CASE HISTORY& MSE

Case history
Socio demographic profile
• Name
• Age
• Marital Status
• Gender: Male/ Female
• Education
• Occupation
• Socio Economic Status: High/Middle/ Lower
• Domicile Urban/Semi urban/ Rural
• District
• State
Informant
• Relationship of the informant to the patient
• Intimacy
• Length of acquaintance with the patient
• Consistency of the Information (Reliability)
• Adequacy of the information
• Psychotic disorders- relative is the best informant
• Neurotic Illness: Patient is best informant
• Corroborate the information with other family members or relatives
• Record separately
Chief complaints
• Chronological Order
• Write in patient/ informant words
• Write important complaints
• Five or six maximum
• Duration of these symptoms/ each symptom decreased or increased

History of Present Illness

• Onset Acute: Hours to weeks
Insidious: Weeks to months

• Precipitating Factors:
Any event that was preceded the illness/ happened just before development of illness
Eg. Medical problems/ family violence/ Death/ Marriage

• Course of the Illness:

Episodic: Symptomatic periods with intervening normalcy periods
Continuous: without any normalcy periods
Fluctuating: Periodic exacerbations of a continuous illness
• Start from Onset of Illness to consultation of NIMHANS.
• If it is episodic illness – Write about the current episode
• Detailed and coherent information
• Match with chronological order in chief complaints
• If it is continuous Illness: also write treatment history in HOPI and % of improvement
• At the end associate disturbances : Sleep, appetite, weight, sexual life socioccupational
functioning

Negative history
Rule out all other symptoms/ disorders
History of trauma, fever , headache, vomiting, confusion, disorientation, memory , diabetes,
hypertension, substance abuse etc.

Past history
• Enquire about past physical illness & Psychiatric illness.
• Nature and duration of symptoms
• Nature of the treatment received
• Response to treatment.
Family history
• Three Generations Genogram
• Symbols used in drawing Genogram
• Description of all the family members
• Age, education, occupation, occupation, marital status, living/dead, relationship with the
patient.
• Physical / Psychiatric Illness in family
• Briefly about dynamics of the family (positive findings only)
Eg; leadership, boundary setting, cohesiveness, family rituals, communications, conflicts
Personal history
1. Birth & Early development:
• Prenatal, Natal and Post natal
• Full term/ premature delivery
• Hospital/ home
• Complications during delivery
• Physical illness in post natal period
 • Mile stones were normal or delayed

2. Behavior during Childhood

• Sleep Disturbances
• Conduct Disturbances: Stealing, lying, frequent fights
• truancy and gang activities
• Relationship with parents, siblings and peers
• Thumb sucking
• Nail Biting
• Temper Tantrums
• Bedwetting
• Stammering
• Tics and Mannerism
3.Physical Illness During Childhood
Specifically ask about epilepsy, meningitis and encephalitis
4.School:
• Age of beginning and finishing school
• Type of school attended
• Scholastic Performance
• Attitude towards peers and teachers
• Competence and future Ambitions

5.occupation
• Age of starting work
• Jobs held (chronological order)
• Work Satisfaction
6.Menstrual History:
• Age of Menarche
• Reaction to Menarche
• Regularity of Periods
• Dysmenorrhea
• Menorrhagia
• Oligomenorrhoea
• Emotional Disturbances in relation to Menstrual Cycle
7.Sexual history

• Puberty
• Knowledge about sex and source of it
• Masturbatory Practices
• Anxiety related to sexual fantasies/ practices
• Homosexual / hetero sexual fantasies
• Inclinations and experiences
• Extra marital Relationships
8.Marital history
• Age at marriage
• Arranged or love
• Mutual consent of partners
• Age, education, occupation, health and personality of partner
• Quality of marital relationship
• Any separation or divorce
• No of children and their details

9.Use and abuse of alcohol, tobacco and drugs:

• Use or abuse
• Frequency and quantity
• cannabis, opiates and barbiturates
Premorbid Personality (8 areas)
• Consists of habitual attitudes and patterns of behavior
• Description of personality before the onset of the illness
1. Attitudes to others in social, family and sexual relationships
• Trust others, sustain relationship,
• anxious or secure,
• leader or follower,
• participation, responsibility,
• capacity to make decisions,
• dominant or submissive,
• friendly or emotionally cold, jealousy, suspiciousness, guardedness etc.
• Difficulty in role taking- gender, sexual, familial, parental and work
2. Attitude to self:
• Egocentric, selfish, indulgent, dramatizing, critical, deprecatory, over concerned, self
conscious, satisfaction or dissatisfaction with work.
• Attitudes towards health and bodily functions
• Attitudes to past achievements and failures and to the future
3.Moral and religious attitudes and standards:
• Rigidity or compliance
• Permissiveness or over conscientiousness
• Conformity or rebellion
• Religious beliefs
4.Mood:
• Stability of mood
• Mood swings: anxious, irritable, worrying or tense
• Lovingly or gloomy
• Ability to express and control feelings of anger, anxiety or sadness
5.Leisure Activities and Interests:
• Interest in reading, play, music, movies etc.
• Creativity
• How was the leisure time spent
 • Number of friends
6. Fantasy Life:
• Day dreams, dreams
Amount of time spent in day dreaming
7.Reaction Pattern to Stress
• Ability to tolerate frustrations, losses, disappointments and circumstances arousing anger,
anxiety or depression
• Excessive use of particular defence mechanisms such as denial, rationalization, projection
etc.

8.Habits:
• Eating, sleeping and excretory functions

2. MENTAL STATUS EXAMINATION

Definition
A mental status examination (MSE) is an assessment of a patient's level of cognitive
(knowledge-related) ability, appearance, emotional mood, and speech and thought patterns at the
time of evaluation
• MSE is a medical process where a clinician working in the field of mental health (usually
a psychotherapist, social worker, psychiatrist, psychiatric nurse or psychologist
systematically examines a patient's mind.
Purpose
• The purpose of a mental status examination is to assess the presence and extent of a
person's mental impairment.
• The cognitive functions that are measured during the MSE include the person's sense of
time, place, and personal identity; memory; speech; general intellectual level; mathematical
ability; insight or judgment; and reasoning or problem-solving ability.
• In elderly people it is advisable to look for dementia by looking into overall decline in a
person's intellectual function-including difficulties with language, simple calculations,
planning or decision-making, and motor (muscular movement) skills as well as loss of
memory.
• The MSE results may suggest specific areas for further testing or specific types of required
tests. A mental status examination can also be given repeatedly to monitor or document
changes in patient’s condition.
Duration of MSE
• The length of time required for a mental status examination depends on the patient's
condition. It may take as little as five to ten minutes to examine a healthy person.
 • Patients with speech problems or intellectual impairments, dementia, or other organic
brain disorders may require twenty minutes. The examiner may choose to spend more
time on certain portions of the MSE and less time on others, depending on the patient's
condition and answers.

CONTENTS OF MSE
1. General appearance and behavior:
• A rich deal of information can be elicited from the examination of general appearance
and behavior. While examining, it is important to remember the socio-cultural

background and personality of the patient.

• Understandably, general appearance and behavior needs to be given more emphasis in the
examination of an uncooperative patient
• Physical appearance: (approximate age, height, weight)
• Dressing: (Adequate, appropriate, any peculiarities)
• Grooming, bodily hygiene and self care:
• Touch with surroundings:
• Eye contact: (maintains gaze- anxious patients, Avoids gaze- Schizo, excessive - manic
patients, hesitant eye contact or normal eye contact).
• Facial expression: (Appropriate or not, is it changed with the subject or not,
Comfortable/ uncomfortable, attentive/ indifferent, elation of mood, fear, anger, sad)
• Posture: (relaxed- Obsessive, Guarded- Paranoid Schi, Sitting at the edge of the chair-
Schizophrenic patients)
• Consciousness: The level of conscious state is assessed whether it is steady or
fluctuating, clouded or clear. Levels of consciousness are determined by the interviewer
and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous,
characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4)
alert, characterized by full awareness.
• Example: Schizophrenic and organic patients may be dirty and disheveled, being
both aware of and unconcerned about appearance. Manic patients are the most
colourful and bizarre in appearance and clothing etc.
• The examiner notes the person's age, race, sex, civil status, and overall appearance.
These features are significant because poor personal hygiene or grooming may reflect
a loss of interest in self-care or physical inability to bathe or dress oneself
• Recall how the patient first appeared upon entering the office for the interview. Note
whether this posture has changed. Note whether the patient appears more relaxed.
Record the patient's posture and motor activity. If nervousness was evident earlier,
note whether the patient still seems nervous. Record notes on grooming and hygiene.
Record whether the patient has maintained eye contact throughout the interview or if
he or she has avoided eye contact as much as possible, scanning the room or staring at
the floor or the ceiling.
• Next, record the patient's facial expressions and attitude toward the examiner. Note
whether the patient appeared interested during the interview or, perhaps, if the patient
 appeared bored. Record whether the patient is hostile and defensive or friendly and
cooperative.
• Note whether the patient seems guarded and whether the patient seems relaxed with
the interview process or seems uncomfortable. This part of the examination is based
solely on observations made by the health care professional.
Cooperative, Uncooperative, Attentive, Evasive (confused) , Guarded ,suspicious ,hostile

• Manner of relating (relaxed, tense, over familiar, aggressive, disinherited, withdrawn)

• Rapport: (whether a working and empathic relationship can be established with the
patient should be mentioned)

2. Psychomotor activity:
• This looks at the way the person moves and the positions in which he/she holds his/her
body. Abnormal movements such as tics or chorea as well as the degree of movement is
noted.
• Inactive
• Hyperactive
• Aggressive
• Abnormal movements or postures, catatonic features, hallucinatory behavior, involuntary
movements,Restlessness,Compulsive acts, rituals or habits ( nail biting)
3. Speech
• Document information on all aspects of the patient's speech, including tone, tempo,
volume and reaction time of speech during the interview.
• Prosody , relevance and coherent
• Some things to keep in mind during the interview are whether patients raise their voice
when responding, whether the replies to questions are one-word answers or elaborative,
and how fast or slow they are speaking.

4. Thought
a. Disorders of Tempo.
• Retardation of thinking
• Circumstantiality
• Flight of ideas
b. Disorders of continuity of thinking:
1. Perseveration
2. Thought blocking
c. Form:
Give sample and comment on loosening of associations, derailment, and neologism
d. Possession:
Obsessions (elicit their nature of obsessions), Thought alienation experience: Thought insertion,
thought withdrawal, thought broadcasting
e. Content:

Delusions or Overvalued Ideas, worries, Preoccupations, hypochodriachal symptoms

 derailment ("loosening of associations") A pattern of speech in which a person's ideas
slip off one track onto another that is completely unrelated or only obliquely related. In
moving from one sentence or clause to another, the person shifts the topic
idiosyncratically from one frame of reference to another and things may be said in
juxtaposition that lack a meaningful relationship. This disturbance occurs between
clauses, in contrast to incoherence, in which the disturbance is within clauses. An
occasional change of topic without warning or obvious connection does not constitute
derailment

• Depressive ideation: ideas of worthlessness, guilt, hopelessness, helplessness and

suicidal ideas

5. Mood

• Affect is the outward show of emotions and mood is the general pervasive emotional
state as reported by the patient. A person's affect may vary through depression, elation,
anger and normality but if the overall sense from examination is of depression then that is
used to describe the mood.

• The range of the affect describes whether the person shows a full or even expanded range
or if his/her affect is blunted or restricted.

Description should be given regarding the following components:

• Range
• Reactivity
• Appropriateness
• Communicability
• Congruence

6. Perception
• Illusions
• Hallucinations: Auditory, visual, gustatory (taste), tactile (touch), Olfactory (Smell).
1. Auditory:
• first person/ second person/ third person
• Single voice or multiple
• Commenting or commanding/ abusive/ threatening
Can be
• Audible thoughts - 1st person auditory hallucinations
• Arguing voices in their head - 2nd person auditory hallucinations (if talking directly to
the patient)
• Running commentary in their head - 3rd person auditory hallucinations
• Familiar or unfamiliar
 • Pleasant or unpleasant
• Pseudo hallucination
• Depersonalization
• Derealisation
7. Cognitive functions:
Cognitive or higher mental functions are an important part of the MSE. Their significant
disturbance commonly points to the presence of an organic psychiatric disorder.

a. Attention and Concentration:

To assess attention and concentration, tests used are;

• Digit Span Test:

A.Forward: Patient is given the following instructions:

• I will be saying some digits, listen to me carefully
• When I finish saying them, you will have to repeat them in the same order
• Give an example ( if I say 3, 7 you say 3.7)
• Read digits at the rate of one per second to the patient
• Notes whether the immediate responses of the patient is correct or incorrect but don’t
reveal it to the patient.
• The following digits may be used:
• 4-2-5
• 6-1-5-8
• 1-4-8-3-9
• The digit span is the highest number of digits repeated correctly.
• The same digits should not be presented more than once
If the patient can not repeat a particular number of digits on one trial, a second trial with
the same number of digits is given and credit is given if the response is correct

B. Backward: The patient is instructed as follows:

• I will be saying some digits. Listen to me carefully and repeat them after me in a reverse
order, for example if I say 6-3, you have to say, 3-6
• The procedure is the same as for digits forward
• The same digits should not be used as for the forward test.
• No digits should be presented in a series
• The digits backward score is the highest number of the digits correct recalled
backward after a maximum of 2 trials.
 • Increasingly difficult tests are presented.
• The examiner a) instructs the patient b) gives an example of how to perform the task c)
notes the responses verbatim and d) notes the time taken in seconds.
• 20-1 20-0 reversed in 15 seconds
• 40-3 40, 37, 34, 31, etc in 60 seconds
• 100-7 100, 93, 86, 79 etc in 120 seconds
• Days or months may be asked for in backward or forward to the patient who is familiar
with the correct order.

Orientation: To elicit responses concerning orientation, ask the patient questions, as

follows.
• "What is your full name?" (ie, person).
• "Do you know where you are?" (ie, place).
• "What is the month, date, year, day of the week, and time?" (ie, time).
• "Do you know why you are here?" (ie, situation).
• This frequently looks at whether the person knows the time (including the date), place
(where he/she are), person (who he/she is), and situation (that he/she is in).\

Memory
Assessment includes immediate, recent and remote memory.
1. Immediate memory - tested by digit span test
2. Recent memory- tested by
• Address test: An address consisting of about 4-5 facts which is not known to the patient
is slowly read to the patient after instructing him to attend to the examiner. He is engaged
in conversation and the response is noted verbatim. Recall is asked for after 3-5 minutes.
• Asking the patient to recall events in the last 24 hours eg. Details of the time and amount
of a meal or visitors to the hospital from an inpatient. Responses given by the patient
should be noted of and cross checked from reliable source.

3. Remote memory: Information on life events

• Date of birth or age
• Number of children
• Names and number of family members
• Time since marriage or death of any family member
• Year of completing education
• 4-5 facts may be asked for, relevant to the patients’ background and answers should b
cross checked.

Abstract ability
 • Is tested by similarities, differences and proverbs.

A .Similarities: The patient is given the following instructions

• I will give you some pair of words. You have to tell me in what way they are alike, what
is common between them or what the similarity between them is.

• Orange and Banana (fruits)

• Dog and Lion (animals)
• Car and Bus (modes of transportation)

b. Differences: The instructions are as follows: I will be presenting to you some pairs of words.
Listen carefully and tell me in what way they are different from each other.
• Stone and potato( not eatable- eatable/ hard- soft)
Cinema and Radio( audiovisual- audio)
c. Proverbs: The patient is asked the following questions:
• Whether he knows what a proverb is
• An example of a proverb and what it means
• If it is clear that the patient has the concept of a proverb, the following may be asked;
• “A bird in the hand is worth 2 in the bush”
• “A barking bog never bites”
• The responses of the patient are to be noted verbatim and the answer is judged to be
correct or incorrect.
General information
The interviewer always should take into consideration the patient's educational background
and other training in evaluating answers and assigning scores.
For literates:
• Name of the Prime minister
• Capitals of countries
• 5 rivers, cities or states
For illiterates:
• Seasons
• Crops or fruits grown in particular seasons

• Prices of lan
Calculation
• The following questions may be asked with increasing time units.
• How much is 4 rupees and 5 rupees?
• I borrowed 6 rupees from a friend and returned 2 rupees , how much do I still owe to
him?Intelligence
• Intelligence: Based on the information provided by the patient throughout the interview,
estimate the patient's intelligence quotient (ie, below average, average, above average).
Judgments
 • Personal J: is assessed by inquiries about the patients future plans
• Social J: is assessed by observing behavior in social situations
• Test J: Fire Problem, Letter problem
Insight
• Insight refers to a person's ability to recognize a problem and understand its nature and
severity. Assess the patients' understanding of the illness. To assess patients' insight to
their illness, the interviewer may ask patients if they need help or if they believe their
feelings or conditions are normal.
• Clinical rating of insight: It is rated on 6 point scale from one to six.
1. Complete denial of illness
2. Slight awareness of being sick, but denying it at the same time
3. Awareness of being sick, blaming it on external factors
4. Awareness that illness is due to something unknown in the patient
5. Intellectual insight:
Awareness of being ill and that the symptoms in social adjustment are due to own particular
irrational feelings/thoughts; yet does not apply this knowledge to the current/future
experiences.
• True emotional insight:

It is different from intellectual insight in that the awareness leads to significant basic
changes in the future behavior and personality.

File Review

• First contact with NIMHANS

• Number of admissions
• Each admission details including: Symptoms presented with, diagnosis, treatment
(Pharmacological and non-pharmacological, response to treatment, Level of
improvement, functioning, follow up, drug compliance, reasons for relapse.
• Prepare a life Chart
Summary
• Short form of Detailed Workup
• Brief description about each area

• Socio demographic details, chief complaints, precipitating factor, HOPI, treatment

history, family history, personal history, premorbid functioning, MSE, Cognitive
functions, insight and diagnosis and management.

Formulation

• Socio Demographic details

• Premorbid history
• Personal history
• Family history
• Past history
Presented with duration and symptoms, MSE positive findings (corroborative), Cognitive
functions tests findings, insight, Multi axial diagnosis and management.