PART-II

PRACTICALS 1 - 12
(Involving Case History Taking and Mental
Status Examination)
&
THE TOOLS TO BE USED

23
24
 PART - II
PRACTICALS 1-12 & THE TOOLS TO BE USED
INTRODUCTION
In this Part, details regarding the following practicals are given:
Practical 1 Case History Taking and Mental Status Examination of a Young
Adult - Male
Practical 2 Case History Taking and Mental Status Examination of a Young
Adult - Female
Practical 3 Case History Taking and Mental Status Examination of an
Individual in Middle Adulthood - Male
Practical 4 Case History Taking and Mental Status Examination of an
Individual in Middle Adulthood - Female
Practical 5 Case History Taking and Mental Status Examination of an Old
Person - Male
Practical 6 Case History Taking and Mental Status Examination of an Old
Person - Female
Practical 7 Case History Taking and Mental Status Examination of a
Preschool Child - Male
Practical 8 Case History Taking and Mental Status Examination of a
Preschool Child - Female
Practical 9 Case History Taking and Mental Status Examination of a Child
in the Middle Childhood Years - Male
Practical 10 Case History Taking and Mental Status Examination of a Child
in the Middle Childhood Years - Female
Practical 11 Case History Taking and Mental Status Examination of an
Adolescent - Male
Practical 12 Case History Taking and Mental Status Examination of an
Adolescent - Female
The tools to be used for history taking and mental status examination of
individuals are also given, viz.
Tool 1: Case History Taking for Adult
Tool 2 : Mental Status Examination Inventory for Adult
Tool 3: Case History Taking for Child/Adolescent
Tool 4: Mental Status Examination Inventory for Child/Adolescent

25
Manual for Supervised Now we would explain in detail how to go about the above mentioned
Practicum
practicals by following the given instructions like writing aim, objectives, method,
tools, findings, analysis and discussion, provisional diagnosis, management plan/
conclusion, and current treatment and observations/ reflections. You need to, of
course, do all the 12 practicals using the tools given in the Manual.

FORMAT TO BE USED FOR DOING AND WRITING DOWN

THE REPORT OF THE PRACTICALS

TITLE : Practical Activity ... (e.g. ‘1’ )—Case History Taking and Mental
Status Examination of ..... (e.g., ‘a Young Adult - Male’)
(In the Practical Title, the individual mentioned would change as per the
practical number)
AIM:
Case history taking and mental status examination of ..... (e.g., ‘a Young Adult
- Male’)
(Under ‘Aim’, the individual mentioned would change as per the practical
number)
OBJECTIVES:
After undertaking this Practical activity, you will be able to:
 Understand the importance of psychiatric case history taking and mental
status examination;
 Know method of taking psychiatric case history in ..... (e.g., ‘a Young Adult
- Male’);
 Apply skills of case history taking in clinical practice;
 Know method of conducting mental status examination in ..... (e.g., ‘a Young
Adult - Male’); and
 Apply skills of assessing mental status of patient.
(Under ‘Objectives’, the individual mentioned would change as per the
practical number)
METHOD:
Materials Required:
Interview schedule for case history taking, Tool for mental health status
examination, pen, paper, tape recorder.

Note: The tools for case history taking and mental status examination are
given in this Section. Use the ones relevant for the individual whom you
have identified for the specific Practical. Thus, for Practicals 1-6, you will
use Tool 1 (meant for case history taking for Adult), and Tool 2 (Mental
Status Examination Inventory for Adult). Likewise, for Practicals 7-12, you
would use Tool 3 (Case History Taking for Child/Adolescent) and Tool 4
(Mental Status Examination Inventory for Child/Adolescent).
26
Sample - The individual identified for the Practical would be as per the title of Case History Taking and Mental
the Practical. Please refer to Course MCFT-001 for the age groups to be Status Examination
selected for each practical.
Procedure:
Identify a patient from the desired age group. Explain the respondent
about the practical activity and convince her or him, and/or the family to give you
an interview. Take a detailed case history and mental status examination (MSE)
by using the given tools. Remember, the schedule is only a broad guideline. If need
be, you can ask more questions or probe further in order to get detailed and
complete information about a topic in the interview. Remember that the patient
has to be accompanied by another person who would be an informant for you
and help in answering your questions. Be sensitive to your respondents. Some of
them may want to take some time to think about the questions. You can also
change the order of some sections in the interview, depending on how the
conversation between you and the respondent progresses. On an average, the
interview should take about 1½ -2 hours. You must record or document the
responses you gathered in the interview, especially for discussions with your
Academic Counsellor and writing report for this practical, and enclose the same
in your file. You may use a tape recorder for recording purpose, after seeking
permission from the respondent. Your report for this practical should include the
case history and mental health status of your respondent and the CD/Tape/Written
Sheets on which the interview was recorded. Refer to the instructions given later
for analysis and report writing for the same.
FINDINGS:
(This would include data obtained from administering the tool of case
history taking and tool for mental status examination.)
........................................................................................................................
........................................................................................................................
........................................................................................................................
In this section, you must enclose the written record of the interview as it look
place. Thereafter, write out the following information on the basis of the interview.
You must also enclose in the File the CD containing the audio recording or the
audio tape if used, or the written sheets (on which you noted the answers of the
respondent during the interview). In this Section, you need to state the information
obtained through interview with the subject and the other informant(s) as well as
that obtained through your own observations. You may use the format of the tools
for the purpose.

ANALYSIS AND DISCUSSION:

........................................................................................................................
........................................................................................................................
........................................................................................................................

27
Manual for Supervised In this section you have to write down your inference and analysis of the
Practicum
observations you have made about the individual. Analyse the behaviour and
characteristics of the individual.
CONCLUSIONS:
........................................................................................................................
........................................................................................................................
........................................................................................................................
In this section you have to conclude this practicum in about 500-750 words. Here
you have to record the inferences that you have been able to draw on the basis
of this practical activity. Broadly, you need to focus on the findings and the
interpretations of the same.
REFLECTIONS:
........................................................................................................................
........................................................................................................................
........................................................................................................................
You may state how you went about this practicum activity, and how your
respondents reacted towards you. Note down any particular behaviour of the
respondent/patient which you came across like too self conscious, adjusting dress
or hair constantly, etc. Write your inner self experience in this whole practicum.
In a simple paragraph of about 250 words, reflect on your experience while
performing this practical.

28
 TOOLS Case History Taking and Mental
Status Examination
You can use the following formats to elicit information from the patient and
accompanying informant who is generally a family member staying with the
patient or some close friend/relative.

Tool 1
Case-History Taking of an Adult
A) Background Information of Patient:
Date of assessment: ........................................................................................
Name: ...............................................................................................................
Age of patient/respondent: ................................................................................
Date of Birth: ....................................................................................................
Sex: ...................................................................................................................
Education: .........................................................................................................
Occupation: .......................................................................................................
Residence: .........................................................................................................
Family Structure: Nuclear/Joint/Other ................................................................
Background Information of Informant:
Name of the informant: .....................................................................................
Relationship with the patient: .............................................................................
Length of acquaintance: .....................................................................................
Adequacy of information: ..................................................................................
Reliability of information: ...................................................................................
B) Specific Information
1. Presenting complaints (Chief complaints to come to the hospital or
seek intervention/help)
According to patient: ......................................................................................
According to informant: ....................................................................................
2. Duration of illness
How long the patient has been ill?
..............................Days / ............................... months / ....................... years
3. Precipitating Factors
Onset (acute or gradual): ................................................................................
Course of illness (time when the patient is unwell and period when he/she feels
better)
29
Manual for Supervised There could be some events for example, marriage, and change of job which
Practicum
could precipitate an illness. Find out if any such things have happened in the
patient’s life before the illness started.
.......................................................................................................................
.......................................................................................................................
4. Family History
Family type: Nuclear/ Extended/ Joint
Socio-economic status: Upper/ Middle/ Lower
Family tree:

S.No Relation with patient Age Education Occupation Health Personality

Family interaction and communication:

.......................................................................................................................
Family history of psychiatric illness:
..............................................................................................................................
Personal history
Date of birth: ...................................................................................................
Place of birth: ..................................................................................................
Mother’s condition during pregnancy: ..............................................................
Full term birth/ normal delivery/others: .............................................................
Any delay in early development and milestones (for example: neck holding
sitting, walking, talking etc.): Yes/ No
If yes, please mention: .....................................................................................
Neurotic symptoms in childhood (like temper tantrums): Yes/ No
If yes, please mention: .....................................................................................
Night terrors: Yes/ No
Behaviour problems like thumb sucking or nail biting etc.: Yes/No
If yes, please mention: .....................................................................................
30
Health during childhood Case History Taking and Mental
Status Examination
If patient suffered from any childhood infections or illness? Yes/ No
If yes, please mention if there was any effect of illness on development?
........................................................................................................................
If patient suffered from any infantile convulsions? Yes/No
School: .............................................................................................................
Special abilities/disabilities: ................................................................................
Performance in academics: ...............................................................................
Number of friends: ...........................................................................................
Relationship with peers: ....................................................................................
Participation in co-curriculum activities like drama/sports etc.: .........................
Hobbies and interests: ......................................................................................
Occupation
Age of starting work: .......................................................................................
Ambition in life: ................................................................................................
Present jobs held:
- Designation: .....................................................................................
- Wages: ..............................................................................................
Satisfaction in work: .........................................................................................
Present economic conditions: ...........................................................................
Menstrual history (for female patients)
Age of 1st period: ...........................................................................................
Regularity/duration: ..........................................................................................
Amount of pain: ..............................................................................................
Sexual inclinations and practice
Sexual information/how acquired: ....................................................................
Masturbation/sexual fantasies: ..........................................................................
Homosexuality/hetero sexuality: .......................................................................
Marital history
Spouse’s age: ................................................................................................
Occupation: .....................................................................................................
Personality: ......................................................................................................
Compatibility: .................................................................................................. 31
Manual for Supervised Pre-morbid Personality
Practicum
Ask from patient and informant to describe her or his personality before the illness
started. Like:
i) Social relations with
 Family: .............................................................................................
 Friends: ............................................................................................
 Relatives: ..........................................................................................
 Societies: ..........................................................................................
 Workmates: ......................................................................................
ii) Intellectual activities like:
 Hobbies:...........................................................................................
 Interests:...........................................................................................
 Memory: ..........................................................................................
 Observation: .....................................................................................
 Judgement: .......................................................................................
iii) Mood of patient:
 Bright/cheerful:..................................................................................
 Despondent: .....................................................................................
 Optimistic :.......................................................................................
 Pessimistic: .......................................................................................
 Self depreciative: ..............................................................................
 Satisfied:...........................................................................................
 Stable: ..............................................................................................
 Unstable: ..........................................................................................
iv) Character
 Attitude to work or responsibility:....................................................
 Interpersonal relationships:................................................................
 Standards in religious/social/health matters:....................................
v) Fantasy life
 Frequency and content of day dreaming: .........................................
vi) Habits
 Eating/alcohol consumption: ..............................................................
 Self medication: ................................................................................

32  Tobacco consumption:......................................................................
Mode and frequency of sexual intercourse: ................................................. Case History Taking and Mental
Status Examination
Sexual satisfaction: ........................................................................................
Contraceptive measures: ................................................................................
Children
Chronological list of children and miscarriages: .........................................
.......................................................................................................................

S.No. Year of birth Name Sex Personality

Medical history
Has the patient undergone any:
 illness
 operation
 accidents
 surgical problem
If yes, Please mention: ..............................................................................
Past psychiatric history
Information of patient’s past psychiatry record:
 Dates: ....................................................................................................
 Duration: ................................................................................................
 Symptoms: ..............................................................................................
 Diagnosis: ..............................................................................................
 Treatment: ..............................................................................................

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Manual for Supervised
Practicum Tool 2
Mental Status Examination Inventory for Adults
This is systematic observation on a standard format. Use the following format to
observe the patient and ask the following questions.
I) General Appearance of Behaviour
(This comprises of a brief description regarding the patient’s appearance,
behaviour and manner of relating to the examiner. This helps to elicit any
abnormalities that might be evident in the way the person appears and
relates to the examiner, for example, a patient suffering from a psychotic
episode may not be able to establish base on support with the examiner.
He/she may look overdressed or untidy and may not cooperate with the
examiner.)
i) General appearance
Record the following observations:
 Physique of body build:
Approximate height: ..................................................................................
Weight: .....................................................................................................
Appearance: .............................................................................................
 Looks: Comfortable/Uncomfortable
 Physical health:
Grooming: .................................................................................................
Hygiene: ....................................................................................................
Self care: ..................................................................................................
Dressing: appropriate/adequate/any peculiarities
 Non verbal expression : ....................................................................
 Mood: ...............................................................................................
 Effeminate/masculine: .........................................................................
ii) Attitude towards the examiner/counsellor
Is the patient
− Cooperative
− Guarded
− Evasive
− Hostile
− Attentive
− Interested/disinterested/apathetic
− Any odd behaviour
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iii) Comprehension Case History Taking and Mental
Status Examination
Can patient understand your questions?
− Intact/impaired (Partially/fully)
iv) Gait and posture

Posture Normal Abnormal

Way of sitting
Standing
Walking

v) Motor Activity
This is observed while interacting with the patient.
 Increased/Decreased
 Excitement/Stupor
 Abnormal involuntary movements : Tics, Tremors
 Restlessness
 Catatonic signs:
− Mannerisms (habitual involuntary movement)
− Stereotypes ( repetitions of physical activities)
− Posturing (strange, fixed and bizarre bodily positions)
− Waxy flexibility (condition in which person maintains the body
position in which he or she is placed)
− Negativism (verbal or non-verbal opposition to suggestion)
− Ambitendency (making series of movements that don’t reach the
goal)
− Stupor (state of decreased activity and less awareness of
surroundings)
− Echolalia (repetitions of words or phrases)
 Social withdrawal/autism
 Compulsive Acts: ...........................................................................
Rituals: ........................................................................
Habits: .........................................................................
vi) Social manner with non verbal behaviour
− Increased
− Decreased
− Inappropriate
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Manual for Supervised Eye contact: Gaze aversion
Practicum
Staring vacantly
Hesitant eye contact
Normal eye contact
vii) Rapport
Whether a working empathetic relationship can be established with the
patient?
Yes/ No
viii) Hallucinatory behaviour
Ask the patient if she or he hears some voices in absence of any external
stimuli or whether the family members notice the following kinds of behaviors
in the patient:
− Smiling or crying without any reason
− Muttering/ talking to self (non social speech)
− Odd gesturing in response to auditory/visual/factory stimuli
− Tactile hallucinations
II) SPEECH
During the interview observe the rate of speech, new words being
coined, stammering and articulation problem. The content of speech is
also important to make diagnosis e.g. a manic patient will be over
talkative and depressed patient will talk after lots of persuasion. You
may record the rate of speech e.g. fast or slow, volume and tone of
speech.
i) Rate with quantity of speech
Observe the patient during the interview for the following:
 Speech: Present/Absent
 Spontaneous speech: Yes/No
 Productivity: Increased/Decreased
 Rate: Increased/Decreased/Appropriate
 Pressure or poverty of speech: .......................................
ii) Volume with tone of speech
On the basis of your interaction with the patient notice whether the speech
is:
 Increased/decreased (its appropriateness)
 Low/high/normal pitch
iii) Flow with rhythm of speech
Observe the patient’s speech, whether it is:
 Smooth/hesitant
36
  Sudden blocking (disruption of thought or break in flow) Case History Taking and Mental
Status Examination
 Derailment (breakdown in logical connections between ideas)
 Stuttering/stammering
 Circumstantialities (including irrelevant details and returning to the
point)
 Tangentiality (responding to the topic being discussed but not answering
the question posed)
 Word salad ( incoherent mixture of words)
 Verbal stereotypy (repeating similar words again and again)
 Flight of ideas (shifting from one idea to the next)
 Clang association (thoughts associated with sounds rather than
words e.g., bang, lang, tang)
III) Mood with affect
Inquire from the patient how her or his mood is usually. This helps to
elicit the emotions felt by the person cross-sectionally and over a period
of time. Example, a patient suffering from a depressive episode may
describe his predominant feelings as that of sadness and appear as
feeling depressed.
Mood (Pervasive feeling tone, which is sustained, total experience of a
person)
Observe and inquire the patient about the following:
i) Quality of mood
Subjectively: How do you feel?
Objectively: By examination
ii) Stability of mood: Over a period of time
iii) Reactivity of mood: Variation in mood with stimuli
iv) Persistence of mood: Length of time the mood lasts
Affect (Outward expression of the immediate experience of emotion
at a given time)
Based on your readings regarding the characteristics of the descriptors
below, observe whether the patient’s demeanor reflects the following:
i) Quality of affect
ii) Range of affect (of emotional changes displayed over time)
iii) Depth or intensity of affect: Normal/increased/blunted
iv) Appropriateness of affect: In relation to thought and surrounding
environment
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Manual for Supervised vi) Anxiety: Anxious, restless
Practicum
vii) Depression: anxious, restless, sad, irritable, angry, anhedonia
viii) Schizophrenia: Shallow, blunted, indifferent, restricted,
inappropriate, labile, anhedonia
IV) Thought
It helps to elicit the patient’s thoughts and ideas, as well as
communicates their attitude towards various aspects of their life. E.g.,
a patient suffering from psychosis may express that other persons are
plotting against him or that the newspaper and T.V sets are broadcasting
his thoughts.
i) Stream and form of thought
Based on the way the person verbally interacts with the examiner, the
following observations regarding the thought can be made:
 Spontaneity: Present/Absent
 Productivity: Present/Absent
 Flight of ideas (shifting from one idea to the next) : Present/Absent
 Prolixity/ordered flight of ideas: Present/Absent
 Poverty of content of speech: Present/Absent
 Thought blocking (sudden disruption in flow of thoughts): Present/
Absent
 Continuity of thought: Present/Absent
 Relevant to questions asked: Yes/ No
Observe the following behaviour in patient:
 Any loosening of associations: Present/ Absent
 Tangential circumstantialities: Present/Absent
 Illogical thinking: Present/Absent
 Preservation: Present/ Absent
 Variegation: Present/Absent
ii) Content of thought
 Obsessions: Present/ Absent
 Contents of phobia: Present/ Absent
 Delusion: Present/Absent
 Over valued ideas: Present/ Absent
Observe the following contents in thoughts of the patient:
 Ideas of persecution :
38
  Grandeur :........................................................................................ Case History Taking and Mental
Status Examination
 Love : ..............................................................................................
 Jealously : ........................................................................................
 Guilt : ...............................................................................................
 Nihilism: ..........................................................................................
 Poverty : ..........................................................................................
 Somatic symptoms : .........................................................................
 Hopelessness : .................................................................................
 Haplessness : ...................................................................................
 Worthlessness : ................................................................................
 Suicidal ideation : .............................................................................
V) Perception
This helps to understand how the patient makes sense of her or his
environment and processes information. For example, a person suffering
from paranoia may perceive that her or his family members are plotting
against her or him or wanting to poison her or him.
i) Hallucinations
 Auditory/visual/olfactory/gustatory/tactile (whether the patient hears
voices discussing something about him/her, smells any unusual odours,
feels certain sensations in the absence of any external stimuli): Yes/
No
 Elementary (sounds) or complex (voices) (hears certain sounds like
the dripping of a tap or a sound which is repetitious in nature): Yes/
No
 What is heard/how many voices, when, male or female, 2nd or 3rd
person?
.................................................................................................
 During wakefulness / hypnagogic ( while going to sleep) or
hypnopompic (while getting up from sleep) for example, sees a human
figure while falling asleep or waking up? Yes/ No
ii) Ask the patient regarding whether she or he reports to have
experienced any of the following:
 Illusions/misinterpretations (misperception of certain stimuli like
mistaking a rope for a snake): Yes/No
 Depersonalization/de-realization (feelings of unreality regarding self
or the environment): Yes/No
 Somatic passivity phenomenon (feeling that any external agency is
controlling one’s actions like making one do certain acts): Yes/No
VI. Cognitive Assessment
This helps to assess the patient’s higher mental functions. For example,
a person suffering from delirium may have confusion in thought. 39
Manual for Supervised i) Consciousness
Practicum
Check for whether person is in a wakeful state by observing her or him as
well as through the way she or he responds verbally and non-verbally
towards the examiner.
− Conscious
− Confusion
− Somnolence
− Clouding
− Delirium
− Stupor
− Coma
ii) Orientation
 Time: Ask Time:.............................................................................
Date: ................................................................................................
Day: ................................................................................................
Month: .............................................................................................
Year: ................................................................................................
Reason: ............................................................................................
Time spent in hospital (if applicable) :...........................................
 Place: Ask present Location:.......................................................
Building: ...........................................................................................
City: ................................................................................................
 Person: Ask Name: ..........................................................................
Her or his role in the setting: .......................................................
People around him/her: ....................................................................
iii) Attention
− Easily aroused/sustained
− Can repeat digit
iv) Concentration
 100 – 7 test
 40 – 3 test (keep on subtracting 3 from 40 until he/she reaches
0 like 40, 37, 34)
 Count backward from 20
40
v) Memory Case History Taking and Mental
Status Examination
 Immediate memory
Digit span test (ask the patient to repeat the digits spoken by the
examiner forwards or backwards)
 Recent memory
Ask how did the patient come to the room? : ............................
What foods did he/she have for breakfast? : .....................................
What foods did he/she have the previous night? : ...........................
 Remote memory
Birth date: ....................................................................................
Date/place of marriage: .............................................................
Any relevant questions from past: ..............................................
vi) Intelligence
 General information
E.g. Current Prime Minister, capital of India or any state etc.
 Simple tests of calculations (e.g., 4 + 5?)
vii) Abstract thinking
 Proverb testing: Atleast 3 simple proverbs, for example, the examiner
should ask the patient what does it means. - ‘every cloud has a silver
lining’, ‘people who live in glass houses should not throw stones’,
‘Sour grapes’.
 Similarities with analogies: For example, ask “what is similar
between banana and orange, dog and cat, table and chair?”.
VII. Insight
This describes the acceptance of whether a patient feels she or he is
suffering from an illness as well as whether she or he is able to understand
the factors which may have caused the illness. Example, a person
suffering from obsessions and compulsions may communicate that she
or he is having repeated thoughts which compel her or him to wash
hands repeatedly and that these thoughts are irrational.
On the other hand, a patient who is having hallucinations or delusions
says that he/she doesn’t have a problem and says that she/he is normal
is said to have an insight rating of 1, that is, she or he has no insight
about her/his illness.
Insight is rated on 6 points scale given below:
1. Complete denial of illness. Yes/No
2. Slight awareness of being sick and needing help, but denying it at the same
time. Yes/ No
41
Manual for Supervised 3. Awareness of being sick, but it is attributed to external or physical
Practicum
factors. Yes/No
4. Awareness of being sick, due to something unknown in self. Yes/No
5. Intellectual insight : Awareness of being ill, and that the symptoms/
failures in social adjustment are due to over particular irrational feelings/
thought; yet does not apply this knowledge to the current/future
experiences. Yes/No
6. True emotional insight: Awareness of being ill leads to significant basic
changes in the future behaviors and personality. Yes/No
VIII) JUDGEMENT
This section involves whether a patient is able to communicate personal
goals and respond to social situations in an appropriate manner.
Example, the patient suffering from manic episode may sing and dance
in the waiting area or during the interview and communicate that her
or his goal is to be the president of India though it is not in accordance
to her or his ability and education.
i) Observed during interview, the ability to assess a situation currently
and act appropriately in that situation like social judgement e.g.,
evaluation of personal judgement
ii) Test judgement by asking what patient would do in particular
situations:
1. He is walking on the road, finds a sealed envelope with address
and stamp lying on the street. What will he do?
......................................................................................................
2. He has gone to watch movie in a theatre, suddenly the theatre
catches fire, what will he do?
......................................................................................................
3. If you find an injured child on the road, what would you do?
.......................................................................................................
4. If it is raining outside, what should you do?
......................................................................................................

42
 Case History Taking and Mental
Tool 3 Status Examination
Case History Taking for Child and Adolescent
The performa for taking history in children and adolescents is given below.
In this more emphasis is placed on early development and adjustment in
school. In this proforma, use only what is relevant with your respondent
and for other items, you may write 'not relevant' or 'not applicable'.
Date of assessment: ........................................................................................
Name: ...............................................................................................................
Age of patient/respondent: ................................................................................
Date of Birth: ....................................................................................................
Sex: ...................................................................................................................
Education: .........................................................................................................
Occupation: .......................................................................................................
Residence: .........................................................................................................
Family Structure: Nuclear/Joint/Other ................................................................
Background Information of Informant:
Name of the informant: .....................................................................................
Relationship with the patient: .............................................................................
Length of acquaintance: .....................................................................................
Adequacy of information: ..................................................................................
Reliability of information: ...................................................................................
B) Specific Information
1. Presenting complaints (Chief complaints to seek intervention/help)
According to patient:
According to informant:
2. Duration of illness
How long the patient has been ill?
.......................... Days / ........................ months / ................... years
3. Precipitating Factors
Onset (acute or gradual): .......................................................................
Course of illness (time when the patient is unwell and period when she/
he feels better)
There could be some events for example, birth of a sibling or change of
school, which could precipitate an illness. Find out if any such things have
happened in the patient’s life before the illness started.
............................................................................................................
..........................................................................................................
.............................................................................................................. 43
Manual for Supervised 4. Family History
Practicum
Family type: Nuclear/ Extended/ Joint
Socio-economic status: Upper/ Middle/ Lower
Family tree:

S.No. Relation with patient Age Education Occupation Health Personality

Family interaction and communication:

.........................................................................................................................
Family history of psychiatric illness:
.........................................................................................................................

1. PERSONAL AND DEVELOPMENTAL HISTORY

History of Early Development
1. Parental attitude towards pregnancy: wanted/unwanted ..........................
2. Mother’s health during pregnancy
(i) Any illness ....................................................................................
(ii) X-ray exposure ............................................................................
(iii) Prolonged drug administration ......................................................
(iv) Attempted abortion ......................................................................
(v) Any other .....................................................................................
3. Nature of birth:
(i) Full term normal delivery .............................................................
(ii) Premature birth ............................................................................
(iii) Instrumental or operation .............................................................
(iv) Complicated delivery....................................................................
44 (v) Head injury ..................................................................................
 (vi) Jaundice, cyanosis ........................................................................ Case History Taking and Mental
Status Examination
(vii) Delayed cry after birth .................................................................
4. Feeding habits in early childhood :
(i) Breast ..........................................................................................
(ii) Bottle ...........................................................................................
5. Age of :
(i) Neck holding ...............................................................................
(ii) Tooth eruption. .............................................................................
(ii) Sitting ...........................................................................................
(iv) Standing (unsupported) ................................................................
(v) Walking ........................................................................................
(vi) First word .....................................................................................
(vii) Three-word sentence ...................................................................
(viii) Bowel control ..............................................................................
(ix) Bladder control............................................................................
Developmental problems (if any) of speech, language, motor function.
......................................................................................................................
......................................................................................................................
......................................................................................................................
Any delay in early development and milestones (for example: neck holding,
sitting, walking, talking etc.): Yes/ No
If yes, please mention: ....................................................................................
.............................................................................................................................
Neurotic symptoms in childhood (like temper tantrums): Yes/ No
If yes, please mention .................................................................................
Night terrors: Yes/ No
Behaviour problems like thumb sucking or nail biting etc.: Yes/ No
If yes, please mention: .................................................................................
Health during childhood
If patient suffered from any childhood infections or illness? Yes/ No
If yes, please mention if there was any effect of illness on development?
........................................................................................................................
If patient suffered from any infantile convulsions? Yes/ No
45
Manual for Supervised Special abilities/disabilities: ...............................................................................
Practicum
Performance in academics: ..............................................................................

Number of friends: ..........................................................................................

Relationship with peers: ...................................................................................

Participation in co-curriculum activities like drama/sports etc.: ........................

Hobbies and interests: .....................................................................................

Occupation

Age of starting work: ......................................................................................

Ambition in life: ...............................................................................................

Present jobs held: - Designation: .....................................................................

- Wages: ..................................................................................................

Satisfaction in work: ........................................................................................

Present economic conditions: ..........................................................................

Menstrual history (for female patients)

Age of 1st period: ..........................................................................................

Regularity/duration: ..........................................................................................

Amount of pain: ..............................................................................................

Sexual inclinations and practice

Sexual information/how acquired: ....................................................................

Masturbation/sexual fantasies: ..........................................................................

Homosexuality/heterosexuality: .........................................................................

Marital history (if early marriage)

Spouse’s age: ................................................................................................

Occupation: ...................................................................................

Personality: .......................................................................................

Compatibility: ..................................................................................................

Mode and frequency of sexual intercourse: .....................................................

Sexual satisfaction: ..........................................................................................

Contraceptive measures: ..................................................................................

46
Children (if early marriage) Case History Taking and Mental
Status Examination
Chronological list of children and miscarriages:

S.No. Year of birth Name Sex Personality

SOCIAL AND PERSONAL HISTORY

1. Habits
(a) Sleep:
(i) Normal ...................
(ii) Over-eating ...................
(b) Feeding
(i) Fussy .....................
(ii) Over-eating ....................
(iii) Others.........................................
(c) Personal care:
(i) Adequate
(ii) Unkempt
2. Neurotic traits
(i) Nail biting
(ii) Thumb sucking
(iii) Morbid fears of persons, animals, darkness
(iv) Nightmares
(v) Night terrors
(vi) Obstinacy
47
Manual for Supervised (vii) Temper tantrums
Practicum
(viii) Enuresis, Encopresis beyond 3 years
3. Behaviour problems
 Stealing
 Lying
 Truancy
 Disobedience
 Others
4. Play:
 individual/group
 companies: a few/many
 older/younger/same age
 good/bad/both/others .........................
5. Sexual history – masturbation, preoccupation
Normal/Malpractices
Medical history
Has the patient undergone any:
 Illness
 Operation
 Accident
 Surgical problem
If yes, please mention: ..........................................................................
Past psychiatric history
Information of patient’s past psychiatry record:
 Dates: .....................................................................................................
 Duration: .................................................................................................
 Symptoms: ..............................................................................................
 Diagnosis: ...............................................................................................
 Treatment: ..............................................................................................
Pre-morbid Personality
Ask from patient and informant to describe her or his personality before
the illness started. Like:
i) Social relations with
48
 Family: .................................................................................................... Case History Taking and Mental
Status Examination
 Friends: ...................................................................................................
 Relatives: ................................................................................................
 Societies: ................................................................................................
 School mates: ............................................................................................
ii) Intellectual activities like
 Hobbies: ................................................................................................
 Interests: .................................................................................................
 Memory: .................................................................................................
 Observation: ...........................................................................................
 Judgement: .............................................................................................
iii) Mood of patient
 Bright/cheerful: .......................................................................................
 Despondent: ...........................................................................................
 Optimistic : ............................................................................................
 Pessimistic: .............................................................................................
 Self depreciative: ...................................................................................
 Satisfied: .................................................................................................
 Stable: ....................................................................................................
 Unstable: ................................................................................................
iv) Character
 Attitude to work or responsibility: ......................................................
 Interpersonal relationships: ...................................................................
 Standards in religious/social/health matters: .......................................
v) Fantasy life
 Frequency and content of day dreaming: ...........................................
vi) Habits
 Eating/alcohol consumption: .................................................................
 Self medication: .....................................................................................
 Tobacco consumption: ..........................................................................
III. EDUCATIONAL HISTORY
1. Qualified upto ..........................................................................................
49
Manual for Supervised 2. Educated at
Practicum
(i) home
(ii) school
(iii) hostel
3. Started reading at............................................ years
4. Educational problems (if any)
(i) poor progress
(ii) repeated absences
(iii) poor peer relationships
(iv) problem with teachers,
(v) scholastic skills development
(vi) any others.
(also make a global assessment of functioning at school here)
5. Failures if any
Class ................................................ no. of failures
6. Problem in attention, concentration, difficulty with any particular subject.
TEMPERAMENTAL CHARACTERISTICS
Activity ............................................................................................................
Rhythmicity ......................................................................................................
Approach-Withdrawal ....................................................................................
Adaptability .....................................................................................................
Mood ..............................................................................................................
Intensity of Reaction ......................................................................................
Threshold of Responsiveness .........................................................................
Attention-Span ................................................................................................
Persistence ......................................................................................................
Distractibility in infancy and later stages ..........................................................
FAMILY HISTORY
1. Family Tree [with age, sex, personality descriptions and any history of
(h/o) mental illness in the family]
.............................................................................................................
.............................................................................................................

50
2. Family functioning (any discord between family members, lack of Case History Taking and Mental
interaction or communication, any problems with the family as a whole, Status Examination
e.g. isolated family).
.............................................................................................................
.............................................................................................................
.............................................................................................................
3. Parent-child interaction (lack of warmth, hostility towards/scapegoating
of child, abuse)
.............................................................................................................
.............................................................................................................
.............................................................................................................
F) PATTERNS OF PARENTAL FUNCTIONING:
Permissiveness/rigidity.....................................................................................
Consistency/inconsistency ...............................................................................
Strictness of discipline/liberal (any inappropriate supervision) .........................
Approval of interests/disapproval ...................................................................
Protectiveness/non-protectiveness (any overprotection) ..................................
Toleration of deviance/non-toleration ..............................................................
Expectations from the child (any pressures, deprivation) ................................
Reactions towards the illness .........................................................................
SOCIAL AND ENVIRONMENTAL CONDITIONS
(Mention any aspect of living conditions which you might consider stressful for the
child)
Type of dwelling ..........................................................................................
Degree of crowding .......................................................................................
Type and amount of help in the care of child ................................................
Affluence of the family/degree of financial stress ............................................
SPECIAL ENVIRONMENTAL CIRCUMSTANCES
(like birth, death, illness, accident, divorce, hospitalization, etc, in the family. If
present, mention the effect of the life event on the child, e.g. on self-esteem.)
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................ 51
Manual for Supervised
Practicum Tool 4
Mental Status Examination of Child/Adolescent
This is systematic observation on a standard format. Using the following format,
you have to observe the patient and ask the following questions.
I) General Appearance of Behaviour
(This comprises of a brief description regarding the patient’s appearance,
behaviour and manner of relating to the examiner. This helps to elicit any
abnormalities that might be evident in the way the person appears and
relates to the examiner, for example, a patient suffering from a psychotic
episode may not be able to establish base on support with the examiner.
She/he may look overdressed or untidy and may not cooperate with the
examiner.)
i) General appearance
Record the following observations:
 Physique of body build:
Approximate height: ................................................................................
Weight: ...................................................................................................
Appearance: ...........................................................................................
 Looks: Comfortable/Uncomfortable
 Physical health:
Grooming: ...............................................................................................
Hygiene: ..................................................................................................
Self care: ................................................................................................
Dressing: appropriate/adequate/any peculiarities
 Non verbal expression : ..................................................................
 Mood: .............................................................................................
 Effeminate/masculine: .......................................................................
ii) Attitude towards the examiner/counsellor
Is the patient
− Cooperative
− Guarded
− Evasive
− Hostile
− Attentive
− Interested/disinterested/apathetic

52
iii) Comprehension Case History Taking and Mental
Status Examination
Can patient understand your questions?
− Intact/impaired (Partially/fully)
iv) Gait and posture
Posture Normal Abnormal

Way of sitting
Standing
Walking

v) Motor Activity
This is observed by the student while interacting with the patient.
 Increased/Decreased
 Excitement/Stupor
 Abnormal involuntary movements : Tics, Tremors
 Restlessness
 Catatonic signs:
− Mannerisms (habitual involuntary movement)
− Stereotypes (repetitions of physical activities)
− Posturing (strange, fixed and bizarre bodily positions)
− Waxy flexibility (condition in which person maintains the body
position in which he or she is placed)
− Negativism( verbal or non-verbal opposition to suggestion)
− Ambitendency (making series of movements that don’t reach
the goal)
− Stupor (state of decreased activity and less awareness of
surroundings)
− Echolalia (repetitions of words or phrases)
− Social withdrawal/autism
− Compulsive Acts: .............................................................................
Rituals: .........................................................................................
Habits: .......................................................................................
vi) Social manner with non verbal behaviour
− Increased
− Decreased
− In appropriate
Eye contact: Gaze aversion 53
Manual for Supervised Staring vacantly
Practicum
Hesitant eye contact
Normal eye contact
vii) Rapport
Whether a working empathetic relationship can be establishedwith the patient?
Yes/ No
viii) Hallucinatory behaviour
Ask the patient if she or he hears some voices in absence of any external
stimuli or whether the family members notice the following kinds of behaviours
in the patient:
− Smiling or crying without any reason
− Muttering/talking to self (non social speech)
− Odd gesturing in response to auditory / visually/olfactory stimuili
− Tactile hallucinations
II) SPEECH
During the interview observe the rate of speech, new words being coined,
stammering and articulation problem. The content of speech is also
important to make diagnosis e.g. a manic patient will be over talkative
and depressed patient will talk after lots of persuasion. You may record
the rate of speech e.g. fast or slow, volume and tone of speech.
i) Rate with quantity of speech
Observe the patient during the interview for the following:
 Speech: Present/Absent
 Spontaneous speech: Yes/ No
 Productivity: Increased/Decreased
 Rate: Increased/Decreased/Appropriate
 Pressure or poverty of speech: .....................................
ii) Volume with tone of speech
On the basis of your interaction with the patient notice whether the speech
is:
 Increased/decreased (its appropriateness)
 Low/high/normal pitch
iii) Flow with rhythm of speech
Observe the patient’s speech, whether it is:
 Smooth/hesitant
54
  Derailment (breakdown in logical connections between ideas) Case History Taking and Mental
Status Examination
 Stuttering/stammering
 Circumstantialities (including irrelevant details and returning to the
point)
 Tangentiality (responding to the topic being discussed but not answering
the question posed)
 Word salad ( incoherent mixture of words)
 Verbal stereotypy (repeating similar words again and again)
 Flight of ideas (shifting from one idea to the next)
 Clang association (thoughts associated with sounds rather than words;
eg., bang, lang, tang)
III) Mood with affect
Inquire from the patient how her or his mood is usually. This helps to
elicit the emotions felt by the person cross-sectionally and over a period
of time. Example, a patient suffering from a depressive episode may
describe her/his predominant feelings as that of sadness and appear as
feeling depressed.
Mood (Pervasive feeling tone, which is sustained, total experience of a
person)
Observe and inquire the patient about the following:
i) Quality of mood
Subjectively: How do you feel?
Objectively: By examination
ii) Stability of mood: Over a period of time
iii) Reactivity of mood: Variation in mood with stimuli
iv) Persistence of mood: Length of time the mood lasts
Affect (Outward expression of the immediate experience of emotion at a given
time)
Based on your readings regarding the characteristics of the descriptors below,
observe whether the patient’s demeanor reflects the following:
i) Quality of affect
ii) Range of affect (of emotional changes displayed over time)
iii) Depth or intensity of affect: Normal/increased/Blunted
iv) Appropriateness of affect: In relation to thought and surrounding
environment
v) Mania: Euphoria, elation, exaltation, ecstasy.
vi) Anxiety:Anxious, restless 55
Manual for Supervised vii) Depression: anxious, restless, sad irritable, angry, anhedonia
Practicum
viii) Schizophrenia: Shallow, blunted, indifferent, restricted, inappropriate,
labile, anhedonia
IV) Thought
It helps to elicit the patient’s thoughts and ideas as well as communicate
their attitude towards various aspects of their life. E.g., a patient
suffering from psychosis may express that everyone is plotting against
him or that the newspaper and T.V sets are broadcasting his thoughts.
i) Stream and form of thought
Based on the way the person verbally interacts with the examiner, the
following observations regarding the thought can be made:
 Spontaneity: Present/Absent
 Productivity: Present/Absent
 Flight of ideas (shifting from one idea to the next) : Present/Absent
 Prolixity/ordered flight of ideas: Present/Absent
 Poverty of content of speech: Present/ Absent
 Thought blocking (sudden disruption in flow of thoughts): Present/
Absent
 Continuity of thought: Present/Absent
 Relevant to questions asked: Yes/ No
Observe the following behaviour in patient:
 Any loosening of associations: Present/Absent
 Tangential circumstantialities: Present/Absent
 Illogical thinking: Present/Absent
 Preservation: Present/Absent
 Variegation: Present/Absent
ii) Content of thought
 Obsessions: Present/ Absent
 Contents of phobia: Present/ Absent
 Delusion: Present/Absent
 Over valued ideas: Present/ Absent
Observe the following contents in thoughts of the patient:
 Ideas of persecution : ...................................................................
 Reference :.....................................................................................

56  Grandeur :.....................................................................................
  Love : .............................................................................................. Case History Taking and Mental
Status Examination
 Jealously : ........................................................................................
 Guilt : ...............................................................................................
 Nihilism: ..........................................................................................
 Poverty : ..........................................................................................
 Somatic symptoms : .........................................................................
 Hopelessness : .................................................................................
 Haplessness : ...................................................................................
 Worthlessness : ................................................................................
 Suicidal ideation : .............................................................................
V) Perception
This helps to understand how the patient makes sense of her or his
environment and processes information. For example, a person suffering
from paranoia may perceive that her or his family members are plotting
against him or wanting to poison him.
..............................................................................................................
i) Hallucinations
 Auditory/visual/olfactory/gustatory/tactile (whether the patient hears voices
discussing something about him/her, smells any unusual odors, feels certain
sensations in the absence of any external stimuli). Yes/ No
 Elementary (sounds) or complex (voices) (hears certain sounds like the
dripping of a tap or a sound which is repetitious in nature). Yes/ No
 What is heard/how many voices, when, male or female, 2nd or 3rd person?
..............................................................................................................
 During wakefulness/hypnagogic (while going to sleep) or hypnopompic (while
getting up from sleep) for example, sees a human figure while falling asleep
or waking up? Yes/ No
ii) Ask the patient regarding whether she or he reports to have
experienced any of the following:
 Illusions/misinterpretations (misperception of certain stimuli like mistaking a
rope for a snake). Yes/ No
 Depersonalization/de-realization (feelings of unreality regarding self or the
environment).Yes/ No
 Somatic passivity phenomenon (feeling that any external agency is controlling
one’s actions like making one do certain acts). Yes/ No
VI. Cognitive Assessment
This helps to assess the patient’ s higher mental functions. For example,
a person suffering from delirium may have confusion in thought.
57
Manual for Supervised i) Consciousness
Practicum
Check for whether person is in a wakeful state by observing her or him as
well as through the way she or he responds verbally and non-verbally
towards the examiner.
− Conscious
− Confusion
− Somnolence
− Clouding
− Delirium
− Stupor
− Coma
ii) Orientation
 Time: Ask Time:................................................................................
Date: ..................................................................................................
Day: ..................................................................................................
Month: ...............................................................................................
Year: ..................................................................................................
Reason: ..............................................................................................
Time spent in hospital:........................................................................
 Place:Ask present Location:..............................................................
Building ..............................................................................................
City: ..................................................................................................
 Person:Ask Name: ........................................................................
Her or his role in the setting: .............................................................
People around him/her: ......................................................................
iii) Attention
- Easily aroused/sustained
- Can repeat digit
iv) Concentration
 100 – 7 test
 40 – 3 test (keep on subtracting 3 from 40 until he/she reaches
0 like 40, 37, 34)
 count backward from 20

58  Names of months/days of week in reverse order

v) Memory Case History Taking and Mental
Status Examination
 Immediate memory
Digit span test (ask the patient to repeat the digits spoken by the
examiner forwards or backwards)
 Recent memory
Ask how did the patient come to the room? : ......................
What foods did he have for breakfast? : ...........................................
What foods did he have the previous night? : ...................................
 Remote memory
Birth date: ..........................................................................................
Any relevant questions from past: ......................................................
vi) Intelligence
 General information
E.g. Current Prime Minister, capital of India etc.
 Simple tests of calculations (e.g., 4 + 5?)
vii) Abstract thinking
 Proverb testing:Atleast 3 simple proverbs, for example, the examiner
should ask the patient what does it means—‘every dark cloud has a
silver lining’, ‘people who live in glass houses should not throw stones’,
‘Sour grapes’.
 Similarities with analogies: For example, ‘ask what is similarity between
banana and orange, dog and cat, table and chair’?
VII. Insight
This describes the acceptance of whether a patient feels she or he is
suffering from an illness as well as whether she or he is able to understand
the factors which may have caused the illness. Example, a person
suffering from obsessions and compulsions may communicate that she
or he is having repeated thoughts which compel her or him to wash
hands repeatedly and that these thoughts are irrational.
For example, the patient who is having hallucinations or delusions says
that he/she doesn’t have a problem and says that he/she is normal is
said to have an insight rating of 1, that is, he or she has no insight
about his/her illness.
Insight is rated on 6 points scale given below:
1. Complete denial of illness. Yes/ No
2. Slight awareness of being sick and needing help, but denying it at the same
time. Yes/ No
3. Awareness of being sick, but it is attributed to external or physical factors.
Yes/ No 59
Manual for Supervised 4. Awareness of being sick, due to something unknown in self. Yes/ No
Practicum
5. Intellectual insight : Awareness of being ill, and that the symptoms/failures in
social adjustment are due to over particular irrational feelings/thought; yet
does not apply this knowledge to the current/future experiences. Yes/ No
6. True emotional insight. Awareness of being ill leads to significant basic changes
in the future behaviours and personality. Yes/ No
VIII) JUDGEMENT
This section involves whether a patient is able to communicate personal
goals and respond to social situations in an appropriate manner.
Example, the patient suffering from manic episode may sing and dance
in the waiting area or during the interview and communicate that her
or his goal is to be the president of India though it is not in accordance
to her or his ability and education.
i) Observed during interview, the ability to assess a situation currently and
act appropriately in that situation like social judgement e.g., evaluation
of personal judgement
ii) Test judgement by asking what patient would do in particular situations:
1. You are walking on the road, and find a sealed envelope with address
and stamp lying on the street. What will you do?
..........................................................................................................
2. You have gone to watch movie in a theatre. Suddenly the theatre
catches fire.What will you do?
..........................................................................................................
3. If you find an injured child on the road, what would you do?
...........................................................................................................
4. If it is raining outside, what should you do?
..........................................................................................................

60