DEPARTMENT OF CLINICAL PSYCHOLOGY

SCHEME FOR CASE HISTORY TAKING

Case history taking in psychiatry/clinical psychology is both a science and an art. The
ability to systematically work up a case and obtain the most relevant information in as short a
time as possible, to synthesize this information, to arrive at a diagnosis and workout a
management plan in a skill which should be mastered over time. As in traditional medicine,
perhaps to a greater extent, utmost importance should be given to the elicitation of history
focusing on the symptoms reported, their development over time, the frequency and severity of
the symptoms as experienced by the individual as well as any other signs as reported by
significant others. This should be supplemented by a systematically carried out mental status
examination and physical examination. The following is the scheme for case taking

1. History
2. Mental Status Examination
3. Physical examination*
4. Summary
5. Initial formulation
6. Psychological Assessment
7. Final formulation
* To be conducted by a Medical Examiner only

These components of case taking are described in the following pages. The material
presented here is intended to provide a guideline that will enable students to follow a uniform
method of case history taking. All the areas have not been covered exhaustively; students are
instructed to read cited references given in the end to become more proficient in collection of
case history.

History Taking
Socio-Demographic Data

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Name: Age: Sex: CP. No:

Education: Occupation: Marital Status:

Socioeconomic status: Urban / Rural

Informant:

Mention here the sources of information, relationship of the informant to the

patients; intimacy and length of acquaintance with the patient and reliability of the
information. It is often necessary to obtain information from more than one source. In
certain types of illness like psychoses, relatives will be able to provide more reliable
information while in neurotic illness the patient would be the best informant. When
information is collected from more than one source, do not collate the accounts of several
informants into one, but record them separately. E.g. According to X (father, mother,
etc) the following behavior (description of signs they have noticed) have been noticed for
(duration, frequency, intensity).

Note: All the information collected from different sources should stand the 3 C tests i.e.
the information should be
1) consistentcy: the same version should be given by different informants,
2) constancy: the version given should not be different at different points of time
3) continuity: there should be no gaps in the information about the duration of the
illness
Mention as to whether the information collected is adequate and reliable

Complaints and their duration

Record the complaints in a chronological order. Do not write a long list of

complaints, but present the salient disturbances in the different areas of functioning. This
could be collected by noting what is said in response to an open-ended question like
“What is the reason you have come for?/ What brings you here?”

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 While some patients / relatives may present an elaborate list of their
complaints, other might not spontaneously report their difficulties unless more direct
questions are posed. Hence use your skills and discretion in eliciting the complaints
The duration of the signs and symptoms also have to be elicited and recorded.

History of Present Illness:

Give a detailed and coherent account of the symptoms from the onset to the time
of consultation including their chronological evolution and course. Specific attention
must be paid to the following:

(a) Onset: Note if the onset of the symptoms is

acute (i.e. developing within few hours, generally < 48 hours),
sub-acute (few days to few weeks, generally 2 weeks) or
gradual (few weeks to few months).
Prodromal stage refers to the period preceding the onset of florid symptoms,
where oddities and changes in behavior patterns are noticed in the absence of positive
symptoms.

(b) Precipitating Factors: Enquire about any precipitating events. These could be
physical (e.g. A febrile illness, viral infections )
psychological in nature (e.g. Death / loss).
Ascertain in whether the events clearly preceded the illness or were consequences of
the illness (eg. Job loss following the onset of a schizophrenic illness). The temporal
correlation with the event must be clearly established, and also whether it was
perceived as stressful by the individual. It should be kept in mind that life events,
both positive as well as negative, can be perceived as stressful by an individual. Also
an event perceived as stressful by one individual need not be seen as stressful by
another person.

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Course of illness:

The course of an illness can be

1) episodic (discrete symptomatic periods with intervening periods of normalcy),
2) continuous ( ongoing symptoms with no intervening periods of normalcy) or
3) fluctuating (periodic exacerbations of a continuous illness)
At times a different pattern of symptoms may evolve in a continuous illness. For
example delusions, hallucinations, and intense affects may be prominent in the initial
phases of a schizophrenic illness, while in the later stages apathy and emotional blunting
might be prominent.

Graphic presentation of the course of illness can often be very informative, as shown
below.

(a) Continuous it means patient never reach premorbid level of functioning

(b) Episodic more than one level of illness with intervening periods of normalcy
attaining pre-morbid levels of functioning

(c) Residual the patient has almost improved significantly but there are residual
symptoms. The course may be continuous and ongoing and pre-morbid levels of
functioning may not have been attained

Financial Loss Got Married

Age: 25 years Age: 27 Years Present episode

Untreated No definite Precipitating factor Age: 30 years
treated with antidepressants

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(d) Associated Disturbance: Enquiry should also be made of impairment in other
areas of functioning. These include disturbances in sleep, appetite, weight, sexual
life, social life and occupation functioning. The specific nature of the disturbance
and the degree of disability should be recorded. Personal hygiene of the patient
has to be recorded, especially lapses in maintaining good personal hygiene.
Clinical conditions of the patient

(e) Negative History: Lastly, certain historical details must be routinely enquired
into, to rule out an organic etiology. These include: history of trauma, fever,
headache, vomiting, confusion, disorientation memory disturbance, history of
physical illnesses like hypertension / diabetes and history of substances abuse.
Seizures while these details are important regardless of the nature of presentation,
they are particularly important in the elderly. It is a good practice to routinely
record the absence commonly associated signs and symptoms, like signs of
autonomic arousal, worries and ruminations, intrusive thoughts, compulsions,
suicidal thoughts, ideas of hopelessness, hallucinations of various modalities,
delusions, instances of depersonalization and derealization when recording the
case history

(f) Treatment History: Details of previous treatment taken, if any, and the response
to treatment. Social cultural influences like traditional methods of healing using
Ayurveda, homeopathy, Unani, poojas, etc.

(g) Past History: Enquire about both past physical illness, and past psychiatric
illness, try to ascertain the nature and duration of symptoms, the nature of
treatment received, and the pattern of response. In certain instances, it may be
more meaningful to describe the previous episodes in the history of present illness
rather than in the past history (for example frequent episodes of a manic-
depressive illness). Record the type of illness, type and duration of treatment,
whether hospitalization was required and for what duration, response to treatment,

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 follow-up details and also reasons for discontinuing treatment. Indicate if any
residual symptoms are present.

(h) Family History:

Give a description of the individual family members (parents and siblings). The
description should include information as to whether they are living or dead, age (or age
of death), education, occupation, martial status, personality and relationship with the
patients. Enquire about the presence of any physical and or psychiatric illness in the
family and record it in detail. Describe the socioeconomic conditions of the family,
leadership pattern, role functions, decision making and communication patterns within
the family. Indicate the socialization pattern of the family, the family atmosphere
(formal, rigid, friendly, aloof); how the patient was treated by the family, to whom the
patient is more attached and has confiding relations, and preferential treatment if any.

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PERSONAL HISTORY:

Birth and Early Development:

Record the details of prenatal, perinatal and post natal periods.
Was the birth at full term?
Whether delivered in the hospital or at home?
Was it a normal delivery or were there any complications during delivery?
Was there any physical illness in the pre or post natal periods?
Ascertain whether milestones of development were normal or delayed.

Behaviour during Childhood:

Enquire about sleep disturbance, thumb sucking, nail biting, temper tantrums,
bedwetting, stammering, tics, mannerisms and other features of anxiety. Look for
conduct disturbances in the form of frequent fights, truancy, stealing, fire setting, cruelty,
lying and gang activities. Also enquire about relationship with parents, siblings, and
peers.

Psychical Illness during childhood:

Record physical illnesses suffered in childhood. Enquire specifically regarding
epilepsy, meningitis and encephalitis.

School:
Enquire about age of beginning and finishing school, type of school attended;
scholastic performances, attitudes towards peers and teachers. Indications of learning
difficulties, school phobia, or avoidance, truancy, adjustment difficulties, extra-curricular
activities, and pattern of coping.
In case of adolescents indicate peer group involvement and pressure, pressure to
conform, identity crises, substance abuse, sexual knowledge, orientation and practices.

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Occupation:
Age of starting work; jobs held, in chronological order; work satisfaction,
competence, future ambitions. In events of changing jobs, enquire into the reasons for
doing so, as well as relationships with employers and colleagues. Indications of fear of
success, promotions, demotions, suspension, and type of relationship with superiors and
peers.

Menstrual History:
Enquire about age of menarche; reaction to menarche; regularity of periods;
dysmenorrhoea; menorrhagia, Oligomenorrhoea; emotional disturbance in reaction to
menstrual cycle. In the event of sexual abuse, record the date of the last menstrual period.
In the event of attaining menopause, indicate age and associated physical distress

Sexual History:
Enquire about age at onset of puberty level of knowledge regarding sex and mode
of gaining the same, masturbatory practices; anxiety or guilt related to sexual fantasies /
practices. Homosexual and heterosexual fantasies, inclinations and experiences, extra
martial relationships, unsafe practices and risk for exposure to STD/AIDS to be recorded.
Check the nature of sexual relationship in case of married couples
(satisfactory/unsatisfactory), instances of sexual problems like impotence, or frigidity etc.

Martial History:
Enquire regarding age at time of marriage, whether arranged by elders or by self;
was there mutual consent of the partners, age, education, occupation, health and
personality and personality of partner; habit quality of marital relationship, any separation
or divorce. Note the number of children, their ages, and health status. Indicate inter
religious / intercaste marriages, differences in age, education, urban/rural upbringing,
occupation, general health

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Use and Abuse of alcohol, tobacco, and drugs:
Enquire about habits like smoking, chewing tobacco and drinking alcohol,
recording frequency and duration of habits, periods of abstinence if any. Enquire about
usage of other drugs like cannabis, opiates, barbiturates, heroin etc, and record pattern of
abuse and its severity. Record presence of peer pressure or childhood models, attempts at
abstinence, treatment taken, if any, and its result

Permorbid Personality:
Personality of patients consists of those habitual attitudes and patterns of behavior
which characterize an individual. Personality sometimes changes after the onset of an
illness. Get a description of the personality before the onset of the illness. Aim to build
up a picture of the individual, not a type. Enquire with respect to the following areas.

(1) Attitudes to others in social, family as sexual relationships:

Ability to trust others; make and sustain relationships, anxious or secure, leader or
follower, participation, responsibility, capacity to make decisions, dominant or
submissive, friendly or emotionally cold, evidence of any jealously, suspiciousness,
guard ness etc. Evidence of difficulty in role taking – gender, sexual, familial parental
and work. Certain adaptive qualities like respecting, obedient optimistic, adjustive,
warm, outgoing, empathy manifested..
(2) Attitudes to self:
Egocentric, selfish, indulgent, dramatizing, critical, deprecatory, over concerned,
self conscious, satisfaction, or dissatisfaction with work. Narcissism, pathological levels
of increased self esteem, self absorption, attitudes towards health and bodily functions.
Attitudes to past achievements and failures, and to the future.

(3) Moral and religious attitudes and standards:

Evidence of rigidity or compliance, permissiveness or over conscientiousness,
conformity, or rebellion. Enquire specifically about religious beliefs, ability to cope up.

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(4) Mood:
Enquire about stability of mood, mood swings, whether anxious, irritable,
worrying or tense. Whether lively or gloomy. Ability to express and control feelings of
anger, anxiety, or depression.

(5) Leisure activities and interests:

Interest in reading, play music, movies etc. Enquire about creative ability.
Whether leisure time is spent alone or with friends. Is the circle of friends large or small,
if it enhances wellbeing, helps in mastery, improves self esteem.(***)
(6) Fantasy Life:
Enquire about content of day dreams and dreams amount of time spent in day
dreaming, wishful thinking.

(7) Reaction Pattern to stress;

Ability to tolerate frustration, losses, disappointments and circumstances
arousing anger, anxiety r depression. Evidence for the excessive use of particular defense
mechanism such as denial, rationalization, projection, etc.

(8) Biological functions and Habits:

Eating, sleeping and excretory functions.

Mental Status Examination:

A systematically conducted mental status examination is an important component
of case taking. It is essential to record the observations properly. Whenever positive
findings are obtained, they should be described in detail. It is not adequate to say
delusions present or hallucinations ++. MSE has to be repeated several times during the
course of the illness to know the evolution of symptoms, effectiveness of treatment etc.
The time frame covered by the MSE is not restricted to the hour of observation, but

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extends longer. While the following account highlights the major components of MSE,
detail should be obtained from other sources cited.
General Behavior:
Description as complete, accurate, life like as possible, of the observation of ward
staff and your own. The following points may be considered, through not exclusively.
Enquire about the way of spending the day, eating, sleeping, cleanliness in
general, self care, hair and dress. Behavior towards other patients doctors and nursing
staff. Does the patient look ill?. Note whether the patient is fully conscious, stuporose or
comatose. Is he in touch with surroundings? Is the patient relaxed or tense and restless?
Is he slow or hesitant? How does he respond to various requirements and situations? Are
there abnormal responses to external events. Can his attention be held or diverted? Is the
patient cooperative? Can adequate rapport be established? Does the patient maintain
adequate eye contact? Does the patient’s behaviour suggest that he is disoriented? Note
the presence of any tics or mannerisms. Note the presence of any catatonic phenomena.

Psychomotor Activity:
Note if the psychomotor activity is increased or normal. Goal directed activity as
well as random acts, tics and mannerisms, restlessness, apathy, lethargy and motor
incoordination have to be checked and recorded
Talk
Note here the form of utterances rather than the content. Does the patient speak
spontaneously or only in response to questions. Is the amount of speech little or
excessive. Is it high toned or low toned? Is the tempo fast or slow. Is the reaction time
increased or decreased? Is the prosody of speech maintained? Is it relevant? Is it
coherent?
Thought:
Examine thought processes with respect to:
a) Stream (Flight of ideas, retardation of thinking circumstantialities, preservation,
thought blocking)
b) Form (Presence of formal thought disorder)

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c) Possession (Obsession and compulsion, thought alienation. With respect to
obsessions, elicit their nature-ideas, doubts, imagery, impulses and phobias. Similarly
clarify the nature of compulsive acts checking, counting or washing. Are these
controlling compulsion or yielding compulsions)
d) Content
Look for the presence of overvalued ideas and delusions. Before making an
inference, a detailed description of the phenomenon must be given. Note whether the
delusion is single or these are multiple delusions, the type of delusion (grandiose,
persecutory, nihilistic etc.) the exact content of the delusions, whether they are fleeting
or fixed, whether they are well systematized or poorly systematized and preoccupations,
hypochondriacal and somatic symptoms. Depressive ideation; ideas of worthlessness,
guilt, hopelessness and suicidal ideas must be enquired and recorded.

Mood:
This should be assessed by both subjective report and objective evaluation.
Assessment should be both longitudinal (mood) and cross sectional (affect). Description
should be given regarding the following components: the quality of emotion (happiness,
sadness, anxiety etc) the intensity or depth of emotional experience, the range of
affective responses, mobility, reactivity (changes in emotion in relation to environmental
factors), diurnal variation congruity (in relation to thought processes) and
appropriateness (in relation to situations). Note any evidence of labiality (rapid and
extreme changes in emotion).
Perception:
Record the presence of perceptual disturbances like illusions and hallucination;
enquiry should be made into the following modalities, vision, hearing smell, touch, taste,
pain and deep sensations, vestibular sensations and sense of presence. Record also the
presence of special varieties of hallucinations like functional hallucinations, reflex
hallucinations, extracampine hallucinations, synaesthesia, and autoscopy. Detailed
description of the actual experience should be obtained. For example with respect to
auditory hallucinations enquire whether the hallucinations are verbal or non vernal;
continuous or intermittent, single voice or multiple voices; familiar voice/unfamiliar; first

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person, second or third person; pleasant or unpleasant; if unpleasant, whether
commanding abusive or threatening; relationship of hallucinations to time of the day, and
daily activities; relationship of hallucinations; whether mood congruent. Distinguish
hallucinations from imagery and pseudo-hallucinations.
Other perceptual disturbances that must be enquired into include heightened
perception, dulled perception, depersonalization derealization experiences, and
disturbances in the perception of time.

COGNITIVE FUNCTIONS:

Attention and Concentration:

Test for the ability to arouse and sustain attention. Is there any distractibility?
Concentration can be tested by asking the subject to tell the days or months in reverse
order or subtraction of serial sevens from 100. (Note if correctly answered and time
taken). It could also be tested by giving the patient four to seven digits to repeat forward
and backward.
Orientation:
Record the patient’s answers to questions about his own name and identity the
place where he is time to day and the date.

Memory:
Test immediate, recent and remote memory. The digit repetition test is a test of
immediate memory. To test recent memory, enquire about what patient had for breakfast,
the events of the previous day; and what he ate the previous night. Patients’ recall can be
tested by presenting him an address and asking him to recall the same after some time.
Always attempt to verify from the informant.
General Information:
The tests should be varied according to the educational level and background of
the patients. Some common questions include.
 Name of the Prime Minister
 Major cities of India, different languages

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  Name of the state, capital, chief minister
 Names of a few countries
Intelligence:
Patients’ level of intelligence should be gauged from his educational level,
occupational record, his general knowledge and supplemented by clinical tests
appropriate to the background of the subject. More standardized tests of intelligence may
be used if felt necessary.
Abstractibility:
Patients can be asked to explain the meaning of certain common proverbs.
Similarly patient can be asked to mention the similarities between certain objects eg.
Table and chair.

Personal Judgment: what is the patient’s attitude to the present state; does he regard it as
an illness? Does he think treatment is necessary?
Social Judgment: Does the patient show appropriate behavior in social situations? Is
there any disinhibition observed, either social, verbal or emotional?
Test Judgment:
What would the patient do if a stamped, sealed, addressed envelope is found in
the street? What would he do if the theater in which he is watching a movie caught fire?
Insight:
Insight
Test the patient’s level of awareness of his illness. Does he think that he is not ill at all
(absence of insight?). Does he recognize the presence of illness but gives explanation in
physical terms (partial insight)? Does he fully realize the emotional nature of his illness
and the cause of his symptoms?
Levels of Insight
Level I: Complete denial of illness
Level II: Slight awareness of being sick and needing help but denying it at the same time
Level III: Awareness of being sick but blaming on others, on external factors or organic
factors
Level IV: Awareness that illness is caused by something unknown in the patient

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Level V: Intellectual insight: Admission that patient is ill and that symptoms or failures
in social adjustment are caused by the patients own particular irrational feelings or
disturbances without applying this knowledge to the future experiences.
Level VI: True emotional insight – emotional awareness of the motives and feelings with
in the patient and the important persons in his / her life which can lead to basic changes in
behavior.

Summary:
The purpose of a summary is to provide concise description of all the important
aspects of the case to enable others who are unfamiliar with the patient to grasp the
essential features of the problem. The summary should be presented in the same format
as described in the previous pages.

Initial Formulation:
This is the student’s own assessment of the case rather than a restatement of facts.
Its length, layout the emphasis will vary considerable from one patient to another. It
should always include a discussion of the diagnosis of the etiological factors which seem
important, a plan of management and an estimate of the prognosis. Regardless of the
uncertainty or complexity of the cases, a provisional diagnosis should always be specified
using the ICD 10 codes
Psychological Assessment
Appropriate psychological testing has to be carried out covering relevant areas of
personality
Investigation Treatment and Follow Up:
Biochemical, radiological or psychometric investigations should be carried out
wherever appropriate. All aspects of management viz., physical, psychological, and
social interventions should be included in the treatment package though the relative
emphasis may differ from case to case. Progress notes should be systematically recorded.
Final Formulation:
This is a revision of the initial formulation drawn up at the time of discharge. It
should specify any divergences of opinion and should state the views of the consultant

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clearly. It should be written in the light of the patient’s response to treatment and other
information becoming available since the time of admission. Its length and layout will
vary considerably but it should always include a final diagnosis, with amplifying
comments and an estimate of the prognosis.
References:
1. Hamilton, M. (Ed.). Fish’s Clinical Psychopathology: signs and symptoms in
psychiatry. John Wright and sons Ltd. Briston 1974.
2. Slater & Roth – Clinical Psychiatry –(ref. lib)
3. Jaspers, K. General Psychopathology. (Translations by J. Hoeing and W.M.
Hamilton) Manchester University Press, 1963.
4. Strub, R. L & Black, F.W. (Eds.) The Mental Status Examination in Neurology.
F.A. Davis Company, Philadelphia 1977.

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