“How do you take case history?
”
In history taking and the examination of the patient, two methods may be followed. They are
not alternatives, and it is best if they are combined , for each has its own deficiences. The free
interview may deterioate into a conversation into social level, and may provide only hints and
indications, rather than solid facts; certain important themes may go untouched. The method
of questionnaire has other defects. It is uncomfortable for the informant or the patient and he
may feel as a pupil in presence of school-master; and the information obtained may consist in
a mass of detail, without highlight or relief, which is very difficult to organize into a coherent
picture.
Thus the best plan is to have a framework of questionnaire in mind, but to allow the patient
to tell his story. As the story unfolds, it is fitted into the framework, so that any gaps that are
still left are apparent. Further questioning will then fill up the gaps and will clarify point of
salient importance. The plan should be subject to modification as the information pours in.
The interviewer should avoid giving the patient any feeling that he is being treated as a “case”
only. He should be both neutral and sympathetic. As far as possible, he should keep his mind
open and guard himself against pre-conceived ideas. So, as with a physician, the examination
by a mental health professional needs to be methodological and should be described under
proper headings and should follow a general schema. But the most important caution in use
of the schema is not to be too rigidly bound by it.
in certain types of illness like psychoses, relatives
will be able to provide more reliable information while in neurotic illnesses, the patient would be
the best informant. When information is collected from more than one source, do not collage the
accounts of several informants into one, but record them separately)
Case presentation
Name: JS
Age: 31
Gender: Male
Educational qualification: postgraduation
Occupation: junior advocate
Income: 1-5 lakhs pm
Religion: Hindu
Marital status: married
Socioeconomic status: upper middle class
Address: Najafgarh
Referred by: Psychiatry
Informant: Patient was unaccompanied; no informant available for corroborative history
Chief complaints:
● “Neend nahi aati, phone chalata hu” since 1 year
● “Ghabrahat mehsoos hoti hai har samay” since 7 months
● “Chhoti baaton pe irritate ho jata hoon.” since 7 months
● “Mujhe har chhoti baat ki bahut zyada tension ho jaati hai.” since 7 months
● “Mujhe lagta hai kuch galat ho jayega future mein.” since 7 months
● “Bhook kam lagti hai” since 7 months
● “Body mein hamesha tension rehti hai, muscles tight lagte hain.” since 6 months
● “Main jaldi thak jaata hoon.” since 6 months
Onset: insidious
Course: continuous
Progress: deteriorating
Total duration of illness: 7 months
Factors in illness
Predisposing factors:
● Biological: family history of alcohol dependence (grandfather, uncle) suggesting genetic
vulnerability to emotional dysregulation
● Psychological: low tolerance for criticism
● Social: lack of emotional support from parents, rigid and strict parenting styles
Precipitating factors:
● Biological: sudden hospitalization due to health concerns in August 2025 related to liver
function, nightmares in sleep
● Psychological: stress related to work
● Social: significant finance-related events involving loss/swindling of money in 2025,
being named in 307 (attempted murder) case in June 2025.
Perpetuating factors:
● Biological: ongoing sleep disturbance, substance dependence (hookah, cigarettes)
● Psychological: poor coping style, emotional withdrawal, intolerance for uncertainty,
excessive focus on negative outcomes
● Social: occupational exposure to interpersonal conflicts in other families, unsupportive
spouse, criticism from superiors at work and relatives
Limiting (protecting) factors:
● Good insight and help-seeking behaviour
● Access to psychological treatment
Modifying factors:
● Use of substance (hookah)
History of Presenting Illness:
The patient was apparently asymptomatic until approximately 7 months ago, when he
developed persistent and excessive worry about multiple domains including work, finances, and
future outcomes. The onset was insidious, with a continuous and deteriorating course. The
symptoms emerged in the background of multiple stressors over the past year, including being
named in a chargesheet for an attempted murder case (later resolved), financial loss after being
deceived by a close cousin, and an incident of a friend arriving intoxicated at his residence late
at night. Since then, the patient reports heightened vigilance, particularly experiencing anxiety
when the doorbell rings, anticipating potential threat or disturbance. He describes a persistently
anxious affect with reduced confidence in handling stressors and a tendency to anticipate
negative outcomes.
The patient reports pervasive and uncontrollable worry triggered even by minor situations
(“mujhe har chhoti baat ki bahut zyada tension ho jaati hai,” “mujhe lagta hai kuch galat ho
jayega future mein”), associated with restlessness, muscle tension, irritability, and easy
fatigability. The anxiety leads to avoidance behaviours, such as delaying or not initiating work
(e.g., not opening his laptop due to anxiety), which provides temporary relief but maintains the
symptoms. Biological functions are disturbed, with reduced appetite, initial insomnia for the past
one year due to excessive phone use and overthinking, and consequent daytime fatigue. Role
functioning is impaired in the form of decreased work efficiency and concentration, along with
some degree of social withdrawal; however, activities of daily living and personal care remain
adequately maintained.
Negative history:
● No persistent sadness, low mood, loss of interest in activities, feelings of hopelessness,
or thoughts of self-harm or suicide.
● No episodes of unusually elevated or irritable mood, increased energy, decreased need
for sleep, excessive talking, or engagement in risky or goal-directed activities.
● No sudden episodes of intense fear or discomfort associated with palpitations, sweating,
breathlessness, chest discomfort, or fear of losing control or dying.
● No recurrent intrusive thoughts, images, or urges that are distressing and difficult to
control, and no repetitive behaviours such as checking, washing, or counting.
● No suspiciousness, fear of being harmed or plotted against, hearing voices in the
absence of external stimuli, or other perceptual disturbances.
● No recurrent distressing memories, flashbacks, or nightmares related to a specific past
event, and no marked avoidance of reminders of such events.
● No history of significant head injury, seizures, episodes of loss of consciousness, or
known hormonal/endocrinal disturbances.
● No history of recent medication use (e.g., steroids or other drugs) that could contribute to
psychological symptoms.
● No current alcohol use; past history of alcohol use present. No use of other substances
except regular hookah consumption.
Treatment history: patient managed symptoms by coping and engaging in physical activity, due
to exacerbation in worry symptoms in the past 4 days, patient sought a psychiatrist in SGT
hospital and was recommended psychological counselling. The patient is undertaking a
combination psychiatric medication and therapy to manage symptoms.
Treatment history
Past history of medical illness/treatment
● Hospitalization at 5-7 years of age for Typhoid
● Treatment sought for discharge from ear due to ear infection in childhood
● Road accident in 2007 lead to major surgery for muscle injury of the calf
● Hospitalized and treated for liver complication in august 2025 due to prolonged alcohol
consumption
Past history of psychiatric illness/treatment
● No history of psychiatric treatment report by patient
Family history
● No consanguinity between parents
● Father survived a heart attack in 2000. Currently has cardiac issues, tends to argue with
patients and gets irritable in general
● Mother is caring and patient confides in her
● Wife is distant and patient does not trust her
● Brother is having an unfavourable attitude and patient finds him to have a mindset that
he is superior
● sister -in-law has a cordial relationship with patient
● Family has a positive attitude towards patient’s illness and treatment
Genogram
Personal history
1. Birth history and early developmental history: full term, normal with no complications, all
developmental milestones achieved on time
2. Presence of childhood disorders: no instances
3. Home atmosphere in childhood and adolescence: lived in village in joint family till 6th,
congenial, shifted to city with parents and felt lonely, parents were supportive
4. Scholastic and extracurricular activities: started education at 3 years, went to private
school, performance was average, attendance was regular, had 15-20 friends, was
considered the “class clown”
5. College history: went to bachelors and pg in university in Rohtak, started smoking
cigarettes and marijuana due to peer influence, discontinued marijuana after 2 years.
6. Occupational history: Started legal practice in 2018, is a junior advocate since 2018, had
started taking cases by self 6 months ago, used to experience anxiety symptoms when
had to face magistrate, has good relationship with superiors and colleagues.
7. Sexual history and marital history: got married in 2022 (arrange), had a normal reaction
to pregnancy, engaged in masturbation practices almost everyday since 7/8th grade
8. Legal history: named in chargesheet for attempted murder, cleared
9. General pattern of living: best period - college life as he felt free and was adventurous,
handles adversity by talking to mother which makes him feel better
Premorbid personality
Information provided by patient due to lack of informant
a. Social relations: attached to family members and friends, is a follower, ambitious,
adjustable and independent.
b. Character:
i. Attitude to self: wants what is best for everyone, seems himself as helpful,
selfless with ambitions and goals and high aspiration level, he is complacent
towards his own behaviour and achievement and is self critical, intolerant to
frustration, evanescent interests
ii. Attitude towards work and responsibility: welcome responsibility, made decisions
easily, methodological, flexible, cautious, foresightful, determined towards goal
iii. Interpersonal relationships: self confident, sensitive to criticism, trusting, unselfish
and altruistic, tactful or outspoken, enjoys self-display, expressive and
demonstrative in speech and gesture, tolerant to others, adaptable, prefer
company, make friends easily, relationships close and lasting, forgiving of others’
mistakes, was okay with attention? Good relationship with work-mates or
superiors
iv. Standards in moral, religious and health matters: is passive about religion,
followed traditions as directed by elders, is prone to concern about health
v. Energy, initiative: energetic and output sustained, low fatigability, no irregular
fluctuations of energy in work
c. Intellectual activities: prefers having conversations with friend group about current affairs
d. Predominant mood: cheerful, worrying, relaxed; optimistic, self-depreciative, mood was
changeable, controlled and stable
e. Habits and dependence: daily hookah session with friends at least thrice, frequent
smoking cigarettes, decreased appetite and difficulty going to sleep
f. Impression: the patient appears to have had a well-adjusted, socially engaged, and
goal-oriented personality, with good interpersonal functioning and a sense of
responsibility. He was confident, expressive, and maintained close relationships.
However, he also exhibited anxious and emotionally sensitive traits, including
sensitivity to criticism, low frustration tolerance, self-critical tendencies, and a propensity
to worry. These features suggest a predisposition to anxiety in the face of stress.
Mental status examination
1. General appearance and behaviour: patient appeared kempt and tidy, appropriate to age
with ectomorphic build, was oriented to surroundings, eye contact was maintained, was
cooperative and rapport was established with ease, psychomotor activity was increased
characterised by restlessness,
2. Speech was spontaneous, audible, normal reaction time, productive, normally rated,
relevant, coherent, goal-directed, with normal pitch, tone and volume
3. Higher mental functions
a. Attention and concentration: aroused and sustained
b. Patient was oriented to time, place and person
c. Immediate, recent and remote memory was intact
d. Abstract thinking was intact
e. Intelligence: Adequate general fund of knowledge and able to do simple and
complex calculation
4. Affect:
a. Subjective: “theek hu”
b. objective: patient was anxious, normal range, reactive, communicable,
appropriate to thought content and context
5. Thought content is reflected by worry
6. Judgement is intact
7. Insight is rated at grade IV
Diagnostic formulation
JS is a 31-year-old married Hindu male, postgraduate, working as a junior advocate, belonging
to an upper middle socioeconomic background from Najafgarh, who presented unaccompanied
with an illness of 7 months duration, characterised by insidious onset, continuous course, and
deteriorating progress. The illness began in the context of multiple psychosocial stressors,
including legal involvement in a chargesheet (later resolved), significant financial loss due to
deception by a close relative, and distressing interpersonal experiences, following which the
patient developed excessive and pervasive worry about multiple domains such as work,
finances, and future outcomes. The symptoms are associated with restlessness, irritability,
muscle tension, easy fatigability, reduced appetite, and sleep disturbance in the form of initial
insomnia, leading to impairment in occupational functioning, reduced concentration, and some
degree of social withdrawal, while activities of daily living remain preserved.
There is no past history of psychiatric illness. Relevant medical history includes hospitalization
for liver complications secondary to alcohol use in the past, with current abstinence from alcohol
but continued use of hookah and cigarettes. Family history is suggestive of alcohol dependence,
and personal history indicates early environmental stressors and current interpersonal
difficulties. Premorbidly, the patient had a well-adjusted, socially engaged, and goal-oriented
personality with anxious and emotionally sensitive traits, including sensitivity to criticism, low
frustration tolerance, and a tendency to worry, which may have predisposed him to anxiety in
the face of stress. Mental status examination reveals an anxious affect with increased
psychomotor activity, intact cognitive functions, preserved judgement, and grade IV insight.
Provisional diagnosis: GAD
Differential diagnosis
Boundary with panic disorder
Panic disorder is characterized by recurrent, unexpected, self-limited episodes of intense fear or
anxiety. Generalized anxiety disorder is differentiated by a more persistent and less
circumscribed chronic feeling of apprehensiveness, usually associated with worry about a
variety of different everyday life events. Individuals with generalized anxiety disorder may
experience panic attacks that are triggered by specific worries. If an individual with generalized
anxiety disorder experiences panic attacks exclusively in the context of the worry about a variety
of everyday life events, or general apprehensiveness without the presence of unexpected panic
attacks, an additional diagnosis of panic disorder is not warranted and the presence of panic
attacks may be indicated using the with panic attacks specifier. However, if unexpected panic
attacks also occur, an additional diagnosis of panic disorder may be assigned.
Boundary with social anxiety disorder
In social anxiety disorder, symptoms occur in response to feared social situations (e.g. speaking
in public, initiating a conversation), and the primary focus of apprehension is being negatively
evaluated by others. Individuals with generalized anxiety disorder may worry about the
implications of performing poorly or failing an examination but are not exclusively concerned
about being negatively evaluated by others.
Boundary with depressive disorders
associated with pessimistic thoughts. Depressive disorders are differentiated by the presence
of low mood or loss of pleasure in previously enjoyable activities, and by other characteristic
symptoms of depressive disorders (e.g. appetite changes, feelings of worthlessness, suicidal
ideation). Generalized anxiety disorder may co-occur with depressive disorders, but should only
be diagnosed if the diagnostic requirements for generalized anxiety disorder were met prior to
the onset of or following complete remission of a depressive episode.
Boundary with adjustment disorder
Adjustment disorder involves maladaptive reactions to an identifiable psychosocial stressor or
multiple stressors characterized by preoccupation with the stressor or its consequences.
Reactions may include excessive worry, recurrent and distressing thoughts about the stressor,
or constant rumination about its implications. Adjustment disorder centres on the identifiable
stressor or its consequences, whereas in generalized anxiety disorder, worry typically
encompasses multiple areas of daily life and may include hypothetical concerns (e.g. that a
negative life event may occur). Unlike individuals with generalized anxiety disorder, those with
adjustment disorder typically have normal functioning prior to the onset of the stressors.
Symptoms of adjustment disorder generally resolve within 6 months.
Boundary with obsessive-compulsive disorder
In obsessive-compulsive disorder, the focus of apprehension is on intrusive and unwanted
thoughts, urges or images (obsessions), whereas in generalized anxiety disorder the focus is
on everyday life events. In contrast to obsessions in obsessive-compulsive disorder, which are
usually experienced as unwanted and intrusive, individuals with generalized anxiety disorder
may experience their worry as a helpful strategy in averting negative outcomes.
Boundary with hypochondriasis (health anxiety disorder) and bodily distress
disorder
In hypochondriasis and bodily distress disorder, individuals worry about real or perceived
physical symptoms and their potential significance to their health status. Individuals with
generalized anxiety disorder experience somatic symptoms associated with anxiety and may
worry about their health, but their worry extends to other aspects of everyday life.
Boundary with post-traumatic stress disorder
Individuals with post-traumatic stress disorder develop hypervigilance as a consequence of
exposure to the traumatic stressor, and may become apprehensive that they or others close to
them may be under immediate threat either in specific situations or more generally. Individuals
with post-traumatic stress disorder may also experience anxiety triggered by reminders of the
traumatic event (e.g. fear and avoidance of a place where an individual was assaulted). In
contrast, the anxiety and worry in individuals with generalized anxiety disorder is directed
towards the
possibility of untoward events in a variety of life domains (e.g. health, finances, work).
Management Plan
a) Further Investigations
● Collateral history from family members (to improve reliability)
● Review of past medical records (liver function, hospitalization details)
● Basic laboratory investigations (LFT, TFT, CBC) to rule out organic contributors
● Psychological assessment (anxiety severity scales, personality assessment if required)
b) Immediate Management
● Patient can be managed on an outpatient basis
● Psychoeducation regarding nature of anxiety and role of worry
● Pharmacotherapy: initiation of SSRI (e.g., escitalopram) with short-term anxiolytics if
required
● Sleep hygiene and reduction of maladaptive coping (excessive phone use)
● Monitoring for risk (though currently no suicidality reported)
c) Long-Term Management
● Psychological: Cognitive Behaviour Therapy focusing on
○ intolerance of uncertainty
○ worry management
○ cognitive restructuring
○ behavioural activation and reduction of avoidance
● Substance use management: gradual reduction of hookah and nicotine
● Stress management and coping skills training
● Family involvement to address interpersonal stressors and improve support