FromPsychiatricSelfInstructionalUnits ByRobertB.White,M.D.

EVALUATION:PSYCHIATRICHISTORY
PRELIMINARYINFORMATION Identifying Information Identificationofthecaseshouldincludethepatients: ReferralSource Sourcesof Information Age Maritalstatus Race Sex Religion Educationallevel Occupation Placeofresidence Dateofadmission

Nameofthereferringphysicianand/oranyothersourceofreferral Sourcesofinformationshouldinclude: identityoftheinformants(includingthepatient) anestimateofeachinformantsreliability howmanytimesandhowlongeachinformantisinterviewed lettersorphonecallsfromotherphysicians

Hospital Justification

Specifywhythispatientneededtobehospitalizedatthistime.Usually,a commonsenseevaluationofthepatientsproblemswillbeadequate.Among thenumerousreasonsforapatientshospitalizationare: Lackofappropriatefacilitiesinthepatientshometown Needtoberemovedfromstressfullifecircumstances Roundtheclocksupervisionforadequateevaluationandtreatment Specialdiagnosticandtreatmentprocedureswhichcanbemostadequately providedinthehospital Symptomstoosevereforoutpatienttreatment Courtmandatedadmission Failuretorespondtooutpatienttreatment

ChiefComplaint

Thestatementoftheproblem(chiefcomplaint)consistsofabriefdescriptionof thenature,duration,andseverityoftheprincipaldifficultieswhichnecessitated admissionofthepatienttothehospital.(Usedirectquotesfromthepatient.) Describetheeventsinchronologicalsequence,specifyingexactdateswherever possible.

PRESENTILLNESS RecordEvents Chronologically Beginningwiththefirstclearevidenceofemotionaldifficultiesorphysical symptoms,recordthechronologyofthepresentillnessuptothedateof admission.Notetheexactsequenceofeventsandrecordtheexactdatesof theiroccurrence(orasnearlyexactasyourinformantscangivethem).

Example: Insteadofsayingapproximately2monthspriortoadmission Thepatientbegantohavenervousspells,state:OnMay10,1962,the Patienthadthefirstofaseriesofnervousspells.

UseSpecific BehavioralTerms

Donotacceptvagueandgeneraltermswhichpatientsandtheirfamilies frequentlyusetodescribesymptoms,anddonotbecontentwiththepatients descriptionofhisepisodesasnervousspells.Gethimtodescribethe subjectiveexperienceofthatspellandtheaccompanyingbehavioralor observablephysicalmanifestations.Inshort,getagoodbehavioraldescription.

Example: Thepatientdescribeshisnervousspellsasepisodesinwhichhisheart suddenlybeginstobeatveryrapidlywhilehefeelsapprehensive,tremulous,andat times,sweatstothepointthathehastomophisbrow.Ifheiswritingoreating,his handmaybecomesotremulousthatheisunabletocontinueorisunabletolighta cigarettewithouthistremorbeingapparenttoonlookers.Althoughhehasnever lostconsciousness,healmostalwayshasthefearduringanepisodethathes goingtoblackoutandfallhelplesslyunconscious.

GetContextof Symptoms

Attempttogetacompletedescriptionofthecontextinwhichepisodicsymptoms occurorthelifecircumstancesleadinguptotheonsetofthemorecontinuous andprogressivesymptoms.Beespeciallyattentivetoprecedinglifeeventsthat haveproducedchangenecessitatingasignificantdegreeofreadjustment, particularlylifechangeeventsinvolvingloss.

INTERACTIONWITHEXTERNALAGENTS SubstanceUse Inquiretactfullyaboutsubstances(alcohol,drugs,etc.)thatthepatientisusing orhasusedextensively.Listthemandnotehowlongthepatienthasused them.Getdetailsofamountandfrequencyofuse. Ifthepatientthinkshemayhavebeenexposedtoatoxicsubstance,ifheisin anenvironment(atwork,atschool,athome,etc.)wherehemayhavebeen exposed,ifheisinanenvironment(atwork,atschool,athome,etc.)wherehe mayhavebeenexposed,orifheissimplyhavingunusualhealthproblems, additionalinquiryaboutpossibletoxicexposureiswarranted.Notethetoxic substancestowhichthepatientmayhavebeenexposedor,ifasissooften thecasetheyareunknown,thecircumstancesinwhichhemaynavebeen exposed. Aparagraphshouldbedevotedtothecurrentmedicationsthatthepatientis using.Listthosethatthepatientistakingandnoteforhowlongthepatienthas beenoneachspecificmedication. Inquireaboutmedicationsthathavebeenusedinthepastandwhateffect(good orbad)themedicationshavehad. Recordinformationaboutanysignificantallergies,treatmentreceived(ifany), andwhetherornotthetreatmentwassuccessful.

ToxicExposure

Current Medications Past Medications Allergies

PASTHISTORY Medical Discussallrelevantdetailsofanysignificantillnesses,injuries,accidents,or operations.Exactdatesshouldalwaysbegiven.Inaddition,inquiryshouldbe madeastowhetherthepatienthaseverhadabloodtransfusion. Specialattentionshouldbegiventowhetherornotthepatienthaseversuffered: anykindofheadtrauma episodesofunconsciousness convulsiveseizures episodesofamnesia episodesofconfusion episodesofdisorientation

FAMILYHISTORY Medicaland Psychiatric Data Summarizethemedicaldataregardingphysicaldiseasesthathaveafamilialor hereditarytendencyandthepsychiatricdiseasesknowntohaveoccurredin parents,grandparents,siblings,aunts,anduncles.Specificmentionshouldbe madeofthepresenceorabsenceofthefollowingmedicalconditionsinthose familymembers: Cancer Allergies Diabetes Hypertension Heartdisease

Determinewhetherthesefamilymembershaveeversufferedfromany emotionaldifficultiesornervousbreakdowns.Wheresuchemotionaldifficulties haveoccurred,specifythe: Describethe PatientsFamily Natureofthesymptomsinvolved Typeoftreatmentprovided Lengthofhospitalization(ifany) Frequencyofrecurrence

Inadditiontothesemedicalandpsychiatricdata,thefamilyhistoryshould includesomereferenceto:culturaltradition,socioeconomicbackground,family interest,aspirations,myths,legends,andsoforth,thatcharacterizethepatients familyoforigin.(Theseaspectsofthefamilyhistorycanusuallybeincorporated inthememberbymemberdescriptionofthefamily.)Includeaclearstatement ofthepatientsdescriptionofeachfamilymember,aswellassomeclear indicationofwhowasimportanttowhomwithinthefamily.Noteparticularlywho wasimportanttothepatientandhowclosetooneanotherthevariousmembers ofthefamilywereinthepastandareatthepresent.Usually,eachparentcan bedescribedadequatelyinaparagraph.Someinformationaboutthefamily backgroundofeachparentshouldbegiven,togivesomenotionofthe circumstancesandthetypeoffamilyinwhicheachparentwasreared. Describetheparentsandthesiblingsinseparateparagraphs.Listthesiblingsin theorderofage,includingthepatient,sothathisrankamongthesiblingsis clearlyindicated.Includeanystillbirthsorabortionsintheirproperchronologic order.Abareminimumoffactsaboutthesiblingswouldincludeage,education, significantillnesses,occupation,degreeofsuccessoccupationallyand academically,maritalstatus,ageatmarriage,numberofchildren,andthe patientsimpressionofthemarriageofthesiblings.Inadditiontobasicfacts, exploreandrecordthepatientsassessmentofeachfamilymembers personalityandhisownrelationshiptothatperson. Notethathere,aselsewhere,directquotationsfromthepatientareuseful.
Thefamilyhistoryisnegativeforcancer,allergies,hypertension,heartdisease,orany otherseriousphysicaldisorders.Thepatienthasonesisterwhowashospitalizedfor 3monthsinapsychiatrichospitalforastateofdepressionfromwhichsherecovered withdrugtherapyandpsychotherapy.Hehasayoungerbrotherwhoisanovert homosexualandhasbeeninpsychotherapyasanoutpatientforseveralyears.

Describethe PatientsSiblings

Illustration (FamilyHistory)

(Father)

Father,age75,cametothiscountryfromEnglandattheageof7.Hebeganto supporthimselfasaclerkinastoreattheageof14whenbothparentsdiedof pneumonia.HehaslivedinDallassincecomingtothiscountry,anddespitehaving onlyahighschooleducation,hehasacquiredalargedepartmentstoreinDallasand isaverysuccessfulbusinessman.AfterlosingallhismoneyintheDepressionofthe 3

(FatherCont.)

1930s,hebuiltupanotherbusinessfromvirtuallynothingandwasabletoretirelast year,adequatelyprovidedfor.Thepatientdescribeshisfatherasaselfmade courageousman,butonewhosemindislimitedtobusinessthings.Nowon excellenttermswithhisfather,whenyoungerthepatientwasintolerantofthefathers faultsandhistendencytoactthebigshot.ThefatherisactiveintheMethodist Churchandmakeslargeannualfinancialcontributionstoit.Inadolescenceand youngadulthood,thepatientwasashamedofhisfatherslimitedmind,andherarely introducedhisfriendstohisparents,whowerenotpresentathismarriagetohis presentwife. Mother,age68,cametothiscountryfromEnglandwhenshewasaninfant.Sheis thoroughlyaTexananddevoutlyMethodist.Althoughshehasonlyahighschool education,sheisbrightandwellreadsheishighlyrespectedinDallas,wheresheis activeincivicactivities,particularlycivicmusicaffairs.Thepatientdescribesheras loveable,unselfseeking,kind,sensible,andwillingtohelpeveryone.Heemphasizes herintelligenceandherabilitytospeakwithgreatspontaneitytopeoplefromvarious socioeconomiclevels.Hesalwaysbeenveryattachedtohismother,althoughhehas seenlittleofhersincehewas14yearsold,whenhelefthometogotoaprepschool. Siblings: 1)Sally,age48,livesinMountVernon,N.Y.,wheresheworkshardtoforwardthe careerofherhusband,ajudge.In1950,shehadanervousbreakdown,evidentlya depression,forwhichshewashospitalizedfor3months.ThepatientstatesthatSally hasmadeagoodadjustmenttoadisappointinglife,meaningthatshehasbeen distressedathavingnochildrenandahusbandwhoismoreattentivetohislegal careerthanheistoher. 2)Florence,age44,wasalwaysthemostattractiveandsociallypopularofallofthe children.Shewasthefavoriteofbothparents.Shestudieddramaandwasonthe stageforashorttime,butquittohelpherfatherinhissecondbusinessventure.Her husband,whomshehadmarriedattheageof28,allegedlyattemptedtoswindlethe patientsfatherinanefforttosetuphisownbusiness.Thepatienthasbeenunableto forgiveFlorenceforherefforttodefendherhusbandduringthatunpleasantepisode. HeandFlorenceshusbanddonotspeaktoeachother.HewasnotclosetoSallyor Florenceeitherinchildhoodorlater. 3)Thepatient,Arnold,age41. 4)Leonard,age38,istheonlysurvivoroftriplets theothersdiedatbirthorshortly thereafter.Sinceearlyinfancy,hehasbeentheweaklingofthefamilyandis describedasundistinguishedandnotveryintelligent.Hedidnotfinishhighschool. Anoverthomosexual,hehasbeenunderpsychiatrictreatmentfromtimetotime withoutnoticeableeffect.Atpresent,heisworkingasanattendantinastatemental hospitalinNewYork.ThepatientalwaystendedtobelittleandbullyLeonardin childhood,butsinceadolescencehashadverylittletodowithhimatall.

(Mother)

(Siblings)

(Spouseand Children)

MaritalFamily Wife,Mary,age31,istheonlyandverypamperedchildofaprominentoldline CatholicNewOrleansfamily. Exceptforherinabilitytobecomepregnantagainafter havinghadonechild,thewifeshealthhasbeenexcellent. Sheandthepatientmetat aMardiGrasparty10yearsago,shortlyaftershegraduatedfromcollege.Boththe patientandhiswifeagreethattheyelopedimpulsivelyandmarriedafteronlya monthsacquaintance.Bothfamiliesopposedthemarriagebecauseofreligious differences.Thepatientdescribeshiswifeasaspoiledchildwhoconstantly demandsattention.Theirrelationshiphasdeterioratedsteadilyforthepast2or3 yearsbutespeciallysointhelast3months. Son,ArnoldJr.,age8,isabright,active,healthychild.Veryclosetohisfather,the boyhaslittletodowithhismother,whoallowedalongtimefamilymaidtorearhim almostentirely.

PERSONALHISTORY Milestones Recordchronologicallythedevelopmentalmilestonesofthepatientasaperson, beginningwiththedateandplaceofbirthandendingwiththeonsetofthe presentillness. Includethedateandplaceofbirthanddescribethefamilycircumstances(social, economic,emotional)atthetimeofthepregnancyandbirth,includingthe parentshealthandmaritalrelationship.Wasthepregnancydesired?Wasthe birthfulltermandnormal?Whatwasthepatientsbirthweight?Wasthepatient breastorbottlefed?Didhefeednormallyandgainweight?Washehealthy? Notetheagesat:walking,talking,weaning,andtoilettraining.Noteearly infectionsandwhethertheseseemedtoinfluencethedevelopmentofthechild. Obtaininformationconcerningtheformationofhabitswithspecialreferenceto bedwetting,nightterrors,sleepwalking,fingernailbiting,thumbsuckingand stuttering.Takenoteofanyhistoryofstomachandbowelcomplaints, headaches,orotherspecialinvalidismandpsychosomaticdisorders.Patients rarelyremembereventsbeforethethirdorfourthyearandoftenrelatewhatthey havelearnedfromparentsthesourceofinformationshouldbeindicated.An informativequestionis,Whatisthefirstthinginyourlifethatyouremember? Theanswer,eventhoughitmayrepresentascreenmemory,maybevery informative.Otherearlymemoriesmaybesought. Next,inquireintothepreschoolyears(approximatelyage3to6)withregardto whatevercanbedeterminedaboutfamilycircumstancesandphysical,emotional andsocialdevelopmentaswellasphysicalhealth.Howdidhegetalongwith hissiblings,withotherchildrenhisownage,andwitholderandyounger children? Thesleepingrelationsofearlychildhoodmaybeofinterest.One shouldhaveaclearlydetailedstoryofthefirstsixyearsoflife,includingthose special,significanteventswhichmighthaveinfluencedthecourseof development. Adolescent History Obtainachronologicalaccountofmajoreventsduringtheprimaryorgrammar schoolyearsandthejuniorhigh,highschoolandcollegeyears.Bybreakingthe earlyhistoryintothesesegmentsonecanoftenhelpthepatientandother informantstorememberspecificeventsthatmightbeoverlooked. Obtaininformationaboutpersonalproblemsthatwereexperiencedduring pubertyandadolescence,especiallyintermsofsocialrelationshipsinschool,in play,heroworship,interpersonalrelationships,tendencytoassociatewiththe sameoroppositesex,religiousandsexualattitudes,evidenceofphilosophical ruminations,obsessivethinking,compulsionsorphobias.Judgmentmustbe usedwhenrequestingsexualinformation.Variousopportunitieswillarise thoughtheinformationshouldthenbeorganizedandrecordedinasection labeled,SexualHistory.Thefollowingtopicsarefruitfulareasfortactfully exploringsexualdevelopmentinthecourseoftakingthehistory: MaritalHistory Relationshipwithparents Birthofsiblings Menstrualhistory Pregnancies Attitudetowardsexualissues Problemsofthepatients children

Childhood History

However,ifthepatientismarried,itislogicaltobeginwiththemarriageand courtship,andthenworkback.Obtaininformation,ifavailable,concerning: Developmentofinterestinsexualtopics Typeandrichnessofsexualfantasies Sexinstructionreceivedinchildhood

5

MaritalHistory (Cont.)

Attitudesoftheparentsandfamilytowardthesesubjects Evidenceofanyperversionsoruntowardexperiences Attitudeofthepatienttowardmarriageandtheresponsibilitiesoffamilylife

Noteanysexualincompatibilitieswiththespousepremaritaland/orextramarital sexandattitudetowardbirthcontrol,especiallyasacauseofconflict.Obtain informationabout: Masturbationage,frequency,feelingsaboutit,reactionsandstatements ofothers Childhoodsexualexperiences,ageatpuberty,relationshipswiththe oppositesex,dates,parties,dances,frequencyofdating,feelingsofease ordiscomfort,crushes Firstheterosexualexperiences Homosexualexperiences Engagementlengthofcourtshipwithspouseparentalattitudestowardthe marriage

Educational History

Giveindetailtheageatwhichschoolwasstartedandfinished.Evaluate:

Vocational History/Economic Status

Theschoolrecord Thesocialadaptation Thepatientsgeneralattitudetowardschoolingandintellectualpursuits

Thevocationalhistoryshoulddetail,chronologically,thejobsheld,wages earned,andreasonsforchanges.Fromthis,oneshouldgatheraclearaccount of: Abilityinthecompetitivefield Thepossibilitiesofgoodinterpersonalrelationships Theabilitytogiveandtakeorders Theamountofambitionandenergy Describethepatientsreactiontopromotion,demotion,andresponsibility.Note periodsofeconomicstressand,ifapplicable,thereactiontounemploymentor welfarestatus.

MilitaryHistory

Militarydatashouldinclude: Branchofservice Durationanddates Experience Combat Injury Illness Rankonentryandatdischarge,typeof discharge,i.e.,honorable,medical,etc. Effectofmilitaryserviceonthepatientslife situationbothatinductionandatdischarge Problemsarisingafterdischarge Hospitalizations

LegalHistory

Notedetailsofanyproblemsinvolvingthelaw: Arrests,jailorprisontime Chargesorconvictions Lawsuits

Also,recordthepatientsattitudestowardtheseevents. ReligiousHistory Gaininsightintothepatientsreligiousbeliefsandpracticesandanyassociated satisfactionsand/orconflicts.

Leisureand SocialHistory

Howdoesthepatientspendleisuretime?Sports,hobbies,clubs,social organizations?WhatdoeshereadorwatchonTV?Doeshehavefriendsand associates,andwhatistheirrelationship?Someawarenessofthepatients culturalandsocialaspirations,interestsandfrustrationsisimportant.Apicture oftheculturalandsocialsettinginwhichthepatientlivesshouldbeobtained. Issuesimportantinthemidphaseofadulthoodshouldbediscussedwhen applicable: Parenthood Grandparenthood Deathofparents Work Healthandmarriage

AdultLife History

Issuesimportantinlateadulthoodare: Current Living Status Retirement Financialsecurity Deathofthespouse healthproblems

Withwhomdoesthepatientlive?Spouse,children,parents,friends,significant other,relativesotherthanimmediatefamily,landlord,renter?Doesheliveina houseoranapartment? Whatistheneighborhoodlike?Doesheownorrent hishabitation?Isheresponsibleformaintainingit?Hastherebeenanyrecent changeinanyofthesefactors? Chronologyisofgreatimportanceanditisadvisable,whereverpossible,to recordsignificanteventsbydesignatingtheyeartheyoccurredandtheage ofthepatientatthetimeoftheoccurrence. Thepatientsfeelingsabouteventsinhislifeandrelationshipswithpeople areasimportantastheactualfactsregardingthoseeventsand relationships.

Remember!

Reorganize AndRetrace

Muchoftheinformationwillbeobtainedduringhistorytakinginahaphazard order.Oncethematerialisobtained,itshouldbereorganizedandrecordedina moresystematicform.Atthattime,areasofomissionorareaswhereimportant informationismissingwillbediscovered.Theseomissionsmayreflectanxiety provokingtopicswhichthepatientconsciouslyorunconsciouslyavoidsand shouldberetracedandpickedupinanadditionalinterview.

REVIEWOFSYSTEMS Askwhetherthepatienthaseverhadeachsymptomofeachsystem. Recordonlypositivefindings. SYSTEM General Skin Eyes Ears Nose Throatand Mouth Neck Cardio respiratory Gastro Intestinal Reproductive SystemFemale SYMPTOMS weightchange,weakness,fatigue,fever,chills,heatintolerance,sleepdisturbance rashes,itching,changesinskintextureorhair changesinvision,glasses,diplopia,blurredvision,scotoma,eyepainphotophobia hearingloss,tinnitus,vertigo,earpain,eardischarge epistaxis,nasaldischarge,obstruction,sinusitis teeth,denture,abnormaltaste,soremouthortongue,gums,sorethroats,speech difficulty,hoarseness areasofswelling,pain,goiter,massesornodes cough,dyspnea,wheezing,hemoptysis,chestpain,palpitations,orthopnea, paroxysmalnocturnaldyspnea,edema,highbloodpressure,syncope anorexia,nausea,vomiting,hematemesis,melena,dysphagia,heartburn, flatulence,abdominalpain,jaundice,changeinbowelhabits,diarrhea, constipation,hematochezia,rectalpain ageatmenarche,menstrualcycle,lastmenstrualperiod,gravida,paraabortus, ageatmenopause,dysmenorrhea,menorrhagia,metrorrhagia,dyspareunia, methodofcontraception,pelvicpain,sexualdysfunction,abilitytoachieveorgasm, discharge,venerealdisease,breastmass,breastpain,breastdischarge sexualdysfunction,discharge,venerealdisease dysuria,frequency,nocturia,hematuria,urgency,incontinence,polyuria backache,jointpain,stiffness bleedingtendencies,bruising,anemia headache,headinjuries,seizures,syncope,impairedmemory,impaired coordination,impairedordisturbedsensation *****

Male UrinarySystem MusculoSkeletal Hematologic Neurological

EVALUATION:MENTALSTATUSEXAMINATION
INTRODUCTIION Methodology Thephysiciangathersmentalstatusdatafromapatientbytwomodes: Pitfalls Relativelyobjectiveexaminationprocedures Personaljudgmentofthepatientstraitsandstatus

Manystudentsareunderstandablyreluctanttomakesubjectiveevaluationsfor fearofpassingunsoundorunfairjudgment.Thephysicianmust: Avoidbeingmoralisticallyjudgmental Understandandrespectthebeliefs,customs,andattitudesofpeoplewith variousbackgrounds

Yethemustlearntoobservecarefullyand,onthebasisofthoseobservations, makeinformedjudgmentsonthebehaviorandemotionalstateofapatient. Unfortunately,therearenodefinitiveproceduresfordoingthis. ObviousExamples Thewayapatientdressescanbeanimportantcluetoemotionalhealth.If dressisgrosslyinappropriateorbizarre,itcansignalapsychosis. Examples: A65yearoldwomanwithapaunchyabdomenandflabby,obeselegs comesintoaclinicorofficeinabriefandrevealingminiskirt. Amedicalschoolapplicantcomestotheadmissionscommitteeinterviews barefootandwearingmilitarymedals. DifficultCases Howshouldonedecidewhatisappropriatedress(orbehavior,etc.)inless obviouscases,whenmeetingapatientforthefirsttime?Rememberthat physiciansareconstantlymakingdecisionsandjudgmentsaboutthephysical andemotionalhealthoftheirpatients,sometimescrucialonesbasedonminimal data. Therearetwoessentialskillsinmakingtimelyandaccuratedecisionsforpatient care.Thephysicianmust: Becomeanacuteobserverofpeopleandtheirbehavior Learntorecordobservationsaccurately

EssentialSkills

Learningtoobserveandtorecorddataaboutpatientsmentalhealthareskills thatmustbedeveloped,justlikehearinganddescribingcardiacmurmurs. Categories Thedatafromamentalstatusexaminationarerecordedandorganizedintosix categories: Generalappearance,behaviorandspeech Moodandaffect Intellectualfunctions Evaluationofthoughtprocesses Insight Judgmentandreliability

Thischapterwillelaborateoneachofthesecategories.

GENERALAPPEARANCEANDBEHAVIOR Observation Thephysicianshouldgatherdataaboutthepatientsappearanceandbehavior throughouttheinterview.Thisrequiresconstant,sharp,andaccurate observation. Thefollowingareindicatorstobescrutinized: Handshake Expression Gait Posture Attitudetowardexaminer Eyesmovementandcontact Dresshair,makeup,clothing

Criteria

Thepatientsspeechisparticularlyimportant.Isit: Tooslow,blocked,halting,orstuttering? Toofast,rhyming,orpunning?

Isthepatientsspeechladenwith: Example Stereotypes? Otheroddities?

Belowisanexcerptfromamentalstatusexaminationthatrecordsthepatients appearanceandbehavioraccurately:
Thepatientisatall,slenderyoungmanwhoappearsandactsmorelikeheis15years oldthanhisactualageof19.Hewalksinanawkward,ganglingmannerandseemsto beallarmsandlegs.Hishandshakewaslimpandhishandswerecoldandsweaty.He satslumpedinhischairwithhisheadandeyesdowncastmostofthetime.Herarely movedaboutinhischairduringtheinterviewandgavetheimpressionthathewasready torunformtheofficeatanymoment.Hewasdressedcasually,infrayedanddirtyblue jeans,atattered,dirtysweatshirt,andfrayedtennisshoes.Hisfaceappearedtense,and herarelylookedattheexaminer.Whenhedid,hiseyesseemedapprehensive,andhe actedasifheexpectedtobescoldedorseverelyreprimandedatanymoment.Hishair wasshoulderlengthbutcarefullyandneatlycombed.Hespokeinlow,sullentonesand rarelygavemorethanthebriefestanswerstomostquestions.Towardthelatterpartof theinterview,hebecameobviouslymorerelaxedandlesstense,andhebegantotalkin amuchmorespontaneousmanner.Atnotimedidhesmileormakeanyshowof friendlinesstowardtheexaminer.

Review

Onceagain,thephysicianistheexamininginstrumentforthispartofthe interviewandmustmakeaccurateobservationsinordertojudgeapatients emotionalstatecorrectly.

MOODANDAFFECT Description Patientsmood(prevailingemotionaltone)andaffect(transientshiftsin emotions)shouldbedescribedintermsof:a)typeb)intensityandvariability andc)appropriateness. VerbalPatientsmayrevealtheiraffectivestateverbally,statingthatthey feelsad,angry,suspicious,etc. NonVerbalPatientsmayexpresstheiraffectivestatenonverbally, manifestingitinbehavior,expression,orgeneraldemeanor.

TypeofAffect

10

Questioningthe Patientabout Affect Categoriesof Affect

Ifthepatientappearsinaparticularaffectivestatebutmakesnomentionofit, thephysicianshouldcommentonthisappearance,usingconfrontationto determineifthatishowthepatientfeels.Thisprocedureshouldbedone wheneverthepatientisobviouslyexpressinganaffectnonverbally. Thefollowingcategoriesofaffectivestatesarecommonlyrecognized:

Intensityand Variability

normal elated,euphoric depressed guilty

anxious hostile suspicious flat

Lookforthesedifferencesinaffect: IntensityIsthepatientseverelyoronlyslightlyaffected? VariabilityDoesoneaffectpersist(i.e.,unwaveringindifferenceaflat affect)?Attheotherextreme,doesthepatientsaffectfluctuaterapidlyand extremely?Eitherextremeisanominoussignofsevereemotional disturbance.

Appropriateness

Thepatientsaffectshouldbejudgedasappropriateorinappropriatein referencetothe: topicorcontentaboutwhichthepatientspeaks realityofthepatientscurrentcircumstances

Thefollowingchartgivesexamplesofbothkindsofaffect: APPROPRIATE Topicof Conversation Depressedpatienttalksmostly. aboutsadordistressingevents. Elatedpatienttalksmainly ofexcitingandpleasantevents. Anxiouspatientexpresses fearfulthoughts. Suspiciouspatienttalksof ominousplots. INAPPROPRIATE Certainpatients,usually schizophrenics,mayexpress bizarreandfrighteningdelusions (e.g.,thatraysfromtheTVare causingtheirbrainstorot)while laughingandgiggling. Severelydisturbedpatients, exhibitaflataffect,thatis, unwaveringindifferencetosad, happy,orfrighteningevents. Abereavedpersonexpresses nosadnessordepression. Aphysiciancommittedtoa closedpsychiatricunitexpresses extremeconfidencethatthe worldwilleventuallyhonorhis genius.

Realityof Circumstance

Depressedandbereaved patientwhohaslosta lovedoneexpresses sadness. Anattorneyinalocked psychiatricwardundercourt commitmentworriesaboutthe consequencesforhisfuture work.

11

INTELLECTUALFUNCTIONS:OVERVIEW Introduction Thispartoftheexaminationinvolvessystematicandrelativelyobjectivetesting ofthepatientsintellectualabilities.Intellectualfunctiontestingdoesnotdepend asmuchonthephysicianssubjectiveimpressionsandjudgmentasmostother partstothementalstatusexamination. Thedatafromthispartoftheexaminationareofspecialsignificancefor differentiatingdisturbancescausedbyorganicbraindiseasefromthefunctional psychiatricdisorders: Secondary Significance neuroses psychoses personalitydisorders transientsituationalstressreactionswithnoknownorganiccause

Primary Significance

Alsodetectedareparticularpatternsofthoughtwhichdifferentiatethe psychoses: schizophreniafragmentedandconcrete depressionslowedorretarded maniarapidanddistractible

Functionsto BeEvaluated

Theexaminationconsistsofevaluationsofthepatients: sensorium memory problemsolvingability capacityforabstractthought fundofgeneralknowledge basicintelligencelevel

Techniquesforevaluatingeachfunctionarediscussedonthefollowingpages: INTELLECTUALFUNCTIONS:SENSORIUM Definition Sensoriumreferstothepatientsorientationsto: Determining Orientationto PersonandPlace Determining Orientationto Time Person:Doesheknowwhoheis? Place:Doesheknowwhereheis? Time:Doesheknowthedayofthemonthandtheyear?

Thephysiciancanusuallydeterminewhetherthepatientiscorrectlyorientedto personandplacewithoutaskingdirectly.Closeobservationshouldrevealthe patientsorientationduringtheinterview. Thephysicianwillusuallyhavetoaskthepatientabouthisorientationtotime. Tactfulcommentsandquestionsshouldelicitadequateresponses.

Example: NowIwanttoaskyousomequestionstoseehowwellyourmemoryworks. Forexample,canyoutellmewhatthedateistoday?(Ifthepatientsimplyreplies Yes,dontbelieveit). Whatisthedate?(IfthepatientsaysThetenthofthemonth,ask Thetenthofwhatmonth?andifneeded,Ofwhatyear?

12

INTELLECTUALFUNCTIONS:MEMORY MemoryTesting Memoryistestedbygivingthepatientafewsimpletaskstoperform.Thegoal istodetermineifeitherofthesetypesofmemoryhasbeenimpaired: RECENTthelastfewminutes,hours,days REMOTEthelastfewmonths,years,orlonger

andthustobegintodifferentiatebetweenorganicbraindiseaseandfunctional mentaldisease. Typesof MemoryImpairment Inorganicbraindisease,recentmemoryisusuallyimpaired,butremote memoryremainsintactunlessthediseaseissevere. Infunctionalmentaldisease,memoryisusuallyintact.However,anxious, depressed,orconfusedpatientsmayhavegreatdifficultycooperatingin amemorytest.

TestTechnique RecentMemory: TestAddress

Tellpatientsthattodeterminehowwelltheirmemoryworks,youwanttogive themsomesimpletasks. STEP 1 PROCEDURE Tellpatientsyouwillgivethemastreetaddressto remember,andyouwillaskforitinaboutfiveminutes. 2 3 Say:Theaddressis713OsborneSt. Repeatittobesurethepatientunderstands. Thenumbershouldcontainthreedigits,andthestreet nameshouldnotbecommon. Usethesameaddresswithallpatients.

Proceedwithotheraspectsofmemorytesting. Afterabout5minutes,askpatientstorecalltheaddress. Patientsofnormalintelligencecanrecallcorrectlythe addressunlesstheyhaveorganicbraindisease.

RecentMemory: DigitRecall

Inthispartoftheexamination,thepatientisaskedtorepeataseriesofrandom numbers,firstforward,thenbackward.Intestingthepatientsmemoryfordigits, itisbesttouseawrittenlistofrandomnumbersliketheonesbelow: Beprepared:Donottrytomakeupthenumberlistduringatestconfusionwill result. FORWARD 582 694 6439 7286 42721 75836 619473 392487 5917428 BACKWARD 24 58 629 415 3279 4968 15286 61843 539418

13

Procedure

Followtheproceduregivenbelow: Tellthepatient: Iamgoingtoreadaseriesofnumberstoyou.WhenIhavereadthem,I wantyoutorepeatthemtome.Forexample,Iwillsay123. Continuewith3digits,then4,upto7,noticinghowmanythepatientcan repeatbeforemakingmistakes. Givethepatientthesameinstruction,buttellhimtorepeatthenumbers backward.

NormalMemory

Patientswithnormalintelligencecanusuallyrepeatsix(6)digitsforwardandfive (5)inreverse.Patientswhoareknowntohavehadnormalintelligenceinthe pastandwhocanrepeatnomorethan5digitsforward,4inreverseusually haveanorganicbraindisease. Questionsinthiscategoryfurthertestthepatientsrecentmemory,andhelp determinethelevelofintelligence. Confabulationisthetendencyofpatientswithimpairedmemoryduetoorganic braindiseasetofillintheblankspotsintheirimpairedmemorybyunconsciously (thatis,withoutdeliberateintent)makingupanswersforquestionstowhichthey cannotremembertheproperanswer.Patientswithorganicbraindisease confabulateinordertoavoidthepainfulrealizationthattheirmemoryis impaired. Askthepatientaboutthefollowingtopics: Whatwasforbreakfast? Howlonghaveyoubeeninthehospital? WhathasbeenonTVlately? Whathaveyoureadinnewspapers,books,ormagazines?

RecentMemory: RecallofEvents Definition

TestTechnique

Beabletocheckthepatientsanswers(particularlyforthefirsttwoquestions)for anyconfabulations. RemoteMemory TestTechnique Remotememoryis veryrarelyimpairedinanypsychiatricdisorder.Itbeginsto showimpairmentonlyinsevereorganicbraindisease. Onecantestremotememorybyaskingaboutthefollowingvitalstatistics(and otherslikethem): Dateandplaceofbirth Dateandplaceofhighschoolorcollegegraduation Dateofmarriage

Theaccuracyofanswerstothesequestionsmustbeverifiable. Remotememory,aswellasintelligence,canalsobetestedbyaskingthe patientaboutmajorhistoricaleventsinafieldinwhichheindicatesapersonal interest(history,sport,TV,etc.). WhathappenedtoJ.F.Kennedy? WhenwasWWII? WhowasWinstonChurchill? InwhatsportwasJoeLouisfamous? What(insport)wasMurderersRow? WhatsportisplayedattheRoseBowl?
14

WhatwasSputnik? WhatistheBerlinWall? WhatwasWatergate? WhereisVietnam?

INTELLECTUALFUNCTIONS:PROBLEMSOLVING Introduction Toevaluateapatientsproblemsolvingability,thephysicianmustconsider: Examples thepatientsdegreeofcooperation whetherthepatientisanxious,preoccupied,ordistractible thepatientsbasicintelligenceandeducationlevel thepatientssocioeconomicbackground Thecollegegraduatewhocannotperformsimplearithmeticproblemsand isobviouslytryingtocooperateverylikelysuffersfromorganicbrain disease. Asimilarinabilityinapatientfromadeprivedsocioeconomicbackground andwithnoeducationmaynotindicateorganicbraindisease. Ananxious,distracted,oruncooperativepatientmaynotperformwell,but organicbraindiseasewouldnotbeindicated.

Comment

Mostpatientswithfunctionalpsychiatricillnessarenotimpairedintheir fundamentalabilitiesofrememberingaccuratelyorsolvingproblems.But anxiety,depression,distraction,orpreoccupationwillpreventpatientsfrom performingwell,fully,orevenattemptingthetests.However,patientswith organicbraindiseasemaybefullycooperativebutunabletosolveallbutthe simplestproblems. Thetestsusedtoevaluateproblemsolvingabilityare: simplemultiplication morecomplexarithmetic,includingwordproblems subtractionofserialsevens

TheTests

Instructions

Intestingtheabilityofapatienttoperformcomplexintellectualtasks,the physicianmuststartwiththesimplestproblems,thenprogresstomorecomplex ones.Inthiswaythepointatwhichthepatientbeginstofailcanbedetermined accurately.Consequently,thedegreeofimpairmentcanbeestimated.Ifthe patientisinitiallygivenataskbeyondhisability,anxietymayresultinpoor performanceonevensimpletasks. Havethepatientperformthefollowingmultiplicationswithoutpaperandpencil: 5x3 5x5 5x10 5x13 5x15 5x19 5x23 5x52

Simple Multiplication

WordProblems

Theseproblemsinvolvemorethanonetask.Thepatientmustunderstandand remembertheproblemasitisread,thendothecalculation.Thusrecent memoryisalsotested. Examples: Ifyoutravel300milesinyourautomobilegoing50milesperhour,howlong doesittaketocompletethetrip? Ifyoutravel3,000milesinyourautomobileat50milesanhour,howlong doesittaketocompletethetrip? Ifyoutravel300milesinyourautomobileat50milesanhour,butstop twice,onceforonehourforlunchandonceforthreehoursfordinner,how longdoesittakeyoutoreachyourdestination?

15

WordProblems (Cont.)

Ifyoubuysixapplesat13centseachbutgethomeandfindtwoofthe applesarebadandreturnthesetwoandgetyourmoneybackonthem, howmuchdidyouspendfortheapplesthatyoukept?

Subtraction ofSerial7s Purposeof Test Numberof Mistakes

Instructthepatienttosubtract7from100,then7fromthedifference,andsoon, untilnothingisleft.Demonstratetheprocessifnecessary. Thisexaminationteststhepatientsproblemsolvingabilityaswellasrecent memoryandconcentration. Apersonofnormalintelligenceshouldmakenomorethantwomistakes.Four mistakesormoreinapersonwhoformerlyhadnormalintellectualabilities suggestorganicbraindisease,althoughpoorperformancemayreflect symptomsoffunctionalmentaldisorders. Theexaminershouldrecordthepatientsanswersastheyaregiven,because thepatternofmistakesalsoprovideshelpfuldiagnosticinformation: Ananxiousorlessintelligentpersonmaymakemistakesbutwillprobably notelosehisplaceinthecalculations. Apatientwithsevereorganicbraindiseasewillforgettheorder. Atypicalserial7patterninorganicbraindiseaseisasfollows: 100,93,86,96,89,91,84,74,64,54,etc.

Patternsof Mistakes

INTELLECTUALFUNCTIONS:CAPACITYFORABSTRACTTHOUGHT Introduction Capacityforabstractthoughtisdeterminedbytestingthepatients: a)abilitytointerpretproverbsb)abilitytocomparephysicalobjectsand c)spontaneousexpressionofconcretethought. Thisabilityistestedbygivingthepatientaseriesofproverbsandaskingwhat theymean.Anadultofaverageintelligenceisusuallycapableofabstract thinking. Abstractthoughtimpliesinthistesttheexplanationofaproverbin conceptualorfigurativeterms,ratherthaninjustconcreteorliteralterms. Ifanadultpatienthasaverageintelligence,butisunabletogiveadequate abstractionsofthefollowingproverbs(evenoneortwoofthem),schizophrenia shouldbestronglysuspectedunlessthereisgrossevidenceoforganic braindisease. Impairment Theindicationsofimpairmentareasfollows: UNIMPAIRED Normal patient PARITIALLYIMPAIRED Organicbraindiseases Mentaldefectives Severemanias Deprivedbackgrounds FULLYIMPAIRED Schizophrenics

Proverb Interpretation

Delivery

Eachproverbshouldbeprefacedbythecomment,Nowtellmewhatthissaying means.Ifapatientisunfamiliarwiththeproverbs,heshouldstillhaveno troubleexplainingtheirmeanings. Dontcountyourchickensbeforetheyarehatched. ConcreteanswerItisnotagoodideabecausesomeofeggsmaynotbe fertilized.

16

Delivery(Cont.)

AdequateabstractionItmeansdontalwaysthinkthingswillturnoutlike youhopetheywill. SuperiorabstractionHopefulanticipationsmaynotbecomereality. Dontcryoverspilledmilk. ConcreteanswerOncemilkisspilledthereisnowaytogetitbackintothe bottleoruseit. AdequateabstractionItdoesnogoodtoworryaboutthingsthathappened inthepast. SuperiorabstractionPastmisfortunescantbechangedbyregrets. Thesqueakywheelgetsthegrease. ConcreteanswerThewheelthatsqueaksneedsgreasemorethana wheelthatdoesntsqueak. AdequateabstractionThepersonwhocomplainsloudestgetsthemost attention. SuperiorabstractionVigorousprotestcallsattentiontoproblemsthat needcorrection. Dontchangehorsesinmidstream. ConcreteanswerItisabadideabecauseyoumightfalloffandgetwetor drown. AdequateabstractionItisbettertocarrythroughwithaprojectthanto keepchangingfromonetoanother. SuperiorabstractionIndecisionpreventsprogress. Peoplewholiveinglasshousesshouldntthrowstones. ConcreteanswerTheywouldbreaktheirhouseiftheythrewstones. AdequateabstractionYoushouldnotcriticizeothersifyouhave weaknessesandfaultsyourself. SuperiorabstractionImperfectionsproducevulnerability. Youcatchmoreflieswithhoneythanwithvinegar. ConcreteanswerFlieslikesweetthingsandswarmtothemandcanbe caught.Theydontlikevinegar. AdequateabstractionIfyouhaveasweetdisposition,youwillhavemore friendsthanifyouareagrouch. SuperiorabstractionKindnessisamorepowerfulinfluencethancriticism.

Similarities

Inthispartoftheexaminationthepatientistold:NowIwillnameforyoutwo objectssuchasanappleandanorange,andIwillaskyoutotellmeinwhat waythetwoobjectsaresimilar. Tobesurethatthepatientunderstandsthetask,firstexplainthatanorangeand applecanbesaidtobesimilarinthefollowingways: Bothhaveskins. Botharecolored. Bothhaveseeds. Bothcanbeeaten. Botharefruit.

Donotgivethepatientanycluesastowhichkindofanswerispreferable. UseoftheTest Theuseofsimilaritiestodetectabstractthoughthasadvantagesovertheuseof proverbs,inthatthetestislessdependentoneducationallevelorsocio economicbackground,anditiseasiertoexplaintounsophisticatedpatients.

17

Interpretation

Ifoneasksapatientaboutthesimilaritiesbetweenadogandacatandthe patientstatesthatbotharemammals,hehasdemonstratedagoodcapacityfor abstractthoughtbothbelongtoageneralclassorcategory.Butifthe similaritiesareBothhavefurorBotharepets,heisnotthinkinginabstract termsandcangrasponlypartialorconcretesharedattributes. Aftermakingsurethepatientunderstandsthetask,readthepairsgivenbelow, andrecordtheanswers.Prefaceeachpairwiththequestion,Howarethe followingsimilar? Tableanddesk. AbstractanswerBotharefurniture. ConcreteanswerBotharemadeofwood(orhavefourlegs,etc.). Coatandsweater. AbstractanswerBothareclothes. ConcreteanswerYouwearthem(ortheyareusuallymadeofwool, etc.). Cupandpitcher. AbstractanswerBothareeatingutensils. ConcreteanswerYoucanputmilkorwaterinbothofthem. Wineandwhiskey. AbstractanswerBotharealcoholicbeverages. ConcreteanswerBothmakeyoudrunk(orbotharesoldinbottles).

Procedure

Spontaneously Expressed ConcreteThought

Thepresenceofconcretethoughtandinabilitytoabstractmayalsobedetected inspontaneouscomments.Forexample,whenapatientwasaskedWhat broughtyoutothehospital?(meaningwhatsymptom),hereplied,An automobilebroughtme.Whenthepatientwasasked,Whatkindofbuilding areyouinnow?(meaningtypeofinstitution),hesaiditwasabuildingmadeof bricks.

INTELLECTUALFUNCTIONS:FUNDOFGENERALKNOWLEDGE Introduction Thequestionsbelowtest:a)remotememoryb)levelofintelligencec) breadthofknowledge. Thequestionsaremostapplicabletomiddleclasspatientsofnormal intelligence.Otherquestionsmustbedevisedtotestpatientsofdifferent backgroundsorintelligence. Example: Amigrantfarmworkermaybequiteinformedaboutseasonal changesandrelatedworkindifferentpartsofthecountrybutbeunableto respondtothequestionsbelow. SampleQuestions Namethreemajorworldrivers. Namethecapitalsoffourlargecountries. Whoisourpresident?Whowasthepresidentbeforehim? Whoisthevicepresident? Whoisthegovernor? Whatisthestatecapital? WhendidWorldWarIIstart? WhatIsNASA?

18

INTELLECTUALFUNCTIONS:GENERALESTIMATEOFINTELLIGENCE Estimating Intelligence Thephysiciancanmakearemarkablyaccurateestimateofthepatientsgeneral levelofintelligenceformthepatients:a)performanceonmentalstatustests b)vocabularyandc)occupationalhistory.Useyourownpersonal experienceandjudgmenttogaugethepatientsintelligence. Takingintoaccounttheabovethreecriteria,estimatethepatientsintelligencein termsof: aboveaverageintelligence(onparwithmostpeopleyouknewincollege) averageintelligence(capableofhighschoolbutprobablynotofcollege work) belowaverageintelligence(probablynotcapableofhighschoolleveltasks)

Categoriesof IntelligenceLevels

EVALUATIONOFTHOUGHTPROCESSES:TYPESOFTHOUGHTPATTERNS General Comments Thepatternofapatientsthoughtprocessescanbejudgedfromthestylein whichthepatientexpresseshimself.Inrecordingthementalstatus examination,oneshoulddescribethepatternofthoughtthepatientexhibits. Thispartoftheexaminationisofspecialsignificancefordetecting schizophrenicthoughtdisorders. Ifthepatientthinksinaclearandcoherentpatternthatiseasytofollowand understand,onecanbereasonablycertainthathedoesnotsufferfromamajor psychoticdisturbance. Thistypeofthoughtismanifestedinastyleofspeakingthatincludesmany tediousandirrelevantdetailsbeforetherealpointoftheideaisexpressed. Circumstantialthoughtsuggeststhatthepatientissufferingfromoneofthe following: Circumstantial Thoughtin OrganicBrain Disease Circumstantial Thoughtin Obsessive Patients Circumstantial Thoughtin Schizophrenia FormalThought Disorders organicbraindisease obsessionalpersonalitytraits schizophrenia

Clear,Coherent Thought Circumstantial Thought

Manyelderlypeoplewhosefacultiesarebeginningtodeclineareextremely longwindedandtakealongtimetoreachthepointofastory.Whenthisoccurs inpatientswhoarenotsenilebutshowotherevidenceoforganicbraindisease, itcanhelptoconfirmadiagnosis. Therearepeoplewho,forthesakeofcompletenessandattentiontodetail,find ithardtoomitanypossibleideaorfactthatmightbecogenttothepointtheyare tryingtoexpress.Whetherornotthistypeofcircumstantiallyreflectsan obsessivecompulsivetendencymustbedeterminedformotherfindingsofthe historyandmentalstatusexaminations. Anextremedegreeofcircumstantialityissuggestiveofschizophreniaitborders ontheconfused,fragmentedthoughtsymptomaticofthisillness. Thereisnogenerallyaccepteddefinitionofformalthoughtdisorder.Inthis manual,thetermisusedtodescribeseveralreadilyidentifiablebutnotmutually exclusivedisturbancesofspeechorthinking.Incertaincontexts,theystrongly suggestschizophrenia.However,theyshouldnotbecountedasevidenceof formalthoughtdisorderinthefollowingsituations:

19

FormalThought Disorders(Cont.)

transcientoverwhelmingaffect(suchasfearoranger) sarcasmorhumor limitedintelligenceoreducation languageorculturaldifferences

Neologisms andBlocking

Neologismsandblockingarenotincludedasphenomenaofformalthought disordersbecauseof: generalunreliabilityofclinicaljudgmentofthem theunlikelihoodthateitherwouldbetheonlymanifestationofaformal thoughtdisorder

Documentation Incoherence

Alwaysdocumentapurportedfindingwithanexamplefromthepatientsspeech. Fivethoughtdisordersfollow,withexamplesofeach. Incoherenceoccurswhenunderstandabilityofspeechisimpairedbydistorted grammar,incompletesentences,lackoflogicalconnection,orsudden irrelevancies. Example: Idontquitegather.Iknowonerightandoneleftuseofbothhands, butIcantfollowthesystemthatsworking.Theideaismeantina kindway,butthatsnotthewayIunderstandlife.

Loose Associations

Looseassociationsinvolverepeatedlyjuxtaposingthingswhichlackareadily understandablerelationshiporshiftingidiosyncraticallyfromoneframeof referencetoanother. Examples: Imtired.Allpeoplehaveeyes. Inresponsetoaquestionabouthisconcernthathewillbedesertedbyhis friends,apatientreplies,Iwonderwhatsfordesserttoday? Thislatterexampleisfrequentlyreferredtoasaclangassociation,inwhichthe connectionisbasedonthesoundofwordsratherthantheirmeaning.

IllogicalThinking

Illogicalthinkingoccurswhenfactsareobscured,distorted,orexcluded.Thisis acomplexandsubtlejudgment,whichusuallyrequiresfurtherexplorationofthe patientsreasoning. Example: Apatientrefusestositonachairbecauseitsyellow. ApatientexplainsthatshegaveherfamilypunchedIBMcardstoovercome communicationdifficultieswiththem. Inansweringquestionsabouthisfirsthospitalization,apatientreplies,I couldhavebeenafewyearsbeforeorafterIwasborn.

Povertyof Speech Content

Povertyofspeechcontentoccurswhenspeechconveysverylittleinformation becauseofvagueness,talkingpastthepoint,emptyrepetitions,ortheuseof obscureorstereotypedphrases.Povertyofcontentisnotnecessarilypovertyof amountofspeech.Becauseonemayrecognizethisdisorderinones colleagues,politicians,andothers,itshouldonlybenotedwhenitassumes clearlypathologicalproportions. VonDomarussdisorderofthoughtischaracterizedbyconsideringtwothingsas identicalbecausetheyshareoneortwoattributes.

VonDomaruss Disorder

20

VonDomaruss Disorder(Cont.)

Examples: AwomanbelievedshewastheVirginMarybecausehernameisMary. Amanbelievedhewasawomanafterhenoticedbloodonhissheets (womenbleed,Ibled,therefore). Flightofideasischaracteristicoftheelated,hyperactive,andspeededup manic.Themanictalksandthinksrapidlyandiseasilydistracted.Unlikethe schizophrenicfragmentationofthought,flightofideasretainssomelogical connectionbetweenwordsandphrases.However,themanicjumpsrapidlyfrom onetopictoanotherwithoutcompletinganyofthem.

Example: Inreplytoadoctorsquestionabouthiswellbeing,apatientsays,Imfine!Youlook welltoo!Thatsaprettytieyouarewearing.Mymothermakesties.Sheismarriedto averyrichman.HaveyoueverseenafamilywhereeveryonedrivesaCadillac?But IlikeLincolnContinentalsbetter.Whatkindofcardoyoudrive,Doctor?Bytheway, whencanIleavethehospital?Theresabusat9p.m.CanItakeit?Busesaremore comfortablethantrains,dontyouthink?...

FlightofIdeas Characteristicof ManicStates

RetardedThought Characteristicof Depressive Reactions

Severelydepressedpatientsspeakinaslow,haltingfashion. Itisaneffortfor themtospeakatallandtheyarepreoccupiedwithideasofgloomand hopelessness.Theymayexpressdelusionalideasofworthlessnessandguilt, buttheseideaswillbeexpressedinacoherentmanner.

EVALUATIONOFTHOUGHTPROCESSES:UNUSUALTHOUGHTSANDPREOCCUPATIONS Introduction Inthissectionofthementalstatusexamination,thephysiciandescribesunusual orpathologicbeliefs,thoughts,orexperiencesthatthepatientmayhave.These include: delusions hallucinations depersonalization obsessions compulsiverituals phobias

Inthecourseofobtainingthehistory,theremaybesomeobviousevidenceor subtlehintsthatthepatientsuffersfromoneoftheseunusualmodesofthought. Inquireaboutittactfully.Trytoobtainasclearandspecificadescriptionofthe experienceaspossible. Questionsabout Anxiety Questionsabout Hallucinations Questionsabout Obsessions Questionsabout Compulsions Questionsabout Paranoia Whenpatientscomplainofanxiety,ask,Aretherespecificsituationsorother thingsthatcauseyoutobeanxiouslikehighbuildings,elevators,certain animals,orthingslikethat? Inquiretactfullyaboutthepresenceofhallucinationsbyasking,Haveyouhad anyunusualexperiencesthatbotheredyoulikethefeelingthatpeoplewere talkingaboutyou,orthatyouwerehearingstrangesounds? Toelicitinformationregardingobsessionalthoughts,onecanask,Attimes,do youhavethoughtsthatyoudontliketocomeintoyourmindthoughtsthatyou havedifficultygettingoutofyourmind? Regardingcompulsiveacts,ask,Attimesdoyoufeelcompelledtodocertain thingsorelsetheanxietygetsworsesuchthingsascountingtoacertain numberorknockingonwoodorthelike? Withverysuspiciouspatients,ask,Havetherebeentimeswhenpeoplehave haditinforyou,ortriedtocauseyouproblemsorharm?

21

Delusions

Thesesamplequestionsshouldbeusefulforthephysicianattemptingtoelicit informationaboutdifferenttypesofdelusions.(Differenttypesofdelusionswill bediscussedinthenextfewpages). Thisisthebeliefthatthoughtsarebroadcastoutfromtheheadandintothe worldsothatotherscanhearthem.Thiscanbeadelusionand/ora hallucination.Ifitsthelatter,thepatienthearshisownthoughtsfromthe outside,notjustwithinthehead. Example:Amanbelievedthathisthoughtswerepickedupbyahidden microphoneandbroadcastonTV.

Thought Broadcasting

Thought Insertion

Thoughtinsertionisthebelieforexperiencethatthoughtswhicharenotones ownarebeinginsertedintoonesmind. Example:Awomanbelievedthatthoughtswerebeingputintohermindby radar.

Thought Withdrawal DelusionsofBeing Controlledor Influenced

Thoughtwithdrawalisthebeliefthatthoughtshavebeenremovedfromthe head,sothatfewerthoughtsremain.Thisisextremelyrareandyoumustbe completelyconvincedthatitispresentbeforerecordingthephenomenon. Thebelieforexperiencethatfeelings,impulses,thoughtsoractionsarenot onesownandareimposedbysomeexternalforce.Itdoesnotincludethe convictionsthat: thepatientisactingasanagentofGod acursehasbeenplacedonthepatient thepatientisavictimoffate,orisnotassertiveenough someoneisattemptingtocontrolthepatient

Theessentialcharacteristicisthatthepatientissurethathiswill,thoughts,or experiencesarebeingreplacedbysomeotherforce. Examples: Amanclaimedhiswordswerenothisown,buthisdads. Astudentbelievedheractionswerecontrolledbyayogi. Ahousewifebelievedthatsexualdesireswerebeingputintoherbody. OtherBizarre Delusions Bizarredelusions,(otherthanthosealreadymentioned),suggestschizophrenia, eveniftheyareofshortduration.Tobebizarre,adelusionmustbepatently absurd,fantasticorimplausible.Itdoesnotincludedelusionswhicharethe elaborationofcommonimplausibleideasorsubculturalbeliefssuchas communicatingwithGod,thedevil,ghosts,orancestors,orbeingunderthe influenceofcurses,spells,voodoo,orhypnosis. Examples: Amanbelievedthat,whenhisadenoidshadbeenremoved,aboxhad beeninsertedinhisheadalongwithwiressothatthevoiceheheardwas GovernorNelsonRockefellers. Awomanbelievedthatanundergroundradiostationwasbroadcasting throughnoisethatemanatedfromherwashingmachine. Anexampleofanonbizarredelusionwouldbeamanbelievingthatbecausehis appearancehadchanged,peoplenolongerrespectedhim.

22

Multiple Delusions

Multipledelusionsaretwoseparatedelusionalbeliefswhicharenotelaborations ofasingletheme. Example:Awomanfeltthatnursesapproachedherwithhomosexual intentionsthepatientswerereallynursesanddoctorsindisguiseplanted theretoassistherandpeoplecouldreadhermindbylookingatherhands. Amanwhobelievedthatsomeunknownforcehadenlistedhisfamily,friends, andassociatesinaschemetokillhim,andthattheypoisonedhisfoodand tappedhisphonedidnothavemultipledelusionsbecauseasingletheme wasbeingelaborated.

Delusionsin Schizophreniaor AffectiveDisorders

Delusionsinschizophreniaoraffectivedisordersinclude: delusionsofgrandeurexaggeratedideasofonesimportance,power,or worth. delusionsofpersecutionbeliefthatonehasbeensingledoutfor mistreatment,harassment,orotherformsofpersecution. delusionsofreferencethebeliefthatcasualandobjectivelyunrelated remarksmadebyotherpeopleoractsperformedbyothersaredonewith somespecialrelevancetothedeludedperson.Thesebeliefsmayhavea paranoidorgrandiosequality. delusionsofguiltideasofworthlessnessandguilt,sometimesinvolving thebeliefthatoneistheobjectofscornbecauseofmisdeedsofonesortor another.

Hallucinations

Thistermreferstoafalsesensoryperceptionthatoccursintheabsenceofany externalstimulus,asopposedtoanillusion,themisinterpretationofanactual sensoryexperience.Thefollowingindicationsareimportant: Hallucinationsusuallyindicateapsychoticcondition,andtheymay involveanysensorymodality. Auditoryhallucinationsaremostcharacteristicofschizophrenia. Visualortactilehallucinationsareoftencharacteristicoforganicbrain syndromesforexample,seeingrats,snakes,orpinkelephants,andfeeling wormscrawlontheskinduringdeliriumtremens. Olfactoryhallucinationssuggestanorganicproblem.

Depersonalization

Feelingsofunrealityorstrangeness.Thevictimmayfeelthatheisunreal,or notreallyalive,orthattheworldaroundisstrangeandunreal. Whensucha feelingispersistent,itindicatesaseriouspsychiatricillness,usually schizophrenia. Obsessionalideasarepersistentideasorimpulsestocontrolsomeact,ideas thatcannotbeeliminatedfromconsciousnessbylogicoraneffortofthewill, andthatarefeltasunwantedandintrusive.Commonfeaturesofobsessions are: Theyarecharacteristicofanobsessionalneurosisandareusuallyofa distastefulaggressiveorsexualnature. Mostnormalpeoplehavesimilarexperiencese.g.,anannoyingtunethat creepsintotheconsciousnessforafewhours.

ObsessionalIdeas

CompulsiveRituals

Thetermcompulsiveritualsreferstorepetitiveactionsthatapersonfeels compelledtocarryoutagainstthewill.Thepersonusuallybelievesthatunless thecompulsiveritualisperformedcatastrophewillhappen.Compulsiveactsare similartothefairlycommontendenciesthatrelativelynormalpeoplehaveto knockonwoodoradheretoothersuperstitionsandrituals.Thecompulsive

23

CompulsiveRituals (Cont.) Phobias

patienthasnooptionbuttofollowtheritualinordertoavoidfeelingvery apprehensive. Thesearepersistent,unrealisticfearsofcertainobjectsorsituations.The objectsoftenreflectadegreeofdanger,e.g.,dogs,knives,airplanes,or thunderstorms.Thepatientoftenrealizestheirrationalityofthefearbutis unabletocontrolit.Thissymptomischaracteristicofthephobicneuroses, althoughapatientwithseveralincapacitatingphobiasmaybesufferingfroman incipientschizophrenicbreakdown.

JUDGMENTANDRELIABILITY Judgment Inthissectionofthementalstatusexaminationthephysicianrecordsan estimateofhowgoodthepatientsjudgmentis. Examples: Amanicpatientwhohasrecentlyinvested$10,000inabusinessventureto constructadiamondmakingmachinesurelyhasimpairedjudgmentandis atleastilladvised. Apatientwhorealizesthathehassomeemotionaldifficultyandhassought helpforitonhisownobviouslyhasgoodjudgment. Reliability Thephysicianshouldalsogaugethereliabilityofapatientasaninformant.A patientsreliabilityisdeterminedinpartbycomparingthehistoryobtainedfrom himwiththatobtainedfromotherinformants. Examples: Alcoholicpatientsarenotoriousforminimizingtheextentoftheirdrinking. Talkingtoamemberofthefamily,onemaylearnthatwhatthepatientsaid wasjustadrinkortwocouldbeaquartofwhiskeyperday. Apatientwhocontradictshimselfwithoutseemingtorealizeitgives independentevidenceofunreliability,andonecanmakeadeterminationof reliabilitywithoutoutsidecorroboration. Thesepatientswouldbeconsideredtobeunreliableinformants. INSIGHT Insight Inthiscategory,thephysicianrecordsanimpressionofhowmuchawareness thepatienthasofhisownimpairment. Examples: Aparanoidpatientwiththesystematizeddelusionalbeliefthatthehospital isrunbycommunistswhoareattemptingtobrainwashhimandmakehima traitortohiscountryobviouslyhaslittleornoinsightintohisownpsychosis. Apatientwithaphobiaofelevatorsmaysaythatherfearsareirrationaland thatshewantshelpforthem.Shegivessoundevidenceofinsightabout herproblem.

24

PROBLEMLIST UseBehavioral Terms Categories Listtheproblemsinthepatientslifeanddescribetheminbehavioralterms, ratherthanindiagnosticortechnicaltermsorinpsychiatricjargon. Thecategoriesofproblemsgivenbelowshouldalwaysbecovered,evenifonly byastatementthatnosignificantproblemsexistinaparticularcategory. PROBLEMS Notetheoutstandingbehavioralandsubjectivemanifestationsofthepatients psychiatricdifficulties. Example: Ifthepatientisobviouslyschizophrenic,thislistmightbe: paranoiddelusions hostileimpulsivebehavior confusedthinking auditoryhallucinations homicidalimpulses Medical Family Listsymptomsandsignssuchasvomiting,diarrhea,headache,fever,etc. Usedescriptivestatementssuchas: Social Interpersonal excessivedependenceonspouse episodesoftempertantrumsinrelationtothespouse overprotectiveattitudetowardchildren

CATEGORY Psychiatric

Notethedifficultiesthatthepatienthasgettingalongwithotherpeopleand copingwithordinarysocialrelationships,activities,andobligations. Example: becomesapprehensiveinsocialgroups becomesirrationallyhostiletowardauthorityfiguresatwork Giveexamples.

Occupational

Notethedifficultiesthatstemfrom: worklife,withparticularreferencetodifficultiesingettingalongwith colleagues,superiors,orsubordinates beingpromotedordemoted:achangetoadifferentjobimpending dismissalorretirement technologicalchangesinhisjobthatmakehimoutmoded Forpatientswhoareinsomeactiveeducationalprogram,noteacademic difficulty,conflictswithteachersorfellowstudents,erraticacademic performance,orexcessiveconscientiousnessorirresponsibilityregarding educationalactivities,aswellasthepatientsparticipationinextracurricular activities.Giveexamples. Includeproblemsduetoindebtedness,suddenaffluence,etc.Howapatient handlesmoneyandthepressuresthatheisunderfromeconomicfactorsinhis lifeareoftencrucialandshouldbespecifiedhere.Giveexamples. Thisappliesprimarilytomembersofminoritygroupsandshouldcontain examplesofethnicdifficultiesthatarisefromthepatientsattitudesand subjectiveexperiences,aswellasfromrealandactualdiscriminationorother ethnicproblems.
25

Educational

Economic

Ethnic

DIAGNOSIS Assessment Summarizefindingssupportiveofthosediseaseconditionsthepatientmaybe sufferingfrom.Systematicallycompareandcontrastthepatientsclinical findingswithwhatisexpectedforeach. Inmostcases,anabsolutelydefinitediagnosiswillnotbepossibleatthispoint intheworkup.Formedicalandlegalreasons,itisimportantthatthisisa workingdiagnosisandnotthefinaldiagnosis. Alldiagnosesofnonpsychiatricconditionsmustberecordedaccordingto theStandardNomenclatureofDiseasesandOperations. Allpsychiatricdiagnosesmustbeaccordingtothecategoriesand terminologyofDiagnosticandStatisticalManualofMentalDisorders DSMIVTR.

WorkingDiagnosis

Standardsfor Nomenclature

26