History taking in psychiatry

Basic principles, interview style, various components and their significance, how to take history of present illness, past history,family and personal history, substance history, premorbid personality

1. HISTORY TAKING IN PSYCHIATRY BY DR. MANISH KUMAR GOYAL RESIDENT UNDER GUIDANCE OF DR. R.K. SOLANKI SMS MEDICAL COLLEGE JAIPUR

2. BASIC PRINCIPLES OF HISTORY TAKING Introduce yourself Explain the purpose and approx how long it will take Ask open ended questions Allow the patient to explain things in his/her own words

3. Encourage the patient to elaborate and explain Avoid interrupting Guide the interview as necessary Avoid asking “why?” questions Listen and observe for cues You might need an informant

4. Aim to understand problems/symptoms and effect on life To put presenting problems into context by enquiring about background history and previous treatment Is followed by MSE Enables formulation to be reached Is therapeutic in itself

5. Preparing The Setting Safety Privacy Try to avoid interruptions Arrange seating so sitting at angle to patient Writing materials.

6. Starting the Interview Rapport: It is a bidirectional empathetic relationship, which the examiner shares with the patient. The development of rapport as encompassing six strategies: 1 . Putting patients and interviewers at ease. 2 . Finding patients' pain and expressing compassion. 3 . Evaluating patients' insight and becoming an ally. 4 . Showing expertise. 5 . Establishing authority as physicians and therapists. 6 . Balancing the roles of empathic listener, expert, and authority . Introduce yourself and explain role Introduce to anyone who is accompanying patient Inform them about the length of interview Need to take notes Confidentiality

7. Interview Style Relaxed even if under time pressure Appropriate eye contact, appear interested Begin with a general question eg “tell me about your problem” Have a systematic but flexible plan – at beginning can be helpful to take a list of headings as prompt Keep in control. May need to interrupt “I’m sorry but I need to move on to other things” “We can come back to this if we have time later”

8. Interview Techniques Use of open questions where possible, especially at beginning eg “ how is your appetite?” Closed questions are useful if time is short eg “is your appetite good?” Avoid leading questions eg “You have a poor appetite, don’t you?”

9. Interview Techniques Encourage patient by leaning forward, nodding, saying “go on” “tell me more about…..” Help them talk about painful or embarrassing subjects by being non-judgmental, acknowledging distress and explaining why you are asking, eg “I can see this is difficult to talk about…”

10. Open versus closed questions: Closed questions Opened questions A closed question can be answered with either a single word (yes/no) or a short phrase . Thus 'How old are you?' and 'Where do you live?' are closed questions. Thus 'Are you happy?' and 'Is that a book I see before me?' are closed questions, whilst 'How are you? Is not. Using closed questions: They give you facts .  They are easy to answer. They are quick to answer. They keep control of the conversation with the questioner. An open question is likely to receive a long answer. Although any question can receive a long answer , open questions deliberately seek longer answers, and are the opposite of closed questions. Using open questions: Open questions have the following characteristics: They ask the respondent to think and reflect. They will give you opinions and feelings . They hand control of the conversation to the respondent.

11. Closed questions Opened questions closed questions are more useful in patients with marked loosening of associations. Closed questions are also useful in patients with organic brain conditions (learning difficulties, delirium or dementia) who can loose track of longer answers. Closed questions have a lot of disadvantages: they don’t build rapport or allow the patient to open up, who can feel grilled. From the point of view of the doctor, you can collect the facts but miss the person. It’s also easy to fall in to the trap of asking another question when you don’t know what to do. Are often more useful in therapeutic work with patients than closed questions. Open-ended questions develop trust, are perceived as less threatening, allow an unrestrained or free response. Can be time-consuming, may result in unnecessary information, and may require more effort on the part of the user.  

12. Records Good notes are vital Record for you, aids formulation Record for others so history taking does not have to be repeated, as a record of presentation for future clinicians Patients may request access to them Life charts may be therapeutic way of recording information together

13. COMPONENTS Identification data Informants Chief complaints H/o present illness Treatment history Past history of illness a) medical/surgical illness b) past psychiatric history 7. Family history

14. COMPONENTS Personal history a. Perinatal history b. Childhood history c. Education history d. Play history e. Emotional problem during adolescence f. Puberty g. Obstetrical history h. Occupational history i. Sexual and marital history j. Premorbid personality

15. IDENTIFICATION DATA Name : Occupation: Age: Income: Sex: Address: Marital status: Date of admission: Religion: Identification marks: Education: Type of admission:

16. Identification - The identification establishes the basic demographics of the patient. It should be adequately and correctly noted as all of these factors have a role to play in onset, course, presentation, treatment and prognosis of various illnesses . Age : Age should be noted and further corroborated while asking duration of illness and age at onset of illness. Various mental as well as physical illnesses have a particular age of onset . Sex : Certain disorders are common in one sex than the other. Certain socio cultural factors might have more importance for one sex than the other. Education : It would help in assessing the overall knowledge of the patient. Signs and symptoms can also vary according to educational background of the patient. In intervention, especially non pharmacological methods, the modality should be adjusted according to the educational level of the patient.

17. Occupation: Knowing the past as well as current occupation of the patient is important as it will have direct implication in socio-economic status of the patient. Impact of illness on occupation can be assessed only if we know what the patient used to do before illness . Socio-economic status : One needs to know the SES of the patient to be aware how much one can afford to spend on treatment and required investigations. Marital status : It is an important prognostic factor. It also helps us to get an information on social support of the individual. Religion: Customs vary from one religion to other significantly. Residence : Customs and beliefs are significantly different for rural/urban population. One should also know how far from the patient is coming, so that to formulate the frequency of follow up visits accordingly.

18. Address: Proper address (both permanent as well as present) needs to be noted along with Phone no and email id, so that any postal/electronic/telephonic contact can be made with the patient or the guardians as per need in the future . Type of admission, if admitted: It needs to be mentioned as it has legal implications as per Mental Health Act, 1987 Identification marks: They have role in identifying the patient and have medico-legal importance. Traceable and permanent marks should be mentioned. Common moles should be avoided. Proper anatomical location should be mentioned.

19. INFORMANTS Informant’s Name Reliability Relation to patient Intimacy with the patient Interest of the patient Does the informant live the patient? Duration of stay with the patient Intellectual and observational ability

20. CHIEF COMPLAINTS ON ADMISSION Presenting complaints and/or reason for consultation should be recorded. Both the patient’s and the informant’s version should be recorded separately. It should be recorded even if the patient is unable to speak and the patient explanation regardless of how bizarre or irrelevant. Recorded as the patient’s own words. Ask leading questions such as -what brings you here today? -how can I help you?

21. HISTORY OF PRESENTING ILLNESS Provides a comprehensive and chronological picture of the events. Probably the most helpful in making an accurate diagnosis. Duration : weeks/months/years Mode of onset : abrupt/acute/insidious Course and progress : continuous/episodic/fluctuating/deteriorating/improving/ unclear Factors in illness : Predisposing factors/Precipitating factors/Perpetuating factors/Limiting factors/Modifying factors

22. Mode of onset: It is assessed as time from being asymptomatic to symptomatic Abrupt- Sudden appearance of signs and symptoms within 48 hours e.g. delirium Acute - Rapid onset of signs and symptoms within 2 weeks e.g. ATPD Insidious - Onset of signs and symptoms takes more than 2 weeks e.g. Schizophrenia Course of illness Continuous - Characterised by uninterrupted change without breaks or with steps infinitely small and thus not detectable e.g. Schizophrenia. Episodic - An illness can be said episodic when it has an onset and an offset of signs and symptoms of the disease with periods of recovery in between at least for a period of 2 months e.g. affective illness, non affective remitting psychosis Fluctuating - When the course is waxing and waning especially under the effect of treatment. e.g. Obsessive compulsive disorder, Schizophrenia

23. Progress of illness- To what extend has the patient’s symptomatology represented an evolution over time Improving - Improving from the date of onset e.g. Depression (with treatment) Deteriorating -Condition is getting worse by time e.g. Schizophrenia Static - Condition remains same no change happens e.g. Dysthymia Predisposing factors - Factors operating from early life that determines a person’s vulnerability to develop a disorder or likelihood that person will develop certain symptoms under given stress conditions. Biological (delayed milestones, head injury, family history of psychiatric illness) Psychological (impaired premorbid personality ) Social (home atmosphere in childhood, neglect, abuse, low education level)

24. Precipitating factors - Events that occur shortly before the onset of a disorder and act as physical or psychosocial stressors and lead to the onset of disorder in a person who may be predisposed to develop the disorder. Biological (fever, accident, onset of severe medical illness ) Psychological (stress intolerance, poor impulse control) Social (trauma, loss of job/partner) Perpetuating factors- Factors due to which the disorder is maintained or aggravated. Biological (chronic medical illness, substance use) Psychological factors (poor insight, poor impulse control, low intelligence) Social (social isolation, unemployment, ongoing expressed emotions in family)

25. Limiting factors- Factors which limit the illness from an extensive progress and may include factors such as good social support or treatment during the course of illness. Modifying factors- Factors which modify natural or expected course of the illness. This includes factors such as use of substance by a patient with Schizophrenia which may lead to affective colouring of illness, use of antidepressants causing a manic switch in patient with depressive illness.

26. The History of Present Crisis Approach The American Heritage Dictionary defines crisis as “A crucial point or situation in the course of anything; a turning point.” As you begin the interview, ask yourself, “Why now? Why is this a crucial point in this person's life? What has been happening recently to bring her into my office?” Often, psychiatric crises occur over a 1-to 4-week period, so focus your initial questions on this period. What has been happening over the past week or two that has brought you into the clinic? Tell me about some of the stressors you've dealt with over the past couple of weeks.

27. History of the Syndrome Approach Alternatively, you can begin your questioning by ascertaining when the patient first remembers signs of the illness. When did you first begin having these kinds of problems? When was the last time you remember feeling perfectly well? Ensuing questions track the course of the illness through months or years, arriving eventually at the present. Now let's talk about this current episode. When did it start?

28. WHAT IS THE HISTORY OF PRESENT ILLNESS? The HOPI is probably the most important part of the psychiatric interview, and yet there is disagreement on exactly what it should entail. Even experienced clinicians differ in how they approach the HOPI. Some think of it as the “history of present crisis” and focus on the preceding few weeks. Such clinicians begin their interviews with questions such as, “What has been going on recently that brings you into the clinic today?” Others begin by eliciting the entire history of the patient's primary syndrome: “Tell me about your depression. How old were you when you first felt depressed?” These clinicians work forward to the present episode.

29. Each of these approaches may be useful, depending on the clinical situation. If a patient has a relatively uncomplicated and brief psychiatric history, it might make sense to explore that first and then move to the HOPI. If the psychiatric history is long, with many hospitalizations and caregivers, starting at the beginning may bring you too far from the present problem.

30. The evolution of the patient’s symptoms should be determined and summarized in an organised and systematic way. Symptom analysis needs to be done at level of each symptom, so as to rule out (as far as possible) all differential reasons for that particular symptom at that point itself. When explaining a particular complain or symptom, it should be dealt in with as ABC model, i.e. assessing the antecedent to that behaviour, then the behaviour itself and then the consequence of that particular behaviour . Adequate and explanatory examples for each behaviour should be mentioned, in chorological order. How and when a particular behaviour is noticed and how it ends, all needs to be explained in the words of the informant, avoiding use of technical words.

31. Other symptoms which the examiner expects to be present should be asked for, even if the informant does not give spontaneous account. Certain symptoms (such as suicidal attempt) should be asked for and ruled out in all cases. Any such relevant symptom, thus present, should be adequately mentioned . One also needs to rule out all other major psychiatric illness, which can be thought of as possible differentials or co-morbid illnesses. Presence or absence of fever or other physical illness, endocrinal disorder, drug (which can cause psychiatric illness for example antimalarial, steroids etc.) intake, significant head injury, substance use disorder, epilepsy should be enquired about.

32. When mental disorder is thought secondary to these enumerated causes, the decision to classify a clinical syndrome as organic/induced is supported by the following a ) Evidence that the cause in question is known to be associated with one of the mental disorder b ) A temporal relationship (weeks or a few months) between the development of the underlying cause and the onset of the mental disorder c ) Recovery from the mental disorder following removal or improvement of the underlying presumed cause d ) Absence of evidence to suggest an alternative cause of the mental disorder (such as a strong family history or precipitating stress) Conditions (a) and (b) justify a provisional diagnosis; if all four are present, the certainty of diagnostic classification is significantly increased.

33. Impact of illness on patient’s attitudes should be noted. This should include mixing with people, interest in work, self confidence, enthusiasm & optimism, experiencing pleasure in light of current problems. Role functioning and biological functions during the period of illness should be asked for . Role functioning refers to any pattern of behaviour involving certain rights, obligation, duties which an individual is expected, trained and indeed encouraged to perform in a social situation. This would include duties such as studies (in case of a student), occupation (in case of a working adult), taking care of children or household duties. Biological functions are considered in this section because they are subjective phenomena appropriately considered with other subjective symptomatology. These include bowel and bladder control, sleep, appetite, weight and libido.

34. Activities of daily living and personal care & hygiene should be asked for. This would include activities such as brushing teeth, taking bath, taking care of bowel and bladder habits, having food and water. The characteristics of symptoms should be described in detail; frequency, duration and impact . small distinctions may be diagnostically useful. Stating that a patient suffers from insomnia is less useful than describing the insomnia. Difficulty in falling asleep, difficulty in maintaining sleep, and a decreased need for sleep are each associated with different disorders . Whether the patient has been in treatment, has been taking any psychotropic medication, and has (or has not) been compliant are essential elements of the history of the present illness.

35. If a patient has stopped taking a prescribed medication the reasons should be determined. Noncompliance is a symptom that needs to be investigated and not simply dismissed as poor judgment or character weakness. Noncompliance has many possible causes: unpleasant adverse effects, failure to understand the necessity for chronic medication despite symptomatic improvement, insufficiently treated symptoms such as the fear of being poisoned by medication, a reluctance to see oneself as psychiatrically impaired, or simply lacking the transportation and money to get a prescription refilled. In the end of HOPI, all relevant histories which were ruled out should be mentioned under the rubric of negative history.

36. TREATMENT HISTORY It includes details of the treatment obtained in the present episode . When was the first contact ; whether treatment was voluntary/ involuntary . who saw the patient and for how long (Psychiatrist/Psychologist/Physician/Faith healer/Traditional practitioner ). the nature of the treatment (Pharmacological/Psychotherapy/faith healing/traditional ). modality that was helpful (psychopharmacological interventions, individual/ group therapy ).

37. medication, if any that were prescribed, details should be mentioned including doses, duration, compliance, response, adverse effects (tabulate details as much as possible). length of treatment. reason for discontinuing treatments or poor compliance. day treatment/ hospitalization if done, all of these domains should be elaborated.

38. PAST HISTORY OF ILLNESS A) Past medical/surgical illness B) Past psychiatric history

39. PAST MEDICAL/SURGICAL ILLNESS History of chronic medical illness and detail of medication received and the duration of illness. Hospitalization Medical/ neurological/ surgical illness Head injury/ convulsion/ unconsciousness Accident/ surgical procedure DM/ HTN/ CAD/ HIV +ve

40. The occurrence of major illness or surgery is likely to be of considerable significance in a person's life and may be the precipitant of psychiatric disturbance. For example, in response to having a heart attack, a middle-aged man might develop anxiety, depression, and a fear of sex. In addition, many medical conditions and their treatments cause psychiatric symptoms that are clinically indistinguishable from primary psychiatric disorders. Hypoglycaemia can cause panic and anxiety; hypercalcemia - depression and lethargy; and Acute porphyria- psychotic symptoms

41. Moreover, the presence of underlying medical conditions will inform treatment decisions: tricyclic antidepressants will be avoided in patients with cardiac conduction abnormalities, and bipolar I disorder patients with a history of renal disease are more likely to be treated with an anticonvulsant than with lithium. The names and dosing schedules for all currently prescribed nonpsychiatric drugs should be obtained to avoid possible adverse interactions with any new prescription.

42. Aspects of the clinical history may also suggest the need for medical investigation: abrupt onset of symptoms in an older adult with no prior psychiatric history, symptoms atypical for purely psychiatric disorders (e.g., vomiting and diarrhoea or shaking chills), or a history of recent illness or treatment. In addition, abnormalities of the sensorium section of the mental status examination are most typical of delirium and dementia and indicate the need to look for underlying medical conditions.

43. PAST PSYCHIATRIC HISTORY Past psychiatric illness H/O alcohol and other substance abuse/ dependence

44. Past Psychiatric illness History of similar or other symptoms in past Previous diagnosis History of treatment – include from primary care, counselling, CAMHS, complementary therapy as well as mental health services Previous hospitalization, medications, ECT. Recovery between episodes Complete relief or not from past treatment. Compliance of previous treatment

45. The past psychiatric history describes all previous episodes and symptoms whether treated or not. The history should begin with the first onset of symptoms and progress chronologically to the current episode. It describes symptoms in detail and clearly delineates their longitudinal progress. Disorders that are chronic and relapsing are distinguished from isolated episodes of disturbance. It is particularly important to obtain the fullest possible information on prior treatments.

46. The best predictor of treatment response is past experience. If a person has taken psychiatric medication before, it is essential to determine not only which drug, but the dosage and length of treatment, to distinguish non-response from a sub-therapeutic drug trial. Therapeutic benefits and adverse effects should be noted. Similarly, if a patient has received psychotherapy it is important to establish which modality of therapy, at what frequency, for what length of time, and with what benefit.

47. Clinical course indicators- Different task forces have come up with definitions for course indicators in different psychiatric illnesses. MacArthur Foundation Research Network task force proposed following definitions for unipolar depressive disorder. Remission - Treatment of a depressive episode, if successful, would lead to a significant reduction of symptoms (“response”) and ideally to “remission,” a state of minimal or no symptoms. Relapse - If symptoms re-emerged following remission, this would be considered a “relapse” within the index episode. Recovery- If remission were stable over a number of months (i.e. there was no relapse or sub- syndromal symptomatic exacerbations), then recovery would result. “Recovery” essentially meant that the index depressive episode had ended at both the clinical and neurobiological levels. Recurrence- After recovery, a subsequent emergence of symptoms would be regarded as a “recurrence,” or a new depressive episode.

48. Work-group of experts in bipolar disorder developed these consensus operational definitions. Response- A 50% reduction in a score from a standard rating scale of symptomatology from an appropriate baseline, regardless of index episode type (manic, depressed, or mixed) is defined as response. In addition, the other pole cannot be significantly worsened during response. Remission was defined as absence or minimal symptoms of both Mania and Depression for at least 1 week. Sustained remission requires at least eight consecutive weeks of remission, and perhaps as many as 12 weeks. A relapse/recurrence was defined as a return to the full syndrome criteria of an episode of mania, mixed episode, or depression following a remission of any duration. Roughening was defined as a return of symptoms at a subsyndromal level, perhaps representing a prodrome of an impending episode.

49. Substance Use Alcohol, tobacco, ganja, bhang, opioid , cocaine and other substances. Pattern of use Age at onset Relationship to symptoms Harmful use Psychological dependency Physical dependency Previous detoxification Patient view

50. For each substance the interviewer gathers basic information about age of onset, pattern of use over time, current frequency, and level of use and consequences of use (physical, mental, social, and legal ). These facts help to identify problematic current or past patterns of use. Inquiry about tobacco use and problem gambling should be a part of the addictive behaviour inventory. The interviewer should identify periods of abstinence and determine what helped the patient achieve control of use including any specialized treatment for substance use with details about the setting, nature of and response to treatment, as well as engagements with peer support engagement such as Alcoholics and Narcotics Anonymous.

51. FAMILY HISTORY Family members share their genes, as well as their environment, lifestyles and habits. Parents, siblings, spouse, children, other relatives age; age and cause of death; health status; important diseases Occurence of Diabetes Hypertension, heart diseases, stroke Infective diseases Malignant diseases Coagulation disorders Psychiatric diseases, alcoholism, drug addiction Symptoms like those the patient

52. Many psychiatric disorders are familial, and many of those appear to have a genetic component to the cause. Knowing who is in the patient's family and which, if any, psychiatric disorders have been diagnosed may help in diagnosis and treatment planning. Family history can clearly show who is in the family, who is available for support, who may be exacerbating symptoms, whether a general vulnerability to psychiatric disorders exists, and what stresses have been caused by a family member's illness. Any family history of alcohol or substance abuse or of personality problems should be documented. In addition, the family history should provide a description of the personalities and intelligence of the various households in which the patient lived.

53. Consanguinity : Relation by blood/descent from a common ancestor within the same family stock. If present than degree of the consanguinity should be noted. Relationships amongst family members : Patient’s relationship with family members, interpersonal relationship among family members; family squabbles, attitude of family towards patient’s illness; family support system should all be noted in family history part. Genogram : The genogram is a valuable assessment tool for learning about a family’s history over a period of time. Based upon the concept of a family tree, it usually includes data about three or more generations of the family, which provides a longitudinal perspective. The genogram provides a graphic picture of family geneology, including significant life events (birth, marriage, separation, divorce, illness, death);

54. PERSONAL HISTORY It comprises of a chronological account of the person’s personal experiences starting with his birth and birth details. The personal history is usually divided into perinatal, early childhood, late childhood and adulthood . The predominant emotions associated with the different life periods (e.g. painful, stressful and conflictual) should be noted. The personal history may contain information helpful in making a prognosis as well as diagnosis. For example, a good premorbid adjustment reflected in school and work history indicates a good prognosis in patients diagnosed with schizoaffective disorder. The personal history also helps identify key events that may have helped precipitate current symptoms: divorce, loss of work, death of a family member, serious financial setbacks.

55. Birth and Early Development : Antenatal history should start from presence of any illness, medication, drugs, alcohol use, trauma or bleeding, exposure to X-rays, any physical/ psychiatric illness during pregnancy. Illness can include infectious disease which can present as fever with or without rash, sexually transmitted diseases, diabetes, hypertension, jaundice etc. For medications used in pregnancy, one should be aware of teratogenic effects of common drugs. Whether he/she was wanted? Whether it was a planned or unplanned conception? Whether a failed abortion attempt was made? Whether the delivery was full term, preterm or postterm?

56. Place (home/ hospital/ other) and type of delivery (normal/ instrumental/ episiotomy/ caeserian section ) A ny injury at the time of birth, birth weight, normal or delayed cry should be documented. Any other complication during delivery such as abnormal presentation, cord around neck, prolapsed cord, multiple pregnancy or congenital anomaly noticed immediately after birth and presence of neonatal jaundice or cyanosis and its extent should be enquired about. Mode of feeding after birth, any problems associated with feeding, age at weaning, recurrent infections, significant injury, convulsions in period immediate after birth and early childhood should be reported. Any delay in developmental milestones should be documented.

57. Presence of childhood disorders : Comment on presence of hyperactivity, attention deficits and impulsivity. Conduct problems during childhood should be probed into and will include disobedience, lying, stealing, truancy (running away from school), cruelty towards animals, bossy attitude towards younger children, not obeying rules while playing etc. If these symptoms are found in childhood, do make a attempt to look for dissocial personality traits in adolescent period . Temper tantrums are very common in children; when present, extent and intensity should be carefully noted. Neurotic traits (nail-biting, thumb sucking, stammering, mannerisms, bedwetting, phobias, night-terrors, sleep walking, etc.) during childhood should be probed into and if present, the details should be mentioned.

58. Scholastic and extracurricular activities : Comment on age and class of entry in school, type of school, scholastic performance and progress in studies, regularity in school, failures if any, disciplinary problems/actions if any, relational problems with peers/authorities, any discontinuity or change in school/college with reasons, involvement in games and extracurricular activities. Also mention special interests in games if any during childhood. Vocational/Occupational history : Mention the age at which the individual started working professionally for the first time. Duration at each work place, positions held, reasons for leaving, relation with work mates and superiors, promotion (in comparison to colleagues) should be commented upon.

59. Menstrual history: Age of menarche should be asked. What was the reaction of patient towards it and also information and attitude towards mensuration subsequently? Regularly and duration of usual cycle, whether associated with psychological and physical change (pain or any other). Date of last menstruation, duration and reasons of amenorrhea, if any. Sexual and marital history: How and when sexual information and knowledge was first obtained and of what kind, masturbatory history (fantasy and activity), sex play if any, adolescent sexual activity, premarital and extramarital sexual relationship if any, sexual disorders (normal and abnormal), presence of any gender identity disorder are areas to inquire about. Also probe for any history of childhood sexual abuse.

60. Ask for age at marriage and parental consent for marriage. The spouse’s age, occupation, personality and state of health are relevant to the patient’s circumstances should be documented. Also ask for role allocation, sharing of responsibilities and decision making, perceived adequacy of sexual relation. Knowledge and use of contraception should be documented . Forensic history: Trouble with police, law; charges and convictions (sections), status of cases should be adequately mentioned here as per the available information. General pattern of living: Physical environment of the individual should be mentioned here (accommodation, number of rooms, ownership). Also make a comment on ways of handling adversity in home environment.

61. PREMORBID PERSONALITY It is individualised styles of dealing with the environment that is characteristic to each person prior to the onset of psychiatric disorder. It is important to elicit details regarding the personality of the individual. Assess from patient/relatives/others who know the patient well. Mention source of information and its reliability . Describe as under : 1 . Social relations: How were his relation to family (attachment, dependence ); to friends, groups, societies, clubs; to work and work-mates (leader or follower, aggressive or submissive , organizer, ambitious, adjustable, independent)

62. Intellectual activities, hobbies and use of leisure time: Comment on books, plays, pictures preferred; memory, observation, judgement , critical faculty. 3. Predominant Mood: What used to be persistent mood like, was it cheerful or despondent; worrying or placid; strung up or relaxed ; optimistic or pessimistic; self-depreciative or satisfied? Was mood changeable- could he express feelings of love, anger, frustration or sadness, did he loses control over feelings, had he been violent? Was mood stable or unstable (with or without any reason). 4 . Character: a. Attitude to Self : How does patient describe self? What were his strengths and abilities, shortcomings, ability to plan ahead, resilience in face of adversity, hopes and ambitions? Was the level of aspiration high or low? Was he self critical and perfectionist or self approving and complacent in relation to own behaviour and achievements ? Was he steadfast in face of difficulties or intolerant to frustration? Were his interests sustained or evanescent?

63. b . Attitude to Work & Responsibility: Did he welcome responsibility or was worried by it; made decisions easily or with difficulty? Was he methodological or haphazard in his approach ? Was he flexible or rigid? Was he cautious, foresightful and given to checking or impulsive & slipshod? Was he determined towards goal or used to get bored or discouraged easily ? c. Interpersonal relationships : Was he insensitive or sensitive to criticism? Was he trusting or suspicious and jealous? Was he selfish and egotistical or unselfish and altruistic? Was he emotionally controlled or irritable and quick tempered? Was he quiet and restrained or expressive and demonstrative in speech and gesture? Was he tolerant or intolerant to others? Was he adaptable or unadaptable? Did he use to prefer company or solitude? Was he shy or used to make friends easily , were relationships close and lasting? How he used to handle others’ mistakes, did he always want to be centre of attention ? How was the relation with work-mates or superiors , any affiliations to any society?

64. d . Standards in moral, religious and health matters: What were his religious and moral attitudes? Was he given to much or little concern about own health? e. Energy, initiative: Was he energetic or sluggish? Was output sustained or fitful? Did he used to get easily fatigued? Were there regular or irregular fluctuations in energy or work output? 5 . Fantasy life: What was the frequency and content of day dreaming ? 6. Habits : Use of alcohol, drugs, tobacco; comment on food and sleep pattern

65. Thank you