New York (State). Dept. of Mental Hygiene.

Guides for history taking and clinical examination of psychiatric cases online

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GUIDES FOR HISTORY TAKING
AND CLINICAL EXAMINATION

OF

PSYCHIATRIC CASES



EDITED BY

GEORGE H. KIRBY, M. D.
Director, New York State Psychiatric Institute



PUBLISHED BY

THE NEW YORK STATE HOSPITAL COMMISSION
ALBANY, N. Y.



UT1CA. N. Y.

STATE HOSPITALS PRESS
1921




THE LIBRARY

OF

THE UNIVERSITY
OF CALIFORNIA

LOS ANGELES



GIFT OF



DR. ROY VAN WART



Biomedieal
Library



CONTENTS



PAQ

PREFACE 5

I . THE USE OF GUIDES IN CLINICAL PSYCHIATRY ... 6

II . THE ANAMNESIS GUIDE 9

III . THE PERSONALITY 21

IV . PHYSICAL EXAMINATION GUIDE 29

V . BODY DEVELOPMENT AND ENDOCRINE GLANDS ... 43

VI . MENTAL EXAMINATION 57

VII . FURTHER PSYCHOLOGICAL ANALYSIS 78

VIII. EXAMINATION OF NON-COOPERATIVE OR STUPOR-

ous PATIENTS . 81



635441



PREFACE

Over fifteen years ago Dr. Adolf Meyer, then Director
of the Psychiatric Institute, prepared a set of clinical guides
or outlines for use in the New York State Hospitals. These
were furnished the physicians in typewritten form. Their
practical value was quickly recognized with the result that
they were adopted as the standard method of clinical study,
not only in the New York State Hospitals, but in many other
institutions throughout the country. A number of changes
and additions to the guides have been made with the pas-
sage of time and the advance of psychiatric knowledge, but
there has been no departure from the general plan origin-
ally formulated by Dr. Meyer for history taking and clinical
examination of mental cases.

There has long been a demand that the guides be made
available for use in permanent printed form. The decision
of the State Hospital Commission to publish the guides
gave the editor an opportunity to revise and amplify them
in several directions and to add considerable new material
which has been accumulated as the result of the experience
of recent years.

The guide for the study of the personality make-up is
based on the well known work of Hoch and Amsden and fol-
lows in a general way the outline prepared by Dr. Hoch
for use in the State Hospitals while he was Director of the
Institute.

Dr. Clarence 0. Cheney, Assistant Director of the Insti-
tute helped materially in the revision, and the guide for
the study of body development and the endocrine glands
is almost entirely his work. Dr. Charles E. Gibbs of the
Institute Staff assisted in revising the anamesis guide.

From various physicians in the New York State service
helpful suggestions have been received. The Editor wishes
to acknowledge particularly the assistance rendered by Dr.
George W. Mills, Clinical Director of the Central Islip
State Hospital, and Dr. Mortimer W. Raynor, Clinical
Director of the Manhattan State Hospital.

October 1, 1921. G. H. K.



THE USE OF GUIDES IN CLINICAL PSYCHIATRY

The necessity of following some kind of a plan or method
of case-study in psychiatric work is universally recognized.
Physicians taking up psychiatry should, therefore, first
of all, try to perfect themselves in the art of history taking
and strive to develop a good technique for the examination
of mental patients. Facility and skill in these directions
will* be acquired slowly and only after painstaking effort.
Method and technique are certainly just as important in
psychiatry as in any branch of internal medicine or clinical
diagnosis.

Owing to the variety and complexity of the situations
dealt with in the investigation of life histories and the
difficulties encountered in the examination of many types
of mental disorder, the physician who approaches a case
without a definite plan in mind is certain to overlook im-
portant facts or permit the patient to lead too much in the
examination, often with the result that the time is not spent
to the best advantage.

One of the chief obstacles in developing a satisfactory
scheme has lain in the difficulty of devising guides that
would meet the requirements of the widely differing types
of cases without at the same time becoming too cumbersome
and involved for practical clinical application. Further-
more, the kind of guidance needed by one beginning psychi-
atric work is quite different from that required by an
experienced clinician. One unfamiliar with the guides
presented in the following pages will perhaps at first feel
that they are too elaborate and go too much into detail;
especially is this likely to be the reaction of one who must
examine fairly rapidly a large number of cases, a situation
which, unfortunately, often confronts physicians in state
hospitals. The fact that work must sometimes be done



under conditions unfavorable for the best and most satis-
factory results furnishes no valid reason for objection to a
method which aims at a higher level of thoroughness and
completeness.

The guides present in some detail the various topics
which it is essential to keep in mind if cases are to be care-
fully and adequately studied. It is not expected that one
would, even under ideal conditions, undertake to follow out
in every case every line of inquiry suggested in the various
guides. The guides contain a good deal of information and
various tests which should be available when needed. One 's
experience and judgment must decide how far it is desirable
or necessary to push the examination in this or that direc-
tion. Thorough familiarity with the guides and the general
plan of study outlined will give the physician a solid foun-
dation on which to develop good psychiatric technique and
clinical skill, will make the daily work more interesting and
valuable, and will qualify him to make special clinical
studies and investigations as opportunities arise.



8



THE ANAMNESIS GUIDE

(Synopsis)

INTRODUCTION

1. INFORMANT

2. FAMILY HISTORY

3. PERSONAL HISTORY

I. Birth and Early Development

II. Intellectual and Social Development

HI. Sexual Development and Function

TV . Diseases and Injuries

V . Occupation

VI. Alcohol and Other Toxic Influences

VII. Previous Attacks of Mental Disorder

VIII. Etiologic Factors and Precipitating Causes

4. ONSET AND SYMPTOMS OF THE PSYCHOSIS



II

THE ANAMNESIS GUIDE

Introduction. In the study of mental cases nothing is
more important than a good account of the previous history
of the patient, the physical and mental development, and
the manner in which the psychosis began. Without this
information it will be quite impossible in many cases to
understand the nature of the disorder or to make a satis-
factory diagnostic grouping of the cases. It is therefore
essential to devote as much time and care as possible to the
obtaining of full and reliable statements from visitors. It
requires time and experience to become proficient in this
aspect of psychiatric work.

In mental cases the practice should be to try always to
get the anamnesis from relatives or friends, as in many
instances one cannot depend on the patient for the previous
history as is usually done in general medical cases. A
number of interviews with the same informant, or with
different members of the family, or friends, will in most
cases he necessary in order to obtain a correct estimate
of the family stock and traits and to get a satisfactory ac-
count of the patient's life and mental breakdown. It is
particularly difficult to obtain a good anamnesis by means
of correspondence or through attendants, although the latter
often do very well if an effort is made to train them by some
systematic instruction in history taking and in the use of
suitable guides or forms. Trained psychiatric social work-
ers may often be of great assistance in getting histories and
the physician should not neglect to utilize to the fullest
extent the services of the social worker in securing the
desired information.

In the following guide various important lines of inquiry
are taken up under certain general headings. This is done
for purposes of convenience and systematic approach, but



10

the sequence suggested need not in all cases be followed.
It must also be constantly borne in mind that a psychiatric
history portrays growth, development and change a
stream of events and the reaction to them, so that an ac-
count of the individual as to tendencies or health at one
period may be quite different from that of another time
of life. There are some advantages in dividing up the
descriptions roughly into the periods of infancy and child-
hood, puberty, adult life, involution, senescence all of
which have special features, physical and mental, that are
of great psychiatric importance.

Before the anamnesis is considered complete, all of the
topics mentioned should be covered by an appropriate in-
quiry. But common sense and judgment must be used in
deciding just what amount of detailed investigation the
different topics call for. We learn by experience where to
place the emphasis and in what direction to press our in-
quiries. The anamnesis of a case of senile psychosis will
be taken with a different object in view than that pursued
in a case of dementia prsecox.

The use of short summarizing headings for the different
paragraphs or topics is advised, as these render it easy to
get rapidly the salient facts from a case history. The
headings should, however, be brief and concise and not
simply a somewhat shorter statement of what is to follow
in the paragraph.

In cases where there are no relatives or visitors and the
patient must give the' previous history, it is advised that
this be recorded in the usual form of an anamnesis and be
placed, as is customary, in the front part of the case record
rather than incorporated in that division of the mental
status dealing with memory tests and the patient's ability
to give personal data. In some cases it will, of course, not
be possible to take an anamnesis from the patient until the
more disturbed phase of the psychosis has subsided or
even until convalescence has set in. Case histories often
lose a great deal of their value because no anamnesis was



11

obtained from the patient before discharge or from the
visitor who came to take the patient home.

It is suggested that the physician always have the guide
at hand when the visitors are interviewed. In addition the
physician should have before him the following :

1. The commitment paper or a typewritten copy of it
if the patient is a committed one. It is important to go
over the statements of the relatives and the patient con-
tained in the paper. Very often relatives deny statements
made to the committing physicians or give quite a different
account of happenings preceding the patient's admission
than that recorded in the commitment paper.

2. The statistical data sheet (New York State Hospital
Form 22-Medical). This should be filled in as far as pos-
sible at the time the anamnesis is taken because many of
the items require special inquiry if accurate statistical data
are to be obtained. It is also important to complete as
much of the data sheet at this first interview as possible
because of certain information called for in death certifi-
cates, in questions of legal residence, in deportation pro-
ceedings, etc.



12



THE ANAMNESIS

Taken by Date

INFORMANT :

1. Name

2. Address

3. Relationship to patient

4. Intelligence and reliability

Record any mental or physical abnormality observed in
the informant and other relatives seen. Subsequent family
history and observations made on relatives may be recorded
as an addition to the family history and inserted in the
case record.

FAMILY HISTORY:

The family history furnishes evidence as to the hereditary
factor as well as the environmental influences. In addition
to a history of definite psychosis or nervous disease, it is
desirable to secure evidence of the various less direct and
specific factors which throw light on the social reactions
and intellectual development as well as the physical make-
up and defects of the different members of the family.
Deviations from normal may not be manifest in the same
way in each generation. A member of one generation may
show evidence of endocrine disturbance in the form of
goiter, while a member of the previous generation may have
displayed the disturbed metabolism of diabetes.

It is not sufficient to ask simply the general question:
has any member of the family been insane or nervous? A
great many persons will answer in the negative, whereas,
a detailed inquiry will often bring out a number of in-
stances of nervous or mental troubles. In a similar way
questions regarding physical defects and diseases in the
ancestors must be as specific as possible. All questions
should be put in non-technical terms, and judgment and



13

discrimination must be used in accepting as a settled fact
diagnoses or causes of death as given by the informant.
A descriptive statement as a rule is much preferable to a
one-word diagnosis.

In order to cover the ground satisfactorily specific in-
quiry should be made concerning each member of the family
indicated below and the data recorded in the sequence
given. If the informant has no knowledge regarding any
individual of the given generations, it should invariably
be mentioned in order that in our statistical studies we
may be able to put together the cases about which we have
the facts and exclude those about which we have no infor-
mation. It is not permissible merely to say that the family
history is negative : this rarely if ever can be proven to be
true especially if we have complete and reliable data cover-
ing several generations. One may, therefore, usually make
a statement that the history is negative only in reference
to a particular generation or branch.

The direct line includes

1. Paternal grandfather

2. Paternal grandmother

3. Maternal grandfather

4. Maternal grandmother

5. Father

6. Mother

7. Children in family, siblings or brothers and sisters of

patient. Record in order of birth, including still-births
and those dead.

8. Children of patient, give in order of birth.

The collateral line includes
Uncles, aunts, and cousins.

The aim should be to obtain as complete information as
possible regarding all members of the direct line and to
gather as many facts as is feasible regarding the collateral
lines. With this object in view, the history of each individ-
ual of the different generations, as above indicated, must



14

be systematically recorded. The data may be conveniently
arranged and classified as follows : '

1. Name, relationship to the patient, living or dead, age, cause

of death, occupation

2. Mental disease: psychosis or suicide

3. Mental deficiency: idiot, imbecile, moron

4. Nervous disease :

(a) Organic: brain tumor, cerebral arteriosclerosis, mul-

tiple sclerosis, paralysis agitans, Huntington 's chorea,
muscular atrophies, etc.

(b) Functional: psychoneuroses, ''nervous prostration,"

acute chorea, migraine, epilepsy, etc.

5. Psychopathic personality: eccentricity, seclusiveness, emo-

tional instability (excitable, depressive, cyclothymic),
irritability, stubbornness, suspiciousness, suicidal impulses,
nomadism, criminality, sexual perversions, etc.

6. Alcoholism, drug addiction, or exposure to other toxic exog-

enous agents

7. Physical defects and diseases :

(a) General

Gastro-intestinal

Cardio-vascular, often referred to as "apoplexy",

"stroke" or paralysis
Renal disease
Cancer
Gout
Asthma

(b) Infections

Tuberculosis
Syphilis

Other infections: typhoid, rheumatism, pneumonia,
etc.

(c) Endocrine and metabolism disorders

Giantism, dwarfism
Obesity, abnormal leanness
Thyroid disease, diabetes



15

(d) Defects of development and "stigmata of degenera-
tion", deaf -mutism, albinism, congenital deform-
ities, unusually large or small hands, feet, or head.

PERSONAL HISTORY :

I. Birth and early development

Present age Date of birth

Place of birth

Mother's condition during pregnancy

Character of labor Unusual incidents or complications

General health in infancy and childhood : Robust, delicate

or sickly
Infantile and childhood diseases Age, severity and

complications Injuries Spasms Convulsions
Bed-wetting When stopped

Talked and walked at what age
Disposition as a child Docile, happy, cranky, peevish,

fretful Tantrums or fits of temper
Night terrors, fears, frights, chorea
Was growth regular, slow, or rapid.
Any special period of rapid growth
Thin or fat

Nose bleeding: Periodicity
Headaches: Character, location, periodicity

II. Intellectual and Social Development

Infancy and childhood : bright, dull, or average

School history : years at school, progress, interest, behavior.

age and grade at which stopped Play activities and

attitude to playmates
Delinquency: truancy, waywardness, tramp-life, police

record

Adult intellectual level: well informed or ignorant
General range of interests and social activities
Religious affiliations: devout or indifferent

III. Sexual Development and Function

1 . Physiologic

Males. Age at puberty or when first shaved, or when
voice changed Masturbation, when begun,
how long continued Frequency



16

Sexual activity : relations with women, char-
acter and frequency Single or married,
age at marriage, number of children Anti-
conceptual measures Any change in sexual
power Impotency How long Date of
last intercourse

Females. Menstrual history Age at onset

Regularity Amount and duration
Preceding symptoms
Associated symptoms
Post-menstrual symptoms
Headaches Character and duration
,; Masturbation When begun How long

continued Frequency
Single or married Age at marriage
Pregnancies Abortions
Number of children Anti-conceptual

measures

Menopause : Age and accompanying symp-
toms
2. Psycho-sexual

Unusual childhood interests or curiosity
Adolescent interests. Abnormal love attachments or

perversions

Family situation: strong attachments or antagon-
isms to either parent, or to other members of the
family Special dependence or reluctance to leave
home Attitude toward family determined by any
special occurrences.
Love affairs and disappointments
Sexual irregularities, seduction or prostitution
Reasons for marriage or for single life
Treatment of partner abuse, separation, divorce

IV. Diseases and Injuries

1. General. What sickness has patient had since child-
hood Were any mental symptoms associated
Gastro-intestinal, cardio-vascular, renal, or urinary
disorders Gout Convulsions, fainting attacks,
migraine



17

2. Infections

Tuberculosis. Evidence of active infection, loss of
weight, cough, hemoptysis, weakness, hematuria,
pleurisy, adenitis, night sweats, etc.

Syphilis. Sore, eruptions, etc. Age when acquired,
treatment, symptoms of involvement of nervous
system

Focal and other infections. Tonsilitis, ulcerated
teeth, otitis and sinusitis, rheumatism, heart disease,
acute chorea, gonorrhoea, prostatitis, etc. Measles,
diphtheria, typhoid, pneumonia, influenza

3. Symptoms suggestive of endocrine and vegetative

nervous system disturbances

The information already obtained regarding the
family and personal history may have indicated
the presence of some endocrine or vegetative nervous
system disturbance. In any case the following
points should be covered in the inquiry for endoc-
rine disorders:

Abnormal desire for sweets, fats, fluids

Regularity, degree of such desire, and bad symp-
toms following

Increased urination day or night

Diabetic symptoms

Investigation of disorders referable to the vegetative
nervous system should include the following :
Sensations of heat or cold
Hay fever, asthma, eczema, urticaria
Exhaustion or lassitude
Chills and goose flesh

V. Occupation

Kinds of work undertaken, ambition, efficiency, wages, etc.
Length of time in different positions, reasons for changes, etc.

VI. Alcohol and Other Toxic Influences

Intemperate, moderate, or total abstainer. If intemperate,
age at which drinking began, apparent cause of excesses, kind
of beverage consumed and approximate amounts. Periodic
or steady drinker. Usual reaction to alcohol.



18

If intemperate, inquire about attacks of neuritis, delirium,
hallucinatory episodes, suspicions, ideas of jealousy.

Other Toxic Influences. Drug habits, occupational poisons,
lead, arsenic, phosphorus, mercury, etc.

Illuminating gas poisoning, nicotine, intoxication, food
toxicoses.

VII. Previous Attacks of Mental Disorder

Get dates, places where treated, apparent cause, duration
of attacks and general character of symptoms.
Associated physical diseases.

VIII. Etiologic Factors and Precipitating Causes of Present

Psychosis

Often the psychosis appears to have gradually developed
in connection with causes, physical or mental, or both, oper-
ating over a comparatively long period. In some cases the
causes may be indefinite or not easily elicited, but careful
inquiry should be made in such instances for possible etiologic
factors and an evaluation made of them.

In other cases, however, the mental break-down seems to
have come on more or less abruptly as if precipitated by some
special occurrence or situation. Especially to be inquired
about are:

Mental Causes of an emotional nature such as love affairs,
sexual episodes, disappointments, reverses, quarrels, separa-
tions, deaths in the family, childbirth, etc.

Physical Causes such as acute or chronic illness, infection,
childbirth, exhaustion, injury, operation, etc.

ONSET AND SYMPTOMS OF THE PSYCHOSIS

Take as far as possible a spontaneous account beginning with
the date when the first symptoms were noticed in the patient.
In this connection particular attention should be given to
changes in behavior, in mood, in manner of speech, in attitude
toward others and toward work.

The early symptoms may be physical. In an organic brain
disease we may find among the first symptoms an eye-muscle
palsy, a fainting spell, headache, pains, etc; in constitutional
mental disorders the onset may be associated with prominent
physical complaints, e. g., gastro-intestinal symptoms, fussing
about health, hypochondriasis, etc.



19

Inquiry should be made regarding the appearance of sus-
picions, unusual interests, peculiar ideas and delusions.

Hallucinations in various fields and the reaction to them.

Obtain as much as possible regarding the trend of
patient's ideas, topics of conversation and content of hallucin-
ations. What did the voices say? What was seen in visions?

Forgetfulness, impairment of memory, loss of orientation,
clouding of sensorium, delirium.

Always inquire regarding suicidal inclinations or attempts,
threats of violence, assaults or homicidal tendencies.

Compare informant's statement with those given in com-
mitment certificate.

What treatment was given at home? Name of physician in
attendance.

Date on which patient was taken from home to hospital.
By what means taken, by whom accompanied, and what was
the patient's reaction to the removal?



20



THE PERSONALITY

(Synopsis)
INTRODUCTION

I. GENERAL, INTELLIGENCE, KNOWLEDGE AND
JUDGMENT

II . OUTPUT OF ENERGY

III. GENERAL ATTITUDE TOWARD ENVIRONMENT

VI . ATTITUDE TOWARD SELF : INNER MENTAL LIFE

V . ATTITUDE TOWARD BEAUTY

VI. MOOD: EMOTIONAL REACTIONS

VII. SEXUAL INSTINCTS

VIII. FEELING OF INFERIORITY

IX. SUMMARY OF PERSONALITY TRAITS



in

THE PERSONALITY

Introduction. In taking the general anamnesis, ques-
tions of mental make-up and temperamental reactions will
naturally be touched upon to some extent. The relation of
psychosis to personality is, however, such an extremely im-
portant one that it becomes necessary to make a special
inquiry into the habitual or preferred mental reactions
which characterized the individual prior to the time of the
appearance of definite signs of a mental breakdown.

The various traits which together form the ensemble
which we call the personality are of complex origin, being
determined by instinctive reactions, early experiences and
training and a gradual development of mental habits, in-
terests and attitudes. It is of great importance to
know something about an individual's customary way
of meeting various situations, e. g., whether the prefer-
ence is for a square facing of difficulties or for evasion,
substitution or some sort of escape. It is now well estab-
lished that the preferred or habitual reactions peculiar to
a person tend to appear in accentuated form in the psychosis
which thus derives many of its characteristics directly from
the constitutional background ; from the standpoint of path-
ogenesis there is reason to believe that preferred reactions
often actually serve to guide an individual into a psychosis.


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Online LibraryNew York (State). Dept. of Mental HygieneGuides for history taking and clinical examination of psychiatric cases → online text (page 1 of 5)