History Taking
History Taking
History Taking
Contents
1. Introduction ……………………………………………… 1
2. Personal information ……………………………………………… 3
3. History of presenting complains ………………………………………… 5
4. Past History ……………………………………………… 9
5. Family History ……………………………………………… 10
6. Personal History ……………………………………………… 11
7. Physical Examination ……………………………………………… 15
8. Mental Status Examination……………………………………………… 17
9. MSE of an uncooperative patient………………………………………… 53
10. Diagnostic formulation ……………………………………………… 55
11. Diagnosis and Diagnostic nomenclature systems……………………….. 58
12. Special populations ……………………………………………… 59
12.1 Children and adolescent……………………………………………. 59
12.2 Substance use disorders…………………………………………… 63
12.3 Epilepsy ……………………………………………… 66
13. Appendices ……………………………………………… 73
13.1 Symptom analysis ……………………………………………… 73
13.2 Mood graph & Illness graph ……………………………………… 75
13.3 Cognitive function assessment……………………………………… 77
13.4 Mini Mental Status Examination…………………………………… 89
13.5 Bush Francis Catatonia Rating Scale………………………………. 91
13.6 Abnormal Involuntary Movement Scale (AIMS) …………………... 93
13.7 Intoxication states for substance of abuse…………………………… 95
13.8 Withdrawal states for substance of abuse…………………………… 99
13.9 Epilepsy classifications ……………………………………………… 101
Introduction
If a person has physical illness, he goes to a doctor with certain complaint. The complaint
points to the direction in which its cause is to be sought and narrowes the field of enquiry. A
careful physician makes a full examination of all the systems, but with a mind that is
sensitized to a limited number of possibilites, his history taking will be governed by same
principle. The mental health professional proceeds in the same way, but in the field which has
been left almost untouched by the physician. He will pay attention to matters which the latter
has dismissed as personal or accidental. He sees beyond abnormalities of structure, into the
complexities of behaviour or deviations of mood.
In behavioural sciences, nearly everything of clinical importance is derived from the study of
the patient as an individual, and precise and detailed knowlwdge is therefore required of the
way in which the patient’s personality differed from that of other people, how it had grown,
and how it had been influenced by all the events of his life. Thus the interviewer will
necessarily be interested in circumstances of patient’s life, his hopes, fears, conflicts &
disappointments.
In history taking and the examination of the patient, two methods may be followed. They are
not alternatives, and it is best if they are combined , for each has its own deficiences. The free
interview may deterioate into a conversation into social level, and may provide only hints and
indications, rather than solid facts; certain important themes may go untouched. The method
of questionnaire has other defects. It is uncomfortable for the informant or the patient and he
may feel as a pupil in presence of school-master; and the information obtained may consist in
a mass of detail, without highlight or relief, which is very difficult to organize into a coherent
picture.
Thus the best plan is to have a framework of questionnaire in mind, but to allow the patient
to tell his story. As the story unfolds, it is fitted into the framework, so that any gaps that are
still left are apparent. Further questioning will then fill up the gaps and will clarify point of
salient importance. The plan should be subject to modification as the information pours in.
The interviewer should avoid giving the patient any feeling that he is being treated as a “case”
only. He should be both neutral and sympathetic. As far as possible, he should keep his mind
open and guard himself against pre-conceived ideas. So, as with a physician, the examination
by a mental health professional needs to be methodological and should be described under
proper headings and should follow a general schema. But the most important caution in use
of the schema is not to be too rigidly bound by it.
Only in the course of time, one can develop the art of eliciting, by tactful questioning, of all
he has to know. Long training is required to learn how to overcome the patient’s resistance, to
be aware of where his tale is biased, where information has been witheld and where it has
been coloured by an emotional attitude. It is better for the beginer to be too circumstantial in
his descriptions rather than being too selective.
A general schema and description of terms used in history taking are given in following
pages.
Psychiatric
history
taking
1
The aim of this write-up is to facilitate the learning of an art. For that the learner will
encounter certain terms, whose meaning and significance he would want to know. This write-
up is no where intented to replace any of the standard text material available in context.
The books which will be handy for a trainee, and which are directly or indirectly source of
information in this write-up includes:
Name of the individual: It is very important to know the name of the person before an
interview is started. It is the primary identification of an individual. It may be asked as the
opening sentence of interaction or it may be read from the documents. It is advicable to call
the patient by his name (with due respect and regard) in subsequent interaction, because it
gives a feeling of being familiar to the patient and helps in making him at ease throughout the
interaction.
Age: Age should be noted and further coroborrated while asking duration of illness and age at
onset of illness. Various mental as well as physical illnesses have a particular age of onset.
Thus knowing current age as well as age at onset of illness becomes important.
Sex: Certain disorders are common in one sex than the other. Certain socio cultural factors
might have more importance for one sex than the other.
Education: It would help in assessing the overall knowledge of the patient and also to base
our testing based on educational status of the patient. Signs and symptoms can also vary
according to educational background of the patient. In intervention, especially non
pharmacological methods, the modality should be adjusted according to the educational level
of the patient.
Occupation: Knowing the past as well as current occuaption of the patient is important as it
will have direct implication in socio-economic status of the patient. Impact of illness on
occupation can be assessed only if we know what the patient used to do before illness.
Socio-economic status: One needs to know the SES of the patient to be aware how much one
can afford to spend on treatment and required investigations.
Religion: Customs vary from one religion to other significantly. Also the examiner needs to
have basic idea about customs of prevelant religions in his/her area.
Residence: Customs and beliefs are significantly different for rural/urban population. One
shouls also know how far from the patient is coming, so that to formulate the frequency of
follow up visits accodingly.
Address: Proper address (both peramanent as well as present) needs to be noted along with
Phone no and email id, so that any postal/electronic/telephonic contact can be made with the
patient or the gaurdians as per need in the future.
Source of referral: It will hint us about the awareness of the patient and his/her caregivers
about the current condition of the patient. If referred from some authority, proper mention
should be made.
Indentification marks: They have role in identifying the patient and have medico-legal
importance. Traceable and permanent marks should be mentioned. Common moles should be
avoided. Proper anatomical location should be mentioned.
Patient’s report of his illness: It should take precedence over the other informants’ report.
Patient should be asked about his version of the illness. Using the patient’s own words gives
insight into his state of mind and how he himself views his symptoms. In case information
from patient is unsatisfactory or he denies symptoms or is non communiactive, it should be
mentioned with reasons and then should be proceeded for history taking from other available
informants.
Informant’s report: Details of all the available informants should be documented first,
including their names, relationship with the patient, acquaintance, length of contact,
consistency of the information. Also mention the reason for seeking help at current point of
time and what do they expect from the treatment they are seeking currently.
Reliability- It refers to the likelihood that similar results will be obtained by different
observers. The verification of the information especially factual data given by an
informant can be cross- checked by talking to another informant. Essentials for
reliability are (remembered by acronym of 5Cs)
! Contact- between the patient and informant
! Closeness- of realtionship between the patient and informant
! Continuity- of the account given by informant
! Consistency- of the verbatims of the informant
! Coroborativeness- between various sources of information
Chief complaints- The chief complaints, often recorded verbatim states, why he has come or
has been brought in for help. It usually describes present symptoms, including the duration of
each and an account of the development of the illness. Complaints should be in chronological
order with the earliest complaint first and recent most being last in list.
History of present illness- Popularized by the acronym of HOPI, this history forms the
backbone of psychiatric case work up. This provides a comprehensive and chronological
picture of the events leading up to the current moment in the patient’s life. The evolution of
the patient’s symptoms should be determined and summarized in an organised and systematic
way.
Factors in illness
Predisposing factors- Factors operating from early life that determines a person’s
vulnerability to develop a disorder or likelihood that person will develop certain
symptoms under given stress conditions.
! Biological (delayed milestones, head injury, family history of psychiatric
illness)
! Psychological (impaired premorbid personality)
! Social (home atmosphere in childhood, neglect, abuse, low education level)
Past medical history: This includes an account of major medical illness and conditions,
including common as well as uncommon chronic childhood illness, conditions leading to
frequent medical consultation and treatment and those requiring emergency department visits,
and those requiring hospitalization.
Past Psychiatric History: Take a detailed history of previous episodes, symptoms, duration,
probable diagnoses, all available treatment details including hospitalization, inter-episodic
functioning, deficits.
Clinical course indicators- Different task forces have come up with definitions for course
indicators in different psychiatric illnesses. The ones worthy of mention are as follows
MacArthur Foundation Research Network task force proposed following definitions for
unipolar depressive disorder, based on the assumption that major depression was episodic
and that the episodes in the illness have an ending.
! Remission- Treatment of a depressive episode, if successful, would lead to a
significant reduction of symptoms (“response”) and ideally to “remission,” a state of
minimal or no symptoms.
! Relapse- If symptoms reemerged following remission, this would be considered a
“relapse” within the index episode.
! Recovery- If remission were stable over a number of months (i.e. there was no relapse
or sub-syndromal symptomatic exacerbations), then recovery would result.
“Recovery” essentially meant that the index depressive episode had ended at both the
clinical and neurobiological levels.
! Recurrence- After recovery, a subsequent emergence of symptoms would be regarded
as a “recurrence,” or a new depressive episode.
Work-group of experts in bipolar disorder developed these consensus operational definitions.
! Response- A 50% reduction in a score from a standard rating scale of symptomatology
from an appropriate baseline, regardless of index episode type (manic, depressed, or
mixed) is defined as response. In addition, the other pole cannot be significantly
worsened during response.
! Remission was defined as absence or minimal symptoms of both Mania and
Depression for at least 1 week. Sustained remission requires at least eight consecutive
weeks of remission, and perhaps as many as 12 weeks.
! A relapse/recurrence was defined as a return to the full syndrome criteria of an episode
of mania, mixed episode, or depression following a remission of any duration.
! Roughening was defined as a return of symptoms at a subsyndromal level, perhaps
representing a prodrome of an impending episode.
For Schizophrenia, The Schizophrenia Work Group recommended that remission include
attaining minimal levels of psychoticism, disorganization, and negative symptoms as assessed
by the Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of
Negative Symptoms (SANS), Positive and Negative Syndrome Scale (PANSS), and Brief
Psychiatric Rating Scale (BPRS) for a minimum of 6 months.
Psychiatric
history
taking
9
Family history
Parents and siblings: Age now or at death (if dead, the cause), occupation, personality,
quality of relationship with parents, psychiatric and medical history.
A brief statement about any psychiatric illness, hospitalization, and treatment of the patient’s
immediate family members should be placed in the family history part of the report.
Any family history of alcohol or substance abuse or of personality problems should be
documented. In addition, the family history should provide a description of the personalities
and intelligence of the various households in which the patient lived.
Consanguinity: Relation by blood/descent from a common ancestor within the same family
stock. If present than degree of the consanguinity should be noted.
Relationships amongst family members: Patient’s relationship with family members,
interpersonal relationship among family members; family squabbles, attitude of family
towards patient’s illness; family support system should all be noted in family history part.
Genogram: The genogram is a valuable assessment tool for learning about a family’s history
over a period of time. Based upon the concept of a family tree, it usually includes data about
three or more generations of the family, which provides a longitudinal perspective. The
genogram provides a graphic picture of family geneology, including significant life events
(birth, marriage, separation, divorce, illness, death); occupations; places of family residence
It comprises of a chronological account of the person’s personal experiences starting with his
birth and birth details. The personal history is usually divided into perinatal, early childhood,
late childhood and adulthood. The predominant emotions associated with the different life
periods (e.g. painful, stressful and conflictual) should be noted.
Birth and Early Development: Antenatal history should start from presence of any illness,
medication, drugs, alcohol use, trauma or bleeding, exposure to X-rays, any physical/
psychiatric illness during pregnancy. Illness can include infectious disease which can present
as fever with or without rash, sexually transmitted diseases, diabetes, hypertension, jaundice
etc. For medications used in pregnancy, one should be aware of teratogenic effects of
common drugs.
How was the home situation into which the patient was born. Whether he/she was wanted?
Whether it was a planned or unplanned conception? Whether a failed abortion attempt was
made?
What was the mother’s emotional and physical state at the time of pregnancy as well as
delivery. Whether and from when fetal movements were perceived by the mother.
Whether the delivery was full term, preterm or postterm? Place (home/ hospital/ other) and
type of delivery (normal/ instrumental/ episiotomy/ caeserian section), any injury at the time
of birth, birth weight, normal or delayed cry should be documented. Any other complication
during delivery such as abnormal presentation, cord around neck, prolapsed cord, multiple
pregnancy or congenital anamoly noticed immediately after birth and presence of neonatal
jaundice and its extent should be enquired about.
What was the mode of feeding after bith, any problems associated with feeding, age at
weaning, recurrent infections, significant injury, convulsions in period immediate after birth
and early childhood should be reported
Adaptive skills
Feeds self in any way 8 months Drink from bottle 34 months
Helps in house 15 months Bladder control night 36 months
Feeds properly 20 months Brushes teeth, wash hands 36 months
Bowel control day 20 months Helps to dress 36 months
Bowel control night 22 months Visit key places around 42 months
Bladder control day 24 months Plays with several children 48 months
Helps to undress 24 months Dresses and undresses self 60 months
Conduct problems during childhood should be probed into and will include disobedience,
lying, stealing, truancy (running away from school), cruelity towards animals, bossy attitude
towards younger children, not obeying rules while playing etc. If these symptoms are found in
childhhod, do make a attempt to look for dissocial personality traits in adolescent period.
Temper tantrums are very common in children; when present, extent and intensity should be
carefully noted. Neurotic traits (nail-biting, thumb sucking, food-faddiness, stammering,
mannersisms, bedwetting, phobias, night-terrors, sleep walking, etc.) during childhood
should be probed into and if present, the details should be mentioned.
A comment on social relation with peers, elderly and authority figures and younger children
should be made.
Scholastic and extracurricular activities: Comment on age and class of entry in school,
type of school, scholastic performance and progress in studies, regularity in school, failures if
any, disciplinary problems/actions if any, relational problems with peers/authorities, any
Vocational/Occupational history: Mention the age at which the individual started working
professionally for the first time. Duration at each work place, positions held, reasons for
leaving, relation with work mates and superiors, promotion (in comparison to colleagues)
should be commented upon. Impact of illness on occupation will form a part of history of
presenting illness itself.
Menstrual history: Age of menarche should be asked. What was the reaction of patient
towards it and also information and attitude towards mensuration subsequently? Regularly
and duration of usual cycle, whether associated with psychological and physical change (pain
or any other). Date of last menstruation, duration and reasons of amenorrhea, if any.
Sexual and marital history: How and when sexual information and knowledge was first
obtained and of what kind, masturbatory history (fantasy and activity), sex play if any,
adolescent sexual activity, premarital and extramarital sexual relationship if any, sexual
disorders (normal and abnormal), presence of any gender identity disorder are areas to inquire
about. Also probe for any history of childhood sexual abuse.
Marital history includes all enduring intimate relationships. Ask for age at marriage and
parental consent for marriage. The spouse’s age, occupation, personality and state of health
are relevant to the patient’s circumstances should be documented. Also ask for role allocation,
sharing of responsibilities and decision making, perceived adequacy of sexual relation.
Knowledge and use of contraception should be documented.
Forensic history: Trouble with police, law; charges and convictions (sections), status of
cases should be adequately mentioned here as per the available information.
General pattern of living: Physical environment of the individual should be mentioned here
(accommodation, number of rooms, ownership). Also make a comment on ways of handling
adversity in home environment.
Try to give illustrative anecdotes and detailed statements. Aim at a picture of individual, not a
type. The following is merely a collection of hints, not a scheme. Describe as under:
1. Social relations: How were his relation to family (attachment, dependence); to friends,
groups, societies, clubs; to work and work-mates (leader or follower, aggressive or
submissive, organizer, ambitious, adjustable, independent)?
3. Predominant Mood: What used to be persistent mood like, was it cheerful or despondent;
worrying or placid; strung up or relaxed; optimistic or pessimistic; self-depreciative or
satisfied? Was mood changeable- could he express feelings of love, anger, frustration or
sadness, did he loses control over feelings, had he been violent? Was mood stable or unstable
(with or without any reason)
4. Character:
a. Attitude to Self: How does patient describe self? What were his strengths and abilities,
shortcomings, ability to plan ahead, resilience in face of adversity, hopes and ambitions? Was
the level of aspiration high or low? Was he self critical and perfectionist or self approving and
complacent in relation to own behaviour and achievements? Was he steadfast in face of
difficulties or intolerant to frustration? Were his interests sustained or evanescent?
b. Attitude to Work & Responsibility: Did he welcome responsibility or was worried by it;
made decisions easily or with difficulty? Was he methodological or haphazard in his
approach? Was he flexible or rigid? Was he cautious, foresightful and given to checking or
impulsive & slipshod? Was he determined towards goal or used to get bored or discouraged
easily?
c. Interpersonal relationships: Was he self confident or shy and timid? Was he insensitive or
sensitive to criticism? Was he trusting or suspicious and jealous? Was he selfish and
egotistical or unselfish and altruistic? Was he emotionally controlled or irritable and quick-
tempered? Was he tactful or outspoken? Did he use to enjoys or avoids self-display? Was he
quiet and restrained or expressive and demonstrative in speech and gesture? Was he tolerant
or intolerant to others? Was he adaptable or unadapatable? Did he use to prefer company or
solitude? Was he shy or used to make friends easily, were relationships close and lasting?
How he used to handle others’ mistakes, did he always want to be center of attention? How
was the relation with work-mates or superiors, any affiliations to any society?
d. Standards in moral, religious and health matters: What were his religious and moral
attitudes? Was he given to much or little concern about own health?
e. Energy, initiative: Was he energetic or sluggish? Was output sustained or fitful? Did he
used to get easily fatigued? Were there regular or irregular fluctuations in energy or work
output?
5. Fantasy life: What was the frequency and content of day dreaming?
6. Habits: Use of alcohol, drugs, tobacco; comment on food and sleep pattern
General Survey: One need to start by taking height, weight and body temperature of the
patient. Then comment on build, posture, skin colour, eruptions, petechiae, vitiligo, spider
naevi, nutrition, oedema, hair, nails, clubbing, lymph nodes, swelling, deformities, thyroid
gland, injuries, scars on whole of the body after doing a thorough inspection.
Cardiovascular System: Start with taking the pulse of the patient. Look for at least radial
and femoral pulse. Comment on rate, rhythm, volume, character, arterial wall, radio-radial
and radio-femoral delay.
Take the blood pressure in right upper arm in both supine and erect position.
Look for neck veins, any engorgement and jugular venous pressure.
Respiratory system: Bare the chest of the patient and go for inspection (rate and character of
respiration, chest wall movements); palpation (position of trachea, swelling, tenderness,
fremitus); percussion (character of note, symmetry); auscultation (breath sounds, added
sounds, if any).
Central Nervous System: Start with higher mental functions; look for consciousness and
comprehension, attention and concentration and orientation.
Examine cranial nerves one by one. Here one should be ready with all the apparatus required
for cranial nerve examination such as for smell (soap, toothpaste, coffee, asafetida, ginger
etc.), for vision (Ishiara Charts, Snellen’s chart, Jaguar chart/ newspaper), for fundus
examination (ophthalmoscope), for eye reflexes (cotton wisp, a torch), for deep tendon
reflexes (knee hammer), for temperature testing (test tubes with hot and cold water), for taste
Psychiatric
history
taking
15
(salt, sugar, lemon and quinine solution, drinking water, cotton swabs, placards with names of
different tastes), for hearing (tuning folks of different frequencies), for touch (a blunt pin)
Proceed for examination of motor system. Look for strength, bulk, tone, co-ordination of all
major muscles and any involuntary movements.
In sensory system, look for pain, touch, temperature, position, vibration in all possible
dermatomes. In case of deficiency, try to find out level of deficiency.
Look for both deep tendon and superficial reflexes. Check for bilateral biceps, triceps,
supinator, knee, ankle reflexes and plantar, abdominal and cremastric reflex
Look for signs of autonomic system instability. This includes a thorough examination of skin
(and its appandages) and mucous membrane, pulsations in extremities, gland functions
(sweat, salivary, lacrimatory), endocrine system, postural fall in blood pressure, other cardio-
vascular reflexes, valsalva maneuver, deep breath test, genito-urinary functions and skin
reaction to various stimuli.
Cerebellar Signs should be looked into and include rebound phenomenon, finger-nose test,
heel-shin test, rapid alternating movements (dysdiadokokinesis).
Signs of meningeal irritation including neck rigidity, Kernig’s sign and Brudzinski's Neck
sign should be checked.
The central nervous system will become all the more important in a neurological case work-
up. This will be of great help in clinically localizing the lesion in brain or spinal cord.
Results of Investigation, if any available: If the patient has got any investigation done prior
to current consultation, which might include blood investigations such as blood counts,
endocrinological profile (Blood sugar level, thyroid function test, etc.), function tests (liver,
kidney etc.), blood electrolyte levels (sodium, potassium, chloride, calcium, etc.), lipid
profile, antibody levels; X ray of any body part; CT scan; MRI; EEG; EMG or any other
relevant investigation, that should be noted.
Mental Status Examination: It is the part of clinical assessment that describes the sum total of
the examiner’s observation and impressions of a psychiatric patient at the time of the
interview (SOP).
It is a process of clinical observation of the patient for evaluation of psychological signs and
symptoms. It is analogous to physical examination in medicine and follows a definite
procedure. In psychiatry we are largely dependent upon the patient’s subjective account of
symptoms in order to reach a diagnosis, with few opportunities to do objective diagnostic
tests. This can be difficult task for the patient, struggling to put complex feelings and
experience into words, and for the interviewer, looking for diagnostic signs among all the
information given. The mental status examination helps to overcome these difficulties by
providing a structure for a detailed, systematic description of the patient’s symptoms and
behaviour. Herein, one starts with basic functions (level of consciounsness) to more complex
ones.
Four assessment techniques are used to take a mental status examination of the patient
Getting an expertise at mental status examiantion is the most difficult and challenging part of
psychiatric case work-up. As already mentioned, it is a structured set up which should not be
rigidly followed. For beginers, a performa of examination given in SCAN i.e. present state
examination (PSE-9) is a helpful guide to proceed for mental status examination and thus it
should be losely followed.
General Appearance: It is the evaluation of the patient’s manner of presentation at the time
of interview. The description should be as avid as possible. By listening to the description,
one should be able to pin point that individual from a crowd. A rich deal of information can
be elicited from examination of the general appearance and behaviour. While examining, it is
important to remember patient’s sociocultural background and personality. It is significant in
assessing the duration of illness and in some cases, the severity of the disorder.
General physical appearance: External attributes need to be examined. Body build, hygiene
and grooming should also be commented upon. Following hinters should be considered.
Overtly made up: Exaggerated concern or preoccupation with appearance and dress.
May be found in Mania/Hypomania; Histrionic and Narcissistic personality disorder;
some cases of Schizophrenia.
Unkempt and untidy: This refers to neglect of personal appearance with regard to
dress and hygiene. This may be found in Organic psychosis, Dementia, Substance
abuse disorders, Severe Depression, Schizophrenia.
Sickly: Refers to a patient who looks ill or has complete neglect of his health. This
may be found in Substance abuse disorders, severe and long-standing Dementia.
Perplexed: This is used to describe a confusional state in which a patient has inability
to decide on a task or a solution.
Estimate of age: It should be commented whether the patient appears appropriate to his stated
or real age. This also gives insight into the overall manner of lifestyle.
Body built: Make a comment on body built of a person. Ernst Kretschmer proposed a system
of body typing:
William Herbert Sheldon devised another system of body type classification most widely
used today. Sheldon's system, known as somatotyping, is based on three components
(endomorph, mesomorph, ectomorph) of body shape. Any given individual is said to be a
mixture of these three in various proportions.
The extreme endomorph is as spherical as humanly possible. He has a round head, a
large, fat abdomen predominating over his chest and weak, floppy, penguin like arms
and legs with heavy upper arms and thighs but slender wrists and ankles.
The extreme mesomorph is represented by the classical “Hercules”. He has a massive,
cubical head, broad shoulders and chest, and heavily muscular arms and legs.
The extreme ectomorph is the linear man. He has a thin face with a receding chin and
high forehead; a thin, narrow chest and abdomen and spindly arms and legs.
In Sheldon's system, the amount of each component that a person has, is rated on a scale
ranging from 1 to 7. Most people have mid-range somatotypes, such as 3-4-4 or 4-3-3.
Touch with surroundings: In this we evaluate the patient’s perception of self in respect to his
surroundings.
Partial: Some aspect of his surroundings or their significance to the patient is lost.
Eye contact with the examiner: This is useful in assessing the establishment of rapport,
truthfulness, insight and concentration of the patient.
Partial: Fleeting eye contact with the examiner, which is not adequate for the
continuation of a successful interview. Seen in Depression- lowered eyes; Anxiety-
Shifting gaze.
Absent: Here, there is complete loss of eye contact with the examiner. This is found in
Paranoid Schizophrenia, Acute delusional disorder.
Dress: Dress is the key to person’s appearance and gives the interviewer an impression of the
patient’s cultural background and his economic position.
Appropriate: Dress is properly worn, clean and in conformity with the situation. This
is found in normal people.
Shabby: Neglect or decreased care for dress occurs concurrently with neglect of other
aspects of appearance. Found in Dementia, Substance abuse disorders.
Facial expression: It provides information and a rough estimate about certain diagnosis.
In depression, the corners of mouth are turned down and there are vertical furrows on
the brow
Anxious patients have horizontal creases on the forehead, widened palpebral fissures
and dilated pupils.
The facial expressions may also suggest physical disorders e.g. thyrotoxicosis.
Depressed patients characteristically sit with hunched shoulders, with head and gaze
inclined downwards.
An anxious patient may sit on the edge of the chair with hands gripping its sides.
Anxious patients and those with agitated depression may be tremulous and restless,
touching their jewelry or picking at their fingernails.
Attitude towards examiner: Attitude is a mental and neural state of readiness organized
through experience; exerting a directive and dynamic influence upon the individual’s
response to all objects and situations with which it is related.
Defensive: It is the kind of behaviour that turns the examiner’s attention away from
one’s deficiencies, or behavior that might cause him guilt or embarrassment. Seen in
Paranoid Schizophrenia, Delusional disorder.
Frank: This behaviour helps to conduct an open conversation that includes all the
deficiencies without guilt or embarrassment.
Seductive: The patient (mostly a female) tries attention-seeking behaviour that uses
verbal or non-verbal seductive clues towards the examiner. Found in Histrionic
personality disorder.
Guarded: Patient will restrict his information and weigh the information as per his/her
ideas of importance. Seen in Paranoid Schizophrenia, Delusional disorder.
Evasive: Patient attempts to escape from an argument and shifts topics. Seen in
Organic Psychoses, Substance abuse disorders.
Rapport: It is a bidirectional empathetic relationship, which the examiner shares with the
patient. Ekkehard Othmer and Sieglinde Othmer defined the development of rapport as
encompassing six strategies:
Motor Behaviour: It denotes both the quantitative and qualitative aspects of a person’s motor
behaviour and the level of his activity. For example: psychomotor agitation or retardation.
Preoccupied: Preoccupied is the state of being excessively focused on one task with
neglect or avoidance of any other thought. Found in Depression, Paranoid
Schizophrenia.
Awkward: Clumsy moments having a little skill in dealing with the surrounding items/
events. For examples: apraxia, mental retardation.
Silly Smiling: Apparently spontaneous and childish laughter on little provocation. For
example: Mania, Hebephrenia.
Tics: Tics are sudden, involuntary twitchings of small group of muscles and are
usually reminiscent of extensive movements or defensive reflexes. Commonly the face
is affected so that the tic takes the form of blinking; distortions of the forehead, nose
or mouth; but clearing of the throat and twitching of the shoulders may also be tics
(Fish). Tics are usually rapid, repetitive, coordinated and stereotyped movements,
most of which can be mimicked and are usually reproduced faithfully by the
individual. For example: Gilles de la Tourette syndrome (SIMS).
Rigidity- Assumption of a rigid posture against all attemps to move. For example:
Catatonia, Mania, Depression.
Touching the examiner- The patient may touch the examiner in a way different from
formal greetings. E.g.: touching feet- depression; kicking/caressing- Histroinic patient.
Waxy Flexibility- Condition in which person maintains the body position into which
they are placed (CTP). In waxy flexibility when the limbs of the patient are put into
any posture by the interviewer, they will be retained in that posture for a sustained
period (a minute or more) (SIMS).
Athetosis- Spontaneous movements that are slow, twisting and writhing; which bring
about strange postures of the body, especially of the hands.
Speech: This part describes the physical characteristics of speech. Speech can be described
in terms of its intensity, pitch, quality, prosody, reaction time, speed, ease, coherence,
relevance, goal directedness, rate of production, manner of relation and deviations .
Audible- The examiner can listen to the voice of the patient. This occurs in normal
conversation.
Excessively loud- Intensity of speech is louder than required. For example: Excited
patient, Mania, Hypomania.
Abnormally soft- Intensity of speech is softer than required. For exmaple: Vocal cord
palsy, Depression, Paranoid Schizophrenia.
Soft- Spoken politely, usually in low volume and with slow speed. Example:
Obsessive compulsive personality disorder, Anxious avoidant personality disorder.
Hoarse- Spoken forcefully, usually in a husky tone. Example: Mania after they have
shouted for long periods of time, certain normal individuals.
Prosody: Use of pitch, loudness, tempo and rhythm in speech to convey information about the
structure and meaning of an utterance.
Reaction Time: The time taken by the patient from listening the question to answering.
Decreased reaction time- Time taken is decreased. Sometime patient doesn’t listen to
the examiner properly and is in a hurry to answer. For example: Mania.
Very slow- The output of speech is slow e.g. Depression, Dementia, Hypothyroidism
Rapid- The rate of speech output and production is more than normal. It is associated
with prolixity and flight of ideas. Example: Mania, Hypomania, Hyperthyroidism.
Mutism- Complete loss of speech; comprehension may be fully preserved; the patient
may be able to communicate by writing his/her thoughts. Examples: Stupor, dementia.
Slurring- A form of speech in which the words are pronounced with prolongation of
syllables. Example: Cerebellar damage.
Whispering: Production of sound by using breath but not vocal cords. Example:
Pseudobulbar palsy.
24
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Muttering- Speaking in a low voice, not meant to be heard (using lip movement).
Example: Schizophrenia, Dementia.
Speaking only when questioned- Speaks only when very much required. Patient uses
words very economically.
Relevant- There is relevance between the question and the answer given by the patient
but the answer may not be correct. E.g. Examiner’s question- where is your home?
Patient’s answer- America (His answer is matching with the question but if we ask the
informant we find that it is not true).
Goal Direction: A speech can be said to be goal directed when it is reaching the goal and
answering what examiner has asked.
Manner of relating: The way in which the patient speaks/interacts with the examiner.
Excessively formal- Patient using more than required number of formal gestures
(formalities) during the interview. Example: Obsessive compulsive personality
disorder, Antisocial personality disorder, Hypomania.
Tensed up- Showing features of anxiety i.e. wringing of hands, sweating, fidgeting
etc. during conversation. Example- anxious trait/state, Avoidant personality disorder.
Inappropriately familiar- Patient acts as if he is very much used to the present set of
examination/situation. Example: Histroinic personality disorder, Antisocial
personality disorder, Hypomania.
Rhyming and punning- Rhyme is sameness of the sounds of the endings of two or
more words. i.e. I am going… rowing… especially at the end of lines or verses;
Punning is humorous use of words with similar meanings of a word with double
meaning i.e. both me and my bike need fluid. Example: Mania, Hypomania.
Talking past the point- Delibrate answering of an associated topic related to the
answer. The patient answers to the questions quite readily but mostly these are
incorrect answers. Such as: what is the colour of grass? Replies- white. Examples:
Ganser’s Syndrome, Schizophrenia.
Clang association- Association or speech directed by the sound of a word rather than
its meaning; words have no logical connections, punning and rhyming may dominate
the verbal behaviour. Seen most frequently in Schizophrenia or Mania. (CTP). A
pattern of speech in which ‘sounds’ rather than ‘meaningful relationship’ appear to
govern word choice so that intelligibility of the speech is impaired and redundant
words are introduced (TLC).
Cognitive Functions
Memory: Mental process that allows the individual to store information for last recall (Strub
& Black). Process whereby what is experienced or learned is established as a record in the
CNS (Registration) where it persists with available degree of permanence (Retention) and can
be recollected or retrieved from storage at will (Recall) (CTP). Memory is the encoding,
storage and retrieval of what was learned earlier (Morgan & King).
Abstract Ability: It is the ability to deal with concepts. Patients can have disturbances in the
manner of conceptualizing or handling ideas. The appropriateness of answers and the manner
in which they are given also be noted (SOP). Abstract ability refers to ability to shift
voluntarily from one aspect of a situation to another (at the same time) keeping in mind
simultaneously the various aspects of a situation. In Piaget’s theory of cognitive development,
the capacity for abstarct thinking is acquired around 12 years i.e. stage of formal operations.
Abstract thinking is synonymous for conceptual thinking.
Disturbance in abstract thinking are seen in Schizophrenia, Dementia, past head injury.
Mood- Mood is perceived as a persistent and sustained emotion that colours the patient’s
perception of the world (SOP). Mood is the prevailing and conscious emotional feeling
expressed by the patient (Strub & Black). Mood is an emotional state which usually lasts for
some time and which colours the total experience of the subject. It is also referred as a “mood
state” (Fish).
Affect- Affect can be defined as the patient’s present emotional responsiveness, inferred from
the patient’s facial expression, including the amount and range of expressive behaviour
(SOP). Affect is a wave of emotion in which there is a sudden exacerbation of emotion
usually as a response to some event (Fish). It is immediate experience of emotion attached to
idea or some event. It had both subjective and objective manifestations.
In the absence of a psychopathological process, affect fluctuates with time and context and
ranges from sadness to anger to elation, depending on the emotional state.
Affect can be expressed through autonomic responses, body movements and alterations in
speech to concrete or abstract stimuli. Speech changes that reflect affect include tone of voice,
vocalization, and word selection. Visible autonomic changes that may reflect changes in
affect include sweating, trembling, blushing and becoming flush. Changes in posture,
alterations in facial expression, reactive responses and grooming movements are body
changes seen in expression of affect. Reactive movements include movements of the body
and face made in response to a novel stimulus, such as in a startle response, when an
individual jumps or turns and looks at the stimulus. Changes in facial movements of the
mouth, nose, and eyes are found with different affective states. Manipulation of one’s
appearance is common in states of discomfort; individuals may fix their hair, clean their nails,
scratch or straighten their clothes.
Evaluation of affect consists of monitoring gestures, body movements, and facial expressions.
Because adults are frequently capable of controlling facial expression in attempts to
28
Psychiatric
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taking
intentionally or unintentionally suppress their affect, other behavioural gestures may give
clues to the underlying affect.
Affect can be assessed under the following domains-
Quality of Affect- the label or valence of the affect. Assessed on two criteria.
Irritable- A state of poor control over aggressive impulses directed towards others;
most frequently to those nearest and dearest. May manifest in outbursts in which a
person is easily annoyed and provoked tom anger.
Elevated- An exaggerated feeling of well-being out of keeping with the life situation.
Euphoric- Increased sense of well-being with cheerful thoughts and lack of response
to depressing influence so that everything is seen in the best possible light.
Elated- Feeling of well-being and euphoria leading to faulty judgement, general over
activity and disinhibited behaviour.
Intensity of affect- It is the strength of the emotional expression. It normally varies according
to the situation. Those with a limited intensity of emotional experience may have-
Fixed affect- When affect is extremely constricted to one emotion it is called fixed or
immobile.
Range of affect- The range of the affect is characterized by the variety of emotional
expression noted in a session. Ordinarily, there are different feeling experienced at the
different times. The criterion for assessing range are
Full Range- appropriately expressed many emotions depending on the context have a
full or broad range of affect.
Reactivity- The reactivity is the extent to which affect changes in response to enviormental
stimuli. When patient does not respond to examiner’s provocation in the form of joking, for
instances, the affect is said to be non-reactive.
Appropriateness- It is refers to the congruence or fit between the expressed quality of emotion
and the content of speech, thought, expected degree of intensity and the overall situation.
Diurnal variation of affect- The change in affect occuring with passage of the day.
Pressured Speech- (Detailed under heading of Speech- Speed)- Increase in the amount
of spontaneous speech, rapid, loud, accelerated speech. Occurs in Mania,
Schizophrenia and cognitive disorders.
Flight of ideas: In flight of ideas thoughts follow each other rapidly; there is no
general direction of thinking; and the connections between successive thoughts appear
to be due to chance factors which, however, can usually be understood. The patient’s
speech is easily diverted to external stimuli and by internal superficial associations.
The absence of a determining tendency to thinking allows the associations of the train
of thought to be determined by chance relationships, verbal associations of all kinds
(such as assonance, alliteration and so on), clang associations, proverbs, maxims,
clichés. The chance linkage of thoughts in flight of ideas is demonstrated by the fact
that one could completely reverse the sequence of the record of a flight of ideas, and
the progression of thought would be understood just as well (Fish).
Prolixity: ‘Ordered flight of ideas’ or marginal variety of flight of ideas has been
called as prolixity. In prolixity, despite many irrelevances, the patient is able to return
to the task in hand; clang and verbal associations are not so marked; the speed of
emergence of thoughts is not as fast as in flight of ideas; although patients cannot keep
accessory thoughts out of the main stream, they only lose the thread for a few
moments and finally reach their goal; unlike the tedious elaboration of details in
circumstantiality, there is a lively embellishment of the thinking. Seen in Hypomania
(Fish).
Thought blocking- Thought blocking occurs when there is a sudden arrest of the train
of thought, leaving a ‘blank’. An entirely new thought may then begin (Fish).
Interruption of a train of speech before a thought or idea has been completed. After a
period of silence which may be from a few seconds to minutes, the person indicates
that he can not recall what he had been saying or meant to say. Blocking should only
be judged to be present either if a person voluntarily describes losing his thought or if
upon questioning by the interviewer the person indicates that that was his reason of
pausing (TLC). Abrupt interruption in train of thinking before a thought or idea is
finished; after a brief pause, person indicates no recall of what was being said or was
going to be said; also called as thought deprivation (CTP). “Snapping off” is the
experience that a patient with Schizophrenia has, of his chain of thoughts quite
32
Psychiatric
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unexpectedly and unintentionally breaking off or ceasing. It may occur in the middle
of sorting out a problem or even mid-sentence (SIMS). While they are flowing freely,
the respondent experiences a sudden unexpected stopping of thought. When this
occurs, it is dramatic and usually happens on several occasions. The experience is
passive (SCAN). When thought blocking is clearly present it is a terrifying experience
and highly suggestive of Schizophrenia. However, similar thing may occur in persons
who are exhausted and anxious and may appear to have thought blocking.
2 Form- Form of thought means “the arrangement of parts”. Disturbance in the form of thought
are disorder in the logical connections between ideas.
Formal thought disorder- Disorder of form of thinking is also called formal thought
disorder. This is disorder of conceptual or abstract thinking, which occur in
Schizophrenia and coarse brain disease. Formal thought disorder, from the subjective
phenomenological standpoint is abnormality in the mechanism of thinking described
by the patient in his own words as a process of thinking which is clearly abnormal to
the outside observer (SIMS). Disturbance in form of thought rather than content of
thought, is thinking characterized by loosened associations, neologisms and illogical
constructs; thought process is disordered and the person is described as psychotic.
This is characteristic of Schizophrenia (CTP)
Derailment: A pattern of speech in which a person’s idea slip off from one track to
another that is completely unrelated or only obliquely related. In moving from one
! Obsessional thoughts- They are repeated intrusive words or phrases which are
upsetting to the patient.
! Obsessional images- These are repetitive and vivid images that occupy the
patient’s mind. At times they may be so vivid that they can be mistaken for
pseudo-hallucinations.
! Obsessional ruminations- They are repeated worrying themes of a more
complex kind.
! Obsessional doubts- they are repeated themes expressing uncertainty about
previous actions, e.g. whether or not the person turned off an electrical
appliances that might cause a fire. Whatever the nature of the doubt, the person
realizes that the degree of uncertainty and consequent distress is unreasonable.
! Obsessional impulses- They are repeated ways to carry out actions, usually
actions that are aggressive, dangerous or socially embarrassing. Whatever the
urge, the person has no wish to carry it out, resists it strongly.
! Obsessional phobias- Denotes a symptom associated with avoidance as well as
anxiety.
! Obsessional fear of illnesses called illness phobias.
! Obsessional slowness- Many obsessional patients perform actions slowly
because their compulsive rituals or repeated doubts take time and distract them
from the main purpose.
Somatic syndrome associated with depression (4/8 should be present for diagnosis)-
Marked loss of interest or pleasure in activities that are normally pleasurable; lack of
emotional reactions to events or activities that normally produce an emotional
response; waking in the morning 2 hours or more before the usual time; depression
worse in the morning; objective evidence of marked psychomotor retardation or
agitation; marked loss of appetite; weight loss (5% or more of body weight in the past
month); marked loss of libido.
Religious pre-occupations- It is thinking that predominantly centres around ethical and
religious matters. Seen in OCD.
Preoccupation with precipitating factor- It is the thinking that centres around the
precipitating factor (which is responsible for current illness/exacerbation) and
coloured by an affective tone relating to precipitating event. Seen in reactive
depression.
Excessive day dreaming- This refers to excessive continuous indulgence in fantasising
or engaging in imaginative, speculations regarding the future, which otherwise are
beyond the means of the concerned individual. It occurs in most parts of the working
hours hampering normal activities. Example: Schizotypal personality disorder.
Antisocial urges- These are sudden and episodic behaviours characterised by
aggressiveness, impulsiveness, rage not withstanding social rules and norms and are
not associated with any guilt feeling or remoarse for the acts. Seen in antisocial
personality disorder
Homicidal ideas- This means the idea of killing someone or causing grievous injury.
These ideas might have been expressed for the first time during the interview either as
a response to a halluciantion or active delusion of persecution. Seen in Schizophrenia,
antisocial personality disorder.
Philosphical ideas- This refers to pre-occupation with the thoughts regarding
philosphical issues example existence of God, creation of universe, the difference
between mind and matter. Seen in normal individuals, mild depression, OCD,
Schizotypal personality disorder.
Magical thinking- The person believes that apparently irrelevant actions can make a
difference to reality, and some patients (for e.g. OCD) engage in compulsive
Death wishes- A wish that something happens and the person’s life is ended so that all
his agonies are finished along with that. It is just praying for death rather than thinking
to end own life. i wish i was dead, not alive , things would be better without me
but wont do anything to make it happen
Deliberate self-harm (DSH) includes self-injury (SI) and self- poisoning and is defined
also it is a cry for help
as the intentional, direct injuring of body tissue without suicidal intent. Although
suicide is not the intention of self-harm, the relationship between self-harm and
suicide is complex, as self-harming behaviour may be potentially life threatening.
There is also an increased risk of suicide in individuals who self-harm (SCAN).
Inflated self esteem- In social sciences, self esteem is a hypothetical construct that is
quantified as sum of evaluations across salient attributes of one’s self or personality. It
is the overall affective evaluation of one’s own worth, value or importance. Inflated
slef esteem is inflation of the self esteem and seeing oneself capable of doing things
beyond one’s abilities. The person may boast of himself as being the best in whatever
things he do. It is seen in Mania and Narsissictic personality disorder. In literature, it
is often used synonymously with grandiosity. hystyonic
grandeosity
false fixed belief
Delusion- A false firm belief based on incorrect inference about external reality that is
firmly sustained despite what almost everyone else believes and despite what
constitutes incovertible and obvious proof or evidence to the contrary. The belief is
not one ordinarily accepted by other members of the persons culture or subculture
(DSM-IV-TR). A delusion is a belief that is firmly held on inadequate grounds, is not
affected by rational arguments or evidence to the contrary and is not a conventional
belief that the person might be expected to hold given his educational and cultural
background. False is omiited from this definition because in some cases a delusional
belief can be true or subsequently become true e.g. pathological jealousy (OTP).
Rather than suggesting a unitary definition for delusion, Kendler et al. (1983) have
proposed several poorly correlated dimensions or vectors of delusions. (ABCDE P.S.)
! Affective response: the degree to which the patient’s emotions are involved
with the beliefs.
! Bizarreness: the degree to which the delusional beliefs depart from culturally
determined consensual reality
! Conviction: the degree to which the patient is convinced of the reality of the
delusional beliefs. to what degree or extent am i believing this idea?
the level of intensity
! Disorganization: the degree to which the delusional beliefs are internally
consistent, logical and systematized.how bad the thought can disrupt your thinking process.
! Deviant behaviour: acting out on beliefshaving conflicts
! Extension: the degree to which the delusional belief involves areas of the
patient's life. how does my everyday life is affected bcs of the thought
! Pressure (Preoccupation): the degree to which the patient is preoccupied and
concerned with the expressed delusional beliefs.constantly
else
thinking abt the thought and not doing anything
There is also a distinction between true delusions and delusion-like ideas. True
delusions are the result of a primary delusional experience that cannot be deduced
from any other morbid phenomenon, while the delusion like idea is secondary and can
be understandably derived from some other morbid psychological phenomenon –
these are also described as secondary delusions. Thus to summarize, delusions are
divided into true (primary) delusions and delusion like ideas (secondary delusions).
Primary delusion- a primary delusion is one that appears suddenly and with full
conviction but without any mental events leading up to it. The essence of the primary
delusional experience (also termed apophany) is that a new meaning arises in
connection with some other psychological event. Primary delusional experiences tend
to be reported in acute Schizophrenia but are less common in chronic Schizophrenia,
where they may be buried under a mass of secondary delusions arising from primary
40
Psychiatric
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true delusion and secondary delusion(overvalued aideas)
delusional experiences, hallucinations, formal thought disorder and mood disorders.
Schneider (1959) suggested that these experiences could be reduced to these forms of
primary delusional experience:
In the delusional mood (or atmosphere) the patient has the knowledge that there is
something going on around him that concerns him, but he does not know what it is.
Usually the meaning of the delusional mood becomes obvious when a sudden
delusional idea or a delusional perception occurs.
spain
In the sudden delusional idea (delusional intuition) a delusion appears fully formed
1950s
everybody
in the patient’s mind. This is also known as an autochthonous delusion. It is not in
dancing itself diagnostic of Schizophrenia because sudden ideas ‘out of blue’ or ‘brain-waves’
togethr
occur in various mental illnesses such as depression, personality disorders, organic
and epileptic psychosis and even in normal individuals.
The delusional perception is the attribution of a new meaning, usually in the sense of
self-reference, to a normally perceived object. The new meaning cannot be understood
as arising from the patient’s affective state or previous attitudes. This last provision is
important because the delusional perception must not be confused with delusional
misinterpretation. Schneider emphasised the importance of this symptom’s ‘two
memberedness’, as there is a link from the perceived object to the subject’s perception
of this object, and a second link to the new significance of this perception (sometimes
also called delusional significance). Using this criterion, Schneider (1959) divided
delusional memories into delusional perceptions and sudden delusional ideas. For
example, if the patient says that they are of royal descent because they remember that
the spoon they used as a child had a crown on it, this is really a delusional perception
because there is the memory and also the delusional significance, i.e. the ‘two
memberedness’. On the other hand, if the patient says that they are of royal descent
because when they were taken to a military parade as a small child the king saluted
them, then this is a sudden delusional idea because the delusion is contained within the
memory and there is no ‘two memberedness’.
Extracampine hallucinations- The patient has a hallucination that is outside the limits
of the sensory field. For example, a patient sees somebody standing behind them when
they are looking straight ahead or hear voices talking in London when they are in
Liverpool (Fish).
start as Physical illness in brain
Autoscopy (phantom mirror-image)- It is the experience of seeing oneself and
knowing that it is oneself. It is not just a visual hallucination because kinaestethic and
somatic sensation must also be present to give the subject the impression that the
hallucination is oneself (Fish). Seen in parietal lobe leisons, normal persons.
Depersonalization-derealization
Body image disturbance- The body image or body schema is a person’s subjective
representation against which the integrity of his body is judged and the movement and
positing of its parts assessed. Parietal lobes play a major role, but the somatic aesthetic
afferent system and the thalamus are also involved.
Paramnesia
have experienced it before.
Déjà vu- Illusion of visual recognition in which a new situation is incorrectly regarded
as a repetition of a previous experience (CTP). It is a disturbance in which the
associated feeling of familiarity that normally occurs with previously experiences
events, occurs when the event is experienced for the first time (SIMS). Here the
subject has the feeling that he has seen or experienced the current situation before. The
sense of recognition in déjà vu is never absolute so that misidentification does not
occur. These experiences occyr occasionally in normal persons but they may become
excessive in temporal lobe leisons (Fish).
as if i have been there but i dont know if i have done this
Jamais vu- In jamais vu, an experience which the patient knows he had experienced
before is not associated with the appropriate feeling of familiarity. The patient may
also have the feeling that some important memory is about to be recalled, although it
Deja entendu- Illusion that what one is hearing, one has heard previously (CTP)
Social judgement- Here the person’s interaction with the other social members and the
interviewer is assessed. It is usually assessed from the history given by the informants.
Personal judgement- the individual’s personal expectations, plans and attitudes are assessed.
Test judgement- It aims to assess the course of action that a person might take in a socially
difficult or disastrous situation.
Conditions causing impaired judgement are organic brain damage, anxiety state, Mania,
Schizophrenia
Insight: It is a patient’s degree of awareness and understanding about being ill. Patient may
exhibit complete denial of their illness or may show some awareness that they are ill but place
the blame on others, on external factors, or even organic factors. They may acknowledge that
have an illness but ascribe it to something unknown or mysterious in themselves. (SOP).
It is one’s ability to understand either oneself or an external situation. (Strub & Black).
True emotional insight is present when patient’s awareness of their own motives and
deep feelings leads to a change in their personality or behaviour patterns. (SOP). It is
the deeper level of understanding of the problem with due motivation to bring about a
positive change in behaviour or personality.
The difficulty of getting information from unco-operative patient should not discourage the
psychiatrist 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 negativistic
reactions is during the period of negativism, the time to 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 a miss an oppurtunity 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 most important points for the purpose if clinical differentiation.
Adapted from: Kuruvilla, K. and Kuruvilla, A. (2010). Diagnostic formulation. Indian Journal of
Psychiatry 2010, 52, 78-82.
When the requirements laid down in the diagnostic guidelines are clearly fulfilled, the
diagnosis can be regarded as "confident". When the requirements are only partially fulfilled, it
is nevertheless useful to record a diagnosis for most purposes. It is then for the diagnostician
and other users of the diagnostic statements to decide whether to record the lesser degrees of
confidence (such as "provisional" if more information is yet to come, or "tentative" if more
information is unlikely to become available) that are implied in these circumstances.
ICD-10: With the introduction of operationalized diagnostic systems the multi-axial approach
became a more important issue. The proposed multi-axial system of ICD-10 consists of three
axes:
! Axis I- Psychiatric diagnoses, made according to the ICD-10 CDDG or DCR
! Axis II (Disability Diagnostic Scale, DDS)- Impairment of psychosocial functioning.
! Axis III- Environmental/circumstantial & personal lifestyle management factors rated.
DSM-IV-TR system of diagnosis uses a five-axes model. Axes 1-3 are compulsory, whereas
axes 4 and 5 are optional, although are usually included as well for a more reliable diagnosis.
DSM-5 moved to a nonaxial documentation of diagnosis, combining the former Axes I, II,
and III, with separate notations for psychosocial and contextual factors (formerly Axis IV)
and disability (formerly Axis V).
The gross outline for psychiatric history taking will remain same across majority of patients,
but a few changes need to be made with regard to certain special population (such as children
and elderly) and in certain diseases such as substance use disorder, neurological complains,
epilepsy). Here one by one, brief description of changes to be made in approach are
delineated under the following headings
The baseline assessment is done on similar lines as in case of a normal adult psychiatry case
work-up. Emphasis needs to be given on a few domains. The major differences are
enumerated below
Socio-demographic profile:
Ask exact date of birth, if such details are available. This will help in knowing the exact age
of the child at the time of presentation.
Include both parents name and their educational qualification and occupation. In case patient
is brought up by some other guardians, their details should be mentioned along with the
reason for the same, whether child was abandoned; or the parents died at very early period in
his/her life, or the child was adopted out of his biological parents’ family along with adequate
reason for the same.
History of presenting complains:
In majority of cases (unless the presenting complains have no role whatsoever in childhood
period), one should try to start history of present illness dating back to the birth of child and
should progress accordingly.
Impact of illness on routine activities here should include interpersonal relation with parents,
other adults, peers, interest in work/study, play behaviour apart from other relevant details as
probed for in a general case work-up.
While asking for negative history, make sure to rule out any childhood disorder which might
not be the reason of prime attention for the informants such as hyperactivity, attention
deficits, impulsivity, disobedience, lying, stealing, truancy, eating difficulties, fears, sleep
disorders, somatization, temper tantrums, attention seeking behaviour, enuresis, encopresis,
tics and unusual habits
Family history:
Try to include household composition including all members like grand parents, parents,
siblings and relatives, whosoever lives in some living hood as the child.
Personal history:
In case of children, personal history becomes more important to probe into because many a
childhood disorders have their roots in some or the other event occurring in prenatal, natal or
postnatal period. Even if such periods are uneventful then early childhood period must have
BCG 1
OPV 0 1 2 3 Booster
Hep-B 0 1 2 3
DPT 1 2 3 B1 B2
Measles 1
TT B3 B4
JE 1 2
Hib 1 2 3
JE vaccine (in selected high disease burden districts) is currently being used in 113 districts
and additional 62 new JE endemic districts have been identified.
Scholastic history assumes more importance in childhood disorders. One should probe in
following areas: What was the type of school (normal/ special/ religious school/ studied at
home)? What was the age of entry in school (reasons if admitted late than expected)? Provide
schooling details (mention changes in schools, durations with reasons). How was scholastic
performance (Good/ Average/ Poor)? How was his attendance in school (regular/ irregular/
discontinued)? What were the reasons for irregularity or discontinuity (school refusal/
wanders/ fearful/ financial problems/ poor progress/ behavioural problems/ Request of school
authorities)? How was his relation with peer group and authorities? Make a mention of
failures and disciplinary actions, if any.
Play behaviour should be enquired about. Whether he enjoys play/ not interested in play/
observes others while playing. What is his play preferences- plays alone/ with older/ younger/
peer group/ animals/ no preferences. Does he have knowledge of games governed by rules?
How does he behave while playing in group-situations? Does he have any special likes and
dislikes? Mention reasons for poor play behaviour (No company/ Siblings or peer group not
interested in playing with the child/ quarrelsome/ overprotected by parents or care-takers/
poor play facilities)
The final step in assessing the child’s temperament is the evaluation of its current
temperament characteristics. The inquiry into the present behaviour, while attempting to
cover all temperamental categories, should concentrate on those, which appear most pertinent
to the present symptoms.
General Appearance and behavior: Physical appearance, appropriate to age, body built and
size, dress and physical handicaps, if any.
Affective behaviour: Any evidence of anxiety, fear, depression, shyness, including child’s
attitude towards examiner.
Attitude towards family members, school and playmates: This should be enquired from
informants.
Stated interests and content of thought: What is the child’s evaluation of problems; any
disturbance of thought.
Motivational insight: What is the child’s knowledge of reasons for problems, desire for help,
sense of own capacity for change.
Play Behaviour: Leave the child with toys in a room with observer; parent can be allowed to
be with the child initially.
History of presenting complains: Here the focus shifts to the substance/s that is/are being
used by the patient. There can be other behavioural problems in the patient, which also should
not be overlooked. For eliciting drug use, the basic structure of history taking is as follows
One should ask for age of onset, setting, amount, type, frequency, pattern of use, determinants
for staring. What was the feeling after first intake, what did the patient think at that time about
future intakes? What subsequently happened to intake pattern: progress including change in
pattern, frequency and amount? One should also ask for any other substances used by the
patient. All relevant details regarding those substances should be noted.
Now it is also equally important to know the current intake pattern; including average
amount, maximum amount, last intake.
One by one criterion for dependence (for diagnosis of dependence, 3 out of 6 should be
present in a given individual) should be asked for which includes
Here, one should be aware about harmful use pattern of substance intake as well. This entity
should be entertained when the intake pattern is not fulfilling the criteria for dependence, but
still the intake is causing identifiable damage to health. The damage may be physical (as in
cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of
depressive disorder secondary to heavy consumption of alcohol).
Special mention should be made about intoxication, blackouts, binge drinking, fits and
flashbacks associated with drug use.
History of abstinence should be asked for. Any periods of abstinence should be acknowledged
and should include all relevant details- period, setting, duration, outcome determinants of
abstinence and relapse etc.
Definitions: A few definitions should be known to start with (Ref: ILAE glossary)
Convulsion: (Primarily a lay term): Episodes of excessive and abnormal muscle contractions,
usually bilateral, which may be sustained or interrupted.
Epilepsies: Those conditions involving chronic recurrent epileptic seizures that can be
considered epileptic disorders.
Focal (syn. Partial): A seizure whose initial semiology indicated or is consistent with initial
activation of only part of one cerebral hemisphere (ILAE Glossary). Focal epileptic seizures
are conceptualized as originating within networks limited to one hemisphere. They may be
discretely localized or more widely distributed. Focal seizures may originate in subcortical
structures. For each seizure type, ictal onset is consistent from one seizure to another, with
preferential propagation patterns that can involve the contralateral hemisphere. In some cases,
however, there is more than one network, and more than one seizure type, but each individual
seizure type has a consistent site of onset (Berg et al., 2010). The clinical characteristics of the
seizure reflect the part of brain affected, and a wide variety of symptoms may thus occur.
Partial seizures are divided into three main categories (Duncan and Shorvon).
Simple partial seizures: These are short lived, lasting a few seconds or so. Clinical features
include focal signs (motor, sensory or psychic), sudden onset and cessation, no alteration of
consciousness and no amnesia. These are due to focal cortical pathology and focal
signs/symptoms reflect the anatomical origin of seizure and thus are useful in localizing the
underlying pathology.
Complex partial seizures: These seizures have sudden onset and gradual recovery. Four
remarkable components are (4As) aura, altered consciousness, amnesia after the attack and
automatism. Altered consciousness is essential feature for CPS and that differentiates these
seizures from SPS. Like SPS, CPS also have a focal cortical pathology and arise most
commonly in temporal lobe, but can also occur in other lobes especially frontal.
Generalized (syn. Bilateral): A seizure whose initial semiology indicated or is consistent with
more that minimal involvement of both cerebral hemispheres (ILAE Glossary, 2001).
Consciousness is almost invariably impaired from the onset of the attack (owing to the
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extensive cortical and subcortical involvement) (Duncan & Shorvon). Generalized epileptic
seizures are conceptualized as originating at some point within, and rapidly engaging,
bilaterally distributed networks. Such bilateral networks can include cortical and subcortical
structures, but do not necessarily include the entire cortex. Although individual seizure onsets
can appear localized, the location and lateralization are not consistent from one seizure to
another. Generalized seizures can be asymmetric (Berg et al. 2010)
Absence seizures (typical): The seizure comprises an abrupt sudden loss of consciousness (the
absence) and cessation of motor activity (e.g. speaking, eating, walking). There is no warning
or aura; tone is usually preserved and falling does not occur. The patient is unaware,
inaccessible and motionless. The eyes appear glazed, usually staring ahead. The attack ends as
abruptly as it started and previous activity is resumed as if nothing had happened. There is no
confusion, but the patient is often unaware that an attack has occurred.
Clonic: Myoclonus that is regularly repetitive, involves the same muscle groups, at a
frequency of 2-3 cycles/sec, and is prolonged. Syn: rhythmic myoclonus.
Atonic: Sudden loss or diminution of muscle tone without apparent preceding myoclonic or
tonic event lasting >1-2 seconds, involving head, trunk, jaw or limb musculature.
Dystonic: Sustained contractions of both agonist and antagonist muscles producing athetoid
or twisting movements, which, when prolonged, may produce abnormal postures
Astatic: Loss of erect posture that results from an atonic, myoclonic or tonic mechanism. Syn:
Drop attack.
Versive: A sustained, forced conjugate ocular, cephalic, and/or truncal rotation or lateral
deviation from midline.
History of epilepsy: Following points are kept in mind while taking history of a patient
suffering from attack of fits.
Age of onset and total duration of epilepsy at the time of presentation should be asked.
Interval between first and second episode gives a rough idea of baseline frequency of seizure
attacks
Abortive attack (in respect to a full blown attack): A patient suffering from generalized tonic-
clonic seizures (either primary or secondarily), may experience attacks, which might not be
associated with loss of consciousness (unlike the full blown attacks) and may include attacks
such as movements of certain body parts such as limbs (viz. partial seizures) or absence
seizures; such attacks are termed as abortive attacks and history of such attacks should be
adequately asked for.
Change in pattern of seizures since onset of illness, if any, all seizure types should be
adequately explained.
Cluster attacks: Incidence of seizures within a given period (usually one or a few days) that
exceeds the average incidence over a longer period for the patient. So any clustering of
attacks currently or in past should be mentioned here.
Status attacks: A seizure that shows no clinical sign of arresting after a duration
encompassing the great majority of seizures of that type in most patients or recurrent seizures
without inter-ictal resumption of baseline central nervous system functions. So history of
status attacks and their treatment should be mentioned.
Last attack: Here mention both abortive and full-blown attacks separately.
Time of attack: One should try to look for any diurnal pattern of seizure attacks, whether the
attacks are nocturnal, day time, early in the morning, sleep related (if so, whether occur
during falling asleep or during sleep or while getting up from sleep) or these attacks occur
anytime in the day. Some particular seizure types are known to occur at a specific time in the
day. For e.g. myoclonic attacks usually occur during sleep.
Precipitants (if any) for the seizure attack: Try to find whether any antecedent precipitates the
attacks. If present, then try to find exact reason. Possible reasons can be: reactive seizures (in
association with transient systemic perturbation such as fever, lack of sleep or emotional
stress) catamenial seizures (occurring primarily or exclusively in any one phase of menstrual
cycle), state dependent seizures (occurring primarily or exclusively in various stages of
drowsiness, sleep or arousal), associated with emotional factors (such as anger, worry, fear,
laughter, weeping, frustration, stress), toxic and metabolic causes (such as alcohol, drugs,
hypoglycaemia, fatigue), and skipping of drug.
Try to find any factor that prevents or aborts an attack. If present, elaborate
Aura: Aura is defined as a subjective ictal phenomenon that in a given patient may precede an
observable seizure (ILAE). According to Duncan and Shorvon, aura is simple partial seizure
and can take any of the forms of SPS (motor, sensory or psychic). It is usually short lived,
lasting a few seconds or so, although in rare cases a prolonged aura persists for minutes, hours
or even days. Patients often describe the same features occurring in isolation as self-limited
simple partial seizures. The occurrence of an aura prior to complex partial seizures may be
noticed by an alert witness, but not subsequently recalled by the patient.
Make a mention of type of aura, if present and describe in detail. Possible types of aura are
enumerated below
Focal motor: Movement of different muscle groups can be seen. Specify the part of body that
shows motor activity. It can be eyelids (unilateral or bilateral), angle of mouth (specify which
side), thumb (specify side), finger (specify which finger and which side), toe (specify which
toe and which side), versive movements (specify side) or jacksonian march of events
Auditory: Again it can present as sensory distortion such as change in intensity of sound
(louder or fainter), deceptions such as auditory hallucinations (elementary or formed)
Disturbance of awareness: It can present with blank staring look, impaired (partial/ delayed/
irrelevant/ no) responsiveness to stimuli or a dreamy state
Automatism: A more or less coordinated, repetitive, motor activity usually occurring when
cognition is impaired and for which the subject is usually amnestic afterwards. This often
resembles a voluntary movement and may consist of inappropriate continuation of ongoing
preictal motor activity. There can occur various bodily movements such as masticatory
Emotions: Various emotions can be seen as a part of aura. To mention a few, it can be fear
without any reason, running to catch hold of some person/object, euphoria or laughter (seen in
gelastic seizures).
Pain: Pain can be associated with seizures and can be cephalic pain (holocranial, bifrontal,
bioccipital, right or left hemicranial), Unilateral ictal pain (either sided arm, leg, face or
trunk), abdominal pain
Postural: Slow loss of posture or adoption of a posture that may be bilaterally symmetrical or
asymmetrical (such as fencing posture) can be associated with a seizure attack
Epigastic aura: It can take the form of abdominal discomfort such as emptiness, tightness,
churning, butterflies, sense of ball of gas rising up, borborygmi, belching, flatulence, nausea,
vicarious or insatiable appetite
Autonomic aura: It can be seen in form of flushing or blanching, pallor of face, sweating (can
be profuse or focal), palpitation, tachypnea, sub-sternal distress, chocking, feeling of
temperature sensation (warmth/cold), pilo-erection or pupillary dilatation.
Description of ictal phenomenon: After elaboration of aura (if present), examiner should give
a full description of the ictal attack. Emphasis should be on how a typical attack starts and
progresses. One should also explain average duration of the attack.
If properly delineated, this helps to identify whether the attack is focal or generalized, if focal,
then whether simple or complex.
After explaining in detail about a typical attack (or all types of attacks, if more than one type
of attacks occur in a given patient), one should make a mention about effects of illness on the
patient such as effect on daily activity, role functioning (such as school/vocational) etc. Also
see if any behavioural problems are present amounting to post-ictal or inter-ictal psychosis.
Is there any personality change due to illness: Associated personality change can be varied
such as stubbornness, stickiness, circumstantiality, perseveration, retardation, decreases
general interest, humourlessness, hypergraphia etc.
Are there any changes in mental function due to illness: Look for any changes in attention and
concentration, comprehension, memory, reasoning and judgement, intelligence, learning,
scholastic or occupational performance.
Injuries associated with seizure attacks: Make a comment whether injuries occur in the
patient, if so, then how often? What is type of injury that usually occurs? It may be minor soft
tissue injury, tongue/cheek bite, head injury (contusion/laceration), fracture (facial bone/
mandible/ vertebrae/ ribs/ scapula/ clavicle/ skull bones/ teeth loss/ any other site), joint
dislocation (shoulder/ hip/ other joints), sprain (ankle/ wrist/ elbow/ knee/ other joints). There
may even be history of burns associated with seizure attack which may be first degree or even
second or third degree. The injury may or may not have received hospitalization for treatment.
Also enquire, where the injury was acquired: at work place, at home or while walking or
driving on road.
Treatment history: treatment history proceeds as in a normal case work-up. One should be
acquaint with the possible side effects of anti-epileptic drugs.
Past history: Special emphasis needs to be given on presence or absence of birth trauma or
asphyxia, febrile convulsions in early childhood, head injury or CNS infections anytime prior
to onset of seizures, any other insult to the brain such as chronic headache or stroke.
Family history: History of epilepsy, psychiatry disorders in family need to be asked for.
Personal history: Dietary habits such as such use of pork or food contaminated with animal
excreta need to be looked into. Also ask for use of substance of abuse such as alcohol or
opioid and any relation of these substances to seizure attacks.
Investigation reports: Any report available should thoroughly seen, both for the accuracy
and the suggested findings. Investigations that may be of help include EEG, CT scan, MRI,
ELISA (for neuro-cysticercosis and TB), psychological; testing (such as meuropsychological
assessment)
Multi-axial diagnosis: There is a proposed diagnostic scheme for people with epileptic
seizures and with epilepsy (Engel, 2001). That diagnostic scheme is divided into five parts, or
Axes which are as follows
Asix 2: Seizure type: from the List of Epileptic Seizures. Localization within the brain and
precipitating stimuli for reflex seizures should be specified when appropriate.
Axis 3: Syndrome: from the List of Epilepsy Syndromes, with the understanding that a
syndromic diagnosis may not always be possible.
Axis 5: Impairment: this optional, but often useful, additional diagnostic parameter can be
derived from an impairment classification adapted from the WHO ICIDH-2.
ILAE has proposed several classifications from time to time. The ones that are accepted are:
Several other classifications and amendments have been proposed subsequently, but none has
been accepted officially.
Appendix 1
What all questions one should ask if a particular complain is put forward?
A method can’t be taught to decipher each and every symptom a patient or his informants can
present with. Here are a few question one can ask in given complains. Further expertise is
acquired over period of time and with seeing more and more patients
Aggressive behaviour: From when/ on what matters/ in which situations/ with whom (known
or unknown or anyone)/ provoked or unprovoked/ if provoked, whether on trivial issues or
major issues/ planned or not/ associated with grievous injuries to others or self/ any police or
court case thereof/ reaction after the behaviour/ any feelings of guilt or remorse/ any other
related information/ progression of behaviour
Suspiciousness: From when/ how did it started/ how it was notices/ usually on whom (family
members or spouse or relatives or neighbors or work mates or strangers or anyone or
everyone)/ on which matters/ how exactly is the behaviour, give examples/ does it lead to
verbal or physical altercation/ progression of behaviour
Increased talk: From when/ how did it started/ understandable or not/ with known or strangers
or anyone or everyone/ talks how much in whole day/ gets tired of talking or not/ content of
talks/ whether says one thing again and again or talks on different issues/ associated with tall
claims/ whether stoppable or not/ what was behaviour used to when he/she was interrupted/
sings songs (even if no-one is there to listen)/ progression of behaviour
Demanding behaviour: From when/ from whom (any specific individual or family members
or strangers or anyone or everyone)/ if demands are not fulfilled then/ associated with
excessive spending or spree buying/ distributes to friends or stangers.
Muttering: From when/ how did it start/ what was noticed in initial days/ what does he/she
says when asked about it/ whether audible or not/ whether it looks like as if he/she is talking
to someone/ associated with smiling to self- softly or loudly/ whether makes hand gestures
along/ whether associated with sudden anger outbursts and speaking out abuses/ whether
he/she tells what he/she is muttering/ what time in the day is it more/ does it occurs in night
also/ whether he/she is able to sleep/ progression of behaviour
Wandering: From when/ how did it start/ where he/she used to wander initially and
subsequently/ how frequently he wanders around: daily or on some days/ what time in the day
does he/she sets out/ whether comes back on own or has to be traced and brought back/ what
does he/she do when outside/ does he/she interacts with people around when he/she roams/
collects unwanted or dirty things or garbage/ what does he/she says when enquired about this
behaviour/ progression of behaviour.
Long standing postures: From when/ how did it start/ whether stands also in sunshine or rain
till he/she is not removed by others from there/ how frequently does it happen/ for how long
Poor interaction: From when/ how did it start/ what was noticed in initial days/ whether stays
away from people/ how he/she behaves when someone else tries to interact/ whether gets
irritated/ maintains eye contact with talking or not/ whether he/she expresses will to interact/
what is the behaviour in times of festival or get-togethers or times of sorrow/ how does he/she
behaves with guests at home/ progression of behaviour
Repetitive acts: From when/ how did it start/ what was noticed in initial days/ how many
times do you do an act/ for how much time/ whether able to stop or not/ associated with any
thoughts/images/impulses (probe for obsessions, which usually precede the acts)/ how much
time is spent in cleaning/ any checking behaviour/ any difficulty in deciding/ progression of
behaviour
Low mood: From when/ how did it start/ how it was in initial days/ what is the thought in the
mind/ what is future like/ any ideas of hopelessness/helplessness/worthlessness/ any suicidal
thoughts/acts/ how is self confidence/ progression from time of onset
Sleep disturbance: From when/ duration of sleep before and now (more or less than usual)/ if
less then whether problem in falling sleep or maintaining or gets up earlier than before/ at
what time you go to bed/ at what time you actually fall asleep/ when do not fall asleep what
do you do/ whether there are breaks in-between/ if breaks, what do you do/ at what time u get
up/ whether sleep is refreshing/ how to you feel after getting up/ whether you have to take
medicine/ dreams (if any), comment.
It is suggested that a rough graphic depiction of illness patterns be done as part of the initial
work up and be the primary mode of recording a patient's history, even preferable to an
extensive written account. In this way, the patient and the mental health professional are
immediately and systematically focused on the longitudinal course of the illness and its
variation over time, rather than being sidetracked by focus only on acute symptoms and their
improvement. The graphic approach and its associated temporal landmarks can also facilitate
recall of important events, dates, and even entire prior episodes that would otherwise be
obscured or forgotten, as well as psychosocial precipitants. In this fashion, the mood chart
may facilitate the formulation and institution of appropriate psychotherapeutic interventions
as well. This chart can be further prospectively and longitudinally, updated at each patient
visit.
! Any stressor or life event (such as loss of job, death of a relative etc.) in course of
illness
! Use of medications and their effect on the course of symptoms
! Event such as suicidal attempt, self harm
This way, it would be easy to find out the evolution of various symptoms, role (if any) of
various factors such as precipitating factors, perpetuating factors, limiting or modifying
factors. Treatment received would be incorporated in the graph itself and would help in
determining future treatment in the given case.
Before starting to assess cognitive functions, one should keep in mind the profile of the
patient. When attempted as a part of overall mental status examination, these variables are
already entered in socio-demographic profile of the patient. So one should be verse with
patient’s name, address, age, sex, education (highest level, failures or honors, age at
completion) and occupation.
Also make a remark on any neurological or neurosurgical diagnosis such as hemiplegia,
hemianopia etc., whether recovered or not, any deficits if present). Any investigation reports
available such be entered such as EEG, MRI, CT Scan, Angiogram
Detailed examination will be covered under following headings
I. Behavioural Observation:
a. History of behaviour change, memory difficulties, bizarre behaviour, change in
work habits, and the like
b. Physical Appearance:
c. Emotional Status:
d. Frontal Lobe Test Results:
e. Denial or Neglect
IV. Handedness
Which hand do you often use for combing your hair?
Which hand do you often use to open a tap?
Which hand do you often use to lift a bucket?
Which foot do you often use to kick something?
Take an X-Ray film, fold it and see through it (See which eye he uses)
Does anybody in your family is left-handed?
V. Attention
a. Observation of the patient during examination
b. Digit Repetition: First ask the patient that which language is he comfortable
in? Then start with the procedure for testing Digit forward and digit backward.
Digit Forward (DF): Instruct that I will speak out a few numbers, listen to then
carefully and repeat after I finish. Make sure that the instructions are clearly
understood by the patient. It is better to give an example before starting the
test. Speak digits at a rate of one per second, and avoid associations between
numbers. It is thus advisable to keep a list handy at the time of assessment.
Stop once the patient fails twice at a given number of numerical. Last
successful repetition is taken as digit forward span. Normal DF- 7±2
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Digit backward (DB): Instruct the patient that now I will speak similar strings
of numbers. You will have repeat in opposite sequence. For example, if I say
3-7, you will say 7-3. Normal DB span is 5±2.
3-7 9-2
2-4-9 1-7-4
8-5-2-7 5-2-9-7
2-9-6-8-3 6-3-8-5-1
5-7-1-9-4-6 2-9-4-7-3-8
8-1-5-9-3-6-2 4-1-9-2-7-5-1
3-9-8-2-5-1-4-7 8-5-3-9-1-6-2-7
7-2-8-5-4-6-7-3-9 2-1-9-7-3-5-8-4-6
ल-त-प-ए-अ-औ-अ-ई-च-त-द-अ-ल-अ-अ-अ-न-ई-अ-ब-फ-स-अ-म-र-ज-ए-औ-अ-ड-प-
अ-क-ल-अ-उ-च-ज-त-ओ-इ-अ-ब-अ-अ-ट-य-फ-म-ह-स-अ-ह-ख-व-अ-अ-र-अ-त
Make a comment on errors of omission and errors of commission
VI. Language:
a. Spontaneous Speech: Describe, including fluency, articulation, and presence of
paraphasias.
Can you tell something about your village?
b. Verbal fluency:
Animal naming test: Normal- 18-22 ± 5-7
I know that you must be aware of names of animals. Kindly tell me
names of some animals, as many as you can in a period of 1 minute.
c. Comprehension:
Patient’s response to pointing commands: Ask the patient to point to one, two,
three, then four room objects or body parts in sequence. Continue to test until
consistent failure occurs. Normal person succeeds in pointing to 4 or more
objects.
I would name certain things in this room. Kindly point towards them
and let me know:
Pen (Look for response)
Chair and then fan (look for response)
Window then table and then your nose (look for response)
Door then book then your hand and then watch (look for response)
d. Repetition: Tell the patient to repeat words or phrases. Look for paraphasias,
grammatical errors, omissions and additions. Normal people can repeat
sentences of 19 or more syllables
I would say some words or phrases. Kindly repeat after me:
Ball
Help
Airplane
Hospital
Mississippi River
The little boy went home.
We all went over there together.
The old car wouldn’t start on Tuesday morning.
The fat short boy dropped the china vase.
Each fight readied the boxer for the championship bout.
VII. Memory
a. Immediate Recall (Short term memory): Digit Repetition (DF, DB)
b. Recent memory: Orientation as already tested also checks for recent memory.
To add to that, can ask
What you ate in breakfast today?
With whom have you come here?
Historic Facts:
When did India get its Independence?
Who was the first prime minister of India?
Ranchi is in which state?
How many brothers Pandavas were?
Verbal story for Immediate Recall: Look for number of correct memories and
describe confabulation if present. Story contains 26 relatively separate ideas.
Normal individuals under 70 years should be expected to produce at least 10 of
these items on immediate recall. In patients with good immediate recall, it may
be useful to ask for another recall after 30 minutes, which is a sensitive method
to test short-term verbal recall.
I am going to read you a short paragraph. Listen carefully, because
when I finish reading, I want you to tell me everything that I told you.
(Read the story slowly and carefully, but without pausing at the slash
marks).
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“It was July / and the Gupta family / had packed up / their four
children / in the maruti car / and were off / on vacation. They were
taking / their yearly trip / to the beach / at Goa. This year / they were
making / a special / one-day stop / at the Durga temple / in Pune. After
a long day’s drive / they arrived / at the hotel / only to discover / that in
their excitement / they had left / the twins / and their suitcases / in the
front yard.”
Now tell me everything that you can remember of the story. Start at the
beginning and tell me all that happened. (Record the number of correct
memories i.e. information within the slashes).
Visual Memory (Hidden Objects): Look for number of hidden objects found,
number of hidden objects named but not found and number of locations
indicated but objects not named. Normal people under 60 years should find 4-5
of hidden objects after a 5-minute delay without difficulty.
I am going to hide some objects around the office; desk or bed and I
want you to remember where they are. (Hide five common, small,
easily recognizable objects (keys, pen, comb, coin and reflex hammer)
in various areas in the patient’s sight. Name the items when they are
being hidden. After a delay of five minutes, ask the patient to find the
objects. Ask patient to name those items he or she is unable to find).
Paired Associated Learning: Normal-3 out of 4 in 1st trial and 4/4 in 2nd trial
I am going to read a list of words two at a time (in pairs). You listen to
them carefully. You will be expected to remember the words that go
together. Then once I say the first word of the pair, you will be
expected to tell the second word. (After reading the first list, test for
recall by presenting the first recall list. Give the first word of the pair
and ask for the word that went with it. Correct the incorrect responses
and proceed to the next pair. After the first recall has been completed,
allow a 10 second delay and continue with the second presentation and
recall lists).
Presentation lists: Recall lists:
1st list 1st list
Weather-Box House-
High-Low High-
House-Income Weather-
Book-Page Book
c. Block Designs: The use of this test requires four multi-colour cubes (used in
WAIS-III or Kohs block test) and four stimulus designs. Because of need of
extra equipment, this test is considered ancillary. Details can be learnt from
block test instructions used in intelligence testing.
c. Proverb Interpretation:
Do you know of any proverbs that are used in your place? Can you tell
a few of them and their meaning?
If patient does not spontaneously comes up with proverbs of his choice then
ask commonly used proverbs in his culture. Continue asking till two
consecutive failures. Score of 0-2 is given after assessing whether the response
is concrete/semi-abstract/abstract. Total score of less than 5 is suspicious.
Don’t cry over spilled milk.
Rome wasn’t built in a day
A drowning man will clutch at a straw.
A golden hammer breaks an iron door.
The hot coal burns, the cold one blackens.
c. Right-Left Disorientation:
Identification on self:
Show me your right foot
Show me your left hand
Crossed commands on self:
With your right hand touch your left shoulder
With your left hand touch your right ear
Identification on examiner:
Point to my left knee
Point to my right elbow
Crossed commands on examiner:
With your right hand point to my left eye
With your left hand point to my left foot
g. Geographic Disorientation:
Describe evidence of disorientation obtained from history:
Map localization: Describe patient’s ability to localize well-known
cities on a map.
Orientation of self in hospital: Describe patient’s ability to orient self
within the hospital environment.
Fist-Palm- Side test: Like I just demonstrated, hit the top of the table
repeatedly, first with a fist, then with an open palm, and then with the
side of the hand. Perform it until I ask you to stop. (Performance for
15-20 seconds should suffice to assess the adequacy of these
alternating movements)
Fist- Ring test: Now see, how I do this one. Extend your arm several
times, first with the hand in a fist, and then with the thumb and
forefinger opposed to form a ring. With successive extension of the
arm, alternate between these two positions.
Primitive reflexes: The frontal release signs should be looked for. These
primitive reflexes include (briefly described hereunder):
! Glabbelar reflex. Failure to extinguish eye blink response to gentle
tapping to the center of the forehead right above the nose.
! Grasp reflex. Perhaps the most helpful frontal release sign, as it is fairly
specific of frontal lobe injury, and has localizing value to the
contralateral supplementary motor area located in the medial frontal
Psychiatric
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87
lobe. The grasp reflex occurs when the hand grasps onto an object (or
examiner’s finger). It is elicited by stroking the inside palm in a distal
motion towards the base of the fingers. One may also stroke the
proximal surface of the fingers (towards the palm). The grasp can be
quite strong, allowing the person’s torso to be lifted up from a lying
position. Release may be voluntary or in some cases, takes
considerable effort to release.
! Palmomental reflex. Ipsilateral contraction of the muscle of the chin
(mentalis muscle) occurring to an unpleasant stimulus of the thenar
eminence (body of the palm just proximal to the thumb). The ipsilateral
corner of the mouth may also contract. The stimulus eliciting the reflex
is started at the lower wrist and up the base of the thumb. The stimulus
can be a tongue depressor or the handle of a reflex hammer.
! Root reflex. The turning of the patient’s head ipsilateral to the side of
the cheek that is lightly stroked. It is associated with the suck reflex in
its adaptability for infants to breast feed.
! Snout reflex. The puckering of the lips to make a “snout” when the top
lip is gently tapped (percussed). Typically, the Snout reflex can be
elicited by gently tapping on the center of the upper lip when the lips
are closed with your finger.
! Suck reflex. Sucking movements of the lips when the lips are generally
stroked or touched. The sucking movement can be elicited by stroking
the upper or lower corners of the mouth.
Instructions: Score one point for each correct response within each question or activity.
Parameter Item Score
Orientation What is the year 1
(10) What is the season 1
What is the date 1
What is the day 1
What is the month 1
What state are we in 1
What country are we in 1
What town/city are we in 1
What building are we in 1
Which floor are we on 1
Registration Name 3 unrelated objects clearly and slowly, then ask the 3
(3) patient to name all three of them (1 point for each correct item
named). Repeat them until patient learns all of them, if possible
Attention and Serial 100-7 (1 point for each correct 5 answer). Alternative: 5
concentration “Spell WORLD backwards.” (D-L-R-O-W)
(5)
Recall (3) Ask names of three objects told above. (1 point for each item) 3
Language (9) Ask to identify a pen and a watch 2
Repeat the sentence – no ifs and buts 1
Ask to follow a three step command Take 3 the paper in your 3
right hand, fold it in half, and put it on the floor.”
Read and obey “Close your Eyes” 1
Write a meaningful sentence 1
Please copy this picture. (All 10 angles must be present and two 1
pentagons must intersect.)
Total (30) 30
Ref: Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state: A practical method for
grading the cognitive state of patients for the clinician.” Journal of Psychiatric Research, 12, 189-198.
Bush-Francis Catatonia Rating Scale is a 23-item scale and measures the severity on these
items on a scale of 0-3. The method described here is used to complete the 23-item Bush-
Francis Catatonia Rating Scale (CRS) and the 14-item Catatonia Screening Instrument (CSI).
Item definitions on the two scales are the same. In contrast to CRS, which measures the
severity, the CSI measures only the presence or absence of the first 14 signs.
Ratings are to be made solely on the basis of observed behaviour during the examination with
the exception of completion of the items for 'withdrawal' and autonomic abnormality', which
may be based on directly observed behaviour and for chart documentation.
1. Excitement: Extreme hyperactivity, constant motor unrest 2. Immobility/stupor: Extreme hypoactivity, immobile,
which is apparently non-purposeful minimally responsive to stimuli
0 = Absent 0 = Absent
1 = Excessive motion 1 = Sits abnormally still, may interact briefly
2 = Constant motion, hyperkinetic without rest periods 2 = Virtually no interaction with external world
3 = Full blown catatonic excitement 3 = Stuporous, non-reactive to painful stimuli
3. Mutism: Verbally unresponsive or minimally responsive 4. Staring: Fixed gaze, little or no visual scanning of
0 = Absent environment, decreased blinking
1 = Unresponsive to majority of questions, incomprehensible 0 = Absent
whisper 1 = Poor eye contact, repeatedly gazes less than 20 seconds
2 = Speaks less than 20 words/5mins between shifting of attention; decreased blinking
3 = No speech 2 = Gaze held longer than 20 s, occasionally shifts attention
3 = Fixed gaze, non-reactive
5. Posturing/Catalepsy: Spontaneous maintenance of posture(s) 6. Grimacing: Maintenance of odd facial expressions.
including mundane (.g. setting or standing for long periods 0 = Absent
without reacting). 1 = Less than 10 seconds
0 = Absent 2 = Less than 1 minute
1 = Less than 1 minute 3 = Bizarre expression(s) or maintained more than 1 minute
2 = Greater than one minute, less than 15 minutes
3 = Bizarre posture, or mundane maintained more than 15 mins
7. Echopraxia/echolalia: Mimicking of examiner’s movements/ 8. Stereotypy: Repetitive, non-goal-directed motor activity
speech (e.g. finger-play; repeatedly touching, patting or rubbing
0 = No mimicking of examiner’s movements/speech self); abnormality not inherent in act but in frequency.
1 = Occasional 0 = Absent
2 = Frequent 1 = Occasional
3 = Constant 2 = Frequent
3 = Constant
9. Mannerisms: Odd, purposeful movements (hopping or 10. Verbigeration: Repetition of phrases or sentences (like a
walking tiptoe, saluting passers- by or exaggerated caricatures scratched record).
of mundane movements); abnormality inherent in act itself. 0 = Absent
0 = Absent 1 = Occasional
1 = Occasional 2 = Frequent
2 = Frequent 3 = Constant
3 = Constant
11. Rigidity: Maintenance of a rigid position despite efforts to 12. Negativism: Apparently motiveless resistance to
be moved, exclude if cog- wheeling or tremor present. instructions or attempts to move/examine patient. Contrary
0 = Absent behaviour, does exact opposite of instruction
1 = Mild resistance 0 = Absent
2 = Moderate 1 = Mild resistance and/or occasionally contrary
3 = Severe, cannot be repostured 2 = Moderate resistance and/or frequently contrary
3 = Severe resistance and/or continually contrary
13. Waxy Flexibility: During reposturing of patient, patient 14. Withdrawal: Refusal to eat, drink and/or make eye
offers initial resistance before allowing himself to be contact.
repositioned, similar to that of a bending candle. 0 = Absent
0 = Absent 1 = Minimal PO intake/interaction for less than 1 day
3 = Present 2 = Minimal PO intake/interaction for more than 1 day
3 = No PO intake/interaction for 1 day or more
21. Perseveration: Repeatedly returns to same topic or persists 22. Combativeness: Usually in an undirected manner, with
with movement. no, or only a facile explanation afterwards.
0 = Absent 0 = Absent
3 = Present 1 = Occasionally strikes out, low potential for injury
2 = Frequently strikes out, moderate potential for injury
3 = Serious danger to others
23. Autonomic abnormality: Circle: temperature, BP, pulse,
respiratory rate, diaphoresis. TOTAL:_______________
0 = Absent
1 = Abnormality of 1 parameter [excluding pre-existing HTN]
2 = Abnormality of two parameters
3 = Abnormality of three or more parameters
As a general rule, only rate items, which are clearly present. If uncertain as to the presence of
an item, rate the item as '0'.
Procedure Examines
6 Reach into pocket and state, "Stick out your tongue, I want to Automatic obedience
stick a pin in it".
7 Check for grasp reflex. Grasp reflex
Ref: Bush, G., Fink, M., Petrides, G., Dowling, F., and Francis, A. (1996). Catatonia. I. Rating scale and
standardized examination. Acta Psychiatry Scandinavia, 93, 129–136.
According to the original AIMS instructions, one point is subtracted if movements are seen
only on activation.
Alcohol
Dysfunctional behaviour, as evidenced by at least one of the following:
1. Disinhibition
2. Argumentativeness
3. Aggression
4. Lability of mood
5. Impaired attention
6. Impaired judgment
7. Interference with personal functioning.
At least one of the following signs:
1. Unsteady gait
2. Difficulty standing
3. Slurred speech
4. Nystagmus
5. Decreased level of consciousness (e.g. stupor, coma)
6. Flushed face
7. Conjunctival injection.
When severe, it may be accompanied by hypotension, hypothermia; depression of gag reflex.
Opioid
Dysfunctional behaviour as evidenced by at least one of the following
1. Apathy and sedation
2. Disinhibition
3. Psychomotor retardation
4. Impaired attention
5. Impaired judgement
6. Interference with personal functioning.
At least one of the following signs
1. Drowsiness
2. Slurred speech
3. Pupillary constriction (except in severe overdose when pupillary dilatation occurs)
4. Decreased level of consciousness (e.g. stupor, coma)
When severe, it may be accompanied by respiratory depression (and hypoxia), hypotension
and hypothermia
Alcohol
Presence of any three of the following:
1. Tremor of the outstretched hands, tongue or eyelids
2. Sweating
3. Nausea, retching or vomiting
4. Tachycardia or hypertension
5. Psychomotor agitation
6. Headache
7. Insomnia
8. Malaise or weakness
9. Transient visual, tactile or auditory hallucinations or illusions
10. Grand-mal convulsions.
If delirium is present, the diagnosis of alcohol withdrawal state with delirium ("delirium
tremens") should be made.
Cannabis
This is an ill-defined syndrome for which definitive diagnostic criteria are not yet established.
It has been reported variously as lasting from several hours to up to seven days following
cessation of prolonged high-dose use of cannabis. Symptoms and signs include anxiety,
irritability, tremor of the outstretched hands, sweating, and muscle aches.
Opioid
Presence of any three of the following
1. Craving for an opioid drug
2. Rhinorrhea or sneezing
3. Lacrimation
4. Muscle aches or cramps
5. Abdominal cramps
6. Nausea or vomiting
7. Diarrhea
8. Pupillary dilatation
9. Piloerection, or recurrent chills
10. Tachycardia or hypertension
11. Yawning
12. Restless sleep
ILAE Commission on Classification and Terminology, 2005–2009 in its report has suggested
some revision in terminology and concepts for organization of seizures and epilepsies. A
summary of those suggestions is given in tables that follow
102
Psychiatric
history
taking
TABLE 3. Classification of Seizures
I. Generalized onset
A. Tonic-clonic seizures (in any combination)
B. Absences
1. Typical absences
2. Atypical absences
3. Absence with special features
a. Myoclonic absences
b. Eyelid myoclonia
C. Myoclonic
1. Myoclonic seizures
2. Myoclonic atonic
3. Myoclonic tonic
D. Clonic seizures
E. Tonic seizures
F. Atonic seizures
II. Focal onset (partial)
A. Without impairment of consciousness/responsiveness
1. With observable motor or autonomic components (roughly corresponds
to concept of SPS)
2. Involving subjective sensory or psychic phenomenon only (corresponds
to concept of aura)
B. With impairment of consciousness/responsiveness (roughly corresponds to
concept of CPS)
C. Evolving to a bilateral convulsive seizure (involving tonic, clonic or tonic and
clonic components, replaces the term secondarily generalized seizure)
III. May be focal, generalized or unclear
A. Epileptic spasms