MENTAL STATUS

STATE OF CONSCIOUSNESS: clear, dim, amentia, delirium, oneiroid, twilight.

ORIENTATION: in time, surrounding, one’s own personality.

APPEARANCE: constitutional features, posture, posture, clothing, neatness, grooming, condition of nails and hair. Facial expression.

ATTENTION: passive, active. Ability to concentrate, stability, absent-mindedness, exhaustion, distractibility, poor distribution, inertia, pathological concentration, perseveration.

BEHAVIOR AND MENTAL ACTIVITY: gait, expressiveness of movements, adequacy to experiences, gestures, mannerisms, tics, twitching, stereotypical movements, angularity or plasticity, agility of movements, lethargy, hyperactivity, agitation, belligerence, echopraxia.

SPEECH: (quantity, quality, speed) fast, slow, labored, stuttering, emotional, monotonous, loud, whispering, slurred, mumbling, echolalia, speech intensity, pitch, ease, spontaneity, productivity, manner, reaction time, vocabulary .

ATTITUDE TOWARDS THE CONVERSATION AND THE DOCTOR: friendly, attentive, interested, sincere, flirtatious, playful, inviting, polite, curious, hostile, defensive, reserved, wary, hostile, cold, negativistic, posturing. Degree of contact, attempts to avoid conversation. Active desire for conversation or passive submission. Presence or absence of interest. The desire to emphasize or hide a painful condition.

ANSWERS TO QUESTIONS: exhaustive, evasive, formal, deceitful, irritable, rude, cynical, mocking, brief, verbose, generalized, with examples.

EMOTIONAL SPHERE: prevailing mood (color, stability), mood fluctuations (reactive, autochthonous). Excitability of emotions. Depth, intensity, duration of emotions. Ability to regulate emotions, restraint. Melancholy, a feeling of hopelessness, anxiety, tearfulness, timidity, attentiveness, irritability, horror, anger, expansiveness, euphoria, a feeling of emptiness, guilt, inferiority, arrogance, agitation, dysphoria, apathy, ambivalence. Adequacy of emotional reactions. Suicidal thoughts.

THINKING: thoughts, judgments, conclusions, concepts, ideas. Tendency to generalizations, analysis, synthesis. Spontaneity and non-spontaneity in conversation. Pace of thinking, correctness, consistency, clarity, focus, switching from one topic to another. Ability to make judgments and inferences, relevance of answers. Judgments are clear, simple, adequate, logical, contradictory, frivolous, complacent, vague, superficial, stupid, absurd. Thinking abstract, concrete, figurative. Tendency to systematize, thoroughness, reasoning, pretentiousness. Contents of thoughts.

MEMORY: dysfunction of fixation, storage, reproduction. Memory for past life events, recent past, remembering and reproducing current events. Memory disorders (hyperamnesia, hypomnesia, amnesia, paramnesia).

INTELLECTUAL SPHERE: assessment general level knowledge, educational and cultural level of knowledge, prevailing interests.

CRITICISM: the patient’s degree of awareness of his illness (absent, formal, incomplete, complete). Awareness of the connection between painful experiences and disorders of social adaptation with the underlying disease. The patient's opinion about changes since the onset of the disease. The patient's opinion about the reasons for admission to the hospital.

Mood and attitude towards the upcoming treatment. The patient’s place in the upcoming treatment process. Expected Result.

PSYCHOPATHOLOGICAL PRODUCTS (perceptual deceptions, delusions).

COMPLAINTS ON ADMISSION.

1. State of consciousness.

Orientation in place, in time, in one’s own personality, in the environment. Possible types of disturbance of consciousness: stupor, stupor, coma, delirium, amentia, oneiroid, twilight state. Disorientation of the patient in place, time, situation may indicate both one form of disturbance of consciousness (somnolence, stupor, delirium, oneiroid, etc.) and the severity of the disease process. In a tactful manner, you need to ask the patient what date it is, day of the week, where he is, etc.

2. Contact with reality.

Fully available for conversation, selectively contactable, inaccessible for contact. Reasons for insufficient accessibility: physical (hearing loss, stuttering, tongue-tiedness), psychopathological (lethargy, overload with internal experiences, confusion), attitudinal.

3. Appearance.

The nature of clothing (neat, sloppy, conspicuously bright, etc.) and manner of behavior (appropriate to the situation, friendly, unfriendly, gender inappropriate, passive, angry, affective, etc.). Posture, facial expressions, gaze and facial expression.

4. Cognitive sphere.

Feeling and perception of one’s own body, one’s own personality, and the surrounding world. Sensory disturbances: hypoesthesia, hyperesthesia, paresthesia, anesthesia. Perception disorders: illusions, hallucinations, pseudohallucinations, psychosensory disorders (body diagram disturbance, metamorphopsia), depersonalization, derealization. The presence of various types of pathology of perception (affective illusions, true and false hallucinations, etc.) can be judged by the patient’s facial expressions: expression of tension, fascination, bewilderment, etc. The patient’s attitude towards deceptions of perception is also noted.

Attention. Stability, absent-mindedness, increased distractibility, tendency to get stuck. Attention and, at the same time, the combinatorial function of the brain can be assessed by solving arithmetic problems that become more complex in meaning (see Appendix 1).

Memory. Peculiarities of the patient's memory and possible disorders: hypo- and hypermnesia, paramnesia, amnesia.

Intelligence. The stock of knowledge, the ability to replenish it and use it; interests of the patient. State of intelligence - high, low. The presence of dementia, its degree and type (congenital, acquired). The ability for patients to critically assess their condition. Installations for the future. Significant information about the patient’s memory and intellect in general can be provided by his knowledge and appreciation of historical events, works of literature and art.

Thinking. Logicality, pace of associations (slowing down, speeding up, “jump of ideas”).

Thinking disorders: thoroughness, fragmentation, perseveration, symbolic thinking, interruptions of thoughts, obsessive, overvalued and delusional ideas. Content of nonsense. The severity and degree of its systematization.

Syndromes: Kandinsky-Clerambault, paraphrenic, Cotard, etc. The patient’s speech may reflect the pathology of thinking, features of tempo and purposefulness. In many painful processes, subtle conceptual thinking is impaired, which is expressed in the inability to understand the allegorical meaning of metaphors, proverbs and sayings. During the examination, it is always advisable to conduct a psychological experiment in a delicate manner, offering the patient several proverbs for interpretation, such as, for example, “don’t spit in the well - you’ll need to drink water”, “they cut down a forest - the chips fly”, “it’s not the hut that’s red in its corners, but the red pies." A more accurate description of the state of cognitive activity can be obtained from a psychological study using the MMSE (Mini-Mental State Examination) scale by N. Jacqmin-Gadda et al., (1997). This study is especially indicated in the case of obvious intellectual-mnestic deficiency (see Appendix 2).

5. Emotional sphere

Mood: adequate to the situation, low, high. Pathological conditions: depression, its manifestations (sadness, agitation, mental insensitivity, suicidal thoughts and tendencies), euphoria, apathy, emotional dullness, emotional lability. The emotional state of the patient is reflected primarily in facial expressions. It indicates both the mood (complacency, depression, dysphoria, apathy) and the characteristics of reactions to the environment. Adequacy of emotional reactions to the topic of conversation, variety or uniformity of affects, emotional richness (exaltation) or inexpressiveness. Preservation of emotional relationships with relatives, staff, and other patients. Self-assessment of mood: adequate, uncritical, original.

At the same time, it is important to know that the manifestation of emotional disorders is not only an altered mood, but also a disturbed somatic state. This is especially obvious in the example of depressive syndrome. Suffice it to recall Protopopov’s depressive triad - mydriasis, tachycardia, spastic constipation. Sometimes, with so-called hidden depression, it is somatic changes that make it possible to correctly assess emotional condition. In order to sufficiently fully take into account all the components of the depressive syndrome, it is useful to use M. Hamilton’s depression scale (A Rating Scale for Depression, 1967) (see Appendix 2).

It should be noted that the diagnosis of depressive disorder is based primarily on a clinical assessment of the patient’s condition. The scale presented in Appendix 2 is used as an additional psychometric tool to provide a quantified assessment of the severity of depression. It can also be used to assess the dynamics of depressive disorders during treatment. A statistically significant response of a patient to antidepressant therapy is considered to be a reduction in the total initial score on the HDRS scale by 50% or more (such a patient is considered a “full responder” - from English, response - answer). A reduction in the total initial score from 49 to 25% is considered a partial response to therapy.

Along with symptoms of depression, the clinical picture of a number of mental disorders includes episodes of mania and hypomania.

Depressive and manic states can alternate with each other as part of bipolar affective disorder (F31 ICD-10). This recurrent chronic disorder ranks third among mental illnesses leading to disability or premature death (after unipolar depression and schizophrenia) (Mikkay C.J., Lopez A.D., 1997).

A diagnosis of bipolar affective disorder type 1 (DSM-1V-TR, APA, 2000) requires at least one episode of mania, defined as a minimum week or longer period of inappropriately elevated mood, accompanied by symptoms such as being more talkative than usual. , “jumping” thoughts, impulsiveness, reduced need for sleep, as well as unusual “risky” behavior, accompanied by alcohol abuse, excessive and inappropriate spending of money, expressed sexual promiscuity. A manic episode leads to a significant decrease in the level of social and professional functioning and often determines the need for hospitalization of the patient in a psychiatric hospital.

To optimize the diagnosis of a manic state (episode), along with the clinical-psychopathological method, an additional psychometric method can be used - the Young Mania Rating Scale (Young R.S. et al., 1978) (see Appendix 2). It reflects possible disorders of the main components of mental activity (cognitive, emotional, behavioral) and associated autonomic symptoms.

The patient is asked to mark his condition over the past week in each of eleven points. In case of doubt, a higher score is given. The patient interview lasts 15-30 minutes.

6. Motor-volitional sphere.

The state of the patient’s volitional activity: calm, relaxed, tense, excited, motor inhibited. Excitation: catatonic, hebephrenic, hysterical, manic, psychopathic, epileptiform, etc. Stupor, its variety. Astasia-abasia, pathological desires, etc. Socially dangerous actions of the patient.

The state of the motor-volitional sphere is manifested in demeanor, gestures, facial expressions, and behavior in the department (walking, observing hygiene rules, reading, watching TV, participating in labor processes). By how often the patient has urges to engage in a particular activity, his initiative is judged. Determination (indecisiveness) is indicated by the duration of the struggle of motives. Persistence in achieving goals demonstrates determination. Originality psychomotor sphere: stereotypies, echopraxia, mannerisms, angularity of movement, inhibition, etc.).

7. Suicidal tendencies.

Antivital experiences, passive suicidal thoughts, suicidal intentions.

8. Criticism of your condition.

Considers himself to be suffering from a mental disorder or healthy. What features of his condition does the patient consider painful. If he considers himself healthy, then how does he explain the existing disorders (perceptual deceptions, mental automatisms, altered mood, etc.). The patient’s ideas about the causes, severity and consequences of the disease. Attitude towards hospitalization (expedient, unfair). Degree of criticality (criticism is complete, formal, partial, absent). Plans for the distant and near future.

To objectify the results of a mental state study and assess the dynamics of psychopathological symptoms, the PANSS (Positive and Negative Syndrom Scale) scale for assessing positive and negative symptoms is used (Kay S.R., Fiszbein A., Opler L.A., 1987).

To further quantify the severity of a mental disorder, the Clinical Global Impression Scale - severity (severity) of illness (Guy W, 1976) can be used. This scale is used by the doctor at the time of examination (consultation) of the patient.

For an additional quantitative assessment of the possible improvement in the patient's condition under the influence of the treatment, the scale of general clinical impression - improvement is also used (Gui W., 1976). The rating scale varies from 7 points (the patient's condition has deteriorated very much - Very much worse) to 1 point (the patient's condition has very much improved - Very much improved). Responders are those patients whose condition at a certain stage of therapy corresponds to 1 or 2 points on the CGI - Imp scale. The assessment is usually carried out before the start of treatment, at the end of the 1st, 2nd, 4th, 6th, 8th, 12th week of therapy (see Appendix 2).

V. NEUROLOGICAL STATUS

A neurological examination is carried out not only during the initial examination, but also during treatment, since when many antipsychotics are prescribed, neurological complications can occur in the form of the so-called neuroleptic syndrome (akathisia, parkinsonism). To assess neurological side effects use the drug-induced akathisia scale (BARS) Barnes Akathisia Rating Scale (Barnes T., 1989) and the Simpson-Angus Rating scale for extrapyramidal side effects (SAS) (Simpson G.M., Angus JWS., 1970) (see Appendix 2).

A neurological examination usually begins with determining the condition of the cranial nerves. Check the condition of the pupils and the range of movements of the eyeballs. Narrow pupils (miosis) are observed in many organic diseases of the brain, wide pupils (mydriasis) - in intoxication and depressive states. They check the reaction to accommodation and convergence, grin of teeth, symmetry of the tongue when protruding. Pay attention to the asymmetry of the nasolabial folds, involuntary movements muscles and disturbances in facial movements (twitching of the eyelids, squinting of the eyes, puffing out of the cheeks). Violations of voluntary movements and deviation of the tongue.

Pathological signs from the cranial nerves may indicate an ongoing organic process in the central nervous system (tumor, encephalitis, cerebrovascular accident) or residual effects previously suffered organic damage to the central nervous system.

Movement disorders of the trunk and limbs, hyperkinesis, tremor. Performing the finger-nose test, stability in the Romberg position. Gait: shuffling, small steps, uncertain. Increased muscle tone.

Tendon and periosteal reflexes. When examining the neurological status, it is imperative to check for pathological reflexes of Babinsky, Bekhterev, Oppenheim, Rossolimo, etc. It is also necessary to check for stiffness of the neck muscles and meningeal symptoms(Brudzinsky, Kernig). Deviations in the vegetative state nervous system: hyperhidrosis or dryness skin, dermographism (white, red).

It is important to pay attention to the patient’s speech condition (slurred speech, dysarthria, aphasia). With organic diseases of the brain, atrophic psychoses, various types of aphasia (motor, sensory, semantic, amnestic) are often encountered.

VII. SOMATIC STATUS

Appearance appropriate for age. Signs of premature wilting. Body weight, height, chest volume.

Body type(asthenic, dysplastic, etc.). Developmental anomalies of the whole body (discrepancies in height, weight, size of body parts, physical infantilism, feminism, gynecomastia, etc.) and individual parts (structural features of the torso, limbs, skull, hands, ears, teeth, jaws).

Skin and mucous membranes: color (icterus, cyanosis, etc.), pigmentation, humidity, greasiness. Damage - wounds, scars, traces of burns, injections. Tattoos.

Musculoskeletal system: the presence of developmental defects (clubfoot, flatfoot, cleft lip, upper jaw, nonfusion of vertebral arches, etc.). Traces of wounds, bone fractures, dislocations. Bandages, prostheses.

Oral cavity: lips (dry, presence of herpes), teeth (presence of carious teeth, bite pattern, Hutchinson teeth, dentures), gums (“lead border”, loosening, hyperemia, bleeding from the gums), tongue (appearance), pharynx, tonsils. Breath odor (putrid, “hungry”, smell of alcohol, other substances).

Nasal cavity: paranasal sinuses (discharge, deviated nasal septum, scars). Discharge from the ears. Traces of surgery. Diseases of the mastoid process.

Circulatory organs. Inspection and palpation of blood vessels, pulse, examination of the heart (heartbeat, borders of the heart, sounds, noises. Swelling in the legs).

Respiratory system. Cough, presence of sputum. Frequency and depth of breathing. Auscultation - breathing pattern, wheezing, pleural friction noise, etc.

Digestive organs. Swallowing, passage of food through the esophagus. Inspection and palpation of the abdomen, abdominal organon. Diarrhea, constipation.

Genitourinary system. Urinary disorders, Pasternatsky's symptom, swelling of the face and legs. Impotence, frigidity, etc.

Condition of the endocrine glands. Dwarfism, gigantism, obesity, cachexia, hair type, voice timbre, exophthalmos, enlarged thyroid gland, etc.

VIII. PARACLINICAL STUDIES

Laboratory studies in clinical psychiatric practice are aimed at assessing the patient’s somatic condition and monitoring it during therapy, as well as identifying somatic diseases associated with the development of mental disorders.

• - Blood test (clinical, blood sugar, coagulation, Wasserman reaction, HIV, etc.).
• - Urinalysis (clinical, protein, sugar, etc.)
• - Analyzes of cerebrospinal fluid.
• - Stool analysis (for dysentery group, cholera, helminthiasis, etc.).
• - X-ray examination (chest, skull).
• - Data from electrocardiography, electroencephalography, echoencephalography, computed tomography, magnetic resonance imaging.
• - Temperature curve.

The laboratory research data is reported to the curator by the teacher.

IX. EXPERIMENTAL PSYCHOLOGICAL METHODS

In the process of performing psychological tests, various aspects of the psyche and their disorders are revealed: volitional, emotional, personal.

Most often in clinical practice, a psychiatrist uses the following tests:

• 1. Counting operations (Kraepelin test).
• 2. Schulte tables.
• 3. Memorizing numbers.
• 4. Memorizing 10 words (Luria square).
• 5. Tests for generalization, comparison, exclusion of concepts.
• 6. Interpretation of proverbs and metaphors.

A description of experimental psychological methods is presented in Appendix 1.

X. DIAGNOSIS AND ITS RATIONALE. DIFFERENTIAL DIAGNOSTIC PROCEDURE

Clinical assessment of the case includes:

• 1. Identification and qualification of symptoms, syndromes and their relationships (primary-secondary, specific-nonspecific).
• 2. Determination of personality type.
• 3. Assessing the role of genetic, exogenous, situational factors in the development of the disease.
• 4. Assessment of the dynamics of the disease, type of course (continuous, paroxysmal) and degree of progression.
• 5. Evaluation of the results of paraclinical studies.

The diagnosis is given in detail, in accordance with ICD-10.

In substantiating the diagnosis there should be no description or repetition of anamnesis and status. All you need to do is name the symptoms, syndromes, features of their occurrence and course. For example: “the disease arose in an anxious and suspicious person against the background of an exacerbation of the rheumatic process. Within a month, asthenic-hypochondriacal syndrome was observed, which suddenly gave way to delirious stupefaction with delusions of persecution...”, etc.

SOMATIC STATUS

It is traditionally described for all body systems. Particular attention is paid to the following indicators:

Somatoconstitutional type - may indicate a predisposition to certain mental and somatic diseases;

NEUROLOGICAL STATUS

Described traditionally, special attention is paid to:

The reaction of the pupils to light is used to diagnose drug addiction, progressive paralysis and other organic diseases;

Coordination of movements, presence of tremor - these disorders are common symptoms intoxication and withdrawal symptoms in patients with drug addiction and alcoholism.

Presence of focal neurological symptoms.

MENTAL STATUS

Determining mental status is the most important part of the process of psychiatric diagnosis, that is, the process of cognition of the patient, which, like any scientific cognitive process, should not occur chaotically, but systematically, according to a pattern - from phenomenon to essence. Actively purposeful and in a certain way organized living contemplation of a phenomenon, that is, the determination or qualification of the patient’s real status (syndrome) is the first stage in recognizing the disease.

Poor quality research and description of the patient’s mental status most often occurs for the reason that the doctor has not mastered and does not adhere to a specific plan or scheme for studying the patient, and therefore does it chaotically.

Since mental illness is the essence of a personality illness (Korsakov S.S.), the mental status of a mentally ill person will consist of PERSONAL FEATURES and PSYCHOPATHOLOGICAL MANIFESTATIONS, which are conventionally divided into POSITIVE and NEGATIVE symptoms (Jackson). Adopting the conventions, we can say that the mental status of a mentally ill person consists of three “layers”: POSITIVE DISORDERS (P). NEGATIVE DISORDERS (N) AND PERSONALITY CHARACTERISTICS (L). PNL - by the first letters.

In addition, manifestations of mental activity can be conditionally divided into four main areas, PEPS - according to the first letters:

• 1. COGNITIVE (intellectual-mnestic) sphere, which includes perception, thinking, memory and attention (P).
• 2. EMOTIONAL sphere, in which higher and lower emotions are distinguished (E).
• 3. BEHAVIORAL (motor-volitional) sphere, in which instinctive and volitional activity (P) are distinguished.
• 4. The sphere of CONSCIOUSNESS, in which three types of orientation are distinguished: allopsychic, autopsychic and somatopsychic (C).

Methods for examining mental status

With the clinical-psychopathological method of research, the main diagnostic technique or method for identifying painful manifestations is questioning and observation in their inextricable unity.

It is recommended to start a conversation with the patient with generally accepted questions about well-being, which psychiatric clinic often serve only as a pretext for starting a conversation, giving the doctor the opportunity to orient himself in the further direction in which the research should be conducted. There are options when, due to the patient’s condition, questioning and conversation are practically impossible. In such cases, when examining the patient’s status, the psychiatrist is forced to limit himself primarily to observation.

In the process of a further, focused conversation, after initial questions about well-being, the psychiatrist determines the maximum level of mental disturbance in the patient under study, in order to then, within this range, find out the details of the individual characteristics of psychopathological manifestations, which may have differential diagnostic significance.

In addition to positive (pathologically productive) disorders, the structure of the syndrome also includes negative (deficiency) disorders. The latter most often give the syndrome features of nosological specificity. They are more inert, once they arise, they do not have a tendency to disappear and, as if merging with the premorbid characteristics of the personality, they deform it to one degree or another depending on the severity of their manifestations.

The need to interpret personal characteristics when analyzing mental status arises in cases where the psychotic state is subacute or chronic in nature, and therefore psychopathological productive symptoms do not completely cover personal manifestations. In addition, personality characteristics must be assessed in states of remission, when determining premorbid and characterological data of the patient’s relatives, as well as when assessing the mental status of patients with borderline disorders (neuroses and psychopathy).

Methodology for describing mental status

A description of the mental status is carried out after drawing up an idea of ​​the syndrome that defines the condition, its structure and individual characteristics. The description of the status is descriptive, if possible without the use of psychiatric terms, so that another doctor who turns to the medical history of this clinical description could, through synthesis, give this condition his own clinical interpretation and qualification.

Adhering to the structural-logical scheme of mental status, it is necessary to describe four spheres of mental activity. You can choose any sequence when describing these spheres of mental activity, but you must follow the principle: without completely describing the pathology of one sphere, do not move on to describing another. With this approach, nothing will be missed, since the description is consistent and systematized.

It is advisable to begin the description from those areas from which information is obtained mainly through observation, that is, from external appearance: behavior and emotional manifestations. After this, one should move on to a description of the cognitive sphere, information about which is obtained mainly through questioning and conversation.

COGNITIVE SPHERE

Perceptual disorders

Perceptual disturbances are determined by examining the patient, observing his behavior, questioning, studying drawings and written products. The presence of hyperesthesia can be judged by the characteristics of reactions to certain stimuli: the patient sits with his back to the window, asks the doctor to speak quietly, he tries to pronounce words quietly, in a half-whisper, he shudders and winces when the door creaks or slams. Objective signs of the presence of illusions and hallucinations can be established much less frequently than obtaining relevant information from the patient himself.

The presence and nature of hallucinations can be judged by observing the patient’s behavior - he listens to something, closes his ears, nostrils, whispers something, looks around with fear, waves someone away, collects something on the floor, shakes something off, etc. In the medical history, it is necessary to describe in more detail such behavior of the patient. This behavior gives rise to appropriate questions.

In cases where there are no objective signs of hallucination, one should not always ask the question whether the patient “sees or hears” something. It is better if these questions are leading in order to encourage the patient to actively talk about his experiences. It is important not only what the patient tells, but also how he tells it: willingly or unwillingly, with a desire for dissimulation or without such a desire, with interest, with visible emotional coloring, an affect of fear or indifferently, indifferently.

Senestopathies. The behavioral features of patients experiencing senestopathies primarily include persistent requests for help from somatic specialists, and later often from psychics and sorcerers. These surprisingly persistent, monotonous pains/unpleasant sensations are characterized by a lack of objectivity of experiences, in contrast to visceral hallucinations, often a peculiar, even pretentious shade and unclear, variable localization. Unusual, painful, unlike anything else sensations “wander” through the stomach, chest, limbs and patients clearly contrast them with pain during exacerbation of diseases known to them.

Where do you feel this?

Are there any specific features of these pains/unpleasant sensations?

Does the area where you feel them change? Does this have anything to do with the time of day?

Are they purely physical in nature?

Is there any connection between their occurrence or intensification with food intake, time of day, physical activity, weather conditions?

Do these sensations go away when taking painkillers or sedatives?

Illusions and hallucinations. When asking about illusions and hallucinations, special tact should be exercised. Before approaching this topic, it is advisable to prepare the patient by saying: “In some people, nervous disorder there are unusual sensations.” Then you can ask if the patient heard any sounds or voices at a time when no one was within earshot. If the medical history gives reason to assume in this case the presence of visual, gustatory, olfactory, tactile or visceral hallucinations, appropriate questions should be asked.

If the patient describes hallucinations, then, depending on the type of sensation, certain additional questions are formulated. It is necessary to find out whether he heard one voice or several; in the latter case, did it seem to the patient that the voices were talking to each other about him, mentioning him in the third person. These phenomena should be distinguished from the situation when the patient, hearing the voices of real people talking at a distance from him, is convinced that they are discussing him (delusion of relation). If the patient claims that voices are speaking to him (second-person hallucinations), it is necessary to determine what exactly they are saying, and if the words are perceived as commands, then whether the patient feels that he must obey them. It is necessary to record examples of words spoken by hallucinatory voices.

Visual hallucinations should be differentiated from visual illusions. If the patient is not hallucinating directly during the examination, this distinction may be difficult to make because it depends on the presence or absence of an actual visual stimulus that may have been misinterpreted.

Auditory hallucinations. The patient reports noises, sounds, or voices that he hears. The voices can be male or female, familiar or unfamiliar, the patient can hear criticism or compliments addressed to him.

Have you ever heard any sounds or voices when no one is there?

near you or did you not understand where they came from?

What they're saying?

Dialogue hallucinations are a symptom in which the patient hears two or more voices discussing something concerning the patient.

What are they discussing?

Where do you hear them from?

Hallucinations of commentary content. The content of such hallucinations is a current commentary on the patient’s behavior and thoughts.

Do you hear any assessments of your actions and thoughts?

Imperative hallucinations. Deceptions of perception that induce the patient to a certain action.

Tactile hallucinations. This group of disorders includes complex deceptions, tactile and general feelings, in the form of a sensation of touch, being covered by hands, some kind of matter, wind; sensations of insects crawling under the skin, pricks, bites.

• - Are you familiar with the unusual sensations of touch in the absence of anyone who could do it?
• - Have you ever experienced a sudden change in your body weight, a feeling of lightness or heaviness, sinking or flying?

Olfactory hallucinations. Patients perceive unusual odors, often unpleasant. Sometimes the patient thinks that this smell comes from him.

Do you experience any unusual smells or smells that others cannot smell? What are these smells?

Taste hallucinations often manifest themselves in the form of unpleasant taste sensations.

• - Have you ever felt that ordinary food changed its taste?
• - Do you feel any taste outside of eating?
• - Visual hallucinations. The patient sees shapes, shadows or people that are not in reality. Sometimes these are outlines or spots of color, but more often they are figures of people or human-like creatures or animals. These may be characters of religious origin.
• -Have you ever seen something that other people are unable to see?
• - Did you have any visions?
• - What did you saw?
• - At what time of day did this happen to you?
• - Is this related to the moment of falling asleep or waking up?

Depersonalization and derealization. Patients who have experienced depersonalization and derealization usually find it difficult to describe them; patients unfamiliar with these phenomena often misunderstand the question asked of them about this and give misleading answers. Therefore, it is especially important that the patient gives specific examples of his experiences. It is reasonable to start with the following questions: “Have you ever felt that the objects around you were not real?” and “Do you ever have a feeling of your own unreality? Did you feel like some part of your body wasn’t real?” Patients experiencing derealization often say that everything in the environment seems unreal or lifeless, while with depersonalization, patients may claim that they feel separated from the environment, unable to feel emotions, or as if they are playing some kind of role. Some of them, when describing their experiences, resort to figurative expressions (for example: “as if I were a robot”), which should be carefully differentiated from delusion.

Phenomena of previously seen, heard, experienced, experienced, told (deja vu, deja entendu, deja vecu, deja eprouve, deja raconte). The feeling of familiarity is never tied to a specific event or period in the past, but refers to the past in general. The degree of confidence with which patients assess the likelihood that an experienced event occurred can vary significantly in different diseases. In the absence of criticism, these paramnesias can support the mystical thinking of patients and participate in the formation of delusions.

• -Has it ever seemed to you that a thought has already occurred to you that could not have arisen before?
• - Have you ever felt that you have already heard before what you are hearing now for the first time?
• - Was there a feeling of unreasonable familiarity of the text when reading?
• -Have you ever seen something for the first time and felt that you had already seen it before?

Phenomena of things never seen, never heard, never experienced, etc. (jamais vu, jamais vecu, jamais entendu and others). To patients, the familiar and well-known seems unfamiliar, new and incomprehensible. The sensations associated with a distortion of the sense of familiarity can be both paroxysmal and long-lasting.

• - Did you have the feeling that you were seeing a familiar environment for the first time?
• -Have you ever felt the strange unfamiliarity of something you must have heard many times before?

Thought disorders

When analyzing the nature of thinking, the pace of the thought process (acceleration, deceleration, retardation, stopping), the tendency to detail, “viscosity of thinking,” and the tendency to fruitless philosophizing (reasoning) are established. It is important to describe the content of thinking, its productivity, logic, establish the ability for concrete and abstract, abstract thinking, and analyze the patient’s ability to operate with ideas and concepts. The ability to analyze, synthesize, and generalize is studied.

For research, you can also use texts with missing words (Ebbinghaus test). While reading this text, the subject must insert the missing words, in accordance with the content of the story. In this case, it is possible to detect a violation of critical thinking: the subject inserts random words, sometimes by association with nearby and missing ones, and does not correct the absurd mistakes made. Identifying the pathology of thinking is facilitated by identifying an understanding of the figurative meaning of proverbs and sayings.

Formal thought disorders

The thinking process cannot be assessed directly, so the main object of study is speech.

The patient's speech reveals some unusual disorders observed mainly in schizophrenia. It is necessary to establish whether the patient uses neologisms, that is, words invented by him, often to describe pathological sensations. Before recognizing a word as a neologism, it is important to make sure that it is not just an error in pronunciation or borrowing from another language.

Next, disturbances in the flow of speech are recorded. Sudden stops may indicate a break in thoughts, but more often it is simply a consequence of neuropsychic excitement. Rapid switching from one topic to another suggests a jump in ideas, while amorphism and lack of logical connection may indicate a type of thought disorder characteristic of schizophrenia.

Slowing the rate of speech (depressive substupor, catatonic mutism).

Some answers do not contain complete information, including additional questions;

The doctor notices that he is often forced to encourage the patient, by way of encouragement, to develop or clarify answers;

Answers can be monosyllabic or very short (“yes”, “no”, “maybe”, “I don’t know”), rarely more than one sentence;

The patient does not say anything and only occasionally tries to answer the question.

Thoroughness. A decrease in the ability to separate the main from the secondary leads to chaotic associations. These thinking features are characteristic of people with organic damage central nervous system and epileptic personality changes.

An increased tendency to detail can be noticeable when presenting freely and answering open-ended questions;

Patients cannot answer specific questions posed, going into detail.

Reasoning. The basis of reasoning is an increased tendency to “value judgments”, a tendency to generalize in relation to a small object of judgment.

Patients tend to talk at length about well-known things, retelling and affirming banal truths;

Extremely verbose speech does not correspond to the paucity of content. Speech can be defined as “empty philosophizing,” “idle philosophizing.”

Paralogicality (so-called “crooked logic”). With this disorder of thinking, facts and judgments are consolidated on a single logical basis, placed in a chain, strung on top of each other with particular bias. Facts that contradict or are not consistent with the original false judgment are not taken into account.

Paralogicality underlies interpretative forms of delusion; in content these are most often delusional ideas of persecution, reform, invention, jealousy and others.

During a conversation, such a disturbance in thinking can manifest itself in connection with a discussion of past mental traumas that have become a “sore point” in the patients’ psyche. Such a “catathymic” nature of paralogical delusion formation can occur in the case of the influence of emotional trauma associated with experiences of a hypochondriacal nature, family, sexual nature, or severe personal grievances.

In more severe cases, paralogical thinking manifests itself regardless of the topic of conversation. In this case, conclusions are determined not by reality, not by logical laws, but are governed solely by the needs (often painful) of the individual.

A break in thought, or shperrung. Manifested by a sudden stop in speech before the thought is completed. After a pause, which can last several seconds, less often minutes, the patient cannot remember what he said or wanted to say.

Prolonged silence can only be qualified as a break in thought when the patient arbitrarily describes the delay in thinking or, after a question from the doctor, determines the reason for the pause in this way.

• - Have you ever experienced a sudden, not related to external reasons, disappearance of thought?
• - What prevented you from finishing your sentence?
• - How did you feel?

Mentism. Thoughts can take on a random, uncontrollable course. More often, an accelerated flow of thinking processes is observed, it is not possible to concentrate attention, and only “shadows” of thoughts or a feeling of a “swarm” of rushing thoughts remain in the consciousness.

• - Do you sometimes (lately) feel confusion in your head?
• -Have you ever felt like you couldn’t control the flow of your own thoughts?
• - Did you have the feeling that your thoughts were flashing by?

It is necessary to pay attention to the patient’s appearance: unusual clothing, facial expression and gaze (sad, wary, radiant, etc.). Unusual posture, gait, and unnecessary movements suggest the presence of delusions or motor obsessions (rituals). The patient usually willingly talks about overvalued and obsessive ideas (as opposed to delusional ones). It is necessary to determine to what extent these ideas are related to the content of thinking in this moment, their influence on the course of thought processes and the connection of these ideas with the patient’s personality. Thus, if dominant and overvalued ideas are completely related to the content of the patient’s thinking and determine it, then obsessive thoughts (ideas) are not related to the content of the patient’s thinking at a given time and may contradict it. It is important to assess the degree of violence of various ideas in the patient’s mind, the degree of their alienness to the opinion, worldview and the degree of his critical attitude towards these ideas.

Obsessive phenomena. Obsessive thoughts are addressed first. It's good to start with this question:

Do certain thoughts constantly come into your head, despite the fact that you try hard not to allow them?

If the patient gives an affirmative answer, you should ask him to give an example. Patients are often ashamed of intrusive thoughts, especially those related to violence or sex, so it may be necessary to question the patient persistently but sympathetically. Before identifying such phenomena as obsessive thoughts, the doctor must make sure that the patient perceives such thoughts as his own (and not inspired by someone or something).

Compulsive rituals can sometimes be noticed by careful observation, but sometimes they take a hidden form (such as mental arithmetic) and are discovered only because they disrupt the flow of conversation. If there are compulsive rituals, it is necessary to ask the patient to give specific examples. To identify such disorders, the following questions are used:

• - Do you feel the need to constantly check actions that you know you have already completed?
• - Do you feel the need to do something over and over again that most people only do once?
• - Do you feel the need to repeat the same actions over and over again in exactly the same way? If the patient answers “yes” to any of these questions, the doctor should ask him to give specific examples.

Delusion is the only symptom that cannot be asked about directly, because the patient is not aware of the difference between it and other beliefs. The doctor may suspect delusions based on information from others or from the medical history.

If the task is to identify the presence of delusional ideas, it is advisable to first ask the patient to explain other symptoms or unpleasant sensations described by him. For example, if a patient says that life is not worth living, he may also consider himself deeply vicious and his career ruined, despite the lack of objective grounds for such an opinion.

A psychiatrist must be prepared for the fact that many patients hide delusions. However, if the topic of delusion has already been revealed, the patient often continues to develop it without prompting.

If ideas are identified that may or may not be delusional, it is necessary to find out how stable they are. It is necessary to determine whether the patient's beliefs are due to cultural traditions rather than delusions. It can be difficult to judge this if the patient was brought up in the traditions of a different culture or belongs to an unusual religious sect. In such cases, doubts can be resolved by finding a mentally healthy compatriot of the patient or a person professing the same religion.

There are specific forms of delirium that are especially difficult to recognize. Delusional ideas of openness must be differentiated from the opinion that others can guess a person’s thoughts by his facial expression or behavior. To identify this form of delirium, you can ask:

Do you believe that other people know what you are thinking, even though you have not expressed your thoughts out loud?

In order to identify the delusion of “investing thoughts,” the following question is used:

Have you ever felt that some thoughts do not actually belong to you, but are introduced into your consciousness from the outside?

Delusional thoughts can be diagnosed by asking:

· Do you sometimes feel like thoughts are being taken out of your head?

When diagnosing delusions of control, the doctor faces similar difficulties. In this case, you can ask:

• · Do you feel like some external force is trying to control you?
• · Do you ever have the feeling that your actions are controlled by some person or something outside of you?

Because this type of experience is far from normal, some patients misunderstand the question and answer in the affirmative, referring to the religious or philosophical belief that human activity is directed by God or the devil. Others think it is about the feeling of loss of self-control with extreme anxiety. Patients with schizophrenia may report having these sensations if they have heard “voices” giving commands. Therefore, positive answers should be followed by further questions to avoid such misunderstandings.

Delirium of jealousy. Its content is the conviction that your spouse is cheating. Any facts are perceived as evidence of this betrayal. Typically, patients make great efforts to find evidence of an extramarital love affair in the form of hair on bed linen, the smell of perfume or cologne from clothes, gifts from a lover. Plans are made and attempts are made to catch the lovers together.

• · Do you ever think that your spouse/friend may be unfaithful to you?
• · What evidence do you have of this?

Delirium of guilt. The patient is sure that he has committed some terrible sin or done something inappropriate. Sometimes the patient is overly and inappropriately preoccupied with worries about the “bad things” he did as a child. Sometimes the patient feels responsible for some tragic events, such as a fire or a car accident, to which in reality he had nothing to do.

• · Do you ever feel like you have done something terrible?
• · Is there something for which your conscience torments you?
• · Can you tell us about this?
• · Do you feel like you deserve to be punished for this?
• · Do you sometimes think about punishing yourself?

Megalomaniacal delirium. The patient believes that he has special abilities and power. He may be sure that he is a famous person, for example, some rock star, Napoleon or Christ; believe that he wrote great books, composed brilliant pieces of music, or made revolutionary scientific discoveries. Suspicions often arise that someone is trying to steal his ideas; the slightest doubt from the outside about his special abilities causes irritation.

• · Do you have any thoughts that you can achieve something great?
• · If you compared yourself to the average person, how would you rate yourself: a little better, a little worse, or the same?
• · If worse; then what? Is there something special about you?
• · Do you have any special abilities, gifts or abilities, do you have extrasensory perception or some way of influencing people?
• · Do you consider yourself a bright personality?
• · Can you describe what you are famous for?

Nonsense of religious content. The patient is overwhelmed by false religious beliefs. Sometimes they arise within traditional religious systems, such as the Second Coming, the Antichrist, or possession by the devil. It could be completely new religious systems or a mixture of ideas from various religions, particularly Eastern ones, such as the idea of ​​reincarnation or nirvana.

Religious delusions may be combined with megalomanic delusions of grandeur (if the patient considers himself a religious leader); delusions of guilt, if the imaginary crime is, according to the patient’s conviction, a sin for which he must bear the eternal punishment of the Lord, or delusions of influence, for example, if he is convinced of possession by the devil.

Delusions of religious content must go beyond the ideas accepted in the patient’s cultural and religious environment.

• · Are you a religious person?
• · What do you mean by this?
• · Have you had any unusual religious experiences?
• · You were brought up in religious family or did you come to faith later? How long ago?
• · Are you close to God? Has God had a special role or purpose for you?
• · Do you have a special mission in life?

Hypochondriacal delusion is manifested by a painful conviction of the presence of a serious, incurable disease. Any statement by the doctor in this case is interpreted as an attempt to deceive, to hide the true danger, and refusal of surgery or other radical way treatment convinces the patient that the disease has reached the terminal stage.

These disorders should be distinguished from dysmorphomonic (dysmorphophobic) syndrome, when the patient’s main experiences are focused on a possible physical defect or deformity. In addition to the actual ideas of a physical defect, those suffering from dysmorphomania, as a rule, have ideas of attitude (the feeling that everyone around them notices their defect, laughs at them), a melancholy background mood. They describe the constant desire of patients to look at themselves in the mirror unnoticed by others (“mirror symptom”), persistent refusal to participate in photography, and requests to beauty salons for operations to correct “deficiencies.” For example, the patient may believe that his stomach or brain is rotten; his arms become elongated or his facial features change (dysmorphomania).

• · Are there any disturbances in the functioning of your body?
• · Have you noticed any changes in your appearance?

Delusional relationship. Patients believe that meaningless remarks, statements or events relate to them or are specifically intended for them. Seeing people laughing, the patient is convinced that they are laughing at him. When reading a newspaper, listening to the radio or watching TV, patients tend to perceive certain phrases as special messages addressed to them. The firm belief that events or statements that are not relevant to the patient apply to him should be considered a delusion of attitude.

• · When you enter a room where there are people, do you think that they are talking about you and maybe laughing at you?
• · Is there any information on television, radio programs and newspapers that is relevant to you personally?
• · How do strangers react to you in public places, on the street, in transport?

Delirium of influence. The patient experiences a clear influence on feelings, thoughts and actions from the outside or a feeling of control over them by some external force. The main feature of this form of delirium is a pronounced sensation of impact.

The most typical are descriptions of alien forces that have settled in the patient’s body and force it to move in a special way, or of some telepathic messages that evoke feelings perceived as alien.

• · Some people believe in the ability to transmit thoughts over a distance. What is your opinion?
• · Have you ever experienced a feeling of lack of freedom that was not associated with external circumstances?
• · Have you ever had the impression that your thoughts or feelings are not your own?
• · Have you ever felt that some force was controlling your movements?
• · Have you ever felt an unusual effect?
• · Was this influence from some person?
• · Were there any unusually caused unpleasant or pleasant sensations in the body?

Openness of thoughts. The patient is convinced that people can read his thoughts based on the subjective perception and behavior of others.

Investing thoughts. The patient believes that thoughts that are not his own are put into his head.

Withdrawal of thoughts. Patients may describe subjective sensations of sudden removal or interruption of thoughts by some external force.

The subjective, perceptual component of the delusion of influence, called mental automatism (ideational, sensory and motor variants), is identified using the same questions:

• · Have you ever felt like people might know what you're thinking or even read your thoughts?
• · How can they do this?
• · Why do they need this?
• · Can you tell who controls your thoughts?

The above symptoms are part of the structure of ideatorial automatism observed in Kandinsky-Clerambault syndrome.

Memory disorders

During the history taking process, questions should be asked about persistent memory difficulties. During a mental status examination, patients are given tests to assess memory for current, recent, and distant events. Short-term memory is assessed as follows. The patient is asked to reproduce a series of single-digit numbers, pronounced slowly enough to allow the patient to fix them.

To begin with, select a short series of numbers that is easy to remember, in order to make sure that the patient understands the task. Call five different numbers. If the patient can repeat them correctly, they offer a series of six and then seven numbers. If the patient fails to remember five numbers, the test is repeated, but with a number of other five numbers.

Correct reproduction of seven numbers is considered a normal indicator for a healthy person. This test also requires sufficient concentration to perform, so it should not be used to assess memory if the results of concentration tests are clearly abnormal.

Next, the ability to perceive new information and immediately reproduce it, and then to remember it, is assessed. For five minutes, the doctor continues to talk with the patient on other topics, after which the results of memorization are checked. A healthy person will make only minor errors.

Memory for recent events is assessed by asking about news events over the past one or two days or about events in the patient's life that are known to the doctor. The news about which questions are asked should be in the interests of the patient and widely covered by the media.

Memory for distant events can be assessed by asking the patient to recall certain points from his biography or well-known facts public life over the past few years, such as the birth dates of his children or grandchildren or the names of political leaders. Having a clear understanding of the sequence of events is as important as having memories of individual events.

When a patient is in a hospital, certain conclusions about his memory can be drawn based on information provided by nursing staff. Their observations concern how quickly the patient learns the daily routine, the names of the clinic staff and other patients; does he forget where he puts things, where his bed is located, how to get to the rest room.

Standardized psychological tests on acquisition and memory can aid in diagnosis and provide quantitative assessment of the progression of memory impairment. Among them, one of the most effective is the Wechsler logical memory test, which requires you to reproduce the contents of a short paragraph immediately and after 45 minutes. Points are calculated based on the number of items correctly reproduced.

Memory impairments are common and occur to one degree or another in most people in the second half of life. Qualifying the specifics of memory disorders can help the doctor form a holistic picture of the leading syndrome, the nosological affiliation of the disease, the stage of its course, and sometimes the localization of the pathological process.

Complaints of “memory loss” may hide another pathology. The actual slowness of thinking is aggravated by the uncertainty or inattention associated with the anxiety of depressed patients, and reduced self-esteem frames these real cognitive impairments within the framework of experiences of low value. In the initial stages of depression, these may be complaints of memory impairment.

In reactive hysterical states, active forgetting or repression of painful traumatic experiences is possible. Outside the time frame of a pathogenic situation, memory remains intact.

Fragmentary loss from memory of individual (often significant) details of events that occurred in the state alcohol intoxication, - palimpsests - are a reliable sign initial stage alcoholism.

To identify memory pathology, tests are used to memorize artificial phrases and ten words.

Elective, selective dysmnesia is the forgetting of specific information that occurs in situations of psycho-emotional tension, time limits, characteristic of cerebral vascular pathology. Forgetting dates, names, addresses or telephone numbers due to anxiety may attract attention already during the collection of anamnesis. In this case, it is especially appropriate to clarify:

• · Have you noticed that you are unable to remember something well known when you need to remember urgently, for example, during an unexpected telephone conversation or when you get excited?
• · Dynamic memory impairment. With vascular diseases of the brain in patients who have suffered traumatic brain injuries, with some intoxications, mnestic activity can be intermittent. Such disorders rarely appear as an isolated monosymptom, but appear in combination with the intermittency of all mental processes. Memory in this case is an indicator of instability and exhaustion of the mental performance of patients in general.

One of the indicators of dynamic memory impairment is the possibility of its improvement with the use of means of mediation, which patients resort to in Everyday life. It is appropriate to ask about such a device:

• · Do you make any notes for yourself (knots on a handkerchief)?
• · Do you leave any objects in a visible place that would remind you of something?

Fixation amnesia consists of impaired memorization of current events, with preservation of memory for the past. This amnesia is the leading symptom of Korsakoff's syndrome in toxic, traumatic and vascular psychoses, occurring both acutely and chronically. Having introduced yourself to the patient, it is appropriate to warn that in the interests of the examination you will ask to be called by name after some time.

The following questions are usually asked:

• · What did you do this morning?
• · What is the name of your attending physician?
• · List the names of the patients in your ward.

Retrograde amnesia is a loss from memory of events that preceded a period of impaired consciousness.

With anterograde amnesia, events disappear from the patient’s memory for a period of time immediately following the period of impaired consciousness.

Congrade amnesia is a lack of memory for events that occurred during a period of impaired consciousness.

Since these amnesias are distinguished by their association with a specific state or action pathogenic factor, then, when questioning the patient, one should outline the boundaries of this period, within which the patient cannot recall events in memory.

Progressive hypomnesia. Memory depletion increases gradually and occurs in a certain sequence: from specific to general, from later acquired skills and knowledge to those acquired earlier, from less emotionally significant to more significant. This dynamics corresponds to Ribot's law. The severity of progressive amnesia can be revealed by questions about life events asked in sequence - from current to distant ones. Could you name:

• · the latest most famous events in the world;
• · the approximate population of the city (village) where you live;
• · opening hours of your nearest grocery store;
• · days of your usual receipt of pension (salary);
• · how much do you pay for the apartment?

Pseudo-reminiscences are memory deceptions that involve a displacement in time of events that actually took place in the patient’s life. Events of the past are presented as the present. Their content, as a rule, is monotonous, ordinary, and plausible. Usually, both pseudo-reminiscences and confabulations are spontaneously stated by patients in the story. Questions aimed at identifying these disorders are not defined.

Confabulation. Memories that have no real basis in the past, no temporary causal connection with it. There are fantastic confabulations, which are fiction about extraordinary events that happened to patients at various periods of life, including in the pre-morbid period. Confabulations can be fragmentary and changeable; with repeated stories, new incredible details are reported.

Attention disorders

Attention is the ability to focus on an object. Concentration is the ability to maintain this concentration. While collecting anamnesis, the doctor must monitor the patient’s attention and concentration. In this way, he will be able to form a judgment of relevant abilities before the end of the mental status examination. Formal tests make it possible to expand this information and make it possible to express it in terms of quantitative indicators changes that develop as the disease progresses. Usually they start with counting according to Kraepelin: the patient is asked to subtract 7 from 100, then subtract 7 from the remainder and repeat this action until the remainder is less than seven. The test execution time is recorded, as well as the number of errors. If it seems that the patient did poorly on the test due to poor knowledge of arithmetic, he should be asked to perform a simpler similar task or list the names of the months in reverse order.

The study of the direction and concentration of mental activity of patients is very important in various fields of clinical medicine, since many mental and somatic disease processes begin with attention disorders. Attention disorders are often noticed by patients themselves, and the almost everyday nature of these disorders allows patients to talk about them to doctors of various specialties. However, with some mental illnesses, patients may not notice their problems in the sphere of attention.

The main characteristics of attention include volume, selectivity, stability, concentration, distribution and switching.

The volume of attention refers to the number of objects that can be clearly perceived in a relatively short period of time.

The limited scope of attention requires the subject to constantly highlight some of the most significant objects of the surrounding reality. This choice of only a few stimuli from a variety of stimuli is called selectivity of attention.

• · The patient shows absent-mindedness, periodically asks the interlocutor (doctor) again, especially often towards the end of the conversation.
• · The nature of communication is affected by noticeable distractibility, difficulty in maintaining and voluntarily switching attention to a new topic.
• · The patient's attention is held on one thought, topic of conversation, object for only a short time

Stability of attention is the subject’s ability not to deviate from directed mental activity and maintain focus on the object of attention.

The patient is distracted by any internal (thoughts, sensations) or external stimuli (extraneous conversation, street noise, any object that comes into view). Productive contact may be virtually impossible.

Concentration is the ability to focus attention in the presence of disturbances.

• · Do you notice that it is difficult for you to concentrate when doing mental work, especially at the end of the working day?
• · Do you notice that you are making more careless mistakes in your work?

The distribution of attention indicates the subject’s ability to direct and focus his mental activity on several independent variables at the same time.

Switching attention is a movement of its focus and concentration from one object or type of activity to another.

• · Are you sensitive to external interference when performing mental work?
• · Are you able to quickly switch attention from one activity to another?
• · Do you always manage to follow the plot of a film or TV show that interests you?
• · Do you often get distracted when reading?
• · Do you often notice that you mechanically skim through a text without catching its meaning?

Attention research is also carried out using Schulte tables and a proof test.

Emotional disorders

Mood assessment begins with observation of behavior and continues with direct questions:

• · What's your mood?
• · How do you feel mentally?

If depression is detected, you should ask the patient in more detail about whether he sometimes feels close to tears (actual tearfulness is often denied), whether he has pessimistic thoughts about the present, about the future; whether he feels guilty about the past. Questions can be formulated as follows:

• · What do you think will happen to you in the future?
• · Do you blame yourself for anything?

In an in-depth study of the state of anxiety, the patient is asked about somatic symptoms and thoughts that accompany this affect:

· Do you notice any changes in your body when you feel anxious?

Then they move on to consider specific points, inquiring about rapid heartbeat, dry mouth, sweating, trembling and other signs of autonomic nervous system activity and muscle tension. To identify the presence of anxious thoughts, it is recommended to ask:

· What comes to your mind when you feel anxious?

Likely responses involve thoughts of possible fainting, loss of control, and impending madness. Many of these questions are inevitably the same as those asked when collecting information for a medical history.

Questions about elevated mood correlate with those asked about depression; Thus, a general question (“How are you feeling?”) is followed, if necessary, by corresponding direct questions, for example:

· Do you feel unusually energetic?

Elevated mood is often accompanied by thoughts reflecting excessive self-confidence, an inflated assessment of one's abilities and extravagant plans.

Along with assessing the dominant mood, the doctor must find out how the mood changes and whether it matches the situation. When there are sudden changes in mood, they say that it is labile. Any persistent lack of emotional responses, usually referred to as dulling or flattening of emotions, should also be noted. In a mentally healthy person, the mood changes in accordance with the main topics discussed; he looks sad when talking about sad events, shows anger when talking about what made him angry, etc. If the mood does not coincide with the situation (for example, the patient giggles while describing the death of his mother), it is marked as inadequate. This symptom is often diagnosed without sufficient evidence, so it is necessary to record typical examples in the medical history. A closer acquaintance with the patient may later suggest another explanation for his behavior; for example, smiling when talking about sad events may be a consequence of embarrassment.

State emotional sphere determined and assessed during the entire survey. When studying the sphere of thinking, memory, intelligence, perception, the nature of the emotional background and volitional reactions of the patient are recorded. The peculiarity of the patient’s emotional attitude towards relatives, colleagues, roommates, medical staff, and his own condition is assessed. In this case, it is important to take into account not only the patient’s self-report, but also objective observation data on psychomotor activity, facial expressions and pantomime, indicators of tone and direction of vegetative-metabolic processes. The patient and those observing him should be asked about the duration and quality of sleep, appetite (reduced in depression and increased in mania), physiological functions (constipation in depression). During examination, pay attention to the size of the pupils (dilated in depression), the moisture of the skin and mucous membranes (dryness in depression), measure blood pressure and count the pulse (increased blood pressure and increased heart rate during emotional stress), find out the patient’s self-esteem (overestimation in a manic state and self-deprecation in depression).

Depressive symptoms

Depressed mood (hypotymia). Patients experience feelings of sadness, despondency, hopelessness, discouragement, and feel unhappy; anxiety, tension, or irritability should also be assessed as dysphoric mood. The assessment is made regardless of the duration of the mood.

• · Have you experienced tension (anxiety, irritability)?
• · How long did it last?
• · Have you experienced periods of depression, sadness, or hopelessness?
• · Do you know the state when nothing makes you happy, when everything is indifferent to you?

Psychomotor retardation. The patient feels lethargic and has difficulty moving. Objective signs of inhibition should be noticeable, for example, slow speech, pauses between words.

· Do you feel sluggish?

Deterioration of cognitive abilities. Patients complain of a deterioration in the ability to concentrate and a general deterioration in thinking abilities. For example, helplessness when thinking, inability to make a decision. Thinking disorders are largely subjective and differ from such gross disorders as fragmented or incoherent thinking.

· Do you experience any problems when thinking; decision making; performing arithmetic operations in everyday life; need to concentrate on something?

Loss of interest and/or desire for pleasure. Patients lose interest, the need for pleasure in various areas of life, and their sex drive decreases.

Do you notice any changes in your interest in your surroundings?

• · What usually gives you pleasure?
• · Does it make you happy now?

Ideas of low value (self-abasement), guilt. Patients derogatorily evaluate their personality and abilities, belittling or denying everything positive, talk about feelings of guilt and express unfounded ideas of guilt.

• · Have you been feeling dissatisfied with yourself lately?
• · What is this connected with?
• · What in your life can be regarded as your personal achievement?
• · Do you feel guilty?
• · Could you tell me what you accuse yourself of?

Thoughts about death, suicide. Almost all depressed patients often return to thoughts of death or suicide. Statements about the desire to go into oblivion, so that it happens suddenly, without the participation of the patient, “to fall asleep and not wake up,” are common. Considering ways to commit suicide is typical. But sometimes patients are prone to specific suicidal actions.

The so-called “anti-suicide barrier”, one or more circumstances that keep the patient from committing suicide, is of great importance. Identifying and strengthening this barrier is one of the few ways to prevent suicide.

• · Is there a feeling of hopelessness, a dead end in life?
• · Have you ever had the feeling that your life is not worth continuing?
• · Do thoughts about death come to mind?
• · Have you ever had a desire to take your own life?
• · Have you considered specific methods of suicide?
• · What kept you from doing this?
• · Have there been any attempts to do this?
• · Could you tell us more about this?

Decreased appetite and/or weight. Depression is usually accompanied by changes, often a decrease, in appetite and body weight. Increased appetite occurs in some atypical depressions, in particular in seasonal affective disorder (winter depression).

• · Has your appetite changed?
• · Have you lost/put on weight lately?

Insomnia or increased drowsiness. Among night sleep disorders, it is customary to distinguish insomnia during the period of falling asleep, insomnia in the middle of the night (frequent awakenings, shallow sleep) and premature awakenings from 2 to 5 o'clock.

Disturbances in falling asleep are more typical for insomnia of neurotic origin; early premature awakenings are more common in endogenous depression with distinct melancholy and/or anxious components.

• · Do you have problems sleeping?
• · Do you fall asleep easily?
• · If not, what prevents you from falling asleep?
• · Do you ever wake up for no reason in the middle of the night?
• · Do heavy dreams bother you?
• · Do you experience premature early morning awakenings? (Are you able to fall asleep again?)
• · In what mood do you wake up?

Daily mood fluctuations. Clarification of the rhythmic features of the mood of patients is important differential feature endo- and exogeneity of depression. The most typical endogenous rhythm is a gradual decrease in melancholy or anxiety, especially pronounced in the morning hours throughout the day.

• · What time of day is the most difficult for you?
• · Do you feel heavier in the morning or evening?

A decrease in emotional response is manifested by poor facial expressions, range of feelings, and monotony of voice. The basis for the assessment is the motor manifestations and emotional response recorded during the questioning. It should be borne in mind that the assessment of some symptoms may be distorted by the use of psychotropic drugs.

Monotonous facial expression

• · Facial expression may be incomplete.
• · The patient's facial expression does not change or the facial response is less than expected in accordance with the emotional content of the conversation.
• · Facial expressions are frozen, indifferent, the reaction to treatment is sluggish.

Decreased spontaneity of movements

• · The patient appears very uncomfortable during the conversation.
• · Movements are slow.
• · The patient sits motionless throughout the conversation.

Poor or absent gestures

• · The patient exhibits a slight decrease in the expressiveness of gestures.
• · The patient does not use hand movements, bending forward when communicating something confidential, etc. to express his ideas and feelings.

Lack of emotional response

• · Lack of emotional resonance can be tested by smiling or making a joke, which usually elicits a response smile or laughter.
• · The patient may miss some of these stimuli.
• · The patient does not react to a joke, no matter how he is provoked.

• · During a conversation, the patient detects a slight decrease in voice modulation.
• · In the patient's speech, words have little emphasis on height or tone.
• · The patient does not change the timbre or volume of his voice when discussing purely personal topics that can cause outrage. The patient's speech is constantly monotonous.

Anergy. This symptom includes a feeling of loss of energy, fatigue or feeling unreasonably tired. When asking about these disturbances, they should be compared with the patient's usual activity level:

• · Do you feel more tired than usual when doing normal activities?
• · Do you feel physically and/or mentally exhausted?

Anxiety disorders

Panic disorders. These include unexpected and causeless anxiety attacks. Somatovegetative symptoms of anxiety such as tachycardia, shortness of breath, sweating, nausea or discomfort in the abdomen, pain or discomfort in the chest, may be more pronounced than mental manifestations: depersonalization (derealization), fear of death, paresthesia.

• Have you ever experienced sudden attacks panic or fear, which made you feel very physically difficult?
• · How long did they last?
• · What unpleasant sensations accompanied them?
• · Were these attacks accompanied by fear of death?

Manic states

Manic symptoms. Elevated mood. The condition of patients is characterized by excessive cheerfulness, optimism, and sometimes irritability, not associated with alcohol or other intoxication. Patients rarely regard elevated mood as a manifestation of illness. At the same time, diagnosing a current manic state does not cause any particular difficulties, so it is necessary to ask more often about past manic episodes.

• · Have you ever felt particularly elated at any time in your life?
• · Did it differ significantly from your norm of behavior?
• · Did your relatives or friends have any reason to think that your condition goes beyond just a good mood?
• · Have you ever experienced irritability?
• · How long did this condition last?

Hyperactivity. Patients discover increased activity in work, family affairs, sexual sphere, in making plans and projects.

• · Is it true that you (were) active and busier than usual?
• · What about work, socializing with friends?
• · How passionate are you now about your hobby or other interests?
• · Can you sit still or do you want to move all the time?

Acceleration of thinking / jump of ideas. Patients may experience a distinct acceleration of thoughts and notice that thoughts are ahead of speech.

• · Do you notice the ease of thoughts and associations arising?
• · Can you say that your head is full of ideas?

Increased self-esteem. The assessment of merits, connections, influence on people and events, power and knowledge is clearly increased compared to the usual level.

• · Do you feel more confident than usual?
• · Do you have any special plans?
• · Do you feel any special abilities or new opportunities in yourself?
• · Don't you think that you are a special person?

Decreased sleep duration. When assessing, you need to take into account average over the past few days.

• · You require less hours for sleep, to feel more rested than usual?
• · How many hours of sleep do you usually have and how much now?

Super-attractiveness. The patient's attention is very easily switched to insignificant or irrelevant external stimuli.

· Do you notice that your surroundings distract you from the main topic of conversation?

Behavioral area

Instinctive activity, volitional activity

The patient’s appearance and his manner of dressing allow us to draw a conclusion about his strong-willed qualities. Self-neglect, manifested in slovenliness and wrinkled clothing, suggests several possible diagnoses, including alcoholism, drug addiction, depression, dementia or schizophrenia. Patients with manic syndrome They often prefer bright colors, choose a ridiculously styled dress, or may appear poorly groomed. You should also pay attention to the patient's physique. If there is reason to believe that he has recently lost a lot of weight, this should alert the doctor and lead him to think about a possible somatic illness or anorexia nervosa or depressive disorder.

Facial expression gives information about mood. With depression, the most characteristic signs are drooping corners of the mouth, vertical wrinkles on the forehead and a slightly raised middle part eyebrows Patients in a state of anxiety usually have horizontal folds on the forehead, raised eyebrows, eyes wide open, and pupils dilated. Although depression and anxiety are particularly important, the observer should look for signs of a range of emotions, including euphoria, irritation and anger. A “stony”, frozen facial expression occurs in patients with parkinsonism symptoms due to taking antipsychotics. The person may also indicate medical conditions such as thyrotoxicosis and myxedema.

Posture and movements also reflect mood. Patients in a state of depression usually sit in a characteristic position: leaning forward, hunching, lowering their head and looking at the floor. Anxious patients sit upright with their heads raised, often on the edge of a chair, holding their hands tightly to the seat. They, like patients with agitated depression, are almost always restless, constantly touching their jewelry, adjusting their clothes or filing their nails; they are shaking. Manic patients are hyperactive and restless.

Social behavior is of great importance. Patients with manic syndrome often violate social conventions and are overly familiar with strangers. Dementia patients sometimes react inappropriately to the procedure of a medical interview or continue to go about their business as if there is no interview. Patients with schizophrenia often behave strangely during interviews; some of them are hyperactive and disinhibited in behavior, others are withdrawn and absorbed in their thoughts, some are aggressive. Patients with antisocial personality disorder may also appear aggressive. When registering violations of social behavior, the psychiatrist must provide a clear description of the patient’s specific actions.

Finally, the physician should carefully monitor the patient for any unusual motor disorders which are observed mainly in schizophrenia. These include stereotypies, freezing in postures, echopraxia, ambitendence, and waxy flexibility. One should also keep in mind the possibility of developing tardive dyskinesia, a motor dysfunction observed mainly in elderly patients (especially women) who have been taking antipsychotic drugs for a long time. This disorder is characterized by chewing and sucking movements, grimacing, and choreoathetotic movements involving the face, limbs, and respiratory muscles.

Pathology of consciousness

Allo-, auto- and somatopsychic orientation.

Orientation is assessed using questions aimed at identifying the patient's awareness of time, place and subject. The study begins with questions about the day, month, year and season. When assessing responses, it must be remembered that many healthy people do not know the exact date, and it is understandable that patients staying in a clinic may be unsure about the day of the week, especially if the same routine is always followed in the ward. When finding out orientation in a place, they ask the patient about where he is (for example, in a hospital ward or in a nursing home). Then they ask questions about other people - for example, the patient's spouse or service personnel wards - asking who they are and what relation they have to the patient. If the latter is unable to answer these questions correctly, he should be asked to identify himself.

Changes in consciousness can occur due to various reasons: somatic diseases leading to psychosis, intoxication, traumatic brain injury, schizophrenic process, reactive states. Therefore, disorders of consciousness are heterogeneous.

Typical symptom complexes of altered consciousness include delirium, amentia, oneiroid, and twilight stupefaction. All of these symptom complexes are characterized by the following, expressed to varying degrees:

• · disorder of remembering current events and subjective experiences, leading to subsequent amnesia, unclear perception of the environment, its fragmentation, difficulty in fixing images of perception;
• · one or another disorientation in time, place, immediate environment, oneself;
• · violation of coherence, consistency of thinking combined with weakening of judgment;
• · amnesia of the period of darkened consciousness

Disorientation. Disorder of orientation manifests itself in various acute psychoses, chronic conditions and is easily verifiable in relation to the current real situation, the environment and the personality of the patient.

• · What is your name?
• · What is your occupation?

A holistic perception of the environment can be replaced by changing experiences of an upset consciousness.

The ability to perceive the environment and one’s own personality through illusory, hallucinatory and delusional experiences becomes impossible or limited to details.

Isolated disturbances in time orientation may be associated not with a disturbance of consciousness, but with a memory impairment (amnestic disorientation).

The examination of the patient should begin by observing his behavior, without attracting the patient’s attention. By asking questions, the doctor distracts the patient’s attention from perception deceptions, as a result of which they may weaken or temporarily disappear. In addition, the patient may begin to hide them (dissimulate).

• · What time of day is it now?
• · What day of the week, day of the month?
• · What season?

To diagnose subtle disorders of consciousness, it is necessary to pay attention to the patient’s reaction to questions. So, the patient can correctly navigate the place, but the question asked takes him by surprise, the patient looks around absentmindedly, and answers after a pause.

• · Where are you at?
• · What is your environment like?
• · Who is around you?

Detachment. Detachment from the real outside world is manifested by patients’ poor understanding of what is happening around them; they cannot concentrate their attention and act regardless of the situation.

At pathological conditions such a characteristic of consciousness as the degree of attention weakens. In this regard, the selection of the most important information at the moment is disrupted.

Violation of the “energy of attention” leads to a decrease in the ability to concentrate on any given task, to incomplete coverage, up to the complete impossibility of perceiving reality. Typically, questions are asked aimed at determining the patient’s ability to be aware of what is happening to him and around him:

• · What happened to you?
• · Why are you in the hospital?
• · Do you need help?

Incoherent thinking. Patients exhibit different degrees of thinking impairment - from weakness of judgment to a complete inability to connect objects and phenomena together. The failure of such thinking operations as analysis, synthesis, generalization is especially characteristic of amentia and is manifested by incoherent speech. The patient may senselessly repeat the doctor's questions, random meaningful elements of thinking may randomly invade consciousness, being replaced by equally random ideas.

Patients can answer a question when repeated many times in a loud or, conversely, quiet voice. Typically, patients cannot answer more complex questions related to the content of their thoughts.

• · What worries you?
• · What are you thinking about?
• · What's on your mind?

You can try to test your ability to establish a relationship between external circumstances and current events:

• · There are people in white coats around you. Why?
• · You are given injections. For what?
• · Is there anything stopping you from going home?
• · Do you consider yourself sick?

Amnesia. All symptom complexes of altered consciousness are characterized by complete or partial loss of memories after the end of psychosis.

Mental life, which takes place in conditions of gross darkness of consciousness, may be inaccessible (or almost inaccessible) to phenomenological research. Therefore, identifying both the presence and characteristics of amnesia is of very important diagnostic importance. In the absence of memories of actual events during psychosis, painful experiences are often retained in memory.

The best experiences during the period of psychosis are reproduced by patients who have undergone oneiroid. This concerns mainly the content of dream-like ideas, pseudohallucinations and, to a lesser extent, memories of the real situation (with oriented oneiroid). When recovering from delirium, memories are more fragmented and relate almost exclusively to painful experiences. The states of amentia and twilight consciousness are most often characterized by complete amnesia of the psychosis suffered.

• · Have you ever had states similar to “dreams” in reality?
• · What did you saw?
• · What is special about these “dreams”?
• · How long did this condition last?
• · Were you a participant in these dreams or did you see it from the outside?
• · How did you come to your senses - immediately or gradually?
• · Do you remember what happened around you while you were in this state?

CRITICISM OF THE DISEASE

When assessing a patient's awareness of his mental state, it is necessary to remember the complexity of this concept. By the end of the mental status examination, the clinician should have made a preliminary assessment of the extent to which the patient is aware of the painful nature of his experiences. Direct questions should then be asked to further evaluate this awareness. These questions concern the patient's opinion about the nature of his individual symptoms; for example, whether he believes that his exaggerated feelings of guilt are justified or not. The doctor must also find out whether the patient considers himself sick (rather than, say, persecuted by his enemies); if so, does he attribute his ill health to physical or mental illness; whether he finds that he needs treatment. The answers to these questions are also important because they, in particular, determine how willing the patient is to participate in the treatment process. A record that only records the presence or absence of the corresponding phenomenon (“there is awareness mental illness” or “no awareness of mental illness”) is of little value.

Mental status (state).

Objectives and principles (diagram).

1. Assessment of mental status begins with the first meeting of the doctor with the patient and continues during the conversation on the anamnesis (life and illness) and observation.

2. Mental status is descriptive-informative character with the reliability of the psychological (psychopathological) “portrait” and from the position of clinical information (i.e. assessment).

Note: You should not use terms and a ready-made definition of the syndrome, since everything stated in the “status” should be an objective conclusion with the possible possibility of further subjective interpretation of the data obtained.

3. Perhaps partial the use of certain pathopsychological examination techniques (the main role in this belongs to a specialist pathopsychologist) in order to objectify complaints and individual pathopsychological disorders ( For example: counting according to Kraepelin, tests for memorizing 10 words, objectification of depression using the Beck or Hamilton scale, interpretation of proverbs and sayings (intelligence, thinking)), other standard questions to determine the general educational level and intelligence, as well as features of thinking.

4. Description of mental status.

4.1. On admission(to the department) - brief information from the diaries of nurses.

4.2. Conversation in the office(or in the observation room, if your mental state precludes a conversation in the office).

4.3. Definition of clear or darkened consciousness(if necessary differentiation of these states). If there is no doubt about the presence of a clear (not darkened) consciousness, this section can be omitted.

4.4. Appearance: neat, well-groomed, careless, makeup, appropriate (inappropriate) for age, features of clothing, etc.

4.5. Behavior: calm, fussy, agitation (describe its character), gait, posture (free, natural, unnatural, pretentious (describe), forced, ridiculous, monotonous), other features of motor skills.

4.6. Contact Features: active (passive), productive (unproductive - describe how this manifests itself), interested, friendly, hostile, oppositional, angry, “negativistic,” formal, and so on.

4.7. Nature of statements(the main part of the “composition” of mental status, from which the assessment follows presenter And mandatory symptoms).

4.7.1. This part should not be confused with the medical history, which describes what happened to the patient, that is, what “seemed” to him. Mental status focuses on attitude

4.7.2. the patient to his experiences. Therefore, it is appropriate to use expressions such as “reports,” “believes,” “convinced,” “affirms,” “declares,” “assumes,” and others. Thus, the patient’s assessment of previous illness events, experiences, and sensations should be reflected. Now, V present time.

4.7.3. Start description real experiences are necessary with presenter(that is, belonging to a certain group) syndrome that caused contacting a psychiatrist(and/or hospitalization) and requires basic “symptomatic” treatment.

For example: mood disorders (low, high), hallucinatory phenomena, delusional experiences (content), psychomotor agitation (stupor), pathological sensations, memory impairment, and so on.

4.7.4. Description leading syndrome must be comprehensive, that is, using not only the patient’s subjective self-report data, but also including clarifications and additions identified during the conversation.

4.7.5. For maximum objectification and accuracy of description, it is recommended to use quotes (direct speech of the patient), which must be brief and reflect only those features of the patient’s speech (and word formation) that reflect his condition and cannot be replaced by another adequate (appropriate) speech pattern.

For example: neologisms, paraphasias, figurative comparisons, specific and characteristic expressions and phrases and more. You should not overuse quotations in cases where the presentation in your own words does not affect the informative value of these statements.

The exception is quoting longer examples of speech in cases of violation of its focus, logical and grammatical structure (slipping, diversity, reasoning)

For example: incoherence (confusion) of speech in patients with disordered consciousness, athymic ataxia (atactic thinking) in patients with schizophrenia, manic (aprosectic) incoherence of speech in manic patients, incoherence of speech in patients with various forms of dementia, and so on.

4.7.6. ichical status, from which follows the assessment of the leader and obligated, oppositional, angry, “aya (describe), forced, butDescription additional symptoms, that is, naturally occurring within a certain syndrome, but which may be absent.

For example: low self-esteem, suicidal thoughts in depressive syndrome.

4.7.7. Description optional, depending on pathoplastic facts (“soil”), symptoms.

For example: pronounced somatovegetative disorders in depressive (subdepressive) syndrome, as well as phobias, senesthopathy, obsessions in the structure of the same syndrome.

4.8. Emotional reactions:

4.8.1. The patient’s reaction to his experiences, the doctor’s clarifying questions, comments, attempts at correction, and so on.

4.8.2. Other emotional reactions(except for a description of the manifestations of affective disorder as a leading psychopathology syndrome - see paragraph 4.7.2.)

4.8.2.1. Facial expressions(facial reactions): lively, rich, poor, monotonous, expressive, “frozen”, monotonous, pretentious (mannered), grimacing, mask-like, hypomimia, amimia, etc.

4.8.2.3. Vegetative manifestations: hyperemia, pallor, increased breathing, pulse, hyperhidrosis, etc.

4.8.2.4. Change in emotional response when mentioning family, traumatic situations, and other emotional factors.

4.8.2.5. Adequacy (compliance) of emotional reactions the content of the conversation and the nature of painful experiences.

For example: absence of manifestations of fear and anxiety when the patient is currently experiencing verbal hallucinations of a threatening and frightening nature.

4.8.2.6. Maintaining distance and tact by the patient (in conversation).

4.9. Speech: literate, primitive, rich, poor, logically coherent (illogical and paralogical), purposeful (with a violation of purposefulness), grammatically coherent (agrammatical), coherent (incoherent), consistent (inconsistent), thorough, “inhibited” (slowed down), accelerated by tempo, verbose, “speech pressure”, sudden stops of speech, silence, and so on. Give the most striking examples of speech (quotes).

5. Celebrate absent in a patient in the present the time of the disorder is not necessary, although in some cases this can be reflected in order to prove that the doctor was actively trying to identify other (possibly hidden, dissimulated) symptoms, as well as symptoms that the patient does not consider to be a manifestation of a mental disorder, and therefore does not actively report them.

However, you should not write in general terms: for example, “without productive symptoms.” Most often, this refers to the absence of delusions and hallucinations, while other productive symptoms (for example, affective disorders) are not taken into account.

In this case, it is better to specifically note that the doctor could not be identified(disorders of perception of hallucinations, delusions).

For example: “delusions and hallucinations cannot be identified (or not identified).”

Or: “no memory impairment was detected.”

Or: “memory within the age norm”

Or: “intelligence corresponds to the education received and lifestyle”

6. Criticism of the disease- active (passive), complete (incomplete, partial), formal. Criticism of individual manifestations of the disease (symptoms) in the absence of criticism of the disease as a whole. Criticism towards illness in the absence of criticism towards “personality changes”.

It should be remembered that with detailed description phenomena such as "delirium" and qualifications syndrome as “delusional” it is inappropriate to mark the absence of criticism (to delusion), since Lack of criticism is one of the leading symptoms of delusional disorder.

7. Dynamics of mental state during a conversation- increasing fatigue, improving contact (deterioration), increasing suspicion, isolation, confusion, the appearance of delayed, slow, monosyllabic responses, anger, aggressiveness, or, on the contrary, greater interest, trust, goodwill, friendliness.

Appearance. the expressiveness of movements, facial expressions, gestures, and the adequacy of their statements and experiences are determined. During the examination, it is assessed how the patient is dressed (neatly, carelessly, ridiculously, inclined to decorate himself, etc.). general impressions about the patient.

Contact and accessibility of the patient. Is the patient willing to make contact and talk about his life, interests, and needs. Does he reveal his inner world or is the contact only of a superficial, formal nature.

Consciousness. As already mentioned, clinical criterion clarity of consciousness is the preservation of orientation in one’s own personality, environment and time. In addition, one of the research methods is to determine orientation based on the sequence of presentation of anamnestic data to the patient, the characteristics of contact with the patient and others, and the nature of behavior in general. At

using this method are specified indirect questions: where the patient was and what he was doing immediately before admission to the hospital, by whom and by what transport he was taken to the hospital, etc. If this method turns out to be ineffective and it is necessary to clarify the nature and depth of the disorientation, then direct questions regarding orientation are asked. In most cases, the doctor receives this data when collecting anamnesis. When talking with a patient, you should exercise caution and tact. At the same time, the patient’s understanding of the doctor’s questions, the speed of answers, and their nature are assessed. It is necessary to pay attention to whether the patient exhibits detachment, incoherent thinking, whether he comprehends what is happening well enough and the speech addressed to him. Analyzing the anamnesis, it is necessary to find out whether the patient remembers the entire period of the illness, since after leaving the state of upset consciousness, the most convincing sign is amnesia for the painful period. Having discovered signs of clouding of consciousness (detachment, incoherent thinking, disorientation, amnesia), it is necessary to establish what type of clouding of consciousness is present: stupor, stupor, coma, delirium, oneiroid, twilight state,

In a state of stunning, patients are usually inactive, helpless and inactive. Questions are not answered immediately, in monosyllables, they do not understand what is happening, and on their own initiative they do not come into contact with anyone.

With delirious syndrome, patients are anxious, restless motorly, and their behavior depends on illusions and hallucinations. If you ask persistent questions, you can get adequate answers. When recovering from a delirious state, fragmentary and vivid memories of psychopathological experiences are characteristic.

Mental confusion is manifested by the inability to comprehend the situation as a whole, inconsistent behavior, chaotic actions, confusion, bewilderment, incoherent thinking and speech. characterized by disorientation in one's own personality. Upon exiting the amental state, as a rule, complete amnesia of painful experiences occurs.

It is more difficult to identify oneiric syndrome, since in this state patients are either completely motionless and silent, or are in a state of fascination or chaotic excitement and are inaccessible. In these cases it is necessary

A careful study of the patient’s facial expressions and behavior (fear, horror, surprise, delight, etc.) is required. Drug disinhibition of the patient can help clarify the nature of the experience.

In the twilight state, there is usually a tense affect of fear, anger, anger with aggression and destructive actions. characterized by a relative short duration of the course (hours, days), sudden onset, rapid completion and deep amnesia.

If the indicated signs of clouding of consciousness are not detected, but the patient expresses delusional ideas, hallucinates, etc., it cannot be said that the patient has “clear consciousness”, it should be assumed that his consciousness is “not darkened”.

Perception. When studying perception means a lot It involves careful observation of the patient’s behavior. The presence of visual hallucinations can be indicated by the patient’s lively facial expressions, reflecting fear, surprise, curiosity, and the patient’s attentive gaze in a certain direction, where there is nothing that could attract his attention. Patients suddenly close their eyes, hide, or fight hallucinatory images. You can use the following questions: “Did you have any dream-like phenomena while you were awake?”, “Did you have any experiences that could be called visions?” In the presence of visual hallucinations, it is necessary to identify the clarity of shapes, colors, brightness, three-dimensional or flat nature of the images, and their projection.

With auditory hallucinations, patients listen to something, speak individual words and entire phrases into space, talking with “voices.” In the presence of imperative hallucinations, it may be misbehavior: the patient makes absurd movements, cynically swears, stubbornly refuses to eat, makes suicide attempts, etc.; The patient’s facial expressions usually correspond to the content of the “voices.” To clarify the nature of auditory hallucinations, the following questions can be used: “Is a voice heard outside or in your head?”, “Is the voice male or female?”, “Familiar or unfamiliar?”, “Is the voice telling you to do something?” It is advisable to clarify whether the voice is heard only by the patient or by everyone else, whether the perception of the voice is natural or “rigged” by someone.

It is necessary to find out whether the patient has senestopathies, illusions, hallucinations, or psychosensory disorders. To identify hallucinations and illusions, sometimes it is enough to ask the patient a simple question about his state of health, so that he begins to complain about “voices”, “visions”, etc. But more often you have to ask leading questions: “Can you hear anything?”, “Do you feel any foreign, unusual odors?”, “Has the taste of food changed?” If perceptual disorders are detected, it is necessary to differentiate them, in particular, to distinguish hallucinations from illusions. To do this, it is necessary to find out whether a real object existed or whether the perception was imaginary. Next, you should ask for a detailed description of the symptoms: what is seen or heard, what the content of the “voices” is (it is especially important to find out whether there are imperative hallucinations and hallucinations of frightening content), determine where the hallucinatory image is localized, whether there is a feeling of being made (true and pseudohallucinations), what conditions contribute to their occurrence (functional, hypnagogic hallucinations). It is also important to establish whether the patient has a criticism of perception disorders. It should be borne in mind that the patient often denies hallucinations, but there are so-called objective signs of hallucinations, namely: the patient suddenly becomes silent during a conversation, his facial expression changes, he becomes wary; the patient can talk to himself, laugh at something, cover his ears and nose, look around, take a closer look, throw something off himself.

The presence of hyperesthesia, hypoesthesia, senestopathies, derealization, and depersonalization is easily detected; patients are usually willing to talk about them themselves. To identify hyperesthesia, you can ask how the patient tolerates noise, radio sounds, bright light, etc. To establish the presence of senestopathies, it is necessary to find out whether the patient is referring to ordinary pain sensations; the unusualness, painfulness of sensations, and their tendency to move speak in favor of senestopathies. Depersonalization and derealization are detected if the patient talks about a feeling of alienation I and the outside world, about changes in the shape and size of one’s own body and surrounding objects.

Patients with olfactory and gustatory hallucinations typically refuse to eat. When experiencing unpleasant odors, they sniff all the time, pinch their nose, try to close the windows, and in the presence of taste deceptions of perception, they often rinse their mouths and spit. The presence of tactile hallucinations can sometimes be indicated by scratching the skin.

If the patient is inclined to dissimulate his hallucinatory memories, the disturbance of perception can be learned from his letters and drawings.

Thinking. To judge disorders of the thought process, one should use the survey method and study the patient’s spontaneous speech. Already when collecting an anamnesis, one can notice how consistently the patient expresses his thoughts, what is the pace of thinking, and whether there is a logical and grammatical connection between phrases. These data make it possible to judge the features of the associative process: acceleration, deceleration, fragmentation, reasoning, thoroughness, perseveration, etc. These disorders are more fully revealed in the patient’s monologue, as well as in his written work. In letters, diaries, drawings one can also find symbolism (instead of words he uses symbols that only he understands, writes not in the center, but along the edges, etc.).

When studying thinking, it is necessary to strive to give the patient the opportunity to speak freely about his painful experiences, without unnecessarily limiting him to the framework of the questions posed. Avoiding the use of direct template questions aimed at identifying frequently occurring delusional ideas of persecution of special significance, it is more advisable to ask general questions: “what interests you most in life?”, “Has anything unusual or difficult to explain happened to you recently? ”, “What are you mainly thinking about now?” The choice of questions is made taking into account the individual characteristics of the patient, depending on his condition, education, intellectual level, etc.

Avoidance of a question, delay in answering or silence makes one assume the presence of hidden experiences, a “forbidden topic.” Unusual posture, gait, and unnecessary movements suggest the existence of delusions or obsessions (rituals). Flushed from frequent washing hands indicate fear

contamination or contamination. When refusing food, you can think about delusions of poisoning, ideas of self-deprecation (“I’m not worthy to eat”).

Next, you should try to identify the presence of delusional, overvalued or obsessive ideas. The patient’s behavior and facial expressions suggest the presence of delusional ideas. With delusions of persecution - a suspicious, wary expression on the face, with delusions of grandeur - a proud pose and an abundance of homemade insignia, with delusions of poisoning - refusal of food, with delusions of jealousy - aggressiveness when dating his wife. An analysis of letters and patient statements can also provide a lot. In addition, in a conversation you can ask a question about how others treated him (in the hospital, at work, at home), and thus identify delusions of attitude, persecution, jealousy, influence, etc.

If the patient mentions painful ideas, you should ask about them in detail. Then you need to try to gently dissuade him by asking if he is mistaken, if it seemed to him (to establish the presence or absence of criticism). Next, a conclusion is made as to what ideas the patient expressed: delusional, overvalued or obsessive (taking into account, first of all, the presence or absence of criticism, the absurdity or reality of the content of the ideas and other signs).

To identify delusional experiences, it is advisable to use letters and drawings from patients, which may reflect detail, symbolism, fears and delusional tendencies. To characterize speech confusion and incoherence, it is necessary to provide appropriate samples of the patient’s speech.

Memory. Memory research includes questions about the distant past, the near past, and the ability to remember and retain information.

During the history taking process, long-term memory is tested. In a more detailed study of long-term memory, it is proposed to name the year of birth, the year of graduation from school, the year of marriage, dates of birth and the names of your children or loved ones. It is proposed to recall the chronological sequence of official movements, individual details of the biography of immediate relatives, and professional terms.

Comparison of the completeness of memories of events of recent years, months with events of distant times (children and youth

age) helps to identify progressive amnesia.

The features of short-term memory are studied by retelling and listing the events of the current day. You can ask the patient what he just talked about with his relatives, what was for breakfast, the name of the attending physician, etc. With severe fixation amnesia, patients are disoriented and cannot find their room or bed.

RAM is examined by directly recalling 5–6 numbers, 10 words or phrases of 10–12 words. If there is a tendency towards paramnesia, the patient is asked appropriate leading questions in terms of fictions or false memories (“Where were you yesterday?”, “Where did you go?”, “Who did you visit?”).

When examining the state of memory (the ability to remember, retain, reproduce both current and past events, the presence of memory deceptions), the type of amnesia is determined. To identify memory disorders for current events, questions are asked: what day, month, year is it today, who is the attending physician, when was the meeting with relatives, what was for breakfast, lunch, dinner, etc. In addition, a technique for learning 10 words is used. The patient is explained that 10 words will be read, after which he must name the words that he remembers. You should read at an average pace, loudly, using short, one- and two-word indifferent words, avoiding traumatic words (for example, “death”, “fire”, etc.), since they are usually easier to remember. You can give the following set of words: forest, water, soup, wall, table, owl, boot, winter, linden, steam. The curator marks the correctly named words, then reads them again (up to 5 times). Normally, after reading it once, a person remembers 5–6 words, and starting from the third repetition, 9–10.

By collecting anamnestic and passport information, the curator can already note what the patient’s memory is for past events. You should pay attention to whether he remembers the year of his birth, age, the most important dates of his life and social historical events, as well as the time of onset of the disease, admission to hospitals, etc.

The fact that the patient does not answer these questions does not always indicate a memory disorder. This may also be due to a lack of interest in the task, attention disorders, or the conscious position of a feigning patient. When talking with the patient, it is necessary to establish whether he has confabulations, complete or partial amnesia of certain periods of the disease.

Attention. Attention disorders are identified by interviewing the patient, as well as by studying his statements and behavior. Often patients themselves complain that it is difficult for them to concentrate on anything. When talking with a patient, you need to observe whether he is focused on the topic of conversation or whether he is distracted by any external factor, whether he tends to return to the same topic or easily changes it. one patient concentrates on the conversation, another is quickly distracted, cannot concentrate, becomes exhausted, the third switches very slowly. Attention disorders can also be determined using special techniques. The identification of attention disorders is facilitated by such experimental psychological methods as subtraction from

100 to 7, listing months in forward and reverse order, detecting defects and details in test pictures, proofreading (crossing out and underlining certain letters on the form), etc.

Intelligence. Based on the previous sections regarding the patient’s status, it is already possible to draw a conclusion about the level of his intelligence (memory, speech, consciousness). The work history and data on the patient’s professional qualities currently indicate a stock of knowledge and skills. Further questions in terms of intelligence itself should be asked taking into account the education, upbringing, and cultural level of the patient. The doctor’s task is to determine whether the patient’s intelligence corresponds to his education, profession, and life experience. The concept of intelligence includes the ability to make one’s own judgments and conclusions, to distinguish the main from the secondary, to critically evaluate the environment and oneself. To identify intellectual disorders, you can ask the patient to talk about what is happening, convey the meaning of a story read, or a movie watched. You can ask what this or that proverb, metaphor, popular expression, ask to find synonyms, make a generalization, count within 100 (first give a simpler test for addition, and then for subtraction). If the patient’s intelligence is reduced, then he cannot understand the meaning of proverbs and explains them specifically. For example, the proverb: “You can’t hide an awl in a bag” is interpreted as follows: “You can’t put an awl in a bag - you’ll prick yourself.” You can give the task to find synonyms for the words “think”, “house”, “doctor”, etc.; name the following items in one word: “cups”, “plates”, “glasses”.

If during the examination it turns out that the patient’s intelligence is low, then, depending on the degree of decline, the tasks should be increasingly simplified. So, if he does not understand the meaning of proverbs at all, then one can ask what is the difference between an airplane and a bird, a river and a lake, a tree and a log; Find out how the patient has reading and writing skills. Ask him to count from 10 to 20, find out if he knows the denomination of banknotes. Often, a patient with reduced intelligence makes gross mistakes when counting within 10–20, but if the question is posed specifically, taking into account everyday life skills, then the answer may be correct. Example task: “You had

20 rubles, and you bought bread for 16 rubles, how many rubles did you have?

Are you left?"

In the process of studying intelligence, it is necessary to structure a conversation with the patient in such a way as to find out the correspondence of knowledge and experience to education and age. When moving on to the use of special tests, special care should be taken to ensure their adequacy to the patient’s expected (based on a previous conversation) stock of knowledge. When identifying dementia, it is necessary to take into account premorbid personality characteristics (to judge the changes that have occurred) and the amount of knowledge before the disease.

To study intelligence, mathematical and logic problems, sayings, classifications and comparisons in order to identify the ability to find cause-and-effect relationships (analysis, synthesis, discrimination and comparison, abstraction). the range of ideas about life, ingenuity, resourcefulness, and combinatorial abilities are determined. richness or poverty of imagination is noted.

Attention is drawn to the general impoverishment of the psyche, a decrease in horizons, loss of everyday skills and knowledge, and a decrease in the processes of comprehension. Having summarized the data from the study of intelligence, as well as using anamnesis, one should conclude whether the patient has oligophrenia (and its degree) or dementia (total, lacunar).

Emotions. When studying the emotional sphere, they use following methods: 1. Observation external manifestations emotional reactions of the patient. 2. Conversation with the patient. 3. Study of somatoneurological manifestations accompanying emotional reactions. 4. Collection of objective

information about emotional manifestations from relatives, employees, neighbors.

Observing a patient makes it possible to judge his emotional state by facial expression, posture, rate of speech, movements, clothing and activities. For example, a low mood is characterized by a sad look, eyebrows drawn to the bridge of the nose, drooping corners of the mouth, slow movements, and a quiet voice. Depressed patients should be asked about suicidal thoughts and intentions, attitudes towards others and relatives. Such patients should be spoken to with compassion.

It is necessary to assess the emotional sphere of the patient: the characteristics of his mood (high, low, angry, unstable, etc.), the adequacy of emotions, the perversion of emotions, the reason that caused them, the ability to suppress his feelings. You can learn about the patient’s mood from his stories about his feelings, experiences, and also based on observations. You should pay special attention to the patient’s facial expression, facial expressions, and motor skills; Does he take care of his appearance? How the patient feels about the conversation (with interest or indifference). Is he correct enough or, on the contrary, cynical, rude, and clingy? Having asked a question about the patient’s attitude towards his loved ones, it is necessary to observe how he speaks about them: in an indifferent tone, with an indifferent expression on his face, or warmly, worriedly, with tears in his eyes. It is also important what the patient is interested in during meetings with relatives: their health, the details of their life, or just the message brought to him. You should ask whether he misses home, work, whether he is worried about being in a psychiatric hospital, reducing his ability to work, etc. It is also necessary to find out how the patient himself assesses his emotional state. Does the facial expression correspond to his state of mind (is there any paramimic expression when there is a smile on the face, but in the soul there is melancholy, fear, anxiety). It is also of interest whether there are diurnal fluctuations in mood. Among all the disorders of the emotional sphere, it can be difficult to identify mild depression, and yet it has a great practical significance, since such patients are prone to suicidal attempts. It can be especially difficult to identify so-called “masked depression.” At the same time, a wide variety of somatic complaints come to the fore,

whereas patients do not complain of decreased mood. they may complain of discomfort in any part of the body (especially often in the chest, abdomen); sensations are in the nature of senestopathies, paresthesia and peculiar, difficult to describe pains, not localized, prone to movement (“walking, rotating” and other pains). Patients also note general malaise, lethargy, palpitations, nausea, vomiting, loss of appetite, constipation, diarrhea, flatulence, dysmenorrhea, and persistent sleep disturbances. The most thorough somatic examination of such patients most often does not reveal the organic basis of these sensations, and long-term treatment by a somatic doctor does not produce a visible effect. It is difficult to identify depression hidden behind the façade of somatic sensations, and only a targeted survey indicates its presence. Patients experience previously unusual indecision, causeless anxiety, decreased initiative, activity, interest in favorite activities, entertainment, “hobbies,” decreased sexual desire, etc. It should be borne in mind that such patients often have suicidal thoughts. “Masked depression” is characterized by daily fluctuations in the state: somatic complaints, depressive symptoms are especially pronounced in the morning and fade away in the evening. In the patient's history, one can identify periods of occurrence of similar conditions, interspersed with periods of complete health. The patient's immediate family may have a history of similar conditions.

Elevated mood in typical cases manifests itself in a lively facial expression (glittering eyes, smile), loud, accelerated speech, bright clothes, fast movements, desire for activity, and sociability. You can talk freely with such patients, even joke, encourage them to recite and sing.

Emotional emptiness manifests itself in an indifferent attitude towards one’s appearance, clothing, an apathetic facial expression, and a lack of interest in the environment. Inadequacy of emotional manifestations, unreasonable hatred, and aggressiveness towards close relatives may be observed. lack of warmth when talking about children, excessive frankness in answers regarding intimate life may serve, in combination with objective information, as a basis for the conclusion about emotional impoverishment.

You can identify a patient’s explosiveness and explosiveness by observing his relationships with his neighbors in the ward and by having a direct conversation with him. Emotional lability and weakness are manifested by a sharp transition from topics of conversation that are subjectively pleasant and unpleasant to the patient.

When studying emotions, it is always advisable to ask the patient to describe his emotional state (mood). When diagnosing emotional disorders, it is important to take into account the quality of sleep, appetite, physiological functions, pupil size, moisture of the skin and mucous membranes, changes in blood pressure, pulse rate, breathing, blood sugar levels, etc.

Drives, will. The main method is to observe the patient’s behavior, his activity, focus and adequacy to the situation and his own experiences. It is necessary to assess the emotional background, ask the patient about the reasons for his actions and reactions, and plans for the future. Observe what he is doing in the department - reading, helping the hundred mines of the department, playing board games or watching TV.

To identify desire disorders, it is necessary to obtain information from the patient and staff about how he eats (he eats a lot or refuses food), whether he exhibits hypersexuality, or whether he has a history of sexual gyrations. If the patient is a drug addict, it is necessary to clarify whether there is currently an attraction to drugs. Particular attention should be paid to identifying suicidal thoughts, especially if there has been a history of suicide attempts.

the state of the volitional sphere can be judged by the patient’s behavior. To do this, it is necessary to observe and also ask the staff how the patient behaves in different times days. It is important to know whether he participates in labor processes, how willingly and actively, whether he knows the patients and doctors around him, whether he strives to communicate, to visit the rest room, what are his plans for the future (work, study, relax, spend time idle). When talking with a patient or simply observing behavior in the department, it is necessary to pay attention to his motor skills (slow or accelerated movements, is there any mannerism in facial expressions, gait), whether there is logic in actions or they are inexplicable, paralogical. If the patient does not respond

to questions, if he is constrained, then it is necessary to find out whether there are other symptoms of stupor: give the patient one or another position (is there any catalepsy), ask him to follow the instructions (is there any gativism - passive, active, echopraxia). When the patient is excited, you should pay attention to the nature of the excitement (chaotic or purposeful, productive); if there are hyperkinesis, describe them.

It is necessary to pay attention to the peculiarities of the patients’ speech (total or selective mutism, dysarthria, scanned speech, mannered speech, incoherent speech, etc.). In cases of mutism, one should try to enter into written or pantomimic contact with the patient. In stuporous patients there are signs of waxy flexibility, the phenomenon of active and passive negativism, automatic subordination, mannerisms, and grimacing. In some cases, it is recommended to disinhibit a stuporous patient using medications.