AETIOLOGY OF MENTAL

HEALTH DISORDERS
3.1 AETIOLOGY OF METAL HEALTH
DISORDERS
• The causes of mental disorders are very complex and vary depending
on the particular disorder and the individual. Although the causes of
most mental disorders are not fully understood, researchers have
identified a variety of biological, psychological and social factors that
contribute to the development or progression of mental disorders.
• Most mental disorders result in a combination of several different
factors rather than just a single factor.
• There are several theories that seek to explain the causes or etiology
of mental disorders. These theories may differ in regards to how they
explain the cause of the disorder, how to treat the disorder, and how
 they classify mental disorders.
• One of the most commonly accepted approach towards mental
health is the suggestion that a range of different, interrelated factors
contribute towards the onset of mental health conditions.
• The theory that introduces this concept is known as the
Biopsychosocial model. It integrates biological, psychological and
social factors.
• The Biopsychosocial model was first conceptualized by George Engel
in 1977. Suggesting that to understand a persons medical condition it
involves the three factors that is biological, psychological and social
 factors. The Biopsychosocial approach systematically considers
biological, psychological and social factors and their complex
interactions in understanding health, illness and health care delivery.
The factors within the model contain the following:
• Biological (physiological pathology)
• Psychological ( thoughts, emotions and behaviors such as
psychological distress, fear/avoidance beliefs, current coping methods
and attribution )
• Social (socio-economical, social-environmental, and cultural factors
such as work issues, family circumstances and benefits/economics)
CAUSES OF MENTAL DISORDERS
• THE BIOPSYCHOSOCIAL MODEL OF ETIOLOGY OF MENTAL
DISORDERS
• BIOLOGICAL FACTORS
• Genetics factors
• Neurochemical factors and Neuroendocrine factors
• Neurophysiological factors and Neuropathological factor
• PSYCHOLOGICAL FACTORS (separation or loss of parents,
psychological distress, pathological patterns of relationship etc)
• SOCIAL FACTORS (negative psychosocial circumstances or events e.g
• Stressful life events (financial loss or loss a job, divorce, health
conditions, death of a loved one, stress due to social change etc.
• BIOLOGICAL FACTORS
• GENETIC FACTORS
• For most psychiatric disorders the mode of inheritance is polygenic, that
is a combination of multiple genes
• The degree of genetic contribution to disorder differs in relation to
different psychiatric disorders, for example the role of genetic aspect in
schizophrenia is higher than their role in relation to anxiety.
• In most instances genetic factors may lead to manifest of psychiatric
 disorders unless they interact with unfavorable environmental
developmental factors.
• These factors may be biological (intrauterine, perinatal or later in life),
psychosocial (developmental traumatic experiences and stressors)
• Neurochemical and Neuroendocrine factors
• Most psychiatric disorders are associated with dysregulation in
different brain neurotransmitter systems. For example
• Schizophrenia is associated with identical dysfunction in dopamine,
serotonin, and possibly other neurotransmitter systems.
• On other hand, some psychiatric disorders may be associated with
certain neuroendocrine dysfunction, for example depressive
disorders are usually associated with Hypothalamo-pituitary-adrenal
axis activity.
• Neurophysiological and Neuropathological Factors
• Recent advances in neuroimaging for example ( CT, MRI and PET ) and
other brain investigative techniques have structural (anatomical)
changes associated with psychiatric disorders.
• Certain Neurophysiological ( that is functional) changes such as
changes in cerebral blood flow, brain electrical and neuronal circuit
 activity may characterize different psychiatric disorders.
• PSYCHOLOGICAL FACTORS
• Vulnerability to psychiatric disorder is strongly related to negative or
adverse psychological influences. They include
• Traumatic psychological experiences such as separation or loss of
parents, physical or sexual abuse, and parental indifference or
neglect.
• Pathological patterns of relationships with significant people
particularly the parents.
• Defective development of personality or self due to defective
satisfaction of essential psychological needs by caregivers.
• SOCIAL FACTORS: Negative of psychosocial circumstances contribute
to predisposition to or precipitation of psychiatric disorders.
• Stressful life events, for example death of a loved people, financial
loss or loss of job, divorce, serious health problems, etc.
• Stresses of social melieu, for example stress related to social class,
culture or social change in society, etc.
• The nature of the society (industrial vs agricultural, rural vs urban
BIOPSYCHOSCIAL MODEL
3.1.2 PREDISPOSING FACTORS
• These are factors which operates from early life and determine the
persons or individuals vulnerability or susceptibility to the disorder or
mental illness. They include
• BIOLOGICAL FACTORS
• Genetics, Physical factors such as :infections, brain defects, prenatal
damage, substance abuse, environmental factors, and biochemical
factors.
• Genetics (heredity): many mental illnesses run in families, suggesting
that people who have a family member with mental illness are more
likely to develop a mental illness. Susceptibility is passed on in families.
 through genes. Experts believe many mental illnesses are linked to
abnormalities in many genes. Susceptibility to mental illness and does
not necessarily develop mental illness.
• Susceptibility to it. Chromosomal increase or decrease may affect the
development of fetus. An extra chromosome may cause mongolism or
down syndrome. Faulty genes also lead to mental retardation.
• INFECTIONS
• Certain infections have been linked to brain damage and development
of mental illness or worsening of its symptoms. For example, a
condition known as pediatric autoimmune neuropsychiatric disorder
(panda) associated with the streptococcus bacteria has been linked to
the development of obsessive-compulsive disorder and other mental
illnesses in children. Others includes HIV/AIDS, Neuro-syphilis, neuro-
cystercosis, meningitis, cerebral malaria
 PHYSICAL FACTORS
• BRAIN DEFECTS or INJURY
• Defects in or injury to certain areas of the brain have also been linked
to some mental illnesses. This may be accompanied by personality
changes and/or schizophrenia-like symptoms. It is generally agreed
that the risk of suicide is substantially increased among head injury
patients, although the reason for this is not clear.
• Encephalitis :due a number of infections , symptoms may include
depression and personality disorders.
• Cerebral abscess: an infection of the brain which can be associated
with symptoms of depression.
• Cerebral vascular (stroke) accident: depressive symptoms are
common after this type of injury.
• Cerebral tumors: this may cause changes in personality.
• Subarachnoid hemorrhage: this is a bleed in the brain. A high
incident of mental disorder has been reported after subarachnoid
hemorrhage. Organic psychiatric problems and adverse personality
changes are common, as well as significant depressive symptoms.
• Hyperthyroidism: occasionally a psychosis can be triggered if there is
too much thyroid hormone
• Hypothyroidism: lack of thyroid hormones will produce mental
effects which can mean psychiatrists may be easily led to a mistaken
diagnosis of dementia/depressive disorder
• Addison’s disease: also known as hypo-adrenalism. Addison’s may be
misdiagnosed as dementia. Occasionally a depressive symptoms are
most frequent psychiatric manifestations. Of cushing’s syndrome,
paranoid symptoms are less common and appear mainly in patients
with severe physical illness.
• Corticosteroid treatment :psychiatric symptoms can be brought on by
corticosteroid treatment, and are similar to cushing’s syndrome.
• Hypopituitarism: patients with hypopituitarism have some
psychological symptoms, whilst half are likely to have severe
symptoms .e.g in depression.
• Hyperparathyroidism: psychological symptoms are common and
among the most frequent is depression.
• Hypoparathyroidism: usually due to removal of or damage to the
parathyroid grands at thyroidectomy. Complications can include
psychiatric conditions e.g depression, bipolar.
• Insulinomas: clinical features may resemble those of psychiatric
syndrome.
• Liver disease: psychiatric features of liver failure such as
hallucinations, are sometimes known as hepatic encephalopathy.
• Vitamin B deficiency: depression is often seen and sometimes a
paranoid hallucinatory state.
• Epilepsy :epileptic patients can sometimes have an abnormal
personality, and it may be unclear if this is an expression of a
personality disorder.
.

• TUBERCULOSIS MENINGITIS: a rare infection of the brain which can

present as a change in personality
• PRENATAL DAMAGE
• Harm or injury to the fetus brain in the mother’s womb can
contribute to development mental illness. Example the use of drugs,
alcohol, stress, birth asphyxia and infections during pregnancy can
predispose a person to develop mental illness in future. Some
individual evidence suggests that a disruption of early fetal
development or trauma that occurs at the time of birth, for example.
 loss of oxygen to the brain ( neonatal asphyxia), may be a factor in the
development of certain conditions, such as autism.
• SUBSTANCE ABUSE
• Long term substance abuse such as amphetamines, alcohol, particular,
has been linked to anxiety, depression, and paranoia.
• OTHER FACTORS
• EXPOSURE TO TOXINS, such as lead, alcohol, barbiturates, may play a
role in the damage of brain tissue.
• ENVIRONMENTAL FACTORS: includes difficulties or stressors that a
person
• deal with on daily basis. These are psychologically based, but tend to
be pervasive a persons life and cause mental illness to a person who is
susceptible to mental illness. These stressors include
• Death or divorce
• A dysfunctional family life
• Living in poverty
• Feelings of inadequacy, low self esteem, anxiety, anger, or loneliness.
• Changing jobs or schools
• Social cultural expectations (for example, a society that associates
 beauty with thinness can be a factor in the development of eating
disorders.) substance abuse by the person or persons parents.
• PSYCHOLOGICAL FACTORS
• Severe trauma suffered as a child, such as emotional, physical or
sexual abuse.
• Poor ability to relate to others
• MATERNAL DEPRIVATION: separation of mother from the child is
bound to affect his growth. The separation can be due to death of
mother or loss of both parents.
• PATHOGENIC FAMILY PATTERN: faulty parental child relationship also
affect behavior of child. rejection by parents can cause a feeling of anxiety,
insecurity, low self esteem and negativism. Over protection or domination
of a child by his parents may cause submissiveness. Lack of discipline in
children may result in aggressiveness and antisocial behavior.
• Children’s interpersonal relationship is disrupted like marital harmony or
broken homes go through a lot of stress. Stress-it is a major cause of
mental illness.
• PHYSICAL HANDICAP: like blindness, deafness and lameness affect the self
concept of an individual, as these are stressful situations for adjustment.
• A person may socialize very less and may develop feelings of
inferiority, self pity and sometimes hostility attitude also.
• PHYSICAL DEPRIVATION: malnutrition and sleep deprivation) severe
malnutrition affects the physical and mental growth of infant.
• They are most prone to any type of infection, mental retardation and
mental depression.
• Disruptive Emotional Factors: it also causes many of the mental
disorders like psychosomatic disorders, for example peptic ulcers,
hypertension, and coronary heart disease.
• SOCIO-CULTURAL FACTORS
• Human being is a social animal. He lives in a community following the
norms, traditions and culture of society. Following are some factors
which affect the development of abnormal behavior.
• War and violence: it leaves impact on the mental health of people.
• Group prejudice: such as religious intolerance and hostility may
affect
 affect the mental health of people when it is enforced by one group on
the other groups.
• ECONOMIC AND EMPLOYMENT PROBLEM
• It is another contributing factor to mental health. Sometime
economic problem leads to suicide and even homicide. On other hand
the energetic and educated young people feel frustrated due to
unemployment and rejection by parents.
PRECIPITATING FACTORS.
• These are events that occur shortly before the onset of a disorder and
appear to have induced it.
• Biological factors
• They may be physical trauma. For example trauma, infection,
intoxication, etc
• Psychological factors ( conflicts, frustrations, deprivation or
bereavement, sexual trauma,)
• Social factors ( they require a predisposed individual to exert their
effect. They do not influence the pattern of the illness or its intensity.
• Bullying, demands at school or work.
• Dysfunctional home environment, domestic violence at homes,
natural disasters, car accidents, social cultural expectations.
CLINICAL FEATURES OF MENTAL
HEALTH DISORDERS
• Depressive disorders
• The common feature of all depressive disorders is the presence of
depressed mood (sad, empty, irritable mood), they feel loss of
pleasure or interest in activities, accompanied by physical symptoms
and cognitive changes that significantly affect a persons capacity to
function.
• A depressive episode last most of the day, nearly everyday, for at least
two weeks. Other symptoms are present, which may include
• Poor concentration
• Feelings of excessive guilty or low self worth
• Hopelessness about the future
• Thoughts about dying or suicide
• Disrupted sleep
• Changes in appetite or weight
• Feeling very tired or low in energy.
• Anxiety disorders
• This group of illnesses is characterized by significant feelings of
anxiety or fear, accompanied by physical symptoms such as shortness
of breath, rapid heartbeat, and dizziness.
• Symptoms includes stress that’s out of proportion to the event,
inability to set aside a worry and restlessness. Other features includes
• Fatigue
• Restlessness
• sweating
• COGNITIVE
• Lack of concentration
• Racing thoughts
• BEHAVIORAL
• Hypervigilance
• Irritability
• Others includes :
• excessive worry
• Insomnia
• Nausea
• Palpitations
• Trembling
• BIPOLAR AND RELATED DISORDERS
• Formerly known as manic depression, bipolar disorders are
characterized by alternating episodes of mania, hypomania, and
major depression.
• It includes symptoms such as :
• High or increased energy
• Reduced need for sleep
• Loss of touch with reality
• Depressive episode may includes symptoms such as
• Low energy
• Low motivation
• Loss of interest in daily activities
• Mood episodes last for months at a time and may also be associated
 with suicidal thoughts.
• Other features the following
• Mood: mood swings, sadness, elevated mood, anger, apathy,
apprehension, euphoria, general discontent, guilty, hopelessness, loss
of interest, or pleasure in activities
• Behavioral: irritability, risk taking behaviors, disorganized behavior,
aggression, agitation, crying excess desire for sex (hyper-libido),
hyperactivity, impulsivity, or self harm.
• Cognitive: unwanted thoughts, delusion, lack, lack of concetration,
• Racing thoughts, slowness, in activity, or false belief of superiority
( grandiosity)
• Psychological: depression, manic episode, paranoia
• Sleep: difficulty falling asleep or excess sleeping.
• Fatigue, or restlessness, weight gain, or loss, pressure of speech.
• SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS
• These disorders are defined by abnormalities in one or more of the
following:
• delusions
• Disorganized thinking
• Disorganized or abnormal motor behavior
• Hallucinations
• Negative symptoms
• It is characterized by thoughts or experiences that seem out of touch
with reality, disorganized speech or behavior and decreased
participation in daily activities.
• Features includes the following
• Behavioral: social isolation, disorganized, behavior, aggression,
• Compulsive behavior, excitability, hostility, repetitive movements, self
harm, or lack of restraint
• Cognitive: thought disorder, delusion, amnesia, belief that an ordinary
event has special and personal meaning, belief that thoughts are not
one’s own, disorientation, mental confusion, slowness in activity, or
false belief of superiority. (grandiosity)
• Mood: anger, anxiety, apathy, feeling detached from self, general
discontent, loss of interest or pleasure in activities, elevated mood, or
inappropriate emotional response.
• Psychological: hallucinations, paranoia, hearing voices, depression,
• Fear, persecutory delusion, or religious delusion.
• Speech : circumstantial speech, incoherent speech, rapid frenzied
speaking, or speech disorder.
• Fatigue, impaired motor coordination, memory impairment, or
restricted affect.
• NEUROCOGNITIVE DISORDERS (dementia)
• These disorders are characterized by decrease in a persons previous
level of cognitive function.
• Changes in mood and behavior sometimes happen even before
memory problems occur.
• Symptoms get worse over time. Eventually, most people with
dementia will need others to help with daily activities.
• Early signs and symptoms are:
• Forgetting things or recent events
• Losing or misplacing things
• Getting lost when walking or driving
• Being confused, even in familiar places
• Losing track
• Difficulties solving problems or making decisions
• Problems following conversation or trouble finding words
• Difficulties performing familiar tasks
• Misjudging distances to objects visually
• Common changes in mood and behavior include:
• Feeling anxious, sad or angry about memory loss
• Personality changes
• Inappropriate behavior
• Withdrawal from work or social activities
• Being less interested in other peoples emotions.
• OBSESSIVE-COMPULSIVE RELATED DISORDERS
• These disorders are characterized by the presence of obsessions and
or compulsions.
• Features includes the following:
• Behavioral: compulsive behavior, agitation, compulsive hoarding,
hypervigilance, impulsivity, meaningless repetition of own words,
repetitive movements, ritualistic behavior, social isolation, or
 repetition of words or actions
• Mood: anxiety, apprehension, guilty, or panic attack.
• Psychological: depression, fear, or repeatedly going over thoughts.
DIAGNOSTIC INTERVIEWS AND
FORMULATION
• COMMUNICATION SKILLS
• These are abilities you use when giving and receiving different kinds
of information. They involve listening, speaking, observing and
empathizing.
• Introduce yourself, shake hands, that is if appropriate and tell the
patient clearly who you are, who has referred the patient to you, the
purpose of the interview and how long it is likely to take.
• Obviously physical contact should be avoided with a patient who
seems very fearful or likely to strike out.
• Sensitivity to a patient’s body language helps to judge the most
appropriate way in which to greet him.
• It is worth asking if he was even expecting to be seen and how he
feels about this, reassuring him that you are a doctor.
• Always inform the patients that the conversation is confidential, but
that information would be shared with other healthcare professionals
as appropriate, for example a letter to the referring GP or to the
physician or surgeon who has made a referral.
• Where patients object to information sharing, be clear that some
note keeping and communication is essential, but details of very
• Sensitive issues can be avoided in letters. However patients have to
know that information cannot be withheld from others if it is likely to
place them or others at risk.
• Note taking whether written or typed can be brief but should be
outline of the key features, while not intrusive to flow of the
interview.
• It is important to write some of the patient’s verbatim to illustrate his
state of mind, and this can provide evidence of the presence of
certain symptoms with respect to MSE and what aspects to focus on.
• Patients should always be offered an interpreter as they may feel
more able and willing to discuss feelings in their own language.
• Conducting an interview through the interpreter has its own pitfalls
when issues of confidentiality come into play. That is some
interpreters may impose their own views and advice and the
interviewer should be alert of this.
• As with any patient, aim for an open, empathic and nonjudgmental
approach and try to maintain non threatening eye contact.
• Avoid open questions, avoid loaded questions, encourage patients to
tell their story in their own words and follow the approaches for
• DIMENSIONS OF THE ASSESSMENT INTERVIEW
• There are important factors which will tend to be different in different
settings, for example, out patients, the emergency department, the
medical or psychiatric ward, the home or even the street.
• Patients factors
• Is the patient aware of the referral? Is he expecting to see a
psychiatrist? What does he think of seen a psychiatrist?
• The assessment may be of a patient following
• An overdose or who has been brought in by police under the Mental
• Health Act section.
• A patient may have presented with what has been assumed to be a
medical problem, and all too often psychiatric referral may not even
have been discussed with the patient before hand.
• The approach to the interview in these situations will be very different
compared to that of a patient voluntarily attending a psychiatric out-
patient clinic, having sought specific help.
• It will require a careful skillful engagement of the patient in the
assessment. How successful this will be will determine the extent of
the history taking that is possible.
• FACTORS IN THE PHYSICAL ENVIRONMENT
• Psychiatric assessment requires a suitable interview room, in terms of
safety, privacy, and confidentiality.
• Quiet surroundings, in which a patient can be listened to and engaged
with, are essential although not always possible.
• SAFETY
• The doctor should sit nearest the door and neither the patient nor
any obstacles should block the doctors ability to exit. There should be
alarm buzzer and someone available to respond to the alarm.
• In the emergency department where patients have been brought to
the hospital in a disturbed state, other safety measures may also be
needed, for example checking for weapons and having a security
presence or a chaperone.
• PRIVACY
• The patient should be interviewed in a quiet private space where he is
not likely to be overheard by other patients and staff.
• Clearly there is a balance to be struck, and the need for police or
security presence near by may sometimes outweigh the privacy and
confidentiality requirement.
• However, such situations are exceptional since most psychiatric
consultations can be conducted privately and confidentially, although
many people like to have a family member or friend with them as
support, and this should be encouraged.
• DEMOGRAPHIC DATA
• Involves identifying data: such as Age, gender, occupation, marital
status, education background, religion.
• Source of history: usually the patient, but can be a family member or
friend, a referral, or the medical record.
• If appropriate, establish source of referral because a written report
may be needed.
• Reliability: varies according to the patients memory, trust and mood.
• OBSERVATIONS
• HISTORY (How to ask questions regarding).
• A more flexible focused, or problem oriented interview is appropriate.
Start with open questions, avoid loaded questions, encourage
patients to tell their story in their own words and follow the
approaches for general history taking. Another way of questioning is
to use normalizing statement. This is employed when asking about
symptoms or behaviors that the patient may find embarrassing or
difficult to acknowledge. For example, may say something like
‘sometimes when people have been feeling very depressed or have
been under great stress, they may have odd experiences which they
• Can not explain. For example they may hear or see things which are
unusual-has anything like this happened to you?
• PRESENT HISTORY: Amplifies the chief complaints; describes how
each symptom developed. Helps establishing the main problem for
which the patient is seeking help.
• In psychiatry there will be situations in which the patient does not
have any complaints and denies any problems (‘you tell me Doc?) in
this situation, details of the presentation and behavior, as reported
by others, as well as the concerns of others (especially the family)
should be recorded as basis for your interview.
• If the patient is being held on any section of the Mental Health Act,
this must be recorded. If the patient cannot define a problem, then
telling him what others have reported and why they are concerned
can help open up the conversation and allow him a chance to give his
version of events.
• Includes patients thoughts and feelings about the illness Every
principle symptom should be well characterized, with descriptions.
Pulls in relevant portions of the Review of systems, called “ pertinent
positives and negatives” that help to clarify the differential diagnosis.
• May include medications, allergies, habits of smoking and alcohol,
which frequently are pertinent to the present illness.
• This section is complete, clear and chronologic account of the
problems prompting the patient to seek care. It should include the
problem’s onset, the setting in which it has developed, its
manifestations, and any treatments.
• Every principle symptom should be well characterized, with
descriptions. The pertinent positives and negatives from relevant
areas of the Review of systems that help clarify the differential
diagnosis.
• The history of presenting complaint (HPC) involves obtaining a
detailed description of how symptoms began (e.g., ‘when did you last
feel well?”, inquiring about the relationship to life events that might
have precipitated or kicked things off.
• Establishing if symptoms are new, that there has been a change in
their condition or they no longer lasting helps to clarify if the current
• Presentation is part of , for example, long standing personality traits
or due to the acute onset of a psychiatric disorder.
• The nature and persistence of symptoms and their impact on day to
day functioning should be clarified. In order to fulfill diagnostic
criteria for a psychiatric disorder, symptoms should persist across
different circumstance and be severe enough to have an impact on a
patients functioning in daily life.
• For example, “low mood,” it is important to establish whether the low
mood is a brief fluctuation or whether it has persisted for a period of
time. ICD 10 specifies 2 weeks of low mood for a formal diagnosis.
• Of depression.) how reactive is it to circumstances? moods unreactive
to day to day events are generally indicative of a greater severity of
depression..
• The evolution of symptoms over time, any help sought or given and
any treatment received should all be clearly noted.
• Patients may volunteer symptoms associated with the presentation,
for example, finding it hard to get up in the morning or focus on
problems, but if none are volunteered a systematic inquirly is
essential.
• PAST MEDICAL AND SURGICAL HISTORY
• Inquire about any current or previous physical health problems,
including operations.
• Note childhood operations or chronic childhood illness, which can be
pointers to a tendency to somatise ( i.e to experience physical
symptoms when anxious or distressed).
• Any chronic debilitating conditions or acute life threatening events,
such as myocardial infarction, are important risk factors for depressive
and anxiety disorders.
• A number of neurological illnesses have important psychiatric
manifestations.
• Ask about all contacts with health services. Frequent consultations
with many different specialist for variety of symptoms in the absence
of a definite medical diagnosis.
• Indicate a distinct somatoform disorder.
• Drug History (current medication)
• Record all the medication a patient is currently taking (including over
the counter medications, any recently ( borrowed medications’ and
• And herbal products ). Overuse of some over the counter medications
can exacerbate a problem ( e.g analgesic overuse headache).
• Record any allergies clearly.
• PAST PSYCHIATRIC HISTORY
• Inquiry should be made about life long history of mental health
problems
• Ask about previous contact with mental health, counselling or
psychological services.
• In women who have had children, inquire as to whether they
experienced any mental health problems during pregnancy.
• Ask about previous use of psychotropic medication. For example anti
depressants, sedatives or sleeping tablet? Establish what previous
medication has been effective in similar episodes or any medication
to which they have reacted adversely.
• Establish whether the patient is currently in contact with any mental
health professionals.
• SOCIAL HISTORY
• Includes occupation and the last year of schooling; home situation
and significant others; sources of stress, both recent and long term;
important life experiences, such as military service, leisure activities.
• Religious affiliation, and spiritual beliefs; and activities of daily living.
Also includes life style habits such as exercise and diet, safety
measures and alternative health practices.
• FAMILY HISTORY
• Ask about parents, their ages, whether they are alive and if so,
whether they have any physical or mental health problems, where
they live and the nature of patients current relationship with them.
• Inquire about the parents occupations and personalities and the
patients relationship with them during childhood.
• Establish if the parents are separated or divorced and if so, how old
the patient was at the time.
• If the parents have died, inquire into when they died, their age at
death, the circumstances of their death, how old the patient was at
the time and how the patient has coped with the grieving process.
• Establish how many siblings there are ,whether full or half siblings,
and the patients order in family.
• As for the parents, inquire into any siblings’ mental and physical
health, place of living, marital status, occupation, personality and the
patients relationship with them.
• NB: some family structures can be very complicated with parental
separations, remarriages or re-partnerships. In this situation, it can be
helpful to draw a family tree and annotate it with the above
information.
• Circles are used for women, squares for men; a line through the
symbol denotes death.
• Marriage liaison are indicated by a line connecting the symbols and
• And divorce or permanent liaisons are indicated by a line connecting
symbols and divorce or permanent separation by two oblique lines
through permanent separation by two oblique lines through
connecting line.
• Inquire whether there is family history of mental health or
psychological problems. When considering the heritable component
of a condition, obviously you are only interested in first-degree
relatives and not an relatives by marriage
PERSONAL HISTORY
• Perinatal history (antenatal or prenatal- “before birth”)
• This a period of time when you become pregnant and up to a year
after giving birth.
• This involves the mothers health during pregnancy and after
pregnancy.
• That is if there is any positive history of any febrile illness or infection
or physical trauma to the abdomen which the mother could have
suffered from during pregnancy which can impact on the brain
development of the unborn baby.
• Any history of psychiatric illness during pregnancy, types of
medication she was on, any use of substances such as alcohol, and
any form of immunization the mother had received during pregnancy,
which could predispose the unborn baby to mental health problems
during childhood and adulthood.
•
• Birth History
• Begins with inquiry about the patients birth. Was the pregnancy full
term or was the baby born prematurely, was it a normal delivery,
instrumental or through cesarean section. were there any medical
interventions or birth complications requiring specialist care. During
delivery or birth did the baby cry immediately or delayed. Any Birth
defects noted.
 Post natal complications-cyanosis/convulsions/jaundice. This is
important to assess the possibility of any early brain injury
• CHILDHOOD HISTORY
• Early Developmental milestones: This is relevant to find out if there
had been problems in early maternal bonding. Feeding - breast
feeding problems or artificial, age at weaning.
• Developmental milestones-Were developmental milestones reached
within normal range or delayed, age and case of toilet training.
• NB: patients may not have knowledge about their birth and
milestones. If the patient tells you about some problems surrounding
their birth and early milestones, this may be significant and is worth
recording.
• Clearly an informant, such as the patients mother, may have more
accurate information about the patient.
• CHILDHOOD HISTORY
• This involves childhood family history, health and early relationships.
Covers the family atmosphere during early upbringing, relationships
between parents and relationships with parents or alternative
caregivers such as grand parents or foster carers.
• It is important to note any periods of separation from parents and the
• Parents and the quality of alternative caregivers.
• Inquire about and record any loss of parents or other care figures
through death, separation or divorce. These factors are important in
understanding whether there has been any early disruption of
attachment bonds for the individual.
• Inquire about operations, hospitalizations, or chronic illness in
childhood and about family attitudes to any illness. Ask how much
time was missed off school due to illness is a good indicator of
childhood health, whether organic or no-organic.
• Ask about physical or sexual abuse.
• Any form of bad treatment, neglected and not provided with
adequate physical care.
• Any history of sexual abuse by anyone as a child.
• Behavioral and emotional problems-thumb sucking, temper
tantrums, tics, head bang , night terror, fears, bed wetting, nail biting,
stuttering ,stammering, enuresis/somnambulism.
• EDUCATION HISTORY
• Schooling can be important in terms of understanding the
development of their peer relationships and indicating whether there
• Were any behavior problems.
• Finding out what education level has been attained. Inquire about
both primary and secondary school, what sort of schools were
attended, whether school was enjoyable and any experience of
bullying. Things enjoyed, peer relationships, ease of relationships and
whether friends from school are still part of the friendship group.
• Truancy (child missing school deliberately usually without parental
knowledge and doing something else such as working or playing with
other truants).
• school refusal (is a situation in which a child stays at home refusing to
go to school despite persuasion from parent, usually due to anxiety
disorder. Exclusions from school and referral to any children’s service
are important.
• Establish patients level of academic achievement ( qualifications
attained). Further education or training on leaving school and their
experience of this (college or university). It is an important point at
which an individual starts to live independently or is an individual or
patient still lives in the parental home.
• Age at start of school and end of full time education, any problems
• Encountered at the highest level of qualifications attained. This
information can be important in evaluating the cognitive state.
 Academic and extra curricular achievements-if any
 Relationship with peers and teachers
 School phobia, truancy, non-attendance, learning disabilities, reason for
termination of studies (if occurs prematurely)
 Play history: Games played at what age and with whom relationships
with playmates
 Emotional problems during adolescence: Running away from home,
delinquency, smoking, drug use, any other
• PSYCHOSEXUAL HISTORY
• Puberty : Age at appearance of secondary sexual characteristics.
 Anxiety related to puberty changes
 Women: Age at menarche, reaction to menarche, menstrual history
(any irregularities of cycle and duration of flow), abnormalities if
any( menorrhagia/dysmenorrhea
 Obstetric history: LMP Any abnormalities associated with
pregnancy/delivery/puerperium
 Men : puberty, sex education at home/school
• A full sexual history would cover sexual fantasies, musterbation, and
deviant sexual behavior (this level of detail is inappropriate unless the
problem is specifically a psychosexual one).
• Boy friends/girl friends in adolescence, age at first sexual relationship.
• Marital history: Type of marriage: self choice/arranged, age at
marriage, how they met, Duration of marriage, parental attitude to
marriage, quality of marital relationship (confiding, conflict,
separations, identity and gender of current partner, reasons for end of
marriage, Partners health and attitude to the patients illness. Nature
and number of previous relationships.
• Frequent broken relationships may reflect abnormalities of
personality and state of health are relevant to the patients
circumstances and like the nature of the relationship its self, will affect
the partners role in the care and management of the patient.
• Sexual history: attitude to sex, any sexual difficulties, and their
relationship to current symptoms. The purpose is to ascertain about
the patients sexual life is any anyway involved in their current
difficulties, whether a cause , a correlate or a consequence. This also
includes childhood abuse especially sexual abuse.
• Children: identities, date of any abortions or still births,
temperament, emotional development, mental and physical health .
who are the child carers.
• REPRODUCTIVE HISTORY: Pregnancy, child birth, miscarriages and
terminations are events that are sometimes associated with adverse
psychological reactions.
• Relationship with the parents, worries about the children, behavior,
schooling.
•
• OCCUPATIONAL HISTORY
 Occupational history
 Age at starting work
 Jobs held in chronological order
 Reasons for change, if any
 Current job satisfaction-including relationship with authorities, peers
and if applicable, subordinates.
 Whether job is appropriate to clients back background
• present job (dates, duties, performance, and satisfaction), earlier. jobs
( list them, with reasons for changes). This helps to understand the
patients current abilities, interests and financial and social
circumstances, and may be a potential source of stress. A list of
previous jobs and reasons for leaving is relevant to assessment of
personality. If status of jobs declined, this may reflect chronic illness
or substance misuse.
• FORENSIC HISTORY
• Inquire if the patient has ever been in any trouble with the police.
Nature of charges, court appearances, convictions, and prison
sentences.
• It is important to pass information to other health professionals about
violent offences, because they are the best predictor of future violent
behavior.
• Substance use and misuse: Use of alcohol, tobacco, illicit drugs –
which ones, when, and how much. Problems arising from substance
use..
• This includes past as well as present consumption of alcohol and
other substances and impact of their use on the patients health and
life.
• MENTAL STATE EXAMINATION
MENTAL STATE EXAMINATION
• MSE is the cornerstone of the psychiatric assessment. It enables a
systematic observation of clinical symptoms and signs on which a
different diagnosis is based.
• It involves looking at and listen to the patient carefully and observe in
a systematic way.
• The examination is word portrait of how the patient appears, using
clinical observation, informed questioning, empathic listening and
accurate recording.
THE MENTAL STATUS EXAMINTION
• Appearance and behavior
• Speech
• Mood: subjective and objective
• Thought: form and content
• Perception
• Cognitive assessment: including orientation, attention, and
concentration, registration and short term memory, recent memory,
intelligence, abstraction
• Insight
• Appearance:
• Describes how patients appear and whether their dress and general
presentation seems appropriate for their age, culture, occupation and
social class.
• Physical appearance such as weight loss ( ill-fitting clothes) may
indicate loss of appetite as a result of depression or even dementia
or failure to eat because of delusional ideas or anorexia nervosa.
• May also represent simple social disorganization in those with
schizophrenic illness (secondary to medication, typically) or can
indicate an eating disorder such as bulimia nervosa or excessive
Alcohol intake ( in some people).
• Poor self care indicated by bogy odor, lack of shaving and dirty clothes
can be due to depression, or patients with schizophrenia or dementia
may become disorganized and lose the capacity to care for
themselves.
• Reduced or lowered levels of consciousness indicates an Organic
Brain disorder.
• This situation calls for a simplified interview, with careful observation
of behavior and an attempt to interview an informant.
• Behavior:
• This is the description of how the patient behaves, in relation to the
environment and the interviewer. Is the behavior socially appropriate
or is it unusual in some way?
• General Demeanour
• Is the patient relaxed or anxious? Is he agitated ( fiddling or wringing
hands), angry or behaving as though suspicious?
• Patients with severe depression may slow to respond or may need to
pace about, unable to stay still because of agitation.
• Excitability due to mania or schizophrenia looks like agitation although
will usually be more disorganized.
• Angry and suspicious behavior may be due to persecutory delusions,
without any natural fear of being examined.
• A distracted or preoccupied patient may just be very anxious (due
inner fearfulness or fearful thoughts) or may be experiencing auditory
hallucinations or may be seen actively responding to auditory
hallucinations ( e.g muttering inexplicably), visual hallucinations
( looking away suddenly) or tactile hallucinations ( reacting as if hit or
bitten).
• Rapport
• Does the patient engage comfortably or seem nervous, awkward and
troubled with interview? He may be warm or indifferent, suspicious,
ingratiating, dismissive, supercilious or hostile.
• The patient way of relating to you could be defined by personality or
mental illness.
• Patients with severe depression may be apathetic and indifferent.
• Those with schizophrenia may be suspicious and hostile and those
with mania may be disimissive, impatient supercilious, being readily
• Irritated by the interruption of whatever important task they may be
engaged in.
• Eye contact
• Does the patient establish good eye contact, exhibit an avoidant gaze
or look suspiciously around? The may be even an abnormal staring
eye contact or a hostile frown or grimace when looking at people.
• Wearing dark glasses indoors may just be fashionable but could imply
a sense of fearfulness, a visual problem or, not uncommonly, drug
withdrawal.
• Gait
• Note abnormalities of gait when a patient walks in. there may be a
manneristic gait.
• Where the patient walks in an exaggerated posing way. There may
functional gait problems, so look for inconsistencies in what can be
done when a patient is asked to walk and what may be eicited on
examination.
• Asking someone to walk as if on a tightrope, heel to toe, can clarify
whether or not they are ataxic.
• Reduced motor activity
• In bradykinesia ( patients seem to act in slow motion), voluntary
movements are reduced and abnormally slow. The face and arms
tend to be particularly affected. This may be due Parkinson’s disease
or medication, particularly anti psychotics.
• slowness and paucity of movement may also occur in psychomotor
retardation, which is a feature of depression.
• In stupor, there is paucity of movements and mutism. This occurs in
severe depression, catatonia, and organic brain disease. Catatonia is
characterized by stuporous state with additoinal features.
• Increased motor activity
• NB: any excessive activity and whether it is purposeful or not. Manic
patients may just be overactive and distractible.
• Agitation has a different quality, being driven by an unpleasant inner
sense of tension. It is generally restless in which there may be
apparently purposeful activity but it is not carried through properly.
• There may be repetitive purposeless behavior such as hand-wringing,
scratching, rubbing hands on knees and pacing up and down.
• Speech
• This divided into two components: rate and structure of speech.
• Rate: slowed speech with a long latency between question and
answer may be a component of psychomotor retardation in
depression; it can occur in dementia or in psychosis due to distraction
by hearing voices or in very anxious patient.
• Lack of spontaneous speech occurs in depression, as negative
symptom of schizophrenia and in some dementias.
• It may be due to excessive aphasia caused by cerebral lesion.
• There may be excessive spontaneous speech, as in a manic patient or
also in some dementia’s, where there is loss of appropriate social
understanding of reciprocal speech.
• Pressured speech refers to an increase in both the rate and amount of
speech, characterized in particular by patients being very difficult to
interrupt, and typical of manic states. Sometimes speech is so
pressured and driven that it becomes incomprehensible.
• By contrast, mute patients will not speak at all, as In states of stupor
due to severe depression, schizophrenia or organic brain disease but
occasionally as hysterical symptom.
• Elective mutism (the patient will speak in some situations but not in
others)
• Structure
• This can be disrupted in a variety of ways due range of disorders.
Other abnormalities of speech that should be noted are any evidence
of dysphasia or dysarthria, which would indicate neurological disease,
that may be due to drug or alcohol side effects.
• MOOD
• This usually divide into subjective and objective mood.
• Some clinicians separate mood (‘my description of how I feel) from
affect ( how the patient’s mood affects the interviewer).
• For subjective mood record how the patient actually feels, for
example “ I am really fed up’, or “ I’m feeling sad” etc. it is useful to
record this verbatim.
• Basically objective mood can be described as depressed ( low mood),
elated ( being happy, irritability which can occur both in depression
and mania. Anxious mood ( feeling of nervous, frightened or shaky),
or angry mood or labile mood or incongruent affect, blunting of
affect.
• THOUGHT