Diagnosis of mental unsoundness needs careful examination and involve the following steps –
1. History taking
2. Examination of the physical state
3. Examination of the mental state
4. Special investigation.
1. History taking –
It should be done very intimately, bringing the patient in total confidence. Interview should be taken with maximum patience and should include –
(a) Present complaints, difficulties, (b) Family history – Parents – alive or dead, (c) Personal history – Date and place of birth, whether the birth was normal or after prolonged labour or if the labour was instrumental. If the birth was premature. What was the state of mother’s health during pregnancy? Whether breast fed or not. Whether brought up by mother or any other person.
Infancy and childhood – Milestones of development, e.g. teething, talking, walking, general health and nervous traits. If there is any history of nightmare, fear-state, phobia (school or otherwise). Any history of stammering, chorea, convulsion or somnambulism. History of any febrile condition, head injury etc.
Schooling – Age of starting, age of leaving, class upto which studied, performance in the school, extraordinary or mentionable success or failure, subject or subjects of interest, attitude towards teacher and classmates.
Occupation and place of work – Age of starting of the job, his interest in the present job, any change in the job, how many changes, how long continuing in the present job, the causes of change from the past jobs.
Menstrual history in case of females – Age of menarchy, length of each cycle, regularity, duration of the period, premenstrual tension, dysmenorrhoea, menopause, reaction to menopause.
Sexual life – Inclination to sexual practice, masturbation, attitude towards same sex and opposite sex, sex-relationship with wife or husband, heterosexual experience apart from with the husband or wife, homosexual practice, if any ; sexual fantasies and perversions, if any.
Marital history – Compatibility with the partner, temperamental difficulties, sex relationship with the partner, any history of divorce ; children, miscarriage, attention towards children, relationship with the children.
Personal habits – If accustomed to alcohol, tobacco or other drugs of addiction or habit formation.
History of physical illness – Acute or chronic diseases, suffering at present or suffered in the past; if underwent any operation then its nature and outcome.
History of previous mental illness.
Personality – Whether timid, over-smart, shy, temperament – if aggressive.
2. Examination of the Physical State –
A detailed examination of all the systems of the body should be performed. It should include the respiratory system, cardiovascular system (pulse; B.P. etc.), nervous system including sensory and motor functions, reflexes, gait, stance, posture etc., condition of the skin, tongue, lips, body temperature, muscular weakness, numbness, tremor, coordination etc.
3. Examination of the mental state –
General appearance and behaviour.
Whether appears younger or older than his age.
Attitude and posture.
Facial expression – tense, anxious, depressed, dejected.
Speech, dress, manner – whether in conformity with and whether in touch with the situation.
Stupor – If there is no spontaneous activity, if does not respond to stimuli.
Overactivity – restlessness, agitated movement.
Behaviour – tics, mannerism, stereotype movements, abrupt, fitful, eratic or constant behaviour, automatic obedience, echolalia, echopraxia, waxy flexibility, negativism.
Personal habit – cleanliness, eating and sleeping habits, hobbies.
Talk – talkative, uncommunicative, retarded speech, mutism, continuous chattering, circumstantiality, if only answers to questions, hesitant in talks, slow, fast, discursive, disconnected talks, change of topics, strange words, perseveration.
Mood – reflected in his speech, behaviour, manner and facial expression.
Mental content – Attitude to himself and others, reaction to the environment, predominant thought, delusions – pleasant or painful.
Disorder of perception – Any hallucination; if present, its type and timing with hours of day and night. Any illusion.
State of consciousness – alert, dull, self-absorbed, confused, delirious, stuporous.
Judgement and insight.
Orientation of time, place and person.
Compulsive phenomena – like obsession, impulse etc.
Sleep – disturbed, contents of dream, insomnia.
Grasp on general information and over current affairs.
4. Laboratory investigations –
Laboratory investigation in the following lines may be necessary.
1. Blood and urine analysis
2. X-ray of the skull
3. C.S.F. analysis
5. Scanning test.
Observation of mental patient –
For the purpose of diagnosis and certification, an alleged mental patient, may be kept under observation of a psychiatrist with order from a magistrate. The period of observation may be upto 10 days at a stretch. During this period of 10 days the doctor not only examines the person regularly, but also observes him at different hours of day and night, in his different activities, with and without his knowledge. If diagnosis cannot be reached during the period of these 10 days’ observation, then the magistrate can order for another 10 days’ observation and that way, the total period of observation can be upto a maximum of 30 days.
Feigned insanity –
With some motive a person may pose to be an insane. Insanity may be feigned by a person to avoid punishment or trial in a criminal case, to avoid certain civil responsibilities or to avail certain advantages. A sane person may be presented as an insane person with some bad motive like to deprive him of his property. It is in such circumstances that observation of the person as described in the preceding para, is essential, particularly when there is any reason to doubt or when there is a reason or motive to feign insanity.
Dangerous Lunatic – A dangerous lunatic is a lunatic who is either dangerous for himself or his property or dangerous for others or others’ property.
Wandering Lunatic – A wandering lunatic is a lunatic who aimlessly roams on road.