychology was first used in print by Lightner Witmer

in 1907. Witmer envisioned clinical psychology as a discipline with

similarities to a variety of other fields, specifically medicine, education, and

sociology. A clinical psychologist, therefore, was a person whose work with

others involved aspects of treatment, education, and interpersonal issues. At

his clinic, the first clients were children with behavioural or educational

problems. However, even in his earliest writings, Witmer (1907) foresaw

clinical psychology as applicable to people of all ages and with a variety of

presenting problems. Defining clinical psychology is a greater challenge

today than it was in Witmer’s time. The field has witnessed such tremendous

growth in a wide variety of directions that most simple, concise definitions

fall short of capturing the field in its entirety. As a group, contemporary

clinical psychologists do many different things, with many different goals,

for many different people (Pomerants, 2011).

According to American Psychological Association, the field of “Clinical

Psychology integrates science, theory, and practice to understand, predict,

and alleviate maladjustment, disability, and discomfort as well as to promote

human adaptation, adjustment, and personal development. Clinical

Psychology focuses on the intellectual, emotional, biological, psychological,

social, and behavioural aspects of human functioning across the life span, in

varying cultures, and at all socioeconomic levels” (Pomerants, 2011).

Clinical psychologists are engaged in an enormous range of professional

activities, but psychotherapy is foremost. Since 1973, the number of clinical

psychologists reporting that they are involved in psychotherapy has always

outranked that of any other professional activity. Somewhat they involved in

each of the following activities like, diagnosis/assessment, teaching,

supervision, research/writing, consultation, and administration. Of these,

diagnosis and assessment generally occupy more of clinical psychologists’

time than the others. Overall, it is evident that, clinical psychologists are

involved in multiple professional pursuits across varied employment sites.

The most common work setting for clinical psychologists is private practice,

but university psychology departments and hospitals of various types are

also somewhat frequent. The most common professional activity for clinical

psychologists is psychotherapy, but they also spend significant amounts of

time in assessment, teaching, research, and supervision activities. The

professional roles of counselling psychologists, psychiatrists, social workers,

and school psychologists each overlap somewhat with that of clinical

psychologists, yet clinical psychology has always retained its own unique

professional identity (Pomerants, 2011).

Clinical psychology shares with other mental health professions a

concern to assess and intervene in the prevention and treatment of

emotional, behavioural, and neurological problems. In contrast to psychiatry

and psychiatric nursing, which have their roots in the treatment of

pathology, psychology is grounded in the science of human behaviour.

Among the mental health professions, psychology is unique in its long-

standing research tradition. From the beginning of their academic training,

students in psychology learn to understand, interpret, and conduct

methodologically sound research. In tracing the history of psychological

assessment, intervention, and prevention, it is clear that systematic

observation and evaluation is a hallmark of clinical psychology. Drawing on

a wealth of knowledge about human functioning and development, clinical

psychologists have earned recognition of their expertise in assessment,

treatment, and prevention of serious problems. The field of clinical

psychology is in a process of constant evolution (Hunsley & lee, 2010).

Abnormal psychology is concerned with understanding the nature,

causes, and treatment of mental disorders. The topics and problems within

the field of abnormal psychology surround us every day. Abnormal

behaviour is a maladaptive behaviour detrimental to an individual or a

group. Abnormal psychology is the field of psychology concerned with the

study, assessment, treatment, and prevention of abnormal behaviour.

History of Abnormal Psychology

The oldest known view of psychopathology is that it arose from

supernatural forces, either magical or spiritual in nature. Treatment included

exorcism. Ancient and modern Chinese views of psychopathology consider

its cause to be blocked or significantly imbalanced qi. The ancient Greeks

attributed mental illness to an imbalance of bodily humours. The term

medical model refers to Hippocrates’ view that illness (including

psychological disorders) is due to a biological disturbance. The development

of medicine and medical concepts among Egyptians and Greeks helped

replace ancient supernatural theories with natural ones. Natural theories

reject supernatural forces and instead look to things that can be observed,

known, and measured as potential causes of events. Particularly influential

in moving forward the field of abnormal psychology was Hippocrates, a

Greek physician known as the father of modern medicine. Hippocrates

rejected demons and evil spirits as causes of abnormal behaviour. He

believed the brain was the central organ of the body and that abnormal

behaviour resulted from brain disorders or dysfunctions. Hippocrates

recommended treatments for abnormal behaviour that 6 would restore brain

functioning, including special diets, rest, abstinence from alcohol, regular

exercise, and celibacy. Hippocrates’ work had great impact on later Greek

and Roman physicians. Throughout Greece and Rome, physicians

emphasized a scientific approach to learning about causes of abnormal

behaviour. Because of limited knowledge about human anatomy and biology

experimentation on humans and dissection of human cadavers was illegal—

questionable practices such as bleeding and purging were employed.

However, treatment of abnormal behaviour focused primarily on creating

therapeutic environments that included healthy diets, regular exercise,

massage, and education (Rosenberg & Kosslyn, 2011).

The Middle Age

The middle ages, saw a resurgence of the view that supernatural forces

cause psychopathology; prophets and visionaries were believed to be

possessed or inspired by the will of God. This view persisted into the

Renaissance, when mental illness was viewed as the result of demonic

possession, and witches were thought to be possessed by, or in league with,

the devil. Treatment of the mentally ill consisted of exorcism, those believed

to be witches were burned alive. By the end of the Renaissance, however,

the mentally ill began to be treated more humanely, and asylums were built

throughout Europe, over time, however, these asylums became a place to

keep the mentally ill poor off the street, which led to overcrowded facilities

(Rosenberg & Kosslyn, 2011).

Renaissance

During the Renaissance (15th through 17th centuries), mental illness

continued to be viewed as a result of demonic possession, and witches (who

were possessed by, or in league with, the devil) were held responsible for a

wide variety of ills. During the Renaissance, people believed that witches

put the whole community in jeopardy through their evil acts and through

their association with the devil. The era is notable for its witch hunts, which

were organized efforts to track down individuals who were believed to be in

league with the devil and to have inflicted possession on other people

(Rosenberg & Kosslyn, 2011).

In the years immediately following the Renaissance, mental illnesses

were thought to arise from irrational thinking, but this approach did not lead

to consistent cures. Mesmer proposed that hysteria was caused by blocked

electromagnetic forces in the body, and he developed a humane technique—

mesmerism— to unblock the flow. His treatment was sometimes successful,

possibly because it induced a hypnotic trance. Another new approach to

treating mental disorders during the Renaissance involved special

institutions known as asylums. Institutions to house and care for people who

are afflicted with mental illness. Asylums were initially meant to be humane

settings for those with mental illness. A victim of their success, asylums

became overcrowded as a result of an influx of delinquents and people with

certain medical illnesses (Rosenberg & Kosslyn, 2011).

Reform Movement

Beginning in the 1790s, Pinel championed humane treatment for those in

asylums in France. Based on careful observation, he proposed that there

were different types of madness, and he used a mental treatment—reasoning

with patients—to treat mental disorders. In other European settings, patients

were given moral treatment, which centered on having them live and work

within a community in the countryside. In the United States, Benjamin Rush

initiated the effort to treat the mentally ill more humanely; similarly,

Dorothea Dix strove to ensure that the mentally ill were housed separately

from criminals and treated humanely. However, public institutions for the

mentally ill became overcrowded and underfunded, which reduced the

amount and quality of the treatment that was provided. By the end of the

19th century in Europe and North America, madness was generally viewed

as caused by a medical abnormality. The characterization of the specific type

of medical abnormality varied, however, from country to country and from

decade to decade (Rosenberg & Kosslyn, 2011).

Modern era

With the emergence of modern experimental science in the early part of

the eighteenth century, knowledge of anatomy, physiology, neurology,

chemistry, and general medicine increased rapidly. These advances led to

the gradual identification of the biological, or organic, pathology underlying

many physical ailments Scientists began to focus on diseased body organs as

the cause of physical ailments. It was only another step for these researchers

to assume that mental disorder was an illness based on the pathology of an

organ-in this case, the brain. It will lead to beginning of new classification

system (Rosenberg & Kosslyn, 2011).

 DSM

DSM stands for Diagnostic and Statistical Manual for Mental Disorders.

It is the manual published by the American Psychiatric Association which

lists all classifications of mental disorders. The organizing concept of the

DSM is to assign symptoms to the classification for which they are most

relevant. The Diagnostic and Statistical Manual of Mental Disorders is used

by clinicians and psychiatrists to diagnose psychiatric illnesses. In 2013, a

new version known as the DSM-5 was released and covers all categories of

mental health disorders for both adults and children. The manual is non-

theoretical and focused mostly on describing symptoms as well as statistics

concerning which gender is most affected by the illness, the typical age of

onset, the effects of treatment and common treatment approaches. The DSM

lists a set of disorders and provides detailed descriptions on what constitutes

disorders such as Major Depressive Disorder. It also gives general

description of how frequent the disorder occurs in the general population,

whether it is more common in males or females and other such facts. The

diagnostic process uses five dimensions called ‘axes’ to ascertain symptoms

and overall functioning of the individual. These axes are as follows:

 Axis I - Particular clinical syndromes

 Axis II - Permanent problems (Personality Disorders, Mental Retardation)

 Axis III - General medical conditions

 Axis IV - Psychosocial or environmental problems

 Axis V – Global assessment of functioning (often referred to as GAF)

Diagnosis of abnormal behaviour generally falls into one or more of the

following categories:

1. Anxiety disorders (Phobias, Panic disorders, Obsessive Compulsive

Disorders)

2. Stress disorders (Post traumatic stress disorder (PTSD), Psycho

physiological disorders)

3. Somatoform and Dissociative disorders

4. Mood disorders (Unipolar depression, Bipolar disorders)

5. Suicide

6. Eating disorders (bulimia, anorexia nervosa)

7. Substance related disorders (Depressants, Stimulants, and Hallucinogens)

8. Sexual disorders and gender identity disorders (sexual dysfunction,

paraphilias)

9. Schizophrenia

10. Personality disorders (Paranoia, Schizoid, Antisocial, Border line, some

Anxiety disorders)

11. Disorders of childhood and adolescence (Oppositional defiant disorders,

Attention Deficit Hyper activity Disorders)

12. Disorder of aging and cognition (Dementia, Alzheimer’s disease)

 ICD – 10

ICD stands for the International Classification of Diseases, and its codes

hold critical information about epidemiology, managing health, and treating

conditions. Healthcare professionals use ICD codes to record and identify

health conditions. Public health workers can use the recording of ICD codes

to see trends in health, and track morbidity and mortality. And insurers use

ICD codes to classify conditions and determine reimbursement. It is

published by the World Health Organization (WHO) and which uses unique

alphanumeric codes to identify known diseases and other health problems.

According to WHO, physicians, coders, health information managers, nurses

and other healthcare professionals also use ICD 10-CM to assist them in the

storage and retrieval of diagnostic information. ICD records are also used in

the compilation of national mortality and morbidity statistics. ICD 10 has

been used by (WHO) Member States since 1994. Chapter five covers some

300 “Mental and Behavioural disorders”. The ICD – 10’s chapter five has

been influenced by APA’s DSM-IV and there is a great deal of concordance

between the two. Below are the main categories of disorders:

 F00 - F09 Organic, including symptomatic, mental disorders.

 F10 - F19 Mental and Behavioural disorders due to psych active substance

use.
 F20 - F29 Schizophrenia and schizotypal and delusional disorders.

 F30 - F39 Mood [Affective] disorders.

 F40 - F49 Neurotic, stress- related and somatoform disorders.

 F50 - F59 Behavioural syndromes associated with physiological

disturbances and physical factors.

 F60 - F69 Disorders of adult personality and behaviour

 F70 - F79 Mental Retardation

 F80 - F89 Disorders of psychological development.

 F90 - F98 Behavioural and emotional disorders with onset usually occurring

in childhood and adolescence.

 F99 - Unspecified mental disorder.

 HISTORY OF THE HOSPITAL

The chapter aims to know light at the historical milestone, the mission

statements and the functioning of TRUST CENTER FOR MINDFUL

LIVING, Manjeri, here the candidate had undergone her online clinical

internship training from first day (JANUARY 5) to the final day

(JANUARY 20). The online internship program was intended towards the

enhancement of the quality of the psychology students and professionals and

thus for meeting the demands of modern society through practice and

training in counselling and psychotherapy.

The candidate has done their clinical practicum work at AL MADINA

HOSPITAL OF ADVANCED SCIENCE (ALMAS) KOTTAKKAL (50

hours of clinical practise and case taking), one of the pioneers of

psychological health care in Kerala. This chapter gives a clear picture about

the faculties and facilities available generally in the institution and

particularly in the department of clinical psychology.

Trust Center for Mindful Living is an organization established with the

intention of promoting mental wellness of the society and thus to reduce the

occurrence of becoming mentally ill rather than treating the mental illness.

We strive towards the development of a healthier world by reducing the risk

of mental illness. The primary goal of the organization is to promote mental

health by creating awareness in the society and to help individuals to

overcome mental health issues by providing professional services.

Professional training programs are also conducted to enhance the expertise

of the young budding professionals in the field of mental health and thus to

promote the wellbeing of the society.

MISSION

The mission of TRUST is to provide people with work by applying key

psychosocial and behavioral skills in their day to day work will improve

overall mental health in primary healthcare. They are a team of

psychologists specialized in individual counseling, family counseling,

psychotherapies and psychological assessment. They have well trained

psychologists in evidence based psychotherapy models and stay up to date

on new development and research.

A commendable accomplishment of the trust is dedicated in providing

high quality medical and health care at lowest feasible cost, primarily

benefiting the surrounding districts and serving the society beyond

boundaries. Promotion of mental health and psychological wellbeing of the

society, action towards the primary prevention of mental health problems,

enhancement of the professional expertise in different fields of psychology,

promotion of research and higher education in the field of psychology are

also focused.

ALMAS Hospital
 A trusted name in health care delivery, Almas is an NABH accredited

hospital. The hospital was established in 2002 with the mission of providing

world class treatment to all at an affordable rate. The hospital has

established all important departments adequately manned with a qualified

and experienced professional team of doctors, nurses and paramedical staff

and equipped with state of the art ultra-modern investigative and therapeutic

biomedical equipment.

Two decades indeed is a very short time in the history of Almas, by when

the humble 10 bedded unit has evolved into the 400 bedded (and still

expanding) unit. This tremendous achievement indeed is the result of the

hard and dedicated efforts of the health care team and the supporting staff

under the leadership of its Chairman & Managing Director Dr. P.A. Kabeer.

Recently Almas established its own Dialysis Department with 22 dialysis

machines handled by well qualified technicians to provide dialysis services

to the poor free of cost in association with Integrated Medical Brotherhood

(IMB) Kerala Chapter.

Since its inception, Almas has always kept its promises intact. It moves

ahead in total acceptance of the Holy and Divine Touch in healing: “Almas

treats; Almighty Heals”

Psychiatry and Psychology

This Department provides diagnostic & treatment services for all

Psychiatric and Neuro-Psychiatric disorders. The special clinics functioning

 here are the Consultation Liaison Psychiatry, Stress Management Programs,

Suicide prevention Clinic, after care for head injury victims, De-addiction

Programs, Child Guidance Clinic and Teenage Guidance Clinic.

Facilities and services

 General Psychiatry – Management of Psychiatric Disorders

 De addiction services. Management of Alcohol, Smoking.

 Prevention of suicidal tendencies

 Child psychiatry

 Anxiety, depression, and other emotional difficulties

 Adolescent issues

 Couple and family problems

 Stress management

 Behavioral Problems

 School Problems

A wide range of therapeutic modalities are available, including

 Cognitive – Behavioral Therapy

 Behaviors Modification

 Relaxation Therapy

 Counseling

 Remedial Training

 Marital Therapy

 Cognitive retraining & rehabilitation

 Early interventions in the management of autism in children, remedial

education for the learning disabled is also focused

WORK CARRIED OUT UNDER SUPERVISION

The candidate had undergone a 15 days online internship program under

“Trust centre for mindful living”. And a 50 hours of clinical practice and

case taking at ALMAS, Hospital, Kottakkal. This chapter describes the

important events and activities of the student attended in the online

internship training from the first day (january 5) to the final day (january 20)

and undergone in the institute under the supervision of clinical psychologist

for 50 hours of the clinical practicum and case taking.

ORIENTATION:

On the first day of the online internship, beginning with an introductory

session held by Dr. Prajeesh Palathara with a topic of “basics of counselling

and psychotherapy”. In later session’s topics like, case assessment and

analysis, person centred counselling, behaviour therapy and basics of CBT,

and also psychological assessment and testing was held. At the time of

ending a brief session of mindfulYoga and meditation and also concepts in

research was taken.

After the completion of the online internship the candidate was given a

chance for the clinical practise and for case taking at the ALMAS, Hospital,

Kottakkal. The student met Dr.Aslam Siddique. He described the general

rules and regulations of the department. Then the student got registered

herself by accepting those rules and regulations. Our clinical practice for 50

hours officially began from the date of registration.

OBSERVATION:

The student was posted under the assistance of Dr. Aslam Siddiuque. The

working hours began at 9 a.m. and ended at 1.30 p.m. on all days. During

this time the candidate got the opportunity to observe all the clinical

activities including psychometric testing, diagnosis, psychotherapy and

counselling carried out at the department. Observation was exposed

to outpatients who were suffering from the more serious form of mental

illness which require some guidance and support.

CLASSES AND CASE DISCUSSIONS:

During the clinical practicum period, the student could attend the clinical

meetings, where the cases diagnosed, and treatment plan were noted. Every

day of the practicum carried out clinical case discussion and

psychopathology related classes in the department. It includes;

• Counselling skills developments.

• Qualities of a successful therapist.

• Detailed case history and MSC taking process.

• Descriptions about psychopathological disorders (Bipolar disorder,

Schizophrenia, sexual deviations, depression etc.)

SUPERVISED WORK:
 The student prepared detailed case histories and observed the therapeutic

procedures carried out under supervision of a certified clinical psychologist.

The student could collect ten cases of varying symptomatic nature. Under

his supervision the candidate got an opportunity to take part in psycho

diagnosis, psychological assessments, and clinical activities of the

department, case discussions, and classes by the clinical psychologist.

Overall, the practicum works at ALMAS. It was indeed a good experience

which gave the student lifelong treasure and useful knowledge.

BENEFITS OF INTERNSHIP

The internship at ALMAS, Kottakkal provided an opportunity to involve

in the following routine activities of the hospital, assessment, therapies and

counselling. We could learn the formal functional activities of the hospital.

Learned to take case studies and understand more about psychiatric illness.

The hospital provides services such as CBT, relaxations, marital therapy,

counselling, managing autism etc. to the patients, and could learn more

about it by assisting the doctor and psychologists. It helped to develop the

skills and techniques that are applicable to the future career. By interacting

with the patients and bystanders we could understand the difference and

depth of each illness and issues for which they are in the hospital. We could

understand and attain the qualities required for a clinical setting and learn

more details about taking case history and mental status examination. I could

understand the clinical, legal and ethical functioning in a medical setting and

I learned that it is very important to have an empathetic attitude towards the

patients while working in a medical setting. We also learned that it is very

important to continue the medication of the patients in order to prevent the

recurrence and that the psycho education given to the patient and their

bystanders provide awareness about mental health and various psychiatric

illnesses.

CONCLUSION

The 15 days online internship program from january 5 to january 20

helped to obtain an understating and getting theoretical basis of basic and

counselling and psychotherapy. The 50 hours of clinical practice helped to

obtain experience in the medical setting and could develop diagnostic skills.

And to know more about various psychiatric illnesses, and its treatment

methods. This internship helped to combine theory with practical work

experience and to develop professional work habits, and gave an opportunity

to analyze the functions in a hospital setting.

EVALUATION

The opportunity to take individual case studies and the participation in

multidisciplinary teams, including consultation of patients, mental health

staff, and medical staff (nurses) helped the trainee to understand the mental

health services within the medical setting. The 15 days of online internship

and a 50 hours of clinical practice at ALMAS hospital helped the trainee to

develop the skills and techniques that are applicable to the future career.
MAJOR PSYCHOLOGICAL DISORDERS

• Schizophrenia (F 20)

• Obsessive Compulsive Disorder (F 42)

• Learning Disability

• Drug Abuse

• Sexual Disorders (F52)

• Conduct Disorder (F 91)

• Dissociative Disorder (F44)

• Mental Retardation (F 70-79)

• Personality Disorders (F60)

• Attention Deficit Hyperactivity Disorder

• Anxiety Disorders (F 41)

• Organic Insomnia (F51.0)

SCHIZOPHRENIA (F 20)

The schizophrenic disorders are characterized in general by fundamental

and characteristic distortions of thinking and perception, and by

inappropriate or blunted affect. Clear consciousness and intellectual capacity

are usually maintained, although certain cognitive deficits may evolve in the

course of time. The disturbance involves the most basic functions that give

the normal person a feeling of individuality, uniqueness, and self-direction.

The most intimate thoughts, feelings, and acts are often felt to be known to
or shared by others, and explanatory delusions may develop, to the effect

that natural or supernatural forces are at work to influence the afflicted

individual's thoughts and actions in ways that are often bizarre. The

individual may see himself or herself as the pivot of all that happens.

Hallucinations, especially auditory, are common and may comment on

the individual's behaviour or thoughts. Perception is frequently disturbed in

other ways: colours or sounds may seem unduly vivid or altered in quality,

and irrelevant features of ordinary things may appear more important than

the whole object or situation. Perplexity is also common early on and

frequently leads to a belief that everyday situations possess a special, usually

sinister, meaning intended uniquely for the individual. In the characteristic

schizophrenic disturbance of thinking, peripheral and irrelevant features of a

total concept, which are inhibited in normal directed mental activity, are

brought to the fore and utilized in place of those that are relevant and

appropriate to the situation. Thus thinking becomes vague, elliptical, and

obscure, and its expression in speech sometimes incomprehensible. Breaks

and interpolations in the train of thought are frequent, and thoughts may

seem to be withdrawn by some outside agency. Mood is characteristically

shallow, capricious, or incongruous. Ambivalence and disturbance of

volition may appear as inertia, negativism, or stupor. Catatonia may be

present. The onset may be acute, with seriously disturbed behaviour, or

insidious, with a gradual development of odd ideas and conduct. The course

of the disorder shows equally great variation and is by no means inevitably

chronic or deteriorating (the course is specified by five-character categories).

In a proportion of cases, which may vary in different cultures and

populations, the outcome is complete, or nearly complete, recovery. The

sexes are approximately equally affected but the onset tends to be later in

women.

• F20.0 Paranoid schizophrenia: This is the commonest type of

schizophrenia in most parts of the world. The clinical picture is dominated

by relatively stable, often paranoid, delusions, usually accompanied by

hallucinations, particularly of the auditory variety, and perceptual

disturbances. Disturbances of affect, volition, and speech, and catatonic

symptoms, are not prominent.

• F20.1 Hebephrenic schizophrenia: A form of schizophrenia in which

affective changes are prominent, delusions and hallucinations fleeting and

fragmentary, behaviour irresponsible and unpredictable, and mannerisms

common. The mood is shallow and inappropriate and often accompanied by

giggling or self-satisfied, self-absorbed smiling, or by a lofty manner,

grimaces, mannerisms, pranks, hypochondriacal complaints, and reiterated

phrases. Thought is disorganized and speech rambling and incoherent. There

is a tendency to remain solitary, and behaviour seems empty of purpose and

feeling. This form of schizophrenia usually starts between the ages of 15 and

25 years and tends to have a poor prognosis because of the rapid

development of "negative" symptoms, particularly flattening of affect and

loss of volition.
• F20.2 Catatonic schizophrenia: Prominent psychomotor disturbances

are essential and dominant features and may alternate between extremes

such as hyperkinesis and stupor, or automatic obedience and negativism.

Constrained attitudes and postures may be maintained for long periods.

Episodes of violent excitement may be a striking feature of the condition.

For reasons that are poorly understood, catatonic schizophrenia is now rarely

seen in industrial countries, though it remains common elsewhere. These

catatonic phenomena may be combined with a dream-like (oneiroid) state

with vivid scenic hallucinations.

• F20.3 Undifferentiated Schizophrenia: Conditions meeting the general

diagnostic criteria for schizophrenia, but not conforming to any of the above

subtypes (F20.0-F20.2), or exhibiting the features of more than one of them

without a clear predominance of a particular set of diagnostic characteristics.

This rubric should be used only for psychotic conditions (i.e. residual

schizophrenia, F20.5, and post-schizophrenic depression, F20.4, are

excluded) and after an attempt has been made to classify the condition into

one of the three preceding categories.

• F20.4 Post-schizophrenic Depression: A depressive episode, which

may be prolonged, arising in the aftermath of a schizophrenic illness. Some

schizophrenic symptoms must still be present but no longer dominate the

clinical picture. These persisting schizophrenic symptoms may be "positive"

or "negative", though the latter are more common. It is uncertain, and

immaterial to the diagnosis, to what extent the depressive symptoms have

merely been uncovered by the resolution of earlier psychotic symptoms

(rather than being

a new development) or are an intrinsic part of schizophrenia rather than a

psychological reaction to it. They are rarely sufficiently severe or extensive

to meet criteria for a severe depressive episode (F32.2 and F32.3), and it is

often difficult to decide which of the patient's symptoms are due to

depression and which to neuroleptic medication or to the impaired volition

and affective flattening of schizophrenia itself. This depressive disorder is

associated with an increased risk of suicide.

• F20.5 Residual Schizophrenia: A chronic stage in the development of a

schizophrenic disorder in which there has been a clear progression from an

early stage (comprising one or more episodes with psychotic symptoms

meeting the general criteria for schizophrenia described above) to a later

stage characterized by long-term, though not necessarily irreversible,

"negative" symptoms.

• F20.6 Simple Schizophrenia: An uncommon disorder in which there is

an insidious but progressive development of oddities of conduct, inability to

meet the demands of society, and decline in total performance. Delusions

and hallucinations are not evident, and the disorder is less obviously

psychotic than the hebephrenic, paranoid, and catatonic subtypes of

schizophrenia. The characteristic "negative" features of residual

schizophrenia (e.g. blunting of affect, loss of volition) develop without being

preceded by any overt psychotic symptoms. With increasing social

impoverishment, vagrancy may ensue and the individual may then become

self-absorbed, idle, and aimless.

OBSESSIVE COMPULSIVE DISORDER (F 42)

The essential feature is recurrent obsessional thoughts or compulsive

acts. Obsessional thoughts are ideas, images, or impulses that enter the

patient's mind again and again in a stereotyped form. They are almost

invariably distressing and the patient often tries, unsuccessfully, to resist

them. They are, however, recognized as his or her own thoughts, even

though they are involuntary and often repugnant. Compulsive acts or rituals

are stereotyped behaviours that are repeated again and again. They are not

inherently enjoyable, nor do they result in the completion of inherently

useful tasks. Their function is to prevent some objectively unlikely event,

often involving harm to or caused by the patient, which he or she fears might

otherwise occur. Usually, this behaviour is recognized by the patient as

pointless or ineffectual and repeated attempts are made to resist. Anxiety is

almost invariably present. If compulsive acts are resisted the anxiety gets

worse.

• F42.0 Predominantly obsessional thoughts or ruminations: These

may take the form of ideas, mental images, or impulses to act, which are

nearly always distressing to the subject.

Sometimes the ideas are an indecisive, endless consideration of alternatives,

associated with an inability to make trivial but necessary decisions in day-to-

day living. The relationship between obsessional ruminations and depression

is particularly close and a diagnosis of obsessive-compulsive disorder should

be preferred only if ruminations arise or persist in the absence of a

depressive episode.

• F42.1 Predominantly compulsive acts [obsessional rituals]: The

majority of compulsive acts are concerned with cleaning (particularly hand

washing), repeated checking to ensure that a potentially dangerous situation

has not been allowed to develop, or orderliness and tidiness.

Underlying the overt behavior is a fear, usually of danger either to or caused

by the patient, and the ritual is an ineffectual or symbolic attempt to avert

that danger.

• F42.2 Mixed obsessional thoughts and acts

• F42.8 Other obsessive-compulsive disorders

• F42.9 Obsessive-compulsive disorder, unspecified

CONDUCT DISORDERS:

F91 Conduct disorders: Conduct disorders are characterized by a repetitive

and persistent pattern of dissocial, aggressive, or defiant conduct. Such

behaviour, when at its most extreme for the individual, should amount to

major violations of age-appropriate social expectations, and is therefore

more severe than ordinary childish mischief or adolescent rebelliousness.

Isolated dissocial or criminal acts are not in themselves grounds for the

diagnosis, which implies an enduring pattern of behaviour. Judgements

concerning the presence of conduct disorder should take into account the

child's developmental level. Temper tantrums, for example, are a normal

part of a 3-year-old's development and their mere presence would not be

grounds for diagnosis. Equally, the violation of other people's civic rights (as

by violent crime) is not within the capacity of most 7-year-olds and so is not

a necessary diagnostic criterion for that age group.

• F91.0 Conduct disorder confined to the family context: Conduct

disorder involving dissocial or aggressive behaviour (and not merely

oppositional, defiant, disruptive behaviour), in which the abnormal

behaviour is entirely, or almost entirely, confined to the home and to

interactions with members of the nuclear family or immediate household.

The disorder requires that the overall criteria for F91.- be met; even severely

disturbed parentchild relationships are not of themselves sufficient for

diagnosis.

• F91.1 Unsocialized conduct disorder: Disorder characterized by the

combination of persistent dissocial or aggressive behaviour (meeting the

overall criteria for F91.- and not merely comprising oppositional, defiant,

disruptive behaviour) with significant pervasive abnormalities in the

individual's relationships with other children.

• F91.2 Socialized conduct disorder: Disorder involving persistent

dissocial or aggressive behaviour (meeting the overall criteria for F91 - and

not merely comprising oppositional, defiant, disruptive behaviour) occurring

in individuals who are generally well integrated into their peer group.

• F91.3 Oppositional defiant disorder: Conduct disorder, usually

occurring in younger children, primarily characterized by markedly defiant,

disobedient, disruptive behaviour that does not include delinquent acts or the

more extreme forms of aggressive or dissocial behaviour. The disorder

requires that the overall criteria for F91.- be met; even severely mischievous

or naughty behaviour is not in itself sufficient for diagnosis. Caution should

be employed before using this category, especially with older children,

because clinically significant conduct disorder will usually be accompanied

by dissocial or aggressive behaviour that goes beyond mere defiance,

disobedience, or disruptiveness.

• F91.8 Other conduct disorders

• F91.9 Conduct disorder, unspecified

SEXUAL DISORDERS (F 65)

• F65.0 Fetishism: Reliance on some non-living object as a stimulus for

sexual arousal and sexual gratification. Many fetishes are extensions of the

human body, such as articles of clothing or foot ware. Other common

examples are characterized by some particular texture such as rubber,

plastic, or leather. Fetish objects vary in their importance to the individual:

in some cases they serve simply to enhance sexual excitement achieved in

ordinary ways (e.g. having the partner wear a particular garment).

• F65.1 Fetishistic transvestism: The wearing of clothes of the opposite

sex principally to obtain sexual excitement.

• F65.2 Exhibitionism: A recurrent or persistent tendency to expose the

genitalia to strangers (usually of the opposite sex) or to people in public

places, without inviting or intending closer contact. There is usually, but not

invariably, sexual excitement at the time of the exposure and the act is

commonly followed by masturbation. This tendency may be manifest only at

times of emotional stress or crises, interspersed with long periods without

such overt behaviour.

• F65.3 Voyeurism: A recurrent or persistent tendency to look at people

engaging in sexual or intimate behaviour such as undressing. This usually

leads to sexual excitement and masturbation and is carried out without the

observed people being aware.

• F65.4 Paedophilia: A sexual preference for children, usually of

prepubertal or early pubertal age. Some paedophiles are attracted only to

girls, others only to boys, and others again are interested in both sexes.

• F65.5 Sadomasochism: A preference for sexual activity that involves

bondage or the infliction of pain or humiliation. If the individual prefers to

be the recipient of such stimulation this is called masochism; if the provider,

sadism. Often an individual obtains sexual excitement from both sadistic and

masochistic activities.

MENTAL RETARDATION (F 70 – 79)

A condition of arrested or incomplete development of the mind, which is

especially characterized by impairment of skills manifested during the

developmental period, skills which contribute to the overall level of

intelligence, i.e. cognitive, language, motor, and social abilities.

Retardation can occur with or without any other mental or physical

condition. Degrees of mental retardation are conventionally estimated by

standardized intelligence tests. These can be supplemented by scales

assessing social adaptation in a given environment. These measures provide

an approximate indication of the degree of mental retardation. The diagnosis

will also depend on the overall assessment of intellectual functioning by a

skilled diagnostician. Intellectual abilities and social adaptation may change

over time, and, howeverpoor, may improve as a result of training and

rehabilitation. Diagnosis should be based on the current levels of

functioning.

• F70 Mild mental retardation: Approximate IQ range of 50 to 69 (in

adults, mental age from 9 to under 12 years). Likely to result in some

learning difficulties in school. Many adults will be able to work and

maintain good social relationships and contribute to society.

• F71 Moderate mental retardation: Approximate IQ range of 35 to 49

(in adults, mental age from 6 to under 9 years). Likely to result in marked

developmental delays in childhood but most can learn to develop some

degree of independence in self-care and acquire adequate communication

and academic skills. Adults will need varying degrees of support to live and

work in the community.

• F72 Severe mental retardation: Approximate IQ range of 20 to 34 (in

adults, mental age from 3 to under 6 years). Likely to result in continuous

need of support.

• F73 Profound mental retardation: IQ under 20 (in adults, mental age

below 3 years). Results in severe limitation in self-care, continence,

communication and mobility.

• F78 Other mental retardation

• F79 Unspecified mental retardation

DISSOCIATIVE DISORDER (F 44)

These disorders have previously been classified as various types of

"conversion hysteria", but it now seems best to avoid the term "hysteria" as

far as possible, in view of its many and varied - 123 - meanings. Dissociative

disorders as described here are presumed to be "psychogenic" in origin,

being associated closely in time with traumatic events, insoluble and

intolerable problems, or disturbed relationships. It is therefore often possible

to make interpretations and presumptions about the individual's means of

dealing within intolerable stress, but concepts derived from any one

particular theory, such as "unconscious motivation" and "secondary gain",

are not included among the guidelines or criteria for diagnosis.

PHOBIC ANXIETY DISORDERS (F40)

In this group of disorders, anxiety is evoked only, or predominantly, by

certain welldefined situations or objects (external to the individual) which

are not currently dangerous. As a result, these situations or objects are

characteristically avoided or endured with dread. Phobic anxiety is

indistinguishable subjectively, physiologically, and behaviourally from other

types of anxiety and may vary in severity from mild unease to terror. The

individual's concern may focus on individual symptoms such as palpitations

or feeling faint and is often associated with secondary fears of dying, losing

control, or going mad. The anxiety is not relieved by the knowledge that

other people do not regard the situation in question as dangerous or

threatening. Mere contemplation of entry to the phobic situation usually

generates anticipatory anxiety.

• F40.0 Agoraphobia: The term therefore refers to an interrelated and

often overlapping cluster of phobias embracing fears of leaving home: fear

of entering shops, crowds, and public places, or of travelling alone in trains,

buses, or planes. Although the severity of the anxiety and the extent of

avoidance behaviour are variable, this is the most incapacitating of the

phobic disorders and some sufferers become completely housebound; many

are terrified by the thought of collapsing and being left helpless in public.

The lack of an immediately available exit is one of the key features of many

of these agoraphobic situations. Most sufferers are women and the onset is

usually early in adult life.

• F40.1 Social phobias: they often start in adolescence and are centered

around a fear of scrutiny by other people in comparatively small groups (as

opposed to crowds), usually leading to avoidance of social situations. Unlike

most other phobias, social phobias are equally common in men and women.

They may be discrete (i.e. restricted to eating in public, to public speaking,

or to encounters with the opposite sex) or diffuse, involving almost all social

situations outside the family circle.

• F40.2 Specific (isolated) phobias: These are phobias restricted to highly

specific situations such as proximity to particular animals, heights, thunder,

darkness, flying, closed spaces, urinating or defecating in public toilets,

eating certain foods, dentistry, the sight of blood or injury, and the fear of

exposure to specific diseases. Although the triggering situation is discrete,

contact with it can evoke panic as in agoraphobia or social phobias.

• F41.1 Generalized anxiety disorder: The essential feature is anxiety,

which is generalized and persistent but not restricted to, or even strongly

predominating in, any particular environmental circumstances (i.e. it is

"free-floating"). As in other anxiety disorders the dominant symptoms are

highly variable, but complaints of continuous feelings of nervousness,

trembling, muscular tension, sweating, lightheadedness, palpitations,

dizziness, and epigastric discomfort are common. Fears that the sufferer or a

relative will shortly become ill or have an accident are often expressed,

together with a variety of other worries and forebodings.

CASE STUDIES
 Case study is an intensive study of a case which may be an individual, an

institution, a system, a community, an organization, an event, or even the entire

culture. Yin has defined case study as “an empirical inquiry that investigates a

contemporary phenomenon within its real life context, when the boundaries

between phenomenon within its real- its real-life context, when the boundaries

between phenomenon and context are not clearly evident, and in which multiple

source of evidence are used”. It is, thus, a kind of research design which usually

involves the qualitative method of selecting the source of data. It presents the

holistic account that offers insights into the case under study. When attention is

focused on the development of the case, it is called case history (Ahuja, 2001).

Case study is not a method of data collection; rather it is a research

strategy, or an empirical inquiry that investigates a contemporary phenomenon

by using multiple sources of evidence. Mitchell (1983) has also maintained that

a case study is not just a narrative account of an event or series of events but it

involves analysis against an appropriate theoretical frame work or in support of

theoretical conclusions. Case study can be simple and specific, such as “Ram,

the delinquent boy” or complex abstract, such as decision making in a

university.” But whatever the subject, to qualify as a case study, it must be a

bounded system/ unit, an entity in itself. Case studies have been used for various

purpose descriptive, exploratory and exploratory-research- and also to generate

theory. While a case study can be either quantitative or qualitative, or even a

combination of both, but most case studies lie within the realm of qualitative

methodology. It is the preferred strategy when “how, who, why and what”
 question is being asked or when the focus is on a contemporary phenomenon

within a real-life context

(Ahuja, 2001).

The purpose of the case study method is to understand the important

aspects of the life cycle unit. In fact, such study deeply analyses and

interprets the interactions between the different factors that influence the

change or growth of the unit. Thus, it is basically a longitudinal approach

which studies the unit over a period of time. A review of literature in this

field reveals that case studies are not confined to the study of individuals

and their important behavioral characteristics, rather, case studies have been

made of all type of communities and of all types of individuals.

METHOD OF DATA COLLECTION

In case study data are gathered through several methods or techniques.

Some of the important ones are as follow:

 Observation of behavior, characteristics, and social qualities of the

unit by the researcher.

 Use of questionnaires, opinionnaires, inventories, checklists and other

psychological tests.

 Analysis of recorded data from newspapers, schools, clinics, courts or

other similar sources.

 Interviewing the subjects, their relatives and others. From the

aforesaid discussion, the following major features of the case study

can be isolated:
  The case study is an approach which views a social unit as a whole.

 The social unit need not be an individual only but it may be a family,

a social group, a social institution or a community.

 In case study the unitary character or the social unit is maintained. It

means that the social unit, whatever it is, is studied as a whole.

 In case study the researcher tends to study the aspects of ‘What’ and’

Why’ of the social unit. In other words, here the researcher not only

tries to explain the complex behavioural pattern of the social unit but

also tries to locate those factors which have given rise to such complex

behavioral pattern.

 Since case study is a descriptive research, no variables are

manipulated here.

 In case study the researcher gathers data usually through methods of

observation, interview, questionnaire, opinionnaire and other

psychological tests.

 Analysis of recorded data from newspapers, courts, government

agencies and other similar sources is not uncommon.

Types of Case Studies

Burns (2000) has started six types of case studies:

1) Historical case studies:These studies trace the development of an

organization/ system over time. The study of an adult criminal right from

childhood through adolescence and youth is an example of this type of

 case study. This type depends more on interviews, recording and

documents.

2) Observational case studies : These focus an observing a drunkard, a

teacher, a student, a union leader, some activity, event, or specific group

of people. However, the researchers in this type of study are rarely total

participants or total observers.

3) Oral history case studies:There are usually first person narratives that

the researcher collects using extensive interviewing of a single individual.

Example: - the case of a drug addict or an alcoholic, or a prostitute or a

retired person who fails to adjust himself in son’s family. The use of this

approach depends more on the nature and cooperation of the respondent.

4) Situational case studies: This form studies particular events. The views

of all participants in the event are sought.

5) Clinical case studies:This approach aims at understanding in depth a

particular individual such as a patient in the hospital, a prisoner in the jail,

a woman in a rescue home, a problem child in a school. These studies

involve detailed interviews, observation, going through records and

reports, and so on.

6) Multi-case studies : It is a collection of case studies or a form of

replication, i.e. multiple experiments. For example, we can take three

case studies and analyses them on replication logic. This logic is that
 each case will either produce contrary results/ similar results. The

outcome will demonstrate either support for the initial propositions or a

need to revise and retest with another set of cases. The advantage of

multi-case design is that the evidence can be more compelling. However,

this approach requires more time and efforts (Ahuja, 2001).

CHARACTERISTICS

The important characteristics of the case study method are as under:

 Under this method the researcher can take one single social unit

or more of such units for his study purpose; he may even take a

situation to study the same comprehensively.

 Here the selected unit is studied intensively i.e., it is studied in

minute details. Generally, the study extends over a long period of

time to ascertain the natural history of the unit so as to obtain

enough information for drawing correct inferences.

 In the context of this method we make complete study of the

social unit covering allfacets. Through this method we try to

understand the complex of factors that are operative within a

social unit as an integrated totality.

 Under this method the approach happens to be qualitative and

not quantitative. Mere quantitative information is not collected.

Every possible effort is made to collect information concerning

all aspects of life. As such case study deepens our perception and

gives us a clear 46 insight into life. For instance, under this

 method we not only study how many crimes a man has done but

shall peep into the factors that forced him to commit crimes when

we are making a case study of a man as a criminal. The objective

of the study may be to suggest ways to reform the criminal

 In respect of the case study method an effort is made to know the

mutual interrelationship of casual factors.

 Under case study method the behaviour pattern of the concerning

unit is studied directly and not by an indirect and abstract

approach.

 Case study method results in fruitful hypothesis along with the

data which may be helpful in testing them, and thus it enables the

generalised knowledge to get richer and richer. In its absence,

generalised social science may be handicapped.

ADVANTAGES

 The case study is a mode of organizing data in terms of some

chosen unit such as the person’s life history, the history of a

group or society, and some delimited social processes. This has

the advantage of intensive study of the social unit.

 According to Goodie and Hatt (1981) the case study method

provides sufficient basal facts for developing a suitable

hypothesis regarding the social unit being studied. This is

 possible because of the in-depth analysis of the concerned social

unit.

 In case study the researcher gets sufficient fact for making a

comparison between two similar social units.

 Goodie and Hatt(1981)are of the opinion that the case study

provides opportunity for careful examination of all those relevant

facts data on the basis of which a questionnaire or an opinionnaire

or any psychological test is to be developed. LIMITATIONS

 Subjective bias: The case study design is regarded with disdain because

of investigator’s subjectivity in collecting data for supporting or

refusing a particular explanation.

 Little evidence scientific generalizations: It is said that case study

provides little evidence for inferences and generalizing theory.

 Time consuming: Case study is time-consuming as it produces a lot of

information which is difficult to analyses adequately.

 Doubtful reliability: It is very difficult to establish reliability in the case

study. The investigator cannot prove his authenticity for obtaining data

or having no bias in analyzing them. It is not easy to fix step and

procedures explicitly to the extent that others are enabled to replicate

the same day.

 Missing validity: The investigators in the case study fail to develop a

sufficiently operational set of measures. As, such, checks and balance

of reliable instruments are found missing. For investigator, what seems

true is more important than what is true. The case study can simplify or

exaggerate leading erroneous conclusions. The validity question also

arises because the investigator by his presence and actions affects the

behavior of the observed but he does not give importance to this

reaction while interpreting the facts.

 Yet one more argument against the case study is that it has no

representativeness. i.e., each case studied does not represent other

similar cases (Ahuja, 2001).

In no other branch of Medicine is the history taking interview as

important as in Psychiatry. In psychiatric assessment, history taking

interview and mental status examination need not to always be

conducted separately (though they must be recorded individually).

During assessment, the interviewer should observe any abnormalities in

verbal and non-verbal communication and make note of them (Ahuja,

2011).

A comprehensive psychiatric interview often requires more than

one session. The psychiatric assessment can be discussed under the

following headings (Ahuja, 2011).

Identification of data

It is the best to start the interview by obtaining some identification data

which may include name, age, sex, marital status, education, address, religion,

and socioeconomic background, as appropriate according to the setting. It is

useful to record the source of referral of the patient (Ahuja, 2011).

Informants

Since sometimes the history provided by the patient may be incomplete,

due to factors such as absent insight or uncooperativeness, it is important to take

the patient’s consent before taking this collateral history unless the patient does

not have capacity to consent (Ahuja, 2011).

Finally, a comment should be made regarding the reliability of the

information provided. The reliability of the information provided by the

informants should be assessed on the following parameters are relationship with

patient, intellectual and observational ability, familiarity with the patient and

length of stay with the patient, and degree of concern regarding the patient

(Ahuja,

2011).

Presenting (chief) complaints

The presenting complaints and / or reasons for consultation should be

recorded. Both the patient’s and the informant’s version should be recorded, if

relevant. If the patient has no complaints (due to absent insight) this fact should
 also be noted. It is the important to use patient’s own words and to note the

duration of each presenting complaints. Some of the additional points which

should be noted include: onset of present illness/ symptoms, duration of present

illness/ symptoms, course of symptoms/ illness, predisposing factors,

precipitating factors (include life stressors) and precipitating and/ or relieving

factors (Ahuja, 2011).

History of presenting illness

When the patient was last well or asymptomatic should be clearly noted.

This provides useful information about the onset as well as duration of illness.

Establishing the time of onset is really important as it provides clarity about the

duration of illness and symptoms. The symptoms of the illness, from the earliest

time at which a change was noted (the onset) until the present time, should be

narrated chronologically, in a coherent manner (Ahuja, 2011).

Past psychiatric and medical history

Any history of any past psychiatric illness should be obtained. Any past

history of having received any psychotropic medication, alcohol, and drug abuse

or dependence and psychiatric hospitalization should be enquired. A past history

or any serious medical or neurological illness, surgical procedure, accidents or

hospitalization should be obtained. The nature of treatment received, and

allergies, if any, should be ascertained (Ahuja, 2011).

Treatment history
 Any treatment received in present and/ previous episodes should be asked

along with history of treatment adherence, response to treatment received, any

adverse effects experienced or any drug allergies which should be prominently

noted in medical records (Ahuja, 2011).

Family history

The family history usually includes the ‘family of origin’ (i.e. the patient’s

parents, siblings, grandparents, uncles). The family of procreation (i.e. patient’s

spouse, children and grandchildren) is conventionally recorded under the heading

of personal history. Family history usually recorded under the following headings

which are, family structure (drawing family tree), family history of similar or

other psychiatric illness, major medical illness, alcohol/ drug dependence and

suicide (suicidal attempts) should be recorded, and current social situation

(Ahuja,2011

Personal and social history

In younger patients, it is often possible to give more attention to details

regarding earlier personal history. In older patients, it is sometimes harder to get

a detailed account of the early childhood history. Personal history can be

recorded under the following headings:

• Perinatal history
Difficulties in pregnancy (particularly in the first three months of gestation) such

as any febrile illness, medications, drugs and/ alcohol use; abdominal trauma, any

physical or psychiatric illness should be asked. Other relevant questions may

include whether the patient was a wanted or unwanted child, date of birth,

whether delivery was normal, any instrumentation needed, where born, any

perinatal complications, birth cry, any birth defects, and any prematurity (Ahuja,

2011).

 Childhood history

Whether the patient was brought up by mother or someone else, breast feeding,

weaning and any history suggestive of maternal deprivation should be asked.

The occurrence of neurotic traits should be noted. These including stuttering,

stammering, tics, enuresis, encopresis, night terrors, thumb sucking, nail biting,

head banging, body rocking, morbid fears or phobias, somnambulism, temper

tantrums, and food fads (Ahuja, 2011).

• Educational history

The age of beginning and finishing formal education, academic achievements,

and relationships with peers and teachers should be asked (Ahuja, 2011).

• Play history
 The questions to be asked include, what games were played at what stage, with

whom and where. Relationships with peers, particularly the opposite sex, should

be recorded. The evaluation of play history is obviously more important in the

younger patients (Ahuja, 2011).

• Puberty

The age at menarche, and reaction to menarche (in females), the age at

appearance of secondary sexual characteristics (in both males and females),

nocturnal emissions (in males), masturbation and any anxiety related to changes

in puberty should be asked (Ahuja, 2011).

 Menstrual and obstetric history

The regularity and duration of menses, the length of each cycle, any

abnormalities, the last menstrual period, the number of children born and

termination of pregnancy

(if any) should be asked (Ahuja, 2011).

• Sexual and marital history

Sexual information, how acquired and of what kind; masturbation (fantasy and

activity); sex play, if any; adolescent sexual activity; premarital and extramarital

sexual relationships, if any; sexual practices (normal and abnormal); and any

gender identity disorder are the areas to be enquired about (Ahuja, 2011).
• Premorbid personality

It is the important to elicit details regarding the personality of the individual.

Instead of using labels such as schizoid/ histrionic, it is more useful to describe

the personality in some detail. The following headings are often used for the

description of premorbid personality which are namely, interpersonal relationship,

use of leisure time, predominant mood, attitude to self and others, attitude to work

and responsibility, religious beliefs and moral attitude, fantasy life and habits

(Ahuja,

2011).

• Alcohol and substance history

Although alcohol and drug history is often elicited as a part of personal history, it

is often customary to record it separately. Alcohol and drugs can often contribute

to causation of several psychiatric symptoms and are often present co-morbidly

alongside many psychiatric diagnoses (Ahuja, 2011).

• Physical examination

A detailed general physical examination (GPE) and systematic examination is a

must in every patient. Physical disease, which is etiologically important or

accidently co-existent/ secondarily caused by the psychiatric condition or

treatment, is often present and can be detected by a good physical examination

(Ahuja, 2011).
 MENTAL STATUS EXAMINATION (MSE)

Mental status examination is a standardized format in which the clinician

records the psychiatric signs and symptoms present at the time of interview.

MSE should describe all areas of mental functioning (Ahuja, 2011).

1. General Appearance and Behavior:

A rich deal of information can be elicited from examination of the general

appearance and behavior. While examining, it is important to remember patient’s

socio cultural background and personality. The factors included in general

appearance and behavior are general appearance, attitude towards examiner,

comprehension, posture, motor activity, social manner, presence of any

hallucinatory behavior in the individual is assessed (Ahuja, 2011).

2. Speech:

Speech can be examined under the following things which are:

• Rate and quantity of speech: Whether speech is present or absent (mutism), if

present, whether it is spontaneous, whether productivity is increased or

decreased.

• Volume and tone of speech: Increased/decreased (its appropriateness),

• Flow of speech (Ease of speech): Presence of any stuttering/ stammering,

clang associations, neologisms, any accent, circumstantiality’s, etc... (Ahuja,

2011).
 3. Mood and Affect:

Mood is the pervasive feeling tone which is sustained (lasts for some length of

time) and colors the total experience of the person. Affect, on the other hand, is

the outward objective expression of the immediate, cross-sectional experience of

emotion at a given time. The assessment of mood includes testing the quality of

mood, which is assessed subjectively (‘how do you feel’) and objectively (by

examination). The affect is similarly described under quality of affect, range of

affect (of emotional changes displayed over time), depth or intensity of affect

(normal, in- creased or blunted) and appropriateness of affect (in relation to

thought and surrounding environment (Ahuja, 2011).

4. Thought:

Thought process that is not goal-directed, or not logical, or does not lead to a

realistic solution to the problem at hand, is not considered normal. In the clinical

examination, thought is assessed (by the content of speech) under the four

headings of stream, form, content and possession of thought. Here spontaneity,

obsessive thoughts, phobias, flight of ideas, loosening of association,

perseveration, delusions and the like are assessed (Ahuja, 2011).

5. Perception
 Perception is the process of being aware of a sensory experience and being

able to recognize it by comparing it with previous experiences. Perception is

assessed under the following headings:

• Hallucinations: The presence of hallucinations should be noted. A

hallucination is a perception experienced in the absence of an external

stimulus. The hallucinations can be in the auditory, visual, olfactory,

gustatory or tactile domains (Ahuja, 2011).

• Illusions and misinterpretations: Whether visual, auditory, or in other sensory

fields; whether occur in clear consciousness or not; whether any steps taken to

check the reality of distorted perceptions (Ahuja, 2011).

• Depersonalization/derealisation: Depersonalization and derealisation are

abnormalities in the perception of a person’s reality and are often described as

‘asif’ phenomena (Ahuja, 2011).

• Somatic passivity phenomenon: Somatic passivity is the presence of strange

sensations described by the patient as being imposed on the body by ‘some

external agency’, with the patient being a passive recipient. It is one of the

Schneider’s first rank symptoms (Ahuja, 2011).

4. Cognition (Neuropsychiatric) Assessment:

A significant disturbance of cognitive functions commonly points to the presence

of an organic psychiatric disorder. Here factors such as level of consciousness,

attention, memory, orientation, abstract thinking, concentration and intelligence of

the individual is assessed (Ahuja, 2011).

7. Insight:

Insight is the degree of awareness and understanding that the patient has regarding

his illness. Patient’s attitudes towards his present state; whether there is an illness

or not; is any treatment needed; cause for illness and whether there is hope for

recovery is asked. Depending on the patient’s responses, insight can be graded on

a six-point scale (Ahuja, 2011).

I. Complete denial of illness

II. Slight awareness of being sick and needing help but denying it at the

same time.

III. Awareness of being sick but blaming it on others, external factors, or

medical or unknown organic factors.

IV. Awareness of being sick due to something unknown in self.

V. Intellectual insight: Admission of illness and recognition that

symptoms or failures in social adjustment are due to irrational feelings

or disturbances, without applying that knowledge to future

experiences.

VI. True emotional insight: Emotional awareness of the motives and

feelings within and of the underlying meaning of symptoms, whether

the awareness leads to changes in personality, and future behavior;

 openness to new ideas and concepts about self and important people in

the person’s life.

8. Judgment

Judgment is the ability to assess a situation correctly and act appropriately within

that situation. Both social and test judgment are assessed

• Social judgment is observed during the hospital stay and during the

interview session. It includes an evaluation of ‘personal judgment’.

• Test judgment is assessed by asking the patient what he would do in

certain test situations. Judgment is rated as Good/Intact/Normal or

Poor/Impaired/ Abnormal (Ahuja, 2011).

Formulation:

After a comprehensive psychiatric assessment, a diagnostic formulation

summarizes the detailed positive (and important negative) information regarding

the patient, before listing differential diagnosis, prognostic factors, and a

management plan. The diagnostic formulation focuses on etiological factors

based on the bio psychosocial model. Similarly, it is useful to devise the

management plan based on the bio psychosocial model. Thus, psychiatric

assessment is an initial step towards diagnosis and management of psychiatric

disorders (Ahuja, 2011)