MCD Notes Part-I

History taking by Dr. Mukesh C. Daderwal:

Points to remember before taking history: (Do’s and Don’ts)

1. The psychiatrist must be both neutral and sympathetic. He/she must keep an open
mind and guard himself/herself against preconceived ideas.
2. Psychiatrist may become inflated with ideas of his own superiority or subordinating
himself/herself to the patient and allow himself/herself to be influenced by patient’s
desire against the clinical judgment.
3. To start the treatment at least we should reach to the provisional diagnosis within 1 st
week of the admission.
4. No man is able to describe or appraise his/her own personality in an adequate way.
5. Information from an independent observer is most significant because we can’t
expect fully impartial information from the relative or friend of the patient (they are to
some extent motivated by sympathies and antipathies).
6. Two methods can be followed for the interview:
a. Free interview:
We let the patient speak freely on different unrelated themes which
may provide hints and indication about the patient rather than solid
facts. So, important themes may forget or left untouched.

b. Questionnaire interview:
History taking in a structured format or predetermined set of questions
which can be uncomfortable for the patient. Obtained information may
consist mass details without relief to the patient and difficult to
organize into a coherent picture.
7. Best way to interview the patient is to have the framework of the questionnaire in the
mind and allow the patient to tell his own story.
8. History should be taken longitudinal and cross sectional of patient’s life. It should be
with longitudinal through patients’ biography and then we should look at the cross-
sectional state of the patient which gives us the comprehensive view.
9. When patient talks about his life, he or she gives us the opportunity to see how he/she
speaks, thinks, judges, feels, how he/she reacted to events in the past, how he deals
with the objective world and people around him and what are his/her ideas on moral,
religious, political and sexual questions.
10. It is important to write down the actual worlds the patient uses to describe his/her
most important symptoms.
11. Formulation of the history is much more difficult and test all the power, judgement
and wealth of experience of psychiatrist.
12. Well-kept case records are basis of all progress in the clinical medicine and are
indispensable for research.
13. Long training is needed to learn how to overcome the patient’s resistance and to be
aware of where his/her tale is biased, where information has been withheld and where
it has been colored by an emotional attitude.
14. It is useless to record that patient is feeling of passivity, thought alienation etc. unless
his actual experience is also recorded in simple everyday language, preferable the
word he has used himself/herself.
15. Throughout the record, language should be as precise and simple as possible.
16. Length is often unavoidable, great experience is required to write a short history
which is also complete.
17. Taking the history and description of the mental state should follow the general
scheme (I added in the notes which we follow at NIMHANS).
a. Do not bound too rigidly to it.
b. The scheme properly demands that negative as well as positive findings
should be recorded.
18. It is better for the beginner to be too circumstantial than too selective.
19. Keep the separate source of information distinct, what is said about the patient by
himself/herself, by the partner and by the relatives or friends. You can synthesize all
the information into a single structure in the final formulation.
20. Patient or the relative is usually full of events of his recent life and wants to discuss
his/her latest problems. He/she will give more reliable information about the remote
past when relieved of this pressure.
21. When patient is describing the psychotic experiences, it is important to pick up all the
threads leading backwards into the historical development and to follow them later
on.
General scheme for history taking:

1. Socio-demographic profile:
 Name:
 Age:
 Sex:
 Education:
 Occupation:
 Marital status:
 Socio-economic status:
 Religion:
 Address:
2. Source of referral
3. Type of admission
 Supported
 Independent
4. Informant:
 Mention the source of information, relationship with the patient, intimacy and
length of acquaintance.
 Assess reliability through 5 ‘C’
o Corroborative information (Similar information from different sources)
o Consistency (Similar information over different time interval from same
source)
o Continuity (How frequently informant in meeting or seeing the patient)
o Closeness (How close is the informant to the patient)
o Contact
 Comment on the adequacy of the information means whether the information is
adequate to make the diagnosis or not.

5. Chief complaints (CC):

 Record the complains in chronological order
  Don’t write long list of complains
 Write only salient disturbances in different areas of functioning
 Better to concise the chief complains into 3-4 in number only

6. History of presenting illness (HOPI):

 Comment on the onset of illness (Onset: starting of symptoms to peak of illness)
o Abrupt (within 48 hours)
o Acute (within 2 weeks)
o Subacute (within 2 weeks to 2 months)
o Insidious (more than 2 months)
 Comment on the course of the illness
o Episodic (must have inter-episodic recovery for at least 2 months)
o Continuous
o Fluctuating
 Comment on progress of the illness
o Improving
o Deteriorating
o static
 Mention the predisposing, precipitating and perpetuating factors
Predisposing factor Precipitating factor Perpetuating factor
(Factors which increases the (Events shortly before the onset (Factors which maintain the illness)
vulnerability for the illness) which leads to disease)

Biological: Biological: Biological:

 Delayed  Fever  Chronic medical
milestones  Accident illness
 Head injury  Onset of severe  Substance use
 Family history medical illness
Psychological: Psychological: Psychological:
 Impaired  Stress intolerance  Poor insight
premorbid  Poor impulse  Poor impulse
personality control control
 Poor intelligence
Social: Social: Social:
  Home atmosphere  Trauma  Social isolation
in childhood  Loss of job or  Unemployment
 Neglect partner  High expressed
 Abuse emotion
 Low education
level

 Patient was apparently alright …………. days/years back (mostly used line before
starting HOPI). It is important to describe a typical day of the patient, so we can
correlate with functional deterioration due to the illness.
 Never use technical word.
 Describe the symptoms analysis by using ABC model (Antecedent, Behavior and
Consequences)
 HOPI should be in flow of ABCDF
o A: Affect
o B: Biological functions (Bowel, bladder, sleep, appetite and libido)
o C: Complaints in behavior
o D: activity of Daily living (ADL) and personal hygiene
o F: role Functioning (studies, occupation or job, social roles)
(Note: symptoms description must be in chronological order as per CC)
 HOPI should also contain a life chart (Template is given below)
 Negative history:
o To rule out organic causes, so inquire about h/o trauma, fever, headache,
vomiting, confusion, disorientation, memory issues, h/o physical illness like
HTN, DM and history of substance use disorder
o Rule out close differential diagnosis
o Never forget to enquire about suicidal tendencies

7. Treatment history:
 It is better to make a chart as following (with example)

Drug Dose duration Compliance Response ADR

Tab 4mg 2 months + 75% EPS+
 Risperidone

 Also mention if any nonpharmacological treatment was done including details

of name of therapy, number of session and response with the same
8. Past history:
 Past medical history: mention the medical illness including drugs and their
effect, controlled or uncontrolled
 Past psychiatric history:
o Previous episodes
o Symptoms
o Duration
o Probable diagnosis
o Treatment details (hospitalization, inter-episodic functions, deficits)
9. Family history:
 3 generation pedigree charts with mentioning age (as template given below)
 Write details about parents and siblings
o Age or age at death including cause
o Occupation and short details about personality
o Quality of relation with the parents
o Psychiatric or medical illness
o Substance use disorder
 Consanguity
 Head of the family
 Enquire about any h/o suicide in family
10. Personal history:
A. Birth and development:
o Antenatal (illness, medication, drugs, alcohol, X-ray, bleeding)
o Planned/unplanned
o Failed abortion
o Full term/term/post term
o Injury at birth, birth weight, normal/delayed cry
o Developmental milestones (given below)
B. Presence of childhood disorder:
o ADHD
o Conduct disorder (disobedience, lying, truancy, cruelty towards
animals, bossy attitude towards younger, do not obey rules while
playing)
o Temper tantrum (extent and intensity should be noted)
o Neurotic traits (nail biting, thumb sucking, food fadedness,
stammering, mannerisms, bed wetting, phobia, night terror, sleep
walking)
o Social relation
 C. Physical illness during childhood
o Epilepsy
o Meningitis
o Encephalitis etc.
D. School:
o Age of entry and finish of school
o Type of school,
o School performance
o Attitude towards peers and teachers
o Discontinuity, change in school
o Games and extra-curricular activities
E. Occupation:
o Age of starting in chronological order
o Work satisfaction
o Future ambitious
F. Menstrual history:
o Age of menarche
o Menstrual: LMP, regular or irregular
G. Sexual history:
o Age of onset of puberty
o Level of knowledge about sex
o Mode of gaining the sex knowledge
o Masturbatory practices
H. Marital history: not only sexual side but also look into the patient’s solution of
the familial and interpersonal problems of married life.
o Age of marriage, arrange or love, mutual consent yes/no
o Personality, education, occupation of the partner
o Separation or divorce
I. Substance:
J. Dietary habit:

11. Pre-morbid personality: (SIM CARE FH);

Most difficult to assess but one of great importance, description should include time
frame before the onset of illness.
A. S: social relation: with the family (attachment, dependence), friends,
societies, groups or clubs and with coworkers (leader or follower, organizer,
aggressive, submissive, ambitious, adjustable, independent).
B. Intellectual activities: hobbies and interests (books, plays, observation,
judgement and critical faculty.
C. Mood: bright or despondent, worrying or placid, strung or calm and relaxed,
optimistic or pessimistic, self-depreciative or satisfied, mood stable or
unstable with or without occasion.
D. Character:
1. Attitude to work and responsibilities: welcomes or is worries
with responsibilities, makes decision easily or with difficulty,
haphazard or methodological and meticulous, rigid or flexible,
cautious, fore-sightful or impulsive and slipshod, preserving
and determined or easily bored discouraged.
2. Interpersonal relationship: self-confident or shy and timid,
insensitive or touchy and sensitive to criticism, trusting or
suspicious and jealous, emotionally controlled or quick
tempered and irritable, tactful or outspoken, enjoys or shuns
self-display, tolerant or intolerant.
E. Energy and initiative: energetic or sluggish, fatiguability, regular or irregular
fluctuation in the energy and output
F. Fantasy life: frequency and content of day dreaming.
G. Habits: eating, alcohol consumption, self-medication with drugs, tobacco
consumption, sleeping, excretory function.
General Physical Examination (GPE):

Physical examination proforma:

BP: …………. mmhg P: ………. /Min Temp: ………f RR: ……… /Min
Pallor: Y/N Icterus: Y/N Cyanosis: Y/N, Clubbing: Y/N,
koilonychia: Y/N, Lymphadenopathy: Y/N, Edema: Y/N
Respiratory system: Sound:
CVS: Heart sound: S1………….. S2…………, murmur:…………….
Per Abdomen: Soft/Hard/Tender
Bowel sounds:
CNS: Orientation: Time…… Place………. Person
Cranial nerves: I/II/III/IV/V/VI/VII/VIII/IX/X/XI/XII
Reflex:
 Superficial reflex:
 Deep reflex:
Gait:
 Romberg’s test:
Cerebellar sign:
 Nystagmus/ scanning speech/ hypotonia
 Intention tremor/ impaired heel shin test
 Dysdiadochokinesia/ rebound phenomenon
 Pendular knee jerk/ impaired tandem walk
 Finger nose test
Motor system:
 Muscle tone:
 Power:
 Tremors:
Sensory system: Touch/ Pain/ Temperature/ Vibration
Meningeal sign:
 Neck rigidity:
 Kernig’s sign:
 Brudzinski’s neck sing:

Mental status examination (MSE):

1. General appearance and behavior:

 1. Conscious and oriented to surroundings
2. Kempt and describe how and with whom patient entered
3. Overtly made up (Mania, hypomania & histrionic and narcissistic PD)
4. Sikly, attentive and distractable
5. Perplexed (confused and not able to take decision)
6. Body built
7. Eye contact with examiner
8. Dress (appropriate or not)
9. Attitude towards examiner
 Cooperative
 Attentive
 Defensive
 Frank
 Hostile
 Seductive
 Guarded
 Evasive (escape from arguments or shifts topics)
10. Rapport
 Easily established
 Difficult to established
 Not possible to established
11. Tics, mannerism or any catatonic sign noted

2. Psycho-motor activity (PMA): Just observe the patient’s speech and motor
activity
 Increase /decrease/ normal

3. Speech:
 Spontaneous: Yes/No
 Tone (loudness of the voice): high/low
 Tempo (speed of the speech): increase or decrease
 Volume (amount of speech): increase or decrease
 Reaction time: increase or decrease
 Relevant (relevant to the questions): Yes/No
 Coherent (logical, consistent and understandable)
 Prosody (melodic intonation and emotional valence of speech)

4. Thought: (taking a speech sample is must on neutral topics like school,

weather etc.)
 Form (Organization and expression of thought: formal thought
disorder): Yes/No,
o Describe the type of FTD as per Nancy C. Andreasen(1)
 Stream (Flow and continuity of thought):
 Possession (thought which are not in control of individual):
o Obsessive and compulsive phenomenon
o Thought alienation
o Made phenomenon
  Content: delusions, over-valued ideas, depressive cognition, worries,
suicidal thought or death wishes.

5. Mood: pervasive and sustained emotion which colors the perception

 Affect (short-lived emotion or cross-sectional mood)
o Objective: observation of the interviewer
o Subjective: patient’s explanation
 Quality of mood:
o Dysphoric: Sadness, anxiety and irritability
o Anxious:
o Depressed:
o Irritable:
o Elevated: exaggerated feeling of wellbeing without keeping life
situation
o Euphoria: increase sense of wellbeing with cheerful thought
and no response of depressive influences
o Elated: feeling of wellbeing with poor judgment, pressure of
speech, increase PMA, flight of ideas, disinhibition
o Exaltation: feeling of intense elation and grandeur
o Ecstasy: intense sense of rapture or blissfulness
 Present in delirium and stuporous mania
 Can present normally in profound religious experience
and following child birth
 Intensity of affect: (How intense is the emotion cross sectionally)
o Shallow: not deep
o Blunt: greatly diminished
o Flat: absent
 Mobility of affect: (How easily an individual shift from 1 emotion to
another)
o Constricted: decrease shift
o Fixed: no shift
o Labile: rapid shift
 Range: (variety of emotional expression)
o Full
o Restricted
 Reactivity: extent to which affect change in response to
environmental stimuli
o Reactive or non-reactive
 Appropriate: to the situation
o Appropriate or inappropriate
 Congruent: to thought process
o Congruent or not
 Diurnal variation
o Yes or no

6. Perception:
  Illusion
 Hallucination:
o Inquiry should be made about all modalities, sense of
presence, functional hallucinations, reflex hallucinations,
extra-campine, synesthesia and autoscopy).
o Distinguish hallucinations from imagery and pseudo-
hallucinations.
o Inquire about hallucination wether continuous or intermittent,
single or multiple voice, familiar or unfamiliar, 1 st person, 2nd
person or 3rd person, pleasant or unpleasant, commanding,
abusive or threatening and relationship to the hallucinations;
wether mood congruent or incongruent.
o Other perceptual disturbance must enquire including
heightened perception, dulled perception, depersonalization
and derealization.

Higher Mental Functions (HMF):

1.