Effective Case taking techniques in Psychiatry

Dr Lakshmi Babu 

Familiarity with the technique of psychiatric assessment is important not only for a psychiatrist but also for a medical practitioner or any mental health professional, since more than one-third of medical patients can present with psychiatric symptoms. Psychiatric disorders may present with primary psychiatric complaints or with physical symptoms, and physical and psychiatric illness often coexist.

CONTENTS

• INTRODUCTION
• CLASSIFICATION IN PSYCHIATRY
• CONCEPT OF HEALTH
• WHAT CONSTITUTES NORMALITY
• PSYCHIATRIC VS MEDICAL INTERVIEW
• STEPS TO BE TAKEN/CONSIDERED PRIOR TO THE INTERVIEW
• PSYCHIATRIC ASSESSMENT
  • INTERVIEWING TECHNIQUE
  • IDENTIFICATION DATA
  • INFORMANTS
  • PRESENTING [CHIEF] COMPLAINT
  • HISTORY OF PRESENTING COMPLAINT
  • PAST PSYCHIATRIC AND MEDICAL HISTORY
  • TREATMENT HISTORY
  • FAMILY HISTORY
  • PERSONAL AND SOCIAL HISTORY
  • ALCOHOL AND SUBSTANCE HISTORY
  • FORENSIC HISTORY
  • PHYSICAL EXAMINATION
  • MENTAL STATUS EXAMINATION
  • INVESTIGATION
  • FORMULATION
• CONCLUSION
• REFERENCE

1.0 INTRODUCTION
Psychiatry is a speciality that requires accumulated clinical experience as well as background knowledge. The proper practice of psychiatry involves an understanding of the normal workings of the mind and brain and a thorough knowledge of psychopathological manifestations of the mind and the behaviours that accrue when mental illness is present. It embraces therefore not only full medical training but also a knowledge of psychology and personality structure and a wider understanding of sociology, culture and belief systems. The mastery of taking a detailed history and performing an examination of the mind, referred to as a mental state examination (MSE) are the cornerstones of becoming a successful practioner in psychiatry

2.0 CLASSIFICATION IN PSYCHIATRY
Although first attempts to classify psychiatric disorders can be traced back to Ayurveda, Plato (4th century BC) and Asclepiades (1st century BC), classification in Psychiatry has certainly evolved ever since . At present, there are two major classifications in Psychiatry, namely

ICD-11 (2022) and DSM-V-TR (2022).
ICD-11 (International Classification of Diseases, 11th Revision, 2019) is World Health Organization’s classification for all diseases and related health problems. Section 6 classifies psychiatric disorders as Mental, Behavioral and Neurodevelopmental disorders and codes them on an alphanumerical system from 6A00 – 6E8Z.

DSM-V-TR (Diagnostic and Statistical Manual of Mental Disorders, Vth Edition, Text Revision, 2022) is the American Psychiatric Association (APA)’s classification of mental disorders.

DSM-V-TR is a text revision of the DSM-V which was originally published in 2013.

3.0 CONCEPT OF HEALTH
According to WHO, Health is a state of complete physical, mental and social well-being, and not merely absence of disease or infirmity.

4.0  WHAT CONSTITUTES NORMALITY ?
Although, normality is not an easy concept to define, some of the following traits are more commonly found in ‘normal’ individuals.

• Reality
• Self-awareness and self-
• Self-esteem and self-
• Ability to exercise voluntary control over their 3
• Ability to form affectionate
• Pursuance of productive and goal-directive

5.0 PSYCHIATRIC VS MEDICAL INTERVIEW

In no other branch of Medicine is the history taking interview as important as in Psychiatry. A psychiatric interview can be different from a medical interview in several ways, some of which can include:

• Presence of disturbances in thinking, behaviour and emotions can interfere with meaningful
• Collateral information from significant others can be really
• Important to obtain detailed information of personal history and pre-morbid
• Need for more astute observation of patient’s
• Difficulty in establishing rapport may be encountered more
• Patients may lack insight into their illness and may have poor

6.0  STEPS TO BE TAKEN/CONSIDERED PRIOR TO THE INTERVIEW I   CONTEXT OF THE INTERVIEW

• PATIENT FACTORS
  • Emergency
  • Routine
  • Legal

The approach to the interview in each of these situations will be different. It will require a careful and a skilful engagement of the patient in the assessment.

• PHYSICAL ENVIRONMENT
  • Safety
  • Privacy

II  COLLATERAL HISTORY

• The background informations accessible and
• A good referral letter from a general Physician can so outline the history that, going onto the specialist part of psychiatric examination can be expedited.

7.0 PSYCHIATRIC ASSESSMENT
A consistent scheme should be used each time for recording the interview, although the interview need not (and should not) follow a fixed and rigid method. The interview technique should have flexibility, varying according to appropriate clinical circumstances.

The psychiatric assessment can be discussed under the following headings.

7.1 INTERVIEWING TECHNIQUE

• The patient should be put at ease and an empathetic relationship should be
• 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 and reassuring him that you are a doctor.
• Always inform patients that the conversation is confidential, but that information will be shared with other healthcare professionals as appropriate. However, patients have to know that information cannot be withheld from others if it is likely to place them or others at risk.
• Notes taken (whether written or typed) can be brief but should be an outline of the key
• It is important to write some of the patient’s statements verbatim to illustrate his state of mind, and this can provide evidence of the presence of certain symptoms with respect to the MSE and what aspects to focus on. Open, non-judgemental approach with a non- threatening eye-contact as much as possible.
• The most important interviewing skills are listening, and demonstrating that you are interested in listening and attending to the patient. It is important to remember that listening is an active, and not a passive, process.
• A comprehensive psychiatric interview often requires more than one

7.2 IDENTIFICATION DATA

• It is best to start the interview by obtaining some identification data which may include Name (including aliases and pet names), Age, Sex, Marital status, Education, Occupation, Income, Residential and Office Address(es), Religion, and Socioeconomic background, as appropriate according to the setting.
• It is useful to record the source of referral of the
• In medicolegal cases, in addition, two identification marks should also be

7.3 INFORMANTS

• Sometimes the history provided by the patient may be incomplete, due to factors such as absent insight or uncooperativeness, therefore, it is important to take the history from patient’s relatives or friends who act as informants and sources of collateral It is important to take the patient’s consent before taking this collateral history unless the patient does not have capacity to consent.
• The reliability of the information provided by the informants should be assessed on the following parameters:
  • Relationship with
  • Intellectual and observational
  • Familiarity with the patient and length of stay with the
  • Degree of concern regarding the

7.4   PRESENTING [CHIEF] COMPLAINT

• Presenting complaints and/or reasons for consultation should be
• Both the patient’s and the informant’s version should be recorded, if relevant. If the patient has no complaints (due to absent insight) this fact should also be noted.
• It is important to use patient’s own words and to note the duration of each presenting

7.5 HISTORY OF PRESENTING COMPLAINT

• When the patient was last well or asymptomatic should be clearly This provides information about the onset and duration. In short, the following should be found out.
  • Onset of present illness/symptom.
  • Duration of present illness/symptom.
  • Course of symptoms/illness.
  • Predisposing
  • Precipitating factors (include life stressors).
  • Perpetuating and/or relieving
• The presenting (chief) complaints should be In particular, any disturbances in physiological functions such as sleep, appetite and sexual functioning should be enquired.
• Enquire about the presence of suicidal ideation, ideas of self-harm and ideas of harm to others, with details about any possible intent and/or plans.
• It is also essential to consider and record any important negative history (such as history of alcohol/ drug use in new onset psychosis).

7.6 PAST PSYCHIATRIC AND MEDICAL HISTORY

• Any history of any past psychiatric illness should be Any past history of having received any psychotropic medication, alcohol and drug abuse or dependence, and psychiatric hospitalization should be enquired.
• A past history of any serious medical or neuro- logical illness, surgical procedure, accident or hospitalization should be obtained. The nature of treatment received, and allergies, if any, should be ascertained.
• A past history of relevant etiological causes such as head injury, convulsion, unconsciousness, diabetes mellitus, hypertension, coronary artery disease, acute intermittent porphyria, syphilis and HIV positivity (or AIDS) should be explored.

7.7  TREATMENT HISTORY
Any treatment received in present and/or previous episode(s) should be asked along with history of treatment adherence, response to treatment received, any adverse effects experienced or any drug allergies which should be prominently noted in medical records.

7.8  FAMILY HISTORY

• The family history usually includes:
  • The ‘family of origin’ e. the patient’s parents, siblings, grandparents, uncles, etc.
  • The ‘family of procreation’ e. the patient’s spouse, children and grandchildren.
• Family history is usually recorded under the following headings:
  • Family structure: Drawing of a ‘family tree’ (pedigree chart) can help in recording all the relevant It should be noted whether the family is a nuclear, extended nuclear or joint family. Any consanguineous relationships should be noted. The age and cause of death (if any) of family members should be asked.
  • Family history of similar or other psychiatric illness, major medical illness, alcohol or drug dependence and suicide/ suicide attempts should be recorded.
  • Current social situation: Home circumstances, per capita income, socioeconomic status, leader of the family (nominal as well as functional) and current attitudes of family members towards the patient’s illness should be noted.

The communication patterns in the family, range of affectivity, cultural and religious values, and social support system, should be enquired.

7.9  PERSONAL AND SOCIAL HISTORY
In a younger patient, it is often possible to give more attention to details regarding earlier personal history. In older patients, it is sometimes harder to get a detailed account of the early childhood history. Parents and older siblings, if alive, can often provide much additional information regarding the past personal history. Not all questions need to be asked from all patients and personal history should be individualized for each patient.

Personal history can be recorded under the following headings:

1)Perinatal History
Difficulties in pregnancy (particularly in the first three months of gestation) such as any febrile illness, medications, drugs and/or alcohol use; abdominal trauma, any physical or psychiatric illness should be asked. Other relevant questions may include whether the patient was a wanted or unwanted child, date of birth, whether delivery was normal, any instrumentation needed, where born (hospital or home), any peri- natal complications (cyanosis, convulsions, jaundice), APGAR score (if available), birth cry (immediate or delayed), any birth defects, and any prematurity.

2)  Childhood History
Whether the patient was brought up by mother or someone else, breastfeeding, weaning and any history suggestive of maternal deprivation should be asked. The age of passing each important developmental milestone should be noted. The age and ease of toilet training should be asked.

The occurrence of neurotic traits should be noted. These include stuttering, stammering, tics, enuresis, encopresis, night terrors, thumb sucking, nail biting, head banging, body rocking, morbid fears or phobias, somnambulism, temper tantrums, and food fads

3)Educational History
The age of beginning and finishing formal education, academic achievements and relationships with peers and teachers, should be asked. Any school phobia, non-attendance, truancy, any learning difficulties and reasons for termination of studies (if occurs prematurely) should be noted.

4) Play History
The questions to be asked include, what games were played at what stage, with whom and where. Relationships with peers, particularly the opposite sex, should be recorded. The evaluation of play history is obviously more important in the younger patients.

5) Puberty
The age at menarche, and reaction to menarche (in females), the age at appearance of secondary sexual characteristics (in both females and males), nocturnal emissions (in males), masturbation and any anxiety related to changes in puberty should be asked.

6) Menstrual and Obstetric History
The regularity and duration of menses, the length of each cycle, any abnormalities, the last menstrual period, the number of children born, and termination of pregnancy (if any) should be asked for.

7) Occupational History
The age at starting work; jobs held in chronological order, reasons for changes; job satisfactions; ambitions; relationships with authorities, peers and subordinates; present income; and whether the job is appropriate to the educational and family background, should be asked.

8) Sexual and Marital History
Sexual information, how acquired and of what kind; masturbation (fantasy and activity); sex play, if any: adolescent sexual activity; premarital and extramarital sexual relationships, if any; sexual practices (normal and abnormal); and any gender identity disorder, are the areas to be enquired about.

The duration of marriage(s) and/or relationship(s); time known the partner before marriage; marriage arranged by parents with or without consent, or by self-choice with or without parental consent; number of marriages, divorces or separations; role in marriage; interpersonal and sexual relations; contraceptive measures used; sexual satisfaction; mode and frequency of sexual intercourse; and psychosexual dysfunction (if any) should be asked. Conventionally, the details of the ‘family of procreation’ are recorded here.

9) Premorbid Personality (PMP)
It is important to elicit details regarding the personality of the individual (temperament, if the age is less than 16 years). Instead of using labels such as schizoid or histrionic, it is more useful to describe the personality in some detail. The following subheadings are often used for the description of premorbid personality:

• Interpersonal relationship
• Use of leisure time
• Predominant mood
• Attitude to self and others
• Attitude to work and responsibility
• Religious beliefs and moral attitudes
• Fantasy life
• Habits

One of the most reliable methods of assessment of premorbid personality is interviewing an informant familiar with the patient prior to the onset of illness.

7.10 ALCOHOL AND SUBSTANCE HISTORY
Although alcohol and drug history is often elicited as a part of personal history, it is often customary to record it separately. Alcohol and drugs can often contribute to causation of several psychiatric symptoms and are often present co-morbidly alongside many psychiatric diagnoses.

7.11  FORENSIC HISTORY

• It is useful to inquire routinely if the patient has ever been in any trouble with the
• Record the nature of any charges, court appearances, convictions and prison
• Particularly important to record in detail, highlight and pass information to other health professionals about violent offences.
• The best predictor of future violent behavior is past violence, and there is a real risk that this information gets buried in notes and forgotten.

7.12 PHYSICAL EXAMINATION
A detailed general physical examination (GPE) and systemic examination is a must in every patient. Physical disease, which is etiologically important (for causing psychiatric symptomatology), or accidentally co-existent, or secondarily caused by the psychiatric condition or treatment, is often present and can be detected by a good physical examination.

7.13 MENTAL STATUS EXAMINATION

• The clinician records the psychiatric signs and symptoms present at the time of the
• MSE should describe all areas of mental
• Some areas, however, may deserve more emphasis according to the clinical impressions that may arise from the history; for example, mood and affect in depression, and cognitive functions in delirium and dementia.

A] GENERAL APPEARANCE AND BEHAVIOUR
While examining, it is important to remember patient’s sociocultural background and personality. Understandably, general appearance and behaviour needs to be given more emphasis in the examination of an uncooperative patient.

I General Appearance

• Physique and body habitus [build]
• Physical appearance [approximate height, weight and appearance]
• Looks comfortable/uncomfortable
• Physical health
• Grooming, Hygiene,    Self-care,    Dressing    [adequate, appropriate,  any peculiarities]
• Facies [non-verbal expression of mood]
• Effeminate/masculine

II Attitude towards examiner

• Cooperation/guardedness/evasiveness/hostility/combativeness/haughtiness.
• Attentiveness
• Appears interested/disinterested/apathetic
• Any ingratiating behaviour
• Perplexity

III.Comprehension

• Intact/impaired (partially/fully)

IV.Gait and posture

• Normal or abnormal (way of sitting, standing, walking, lying)

V. Motor activity

• Increased/decreased
• Excitement/stupor
• Abnormal involuntary movements (AIMS) such as tics, tremors, akathisia
• Restlessness/ill at ease
• Catatonic signs (mannerisms, stereotypies, posturing, waxy flexibility, negativism, ambitendency, automatic obedience, stupor, echopraxia, psychological pillow, forced grasping)
• Conversion and dissociative signs (pseudoseizures, possession states)
• Social withdrawal, Autism
• Compulsive acts, rituals or habits (for example, nail biting)
• Reaction time

VI.Social manner and non-verbal behaviour

• Increased, decreased, or inappropriate behaviour
• Eye contact (gaze aversion, staring vacantly, staring at the examiner, hesitant eye contact, or normal eye contact).

VII. Rapport

• Whether a working and empathic relationship can be established with the patient, should be mentioned.

VIII  Hallucinatory Behaviour

• Smiling or crying without reason
• Muttering or talking to self (non-social speech).
• Odd gesturing in response to auditory or visual

B] SPEECH

I.Rate and quantity of speech

• Whether speech is present or absent (mutism)
• If present, whether it is spontaneous, whether productivity is increased or

II. Volume and tone of speech

• Increased/decreased (its appropriateness)
• Low/high/normal pitch

III.Flow and rhythm of speech

• Smooth/hesitant, Blocking (sudden)
• Stuttering/Stammering/Cluttering
• Any accent
• Circumstantiality, Tangentiality, Verbigeration, Stereotypies (verbal)
• Flight of ideas, Clang

C] MOOD AND AFFECT

Mood is the pervasive feeling tone which is sustained (lasts for some length of time) and colours the total experience of the person.

Affect, on the other hand, is the outward objective expression of the immediate, cross-sectional experience of emotion at a given time.

I .The assessment of Mood includes:

• Testing the quality of mood, which is assessed:
• Subjectively (‘how do you feel’)
• Objectively (by examination).
• The other components are,
  • Stability of mood (over a period of time),
• Reactivity of mood (variation in mood with stimuli)
• Persistence of mood (length of time the mood lasts).

II. The assessment of Affect:

• Quality of affect
• Range of affect [of emotional changes displayed over time
• Depth or intensity of affect [normal, increased or blunted]
• Appropriateness of affect [in relation to thought and surrounding environment]

Mood is described as general warmth, euphoria, elation, exaltation and/or ecstasy (seen in severe mania) in mania; anxious and restless in anxiety and depression; sad, irritable, angry and/or despaired in depression; and shallow, blunted, indifferent, restricted, inappropriate and/or labile in schizophrenia. Anhedonia may occur in both schizophrenia and depression.

D] THOUGHT
Normal thinking is a goal directed flow of ideas, symbols and associations initiated by a problem or a task, characterized by rational connections between successive ideas or thoughts, and leading towards a reality-oriented conclusion. Therefore, thought process that is not goal- directed, or not logical, or does not lead to a realistic solution to the problem at hand, is not considered normal.

I.Stream and form of thought

The ‘stream of thought’ overlaps with examination of ‘speech’.

• Spontaneity, productivity, flight of ideas, prolixity, poverty of content of speech, and thought block should be mentioned here.
• The ‘continuity’ of thought is assessed; Whether the thought processes are relevant to the questions asked; Any loosening of associations, tangentiality, circumstantiality, illogical thinking, perseveration, or verbigeration is noted.

II.Content of thought

Any preoccupations:

• Obsessions (recurrent, irrational, intrusive, ego- dystonic, ego-alien ideas)
• Contents of phobias (irrational fears)
• Delusions (false, unshakable beliefs) or Over-valued ideas

Explore for delusions/ideas of persecution, reference, grandeur, love, jealousy (infidelity), guilt, nihilism, poverty, somatic (hypochondriacal) symptoms, hopelessness, helplessness, worthlessness, and suicidal Ideation.

Delusions of control, thought insertion, thought withdrawal, and thought broadcasting, the presence of neologisms should be recorded here.

E] PERCEPTION

Perception is the process of being aware of a sensory experience and being able to recognize it by comparing it with previous experiences.

Perception is assessed under the following headings:

I.Hallucinations

• The presence of hallucinations should be noted. A hallucination is a perception experienced in the absence of an external stimulus. The hallucinations can be in the auditory, visual, olfactory, gustatory or tactile domains.

II.Illusions and misinterpretations

• Whether visual, auditory, or in other sensory fields; whether occur in clear consciousness or not; whether any steps taken to check the reality of distorted

III .Depersonalization /derealization

• Depersonalization and derealization are abnormalities in the perception of a person’s reality and are often described as ‘as if phenomena.

IV.Somatic passivity phenomenon

• Somatic passivity is the presence of strange sensations described by the patient as being imposed on the body by some external agency, with the patient being a passive
• Others like autoscopy, abnormal vestibular sensations, sense of presence should be noted here.

F] COGNITION [NEUROPSYCHIATRIC] ASSESSMENT
A significant disturbance of cognitive functions commonly points to the presence of an organic psychiatric disorder. It is usual to use Folstein’s mini mental state examination (MMSE) for a systematic clinical examination of higher mental functions.

I.Consciousness

• The intensity of stimulation needed to arouse the patient should be indicated to demonstrate the level of alertness, for example, by calling patient’s name in a normal voice, calling in a loud voice, light touch on the arm, vigorous shaking of the arm, or painful stimulus.
• Grade the level of consciousness: Conscious/confusion/somnolence/clouding/delirium/stupor/coma.
• Any disturbance in the level of consciousness should ideally be rated on Glasgow Coma Scale, where a numeric value is given to the best response in each of the three categories (eye opening, verbal, motor).

II.Orientation

Whether the patient is well oriented to :

• Time (test by asking the time, date, day, month, year, season, and the time spent in hospital).
• Place (test by asking the present location, building, city, and country).
• Person (test by asking his own name, and whether he can identify people around him and their role in that setting).

Disorientation in time usually precedes disorientation in place and person.

III .Attention

• Is the attention easily aroused and
• Ask the patient to repeat digits forwards and backwards (digit span test; digit forward and backward test), one at a time.
• For example, patient may be able to repeat 5 digits forward and 3 digits Start with two digit numbers increasing gradually up to eight digit numbers or till failure occurs on three consecutive occasions.

IV. Concentration

• Can the patient concentrate, Is he easily distractible;
• Ask to subtract serial sevens from hundred (100-7 test), or serial threes from fifty (50-3 test), or to count backwards from 20, or enumerate the names of the months (or days of the week) in the reverse order.
• Note down the answers and the time taken to perform the

V .Memory

• Immediate Retention and Recall (IR and R): Use the digit span test to assess the immediate memory
• Recent Memory: Ask how did the patient come to the room/hospital; what he ate for dinner the day before or for breakfast the same morning. Give an address to be memorized and ask it to be recalled 15 minutes later or at the end of the interview.
• Remote Memory: Ask for the date and place of marriage, name and birthdays of children, any other relevant questions from the person’s past. Note any amnesia (anterograde/ retrograde), or confabulation, if present.

VI.Intelligence

Intelligence is the ability to think logically, act rationally, and deal effectively with environment.

• Ask questions about general information, keeping in mind the patient’s educational and social background, his experiences and interests, for example, ask about the current and the past prime ministers and presidents of India, the capital of India, and the name of the various states.
• Test for reading and
• Use simple tests of

VII .Abstract thinking

Abstract thinking is characterized by the ability to:

• Assume a mental set
• Shift voluntarily from one aspect of a situation to
• Keep in mind simultaneously the various aspects of a
• Grasp the essentials of a ‘whole’ (for example, situation or concept).
• To break a whole’ into its

Abstract thinking testing assesses patient’s concept formation. The methods used are:

• Proverb Testing: The meaning of simple proverbs (usually three) should be
• Similarities (and also the differences) between familiar objects should be asked, such as: table/chair; banana/orange; dog/lion; eye/ear.

G] INSIGHT

Insight is the degree of awareness and understanding that the patient has regarding his illness.

Ask the patient’s attitude towards his present state; whether there is an illness or not, if yes, which kind of illness (physical, psychiatric or both); is any treatment needed; is there hope for recovery: what is the cause of illness. Depending on the patient’s responses, insight can be graded.

H] JUDGEMENT

Judgement is the ability to assess a situation correctly and act appropriately within that situation. Both social and test judgement are assessed:

Social judgement is observed during the hospital stay and during the interview session. It includes an evaluation of ‘personal judgement’.

Test judgement is assessed by asking the patient what he would do in certain test situations, such as ‘a house on fire’, or ‘a man lying on the road’ or ‘a sealed, stamped, addressed envelope lying on a street.

Judgement is rated as Good/Intact/Normal or Poor/Impaired/Abnormal.

I] INVESTIGATIONS
After a detailed history and examination, investigations (laboratory tests, diagnostic standardised interviews, family interviews, and/or psychological tests) are carried out based on the diagnostic and aetiological possibilities.

J] FORMULATION
After a comprehensive psychiatric assessment, a diagnostic formulation summarises the detailed positive (and important negative) information regarding the patient under the focus of care, before listing differential diagnosis, prognostic factors, and a management plan.

8.0 CONCLUSION
Though Psychiatric case taking differes from the conventional Allopathic case taking, it resembles a lot with the Homoeopathic way of confronting a case. Mental symptoms are crucial generals for a Homoeopathic Physician for them being peculiar and queer and helps in individually looking at a person for a Classical Homoeopathic proceeding. Mental symptoms are often misinterpreted or difficult to be elicited. Hence a psychiatric grasp will no doubt helps a Homoeopathic physician to excel in his field.

9.0 REFERENCES

• A short text book of Psychiatry – Niraj Ahuja
• Hutchison’s clinical methods – An integrated approach to clinical
• Fundamentals of Psychiatry – Muideen Bakare

Dr. Lakshmi babu  
PG Scholar, Homoeopathic Repertory & Case taking
Govt Homoeopathic Medical College Calicut
b.geethalakshmi2july@gmail.com