Case Taking TIPPS4

STEP 2018
National Conference for

Postgraduates in Psychiatry
5th & 6th January 2018
Bengaluru
TIPPS CLINICAL NOTES

Authored by: Dr Rishikesh V Behere, Dr Naren P Rao, Dr
Girish Babu N, Dr Sugnyani Devi Patil
Supported by educational grant from

Training Initiative for Psychiatry Postgraduates (TIPPS ) www.tipps.co.in

Psychiatric history taking and mental status examination
HISTORY:
Socio demographic details:
(Ask for name, age, gender, socio-economic status and average family annual income,
marital status, occupational status)
Informant: (Record who is the informant – name and relationship to patient)
ü Reliability of information (Is the information consistent, corroborative, and

continuous?)
ü Adequacy of information (Is the information adequate to come to a provisional
diagnosis?)
Presenting complaints: (present the main 3-4 complaints preferably in patients words
avoid technical terms and arrange in chronological order)
Onset: (The time period between when symptoms started and reached maximum intensity.
Abrupt – within 48 hours, acute – within 2weeks, insidious – gradual)
Course: continuous/fluctuating/episodic
Precipitating factor: (Record significant events – biological or psychosocial which may be

deemed to be associated as a triggering factor with the onset of illness).
History of presenting illness:
Elaborate the presenting complaints in a descriptive manner to elicit all information

pertaining to the symptoms. The flow of description should be such that at the end of history
the listener should be able to make a fair estimation of possible diagnosis. One way is to
think of differential diagnosis for your complaints and arrange your information including and
excluding possible diagnosis.
In psychiatric history it is easy to get carried away by describing only contextual factors and
stressors reported by over anxious informants. While they are important they do not help in
diagnosis and decision making. It may be necessary for interviewer to filter information and
focus on eliciting symptoms.
Thumb rules to follow:
ü Elaborate each presenting complaints for onset, duration, progression,

ü Ask for and cover symptoms in all 3 domains of thought/emotions/behavior
ü Describe the Socio-occupational dysfunction caused by the symptoms
ü A good way to do this is to describe a typical day of the patient and activities over a
24 hour period
ü Describe Biological functions – Sleep/appetite/sexual activity
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ü Describe associated stressors

ü Check for history of substance use
ü Always check for risk of harm to self or others (Suicidal
ideation/attempts/aggression)
ü Check for potential legal issues
ü Start negative history with:
§ Symptoms of likely diagnosis which are not present in this patient
§ Other psychiatric symptoms which are absent to rule out differential
diagnosis
§ Neurological and Medical symptoms/conditions that may be associated with
the likely diagnosis
Treatment history: (Details of past treatment – Drug given. Duration of treatment,

compliance, and adverse effects if any, and if there was any response)
Past history: (Details of past illness. Typically in episodic illness, only current episode is
described in HOPI and details of past episodes come here)
Family history: Record following information
ü 3 generation genogram
ü Family history of medical or psychiatric disorder (Psychosis, bipolar disorder,
depression, suicide, substance use, dementia). The diagnosis may not be clear,
describe the symptoms and behavioral disturbances, and record their treatment
history if available (for e.g. family history of response to lithium may predict good
response to lithium in this patient also).
ü Record current living arrangement and who is primary care giver
ü Record family understanding of illness and attitude towards the patient also record
any family stressors, interpersonal difficulties
Personal history:
ü Antenatal history and birth complications

ü Developmental milestones
ü Childhood history for enuresis, nail biting, school refusal, truancy, conduct symptoms,
ADHD, temper tantrums
ü Schooling history: record average academic performance, last class studied,
grades/marks in 10th and 12th standard and reasons for drop out
ü Occupational history: Jobs held, performance, reason for loss of job. Ask specifically
for any frequent job changes, impersistence in work etc.
ü Marital history: Record for duration of Married life, nature of marital and sexual
relations, marital discord if any, details of family of procreation.
ü Sexual history: Check for sexual misconceptions, high risk sexual behavior
ü Menstrual history in female patients
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Premorbid personality:
Ask about the individual’s attitude to work/family, ability to take responsibility, coping when
faced with stress, hobbies and interests prior to onset of illness.
In young adults/adolescents temperamental history needs to be taken.
Interviewing patients in Psychiatry:
History taking is the first step and interviewing skills are the most important tool to a
psychiatrist. Given the nature of the discipline, most clinical diagnosis are made based on
the available information. Hence eliciting adequate information, analyzing and organizing it
to reach a conclusion is a very important skill.
To be able to elicit important information the interviewer needs to know certain specific skills
1. To be able to establish a rapport

2. Empathy and listening skills
3. Interview technique
Few things to remember are:
ü History taking is a Clinical interview, the focus of which is to obtain adequate

information in order to arrive at a clinical diagnosis. There may be a lot of contextual
information related to circumstances, events and psychosocial stressors which may
be important to understand the person’s reaction and significance of the event but
may not be relevant for clinical diagnosis. Hence the interviewer may need to filter
these out.
ü While analyzing and organizing the information collected the principle of ‘atheoretical’
nature of psychiatric diagnosis needs to be kept in mind.
ü The interviewer should be non-judgemental and empathetic in approach to the
interview
ü Certain questions may need to be asked in a specific set manner to elicit correct
information and eliminate subjectivity in interview techniques and make the process
of eliciting information reproducible.
Establishing rapport
Establishing rapport is probably the most important step in history taking. Especially
when interviewing psychotic patients with poor insight, eliciting personal information like
interpersonal issues, sexual history, sexual abuse etc.
ü Introduce yourself and set the agenda of the interview by stating that you would be
asking questions to understand reason for consultation/admission.
ü Address the patient by name – this is a useful to gain the trust of the patient
ü Ensure confidentiality by making explicit statement that information discussed with
not be revealed without consent
ü Always interview the patient first and get her version of the history. This is also vital in
cases where patients have poor insight and psychopathology involving the
informants
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ü Start with neutral questions such as occupation, education, family details, whether
they are comfortable in the ward etc.
ü Begin with open ended questions such as ‘what brings you to the hospital?’
ü Note the presenting complaints with duration in chronological order
ü Elaborate on the chief complaints by directive questioning.
ü Use close ended questions (Yes/No) for eliciting specific information and negative
history
ü Use paraphrasing to make empathic statements
ü Follow the cues given by the patient and pick up leads for further questioning
ü Summarize at the end of the interview.
General appearance and behavior: Give a good observational description.
ü General appearance and grooming

ü Rapport – could be established/very easily established and overfamiliar/difficult to
establish – guarded/hostile
ü Eye to eye contact – maintained/fleeting/hyper vigilance/avoids/downcast
ü Any observed repetitive motor movements – tics/mannerisms/stereotypies/motor
perseveration/catatonic signs
Psychomotor activity:
ü Increase in goal directed activity/retardation

ü Agitation
ü Hand gestures while conversation
ü Hyperactivity
Speech:
ü Tone (loudness) of speech – normal/increased/decreased

ü Tempo (rate or speed) of talking – normal/increased/pressure of speech/decreased
ü Volume (amount) of speech. Estimate words per minute – verbose/pressure of
speech/decreased
ü Prosody – emotional intonations of speech
ü Reaction time – increased/decreased
Thought:
Form: Obtain speech sample on a neutral topic. Assess for poverty of thought/poverty of
thought content/circumstantiality/flight of ideas/tangentiality/loosening of associations and
derailment/neologisms
Stream: Observe for flow and continuity of thought process – Flight of ideas / prolixity /
retardation / perseveration / thought block
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Possession: Disorders of thought related to the ownership of thought
ü Thought broadcast – thought diffusion/thinking in unison /audible thoughts

ü Thought insertion
ü Thought withdrawal
ü Obsessions – describe if thoughts are repetitive/intrusive/irrational/ego
dystonic/person’s own thoughts. Also mention the form
(ideas/impulses/images/doubts/ruminations) and content of obsessions
ü Compulsions – motor/cognitive
Content:
ü Delusions – Give verbatim description given by patient and then give your impression
whether belief is - Fixed/firm/false/not in keeping with socio-cultural
background/morbid origin. Describe content of belief (persecutory/ referential/
misinterpretation/grandiose/ hypochondriacal/ etc). If there are multiple delusions
also describe whether they are - Single/multiple elaborate/non-elaborate
bizarre/non-bizarre systematized/non-systematized
ü Overvalued ideas
ü Depressive cognitions – hopelessness/worthlessness/helplessness
ü Death wishes or suicidal ideation – Describe frequency, intensity of ideas and
whether there are any active plans
ü Preoccupations & ruminations – somatic/anxious/depressive
Mood:
ü Subjective mood: Ask – “How has been your mood for most periods of the day over
the last one week” – give verbatim description given by patient.
ü Affect: Cross sectional observation of facial emotional expression, motor behavior,
gestures, posture, speech
(Euphoric/irritable/depressed/anxious/perplexed/restricted/blunted or flat).
ü Range: intact/restricted
ü Reactivity: preserved/absent
ü Lability: (rapid shifts of mood during interview) present/absent
ü Appropriateness to situation and congruency to though process
Perception: Give verbatim description of quality and content of perception given by patient
and then give your impression whether the phenomenon:
Occurs in clear consciousness/ clear and vivid/ objective or subjective space / patient has
insight into it / control on the experience
And give your impression whether the perceptual abnormality is a hallucination/pseudo

hallucination/imagery and which modality it occurs in.
Other phenomenon: Describe phenomenon such as somatic passivity/ depersonalization/

derealisation here.
Insight:
ü Awareness: That experiences are out of the ordinary/not real or normal/deviant
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ü Attribution: To psychological/somatic causation for the experiences

ü Acceptance: Of treatment for the same
Also grade insight from 1-6.
ü Complete denial of illness

ü Slight awareness of being sick and needing help, but denying it at the same time
ü Awareness of being sick but blaming it on others, on external factors, or on organic
factors
ü Awareness that illness is caused by something unknown in the patient
ü Intellectual insight: admission that the patient is ill and that symptoms or failures in
social adjustment are caused by the patient's own particular irrational feelings or
disturbances without applying this knowledge to future experiences
ü True emotional insight: emotional awareness of the motives and feelings within the
patient and the important persons in his or her life, which can lead to basic changes
in behavior.
Cognitive function assessment:
Consciousness: Alert / drowsy but arousable with minimal stimulus / obtunded arousable
with deep stimulus / stuporous
Orientation:
ü Time – Ask approximately what time of the day it is now without looking at the time
(Approximation should be within ± 2 hours).
ü Place – Ask patient to identify his surroundings and which place he is in
ü Person – Ask whether patient can identify himself and then people around him
Note: Patient should be alert and well oriented to proceed for the remainder of
cognitive function assessment.
Attention:
ü Digit span test: Give serial digits sequences and ask patient to repeat them after you
have presented the sequence. Numbers should be read clearly and rate of 1 number
per second. First complete the forward sequence then present the backward
sequence. Normal range of digit forward is 7 +/- 2 (5 to 9) and digit backwards is 5
+/-2 (3 to 7).
Forwards Backwards
7-4-9 1-7-4
8-5-2-7 5-2-9-7
2-9-6-8-3 6-3-8-5-1
3-8-1-5-9-2 5-2-9-1-7-4
ü Serial subtraction test: Ask patient to perform 100 minus 7 in 2 minutes, 40 minus 3
in 1 minute and 20 minus 1 in 20 seconds. More than 2 mistakes is taken as
abnormal. Illiterate subjects can be asked to name days of week backwards (They
should be able to tell the backward sequence correctly for 5 steps starting from
Friday).
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Language:
ü Spontaneous speech & Fluency (animal naming test – number of animals’ patient
can name in 1 minute).
ü Comprehension: verbal commands/pointing questions/multistep commands
ü Naming: naming common objects such as pen, coin
ü Reading and writing
Note: If attention and language is impaired the interpretation of the rest of the tests of
cognitive assessment is doubtful.
Memory:
ü Immediate memory: Digit span test / Serial subtraction test as above or 3-word
registration. Instruct patient that you will be giving 3 words which they should listen
carefully, repeat them after you have said them and try to remember them as you will
be asking them to recall it later. The three words should be unrelated and not present
in the room – eg: Lotus, cat, blue
ü Recall: Ask patient to recall words after 5 minutes. Note if they require a cue to recall
/ confabulation. Alternative address test may be used. Give an address with 5 points
to remember and assess recall after 5 minutes. For eg: # 215, 9th Cross, 2 Main,
Vijay Nagar, Bangalore
ü Remote: Ask if person can recollect Personal information like marriage, child birth,
schooling, occupation and Semantic information like year of independence or events
of national importance
General information:
ü General fund of information: common knowledge such name of local rivers, important
towns in your area, important personalities. This question is very subjective and
needs to be asked based on education and socio-cultural background of the patient
Calculation:
ü Calculation: Assess for simple calculation abilities, both verbal and written – addition,
subtraction, multiplication, division. Arithmetic problem-solving questions (for eg: if
you go to a shop and buy chocolates. Each chocolate costs 50 paisa. How may
chocolates can you buy for 4 rupees. I f you have 20 rupees with you and a banana
cost Rs 7. How much money will you have left?)
Abstraction: Describe whether the responses are abstract/semi abstract/ concrete
ü Test for differences between pairs of objects (stone and potato, chair and table)
ü Test for similarities between pairs of objects (orange and apple, bird and
aeroplane)
ü Ask to tell a proverb in his own language and the real meaning of the proverb. If
patient cannot recall, give him some proverbs in his own language and ask for
meaning.
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Judgment:
ü Test: Give specific responses and ask what would the patient do in these scenarios
(What would you do if you saw that your neighbor’s house is on fire? What would
you do if you saw that a child was crawling towards an open well?)
ü Personal: Ask what is the patients immediate future plan after discharge from the
hospital
ü Social: Impression of judgment is made based upon history of behavior over last
one week and cross-sectional observation.
Intelligence: Make an estimate of overall intelligence level based on comprehension,

general information, calculation, abstraction and judgment.
Specific lobe function test:
ü Luria motor sequence: Fist palm side test- Ask the subject to hit the top of the desk
repeatedly, first with a fist, then with the side of the hand, then with an open palm
with his/her right hand. Demonstrate the task thrice with your left hand, make the
subject do it with you thrice and then allow the subject to perform it on his own at
least 6 times. Look for errors of missing the sequence or perseverative errors.
ü Visual pattern completion test: Ask the patient to copy the below figure and continue
the pattern
ü Go no go test: Given the instruction to patient “tap once when I tap once and do not
tap when I tap twice.” Give a practice and then tap in the sequence - 1-1-2-1-2-2-2-1-
1-2. Look for errors of omission/commission/perseveration.
ü Visuo-spatial construction: Ask patient to copy figures presented below. Ensure
visual acuity before interpreting.
§ Cross
§ Cube
§ Intersecting pentagons
§ Clock drawing - “Please draw a picture of a clock with the numbers and set
the hands at 2:30”
ü Apraxia: Listen to my instructions carefully and perform the action I ask you to do
imagining that you are holding that object in your hand
§ Show me how to open a lock with a key
§ Show me how to comb your hair
§ Show me how to open a toothpaste, put the paste on your toothbrush and
brush your teeth.
Note: While presenting; cognitive functions should be reported prior to ‘thought’ as

interpretation of MSE findings is dependent on intact cognitive functions, though
while performing MSE we may have assessed it in the end.
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Proforma For Detailed Work-Up- Child and Adolescent Psychiatry
Name: Informants:
Age (DOB): Reliability:

Reliable/unreliable
Sex: Adequate/inadequate
Educational status: Address/Phone number:
Date of work-up: Source of referrals:
Chief Complaints: Duration Onset: Acute/

Insidious
Course of illness: Continuous / Episodic
Precipitating Factors: No/ Yes – specify
History of Presenting Illness:

Clarify and elaborate disparity in symptom/ symptom severity across different context:
(Home/ school/ other social)
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Past History:
Medical Illness / Psychiatric Illness:
History of feeding problems, recurrent infections (fever, loose motions) fits, visual
impairment, hearing impairment, gait problem
Intervention Initiated: Yes/No, Describe if yes
Medications used: Yes/No, Describe if yes
Family History: Three generation family tree for genetic vulnerability

Consanguinity among parents: Present/ Absent
Parental background: (Age, Education, Occupation, Health status)

• Father
• Mother
Family life and relationships:
• Parent child interaction: Responsive/ Sensitive/ Consistent/ QT Spent/ Supervision
adequate
• Significant other parental figures: G.parents/ Aunt / other caregivers
• Parenting style: Authoritative/ Authoritarian/ Permissive
• Responses/Disciplining pattern across family members: Consistent / Inconsistent
• Family Atmosphere: Warm / Tense / Others –describe
• Overall impression of child’s family life and relationship- Healthy / Needs
Interventions
Family notions about child’s problems:
About the nature of illness, cause, treatment expectations and efforts at training
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Personal History:
Prenatal factors - (Nutritional deficiencies, teratogenic exposure, infection (measles), fever,
hypertension, diabetes)
Peri-natal factors: Labour- Normal, Caesarian section, Premature

Birth cry- immediate/ delayed,
Birth weight -
Cyanosis/ jaundice/ seizure/ Need for resuscitation
Post natal factors: High fever, fits, encephalitis
Motor Speech/ Language
Head control (3 months)- Babbling (ba-ba) (8 months)-
Sits Without Support (7 Months)- 2 meaningful words (15 months)-
Independent Walking (15 Month)- Follows 2-step commands (2years) -
Runs well (3 Years)- 2-word phrases (2years)-
3word sentences (3 years)-
Asks question(4 years)-
Social Cognitive
Social smile (3 months)- Scribbles (18 months)-
Recognizes mother (6 months)- Draws a circle (13 years)-
Imitation (ta-ta-1 years)- Writes few alphabets (4 years)-
Points to object on request (18 months)- Identifies few body parts (18 months)-
Identifies few colours(4 years)-
Dress self without help (4 years)-
Fully toilet trained (5 years)-
Current level of functioning: (self-help skills)
- Toilet – yes/ No
- Dressing- Yes/ No
- Eating – Yea/No
- Bathing/ Washing- Yes/No
Milestones: Age appropriate or Delayed, Focal Delay or global delay
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Schooling history:
Age at starting:
Prolonged adjustment difficulty: Yes / No
Change of school: Yes/ No; any difficulty in adapting: Yes/ No
School refusal: Yes/ No Truancy: Yes/ No
Academic performance: Average/ Above average/ Below average
Parental pressure: Present/ Nil Parental impression: Satisfactory/ Not satisfactory
Teachers impression: NK/ Satisfactory/ Not satisfactory
Peer relationship: Good / Adequate/ Minimal
Extracurricular activities: Good / Adequate/ Minimal
Other relevant attributes: High achievement orientation/ Fear of exams or performance/ Poor
motivation for academic activity/ Difficulty with reading, spelling, arithmetic
Negative experiences in school context: Nil/ Bullying/ Punishment/ Abuse / others
Menstrual and Sexual history:
Opportunity for sex education and safety concepts (At home and school): Yes/ No
Tanner’s stage:
Body image concerns:
Menstrual History: Age at Menarche: LMP:
Reaction of child: Positive/ negative/ nil sig Parental attitudes: Normative/ Restrictive
Premenstrual Dysphoric Symptoms: Yes/ No
Alleged H/O abuse if any- Yes/ No
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Temperament History:
Increased Activity level- Yes/ No Reduced Attention span - Yes/ No
Distant, reserved- Yes/ No Social friendly- Yes/ No
Sensitive, easy to cry- Yes/ No Very moody- Yes/ No
Longer time to feel at ease with a new setting/person- Yes/ No
Shy, fearful and anxious of certain places - Yes/ No
Stubborn, Excessive tantrums, Destructive- Yes/ No
Passive, obedient or complacent- Yes/ No
Overall Imp: Easy/ Slow to Warm/ Difficult
Attachment patterns:
Preferred adult to seek comfort when distressed: Mother / Father/ G.mother/ Others
Response to comfort: Good/ Poor Emotional regulation: Good/ Poor
Willingness to go off with strangers: Present/ Absent
Excessive clinging/ vigilance: Present/ Absent
Overall Impression: Secure / Insecure –anxious-resistant/ avoidant/ disorganized
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Physical Examination:
Weight- Height- HC- Vision - Hearing -
Identity Marks:
Minor physical anomalies:
Neurological system Examination:
Mental Status Examination:
General appearance and Behavior:
• Behavioral Problems noted: hyperactivity, impulsivity, tantrums, crying, self-injuries

behaviour, stereotypy, self-absorbed play
• Separation from parents: with ease / difficulty noted / clinging behavior
• Attention span: Joint attention:
• Eye contact:
• Social engagement- initiation and reciprocity: Good/ poor
• Ability to engage in conversation: Good/ poor
• Receptive and Expressive language ability: Good/ poor
• Other relevant observation: e.g., dissociative spell
Mood:
• Subjective:
• Objective: Pleasant/ Cheerful/ Elated/ Irritable/ Depressed/ Anxious/ perplexed
• Reactivity: Present or absent
• Self-regulation of affect: Good/ poor
Thought process:
• Predominant theme
• child’s version of problem
• Suicidal thoughts/ ideas: present/absent
• Intellectual ability: Task given: Copying figures/ Arithmetic/ DAPT/ Others-to attach
• 3 wish test
Perceptual abnormality:
• Illusion/ pseudo-hallucination/ Hallucination/ Any hallucinatory behaviour noted
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Multi axial diagnosis
Axis I- level of intellectual functioning

(mild, moderate, severe, borderline)-
Axis II- Etiology/ syndrome-
Axis III- Associated medical Problem-
Axis IV- Associated Psychiatric problem
Axis V- Family & Psychosocial factors-(poor
awareness, overprotection, over expectation, under
stimulation, family discord, burnout)
Discussion Notes:
Pharmacological intervention:
Psychosocial Intervention- (Parent counselling, home-based training program, sensori-

motor stimulation, speech therapy, special school referral, physiotherapy, vocational training)
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EXAMINATION OF UNCOOPERATIVE PATIENTS
When patients are uncooperative for examination we need to record the observations till
the patients become cooperative, without leaving any gap in clinical observation.
Kirby’s method for examination of uncooperative patient is used in such situations,
usual situations are when the patient is in stupor or in catatonia. The examination is
recorded under the following headings:
General reaction and posture
• Spontaneous acts:
o Any occasional show of activities or assaultiveness.
o Is the patient tidy or untidy?
o Does the patient eat voluntarily or should be fed.
o Does the patient dress himself or require assistance
o Do the actions show initial slowness or consistent slowness throughout?
• Behavior towards the examiners:
o Resistive or evasive, irritable or apathetic or complaint.
• Voluntary postures:
o Comfortable, natural or awkward or constrained.
o What does the patient do when placed in an awkward position?
• Is the behavior constant or changing with time?
Facial movement and expression
• Is the expression being alert, aware, smiling, mask like, placid, sulky, anxious,
perplexed, distressed, tearful
• Is the facial expression constant or changing with time?
Eyes and pupils
• Are the eyes open or closed: Is there resistance to open the patients eyes by
examiner
• Does he give attention to examiner and move his eyes with that of object or light
source
• Does he have fixed gaze or evasive gaze
• Is there blinking of eyes or flickering of eye lids
• Response to sudden movement of hand towards the patient’s eyes
• Response of pupils to painful sensory stimulus and corneal reflex
Reaction to examiners questions and tests
• What is the response to simple commands: asking to show tongue, lift the hands
• Presence of negativism – either active or passive uncooperativeness
• Check for presence of automatic obedience, echolalia and echopraxia
• Are the movements of limbs being slow or fast or interrupted
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Muscular reactions
• Check for tone of muscles: look for rigidity - lead pipe or cog wheel type, waxy
flexibility, gagenhalten, mitgehen and mitmachen
• Is there urinary or fecal incontinence
Emotional responsiveness:
• Emotional Response when family members speak or when personal facts are told
• Response to unexpected stimulus like clapping sound or by switching on lights
Speech:
• Is there any spontaneous speech

• Is the patient mute, if so whether it is consistent present or not
• Is there any effort to speak or make sounds or whisper
Writing:
• Offer the patient a pencil and paper to write his wishes

Vitals:
• Patients Pulse rate, blood pressure, temperature and respirator rate needs to be
measured at regular intervals
Observe for - Spontaneous movements, speech and emotional response
Examine for – degree of Un-cooperativeness of patients like Negativism, gegenhalten,

rigidity, automatic obedience, mitgehen and mitmachen
Record for - Mutism, echo phenomenon, vital parameters including pulse, BP,
temperature and respiratory rate
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Assessment of a Patient with Suicidal Ideation
Assessment of suicidal behavior is an important skill and has to be performed in all patients
with mood and psychotic spectrum disorders. There is an increasing emphasis on the
concept of risk management in suicide prevention which is based on the evaluation of all the
risk factors of suicidal behavior for each patient. Any patient with suicidal risk should be
evaluated in detail. The risk factors for suicidal behavior can be broadly divided as
modifiable / dynamic and static / unmodifiable factors.
Unmodifiable or Static risk factors for suicide include

• Gender (while more male die by suicide, many more females attempt suicide),
• Age (aged 15-24 years and those over 60 years)
• History of previous attempts, personality disorders (antisocial and borderline)
• Poor socio economic status including unemployment and poverty.
Identified dynamic risk factors include

• Presence of depressive symptoms, psychotic symptoms, cognitive decline
• Lack of insight, impaired judgement
• Impulsivity, substance use
• Relationship instability, and experiences of adversity
Presence of higher number of risk factors increases the risk for suicide and the patient
needs to be hospitalized in intensive observation unit. Management should be directed
towards reducing the risk factors with particular emphasis on reducing the modifiable factors.
Specific measures like lithium, antidepressants, Modified Electro Convulsive Therapy,
antipsychotic medications like clozapine should be considered based on the underlying
clinical problem. For the management of acutely suicidal patient sedation using lorazepam or
haloperidol will help to contain the situation along with the specific anti-suicidal measures
should be initiated.
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Interviewing a patient with suicidal behavior:

Interviewing a patient with suicidal ideation is an important skill in to be mastered. CASE
Approach (Chronological Assessment of Suicide Events approach developed by Shawn
Christopher Shea), the interviewer explores the suicidal feelings, ideation, plans, intent, and
actions of the client over four contiguous time regions, hence its name.
First, the clinician begins by sensitively and carefully exploring the patient’s presenting
suicidal ideation/actions if present, a period of time that generally includes the last 48 hours
but can go back a week or two as deemed necessary Presenting Suicide Events. Second,
the clinician explores the patient’s suicidal ideation/actions during the previous two months
Recent Suicide Events. After completing this exploration, Past Suicide Events consisting of
the past suicide attempts is explored. Finally, the clinician explores Immediate Suicide
Events consisting of suicidal feelings, ideation, and intent that arise during the interview itself
and the patient’s views on possible future suicidal thoughts and what to do if they arise.
During the interview there are two types of behavioral incidents: (1) fact-finding behavioral
incidents and (2) sequencing behavioral incidents. By using a series of behavioral incidents
based questions sequentially, the interviewer can create an interviewing strategy that can
sometimes help a patient to enhance validity by eliciting, step by step, the unfolding of a
potentially sensitive topic such as a suicide attempt.
Interviewing by the above method may help in uncovering the suicidal behavior and risk
management comprehensively
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FORMULATION
What is formulation?
Formula – Forma (latin) meaning shape. It is the organisation of information to reach

a probable diagnosis and management. Formulation is used in various fields used to
describe the, summarisation of various information in appropriate relationships according to
a particular hypothesis or theoretical understanding and analysis integration of information.
Clinical Formulation (case formulation) is a theoretically based explanation or

conceptualisation of the information obtained from a clinical assessment.
• It offers a hypothesis about the cause and nature of the presenting problems
• It used to provide framework for developing a suitable treatment approach In clinical
practice formulations are used to communicate a hypothesis
• Can be considered as an alternative to the current categorical approach of
psychiatric diagnosis
Why should we formulate?
• It helps to organize the available information by arranging and prioritize the

presenting problems.
• Consider all the possible factors involved while applying the current concepts in
psychiatry, which helps in planning for appropriate assessment and treatment
Types of formulation:
Formulation in psychiatry can be broadly divided in to both diagnostic and therapeutic.

Diagnostic/ Etiological formulation are the commonly used on principles
• Biological formulation
• Clinical case formulation
Therapeutic formulation are based on different schools of thoughts considered appropriate
based on the clinical situation and therapists expertise
• Psychodynamic formulation
• Cognitive behavioral formulation
• Eclectic formulation
• Cultural formulation
While formulating, the aetiological hypotheses supported by research evidence should be
used. Formulating plans based on speculation should be avoided.
Diagnostic formulation
The diagnostic formulation is most broadly a structured understanding of the patient's

problems, usually including statements about diagnosis & differential diagnosis, which is
usually based on current concepts and classificatory systems (ICD 10 and DSM 5). It should
also mention about the risk assessment, which is dangerousness to self or others, if present
should be the primary focus of intervention. Finally disability should be separately mentioned
as well as it is a target of longer term interventions.
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Biopsychosocial Formulation
Currently followed formulation is based on the biopsychosocial model, which considered all
the important contribution from biological, psychological and sociocultural factors. This
model is comprehensive and eclectic in nature. The psychiatric condition is understood as
outcome of interaction of between the three components, which includes
• Biological factors Ex- heritability or genetic, brain damage

• Psychological Factors Ex – personality traits, childhood experiences
• Sociocultural factors Ex – Family environment, cultural influence, economy
How to formulate:
While formulating the following format can be followed
• Sociodemographic details
• Relevant premorbid, personal, family and past history
• Presenting complaints and duration
• Important negative history (optional)
• General Physical Examination and Mental Status Examination - positive findings
• Diagnoses and differential diagnosis
• Assessments
• Management – immediate and long-term
• Prognosis
Tips:
• Organization of the information available from history and examination

• Discusses about diagnosis, etiology, investigation and treatment methods based on
the current concepts
• Prioritization of the problems
• Focuses on all the factors responsible implicated in causation
• It is concise, clear and uses technical terms, useful for professional communication
22

TEMPLATE FOR THE CLINICAL DISCUSSION OR DISCUSSION BASED ON ANY CLINICAL PROBLEM
Approach to a case
1. For any symptom

a. Check for psychiatry or neuropsychiatry or general medicine related
symptoms
b. Check for substance use or organic cause
c. Check for presence of psychosis or neurotic disorders
d. Check for presence of affective or non affective psychosis
e. Check for depressive or anxiety or stress related disorders when neurotic
symptoms
2. Check for relevant negative history to confirm or refute the diagnosis

3. Check for presence of past history and any comorbid medical condition
4. Check for significant family history focusing on genetic loading, social support and
expressed emotions
5. Check for birth injury or significant developmental issues, reproductive/ marital
history
6. Check for presence of any abnormal premorbid personality
7. General physical examination should include BMI and relevant systemic examination
8. Mental status examination and cognitive function tests with insight and judgement
Always try to keep a differential diagnosis
1. Keep point for first diagnosis and then against the same (in your mind for
discussion)
2. Differential diagnosis indicates your openness in case management
3. Initial steps of management will always be in evaluating the diagnosis – in terms
of history, examination and investigations
Management
1. Do not forget assessment or don’t jump to treatment – first step is to collect more
information on the diagnosis and differential diagnosis
2. Include medical assessments and psychosocial assessment – at least to interview for
family dynamics, compliance issues, social support
3. Include scales if you are routinely using them in clinical practice – MMSE/HMSE,
Bush Francis scale, YBOCS, HDRS, PANSS, Kirby’s proforma for uncooperative
patients,
Pharmacological management
1. Be clear about choosing medication, dose and duration. As always be flexible in

using medications, based on response & tolerability with patients
2. Explain all the common and major side effects of medications & investigations for the
same
Non pharmacological or psychosocial management
1. Always start with psychoeducation – first with patient & then with family – symptoms,
diagnosis, drugs, duration of use of drugs and prognosis
2. Activity schedule for the patient, subsequently vocational rehabilitation
23

3. Psychoeducation will include – problem solving skills in the patients & communication
skills
4. Family therapy for all patients – again focusing improving social skills & address
expressed emotions
5. Specific areas of interventions will be based on the diagnosis
a. Compliance enhancement, social skills therapy, cognitive retraining in
patients with schizophrenia
b. Vocational rehabilitation along with cognitive retraining if services are
available
c. IPSRT for bipolar disorder
d. IPT for depressive disorders and adjustment disorders
e. CBT for depressive, anxiety disorders
f. ADS – motivation enhancement, relapse prevention strategies
g. Relaxation therapy for anxiety disorders
h. OCD – BT or CBT – exposure and response prevention
i. Children – parent management training, BT, CBT, skills training
Prognosis made simple
• List the good prognostic and bad prognostic issues in the patient
• Based on the list, if more poor prognostic factors are there, then guarded prognosis
• In 50/50 then need to long term medications.
24

Disorders of thought
Assessment of thought is an integral part of the mental status examination. Assessment of

thought is important in almost all psychiatric condition. Considering that humans express
their thoughts through speech, the assessment of thought relies on language. The line of
divide between thought and speech abnormalities is thin and may be artificial. However, it is
important to avoid misdiagnosing neurological condition resulting in speech abnormality as
thought disorder. Assessment of thought requires a skilled interview and a good rapport with
the subject. During MSE thought is described under the headings of form, stream,
possession and content.
Form of thought
Form of thought is the structure and organization of thinking. It is assessed during the
interview process and by recording verbatim the patient’s speech sample. Various definitions
of normal thinking and disorders of thinking have been described. Different definitions are
given at the end of this chapter. Important clinical considerations before judging the form of
thought includes
• Language of patient- the examiner should be aware of the primary language that the
patient speaks and the examiner is having proficiency in that language or has a
translator who speaks the same dialect and language of the patient
• Intelligence – patients intellectual level has significant impact on his thinking process,
hence patient’s intelligence should be evaluated during history and examination
• Comprehension – Patient’s comprehension of the questions or tasks should be
evaluated, as patients with sensory aphasia presents with irrelevant speech
• Attention – Attention towards the questions asked and continuity in thinking is
essential for maintaining the flow in the thought. In patients with delirium or mania
due to distractibility, irrelevant speech can be present.
Speech Sample from the patient verbatim is essential for evaluation of form and stream
of thought. Speech sample is essential when there is incoherent or irrelevant speech
during the interview.
• Topics given for collecting the speech sample should be neutral to the
psychopathology and should be able to elicit abstract concepts. Start with an
abstract topic. If the patient is not able to give an abstract speech sample then give
descriptive topic and if patient cannot give even this then give a concrete topic
• Examples include –
o Descriptive – festivals (describe Holi, Diwali, Pongal etc.); describe your
favorite sport (cricket, football etc.)
o Abstract - current politics, population of our country etc.
o Concrete steps – how do you prepare coffee –tell me the steps
• In the thought sample, we need to look at the goal directedness, semantics and the
syntax.
• Presence of perseveration of ideas and absence of abstract concepts related to the
topic needs to be considered.
To diagnose a formal thought disorder look at the conceptual or abstract aspect of speech
sample. Observe the syntax and grammar and look within sentence. If individual sentences
25

appear correct but the paragraph does not then the abnormality may not be in the form of
thought but in the stream of thought (refer next section). Formal thought disorder (FTD) is of
two types; positive – (A) when patient produces false concepts by blending together
incongruous elements (B) Negative -Patient has lost his previous ability to think.
If there is impairment in the structure of thinking in the form of loss of goal directedness due
to any of the following causes like derailment or tangentiality, presence of neologisms,
incoherence, poverty of content, absence of abstract meaning can be judge as presence
formal thought disorder (refer to definitions section at the end of the chapter). It is sufficient if
an impression of formal thought disorder present or absent is made. Further sub-
classification of type of formal thought disorder is optional.
Examples for common formal thought disorder:
Ø Derailment -one thought slides into another

• I am going to Bangalore. Ramesh is very smart
Ø Omission -senseless omission of a thought or part of it
• This person Mr.……. told me that …sleep
Ø Fusion –heterogeneous elements of thought are interwoven together
• I am going to very smart
Ø Drivelling-disordered intermixture of constituent parts of one complex thought
• He shot a bullet. Tiger jumped on him. He went to forest. He shocked.
Ø Substitution -major thought is substituted by a subsidiary one
• Q –which festival will you celebrate? A -We will celebrate….. at my sister’s place
Stream of thought
Stream of thinking is related to the flow of thought process which is the determining
tendency of thinking. This is significantly influenced by the emotional state of the individual.
In patients with mania or hypomania, there is increase in the flow of thinking which results in
excessive thinking.
Flight of ideas - When the flow is significantly increased like in mania, there is loss of
direction in thinking resulting in irrelevant and incoherent speech. It is usually associated
with pressure of speech and distractibility. There can be chance association between the
thoughts and is usually related to internal and external cues.
Prolixity: When there is increase speech, but the individual reaches goal, then it is called as
prolixity, which is usually seen in hypomania. In prolixity the person has increase speech
output associated with lively embellishment and is able to reach the goal.
Circumstantiality: here the thinking proceeds slowly with many unnecessary trivial details
with tedious elaboration but finally the point or goal is reached.
Retardation of thinking: here the train of thought is slow down and the number of ideas and
images which present themselves are decreased.
• It is seen in usually seen in patients with retarded depression.
26

• In these patients, there is minimal responses to questions and it is associated with

psychomotor retardation.
Thought block is the sudden arrest of train of thought, leaving a blank and the some patients
may become acutely aware of the same. It is usually seen in patients with schizophrenia.
Perseveration is the persistence of the mental operations beyond the point of relevance and
thus prevent progressive thinking. It can be of three types – compulsive, inability to switch
and ideational perseveration. It can be either verbal or ideational. It is usually seen in organic
disorders of brain like dementia – frontotemporal dementia and in chronic schizophrenia.
Possession
Normally the subject experiences his thinking as being his own although this sense of
personal possession is never in the foreground of his consciousness. There is also a feeling
of control over his thinking. It can be affected when there is loss of sense of control over this
thinking. The disorders of possession of thought includes thought alienation and obsessions.
3.1 Thought alienation phenomenon is present when the individual feels that he has lost
control over his thinking and an outside agency is trying to control or participating in his
thinking.
• Thought broadcast. In thought broadcast, the patient knows that as he is thinking

everyone else is thinking in unison with him. Patient reports that others are getting to
know what he is thinking simultaneously or in unison with him.
• Sometimes patient experiences that his thoughts are escaping silently and after they
escape they may be available to other people – this feeling of thoughts getting
diffused from mind is referred to as thought diffusion.
• Sometimes, patient hears his own thoughts being spoken aloud and as a
consequence other people are able to hear his thoughts as well. Though few authors
consider this as thought broadcast, traditionally it is classified as Thought echo.
• Thought insertion is said to occur when the patient thinks that thoughts are being
inserted in to his mind against his will and he recognizes it to be foreign and coming
from without.
• Thought deprivation/thought withdrawal - patient finds that as he is thinking his
thought suddenly disappear and he is acutely aware of the same.
3.2 Obsession:
An obsession occurs when someone cannot get rid of a content of consciousness, although
when it occurs he realizes that it is senseless or at least that it is dominating and persisting
without cause
Characteristics of obsessions:
• Recognized as their own thoughts

• Content is acknowledged as absurd or irrational and there is an attempt to resist
them, but at time obsessions may lack insight
• Typically, repetitive, intrusive and leads to significant anxiety and distress.
Forms of obsessions
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• Ideas
• Impulses
• Images
Dimensions of obsessions based on the content:
• Contamination
• Doubts
• Aggressive
• Sexual - blasphemous
• Symmetry
• Hoarding
Assessment of possession of thought:
As the patient may not report the abnormalities of possession of thought spontaneously or
the informant may not have access to this information, one need to actively elicit
abnormalities of possession of thought. Begin with open ended questions and follow up with
leading and closed ended questions. If there are abnormalities of possession, then one need
to clarify whether it is thought alienation or obsessions. Some typical differences between
them are
Obsession Thought insertion

Thoughts recognized as their own Thoughts recognized as someone else’s
Repetitive Non repetitive
Recognized as meaningless Not recognized absurd. Patient believes in
them
Partial control No control
Associated with anxiety about inability to Associated with persecutory beliefs and
control fear
Few example questions that one may ask to elicit thought possession are:
1. Few people have strange experience about their thoughts. Do you also have any
strange experiences?
2. Some people have a strange experience that their thoughts are known to others even
if they don’t tell. Did you have similar or related experiences
3. Some individuals have a feeling that someone else is meddling with their thinking. Do
you have similar or related experience?
4. Sometimes people say that someone else is controlling their thoughts/ put some
unwanted thoughts/ take their thoughts. Do you have similar or related experience?
5. Sometimes people get unwanted thoughts, often personally distressing. These
thoughts may come again and again and may not stop even when you want to stop
them. Did you have any such experience? Tell me more about them
6. Many people get unwanted sexual thoughts or images. At times these thoughts or
images may be towards your loved ones about whom you don’t have sexual feelings.
28

It may also be about god. It is due to an illness. If you have experienced similar
thoughts or images let me know. We can discuss
Content
Evaluation of content of thought is necessary to understand the patients concerns and ideas.
Disorders of content relate to the ‘what’, as opposed to the ‘how’, of thinking – to the ideas
and beliefs one holds. It is also appropriate to record here any abnormal ideas and beliefs
the prototypical abnormality being delusions, others include overvalued ideas, obsession
and compulsions, depressive ideas about future, self and environment, ideas of reference.
All patients attending a psychiatrist should be evaluated for suicidality.
Delusions: It can be defined as false, unshakable beliefs, out of keeping with the individual's
educational, social and cultural background, which are held with conviction and are arising
out of morbid thinking (illogical or unreasonable thinking).
While describing any delusions, initially patients report of his belief should be recorded
verbatim, followed by making a judgement on the below aspects of the delusion.
• Falsely held with high degree of conviction

• Beliefs are not amenable for logical reasoning
• Belief is not held by the family and not considered normal by the society where
patient belongs
• Primary or secondary delusion. Secondary delusions are usually secondary to other
morbid phenomenon like disturbed mood state or perceptual abnormalities or
personality disorders
• Content of belief may be of persecutory, referential, jealousy, love, grandiose, ill
health, guilt, nihilistic delusion or delusions of poverty
• Single or multiple beliefs. If there are multiple beliefs then are they logically built or
connected, which is called systematization
• Bizarre delusions - Beliefs which are implausible and completely impossible
• Elaboration of the belief with acting out behavior and disturbed affect
• Whether the beliefs are congruent to the underlying mood state or not
Primary vs secondary delusions:

Delusions are classified as primary and secondary. A delusion not occurring in response to
another psychopathological form such as mood disorder is primary delusion. These typically
occur as first abnormal phenomenon and are not secondary to other psychopathology. As
they occur denovo/ autochthonous in otherwise healthy individual they are called primary
delusions. It could be one of the following three.
• Sudden delusional idea- occurs as a single stage. Delusion appears fully formed in
the mind.
• Delusional atmosphere (Delusional mood) –Patient knows that something funny is
going on around him which concerns him but he cannot tell what it is. When a
delusional perception or sudden delusional idea arises it becomes obvious and he
accepts that with a feeling of relief
• Delusional perception:
29

o Attribution of a new meaning usually in the sense of self reference to a

normally perceived object (Fish).
o It is self-referent, momentous, urgent, overwhelming personal significance
and of course false (sims)
o A hallmark of delusional perception is two-memberedness. In this
phenomenon, an object is normally perceived by the individual (1st member).
This normal perception is given a special significance and is given a special
meaning and delusional explanation (2nd member). At times, instead of a
perception the 1st member could be a memory.
o Example: Mr X left home to attend an interview. His family did not notice any
abnormality when he left home. When he reached near the bus stop he saw
the traffic signal turning to “RED” (1st member). By seeing this Mr X got the
belief that CIA is trying to kill him and his family (2nd member). He was very
afraid to stay in that place and ran back to his home
o Delusional perception need to be differentiated from Delusional
misinterpretation. While the former is a primary delusion and occurs denovo.
However, if a new meaning is given to a normal percept in the background of
an existing psychopathology, for example, other delusion or mood then this
misinterpretation is secondary delusional explanation and should not be
considered primary delusion/delusional perception. Classical example – Mr X
is suffering from psychosis and has delusion of persecution. When he went to
meet a friend, he heard some people mentioning the name of the school
where he studied. He interpreted that these individuals are looking for him
and want to kill him. He ran back to his home and did not meet his friend.
Primary delusions are to be distinguished from ‘secondary’ delusions, where the abnormal
belief seems to be based on, grow understandably out of or represent an elaboration of
some other element of psychopathology – as in depressed patients who develop beliefs that
they have sinned greatly, lost everything, died already, etc. – though this term is less often
used nowadays. Where a delusion seems obviously secondary to another psychotic
symptom – e.g. a patient with auditory hallucinations who believes he or she has a radio
transmitter in their head – the term delusional explanation or secondary delusion is
preferred.
Types of delusion based on the content:
• Persecution
• Reference
• Guilt
• Grandiose
• Jealousy
• Love/erotomaniac
• Hypochondriacal
• Nihilistic
• Poverty
• Delusion of control
30

• Delusional mis-identification
o Capgras’ Syndrome – inability to identify a familiar individual and claiming that
they are replica but not the same individual. This is a hypo-identification
syndrome. ex: A close family member is replaced by a stranger who is an
exact double
o Delusion of Fregoli - false identification of familiar people in strangers. This is
a hyper identification syndrome
o Delusion of Subjective Doubles - Another person been physically transformed
into own self.
Tip: Delusions of reference must be distinguished from simple ideas of reference, which are
an exaggerated form of self-consciousness, usually driven by social anxiety, comprising an
uncomfortable feeling taking notice of them. Almost everyone has experienced this symptom
at some time (e.g. on entering a room and noticing that conversation seems to stop) though
insight into the lack of reality is retained. Simple ideas of reference can, however, become
pervasive and socially incapacitating in some conditions, such as anxiety and depressive
states.
Delusions description in MSE:
1. False- firm-fixed belief of morbid origin, not culturally shared
2. Content - type
3. Single/multiple
4. Elaborated
5. Systematized
6. Primary/secondary
7. Mood congruity
8. Acting out
9. Affect associated with
10. Special types
Overvalued ideas are beliefs which, because of the excess of emotional tone invested in
them, come to dominate to an abnormal degree. They do not have obsessional
characteristics (i.e. they are not recognized as absurd or resisted) but rather are qualitatively
akin to ‘preoccupations’ that any of us can, from time to time, develop. Examples include
querulous paranoid states, morbid jealousy and hypochondriasis. Another example of an
overvalued idea, which also illustrates Jasper's argument that not all fixed, incorrigible
beliefs are delusions, is the core belief of anorexia nervosa.
Suicidal ideas: Mental status assessment is incomplete without evaluating the suicidality in
all patients with mental illness. While assessing suicidal ideas and behavior, it is necessary
to be sensitive and ask appropriate questions to elicit risk of suicidality. Presence of thoughts
of helplessness, worthlessness and hopelessness (Beck’s triad – depressive cognition) may
be the beginning of suicidal behavior. Look for
31

Death wishes – Individual has the wish to die. Wants a passive death. Ex: It will be better if
I sleep tonight and don’t get up at all tomorrow morning
Suicidal ideas – Individual has an active wish to die however have not decided the means.
Ex: Doctor, now a days I just feel that it is better for me to kill myself than undergoing this
suffering
Suicidal plan – Individual has an active wish to die and also has formulated the means to
achieve the same. Ex: I just don’t want to be on this earth anymore. I will drink pesticide in
my room tonight and kill myself
Related concepts:
• Retrospective delusion - Pre-dating the delusion. Here the individual claims that he
always had this belief (delusion) while there is sufficient evidence that the individual
did not have such belief during the said period. For example, Mr X was working as a
software engineer and lived with his wife and kids in Bangalore. For the past 2
months, he is not going to work and claims that his team leader is planning to kill him.
He says that he knew this for the past two years but he never told anybody. His
family members deny this and inform that his team leader is a close friend of Mr X
and they had attended multiple parties and movies together in the last three years as
recent as three months back. They inform that he has been having the suspicion only
for past two months
• Retrospective falsification - Recollects previous true incidents in lieu with current
mood state. Ex: Ms. Y, patient with recurrent depressive disorder current episode
moderate depression claims that she has always been a failure and has not achieved
anything in life. She recollects that she had scored only 65% in one internal exams
and she was barely able to answer three of the five questions asked to her in her
viva. She is a renowned gynecologist in the city and the family claims her to be a
genius.
• Delusional Memory – Here the memory is false (delusional) and the person claims
an event that never happened. Ex: Mr Ram, 25-year-old male, is working as a sales
representative in a mobile phone store from rural Karnataka. He claims that he is the
son of Mr Bill Clinton, president of United States of America and he vividly
remembers playing swing in the gardens of white house. He also says that he
remembers going to school in a helicopter along with his mother.
Definitions:
Form of thought:
• Akataphasia: Disorder of expression of thought in speech. Patients may express

themselves with words that sound like the ones intended but are not appropriate to
the thoughts, or they may use totally inappropriate expressions. (A speech thought
mismatch)
• Overinclusion - inability to maintain boundaries of the problem and to restrict their
operations within their correct limits.
• Asyndenesis= Lack of adequate conexions between successive thoughts
• Metonyms= Imprecise approximations in which a substitute term is used instead of a
more exact one
32

• Derailment= one thought slides into another. A pattern of spontaneous speech, in

which the ideas slip off the track onto another one.
• Substitution= major thought is substituted by a subsidiary one
• Omission= senseless omission of a thought or part of it
• Fusion= heterogeneous elements of thought are interwoven together
• Drivelling= disordered intermixture of constituent parts of one complex thought
• Transitory thinking=here the intention itself is interrupted. Grammatical and
syntactical structures are both disturbed. Includes derailment, omission, substitution
• Driveling thinking= loses preliminary organization of thought so that all the
constituent parts get muddled together.
• Desultory thinking= Speech is grammatically and syntactically correct but sudden
ideas force their way in from time to time.
• Poverty of speech – Restriction in the amount of spontaneous speech
• Poverty of content (negative FTD, alogia, verbigeration) – Although speech is
adequate in amount, it conveys little information
• Tangentiality – Replying to a question in an oblique, tangential or even irrelevant
manner. It refers only to questions and not to transitions in spontaneous speech.
• Clanging – Pattern of speech in which sound rather than meaningful relationship
appears to govern word choice
• Neologisms – Completely new word or phrase whose derivation cannot be
understood
• Word approximations (Paraphasia) – Old words that are used in a new or
unconventional way or new words that are developed by conventional rules of word
formation.
• Circumstantiality – Pattern of speech is indirect and delayed in reaching its goal idea.
Thinking proceeds slowly with many unnecessary and trivial details, but finally the
point is reached.
• Ruminations: Prolonged inconclusive chain of thoughts. Three types:
o Depressive: About past negative events
o Obsessive : About neutral events, repetitive, pseudo-philosophical thoughts
o Anxious : About future. The patient is concerned about the remote possibility
of an event happening in future
• Delusions:
o Stoddart- a judgement which cannot be accepted by people of the same
class, education, race and period of life as the person who experiences it
o Jaspers- 3 components namely
§ they are held with unusual conviction
§ not amenable to logic
§ absurdity or erroneous of their content is manifest to other people
o Hamilton - A false unshakeable belief which arises from internal morbid
processes. It is easily recognizable when it is not keeping with the person’s
educational and cultural background.
• Kendler’s vectors of delusion
o conviction
o extension
o bizarreness
o disorganization
33

o pressure
o affective symptoms
o deviant behaviour (acting upon)
• Stages in delusion formation and definitions of individual stages. Five stages as

proposed by Conrad
1. Trema- Delusional mood representing a total change in the perception of the world
2. Apophany- Search for and finding of new meaning to psychological events
3. Anastrophy- Heightening of the psychosis
4. Consolidation/Apocalypse- Formation of new world based on new meanings
5. Residuum- eventual autistic state
• Resolution of delusions
o Disintegration – The delusion fragments. The delusional elaboration,
preoccupation and acting out on delusion decreases. Then the delusional
conviction decreases and the delusion is shakeable. Finally, the individual
accepts that the belief was not true or no longer holds the belief
o Double book keeping- the delusion is in the foreground of thinking. However
there is no acting out behavior. Ex: Mrs X claims that she is the queen of
Mysore kingdom while she is sweeping the corridor of the hospital
o Encapsulation – the delusion is not in the foreground of thinking. However, on
probing or given a cue the delusion comes to the foreground
34

DISORDERS OF EMOTION
Emotion is one of the important components of mental status examination and

probably one of the more challenging aspects of MSE to elicit and interpret. Skill of eliciting
affect and mood states can be important in differentiating between primary psychotic versus
mood disorders and even organic from functional conditions.
Definitions: Important terms to know
Feeling: It is a positive or negative reaction to some experience or event and is the

subjective experience of emotion.
Emotion: Emotion is a stirred-up state caused by physiological changes occurring as a

response to some event and which tends to maintain or abolish the causative event.
Mood: It is a pervasive and sustained emotion that colors the person’s perception of the
world. Description includes intensity, duration, fluctuation and qualitative description.
Affect: It is a short-lived emotion and is assessed by observation of body language and facial
expressions.
It is important to understand the concepts of Mood and affect. Mood is subjective

experience of individual and longitudinal while affect is an objective assessment and cross
sectional. Simple analogy used is that of season and weather. Mood is like the season which
is the predominant climate over a few months and affect is like the weather which pertains to
conditions on that particular day. For eg. It is summer season but today it is cloudy. Similarly,
mood may be sad over the last one week but cross-sectionally affect may be cheerful.
Assessing mood in mental status examination:
Components of assessment: Mood in MSE can be assessed under the following sub
headings:
• Mood and affect

• Range
• Reactivity
• Mobility/lability
• Communicability
• Appropriateness
• Congruency
35

Mood and affect:
Assessment:
Question to ask: How has been your mood for most periods of the day over the last one
week? – record verbatim the response of the patient.
You can ask leading question if you don’t get a satisfactory response- have you been mostly
happy, sad, anxious or fearful?
Observe the facial expressions and body language of the patient during the course of the
interview to assess the affect
Clinical descriptions:
Mood: Record the verbatim the response of the patient
Affect: observe for following facial features
Depressed – downturned angles of mouth, dropping shoulders and posture,

retardation, omega sign, verraguth fold, tearing of eyes, furrowing of forehead
Euphoric/cheerful – facial emotion of happiness, being jovial, smiling/laughing
Elation – euphoria with increased psychomotor activity (distractible, picking cues

from environment)
Exaltation – Elation with grandiosity
Ecstasy – extreme sense of happiness. Person may be catatonic. ‘nirvana’
Irritable – narrowing of palpebral fissures, clenching of teeth, associated increase in

gestures, rising tone of voice
Anxious – restless fidgeting, worried, furrowing of forehead
Fearful – widened eyes, hyper vigilant, constantly looking back over her shoulder
Perplexed – look of bewilderment or puzzled expression confusion without

disorientation. Commonly seen in evolving schizophrenia/ acute psychotic states
Blunt/Flat – lack of emotional expressions. Commonly seen in chronic schizophrenia.
36

Range and reactivity:
Reactivity refers to the whether the individual is able to demonstrate changes in her
emotional expression in response to the topic of discussion in the interview. For eg. When
talking about stressors experienced an individual should demonstrate corresponding
changes in affect (depressed, anxious or irritability)
Range refers to the whether the individual demonstrates emotional changes from both ends
of the spectrum (sadness and happiness) during the clinical interview.
Assessment:
Questions to ask: Can you recall when was the last time you felt really happy? Can you
describe what you were happy about? Can you tell us something about your hobbies and
interests? – observe for subtle changes in expressions and tonal inflections in speech while
describing happy events. This will tell you regarding reactivity.
Similarly ask - can you recall when was the last time you felt sad or annoyed? Can you
describe what were you sad or annoyed about? – again observe for subtle changes in affect.
Ability to describe and express both shades of happiness and sadness gives you information
about range and reactivity.
Sometimes when interviewing patients with mood disorders the patients may not open up to
their emotions and the affect may not be forthcoming during the interview. The patient may
deny mood symptoms. In such instances asking to describe experiences/ stressors /
personal interests such as movies etc can help release the initial inhibition and trigger their
psychopathology. This is a useful clinical tip when faced with such patients.
Clinical descriptions:
Terms used – reactivity preserved or absent, range intact or restricted
Mood disorders: Usually the mood is reactive and affect restricted to happiness or sadness
in mania and depression respectively. Sudden and rapid shifts of mood from one pole to
another (crying to laughing) may be observed. This rapidly changing affect is called lability.
Chronic Schizophrenia: Usually the affect is blunt, not reactive and it is difficult to elicit any
changes is emotional expression despite stimulus during interview
37

One can understand this concept of range reactivity using the example of a pendulum. A
stationary pendulum when given a slight tap or ‘stimulus’ will swing on both sides to equal
heights.
Now if you replace the pendulum ball with a ball bearing, when same tap is given it will swing
to greater heights with increased velocity and rapidly swing from one side to another. This is
analogous to lability in mania where rapid shifts of mood with extreme severity may occur
with minimal stimulus.
Now if you replace the pendulum ball with a shot putt ball and if the same tap is given, it may
move very little or not move at all. A large amount of stimulus would be required to get the
ball to move. This is analogous to blunt affect of schizophrenia where the individual may not
show any changes in emotional reactions despite an emotional stimulus.
Presence of an affect that is incongruent to thought process is most likely to support a

diagnosis of psychotic disorder rather than a mood disorder.
Communicability:
Do the emotions displayed by the patient also trigger similar emotion within yourself (for eg a
euphoric mania during interview will also trigger smiles and laughs from the interviewer!)?
This is a clinically important aspect of assessment of emotions (see clinical importance).
Appropriateness and congruency:
Assessment: Observe and judge whether the emotional states displayed by the patient are
appropriate to the situation and whether they are congruent (go along with) the individuals
thought content.
Clinical description: terms used – appropriate/inappropriate to the situation and congruent to

thought content/ incongruent to thought content.
For eg. A patient who is manic is very cheerful and laughing during the interview. She may
share a joke or sing a song making the whole atmosphere very lively. She may express
grandiose delusions of possessing superhuman powers. Here the affect is appropriate to the
situation and understandable in the context and relevance of the joke shared during the
interview. The affect is also congruent to the thought content of grandiose delusion.
Another patient with schizophrenia may report delusions of persecution and control but
displays a predominantly a flat affect. She intermittently smiles and mutters to self out of
context, without stimulus and without maintaining eye contact. You would expect such an
38

individual with thought content of delusions of persecution to be fearful and appear

distressed. Hence here the affect displayed is inappropriate to the situation and incongruent
to the thought content.
Clinical interpretation:
Assessment of mood and affect can give important clues to diagnosis.
• Preserved reactivity and range in patient reporting syndromal depressive symptoms

could point towards reactive depression, smiling depression. Stressor could be
playing a primary role in etiology of depression. In such patients though the patients
may be smiling, the eyes still communicate sadness.
• Lability/increased mobility in an individual with predominant depressed affect and
depressive features may point to possible mixed affective state and underlying
bipolarity
• Absence of blunt affect in chronic schizophrenia may be indicative of better prognosis
or may indicate for a review of the diagnosis itself!
• Absence of communicability of affect in an individual who otherwise appears
euphoric and grandiose commonly is suggestive of organic etiology (tertiary syphilis,
AIDS mania, personality changes as part of fronto-temporal dementia etc)
• Emotional incontinence or pathological crying and laughter is again an organic state
where patient complains of sudden outbursts of crying or laughter though she
subjectively does not experience that emotion. The affect is also not communicable.
Typically called as pseudo bulbar affect. Commonly seen with pseudo bulbar palsy,
fronto temporal dementia, vascular dementia.
39

DISORDERS OF PERCEPTION
Definitions:
Perception: Perceiving is not merely receiving a sensation. Perception is defined as a

sensation plus a meaning attributed to the sensation. For eg: Hearing a tick tock sound is a
sensation. Hearing the tick tock sound and knowing that it is coming from a clock which is
hung on the wall opposite me is perception.
Disorders of perception:
• Sensory distortion: Change in spatial form of perception or change in intensity or

quality of the stimulus.
• Sensory deception:
§ Illusion: Misinterpretation of stimuli arising from external object
§ Hallucination: A false perception which is not a sensory distortion or
deception and occurs in the same time as real perception (Jasper).
Clinical assessment:
When doing clinical MSE if patient has perceptual disturbances, we need to differentiate
between 3 possible phenomena – Hallucinations, Pseudo hallucinations, Imagery
What questions to ask?
§ In the last week have there been times where you have had any unusual or strange
experiences?
§ For eg. when you were awake and alone and nobody was around you were you able
to hear voices of people talking to you or any unusual sounds?
§ Can you describe to me about these voices or sounds? (whose voices are they?
familiar/unfamiliar people? male or female? Number of voices? What do they say –
friendly/threatening/voices discussing/commentary/commanding? How frequently do
they occur? Do other people also hear these voices?
§ Are these voices as clear as my voice when I am talking to you?
§ Where do these voices come from? Can you pinpoint its location?
§ Can you control these voices and make them stop when u don’t want them?
§ Are these voices real or could they be your imagination?
§ How do these voices make you feel? Do they upset you or cause distress?
§ How do you react to these voices? Is there anything you do to reduce them?
40

§ Have you had any other similar experiences for eg: Do you see things which other
people around you are not able to see or do you get any unusual smells which other
people do not or do you feel any strange sensations?
Answers to these questions will help differentiate the three major perceptual disturbances
Hallucination Pseudo Imagery

hallucination
Consciousness Awake Awake/going into or Awake
coming out of sleep
Clarity Clear and vivid Clear or muffled Not vivid
Control Cannot be controlled Partial control Voluntary control to
large extent
Source of Perceives them to be Attribution is Perceives it to be
perception clearly arising out of variable. Many not clearly a product of
the persons mind. be able to clearly one’s own mind
May attribute it to an distinguish.
external source or
body parts such as
internal organs
Insight Absent Variable – some may Full insight present
not have insight or
some may have full
insight
Typical examples:
Hallucination: A 30-year-old female reports she is able to hear voices of 3 people when she
is alone almost throughout the day. These voices are unknown people, 2 males 1 female
who speak in hushed tones but are clear, voices come from behind the cupboard in her
room but when she looks there she can’t find anyone. These voices talk among themselves
about her and are plotting how to kill her. She believes these voices are true, not her
imagination and cannot control them and is very distressed by them. She reacts to them by
talking back to them and scolding them
41

Pseudo hallucination: The same female patient after 1 year of antipsychotic treatment
reports the intensity and duration of voices has reduced. The female voice has been
silenced but 2 male voices are heard intermittently, but they are not plotting that often. She is
able to talk back to them and silence them and they sometimes listen to her. She still
perceives the voices to be coming from behind the cupboard but says that she is not sure…
since she has looked so many times and cannot find them maybe they could be her
imagination.
Imagery: After 2 years of antipsychotic treatment she now says that since last 3 months she
is able to see pictures of god coming one after the other in front of her eyes like a movie reel.
She is able to distract herself and temporarily stop them by closing her eyes or shaking her
head but they come back. These are nude images of gods and doesn’t want them to come.
She is particularly distressed because she knows that they are coming from her own mind
and are not like the voices she used to hear earlier which were real.
Clinical interpretations:
• Presence of specific types of hallucinations such as running commentary, third

person auditory hallucinations, thought echo are First rank symptoms with diagnostic
significance
• Presence of visual hallucinations should sensitize the clinician to the possible
presence of organicity
• Olfactory hallucinations could be part of aura or ictal phenomenon in complex partial
seizures
• Hallucinations can occur in individuals with sensory deprivation. This phenomenon is
called Charles Bonnet syndrome. Elderly people with paraphrenia and multimodal
hallucinations should be evaluated for sensory impairment (cataract, hearing loss)
• Presence of command hallucinations should sensitize clinician to possible risk of
harm to self or others. The hallucination may command individual to attempt suicide
or attack perceived persecutor.
• Sometimes it may become difficult to differentiate between a hallucination and
delusion. Commonly this is in the case of gustatory hallucination (person may say
family members are persecuting him because he can taste or smell poison in his
food). This is can also occur in case of delusion of reference (person may say people
are talking about him and he knows this because he can hear people talking about
him).
42

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STEP 2018

National Conference for

TIPPS CLINICAL NOTES

Supported by educational grant from

Psychiatric history taking and mental status examination

Socio demographic details:

Informant: (Record who is the informant – name and relationship to patient)

ü Reliability of information (Is the information consistent, corroborative, and

Precipitating factor: (Record significant events – biological or psychosocial which may be

History of presenting illness:

Elaborate the presenting complaints in a descriptive manner to elicit all information

Thumb rules to follow:

ü Elaborate each presenting complaints for onset, duration, progression,

ü Describe associated stressors

Treatment history: (Details of past treatment – Drug given. Duration of treatment,

Family history: Record following information

ü Antenatal history and birth complications

In young adults/adolescents temperamental history needs to be taken.

Interviewing patients in Psychiatry:

1. To be able to establish a rapport

Few things to remember are:

ü History taking is a Clinical interview, the focus of which is to obtain adequate

General appearance and behavior: Give a good observational description.

ü General appearance and grooming

ü Increase in goal directed activity/retardation

ü Tone (loudness) of speech – normal/increased/decreased

Possession: Disorders of thought related to the ownership of thought

ü Thought broadcast – thought diffusion/thinking in unison /audible thoughts

And give your impression whether the perceptual abnormality is a hallucination/pseudo

Other phenomenon: Describe phenomenon such as somatic passivity/ depersonalization/

ü Awareness: That experiences are out of the ordinary/not real or normal/deviant

ü Attribution: To psychological/somatic causation for the experiences

Also grade insight from 1-6.

ü Complete denial of illness

Cognitive function assessment:

Abstraction: Describe whether the responses are abstract/semi abstract/ concrete

Intelligence: Make an estimate of overall intelligence level based on comprehension,

Specific lobe function test:

Note: While presenting; cognitive functions should be reported prior to ‘thought’ as

Proforma For Detailed Work-Up- Child and Adolescent Psychiatry

Age (DOB): Reliability:

Educational status: Address/Phone number:

Date of work-up: Source of referrals:

Chief Complaints: Duration Onset: Acute/

Course of illness: Continuous / Episodic

Precipitating Factors: No/ Yes – specify

History of Presenting Illness:

Medications used: Yes/No, Describe if yes

Family History: Three generation family tree for genetic vulnerability

Parental background: (Age, Education, Occupation, Health status)

Peri-natal factors: Labour- Normal, Caesarian section, Premature

Milestones: Age appropriate or Delayed, Focal Delay or global delay

Menstrual and Sexual history:

Response to comfort: Good/ Poor Emotional regulation: Good/ Poor

Willingness to go off with strangers: Present/ Absent

Excessive clinging/ vigilance: Present/ Absent

Overall Impression: Secure / Insecure –anxious-resistant/ avoidant/ disorganized

Minor physical anomalies:

Neurological system Examination:

Mental Status Examination:

General appearance and Behavior:

• Behavioral Problems noted: hyperactivity, impulsivity, tantrums, crying, self-injuries

• Illusion/ pseudo-hallucination/ Hallucination/ Any hallucinatory behaviour noted