Case history taking is a fundamental process in diagnosing and assessing mental health

disorders. It involves gathering detailed information about the patient's personal, medical,
and psychological background to understand their condition. Here's a step-by-step guide
based on the form you provided:

1. Identifying Information

● Name, Age, Sex, Education, Occupation, Religion, Caste, Residence: Helps in

knowing the demographic details of the patient, which may be crucial for
understanding social, cultural, and economic influences on mental health.
● Family type and Income: Provides insight into the patient's support system and
financial stress, which could influence their mental health.

2. Chief Complaints

● Complaints in Chronological Order: Ask the patient or caregiver to describe the

symptoms they are experiencing, starting from the most recent or severe. This helps
establish a timeline of symptom progression.
● Duration and Intensity: Understanding the duration and severity helps in ruling out
different disorders, such as distinguishing between acute and chronic conditions.

3. History of Present Illness

● Mode of Onset: Was the condition sudden (abrupt) or gradual (insidious)? Acute
onset can indicate disorders like psychosis, while insidious onset might suggest
depression or personality disorders.
● Course and Progress: Are the symptoms continuous, episodic, or fluctuating? Is the
patient improving, deteriorating, or static? This helps in understanding the natural
progression of the illness.
● Predisposing and Precipitating Factors: Identify factors that may have contributed
to the onset, such as trauma, stress, or substance abuse.
● Biological Functions: Assess any changes in sleep, appetite, bowel movements,
libido, and other bodily functions. Changes here often indicate mood or anxiety
disorders.

4. Informant’s Report

● Details of Informant: Obtain information from someone who knows the patient well,
like a family member. Their observations can be more objective, especially if the
patient is in denial or non-communicative.
● Chief Complaints and History from Informant’s View: Cross-check the patient's
account with that of the informant for consistency.

5. Treatment History
 ● Previous Consultations/Hospitalizations: Record any past treatments, including
medication adherence and response to treatments. Non-compliance is often a reason
for relapse.
● Type of Practitioners Consulted: Psychiatric, traditional healers, or alternative
treatments should all be recorded to get a holistic view of the patient's treatment
history.

6. History of Past Illness (Medical/Psychiatric)

● Previous Episodes: Ask about any prior mental or medical illnesses, including their
duration, treatment, and recovery.
● Inter-Episodic Functioning: Assess how well the patient functioned between
episodes, which can give insight into the chronicity and impact of the disorder.

7. Family History

● Mental Illnesses in Family: Assess for any history of mental disorders, substance
abuse, or neurological issues in at least three generations. This provides clues about
genetic predisposition.
● Family Relationships: Investigate the patient's relationship with family members
and any family conflicts or dysfunctions.

8. Personal History

● Early Development: Explore the patient's childhood, including developmental

milestones, to identify any early signs of behavioral issues.
● School Performance and Social Relations: Ask about academic achievements,
extracurricular activities, and relationships with peers and authority figures to
understand social functioning.
● Occupation and Vocational History: Investigate job stability, promotions, or
conflicts at work, which can be stressors or indicators of personality traits.
● Sexual and Marital History: Sexual functioning and relationship satisfaction can
provide clues to personal stressors or relationship dynamics.
● Forensic History: Check for any legal issues, which might suggest behavioral or
impulse control disorders.

9. Premorbid Personality

● Patient’s Self-Description: Understanding how the patient perceives themselves,

their strengths, weaknesses, and ambitions helps in assessing personality and
resilience.
● Social Preferences and Relationships: Explore whether the patient prefers solitude
or company and how they manage social interactions.
● Work and Leisure: Investigate hobbies and social affiliations, as they offer insight
into how the patient spends their time and what they value.
● Mood and Emotional Expression: Ask about mood fluctuations, control over
emotions, and any instances of violence or extreme emotional responses.
10. Mental Status Examination (MSE)

This is a crucial part of psychiatric assessment that provides a snapshot of the patient’s
current cognitive and emotional state:

● General Appearance and Behavior: Observing physical appearance, hygiene,

posture, and motor behavior provides clues about mood and cognitive functioning.
● Speech: Assess the patient’s speech for tone, volume, rate, and coherence. Issues
such as pressured speech, poverty of speech, or circumstantiality could indicate
psychiatric conditions.
● Cognition (Attention, Memory, and Orientation): Test the patient's ability to
concentrate, remember, and orient themselves in time, place, and person.
● Mood and Affect: Compare the subjective mood with observed affect. Flat or
inappropriate affect may indicate schizophrenia, while mood congruence is often
noted in mood disorders.
● Thought Process and Content: Assess for issues like flight of ideas, tangential
thinking, delusions, or obsessions.
● Perception: Look for hallucinations or perceptual disturbances. Sensory deception
like hearing voices can suggest psychosis.
● Judgment and Insight: Test the patient’s understanding of their condition and their
ability to make rational decisions.

11. Diagnostic Formulation

● Diagnosis (ICD-10/DSM-IV): Based on the gathered information, formulate a

diagnosis using standardized criteria like ICD-10 or DSM-IV.
● Points in Favor/Against Diagnosis: Highlight key factors supporting or ruling out
the diagnosis.
● Differential Diagnosis: Consider other possible conditions and rule them out based
on the evidence.
● Prognosis and Treatment Plan: Based on the diagnosis, plan appropriate
treatment, and assess the prognosis for recovery.

12. Treatment

● Based on the diagnosis, develop a treatment plan that may include medications,
therapy, lifestyle changes, and follow-up plans.

This comprehensive approach ensures that all aspects of the patient’s life and mental health
are evaluated to make an accurate diagnosis and develop a treatment plan.

The terms "characteristic features," "clinical features," and "diagnostic features" in the
context of mental disorders are related but have distinct meanings:

1. Characteristic Features
 ● Definition: These are typical traits or behaviors commonly associated with a mental
disorder, but they may not necessarily be diagnostic or sufficient for a formal
diagnosis.
● Purpose: Characteristic features help provide a general picture of the disorder. They
may include behaviors, emotional responses, and personality traits observed in
individuals with the condition.
● Example: In depression, characteristic features may include persistent sadness, loss
of interest in activities, and fatigue. These features are common in most individuals
with depression but aren't the sole basis for diagnosis.

2. Clinical Features

● Definition: These refer to observable signs and symptoms that a clinician detects
during assessment or that a patient reports. Clinical features are what professionals
observe in the context of a patient's presentation.
● Purpose: Clinical features form the basis of the patient’s current mental health
condition and help guide the treatment plan. They may include mood, thought
patterns, speech, and physical symptoms like sleep disturbances.
● Example: In schizophrenia, clinical features might include auditory hallucinations,
disorganized thinking, and flat affect. These features are what a clinician directly
assesses during interviews or observation.

3. Diagnostic Features

● Definition: These are the specific criteria that must be met for a formal diagnosis
according to standardized guidelines like the DSM-5 (Diagnostic and Statistical
Manual of Mental Disorders) or ICD-10 (International Classification of Diseases).
Diagnostic features are stricter and more specific than characteristic or clinical
features.
● Purpose: Diagnostic features are used to officially diagnose a disorder, ensuring that
the condition meets a standardized set of criteria.
● Example: To diagnose Major Depressive Disorder (MDD), diagnostic features
include at least five symptoms (like depressed mood, anhedonia, significant weight
change, insomnia, fatigue, etc.) present for at least two weeks, which cause
significant impairment in functioning.

Differences:

● Breadth:
○ Characteristic features are broader, reflecting common patterns or traits
without a structured format for diagnosis.
○ Clinical features are more focused on what is currently manifesting in the
patient and are observable or reportable symptoms.
○ Diagnostic features are the specific, formal criteria used to classify and
diagnose the mental disorder according to established manuals like DSM-5 or
ICD-10.
● Role in Diagnosis:
 ○ Characteristic features alone may not suffice for diagnosis but can indicate
the likelihood of a disorder.
○ Clinical features provide the clinical picture but are still evaluated against
diagnostic criteria.
○ Diagnostic features are mandatory and standardized to confirm the
presence of a specific mental disorder.

Example Using Schizophrenia:

● Characteristic Features: Social withdrawal, flat affect, bizarre behavior.

● Clinical Features: Hallucinations, disorganized speech, and catatonia observed by a
clinician.
● Diagnostic Features: Per DSM-5, at least two symptoms (hallucinations, delusions,
disorganized speech, etc.) lasting for six months, with one month of active
symptoms, must be present.

In summary, characteristic features give a general sense of the disorder, clinical features
are what clinicians observe or what patients report, and diagnostic features are the specific
criteria needed to formally diagnose the disorder.