Case History and Mental
State Examination (MSE)
Ms. Aakriti Varshney
Consultant Clinical Psychologist & Head
Shanti Home KNEUS Hospital
Greater Noida
Overview
• The Case history and Mental Status Examination (MSE) are the most
important diagnostic tools a psychiatrist has to obtain information to make
an accurate diagnosis.
• Although these important tools have been standardized in their own right,
they remain primarily subjective measures that begin the moment the
patient enters the office/therapy room.
• In psychiatric assessment, history taking interview and mental status
examination need not always be conducted separately (though they must be
recorded individually).
• During assessment, the interviewer should observe any abnormalities in
verbal and nonverbal communication and make note of them.
CASE HISTORY TAKING
Socio-demographic details
• Name, Age, Sex, Marital status, Education, Occupation, Residence, Religion,
Socioeconomic status, Referral, Date.
Informant
• Relationship with the patient
• Reliability and adequacy of the information.
• To check the reliability of the information provided.
• Concise
• Coherent
• Consistency
Chief complaints
• The presenting complaints and/or reasons for consultation should be
recorded. Both the patient’s and the informant’s version should be
recorded, if relevant.
• If the patient has no complaints (due to absent insight) this fact should
also be noted.
• Note separately according to patient and according to the informant.
Onset
• First appearance of the signs and symptoms of an illness.
• Abrupt (48 hours)- when the symptoms occur suddenly
• Acute (48 hours- 1 week)- illness that is of short duration, rapidly
progressive and in need of urgent care
• Subacute (1 week- 2 weeks)- indicates longer duration, less rapid
change
• Insidious (more than 1 month)- gradual and subtle development
Course
• Episodic
• Continuous (Static, progressive, fluctuating)
Duration (time period)
Factors
• Precipitating factors (contributory factors)
• These are the factors that causes or trigger the onset of a disorder
• Includes life stressors
• Predisposing factors
• That put the patient at risk/vulnerable of developing a problem
• Example- genetics, temperament, premorbid personality
• Maintaining factors (perpetuating)
• Factors or conditions that maintain the disabling symptoms in an individual
• Protective factors
• Provide relieve
History of present illness (HOPI)
• Detail narration of the illness
• Onset
• Chronological order
• Intensity/severity
• Frequency
• Consequences of the symptoms
Negative History
• Eliminating other disorders
Past psychiatric and medical history
• Past history of any serious medical or neurological illness, surgical
procedure, accident or hospitalization should be obtained. The nature
of treatment received, and allergies, if any, should be ascertained.
Treatment history
• Any treatment received in present and/or previous episode(s) should
be asked along with history of treatment adherence, response to
treatment received, any adverse effects experienced or any drug
allergies which should be prominently noted in medical records.
Family History
• Genogram
• Family Structure
• Family history of similar or other psychiatric illnesses, major medical
illnesses, alcohol or drug dependence and suicide (and suicidal
attempts) should be recorded.
• Family dynamics
• Current social situation
• Communication pattern
• Decision making
• Family’s attitude towards patient’s illness
Personal History
• Perinatal (birth history, nature of birth, birth cry, complications,
weight)
• Developmental history (developmental milestones)
• Childhood History
• Educational
• Occupational
• Sexual & marital history
• Alcohol and Substance History
Premorbid Personality
• Interpersonal relationship: Interpersonal relationships with family
members, friends, and work colleagues; introverted/extroverted; ease
of making and maintaining social relationships.
• Use of leisure time: Hobbies; interests; intellectual activities; critical
faculty; 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; foresight.
• Religious beliefs and moral attitudes: Religious beliefs; tolerance of
others’ standards and beliefs; conscience; altruism.
• Fantasy life: Sexual and nonsexual fantasies; daydreaming-frequency
and content; recurrent or favorite daydreams; dreams.
• Habits: Food fads; alcohol; tobacco; drugs; sleep.
MENTAL STATE EXAMINATION
• Mental status examination is a standardized format in which the clinician
records the psychiatric signs and symptoms present at the time of the
interview.
• The Mental State Examination (MSE) is a structured way of observing
and describing a patient’s current state of mind, under the domains of
appearance, attitude, behavior, mood, affect, speech, thought process,
thought content, perception, cognition, insight and judgement.
• 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.
GENERAL APPEARANCE AND BEHAVIOR:
Appearance
• Hygiene: clean, body odor, shaven, grooming
• Dress: clean, dirty, neat, ragged, climate appropriate — anything
unusual?
• Jewelry: rings, earrings — anything unusual?
• Makeup: lipstick, nail polish, eye makeup — anything unusual?
• Other: prominent scars, tattoos
Behavior
• Eye Contact: decreased, normal, excessive, intrusive
• Mannerisms, stereotypies, posturing
Cooperativeness
• Cooperative, friendly, reluctant, hostile
Rapport
• Note if the patient appears engaged in the consultation and if you are
able to develop a rapport with them.
PSYCHOMOTOR ACTIVITY:
Increased activity (restlessness, agitation), decreased activity
• Observe for any evidence of psychomotor abnormalities:
• Psychomotor retardation: associated with a paucity of movement and
delayed responses to questions.
• Restlessness: the patient may continuously fidget, pace and refuse to
sit still.
SPEECH:
• General: accent, clarity, stuttering, lisp
• Rate- fast or slow (Slow speech: may occur due to psychomotor retardation which
is typically associated with major depression)
• Tone- soft, harsh, confronting, normal, Monotonous speech (associated with
conditions such as depression, schizophrenia and autism), Tremulous speech
(associated with anxiety)
• Volume- whispered, soft, normal, loud
• Pitch- increased or decreased
• Pressure of speech- a tendency to speak rapidly, motivated by an urgency that may
not be apparent to the listener (often a manifestation of thought abnormalities such
as flight of ideas) pressured speech, increased or decreased
• Reaction time- Increased, delayed
MOOD AND AFFECT:
• Mood- A patient’s mood can be explored by asking questions such as:
• “How are you feeling?”
• “What is your current mood?”
• “Have you been feeling low/depressed/anxious lately?”
• Affect-
• Subjective and Objective
• Type: depressed/sad, anxious, euphoric, angry
• Range: full range, labile, restricted, blunted/flattened
• Appropriateness to content and congruence with stated mood
THOUGHT:
FLOW OF THOUGHT
• How it is being thought about – The amount and speed of thinking
• Increased, Decreased, or Normal, flight of ideas
• Flight of ideas- Rapidly shifting from one topic to another which are related via superficial
associations. In its extreme forms, it involves cognitive incoherence and disorganisation.
For example-
• Doctor: “How are you sleeping at night?”
• Patient: “Why would I sleep tonight? Would you be able to do my work. I whistle while I
play and I am happy to do it all. Okay? So that is like a haul.”
Types of Flight of Ideas are:
• Rhyming or clanging (well, hell, bell).
• Distraction (A patient talking about his appetite sees another patient walk past a window
and assume the patient is going for ECT and starts talking about ECT).
FORM-
• Abnormalities of the way thoughts are linked together.
• Identify presence of any FTD.
• FTD:
• Circumstantially: A person talks at length about irrelevant and trivial
details (i.e. circumstances) and is very delayed at reaching its goals
(excessive long windedness). However, there is a clear association
between sentences. A patient affected with this condition, for example,
when asked about a certain recipe, could only minute details about
going to the grocery store, the shopping experience, people there, etc.
• Tangentially: Replying to questions in an irrelevant manner and
never reaching the goal. However, there is a clear association between
the sentences (but end is not reached). For example-
• Question: “What city are you from?”
• Answer: “Well, that’s a hard question, I really don’t know where my relatives
came from so I don’t know if I’m Irish or French”.
• Word Salad (or incoherence): Is at the extreme end of the scale. The
words are just random words.
• For e.g., “Blue afraid you know carpet cat”.
• Neologisms- New word formations.
• For example- “I got so angry. I picked up dish and threw at the geshinker”;
“hand shoes” (gloves).
• Echolalia- Echoing of other people’s speech.
• For example- “Can we talk for a few minutes?”
• Patient says: “talk for a minutes, talk for a few minutes”.
• Blocking- The patient stops speaking and after a period of seconds
indicates he/she is unable to remember what he/she had intended to
say. Blocking may give rise to the delusions that thoughts have been
withdrawn from the head (thought withdrawal).
• Mutism- Refusal or inability to speak.
THOUGHT CONTENT
• Abnormalities of thought content can include:
• Delusions: a firm, fixed belief based on inadequate grounds, not amenable to a
rational argument or evidence to the contrary and not in sync with regional and
cultural norms. These may include persecutory delusions, in which the patient
erroneously believes another individual or group is trying to harm them or ideas of
reference, in which the individual incorrectly believes specific events relate to
them.
• Obsessions: thoughts, images or impulses that occur repeatedly and feel out of the
person’s control. The patient is aware these obsessions are irrational, but the
thoughts continue to enter their head.
• Compulsions: repetitive behaviors that the patient feels compelled to perform
despite recognizing the irrationality of the behavior.
• Overvalued ideas: a solitary, abnormal belief that is neither delusional nor
obsessional in nature, but which is preoccupying to the extent of dominating the
sufferer’s life (e.g. the perception of being overweight in a patient with anorexia
nervosa).
• Suicidal thoughts
• Homicidal/violent thoughts
POSSESSION-
• Abnormalities of thought possession include:
• Thought insertion: a belief that thoughts can be inserted into the patient’s
mind.
• Thought withdrawal: a belief that thoughts can be removed from the
patient’s mind.
• Thought broadcasting: a belief that others can hear the patient’s thoughts.
• Some examples of questions which can be used to screen for thought
possession abnormalities include:
• “Do you think people can put ideas in your head, without your control?”
• “Have you ever felt like people have removed memories or thoughts from
your mind?”
• “Do you ever feel like others can hear what you’re thinking?”
PERCEPTION:
Perception involves the organization, identification and interpretation of
sensory information to understand the world around us. Abnormalities of
perception are a feature of several mental health conditions.
• Observe perceptual abnormality.
• Hallucinations
• Illusions
• Depersonalization
• Derealization
COGNITIVE FUNCTIONING:
Orientation to:
• Time-
• Place- Disoriented or Oriented/ Intact
• Person-
• Whether the patient is well oriented to time (test by asking the time, date,
day, month, year, season, and the time spent in hospital), place (test by
asking the present location, building, city, and country) and person (test by
asking his own name, and whether he can identify people around him and
their role in that setting). Disorientation in time usually precedes
disorientation in place and person.
Memory-
• Immediate- Intact or impaired. Use the digit span test to assess the
immediate memory; digit forwards and digit backwards subtests.
Digit forward (Numbers given- 5, 9, 3, 7, 1, 4)
Digit Backward
• Recent- Intact or impaired
• Ask how did the patient come to the room/hospital; what he ate for dinner
the day before or for breakfast the same morning. Give an address to be
memorized and ask it to be recalled 15 minutes later or at the end of the
interview.
• Remote- Intact or impaired
Attention and concentration: Could be aroused and sustained
Calculation- Serial subtraction of 7’s from 100
Response: “93, 86, 79, 72, 65”
Abstract thinking:
• Proverb Testing: The meaning of simple proverbs (usually three) should be
asked.
• Similarities (and also the differences) between familiar objects should be asked,
such as: table/ chair; banana/orange; dog/lion; eye/ear.
The patient was asked about the similarity between mango and apple.
Response- “both are fruits and are sweet”
The patient was asked about the similarity between tube light and fan.
Response- “both work with electricity”
General intellectual ability: Adequate/ Inadequate
• Ask questions about general information, keeping in mind the patient’s
educational and social background, his experiences and interests, for
example, ask about the current and the past prime ministers and
presidents of India, the capital of India, and the name of the various
states.
JUDGEMENT:
• Judgement refers to the ability to make considered decisions or come to a sensible conclusion when
presented with information. Judgement can become impaired in several mental health conditions leading to
poor decision making.
• Social judgment- Intact/ impaired/ partially intact
The patient have friends and have good relations with employees at workplace.
• Test judgment- Intact/ impaired/ partially intact
If you see a stamped and addressed envelope on the road which contains money, then what will you do?
Patient’s response- “I will try to post it to the address”.
If there is fire in the next room, then what will you do?
Patient’s response- “I will call for help”
• Personal judgement- Intact/ impaired/ partially intact
INSIGHT:
• Insight is the degree of awareness
and understanding that the patient
has regarding his illness.
