PERSONAL HISTORY
1) Birth & early development
Record the details of prenatal, natal & postnatal periods. Was the birth at full term?
Any complication during delivery? Any physical illnesses in postnatal period? Ascertain
whether milestones of development were normal or abnormal.
2) Behaviour during childhood
Enquire about sleep disturbances, thumb sucking, nail biting, temper tantrums, bed-
wetting, stammering, tics and mannerisms. Look for conduct disturbances in form of
frequent fights, truancy, stealing, lying & going activities also enquire about the
relationship with parents, siblings and peers.
3) Physical illness during childhood
Record physical illness suffered in childhood. Enquire specifically regarding epilepsy,
meningitis and encephalitis.
4) School
Enquire about age of beginning and finishing school, type of school attended, scholastic
performance, attitude towards peers and teachers
5) Occupation
Age of starting work, jobs held – in chronological order, work satisfaction, competence,
future ambitions
6) Menstrual history
Enquire about the age of menarche, reaction to menarche, regularity of the periods,
dysmenorrhea, menorrhagia/oligomenorhea, emotional disturbance in relation to
menstrual cycle.
7) Sexual history
Enquire about age of onset puberty, level of knowledge regarding sex and mode of
gaining the same, masturbating practices, anxiety related to sexual practices/fantasies,
homosexual and heterosexual fantasies, inclination and experience, extramarital
relationships.
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8) Marital history
Enquire regarding age at time of marriage. Whether arranged by elders or by self. Was
there mutual consent of the marriage by parents; age, occupation, health and
personality of the partner, quality of marital relationship, any separation or divorce.
9) Use and abuse alcohol, tobacco and drugs
Enquire about smoking, drinking pattern and abuse of other drugs, cannabis, opioids
and barbiturates.
PRE MORBID PERSONALITY
In this description of the personality prior to the beginning of mental illness, do not
be satisfied with a series of adjectives and epithets, but give an illustrative anecdotes and
detailed statements. Aim at a picture of an individual, not a type; following is merely a
collection of hints, not scheme. It will not be possible to cover all the items listed in the
course of the first interview, but an attempt should be made, particularly in cases of
neurosis or affective disorder, to elicit evidence about all aspects premorbid personality in
the course of exploration extending over a period.
1. Social Relation to family (attachment, dependence), friends and groups, clubs, to
work and workmates (leader or follower, organiser, aggressive, submissive,
ambitious, adjustable, independent)
2. Intellectual activities, hobbies and interests, books, plays, pictures, memory,
observation, judgement
3. Mood: bright and cheerful or despondent, worrying or placid, strung or calm and
relaxed, optimistic or pessimistic, self depreciative or satisfied; mood stable or
unstable with or without any occasion.
4. Character
A. Attitude: to work and responsibility, welcomes or be worried by responsibility,
makes decision easily or with difficulty, haphazard and slapdash or methodical
and meticulous, rigid and flexible, cautions foresightful and given to checking or
impulsive, preserving and determined or easily bored, discouraged.
B. Attributes: self confident or shy and timid, insensitive or touchy and sensitive to
criticism, trusting or suspicious and jealous; emotionally controlled or quick
tempered and irritable, enjoys or shows self display; quiet and restrained or
expressive and demonstrative in speech and gesture; interests and enthusiasms
sustained or evanescent, tolerant or intolerant of others, adaptable and rigid.
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C. Standards: in moral, religious, social and health matters, level of aspiration high
or low, perfectionist and self critical or complacent and self approving in relation
to own behaviour and achievement, steadfast in face of difficulties or intolerant
of frustration, selfish and egoistical or unselfish and altruistic, given too much or
little concern about own health.
D. Energy and Initiative: Energetic or sluggish, output sustained or fitful, fatigability,
any regular or irregular fluctuations in energy or output.
5. Fantasy life: Frequency and content of day dreaming
6. Habits: Eating, alcohol consumption, self medications with drugs or other medicines
- specify amount, taken recently or earlier, tobacco consumption, excretory
functions.
MENTAL STATUS EXAMINATION
A systematically conducted mental status examination is an important
component of case taking. It is essential. Record the observations properly. Whenever
positive findings are obtained, they should be described in detail. It is not adequate to say
delusions or hallucination present. MSE has to be repeated several times during the course
of the illness to know the evolution of symptoms, effectiveness of treatment etc. The time
frame covered by the MSE is not restricted to the hour of observation, but extends longer.
While the following account highlights the major components of MSE, details should be
obtained from the other sources cited.
1. GENERAL BEHAVIOUR
Description as complete, accurate, life like as possible of the observations of
ward staff and your own. Following points may be considered, though not
exclusively.
Enquire about the ways of spending the day, eating, sleeping, cleanliness in
general, self care, hair and dress, behaviour towards other patients, doctor and
nursing staff. Does the patient look ill? Note whether the patient is fully conscious,
stuporous or comatosed. Is he in touch with surroundings or is the patient relaxed or
tensed and restless? Is he slow or hesitant? How does he respond to the various
requirements and situations? Note the patient’s response to external events. Can his
attention be held or diverted? Is the patient cooperative? Can adequate rapport be
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established? Does the patient maintain adequate eye contact? Does the patient’s
behaviour suggest that he is oriented/disoriented? Note the presence of any tics or
mannerisms. Note the presence of any catatonic phenomena.
2. PSYCHOMOTOR ACTIVITY
Note if the psychomotor activity is increased or decreased or normal
3. SPEECH
Note the form of utterance rather than content. Does the patient spaek
spontaneously or only in response to question? Is the amount of speech little or
excessive? Is it high toned or low toned? Is the tempo fast or slow?
Is the reaction time increased or decreased?
Is the prosody of speech maintained?
Is it relevant?
Is it coherent?
4. THOUGHT
Examine thought processes with respect to the
Form: Presence of formal thought disorder
Stream: Flight of ideas, retardation of thinking, circumstantiality, perseveration,
thought blocking.
Possession: Obsessions & compulsions, thought alienation with respect to
obsessions, elicit their nature – ideas, doubts, imagery, impulses and phobias.
Similarly clarify the nature of compulsive acts checking, counting or washing. Are
these controlling compulsions or yielding compulsions?
Content: Look for the presence of overvalued ideas and delusions before making an
inference, a detailed description of the phenomenon must be given. Note whether
delusion is single or these are multiple delusions, the types of delusions ( Grandiose,
persecutory, nihilistic etc.), the exact content of the delusions, whether they are well
systematized or poorly systematized and whether they are mood congruent or not.
Enquire about worries and preoccupations, hypochondriacal and somatic symptoms,
depressive ideation, ideas of worthlessness, guilt, hopelessness and suicidal ideas
must be enquired and recorded.
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5. MOOD
This should be assessed both by subjective report and objective
evaluation; assessment should be both longitudinal (mood) and cross-sectional
(affect). Description should be given describing the following components; the
quality of emotion (happiness, sadness, anxiety etc.), intensity or depth of emotional
experience, the range of affective responses, mobility, reactivity (changes in
emotions in relation to the environmental factors), diurnal variation, congruity in
relation to thought processes), and appropriateness (in relation to situations). Note
any evidence of labiality (rapid and extreme changes in emotions).
6. PERCEPTION
Record the presence of illusions and hallucinations. Enquiry should be
made into the following modalities: vision, hearing, smell, touch, taste, pain and
deep sensation, vestibular sensations and sense of presence, record also the
presence of special varieties of hallucinations like functional hallucinations, reflex
hallucinations, extra-campine hallucinations, synaesthesia and autoscopy. Detailed
description of the actual experience should be obtained. For example, with respect
to auditory hallucinations, enquire whether the hallucinations are verbal or non
verbal, continuous or intermittent, single voice or multiple voices; familiar voice or
unfamiliar voice, first person, second person or third person, pleasant or unpleasant,
if unpleasant whether commanding, abusive or threatening, relationship of
hallucinations whether mood congruent distinguish hallucinations from memory and
pseudo hallucination.
Other perceptual disturbances that must be enquired into include
heightened perception, dulled perception, depersonalisation/ derealisation
experiences and disturbances in the perception of time.
7. COGNITIVE FUNCTIONS
Clinical assessment of cognitive functions includes the areas of
a) Orientation
b) Attention and concentration
c) Memory
d) Intelligence
e) Judgement
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a) ORIENTATION
TIME:
1. Appropriately what time of the day is it? If the patient is unable to reply, a more
specific question may be asked.
2. Is it morning, afternoon, evening or night? (in addition further questioning may
be done to assess estimation of time)
3. Approximately how long is it since you had your breakfast/lunch/tea/ dinner?
OR approximately have I been talking to you?
4. What is the day today? (day of the week)
5. What is the date (day of the month, year) today?
PLACE:
1. What place is this? (if the answer is not forthcoming, a specific question is asked)
2. Is this a school, office, hospital, restaurant etc.? (if the patient says it is a
hospital, details may be asked depending on the background)
PERSON
1. Orientation to self is tested by asking the identity of the patient.
2. Inquiry about the identity of the patient’s relative or family members.
b) ATTENTION AND CONCENTRATION
Tests used in clinical situations include
i. The digit span test
ii. Serial subtraction
iii. Days or months forward to backward
i. Digit Span Test:
a. Forward: Patient is given the following instructions:
I will be saying some digits. Listen to me carefully. When I finish, you will have to
repeat them in the same order. The examiner after instructing the patient
a. Gives an example ( For example if I say 3,7, you say 7,3 )
b. Reads digits at the rate of one per second to the patient
c. Notes whether the immediate response of the patient is correct or incorrect.
The following digits may be used.
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5-7-3 4-1-7
5-3-8-7 6-1-5-8
1-6-4-9-6 2-9-7-6-3
3-4-1-7-9-6 6-1-5-8-3-9
7-2-5-9-1-6-8-5 4-6-1-5-3-8-6
4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4
The digit span test is the highest of digits repeated correctly.
The same digits should not be presented more than once. If the patient cannot
repeat a particular number of digits on one trial, a second trial with the same
numbers of digits is given and credit is given if the response is correct.
b. Backward: The patient is instructed as follows: I will be saying some digits, listen
to me carefully and repeat them after me in a reverse order. For example if I say,
2-5, you have to say 5-2. The procedure is the same for digit forward. The same
digits should not be used as for the forward test. No digits should be repeated in
a series presented. The digit backward score is the highest number of digits
correctly recalled backward after a maximum of two trials.
ii. Serial subtraction
Increasingly difficult tests are presented. The examiner a) instructs the patient b)
gives an example of how to perform the task, c) notes the responses verbatim
and, d) notes the time taken in seconds.
Task correct responses and the limits
20-1 20 to 0 reversed in 15 seconds
40-3 40, 37, 34, 31 etc. in 60 seconds
100-7 100, 93, 86, 79 etc. in 120 seconds
iii. Days or months may be asked for in backward or forward to the patient who is
familiar with the correct order.
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c) MEMORY
Assessments include immediate, recent and remote memory
A. Immediate memory – tested by digit span test
B. Recent memory – tested by
1. Address Test: An address consisting of about 4-5 facts which is not known to the
patient is slowly read to the patient after instructing him to attend to the
examiner. He is engaged in conversation (to avoid rehearsal) and the response is
noted verbatim. Recall is asked after 3-5 minutes
2. Asking the patient to recall events in the last 24 hours. Ex: details of the time and
amount in a meal, visitors to the hospital from an inpatient. Responses given by
the patient should be cross checked from the reliable sources.
C. Remote Memory : Information on life events
a. Date of birth or age
b. Names and number of family members
c. Time since marriage or death of any family members
d. Year of completing education
4-5 facts may be asked relevant to the patient’s background and answer should
be cross checked.
d) INTELLIGENCE
This includes the area of general information, comprehension, arithmetic and
vocabulary.
General Information
Information relevant to the patient’s literacy age or occupation may be asked eg.
Illiterate
A) Name of the prime minister
B) 5 rivers, cities or states
C) Capital or countries
D) Current events (Major)
For illiterate:
A) Seasons
B) Group of fruits growing in particular seasons
C) Prices of food grains or food items
D) Prices of land
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Comprehension
The ability to understand is the questions asked during an interview is or index.
Specifically the following questions of increasing difficulty may be asked.
1. What will you do when you feel cold?
2. What will you do if it rains when you start to work?
3. What will you do if you miss the bus when you are on a journey?
4. What will you do when you find on your way that it will be late when you reach
your work spot?
5. Why should we be away from bad company?
Arithmetic
The following questions may be asked with increasing time units
1. How much is four rupees and five rupees?
2. I borrowed 6 rupees friend and returned 2 rupees, how much do I owe to him?
3. If a man buys clothes for 12 rupees and gives a shop keeper for 20 rupees. How
much change does he get back?
4. How many pencils can you buy for 2 rupees if one pencil costs quarter of a rupee
or 25 paisa?
5. If 18 boys are divided into groups of six, how many groups will be there?
Time Limit: 1 - 3 15 Seconds, 4 - 5 30 seconds
Correct answers - 1)9, 2)4, 3)8, 4) 8, 5)3
Abstraction
Tested by similarities, differences and proverbs.
Similarities
The patient is given the following instructions.
I will be giving you some pair of words. You have to tell me in what way they are
alike, what is common between them or what is the similarity between them.
Orange - Banana (fruits)
Dog - Lion (animal)
Eye - Ear (sense organ)
North - West (direction)
Table - Chair (items of furniture)
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Correct response i.e., abstract responses are given in the brackets.
Differences being an easier task, is always presented before similarities.
Differences
The instructions are as follows. I will be presenting to you some parts of words.
Listen carefully and tell me in what way they are different from each other.
Stone - Potato (Not edible-edible/ hard- soft)
Fly - butterfly (Small-large/ colourful-not colourful)
Cinema - radio (audio- visual/ audio)
Iron - silver (heavy –light/ dull – bright)
Praise - punishment (positive- negative/ pleasant- unpleasant)
Proverbs
The patient is asked the following questions
a. Whether he knows what a proverb is
b. An example of a proverb and its meaning (atleast 3 proverbs should be asked.)
If it is clear that the patient has the concept of a proverb, the following may be
asked.
1. Slow and steady wins the race.
2. A barking dog seldom bites.
3. As you sow, so you shall reap.
4. All that glitters is not gold or all that is white is not milk.
5. Where there is a will there is a way.
6. Every potter praises his pot.
7. Empty vessel makes more noise.
8. It is useless to cry over spilt milk.
e) JUDGEMENT
Mental ability of comparing or evaluating choice in the frame work of a genuine set
of values for the purpose of action is assessed in the following areas:
1. Personal
2. Social
3. Test
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Personal judgement to be assessed by inquiries about the patient’s future plans.
Social judgement is assessed by observing behaviour in social situations.
Test judgement – the following problems are presented to the patient in a manner
in which he can comprehend.
1. Fire Problem:
If the house in which you live catches fire what is the first thing that you will
do? (Correct answer- try to put it off with water)
2. Letter problem:
If when you are walking on the road, you see a stamped and sealed envelope
with an address on it, which someone had dropped. What will you do?
(Correct answer – post it in a letter box, give it to the post man)
3. Baby near the pond:
If a small baby is lying near the pond, what will you do?
8. INSIGHT
Test the patient’s level of awareness of his illness. Does he think that he is not ill at
all (absence of insight)? Does he recognise the presence of the illness but gives
explanation in physical terms (partial insight)? Does he fully recognise the emotional
nature of his illness and the cause of his symptom (insight present)?
SUMMARY: The purpose of a summary is to provide concise description of all the important
aspects of the case to enable others who are unfamiliar with the patient to grasp the
essential features of the problem. The summary should be presented in the same format as
described in the previous pages.
DIAGNOSTIC FORMULATION: This is the student’s own assessment of the case rather than
as restatement of the facts. Its length, layout and emphasis will vary considerably from one
patient to the other. It should always include a discussion of the diagnosis, of the etiological
factors which sees important, a plan of management and an estimate of the prognosis
regardless the uncertainty or complexity of the case. A provisional diagnosis should always
be specialised using the ICD. A complete physical examination is mandatory for each
patient.
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INVESTIGATION, TREATMENT & FOLLOW UP: Biochemical, radiological or psychometric
investigations should be carried out wherever appropriate. All aspects of management viz.,
physical, psychological and social interventions should be included in the treatment
package. Though the relative emphasis may differ from case to case, prognosis notes should
be systematically recorded.
EXAMINATION OF NON CO-OPERATIVE STUPEROUS PATIENTS (KIRBY 1921)
The difficulty of getting information from non cooperative patients should
not discourage the physician from making and recording certain observations. These may be
of great importance in the study of various types of cases and give valuable data for the
interpretation of different clinical reactions. It is hardly necessary to say that the time to
study negative reaction is during the period of negativism. The term of study of a stupor is
during the stuporous phase- to wait for the clinical picture to change or for the patient to
become more accessible is like to miss an opportunity and leave a serious gap in the clinical
observation. Obviously it is necessary in the examination of such persons plan that used in
making the casual mental evaluation .following guidelines were advised to cover in a
systematic way the most important points for the purpose of clinical differentiation.
1. GENERAL REACTION AND POSTURE:
A. Attitude: Voluntary or Passive
B. Voluntary postures: Comfortable, natural or awkward
C. What does the patient do if he is placed in awkward and uncomfortable
situations?
D. Behaviour towards physician and nurses: Initiative, evasive, irritable,
apathetic, compliant
E. Spontaneous acts: Any occasional show of play, mischievousness and
assaultiveness. Patient’s movements when interfered with or when pricked
with pain, eating & dressing. Attention to bowel and bladder. Do the
movements show initial retardation or are they consistent throughout?
F. To what extent does the attitude change? Is the behaviour disturbance
influence the condition?
2. FACIAL EXPRESSION: Alert, attentive, placid, vaunt, stolid, sulky, scowling, averse,
distressed etc. Any signs of facial expressions of emotions, tears, smiles,
perspiration. On what occasion?
3. EYES: Open or closed. If closed having lid raised. Movement of eyes absent or
obtained on request. Gives attention and follows the examiner or moving objects or
shows only fixed gazing, furtive glances or evasion. Rolling of eyeballs upward.
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Blinking, flickering or tremors of lids. Reaction to sudden approach to threat to stick
to pin in eye. Sensory reaction of pupils (dilation from painful stimuli or irritation to
skin of neck).
4. REACTION TO WHAT IS SAID OR DONE: Commands show tongue, move lips, grasp
with hand (clinging, clutching etc). Movements slow or sudden. Reaction to pin
pricks. Automatic obedience. Tell patient to produce the tongue to have pin stuck
into it.
5. MUSCULAR REACTIONS: Test for rigidity, muscles relaxed or tense when limbs or
body is moved. Catalepsy, waxy flexibility, negativism shown by movements in
opposite direction or springy or cog-wheel resistance. Test head and neck by
movement forward and backward to side. Test also the jaw, shoulders, elbows,
fingers and the lower extremities. Does distraction or command influence the
reactions? Closing of mouth, protrusion of lips, holding of saliva, drooling.
6. EMOTIONAL RESPONSIVENES: Is feeling shown when talked to of family or children?
Or when sensitive points in history are mentioned or when visitors come? Note
whether or not acceleration of respiration or pulse occurs. Also look for flushing,
perspiration, tears in eyes etc. Do jokes elicit any response? Effect of unexpected
stimuli (clap hands, flash of electronic lights).
7. SPEECH: Any apparent effort to talk, lip movements, whispers, movements of head.
Note exact utterances with accompanying emotional reaction (may indicate
hallucinations).
8. WRITING: Offer paper and pencil. Unresponsive or partially stuporous? Patients will
often write when they fail to talk.
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