This document provides an overview of psychiatry case taking and examination, including history taking and mental status examination (MSE). It discusses the purpose and general principles of history taking, as well as how to structure the interview room and questions. It then describes how to obtain information on a patient's identifying data, chief complaints, history of present illness, past history, family history, personal history, and pre-morbid personality. Finally, it outlines the components of the MSE including general appearance, psychomotor activity, speech, mood, thought, perception, and cognitive functions.

1. Psychiatry case taking &
Examination
Dept. of Psychiatry
KIMSRF

2. Roadmap
History taking
• Purpose
• General principles
• Interview room
• Questioning
• Basic details
• HOPI
• Past history
• Personal history
• Family history
• Pre morbid personality
MSE
• General appearance &
Behaviour
• Psychomotor activity
• Speech
• Mood
• Thought
• Perception
• Cognitive functions

3. History taking
• Most important in evaluation and care of
persons with mental illness.
• Purpose-
– Establish diagnosis.
– Prediction of course & prognosis.
– Treatment decisions.
– Shapes patient-physician relationship.

4. General principles
• Agreement to the process-
– Introducing
– Voluntary/ Involuntary patient
• Privacy & Confidentiality-
– Very essential
– Assure patient of confidentiality
– Legal obligation
• Respect & Consideration-
– Allaying anxiety

5. • Rapport/ Empathy-
– Harmonious responsiveness of physician to patient
and vice versa
– Understanding what the patient is thinking and feeling
by putting in patient’s place
– Verbal & Non verbal responses
– Not to get carried away
• Patient-Physician relationship-
– Increases trust & therapeutic alliance
• Safety & Comfort-

6. Interview room
• Relatively soundproof
• Décor- pleasant, non distracting
• Chair of patient
• Approx 4 to 6 feet apart
• Distractions should be kept minimum
• No telephone

7. Questioning
• Open ended vs Closed ended
• They identify an area, provide minimal structure
as to how to respond.
• Ex- tell me about your problem
• Provide structure and narrow the field of
responses. Mostly yes or no.
• Ex- is sleep your problem

8. • History- obtained from patient and collaterals,
like family members & other caregivers.
• MSE- Interviewer’s objective tool similar to
physical examination in other areas of
medicine.
• Physical examination- to rule out organic
conditions.

9. • Identifying data
• Source & reliability
• Chief complaints
• HOPI
• Past history
• Family history
• Personal history
• Pre Morbid Personality

10. Basic details
• Identifying data-
– Patient’s name, age, sex, marital status, education,
occupation & residence
• Source & reliability-
– From the information came & how reliable is the data
• Chief complaints-
– In patient’s own words.
– Noted chronologically.

11. HOPI
• Onset, duration of illness.
• Basic information of specific chief complaints-
duration, intensity etc..,
• Details of precipitating factors.
• Positives & negative history.
• Note down important life events.
• Different approaches may be needed-
– Emergency setting
– Out patient setting

12. Past history
• Includes- psychiatric & medical.
• Information about past psychiatric illnesses,
course including symptoms & treatment.
• Details like- when, how long, frequency,
severity etc..,
• Treatment details should be reviewed in detail
like- pharmacotherapy, psychotherapy, ECT.
• Making a life chart gives a clear picture.

13. Family history
• Genogram- 3 generations
• Family history of psychiatric illness- details
regarding the same.
• Many- familial & significant have genetic
predisposition.
• There appears to be familial response to
medications, suicide- important in
management of patient.
• Interpersonal issues.

14. Personal history
• Birth & early development
• Behavior during childhood
• Physical illness during childhood
• Schooling
• Occupation
• Menstrual history
• Sexual history
• Marital history

15. Pre morbid personality
• Prior to the beginning of mental illness
• Details like-
– Social Relation
– Mood
– Intellectual activities, hobbies & interests
– Fantasy life
– Habits

16. Mental status examination
• General behavior and appearance
• Psychomotor activity
• Speech
• Thought
• Mood
• Perception
• Cognitive functions

17. Definitions
• Hallucination-
– A false perception which is not a sensory distortion or a
misinterpretation, but which occurs at the same time as real
perception.
• Illusion-
– False perception of the stimulus.
• Obsession-
– A thought that persists & dominates an individual’s thinking.
• Compulsion-
– Obsessional motor acts.

18. • Delusion-
– False, unshakable belief that is out of keeping with the patient’s
social and cultural background.
• Amnesia-
– Partial or total inability to recall past experiences and events.
• Emotion-
– Stirred up state caused by physiological changes occurring as a
response to some event.
• Mood-
– Pervasive & sustained emotion that colors the person’s
perception of the world.

19. General behavior and appearance
• Appearance- grooming, hair and nails.
• Rapport- established or not
• Eye to eye contact- maintained or not
• Presence of any tics or mannerisms.
• Behaviour towards examiner.
• Anxiety signs-moist hands, perspiring
forehead, tense posture, wide eyes, wringing
of hands, fidgeting behaviour etc..,

20. Psychomotor activity
• Increased
• Decreased

21. Speech
• Form of utterance
• Spontaneously or not?
• Amount- little or excessive?
• Tone- high or low?
• Tempo- fast or slow?
• Reaction time- increased or decreased?
• Prosody of speech maintained?
• Relevant & Coherent?

22. Thought
• Formal thought disorder
• Stream-
– Flight of ideas,
– Thought block, circumstantiality, perseveration.
• Possession-
– Obsessions & compulsions,
– Thought alienation.
• Content-
– Overvalued ideas and Delusions.

23. Mood
• Assessed as-
– Subjective report
– Objective evaluation
• Quality of emotion
• Intensity or depth of emotional experience
• Range of affective responses, mobility, reactivity, and
appropriateness.
• Evidence of labiality.

24. Perception
• Illusions
• Hallucinations- visual, auditory, tactile, gustatory,
olfactory & kinesthetic.
• Special varieties- Functional hallucinations, Reflex
hallucinations, Extra-campine hallucinations,
Synaesthesia and Autoscopy.
• Other perceptual disturbances-
Depersonalisation/ derealisation experiences.

25. Cognitive functions
• Orientation
• Attention & Concentration
• Memory
• Intelligence
• Judgment
• Insight

26. Orientation
• Time-
– Appropriately what time of the day is it?
– Is it morning, afternoon, evening or night?
• Place-
– What place is this?
– Is this a school, office, hospital, restaurant etc.?
• Person
– Identifying of the patient’s relative or family
members.

27. Attention & Concentration
• Tests used-
– Digit span test
– Serial subtraction
– Days or months forward to backward
• Digit span test-
– Forward- numbers are given & asked to repeat in the same order
– Backward- numbers are given & asked to repeat in opposite order.
• Serial subtraction-
– increasingly difficult tests are presented.
– 20-1, from 20 to 0 reversed in 15 seconds, 40-3 & 100-7.
• Days or months may be asked for in backward or forward.

28. Memory
• Memory is tested as
– Immediate,
– Recent and
– Remote memory
• Immediate memory – tested by digit span test
• Recent memory –
– Address test-an address consisting of about 4-5 facts is given & patient to
repeat.
– 2. Asking the patient to recall events in the last 24 hours.
• Remote memory-
– Date of birth or age
– Names and number of family members
– Time since marriage or death of any family members

29. Intelligence
• Tested as-
– General information,
– Comprehension,
– Arithmetic and
– Abstraction
• General Information - Information relevant to the patient’s literacy age or
occupation may be asked
• Comprehension - ability to understand the questions asked, like-
– What will you do when you feel cold?
• Arithmetic - basic questions on calculation, like
– How much is four rupees and five rupees?

30. • Abstraction- tested by-
– Similarities, differences and proverbs.
• Similarities- two items are given & asked to point out the
similarities
– Orange - banana (fruits)
– Dog - lion (animal)
• Differences- two items are given & asked to point out the
differences
– Stone - potato (not edible-edible/ hard- soft)
– Fly - butterfly (small-large/ colourful-not colourful)
• Proverbs- a proverb is given & patient is asked to interpret it .

31. Judgment
• Assessed in the following areas:
– Personal
– Social
– Test
• Personal judgement- assessed by inquiries about the patient’s future
plans.
• Social judgement- assessed by observing behaviour in social situations.
• Test judgement – following problems are presented
– Fire Problem- if the house in which you live catches fire what is the first thing
that you will do?
– Letter problem- If when you are walking on the road, you see a stamped and
sealed envelope with an address on it, which someone had dropped. What
will you do?
– Baby near the pond- If a small baby is lying near the pond, what will you do?

32. Insight
• To know patient’s level of awareness of his illness.
• Absent insight- does not think that he/she is ill
• Partial insight- he/she recognises the presence of
the illness but gives explanation in physical terms.
• Complete insight- he/she fully recognise the
emotional nature of his illness and the cause of
his symptom.

33. Thank you