Mental status (state). Tasks and principles (diagram)

Passport part.

FULL NAME:
Gender: male
Date of birth and age: September 15, 1958 (45 years old).
Address: registered in TOKPB
Cousin's address:
marital status: Not maried
Education: secondary special (geodesist)
Place of work: not working, disabled person of II group.
Date of admission to the hospital: 06.10.2002
ICD referral diagnosis: Paranoid schizophrenia F20.0
Final Diagnosis: Paranoid schizophrenia, paroxysmal type of course, with a growing personality defect. ICD-10 code F20.024

Reason for admission.

The patient was admitted to TOKPB on October 6, 2002 by ambulance. The patient's cousin asked for help due to his inappropriate behavior, which consisted in the fact that during the week before admission he was aggressive, drank a lot, had conflicts with relatives, suspected them that they wanted to evict him, deprive him of the apartment. The patient's sister invited him to visit, diverted attention, interested in children's photographs, and called an ambulance.

Complaints:
1) for poor sleep: falls asleep well after taking chlorpromazine, but constantly wakes up in the middle of the night and cannot fall asleep again, does not remember the time of occurrence of this disorder;
2) for headache, weakness, weakness, which is associated both with taking medications and with an increase in blood pressure (maximum figures are 210/140 mm Hg);
3) forgets names and surnames.
4) cannot watch TV for a long time - “eyes get tired”;
5) hard to work "inclined", dizzy;
6) “cannot engage in the same business”;

History of present disorder.
According to relatives, it was possible to find out (by phone) that the patient's condition had changed 1 month before hospitalization: he became irritable, actively engaged in "entrepreneurial activities". He got a job as a janitor in a cooperative and collected 30 rubles from the tenants. a month, worked as a loader in a store, and repeatedly took food home. I didn’t sleep at night, at the request of relatives to see a doctor, I got annoyed and left home. An ambulance was called by the patient's cousin, because during the week before admission he became fussy, drank a lot, began to conflict with relatives, accusing them of wanting to evict him from the apartment. Upon admission to the TOKPB, he expressed some ideas of attitude, could not explain the reason for his hospitalization, stated that he agreed to stay in the hospital for several days, was interested in the terms of hospitalization, because he wanted to continue working (he did not collect money from everyone). Attention is extremely unstable, speech pressure, speech is accelerated in pace.

Psychiatric history.
In 1978, while working as the head of the surveying party, he experienced a pronounced sense of guilt, reaching suicidal thoughts due to the fact that his salary was higher than that of his colleagues, while the duties were less burdensome (in his opinion). However, it did not come to suicide attempts - it was stopped by love and affection for her grandmother.

The patient considers himself ill since 1984, when he first entered a psychiatric hospital. This happened in the city of Novokuznetsk, where the patient came "to earn money." He ran out of money, and in order to buy a ticket home, he wanted to sell his black leather bag, but no one bought it in the market. Walking down the street, he had the feeling that he was being followed, he "saw" three men who "followed him, wanted to take away the bag." Frightened, the patient ran to the police station and pressed the button to call the policeman. The police sergeant who appeared did not notice the surveillance, ordered the patient to calm down and returned to the department. After the fourth call to the police, the patient was taken to the department and "began to beat." This was the impetus for the onset of an affective attack - the patient began to fight, scream.

A psychiatric team was called to take the patient to the hospital. Along the way, he also fought with the orderlies. He spent half a year in a psychiatric hospital in Novokuznetsk, after which he “on his own” (according to the patient) went to Tomsk. At the station, the patient was met by an ambulance, who took him to the regional psychiatric hospital, where he stayed for another year. Of the drugs that were treated, the patient remembers one chlorpromazine.

According to the patient, after the death of his grandmother in 1985, he left for the city of Biryusinsk, Irkutsk Region, to live with his sister, who lived there. However, during one of the quarrels with his sister, something happened (the patient refused to specify), which led to a miscarriage in the sister and hospitalization of the patient in a psychiatric hospital in Biryusinsk, where he stayed for 1.5 years. The ongoing treatment is difficult to specify.

It should be noted that, according to the patient, he "drank a lot, sometimes there was too much."
The next hospitalizations in the hospital were in 1993. According to the patient, during one of the conflicts with his uncle, in a fit of anger, he told him: “And you can use a hatchet on the head!”. Uncle was very frightened and therefore “deprived me of my residence permit.” After the patient was very sorry about the words spoken, repented. The patient believes that it was the conflict with his uncle that caused the hospitalization. In October 2002 - a real hospitalization.

Somatic history.
He does not remember childhood illnesses. He notes a decrease in visual acuity from grade 8 to (-) 2.5 diopters, which has persisted to the present day. At the age of 21, he suffered an open form of pulmonary tuberculosis, was treated in a tuberculosis dispensary, and does not remember the drugs. The last five or six years have been marked by periodic rises in blood pressure to a maximum of 210/140 mm. rt. Art., accompanied by headache, tinnitus, flies flashing. He considers BP 150/80 mm as normal. rt. Art.
In November 2002, while in the TOKPB, he suffered from acute right-sided pneumonia, and antibiotic therapy was carried out.

Family history.
Mother.
The patient does not remember the mother well, since she spent most of her time in inpatient treatment at the regional psychiatric hospital (according to the patient, she suffered from schizophrenia). She died in 1969 when the patient was 10 years old; she does not know the cause of her mother's death. His mother loved him, but she could not significantly influence his upbringing - the patient was brought up by his grandmother on his mother's side.
Father.
The parents divorced when the patient was three years old. After that, my father left for Abkhazia, where he started a new family. The patient met his father only once in 1971 at the age of 13, after the meeting painful, unpleasant experiences remained.
Sibs.
There are three children in the family: an older sister and two brothers.
The elder sister is an elementary school teacher, lives and works in the city of Biryusinsk, Irkutsk region. Does not suffer from mental illness. Relations between them were good, friendly, the patient says that he recently received a postcard from his sister, showed it.
The middle brother of the patient has been suffering from schizophrenia since the age of 12, he is a disabled person of group II, he is constantly being treated in a psychiatric hospital, at present the patient does not know anything about his brother. Prior to the onset of the disease, relations with his brother were friendly.

The patient's cousin is also currently in the TOKPB for schizophrenia.
Other relatives.

The patient was raised by his grandparents, as well as his older sister. He has the most tender feelings for them, speaks with regret about the death of his grandfather and grandmother (his grandfather died in 1969, his grandmother - in 1985). However, the choice of profession was influenced by the patient's uncle, who worked as a surveyor and topographer.

Personal history.
The patient was a desired child in the family, there is no information about the perinatal period and early childhood. Before entering the technical school, he lived in the village of Chegara, Parabelsky district, Tomsk region. From friends he remembers "Kolka", with whom he is still trying to maintain relations. He preferred games in the company, smoked from the age of 5. I went to school on time, loved mathematics, physics, geometry, chemistry, and received "triples" and "deuces" in other subjects. After school with friends, “I went to drink vodka”, the next morning I was “sick with a hangover.” In the company, he showed a desire for leadership, was a "ringleader". During fights, he experienced physical fear of pain. The grandmother did not raise her grandson very strictly, she did not use physical punishment. The object to follow was the patient's uncle, a surveyor-topographer, who later influenced the choice of profession. After graduating from 10 classes (1975) he entered the geodetic technical school. He studied well at the technical school, he loved his future profession.

He strove to be in a team, tried to maintain good relations with people, but he could hardly control the feeling of anger. Tried to trust people. “I believe a person up to three times: if he deceives me, I will forgive him, if he deceives me a second time, I will forgive him, if he deceives him a third time, I will already think what kind of person he is.” The patient was absorbed in work, the mood was good, optimistic. There were difficulties in communicating with the girls, but the patient does not talk about the reasons for these difficulties.

I started working at the age of 20 in my specialty, I liked the work, there were good relations in the labor collective, I held small managerial positions. He did not serve in the army because of pulmonary tuberculosis. After the first hospitalization in a psychiatric hospital in 1984, he changed his job many times: he worked as a salesman in a bakery, as a janitor, and washed entrances.

Personal life.
He was not married, at first (until the age of 26) he considered “what is still early”, and after 1984 he did not marry for the reason (according to the patient) - “what's the point of producing fools?”. He did not have a permanent sexual partner, he was wary of the topic of sex, he refuses to discuss it.
attitude towards religion.
He showed no interest in religion. However, recently he began to recognize the existence of a "higher power", God. Considers himself a Christian.

Social life.
He did not commit criminal acts, he was not brought to trial. Didn't use drugs. She has been smoking since the age of 5, in the future - 1 pack a day, recently - less. Prior to hospitalization, he actively consumed alcohol. He lived in a two-room apartment with his niece, her husband and child. He loved to play with the child, look after him, and maintained a good relationship with his niece. Conflict with sisters. The last stress - a quarrel with a cousin and uncle before hospitalization about an apartment, is still going through. No one visits the patient in the hospital, relatives ask doctors not to give him the opportunity to call home.

Objective history.
It is impossible to confirm the information received from the patient due to the lack of an outpatient card of the patient, an archived medical history, and contact with relatives.

Somatic status.
The condition is satisfactory.
The physique is normosthenic. Height 162 cm, weight 52 kg.
The skin is of normal color, moderately moist, turgor is preserved.
Visible mucous membranes of normal color, pharynx and tonsils are not hyperemic. The tongue is moist, with a whitish coating on the back. Sclera subicteric, hyperemia of the conjunctiva.
Lymph nodes: submandibular, cervical, axillary lymph nodes 0.5 - 1 cm in size, elastic, painless, not soldered to surrounding tissues.

The chest is normosthenic, symmetrical. The supraclavicular and subclavian fossae are retracted. Intercostal spaces are of normal width. The sternum is unchanged, the epigastric angle is 90.
The muscles are developed symmetrically, to a moderate degree, normotonic, the strength of the symmetrical muscle groups of the limbs is preserved and the same. There is no pain during active and passive movements.

Respiratory system:

Inferior borders of the lungs
Right left
Parasternal line V intercostal space -
Midclavicular line VI rib -
Anterior axillary line VII rib VII rib
Middle axillary line VIII rib VIII rib
Posterior axillary line IX rib IX rib
Shoulder line X rib X rib
Paravertebral lineage Th11 Th11
Auscultation of the lungs With forced exhalation and calm breathing during auscultation of the lungs in the clino- and orthostatic position, breathing over the peripheral parts of the lungs is hard vesicular. Dry "crackling" rales are heard, equally expressed on the right and left sides.

The cardiovascular system.

Percussion of the heart
Limits of Relative stupidity Absolute stupidity
Left Along the mid-clavicular line in the 5th intercostal space medially 1 cm from the mid-clavicular line in the 5th intercostal space
Upper third rib Upper edge of fourth rib
Right IV intercostal space 1 cm outward from the right edge of the sternum In the IV intercostal space along the left edge of the sternum
Auscultation of the heart: the tones are muffled, rhythmic, no side murmurs were detected. Emphasis of II tone on the aorta.
Arterial pressure: 130/85 mm. rt. Art.
Pulse 79 bpm, satisfactory filling and tension, rhythmic.

Digestive system.

The abdomen is soft, painless on palpation. There are no hernial protrusions and scars. The tone of the muscles of the anterior abdominal wall is reduced.
Liver on the edge of the costal arch. The edge of the liver is pointed, even, the surface is smooth, painless. Dimensions according to Kurlov 9:8:7.5
Symptoms of Kera, Murphy, Courvoisier, Pekarsky, phrenicus-symptom are negative.
The chair is regular, painless.

genitourinary system.

Pasternatsky's symptom is negative on both sides. Urination regular, painless.

Neurological status.

There were no injuries to the skull and spine. The sense of smell is preserved. The palpebral fissures are symmetrical, the width is within the normal range. The movements of the eyeballs are in full, the nystagmus is horizontal, small-sweeping.
The sensitivity of the skin of the face is within the normal range. There is no asymmetry of the face, nasolabial folds and corners of the mouth are symmetrical.
The tongue is in the midline, the taste is preserved. Hearing disorders were not found. Gait with open and closed eyes is even. In the Romberg position, the position is stable. Finger-nose test: no misses. There are no paresis, paralysis, muscle atrophy.
Sensitive sphere: Pain and tactile sensitivity on the hands and body is preserved. The joint-muscular feeling and the feeling of pressure on the upper and lower extremities are preserved. Stereognosis and a two-dimensional-spatial sense are preserved.

Reflex sphere: reflexes from the biceps and triceps muscles of the shoulder, knee and Achilles are preserved, uniform, slightly animated. Abdominal and plantar reflexes were not studied.
Sweaty palms. Dermographism red, unstable.
There were no pronounced extrapyramidal disorders.

mental status.

Below average height, asthenic build, dark skin, black hair with a slight graying, appearance corresponds to age. He looks after himself: he looks neat, neatly dressed, his hair is combed, his nails are clean, clean-shaven. The patient easily comes into contact, talkative, smiling. Consciousness is clear. Oriented to place, time and self. During the conversation, he looks at the interlocutor, showing interest in the conversation, gesticulates a little, movements are fast, somewhat fussy. He is distant with the doctor, friendly in communication, willingly talks on various topics related to his numerous relatives, speaks positively of them, except for his uncle, from whom he took an example in childhood and whom he admired, but later began to suspect of a bad attitude towards himself, the desire to deprive his living space. He talks about himself selectively, almost does not reveal the reasons for hospitalization in a psychiatric hospital. During the day, he reads, writes poetry, maintains good relations with other patients, and helps the staff in working with them.

Perception. Perceptual disturbances have not been identified so far.
The mood is even, during the conversation he smiles, says that he feels good.
Speech is accelerated, verbose, articulated correctly, grammatically phrases are built correctly. Spontaneously continues the conversation, slipping on extraneous topics, developing them in detail, but not answering the question asked.
Thinking is characterized by thoroughness (a lot of insignificant details, details not related to the directly asked question, the answers are lengthy), slips, actualization of secondary features. For example, to the question “Why did your uncle want to deprive you of your registration?” - replies: “Yes, he wanted to remove my stamp in the passport. You know, the registration stamp, it's like that, rectangular. What do you have? I had my first registration in ... year at ... address. The associative process is characterized by paralogicality (for example, the task “exclusion of the fourth extra” from the list “boat, motorcycle, bicycle, wheelbarrow” excludes the boat according to the principle of “no wheels”). He understands the figurative meaning of proverbs correctly, he uses them in his speech for its intended purpose. Content disorders of thinking are not detected. It is possible to concentrate attention, but we are easily distracted, cannot return to the topic of conversation. Short-term memory is somewhat reduced: he cannot remember the name of the curator, the test "10 words" does not reproduce completely, from the third presentation of 7 words, after 30 minutes. - 6 words.

The intellectual level corresponds to the education received, the way of life, which is filled with reading books, writing poems about nature, about mother, death of relatives, about one's life. The lyrics are sad in tone.
Self-esteem is lowered, he considers himself inferior: when asked why he didn’t get married, he answers, “what’s the point of breeding fools?”; criticism of his disease is incomplete, I am convinced that at present he no longer needs treatment, he wants to go home, work, and receive a salary. He dreams of going to his father in Abkhazia, whom he has not seen since 1971, to give him honey, pine nuts, and so on. Objectively, the patient has nowhere to return, as his relatives deprived him of his registration and sold the apartment in which he lived.

Mental status qualification.
The mental status of the patient is dominated by specific thinking disorders: slippage, paralogicality, actualization of secondary signs, thoroughness, attention disorders (pathological distractibility). Criticism of his condition is reduced. Makes unrealistic plans for the future.

Laboratory data and consultations.

Ultrasound examination of the abdominal organs (12/18/2002).
Conclusion: Diffuse changes in the liver and kidneys. Hepatoptosis. Suspicion of doubling of the left kidney.
Complete blood count (15.07.2002)
Hemoglobin 141 g/l, leukocytes 3.2x109/l, ESR 38 mm/h.
The reason for the increase in ESR is possibly the premorbid period of pneumonia diagnosed at this time.
Urinalysis (15.07.2003)
Urine clear, light yellow. Sediment microscopy: 1-2 leukocytes in the field of view, single erythrocytes, crystalluria.

Substantiation of the diagnosis.

Diagnosis: “paranoid schizophrenia, episodic course with progressive defect, incomplete remission”, ICD-10 code F20.024
Placed on the basis of:

History of the disease: the disease began acutely at the age of 26, with delusions of persecution, which led to hospitalization in a psychiatric hospital and required treatment for a year and a half. The plot of the delusion: "three young men in black jackets are watching me and want to take away the black bag that I want to sell." Subsequently, the patient was hospitalized several times in a psychiatric hospital due to the appearance of productive symptoms (1985, 1993, 2002). During periods of remission between hospitalizations, he did not express delusional ideas, there were no hallucinations, however, the violations of thinking, attention and memory characteristic of schizophrenia persisted and progressed. During hospitalization in the TOKPB, the patient was in a state of psychomotor agitation, expressed separate delusional ideas of relationship, stated that "relatives want to evict him from the apartment."

Family history: heredity is burdened by schizophrenia on the part of the mother, brother, cousin (treated in TOKPB).
Actual mental status: the patient has persistent thinking disorders, which are obligate symptoms of schizophrenia: thoroughness, paralogism, slippage, actualization of secondary signs, non-criticality to one's condition.

Differential Diagnosis.

Among the range of possible diagnoses when analyzing the mental status of this patient, we can assume: bipolar affective disorder (F31), mental disorders due to organic brain damage (F06), among acute conditions - alcoholic delirium (F10.4) and organic delirium (F05).

Acute conditions - alcoholic and organic delirium - could be suspected at first after the patient's hospitalization, when fragmentary delusional ideas of attitude and reformation were expressed to them, and this was accompanied by activity adequate to the expressed ideas, as well as psychomotor agitation. However, after the relief of acute psychotic manifestations in the patient, against the background of the disappearance of productive symptoms, the obligate symptoms characteristic of schizophrenia remained: impaired thinking (paralogical, unproductive, slipping), memory (fixation amnesia), attention (pathological distractibility), sleep disturbances persisted. There were no data on the alcoholic genesis of this disorder - withdrawal symptoms, against which a delirious clouding of consciousness usually occurs, data on the patient's massive alcoholization, characteristic of delirium of the undulatory course and disorders of perception (true hallucinations). Also, the lack of data on any organic pathology - previous trauma, intoxication, neuroinfection - a place with a satisfactory somatic condition of the patient allows us to exclude organic delirium during hospitalization.

Differential diagnosis with organic mental disorders, in which there are also disorders of thinking, attention and memory: there are no data for traumatic, infectious, toxic lesions of the central nervous system. Psycho-organic syndrome, which forms the basis of the long-term consequences of organic brain lesions, is absent in the patient: there is no increased fatigue, pronounced autonomic disorders, and there are no neurological symptoms. All this, coupled with the presence of thought and attention disorders characteristic of schizophrenia, makes it possible to exclude the organic nature of the observed disorder.

To differentiate paranoid schizophrenia in this patient with a manic episode as part of bipolar affective disorder, it is necessary to recall that the patient was diagnosed with a hypomanic episode as part of schizophrenia during hospitalization (there were three criteria for hypomania - increased activity, increased talkativeness, distractibility, and difficulty in concentrating) . However, the presence of uncharacteristic for a manic episode in an affective disorder of delusional attitudes, impaired thinking and attention casts doubt on such a diagnosis. Paralogism, slippage, unproductive thinking, remaining after the relief of psychotic manifestations, rather testify in favor of a schizophrenic defect and hypomanic disorder than in favor of an affective disorder. The presence of a catamnesis for schizophrenia also makes it possible to exclude such a diagnosis.

Rationale for the treatment.
The appointment of neuroleptic drugs in schizophrenia is an essential component of drug therapy. Given the history of delusional ideas, the patient was prescribed a prolonged form of selective antipsychotic (haloperidol-decanoate). Given the tendency to psychomotor agitation, the patient was prescribed a sedative antipsychotic chlorpromazine. The central M-anticholinergic cyclodol is used to prevent the development and reduce the severity of side effects of neuroleptics, mainly extrapyramidal disorders.

Curation diary.

10 September
t˚ 36.7 pulse 82, BP 120/80, respiratory rate 19 per minute Acquaintance with the patient. The patient's condition is satisfactory, complaints of insomnia - he woke up three times in the middle of the night, walked around the department. The mood is depressed because of the weather, thinking is unproductive, paralogical with frequent slips, detailed. In the area of ​​attention - pathological distractibility Haloperidol decanoate - 100 mg / m (injection from 09/04/2003)
Aminazin - per os
300mg-300mg-400mg
Lithium carbonate per os
0.6 - 0.3 - 0.3g
Cyclodol 2mg - 2mg - 2mg

11 September
t˚ 36.8 pulse 74, BP 135/75, respiratory rate 19 per minute The patient's condition is satisfactory, complaints of poor sleep. The mood is even, there are no changes in the mental status. The patient sincerely rejoices at the notebook presented to him, with pleasure reads aloud the verses written by him. Continuation of treatment prescribed on September 10

September 15th
t˚ 36.6 pulse 72, BP 130/80, NPV 19 per minute The patient's condition is satisfactory, there are no complaints. The mood is even, there are no changes in the mental status. The patient is happy to meet, reads poetry. Tachyphrenia, speech pressure, slipping up to the fragmentation of thinking. Unable to exclude the fourth extra item from the presented sets. Continuation of treatment prescribed on September 10

Expertise.
Labor examination The patient was recognized as a disabled person of group II, re-examination in this case is not required, given the duration and severity of the observed disorder.
Forensic examination. Hypothetically, in the case of committing socially dangerous acts, the patient will be declared insane. The court will decide on a simple forensic psychiatric examination; given the severity of the existing disorders, the commission may recommend involuntary inpatient treatment in TOKPB. The court will make the final decision on this issue.
Military expertise. The patient is not subject to conscription into the armed forces of the Russian Federation due to the underlying disease and age.

Forecast.
In the clinical aspect, it was possible to achieve partial remission, reduction of productive symptoms and affective disorders. The patient has factors that correlate with a good prognosis: acute onset, the presence of provocative moments at the onset of the disease (dismissal from work), the presence of affective disorders (hypomanic episodes), late age of onset (26 years). Nevertheless, the prognosis in terms of social adaptation is unfavorable: the patient does not have housing, ties with relatives are broken, persistent disorders of thinking and attention persist, which will interfere with work in the specialty. At the same time, the patient's elementary labor skills are preserved, he participates with pleasure in intrahospital labor activity.

Recommendations.
The patient needs continuous long-term treatment with selected drugs in adequate dosages, with which the patient has been treated for a year. The patient is recommended to stay in a hospital due to the fact that his social ties are broken, the patient does not have his own place of residence. The patient is shown therapy with creative self-expression according to M.E. Stormy, occupational therapy, as he is very active, active, wants to work. Recommended work activity is any, except intellectual. Recommendations to the doctor - work with the patient's relatives to improve the patient's family ties.

Used Books.

1. Avrutsky G.Ya., Neduva A.A. Treatment of the mentally ill (Guide for Physicians).-M.: Medicine, 1981.-496 p.
2. Bleikher V.M., Kruk I.V. Explanatory dictionary of psychiatric terms. Voronezh: NPO MODEK Publishing House, 1995.-640 p.
3. Vengerovsky A.I. Lectures on pharmacology for doctors and pharmacists. – Tomsk: STT, 2001.-576 p.
4. Gindikin V.Ya., Gurieva V.A. Personal pathology. M.: "Triada-X", 1999.-266 p.
5. Zhmurov V.A. Psychopathology. Part 1, part 2. Irkutsk: Irkut Publishing House. University, 1994
6. Korkina M.V., Lakosina N.D., Lichko A.E. Psychiatry. Moscow - "Medicine", 1995.- 608 p.
7. Lecture course on psychiatry for students of the Faculty of Medicine (lecturer - Candidate of Medical Sciences, Associate Professor S.A. Rozhkov)
8. Workshop on psychiatry. (Educational manual) / compiled by: Eliseev A.V., Raizman E.M., Rozhkov S.A., Dremov S.V., Serikov A.L. under the general editorship of prof. Semina I.R. Tomsk, 2000.- 428 p.
9. Psychiatry \ Ed. R. Shader. Per. from English. M., "Practice", 1998.-485 p.
10. Psychiatry. Uch. settlement for stud. honey. university Ed. V.P. Samokhvalova.- Rostov n \ D .: Phoenix, 2002.-576 p.
11. Guide to psychiatry \ Under the editorship of A.V. Snezhnevsky. - T.1. M.: Medicine, 1983.-480 p.
12. Churkin A.A., Martyushov A.N. Brief guide to the use of the ICD-10 in psychiatry and narcology. Moscow: Triada-X, 1999.-232 p.
13. Schizophrenia: a multidisciplinary study \ edited by Snezhnevsky A.V. M.: Medicine, 1972.-400 p.

Important: Generalization of psychopathological features is the basis of diagnosis.

Consider the following:
External state, behavior and
Changes in the state of consciousness, attention, understanding, memory, affect, stimuli/drive and orientation
Disorders of perception and features of thinking
It is also important to establish the current mental state

An example of a possible description of the results of a mental study

The patient, 47 years old, looks young in appearance (build and clothes). During the examination, she is open to communication, which is manifested both in facial expressions and gestures, and in the verbal sphere. Listens attentively to questions addressed to her and then answers them in detail, without deviating from the given topic.

Consciousness is clear, well oriented in space, in time and in relation to the individual. Facial expressions and gestures are very lively and run parallel to the prevailing affect. Attention and concentration seem intact.

Further research does not indicate the presence of a memory disorder and the ability to remember and reproduce previously acquired experience. With a level of general intellectual development above average and a well-differentiated primary personality, rough verbal attacks attract attention: “old Velcro”, “chatter”, formal thinking seems intact, there is no preliminary evidence of the presence of broken thinking. However, the train of thought at the same time gives the impression of a somewhat accelerated.

There is no reason to suspect the presence of a productive psychotic disorder in the form of a delusional phenomenon, hallucinatory manifestations, or primary disturbances in the perception of one's own "I".

In the sphere of affect, excitability, the degree of which is above average, attracts attention. When discussing topics that require increased emotional participation of the patient, the latter tends to speak louder and more demanding, while the number of rude verbal attacks mentioned above increases. The ability to criticize seems to be reduced, there is no reason to assume an actual threat of suicide.

Relevance.

Schizophrenia is an endogenous disease with a progradient course, which is characterized by changes in personality (autism, emotional impoverishment) and may be accompanied by the appearance of negative (drop in energy potential) and productive (hallucinatory-delusional, catatonic and other syndromes) symptoms.

According to the WHO, manifest forms of schizophrenia affect 1% of the world's population. In terms of prevalence and social consequences, schizophrenia ranks first among all psychoses.

In the diagnosis of schizophrenia, several groups of symptoms are distinguished. The main (mandatory) symptoms of schizophrenia include the so-called Blair's symptoms, namely: autism, disorders of the flow of associations, impaired affect and ambivalence. The symptoms of the first rank include the symptoms of K. Schneider: various manifestations of the disorder of the automation of the psyche (symptoms of mental automatism), they are very specific, but far from always occur. Additional symptoms include delusions, hallucinations, senestopathies, derealization and depersonalization, catatonic stupor, mental attacks (raptus). In order to identify the above symptoms and syndromes, it is necessary to assess the mental status of the patient. In this work, we have highlighted the clinical case of a patient with schizophrenia, assessed his mental status and identified the leading psychopathological syndromes.

The purpose of the work: to identify the main psychopathological syndromes of a patient with schizophrenia on the example of a clinical case.

Tasks of the work: 1) evaluate the patient's complaints, anamnesis of the disease and anamnesis of life; 2) assess the mental status of the patient; 3) identify leading psychopathological syndromes.

Work results.

Coverage of a clinical case: Patient I., 40 years old, was admitted to a psychiatric clinic in Kaliningrad in November 2017.

Complaints of the patient at the time of admission: at the time of admission, the patient complained about the “monster” that moved into her from outer space, speaks in a loud male voice in her head, sends some kind of “cosmic energy” through her, performs actions for her (household chores - cleaning, cooking, etc.), periodically speaks instead of her (at the same time, the patient's voice changes, becomes rougher); to “emptiness in the head”, lack of thoughts, deterioration of memory and attention, inability to read (“letters blur before the eyes”), sleep disturbance, lack of emotions; to the "bursting of the head", which is caused by the "presence of a monster inside it."

Patient's complaints at the time of examination: at the time of examination, the patient complained of a bad mood, lack of thoughts in her head, impaired attention and memory.

Anamnesis of the disease: considers himself ill for two years. For the first time, the signs of the disease appeared when the patient began to hear a male voice in her head, which she interpreted as "the voice of love." The patient did not experience discomfort from his presence. She associates the appearance of this voice with the fact that she began a romantic relationship with a man she knew (which in fact did not exist), pursued him. Because of her "new love" she divorced her husband. At home, she often talked to herself, this caused alarm to her mother, who turned to a psychiatrist for help. The patient was hospitalized in the Psychiatric Hospital No. 1 in December 2015, stayed in the hospital for about two months. Reports that after discharge, the voice disappeared. A month later, according to the patient, a “monster, an alien from outer space” settled in it, which the patient presents as a “big toad”. He began to talk to her in a male voice (which came from her head), did household chores for her, "stole all her thoughts." The patient began to feel emptiness in her head, lost the ability to read (“the letters began to blur before her eyes”), memory and attention deteriorated sharply, emotions disappeared. In addition, the patient felt a "bursting of the head", which she associates with the presence of a "monster" in her head. These symptoms were the reason for going to a psychiatrist, and the patient was hospitalized in a psychiatric hospital for inpatient treatment.

Anamnesis of life: heredity is not burdened, in childhood she developed mentally and physically normally, she is an accountant by education, she has not been working for the last three years. Bad habits (smoking, drinking alcohol) denies. Not married, has two children.

Mental status:

1) External features: hypomimic, posture - even, sitting on a chair, arms and legs crossed, condition of clothing and hairstyle - without features;

2) Consciousness: is oriented in time, place and own personality, there is no disorientation;

3) The degree of accessibility to the contact: does not show initiative in the conversation, does not answer questions willingly, in monosyllables;

4) Perception: impaired, synestopathies (“bursting of the head”), pseudohallucinations (male voice in the head) were observed;

5) Memory: remembers old events well, some recent, current events periodically fall out of memory (sometimes she cannot remember what she did earlier, what chores she did at home), Luria square: from the fifth time she remembered all the words, on the sixth time she only reproduced two; pictograms: reproduced all expressions, except for “delicious dinner” (called “delicious breakfast”), drawings - without features;

6) Thinking: bradyphrenia, sperrung, delusional ideas of influence, the “fourth extra” test - not on an essential basis, understands some proverbs literally;

7) Attention: distractibility, test results according to Schulte tables: the first table - 31 seconds, then fatigue is observed, the second table - 55 seconds, the third - 41 seconds, the fourth table - 1 minute;

8) Intelligence: preserved (the patient has a higher education);

9) Emotions: there is a decrease in mood, melancholy, sadness, tearfulness, anxiety, fear (the predominant radicals are melancholy, sadness). Mood background - depressive, often cries, wants to go home;

10) Volitional activity: no hobbies, does not read books, often watches TV, does not have a favorite TV show, observes hygiene rules;

11) Attractions: reduced;

12) Movements: adequate, slow;

13) Three main desires: expressed one desire - to return home to the children;

14) The internal picture of the disease: suffers, but there is no criticism of the disease, believes that the “alien” uses it to transfer “cosmic energy”, does not believe that he can disappear. Strong-willed attitudes towards cooperation and rehabilitation are present.

Clinical assessment of mental status:

A 40-year-old woman has an exacerbation of an endogenous disease. The following psychopathological syndromes have been identified:

Kandinsky-Clerambault syndrome (on the basis of identified pseudo-hallucinations, delusional ideas of influence and automatisms - associative (impaired thinking, sperrung), synestopathic and kinesthetic);

Depressive syndrome (the patient often cries (hypothymia), bradyphrenia is observed, movements are inhibited - “depressive triad”);

Apatico-abulic syndrome (on the basis of pronounced emotional-volitional impoverishment).

Assessment of mental status helps to identify the leading psychopathological syndromes. It must be remembered that a nosological diagnosis without specifying the leading syndromes is uninformative and is always questioned. In our work, an exemplary algorithm for assessing the mental status of a patient was presented. A very important final step in assessing the mental status is to establish the presence or absence of criticism of the patient's illness. It is quite obvious that the ability to realize one's disease in different patients is very different (up to its complete denial), and it is this ability that has the most important influence on the treatment plan and subsequent therapeutic and diagnostic measures.

Bibliography:

1. Antipina A. V., Antipina T. V. INCIDENCE OF SCHIZOPHRENIA IN DIFFERENT AGE GROUPS // International Academic Bulletin. – 2016. – no. 4. - S. 32-34.
2. Gurovich I. Ya., Shmukler AB Schizophrenia in the systematics of mental disorders // Social and clinical psychiatry. - 2014. - T. 24. - No. 2.
3. Ivanets N. N. et al. Psychiatry and narcology // News of science and technology. Series: Medicine. Psychiatry. - 2007. - no. 2. - S. 6-6.

1. State of consciousness.

Orientation in place, in time, self, environment. Possible types of impaired consciousness: stunning, stupor, coma, delirium, amentia, oneiroid, twilight state. Disorientation of the patient in place, time, situation may indicate both one form or another of impaired consciousness (somno-lension, stunning, delirium, oneiroid, etc.), and the severity of the disease process. In a tactful manner, you need to ask the patient what date it is, the day of the week, where he is, etc.

2. Contact with reality.

Fully available for conversation, selectively contactable, unavailable for contact. Reasons for insufficient accessibility: physical (hearing loss, stuttering, tongue-tied tongue), psychopathological (lethargy, congestion with internal experiences, confusion), installation.

3. Appearance.

The nature of clothing (neat, slovenly, emphatically bright, etc.) and demeanor (adequate to the situation, friendly, unfriendly, inconsistent with gender, 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, the surrounding world. Sensation disturbances: hypoesthesia, hyperesthesia, paresthesia, anesthesia. Perceptual disturbances: illusions, hallucinations, pseudohallucinations, psychosensory disorders (violation of the body schema, 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: an expression of tension, fascination, bewilderment, etc. The attitude of the patient to the deceptions of perception is also noted.

Attention. Stability, absent-mindedness, increased distractibility, a 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. Features of the patient's memory and possible disorders: hypo- and hypermnesia, paramnesia, amnesia.

Intelligence. The stock of knowledge, the ability to replenish and use it; the interests of the patient. The state of intelligence - high, low. The presence of dementia, its degree and type (congenital, acquired). The possibility of a critical assessment of the patient's condition. Settings for the future. Significant information about the memory and, in general, about the intellect of the patient can be given by his knowledge and assessment of historical events, works of literature and art.

Thinking. Logic, the rate of flow of associations (deceleration, acceleration, "leap of ideas").

Disturbance of thinking: thoroughness, fragmentation, perseveration, symbolic thinking, breaks in thoughts, obsessive, overvalued and delusional ideas. The content of nonsense. Sharpness and degree of its systematization.

Syndromes: Kandinsky-Clerambault, paraphrenic, Kotara, etc. The patient's speech may reflect the pathology of thinking, especially the pace and focus. In many painful processes, subtle conceptual thinking is disturbed, which is expressed in the inability to understand the allegorical meaning of metaphors, proverbs and sayings. When examining, it is always advisable to conduct a psychological experiment in a delicate form, offering the patient several proverbs for interpretation, such as, for example, “do not spit in the well - it will come in handy to drink water”, “they cut down the forest - chips fly”, “the hut is not red in the corners, but red pies." A more accurate characterization of the state of cognitive (cognitive) activity allows you to get a psychological study on the MMSE scale (Mini-Mental State Examination) by H. Jacqmin-Gadda et al., (1997). This study is especially indicated in case of obvious intellectual-mnestic insufficiency (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. The adequacy of emotional reactions to the topic of conversation, the variety or uniformity of affects, emotional richness (exaltation) or inexpressiveness. Preservation of emotional attitude to relatives, staff, other patients. Self-assessment of mood: adequate, uncritical, peculiar.

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 evident in the example of a depressive syndrome. Suffice it to recall Protopopov's depressive triad - mydriasis, tachycardia, spastic constipation. Sometimes, with the so-called latent depression, it is somatic changes that make it possible to correctly assess the emotional state. In order to sufficiently fully take into account all the components of the depressive syndrome, it is useful to use the M. Hamilton depression scale (A Rating Scale for Depression, 1967) (see Appendix 2).

It should be noted that the diagnosis of a depressive disorder is based primarily on a clinical assessment of the condition of the subject. The scale presented in Appendix 2 is used as an additional psychometric tool to give 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 patient response to antidepressant therapy is a reduction in the total baseline HDRS score by 50% or more (such a patient is considered a “complete responder” - from English, response - response). Reduction of the total baseline score from 49% to 25% is considered as a partial response to therapy.

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

Depressive and manic states can replace each other within the framework of bipolar affective disorder (ICD-10 F31). This relapsing 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).

Diagnosis of bipolar affective disorder type 1 (DSM-1V-TR, APA, 2000) requires at least one episode of mania, defined as a minimum weekly or longer period of inappropriately elevated mood accompanied by symptoms such as greater than usual talkativeness , "jump" of thoughts, impulsivity, reduced need for sleep, as well as unusual "risky" behavior, accompanied by alcohol abuse, excessive and inadequate spending of money, pronounced 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 and psychopathological method, an additional psychometric method can be used - R. 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 the autonomic symptoms associated with them.

The patient is asked to mark his condition in each of the eleven items during the last week. In case of doubt, a higher score is given. Questioning the patient 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 inclinations, etc. Socially dangerous actions of the patient.

The state of the motor-volitional sphere is manifested in the manner of holding, gestures, facial expressions, behavior in the department (walking, observing the rules of hygiene, reading, watching television, participating in labor processes). According to how often the patient has urges to this or that activity, they judge his initiative. The duration of the struggle of motives speaks of decisiveness (indecision). Persistence in achieving the set goals is evidence of purposefulness. The peculiarity of the psychomotor sphere: stereotypes, echopraxia, mannerisms, angular movement, lethargy, etc.).

7. Suicidal tendencies.

Anti-vital experiences, passive suicidal thoughts, suicidal intentions.

8. Criticism to your condition.

Considers himself suffering from a mental disorder or healthy. What features of his condition the patient considers painful. If he considers himself healthy, then how does he explain the existing violations (deceptions of perception, mental automatisms, altered mood, etc.). Representations of the patient about the causes, severity and consequences of the disease. Attitude towards stationing (appropriate, unfair). The degree of criticality (criticism is complete, formal, partial, absent). Plans for the distant and near future.

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

For an additional quantitative assessment of the severity of a mental disorder, a scale of general clinical impression - the severity (severity) of the disease (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 the overall clinical impression - improvement is also used (Gui W., 1976). The rating scale varies from 7 points (the patient's condition has deteriorated very much - Veri much worse) to 1 point (the condition has improved very much - Veri 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 evaluation is usually carried out before the start of treatment, at the end of the 1st, 2nd, 4th, 6th, 8th, 12th weeks 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 the appointment of many neuroleptics may cause neurological complications in the form of the so-called neuroleptic syndrome (akathisia, parkinsonism). To assess neurological side effects, the Barnes Akathisia Rating Scale (BARS) (Barnes T., 1989) and the Simpson-Angus Extrapyramidal Side Effects (SAS) Rating scale for extrapyramidal side effects - Simpson G.M., Angus JWS., 1970) (see Appendix 2).

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

Pathological signs from the side of the cranial nerves may indicate a current organic process in the central nervous system (tumor, encephalitis, cerebrovascular accident) or residual effects of a previously transferred organic lesion of the central nervous system.

Disturbances in the movements of the trunk and limbs, hyperkinesis, tremor. Performing a finger-nose test, stability in the Romberg position. Gait: shuffling, small steps, unsteady. 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 stiff neck and meningeal symptoms (Brudzinsky, Kernig). Deviations in the state of the autonomic nervous system: hyperhidrosis or dry skin, dermographism (white, red).

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

VII. SOMATIC STATUS

Appearance, according to age. Signs of premature wilting. Body weight, height, chest volume.

Body type(asthenic, dysplastic, etc.). Anomalies in the development of the whole body (inconsistencies in height, weight, size of body parts, physical infantilism, feminism, gynecomastia, etc.) and individual parts (structural features of the trunk, limbs, skull, hands, auricles, teeth, jaws).

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

Musculoskeletal system: the presence of developmental defects (clubfoot, flat feet, splitting of the upper lip, upper jaw, non-fusion of the vertebral arches, etc.). Traces of wounds, broken bones, dislocations. Bandages, prostheses.

Oral cavity: lips (dry, presence of herpes), teeth (presence of carious teeth, bite pattern, Hutchinson's teeth, prostheses), gums ("lead border", loosening, redness, bleeding from the gums), tongue (appearance), pharynx, tonsils. Odor from the mouth (putrid, "hungry", the smell of alcohol, other substances).

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

Circulatory organs. Examination and palpation of blood vessels, pulse, examination of the heart (cardiac impulse, heart borders, tones, noises. Swelling in the legs).

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

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

Urogenital system. Urination disorders, Pasternatsky's symptom, swelling on the face, legs. Impotence, frigidity, etc.

The state of the endocrine glands. Dwarfism, gigantism, obesity, cachexia, hair type, voice timbre, exophthalmos, enlargement of the thyroid gland, etc.

VIII. PARACLINICAL STUDIES

Laboratory studies in clinical psychiatric practice are aimed at assessing the somatic state of the patient and its control during therapy, as well as identifying somatic diseases associated with the development of mental disorders.

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

The data of laboratory researches are 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.

The following tests are most often used in clinical practice by a psychiatrist:

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

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

X. DIAGNOSIS AND ITS JUSTIFICATION. DIFFERENTIAL DIAGNOSTIC PROCEDURE

Clinical case evaluation includes:

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

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

There should be no description and repetition of anamnesis and status in the justification of the diagnosis. It is only required to 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-hypochondriac syndrome was noted, which was suddenly replaced by delirious stupefaction with delusions of persecution ... ”etc.

Appearance. the expressiveness of movements, facial expressions, gestures, 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 adorn himself, etc.). general impressions of the patient.

Contact and accessibility of the patient. whether the patient willingly makes contact, whether he talks about his life, interests, needs. Whether he reveals his inner world or the contact is only superficial, formal.

Consciousness. As already mentioned, the clinical criterion for 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 the orientation on the basis of the sequence of presentation of anamnestic data to the patient, the characteristics of contact with the patient and surrounding persons, and the nature of behavior in general. At

Using this method, indirect questions are asked: where was the patient and what was the patient doing immediately before admission to the hospital, by whom and by what transport was he delivered to the hospital, etc. If this method turned out to be ineffective and it is necessary to clarify the nature and depth of disorientation, then direct questions are asked regarding orientation. In most cases, the doctor receives these data already during the collection of anamnesis. When talking with the patient, care and tact should be exercised. At the same time, the patient's understanding of the doctor's questions, the speed of answers, and their nature are evaluated. It is necessary to pay attention to whether the patient reveals detachment, incoherence of thinking, whether he comprehends well enough what is happening, the speech addressed to him. Analyzing the anamnesis, one should 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 precisely amnesia for the painful period. having found signs of clouding of consciousness (detachment, incoherent thinking, disorientation, amnesia), it is necessary to establish what kind of clouding of consciousness is present: stunning, 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, they do not enter into contact with anyone on their own initiative.

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

Amentative 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 leaving the amental state, as a rule, complete amnesia of painful experiences sets in.

It is more difficult to identify the oneiroid syndrome, since in this state the patients are either completely motionless and silent, or are in a state of enchantment or chaotic excitement and are not available. In these cases, you need

we need a careful study of facial expressions and behavior of the patient (fear, horror, surprise, delight, etc.). Medication disinhibition of the patient can help clarify the nature of the experiences.

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

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

Perception. In the study of perception, careful observation of the behavior of the patient is of great importance. the presence of visual hallucinations may be indicated by the patient's lively facial expressions, reflecting fear, surprise, curiosity, 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. The following questions can be used: “Did you have any phenomena similar to dreams 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 forms, coloration, brightness, volumetric or flat nature of images, their projection.

During auditory hallucinations, patients listen to something, speak separate words and whole phrases into space, conversing with “voices”. In the presence of imperative hallucinations, there may be incorrect behavior: the patient makes absurd movements, scolds cynically, stubbornly refuses to eat, makes suicidal 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 the head?”, “Male or female?”, “Familiar or unfamiliar?”, “Is the voice ordering to do something?”. It is advisable to clarify whether the voice is heard only by the patient or by everyone else too, whether the perception of the voice is natural or “rigged” by someone.

It is required to find out if the patient has senestopathies, illusions, hallucinations, psychosensory disturbances. To identify hallucinations, illusions, sometimes it is enough to ask the patient the usual question about how he feels, so that he already begins to complain about “voices”, “visions”, etc. But more often you have to ask leading questions: “Do you hear anything?”, “Do you feel extraneous, unusual smells?”, “Have the taste of food changed?”. If perceptual disturbances are detected, it is necessary to differentiate them, in particular, to distinguish between hallucinations and illusions. To do this, it is necessary to find out whether a real object existed or whether the perception was imaginary. Next, you should be asked to describe in detail the symptoms: what is seen or heard, what is the content of the “voices” (it is especially important to find out if there are imperative hallucinations and hallucinations of frightening content), to determine where the hallucinatory image is localized, whether there is a feeling of being made (true and pseudo-hallucinations), what conditions contribute to their occurrence (functional, hypnagogic hallucinations). It is also important to establish whether the patient has criticism for perceptual disorders. It should be taken into account that the patient often denies hallucinations, but there are so-called objective signs of hallucinations, namely: the patient suddenly falls silent during a conversation, his facial expression changes, he becomes alert; the patient can talk to himself, laugh at something, plug his ears, nose, look around, look closely, throw something off himself.

The presence of hyperesthesia, hypoesthesia, senestopathies, derealization, 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 lights, etc. To establish the presence of senestopathies, it is necessary to find out if the patient does not mean the usual pain sensations, in favor of senestopathies speak the unusual, painful sensations, their tendency to move. Depersonalization and derealization are detected if the patient talks about a feeling of alienation I and the outside world, about changing the shape, size of one's own body and surrounding objects.

Patients with olfactory and gustatory hallucinations are characterized by refusal to eat. Experiencing unpleasant odors, they sniff all the time, pinch their noses, try to open the windows, in the presence of taste deceptions of perception, they often rinse their mouths and spit. scratching of the skin may sometimes indicate the presence of tactile hallucinations.

If the patient tends to dissimulate his hallucinatory memories, the perceptual disturbance can be learned from his letters and drawings.

Thinking. To judge the disorders of the thought process, the method of questioning and the study of the patient's spontaneous speech should be used. Already when collecting an anamnesis, one can notice how consistently the patient expresses his thoughts, what is the pace of thinking, whether there is a logical and grammatical connection between the 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. Symbols can also be found in letters, diaries, and drawings (instead of words, he uses icons that are understandable only to him, writes not in the center, but along the edges, etc.).

In the study of 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 particular importance, it is more appropriate to ask general questions: “what interests you most in life?”, “Has something unusual or difficult to explain happen to you lately? ”, “What are you mainly thinking about now?”. The choice of questions is made taking into account the individual characteristics of the patient, depends on his condition, education, intellectual level, etc.

The avoidance of the question, the delay in the answer or silence make one assume the presence of hidden experiences, a “forbidden topic”. Unusual posture, gait, extra movements allow you to think about the existence of delirium or obsessions (rituals). Hands reddened from frequent washing indicate fear

contamination or contamination. When refusing food, one can think of delusions of poisoning, ideas of self-abasement (“not worthy to eat”).

Next, you should try to identify the presence of delusional, overvalued or obsessive ideas. Assume the presence of delusional ideas allow the behavior and facial expressions of the patient. With delusions of persecution, a suspicious, wary facial expression; with delusions of grandeur, a proud posture and an abundance of homemade insignia; with delusions of poisoning, refusal of food; with delusions of jealousy, aggressiveness when meeting with his wife. Much can also be given by the analysis of letters, statements of patients. In addition, in a conversation, you can ask a question about how others treated him (in the hospital, at work, at home), and thus reveal delusions of attitude, persecution, jealousy, influence, etc.

If the patient has mentioned painful ideas, 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). Further, it is concluded which 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 ideas, and other signs).

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

Memory. The study of memory includes questions about the distant past, the near past, the ability to remember and retain information.

In the process of taking an anamnesis, 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 their children or loved ones. It is proposed to recall the chronological sequence of official movements, individual details of the biography of the closest relatives, professional terms.

Comparison of the completeness of memories of the events of recent years, months with the events of a distant time (childhood and youth

age) helps to identify progressive amnesia.

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

working memory is examined by direct reproduction of 5–6 digits, 10 words or phrases of 10–12 words. With a tendency to paramnesia, the patient is asked appropriate leading questions in terms of fiction or false memories (“Where were you yesterday?”, “Where did you go?”, “Who did you visit?”).

When examining the state of memory (the ability to memorize, retain, reproduce both current and old 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, who is the attending physician, when was a meeting with relatives, what was for breakfast, lunch, dinner, etc. In addition, the technique of memorizing 10 words is used. The patient is explained that 10 words will be read out, after which he must name the words that he remembers. you should read at an average pace, loudly, using short, one- and two-syllable 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 notes the correctly named words, then reads them again (up to 5 times). Normally, after a single reading, a person remembers 5–6 words, and starting from the third repetition, 9–10.

Collecting anamnestic, passport information, the curator can already note what the patient's memory is for past events. It should be noted whether he remembers the year of his birth, age, the most important dates of his life and social and historical events, as well as the time of the 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 simulative 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. Disorders of attention are revealed when questioning the patient, as well as when studying his statements and behavior. Quite often, patients themselves complain that it is difficult for them to concentrate on anything. When talking with the patient, it is necessary to observe whether he is focused on the topic of conversation or any external factor distracts him, whether he tends to return to the same topic or easily changes it. one patient focuses on the conversation, the other is quickly distracted, unable to concentrate, exhausted, the third switches very slowly. you can also determine the violation of attention with the help of 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, detection of 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 status of the patient, it is already possible to draw a conclusion about the level of his intellect (memory, speech, consciousness). The labor history and data on the patient's professional qualities currently indicate a stock of knowledge and skills. Further questions in terms of the actual intellect should be asked taking into account the education, upbringing, and cultural level of the patient. The doctor's task is to establish whether the patient's intellect corresponds to his education, profession, and life experience. The concept of intelligence includes the ability to make one's own judgments and conclusions, to single out the main thing from the secondary, to critically evaluate the environment and oneself. To identify intellectual disorders, you can ask the patient to tell about what is happening, to convey the meaning of the story read, the movie watched. You can ask what this or that proverb, metaphor, catchphrase means, ask you 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 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 will prick yourself.” You can give the task to find synonyms for the words “think”, “house”, “doctor”, etc.; name the following objects 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 decrease, tasks should be simplified more and more. So, if he does not understand the meaning of proverbs at all, then you 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 the skills of reading and writing. Ask to count from 10 to 20, find out if he knows the denomination of banknotes. It is not uncommon for a mentally retarded patient to make blunders when counting between 10 and 20, but if the question is posed specifically, taking into account everyday life skills, then the answer may be correct. Task example: “Did you have

20 rubles, and you bought bread for 16 rubles, how many rubles

Are you left?"

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

For the study of intelligence, mathematical and logical tasks, sayings, classifications and comparisons are used in order to identify the ability to find causal relationships (analysis, synthesis, distinction and comparison, abstraction). the range of ideas about life, ingenuity, resourcefulness, combinatorial abilities are determined. the richness or poverty of the imagination is noted.

attention is drawn to the general impoverishment of the psyche, a decrease in horizons, the loss of worldly skills and knowledge, and a decrease in the processes of comprehension. summarizing the data of the study of intelligence, as well as using the anamnesis, it should be concluded whether the patient has oligophrenia (and its degree) or dementia (total, lacunar).

Emotions. In the study of the emotional sphere, the following methods are used: 1. Observation of the external manifestations of the patient's emotional reactions. 2. Conversation with the patient. 3. Study of somato-neurological manifestations accompanying emotional reactions. 4. Collection of objective

information about emotional manifestations from relatives, employees, neighbors.

Observation of the patient makes it possible to judge his emotional state by facial expression, posture, rate of speech, movements, clothing and activities. For example, a depressed mood is characterized by a sad look, eyebrows reduced to the bridge of the nose, lowered 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 sympathy.

It is necessary to assess the emotional sphere of the patient: the features 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 one's feelings. one can learn about the patient's mood from his stories about his feelings, experiences, and also on the basis of observations. Special attention should be paid to the expression of the patient's face, his facial expressions, motor skills; Does he take care of his appearance? How the patient relates to the conversation (with interest or indifference). Is he correct enough or, conversely, cynical, rude, slick. Having asked a question about the attitude of the patient to his relatives, it is necessary to trace how he speaks about them: in an indifferent tone, with an indifferent expression on his face or warmly, worrying, with tears in his eyes. It is also important what the patient is interested in during meetings with relatives: their health, the details of life, or just the transmission brought to him. It should be asked if he misses home, work, is experiencing the fact of being in a psychiatric hospital, reduced ability to work, etc. It is also necessary to find out how the patient himself evaluates his emotional state. Does facial expressions correspond to his state of mind (is there any paramicry when there is a smile on his face, and longing, fear, anxiety in his soul). It is also of interest whether there are diurnal mood swings. Among all disorders of the emotional sphere, it is not easy to identify mild depression, but meanwhile this is of great practical importance, since such patients are prone to suicidal attempts. it is especially difficult to identify the so-called "masked depression". At the same time, a variety of somatic complaints come to the fore,

while patients do not complain about a decrease in 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, paresthesias and peculiar, hard 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, 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 give a visible effect. Depression hidden behind the facade of somatic sensations is difficult to detect, and only a targeted survey indicates its presence. Patients have previously unusual indecisiveness, unreasonable anxiety, decreased initiative, activity, interest in their favorite business, entertainment, “hobbies”, decreased sexual desire, etc. It should be borne in mind that such patients often have suicidal thoughts. “Masked depression” is characterized by diurnal fluctuations in the state: somatic complaints, depressive manifestations are especially pronounced in the morning and fade away in the evening. In the anamnesis of patients, it is possible to identify periods of occurrence of similar conditions, interspersed with periods of complete health. In the anamnesis of the next of kin of patients, similar conditions may be noted.

Elevated mood in typical cases is manifested in a lively facial expression (glitter eyes, smile), loud accelerated speech, bright clothes, fast movements, desire for activity, sociability. With such patients, one can speak freely, even joke, encourage them to recite, sing.

Emotional emptiness is manifested in an indifferent attitude to one's appearance, clothes, an apathetic facial expression, and a lack of interest in the environment. There may be inadequacy of emotional manifestations, unreasonable envy, aggressiveness towards close relatives. lack of warmth when talking about children, excessive frankness in answers regarding intimate life can serve, in combination with objective information, as the basis for a conclusion about emotional impoverishment.

It is possible to reveal the explosiveness, explosiveness of the patient by observing his relations with his neighbors in the ward and by 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.

In the study of emotions, it is always advisable to offer 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 content of the skin and mucous membranes, changes in blood pressure, pulse rate, respiration, blood sugar, etc.

desire, will. the main method is to observe the patient's behavior, his activity, purposefulness and adequacy of 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, plans for the future. Observe what he is doing in the department - reading, helping the employees of the department, playing board games or watching TV.

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

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

to questions, constrained, it is necessary to find out if there are other symptoms of stupor: give the patient one or another posture (if there is catalepsy), ask him to follow the instructions (if there is no gativism - passive, active, echopraxia). When the patient is excited, attention should be paid to the nature of the excitation (chaotic or purposeful, productive), if there are hyperkinesias, describe them.

It is necessary to pay attention to the peculiarities of the patients' speech (total or elective mutism, dysarthria, scrambled 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 phenomena of active and passive negativism, automatic subordination, mannerisms, grimacing. In some cases, it is recommended to disinhibit a stuporous patient with medical methods.