EXAMINATION OF A PSYCHIATRIC PATIENT
HISTORY TAKING
Socio-demographic details:
Name, Age, Sex, Address, Education, Occupation, Religion, Socio-economic status
Marital status
Identification marks: 1. 2.
Informant: Relationship to patient, whether they stay with the patient or not, duration of
staying together,
Reliable / not reliable, Adequate/ non adequate
Presenting / Chief Complaint (with duration in chronological order of appearance) in
patient’s own words and note the duration of each complaints
According to patient
According to informant
History of Present Illness
Mode of onset: Acute (hours to days)/ subacute (days to weeks)/insidious (exact
duration of onset cannot be elicited i.e., weeks to months) .
Precipitating factors: - Physical factors and Psychological factors.
Course of the illness before coming to hospital : Continuous / Episodic /
Fluctuating / Deteriorating / Improving.
Description of present illness (chronological description of each symptom,
Negative history – information regarding absence of related symptoms)
History of organicity
Treatment History: Drugs (name of the drug, dose, route, side effects, if any),
ECT , Psycho-socio therapies,
Effect of treatment, whether still on treatment or not
Concurrent significant medical illness and its treatments.
Past history:
Significant physical and psychiatric illness in the past
Example:
Manic episode
Current
episode
depression
Hospitalization (Medical/ Psychiatric): Place of hospitalization , duration of stay,
length of the illness, medication, condition on discharge
Last attack, interval functioning (How is the patient between episodes/when "well')
Surgeries / Accidents/ Head injury / Convulsions/ Unconsciousness/
DM/HTN/ CAD / CVA/ Venereal disease/HIV /Suicide attempts/Others
Family History
Genogram (family of origin)
Description : Describe each family member (parents and siblings) briefly: age,
sex, education, occupation, health status, marital history, relationship with the
patient, substance use and abuse, age at death, mode of death
Type of Family –nuclear/joint/extended
Current social situation: Home circumstances, per capita income, socioeconomic
status, leader of the family and current attitude of family members towards the
patient’s illness, mode of coping by the family, social supports – primary ,
secondary, tertiary.
History of any psychiatric / medical illness, epilepsy/mental retardation/suicide in
the family
PERSONAL HISTORY
1.Birth and early development:
Record the details of prenatal, natal and post natal periods; was the birth at full term?
Whether delivered in hospital or home? any complications during delivery ? Any physical
illness in the post natal period? Ascertain whether milestones of development were normal or
delayed
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 the form of frequent
fights, truancy, stealing, lying and gang activities. Also enquire about relationship with
parents, siblings, and peers.
3. Physical illnesses during childhood:
Record physical illnesses 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, attitudes towards peers and teachers.
5. Occupation:
Age of starting work, jobs held, in chronological order; work satisfaction, competence, future
ambitions.
6. Menstrual history:
Enquiry about age of menarche; reaction to menarche, regularity of
periods; Dysmenorrhea, menorrhagia/ oligomenorrhea; emotional disturbances in relation to
menstrual cycle.
7. Sexual history: Enquire about age at onset of puberty; level of knowledge regarding sex
and mode of gaining the same, rnasturbatory practices; Anxiety related to sexual fantasies.
Homosexual and heterosexual fantasies, inclinations and experiences extramarital
relationships
8. Marital history: Enquiry regarding age at the time of marriage, whether arranged by
elders or self, consanguineous / non consanguineous. Was there mutual consent of the
partners; Age, Education, Occupation, Health and personality of partner, Quality of
marital relationship, Any separation or divorce. Note the number of children, their ages
and health status. Genogram (family of procreation)
9. Use and abuse of alcohol, tobacco and drugs: Enquire about smoking and drinking
pattern and abuse of other drugs like cannabis, opiates, barbiturates etc.
PREMORBID PERSONALITY:
In this description of the personality prior to the beginning of the mental illness, do not be
satisfied with a series of adjectives and epithets, but give illustrative anecdotes and detailed
statements. Aim at a picture of an individual, not a type, the following is merely a collection
of hints, not a 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 cases of neurosis or affective
disorder, to elicit evidence about all aspects of pre-morbid personality in the course of
explorations extending over a period.
1. Social relations: The family (attachment, dependence); to friends, groups, societies, clubs,
to work and workmates (leader or follower, organizer, aggressive, submissive, ambitious,
adjustable, independent).
2. Intellectual activities: Hobbies and interests: books, plays, pictures, preferred, memory,
observation, judgment, critical faculty.
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 is worried by responsibility, makes
decisions easily or with difficulty; haphazard and slapdash or methodical and meticulous;
rigid or flexible; cautious, foresight and given to checking or impulsive and slipshod;
preserving and determined, or easily bored discouraged.
(b) Interpersonal relationships.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, tactful or outspoken; enjoys or shuns self-display; quiet and restrained
or expressive and demonstrative in speech and gesture; interest and enthusiasms sustained or
evanescent, tolerant or intolerant of others; adaptable or rigid.
5. Energy & initiative: Energetic or sluggish, output sustained or fitful, fatigability, any
regular or irregular fluctuations in energy or output.
6. Fantasy life: Frequency and content of daydreaming
7. Habits: Eating (fads): alcohol consumption, self medication with drugs or other medicines
specify amounts taken recently and earlier tobacco consumption; sleeping; excretory
functions.
PHYSICAL EXAMINATION:
A complete physical examination is mandatory in each patient. General and Systemic
examination, with a standard screening neurological examination. In-depth neurological
examination is warranted when there are positive findings.
MENTAL STATUS EXAMINATION (MSE):
A systematically conducted mental status examination is an important component of case
taking it is essential or record the observations properly, whenever positive findings are
obtained, they should be described in detail. It is not adequate to say ‘delusions present’ or
'hallucinations'. MSE has to be repeated several times during the course of illness to know the
evolution of symptoms, effectiveness of treatment etc. The time frame covered by the MSE is
restricted to the hour of observation, but extends longer, while the following account
highlights the major components of MSE, details should be obtained from other sources
cited.
1. GENERAL BEHAVIOUR:
Description: as complete, accurate, life-like as possible, of the observations of the following
points may be considered, though not exclusively.
Enquiry about the ways of spending the day, eating, sleeping, cleanliness in general, self care,
hair and dress. Behavior towards other patients, doctors and nursing staff does the patient
look ill? Note whether the patient is fully conscious, stuporous or comatose is he in touch
with surroundings? Is the patient relaxed or tense and restless / is he slow or hesitant? How
does he respond to various requirements and situations? Are there abnormal responses to
external events? Can his attention be held or diverted? Is the patient Co-operative? Can
adequate rapport be established? Does the patient maintain adequate eye contact? Does the
patient's behavior 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, decreased or normal.
3. SPEECH:
Note here the form of utterances rather than the content does: the patient speaks
spontaneously or only in response to questions
Is: the amount of speech little or excessive? Is it high toned or low toned? Is the tempo fast or
slow?
a) Is the reaction time increased or decreased?
b) Is the prosody of speech maintained?
c) Is it relevant?
d) Is it coherent?
e) Describe under these headings; relevance, coherence, volume, tone, tempo, reaction time.
4. THOUGHT:
Examine thought processes with respect to.
Form: Presence of formal thought disorder
Stream: Flight of ideas, retardation of thinking circumstantiality, perseveration, thought
blocking.
Possessions: Obsessions and compulsions, thought alienation. With respect to obsessions,
elicit their nature-ideas doubts, imagery impulses phobias. Similarly clarify the nature of
compulsive acts checking, counting or washing are these ‘controlling’ compulsions of
‘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 the
delusion is single or multiple - the type of delusion (grandiose, persecutory, nihilistic etc.);
the exact content of the delusions, whether they are fleeting or fixed, whether they are well
systematized or poorly systematized and whether they are mood congruent or not. Enquire
about preoccupations, hypochondriacal and somatic symptoms. Depressive ideation, ideas of
worthlessness, guilt, hopelessness and suicidal ideas must be enquired and recorded.
5. MOOD:
This should be assessed by both subjective report and objective evaluation, assessment
should be both longitudinal (mood) and cross-sectional (affect). Description should be given
regarding the following components; the quality of emotion (happiness, sadness, anxiety etc.)
the intensity or depth of emotional experience, the range of affective responses, reactivity
(changes in emotion in relation to environmental factors), diurnal variation, congruity (in
relation to thought processes) and appropriateness (in relation to- situations). Note any
evidence of liability (rapid and extreme changes in emotion).
6. PERCEPTION:
Record the presence of illusions and hallucinations. Enquiry should be made into the
following modalities vision, hearings, smell, touch, taste, deep sensations, 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 descriptions of the actual experience
should be obtained. For example with respect to auditory hallucinations enquiry whether the
hallucinations are verbal or non verbal continuous or intermittent, single voice or multiple
voices; familiar voice; unfamiliar. First person, second person or third person; pleasant or
unpleasant, if unpleasant, whether commanding, abusive or threatening; relationship to
hallucinations; whether mood congruent. Distinguish hallucinations from imagery and
pseudo-hallucinations.
Other perceptual disturbances that must be enquired include heightened perception, dulled
perception, depresonalisation / derealisation experiences in the perception of the
7. COGNITIVE FUNCTIONS: (Detailed section given later).
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 recognize the presence of illness but gives explanation in
physical, terms (partial insight)? Does he fully realize the emotional nature of his illness and
the cause of his symptoms (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.
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 another. It should
always include a discussion of the diagnosis, of the etiology, factor which are seen as
important, a plan of management and an estimate of the prognosis, regardless of the
uncertainty or complexity of the case, a provisional diagnosis should always be specified
using the ICD.
INVESTIGATION, TREATMENT AND 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.
Progress notes should be systematically recorded.
CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS
1. Clinical assessment includes the areas of
2. Attention and concentration
3. Orientation
4. Memory
5. Intelligence
6. Judgment
ORIENTATION
Three aspects are described to time, place and person the following questions may be asked
in the relevant areas:
Time:
1. Approximately 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 now long have I been talking to you?
4. What is the day today? (day of week)
5. What is the date (day of the month, month and 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 background)
Person:
a) Orientation to self is tested by asking the identity of the-patient.
b) Inquiring about the identity of the patient's relatives or family members.
ATTENTION AND CONCENTRATION:
Tests used in clinical situation include:
1. The digit span test
2. Serial subtraction
3. Days or months forward to backward
1 .Digit Span Test
a) Forward:
Patient' is given the following instructions: I will be saying some digits, listen to me
carefully,when I finish saying them, you will have to repeat them in the same order the
examiner after
Instructing the patient. :
Give an example (for example if I say 3, 7 you say 3,7)
Read digits at the rate of one per second to the patient
notes whether the immediate response of the patient is correct or incorrect. The following
digits may be used:
5-7-3 4-1-7
5-3-8-7 6-1-5-8
1-6-4-9-5 2-9-7-6-3
3-4-1-7-9-6 6-1-5-8-3-9
7-2-5-9-4-8-3 4-7-1-5-3-8-6
4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4
The digit span is the highest number 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 2nd trial with the same number of digits are 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 reversed order, for example if I say 2-5 you have to say 5-2. The
procedure is the same as for digits forward:
-the same digits be repeated not be used as tor the forward test
-no digit backward score is the highest number of digits correctly recalled backward after a
maximum of 2 trials
2. Serial Subtractions:
Increasingly difficult tests are presented. The examiner a) instructs the patient, b) gives an
example of now to perform task, c) notes the responses verbatim and d) notes, the time taken
in seconds
TASK: Correct response and the limit
20-1 20 to 0 reversed in 15 sees.
40-3 40,37,34,31 etc. in 60 sees.
100-7 100, 93, 86, 79 etc. in 120 sees
3) Days or months may be asked for in backward to the patient who is familiar with the
correct order.
MEMORY:
Assessment includes 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 for after 3-5 minutes. Minimum 3 facts
2] 24 hours recall test : Asking the patient to recall events in the last 24 hours e.g. details of
the time and amount in a meal, visitors to the hospital from an inpatient.
Responses given by the patient should be noted of any cross-checked from
reliable source.
c) Remote memory: Information on life events:
i} Date of birth or age
ii} Number of children
iii} Names and number of family member
iv} Time since marriage or death of family member
v} Year of completing education
4-5 facts may be asked for relevant to the patients background and answers should be
crosschecked.
INTELLIGENCE
This includes the areas of general information, comprehension, arithmetic and vocabulary.
1. General information: Information relevant to the patient’s literacy, age or occupation
may be asked e.g : in literate.
a) Name of Prime .Minister
b) 5 rivers, cities or states
c) Capitals of countries
d) Current events (major)
For illiterates
a) Seasons
b) Crops of fruits growing particular seasons
c) Prices of food grains or food items
d) Prices of land
1. Comprehension:
The ability to understand questions asked during an interview is raw index. Specifically, the
following questions of increasing difficulty may be asked:
i. What will you do when you feel cold?
ii. What will you do if it rains when you start to work ?
iii. What will you do when you miss the bus when you are on a journey?
iv. What will you do when you find on your that it will be late by the time you ready
your work spot?
v. Why should we be away from bad company?
2. Arithmetic:
The following questions may be asked with increasing time units
a) How much is 4 rupees and 5 rupees?
b) I borrowed 6 rupees from a friend and returned 2 rupees, how much do I still owe to him
c) If a man buys cloth for 12 rupees and gives a shopkeeper 20 rupees, how much change
would he get back?
d) How many pencils can you buy for 2 rupees if one pencil costs quarter of a rupee (or 25
paise)?
e) If 18 boys are divided into groups of 6, how many groups will there be?
Time limits: a to c -15 seconds
d & e- 30 sees
Correct answers: 1)9. 2)4, 3)9. 4)8, 5)3
3. Abstraction:
Tested by a 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 (animals)
Eye - Ear . (sense organs)
North - West (directions)
Table - Chair (items of furniture)
Correct responses, i.e. abstract responses are given in brackets.
Differences being an easier task, is always presented before similarities.
The instructions are as follows: I will be presenting to you some parts of words. Listen
carefully and tell me in what they are different from each other.
Stone - Potato (not edible - edible/hard-soft)
Fly - Butterfly (small-large/not colourful- 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 what it means
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 never bites
3) As you sow, so shall you reap
4) All that glitters is not gold or all that is while is not milk
5) Where there is a will there is a way .
6) Empty vessels make more noise
7) Every potter praises his pot
8) It is useless to cry over spilt milk
The response of the patient is to be noted verbatim and judged to be correct/incorrect.
JUDGEMENT
Is assessed in the following areas
1) Personal
2) Social
3) Test
Personal Judgement is assessed by inquiries about the patient future plans
Social Judgement is assessed by observing behaviour in social situations.
Test for Judgement: The.following 2 problems are presented to the patient in a manner in
which he can comprehend.
Fire problem: If the house in which you are catches fire, what is the first thing you will do?
(correct answer - try to put if oft with water)
Letter problem: If when you are walking on the roadside you see a stamped & sealed
envelop with an address on it which someone had dropped, what will you do?
(correct answer-post it in a letter box or give it to the post man)
EXAMINTION OF NON-CO-OPERATIVE OR STUPOROSE PATIENTS:
(Kirby, 1921)
The difficulty of getting information from non-cooperative patents should not discourage the
physician from making and recording observations. These may be of great importance.
Study of various types of cases give valuable data for the interpretation of different clinical
reactions. It is hardly necessary to say that the time to study negative reactions is during the
period of negativism, the time of study a stupor is during the stuporose phase. To wait for
the clinical picture to change or for the patient to become more accessible is often to miss an
opportunity and leave a serious gap in the clinical observation. Obviously it is necessary in
the examination of such cases to adopt some other plan than that used in making the usual
‘mental status’.The following guide was devised to cover in a systematic way the important
points for purposes of clinical differentiation.
I. GENERAL REACTION AND POSTURE:
Attitude voluntary or passive
Voluntary postures comfortable, natural, constrained or awkward
What does the patient do if placed in awkward of uncomfortable position.
Behavior toward physicians and nurses; resistive, evasive, irritable, apathetic, complaint.
Spontaneous acts: any occasional show of playfulness, mischievousness or assaultiveness.
Defence movements when interfered with or when pricked with pin. Eating and dressing
Attention to bowel and bladder. Do the movements show only initial retardation or are they
consistent throughout?
To what extent does the attitude change? Does the behaviour occurrences influence the
condition?
II. FACIAL EXPRESSION: Alert, attentive, placid, vaunt, stolid, sulky, scowling, averse,
perplexed, distressed, etc. Any play of facial expression or signs or emotion tears smiles,
flushing, perspiration. On what occasions?
III. EYES: Open or closed, if closed resist having lid raised. Movement of eyes absent or
obtained on request: give attention and follow the examiner or moving objects or show only
fixed gazing, furtive glances or evasion.
Rolling of eyeballs upward, blinking, flickering, or tremors of lids, reaction to sudden
approach to threat to sick in eye, Sensory reaction of pupils (dilation from painful stimuli or
irritation to skin of neck)
IV.REACTION TO WHAT IS SAID OR DONE: Commands show tongue, move limbs,
grasp with hand (clinging, clutching, etc.), Motions slow or sudden. Reaction to pin-prices
Automatic obedience tell patient to protrude the tongue to have pin stuck into it.
V. MUSCULAR REACTIONS: Test for rigidity, muscles relaxed or tense when limbs or
body is moved Catalepsy, Waxy flexibility, Negativism shown by movement in opposite
direction or springy or cog-wheel resistance.
Test head and neck by movement forward and backward and 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 (Schnauzkrampl)
Holding of saliva, drooling
VI .EMOTIONAL RESPONSIVENESS: Is seeing down when talked about family or
children, or when specified 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 electric light)
VII. SPEECH: Any apparent effort to talk, lip-movements, whispers, movements of head.
Note exact utterances with accompanying emotional reaction (may indicate hallucinations)
VIII. WRITING: offer paper and pencil. Unresponsive or partially stuporous patients will
often write when they fail to talk.
