CASE
HISTORY
Aishwarya Deshmukh
PERSONAL
INFORMATION
• Name of the Individual – First step of
identification, builds rapport when used
respectfully.
• Father’s/Husband’s Name – Helps in unique
identification when names are common.
• Sociodemographic Profile – Includes age, sex,
education, occupation, SES, marital status,
religion, residence. Plays role in onset, course,
treatment & prognosis.
Key Sociodemographic Details:
• Age – Important for age of onset & duration of
illness.
• Sex – Some disorders more common in one
gender; socio-cultural factors also relevant.
• Education – Assesses knowledge level, guides
assessment & treatment approach.
• Occupation – Shows social & economic status,
and impact of illness on work.
• Socio-Economic Status – Affects affordability of
treatment & investigations.
• Marital Status – Important prognostic factor; gives
info about social support.
Additional Identifiers & Cultural Factors :
• Religion – Customs may affect illness perception &
treatment.
• Residence – Rural/urban background influences
customs, beliefs & follow-up planning.
• Language – Prefer interview in mother tongue for
comfort & accuracy.
• Address & Contact Info – For future communication &
follow-up.
• Source of Referral – Indicates awareness about illness
or authority-based referral.
• Type of Admission – Important for medico-legal
purposes (Mental Health Act, 1987).
• Identification Marks – Permanent marks noted for
medico-legal identification.
HISTORY OF PRESENT
ILLNESS
Patient & Informant’s Report:
• Patient’s Version → Always takes precedence; use
patient’s own words to know their perspective.
• If patient is non-communicative/denies symptoms,
mention reasons → then move to informants.
• Informant’s Report → Document names, relation,
length of contact, consistency, & reason for
seeking help now.
• Gives context of illness & family’s expectations
from treatment.
Reliability & Adequacy of Information:
• Reliability (SCs):
⚬ Source of Contact
⚬ Closeness of relationship
⚬ Continuity of account
⚬ Consistency across reports
⚬ Corroboration with other informants
• Adequacy → Whether information is sufficient to
form diagnosis.
Chief Complaints & History of Present Illness
(HOPI):
• Chief Complaints: Patient’s main symptoms,
verbatim, in chronological order.
• HOPI → Backbone of psychiatric case history.
⚬ Evolution of symptoms in detail.
⚬ Factors:
￭ Predisposing (biological, psychological,
social)
￭ Precipitating (recent stressors/events)
￭ Perpetuating (maintaining factors)
￭ Limiting (good support/treatment)
￭ Modifying (substance use, meds altering
Onset, Course & Symptom Analysis:
• Mode of Onset → Abrupt (<48 hrs), Acute (<2
wks), Insidious (>2 wks).
• Course → Continuous, Episodic, Fluctuating.
• Progress → Improving / Deteriorating / Static.
• Symptom Analysis (ABC Model):
⚬ Antecedent → what triggers behaviour
⚬ Behaviour → description of symptom/act
⚬ Consequence → what follows
• Ask for expected but unreported symptoms
(suicidal ideas, psychosis, etc.).
Treatment History & Compliance:
• Treatment History → First contact, type of
treatment (psychiatrist, psychologist, physician,
faith healer), nature
(pharmacological/psychotherapy), medication
details, response, side effects, hospitalization.
• Compliance → Degree to which patient follows
medical advice.
• Adherence → Jointly agreed plan between patient
& doctor (emphasises patient’s choice, non-
blaming approach).
• Compliance & adherence both crucial for long-term
prognosis.
PAST HISTORY
Past Medical & Psychiatric History:
• Past Medical History → Major illnesses since
childhood (chronic conditions, frequent
consultations, hospitalizations, emergencies).
• Past Psychiatric History → Previous episodes,
symptoms, duration, probable diagnosis,
treatments (meds/therapy), hospitalizations, and
functioning between episodes.
Clinical Course Indicators:
⚬ Remission → Minimal/no symptoms after
treatment.
⚬ Relapse → Symptoms return within same episode.
⚬ Recovery → Stable remission for months = episode
ends.
⚬ Recurrence → New episode after recovery.
⚬ Response → ≥50% symptom reduction.
⚬ Sustained Remission → 8–12 weeks symptom-free.
⚬ Roughening → Early warning (prodrome).
FAMILY HISTORY
• Parents & Siblings → Age, occupation, personality,
medical & psychiatric history, cause of death (if
applicable).
• Psychiatric Illness → Any history of psychiatric
conditions, hospitalization, or treatment in
immediate family.
• Substance Use → Family history of
alcohol/substance abuse or personality issues.
• Personality & Intelligence → Brief description of
family members and households where patient
lived.
• Consanguinity → Note if blood relation within
family exists; mention degree if present.
Family Relationships & Genogram:
• Relationships → Patient’s bond with family,
conflicts, family support, and attitude towards
illness.
• Family Dynamics → Interpersonal relationships,
presence of squabbles or harmony.
• Genogram →
⚬ A family tree covering 3+ generations.
⚬ Includes key life events (birth, marriage,
divorce, death, illness).
⚬ Shows occupations, residence patterns, and
major transitions.
⚬ Helps visualize hereditary and psychosocial
factors.
PERSONAL HISTORY
Personal History: Overview & Birth Details
• Chronological account of patient’s life (birth →
adulthood).
• Perinatal & Birth Details:
⚬ Antenatal: maternal illness, medication,
alcohol/drugs, trauma, X-rays.
⚬ Pregnancy: wanted/unwanted, mother’s
emotional state.
⚬ Delivery: full term/preterm, place (home/hospital),
type (normal/C-section), birth weight, cry,
complications (cord issues, neonatal jaundice).
• Feeding, weaning, recurrent infections, convulsions
after birth.
Childhood & Development:
• Developmental milestones: walking, speech, toilet
training, etc. (delays noted).
• Childhood disorders: hyperactivity, attention deficits,
impulsivity.
• Behavioral issues: lying, stealing, truancy, cruelty to
animals.
• Neurotic traits: nail-biting, thumb sucking,
stammering, phobias, bedwetting, sleepwalking,
night terrors.
• Temper tantrums: frequency & intensity.
• Peer & authority relations: friendships, conflicts,
discipline issues.
Adolescence, Education & Occupation:
• Home atmosphere: disturbed vs. congenial; broken
home, step-parents, adoption.
• Education: age at school entry, type of school,
academic performance, failures, disciplinary
problems, extracurricular activities, hobbies.
• Vocational history: age at first job, work duration,
positions held, relations with colleagues/superiors,
promotions, reasons for leaving jobs.
• Impact of illness on studies/work.
Menstrual, Sexual, Marital & Forensic History:
• Menstrual history (females): menarche, cycle
regularity, duration, PMS symptoms, last
menstruation, amenorrhea.
• Sexual history: sexual knowledge, masturbation,
premarital/extramarital relations, sexual disorders,
childhood abuse, gender identity concerns.
• Marital history: age at marriage, spouse’s details,
parental consent, intimacy, role allocation, sexual
adequacy, contraception.
• Forensic history: trouble with police, charges,
convictions, ongoing cases.
Premorbid Personality & Lifestyle:
• Social relations: family bonds, friendships, group
involvement, leadership style.
• Mood & character: cheerful/pessimistic,
stable/unstable, emotional control.
• Attitude to self & work: strengths, resilience,
perfectionism, responsibility, decision-making style.
• Interpersonal style: confident vs. shy, sensitive vs.
insensitive, tactful vs. outspoken.
• Moral & religious attitudes, health concern level.
• Energy & initiative: motivated vs. sluggish, consistent
vs. irregular effort.
• Fantasy life & habits: daydreaming, alcohol/drug use,
tobacco, food, sleep.
CONCLUSION
• Case history taking is the foundation of psychiatric
assessment.
• It provides a comprehensive understanding of the
patient’s life from birth to present.
• Helps in identifying predisposing, precipitating, and
perpetuating factors of illness.
• Builds a therapeutic relationship and trust between
clinician and patient.
• Serves as a guide for diagnosis, formulation, and
treatment planning.
• A well-taken history not only reveals symptoms, but
also the person behind the illness.
THANK YOU
