CASE HISTORY COLLECTION AND MENTAL STATUS

EXAMINATION

Clinical symptomatology is a branch of medicine concerned with the study and

classification of the symptoms of disease. In medicine, a symptom is any evidence or affliction

which indicates the presence of illness or disease. In many cases, the evidence is subjective and

can only be detected by the patient, such as in the case of nausea, weakness, or pain.

Symptomatology is the science devoted to studying symptoms for the purpose of making a

diagnosis. This term is also used to describe the combined symptoms of a particular disease.

Mental illness is a condition that can rarely be diagnosed with physical tests, but must

rely on careful evaluation of health history, behavior, patient interviews, family observations,

and psychological evaluations. Psychiatric symptomatology is measured by several screening

tests which take into account the subjective responses of patients to determine mental health

conditions and proscribe treatment plans. Some symptoms, when present for a sustained period

of time, may indicate mental health problems. These include wide mood swings, confusion,

sustained irritability, drastic changes in eating or sleeping, rages, or hallucinations.

Case taking in psychiatry is both a science and an art. To systematically work up a case

and obtain the most relevant information in a short period of time, to synthesize this information,

to arrive at a diagnosis and workout a management plan is an art which is mastered over time.

Utmost importance should be given to elicitation of history. This should be supplemented by a

systematically carried out mental status examination and physical examination.

The mental status examination or mental state examination (MSE) is an important part of the

clinical assessment process in psychiatric practice. It is a structured way of observing and

describing a patient's psychological functioning at a given point in time, under the domains of

appearance, attitude, behavior, mood, and affect, speech, thought process, thought

content, perception, cognition, insight, and judgment. The purpose of the MSE is to obtain a

comprehensive cross-sectional description of the patient's mental state, which, when combined

with the biographical and historical information of the psychiatric history, allows the clinician to

make an accurate diagnosis and formulation, which are required for coherent treatment planning.

Data is collected through a combination of direct and indirect means: unstructured observation

while obtaining the biographical and social information, focused questions about current

symptoms, and formalized psychological tests.

Case history procedure begins from history taking process of the client which includes

the name, age, sex, education, occupation, socioeconomic status, family size, residence.

Mention here the source of informant, relationship of the informant to the patient, intimacy

and length of acquaintance with the patient and reliability of the information. It is often

necessary to obtain information from more than one source. In certain types of illness like

psychoses, relatives will be able to provide more reliable information while in neurotic illness;

the patient would be the best informant. When information is collected from more than one

source, do not collect the accounts of several informants into one, but record them separately.
PRESENTING COMPLAINTS

Record the patient’s or informant’s presenting complaint in chronological order, ideally in his or

her own words. Ask questions that gives a verbatim that states why he/she has come/ been

brought in for help – e.g... I ‘m depressed, I have tension, I am not able to sleep .Duration of

each complaint should be mentioned

HISTORY OF PRESENT ILLNESS

(a) Onset – abrupt (developing within 48 hours ), Acute (2 weeks), sub-acute (few weeks to

2 months), Gradual

(b) Course - Episodic ,continuous / fluctuating/ static ,

(c) Predisposing factors of illness.

(d) Precipitating factors- enquire about any precipitating events. These could be physical

(e.g., febrile illness) or psychological in nature (e.g. Death or loss). Ascertain whether the

events clearly precede the illness or were consequences of the illness(e.g., job loss

following the onset of a schizophrenia illness)

(d) Perpetuating factors-

The present illness is a chronological description of the evolution of the

symptoms of the current episode. Should enquire specifically about the changes that have

occurred during the same time period in patient’s interest, interpersonal relationships,

behaviors, personal habits and physical health. Essential response can be gathered in

response to open ended questions or otherwise lead through the presenting complaints.
 Details should include: Length of the time that the current symptoms have been present

and the nature of fluctuations of the symptoms. The presence or absence of stressors

(home, work, legal issues, medical co morbidities, interpersonal issues .Factors that

alleviates or reduced symptoms (medications support, coping skill or time of day).

Identifying the setting in which illness began (help in find the etiology of illness).

The essential questions should include: What (symptoms), How much (severity), How

long (course & duration)

Examine associated factors and try to establish why now.

Alcohol history: Chronological account of development of symptoms from the time of

first consumption (Amount, tolerance, withdrawal, harmful effects and periods of

abstinence if any) till date.

PAST PSYCHIATRIC HISTORY

Should obtain information about all the psychiatric illness and their course over the life time

 It should include details such as :What are the symptoms, When they occurred, How

long they lasted , Frequency and severity of episodes, Enquiry about the previous

diagnosis

 Past treatment review in detail: What was tried. How long and at what doses they were

used. Why they were stopped. What was the response to medication. Whether there were

side effects & Compliance with the treatment.

 Lethality history (Past suicidal ideation ,intent, plan and attempts)

 Violence and homicidal history (Violence actions or intent)

 History of non-suicidal self-injurious behavior (cutting , banging head, biting oneself )

History of use of substances, abuse and addictions: Frequency and amount of use,

Tolerance, Withdrawal, Impact of use on social life, work, legal consequences and

driving while intoxicated. History of treatment detoxification / rehabilitation /group

therapy. Other use of substances and addictions should be included here (tobacco,

caffeine use, gambling, eating behaviors and internet use.

Past medical history :An account of major medical illnesses as well as treatments both

past and present, Any past surgeries are reviewed, Pay attention to seizures, head

injury ,pain disorder ,thyroid, Careful review of the current medications and non-

psychiatric medications.

Negative History: used to rule out history suggestive of head injury, seizure, trauma, use

of alcohol, nicotine, cannabis, sniffing any volatile solvents, hearing voices, seeing things

that others cannot see, thoughts being inserted, withdrawn or broadcasted, suspiciousness,

pervasive sadness, excessive hand-washing or checking, repetitive intrusive thoughts,

impairment in intelligence, pervasive development, persistent dissocial behaviour,

repetitive motor and vocal production, misidentification, anxiety, depersonalization and

derealisation.
FAMILY HISTORY

Description about individual family member (Living or dead, Age,

Education, Occupation, Relationship with the patient), Type of family – joint

/nuclear ,Enquire about the physical and psychiatric illness in the family, Collect data

regarding SES, leadership pattern and role functions and communication, Consanguinity-

relation by blood/descent from a common ancestor within the same family stock. If present

than degree of the consanguinity should be noted.

Genogram - It usually includes data about three or more generations of the family (including

significant life events birth, marriage, separation, divorce, illness, death);

PERSONAL HISTORY

 Birth and Early Development (In detail when client/patient is 16 and below or in case

of developmental delay)

Record the details of Prenatal, natal and post natal

Prenatal: Age of mother at conception, any miscarriages/abortions prior to conception of

patient. If so, how long before she conceived patient. Patient’s birth planned/unplanned

pregnancy; wanted/unwanted, Home atmosphere – eventful/ uneventful,Falls, physical

injuries, infections, bleeding, fever.Inhalation of toxic substances, use of psychoactive

substances (*health in 1st trimester)

Peri-natal: Full Term Normal Delivery/ FTCesareanD or Premature birth (duration in

incubator), Birth cry – Present/Absent/Delayed, Birth weight, Date and place of birth:
 Home/Hospital and reason, Use of forceps, Umbilical cord occlusion/Birth Asphyxia,

Neonatal jaundice

Postnatal: Fever; Febrile seizures; physical health during infancy (0-2 yrs),

Breastfeeding/how long until weaned

Early Development Milestones: Neck Control, Sit without support, Walk, Eye contact.

Speech – first word, 2 word speech, use of gestures and pointing if speech delayed, joint

attention. Any delays/global delay.

 Behaviour during Childhood

Nail-biting, bedwetting, thumb sucking, sleep walking, Temper tantrums, Stammering, Fears and

phobias, Home atmosphere during childhood

Behaviour during Adolescence: School refusal/truancy, Delinquency/vandalism/drug

abuse/smoking, Overweight/underweight, Bullying/Peer pressure, Identity problems

 Physical Illness during Childhood:

Record physical illness suffered in childhood. Enquire specifically regarding

Encephalitis, Epilepsy, Measles, Malaria. Immunisation schedules

 School: Age of beginning, completion, if discontinued – reason for doing so,

performance in academics, relationship with peers and teachers, complaints on

behavioural conduct, promotion by achievement/ grace, change of school/medium of

instruction, adjustment issues. Marks in 10th and 12th or marks of highest grade

completed. College likewise. Participation in extracurricular. Achievements and awards

  Occupational History: Age at employment, Work performance, appraisals, performance

and financial satisfaction, Chronology of job changes and reasons, Relationship with

colleagues, team leader, boss, manager, Absenteeism's, warning memos, conflicts with

others .Effect of working under alcohol/substance influence. Accidents during work

 Menstrual History: Knowledge of menarche and reaction to it, Regularity of cycle,

Duration, Amount, Physical and emotional problems,Hygiene, Menopause.

 Sexual History

Unmarried

Onset of puberty, hygiene, development of secondary sexual characteristics, how patient attained

sexual knowledge, sexual orientation, if had relationships – physical intimacy, reason for

breakup, masturbatory practices, guilt, misconceptions, alcohol consumption and influence on

sexual arousal, erection, maintenance, risky sexual practices, sexual abuse.

Married

Arranged/love, year, duration, relationship consummated/not, sexual satisfaction, extra or pre-

marital affairs, conflicts in sexual life, treatment for sexual dysfunction e.g. premature/delayed

ejaculation, family planning, children –biological/adopted, contraception attitudes/use.

  Marital History

Details not collected in sexual history

Marital satisfaction, patterns of communication between partners, co-dependence, domestic

violence/ verbal abuse, conflicts with in-laws, patterns of communication with children,

household management.

 Use and abuse of alcohol, tobacco and drugs

 Social

Excessive use of social networking sites, cyber abuse, gambling, lottery, loan/debt, poverty,

denied social service, violation of social norms such as traffic signals, legal issues, stealing,

lying, destruction of property, setting things on fire.

Whom Patient confides in, how often in touch with social circle, social support system, how

often patient attends social/family gatherings and functions, expressed emotions among

significant others.

PRE-MORBID PERSONALITY

• It can be viewed as individualised styles of dealing with the environment that is

characteristic to each person prior to the onset of psychiatric disorder. It is important to

elicit details regarding the personality of the individual.

 • Temperament: if age is less than 16 years.

Interpersonal relationship: Interpersonal relationship with family members, friends, and work

colleagues. Extroverted/introverted. Ease of making and maintaining social relationships

Use of Leisure time: Hobbies, Interests, Intellectual activities, Energetic/ sedentary

Predominant mood: Optimistic/ Pessimistic, Stable/ Prone to anxiety, Cheerful/ Despondent,

Reaction to stressful life events

Attitude to self and others: Self confidence level, Self-criticism, Self-consciousness, Self-

centered/ thoughtful of others, Self-appraisal of abilities, Achievements and failures

Attitude to work and responsibility: Decision making, Acceptance of responsibility,

Flexibility, Perseverance

Religious beliefs and moral attitudes: Religious beliefs, Tolerance of other’s standards and

beliefs, Altruism

Fantasy life: Sexual and non-sexual fantasies, Daydreaming- Frequency and content, Recurrent

or favorite daydreams

Habits: Food, Sleep, Alcohol, Nicotine, Drugs

MENTAL STATUS EXAMINATION

General Appearance and Behavior: Overall appearance: looking ones age or not, Rapport and

cooperativeness , Clothes, Nails, Hair, Eye contact, Psycho motor activity,

Gestures/Postures/Facial expressions, Touch with surroundings, Attitude

Speech: Intensity, Reaction time, Speed, Relevance, Coherence, Goal Direction, Productivity

Thought (Assessed through speech sample and further questions):

• Stream- Flow of thoughts :Volume, Acceleration, Pressured Speech, Flight of ideas,

Prolixity, Retardation, Poverty of Speech, Circumstantiality, Tangentiality, Perseveration,

Thought Blocking.

• Form: Loosening of association, Derailment, Neologisms

• Possession: Obsession, Compulsion, Though alienation, Thought insertion, Thought

withdrawal, Thought broadcasting

• Content: Worry, Phobia, Primary Delusions, Secondary Delusions, Mood

Congruence/Mood incongruence

Mood and Affect

Mood: is defined as patient’s internal and sustained emotional state. It’s a subjective

experience. It’s better to use patients own words (verbatim). Example: sad, angry, guilty

or anxious.

Affect: differs from mood. The patient’s mood as it appears to be observed by the

clinician. It should be assessed in: quality, quantity, range, appropriateness and

 congruence. Quality: dysphonic, euthymic, irritable, angry, agitated, tearful, sobbing and

flat. (Speech is at times very important clue to assess it). Quantity: intensity (mild,

moderate, severe). Range: restricted, normal, labile, flat. Appropriateness: how affect

correlates to surrounding (appropriate, inappropriate). Congruence: Congruent/

incongruent

Perception

It is a perception experienced in the absence of any stimuli. Perception is the process of

being aware of a sensory experience and being able to recognize it by comparing it with

previous experiences (auditory, visual, olfactory, gustatory and tactile domains/

pseudohallucinations). These include hallucinations, illusions, and depersonalization.

• Hallucinations: interviewer should include what the patient is experiencing, what

was heard, when it occurs, how often is occurs, in which part of day it occurs, and

whether or not it is uncomfortable. They hear words, commands or

conversations and whether the voice is recognizable to the patient. Whether it

occurs during wakefulness, hypnagogic (while going to sleep) or hypnopompic

(getting up from sleep) hallucinations.

• Illusions and misinterpretation- which sensory field, whether occurs in clear

consciousness or not, steps taken to check reality of distorted perceptions.

• Depersonalization/derealization- are abnormalities in the perception of a person’s reality

and are often described as “as if” phenomena.

 • Somatic passivity- presence of strange sensations described by the patient as being

imposed on the body by ‘some external agency’.

COGNITIVE FUNCTIONS

1. Attention and Concenteraton :digit forward and backward, serial substraction

(100-7,48-3, 20-1), months backward, weeks backward

Impression: Attention is aroused and sustained

2. Orientation to TPP

• Record the patient’s answers to questions about his own name ,identity ,the place where

he is ,the time ,date ,year and identifying people around him

• Impression: oriented to time, place, and person.

3. Memory

Test immediate, recent and remote memory.

Immediate memory: Digit repetition test is used

Recent memory: Enquire about what he had for breakfast, the events of the day and what

he ate at the previous night. Give an address and asking to recall the same after sometime

Remote memory: Ask various personal and impersonal events (date of birth, year they

passed out from school, name of the school teachers

Impression: immediate, recent, remote memory intact

 4. Intelligence

This includes the areas of general information, comprehension, arithmetic, and

Comprehension and Vocabulary .General fund of information: information relevant to the

patient’s literacy age or occupation may be asked: Who is the president of India, Who is

the PM of India, Capital of India, Minimum charge for auto, etc.

Arithmetic ability: Ask questions like how much is 4 Rs and 5 Rs.

Impression: Clinically average/ below average.

Abstraction – tested by differences, similarities and proverb test

 Differences – How are the following items different

• Stone and potato

• Butterfly and cockroach

 Similarities – “How are the following items similar?”

• “an apple and an orange” (round ~concrete, fruit ~abstract)

• “a chair and a table” (made of wood ~concrete, furniture ~abstract

 Proverbs – “How would you describe the meaning of the following sayings?”

• All that glitters is not gold

• Barking dogs seldom bite

• Impression : concrete ,functional ,conceptual, abstract.

5. Judgement

• Personal judgment: judgment is assessed by inquiries about the patient’s future plans.

Ask the questions like: What is the patient’s attitude to the present state, Does he regard it

has an illness, Does he think treatment is necessary, what are his plans after discharge.

• Social judgment: it is assessed by enquires into the patient’s future plans with regard to

occupation or other responsibilities. The assessment is to be made both cross sectional as

well as longitudinally. Ask the questions like Does the patient show appropriate behavior

in social setting (hospital), Hypothetical situation – when guest comes to his house what

will he do

• Test judgment: the following 2 problems are presented to the patient in a manner in

which he can comprehend. What would the he do if he got a sealed ,addressed envelope

is found in the street ,What would he do if the theatre in which he is watching film caught

fire
 6. Insight

• This refers to the patients understanding of how he or she is feeling, presenting and

functioning as well as the potential causes of his or her psychiatric illness. Attitude

towards illness, whether its illness or not, is any treatment needed, is there hope for

recovery etc. is assessed.

Levels of insight:

1- Complete denial of illness

2- Slight awareness of being sick and needing help, but denying at the same time.

3- Awareness of being sick, but it is attributed to external or physical factors.

4- Awareness of being sick, due to something unknown in self.

5- Intellectual Insight- Awareness of being ill and that the symptoms/ failures in social

adjustment are due to own particular irrational feelings/ future experiences.

6- True Emotional Insight- it is different from intellectual insight in that the awareness

leads to significant basic changes in the future behavior.

Ask questions to know how much he is aware of the problem, What is your problem

do you consider it as an illness, Why do you think it is caused, What are you going to do about it.
DIAGNOSTIC FORMULATION

It is also called Case formulation or Summary. The purpose of the summary is

to provide a concise description of all the important aspects of the case to enable others

who are unfamiliar with the patients to grasp the essential features of the problem. It

includes

 Socio- demographic details (Name, age, gender, marital status, SES, hails from) and any

significant history of illness, family history, and suicidal attempts.

With Pre-morbid personality: Negative History, the chief / Presenting complaints,

Behaviours observed during the interview which is relevant to the Diagnosis, Positive findings of

Mental Status Examination (MSE) and the impressions relevant to the case- Test finding, Insight

level and Provisional diagnosis.