Description of psychiatric status. Mental status (state)

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 becomes 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, is there a logical and grammatical connection between the phrases. These data make it possible to judge the features of the associative process: acceleration, slowdown, discontinuity, 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 encountered delusional ideas of persecution, of particular importance, it is more appropriate to ask general questions: “what interests you most in life?”, “Has anything 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, the 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, paresthesia, 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 about 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 any other symptoms of stupor: give the patient one or another posture (is there catalepsy), ask to follow the instructions (is there not 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 speech of patients (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.

Determination of mental status is the most important part of the process of psychiatric diagnosis, that is, the process of cognition of the patient, which, like any scientific and cognitive process, should not occur randomly, but systematically, according to the scheme - from phenomenon to essence. Active-purposeful and in a certain way organized live contemplation of the phenomenon, that is, the definition or qualification of the present status (syndrome) of the patient is the first stage in recognizing the disease. A poor-quality study and description of the patient's mental status most often occurs because the doctor has not mastered and does not adhere to a specific plan or scheme for studying the patient, and therefore does it chaotically.

Since mental illness is the essence of a personality illness, the mental status of a mentally ill person will consist of personal characteristics and psychopathological manifestations, which are conventionally divided into positive and negative. By convention, the mental status of a mentally ill person can be said to consist of three “layers” of PNL: positive disorders (P), negative disorders (N), and personality traits (P).

In addition, the manifestations of mental activity can be conditionally divided into four main areas of PEPS: 1. Cognitive (intellectual-mnestic) sphere, which includes perception, thinking, memory and attention (P). 2. Emotional sphere, in which higher and lower emotions are distinguished (E). 3. Behavioral (motor-volitional) sphere, in which instinctive and volitional activity are distinguished (P). 4. The sphere of consciousness, in which three types of orientation are distinguished: allopsychic, autopsychic and somatopsychic (C).

Table 1. Structural and logical scheme of mental status

mental activity	Positive Disorders (P)	Negative Disorders (N)	Personal characteristics (L)
Cognitive sphere (P)	Perception Thinking Attention
Emotional sphere (E)	lower emotions Higher Emotions
Behavioral (P)	instinctive activity Volitional activity
Sphere of consciousness (C)	Allopsychic Orientation Autopsychic Orientation Somatopsychic orientation

The description of the mental status is carried out after drawing up an idea of the syndrome, which determines the condition, its structure and individual characteristics. The description of the status is descriptive, if possible without the use of psychiatric terms, so that another doctor who turned to the case history and therefore the clinical description could, by synthesis, give this condition its clinical interpretation, qualification. Adhering to the structural-logical scheme of mental status, it is necessary to describe four areas of mental activity. You can choose any sequence in describing these areas of mental activity, but you must follow the principle: without fully describing the pathology of one area, do not proceed to describe another. With this approach, nothing will be missed, as the description is consistent and systematized.

It is recommended to start the presentation of mental status with a description of the appearance and behavior of the patient. At the same time, it should be noted how the patient was brought to the office (he came on his own, accompanied, went to the conversation willingly, passively or refused to come to the office), the position of the patient during the conversation (standing, sitting calmly, carelessly or restlessly moving, jumping up, somewhere then strives), his posture and gait, facial expression and eyes, facial expressions, movements, manners, gestures, neatness in clothes. Attitude to the conversation and the degree of interest in it (listens intently or is distracted, whether he understands the content of the questions and what prevents the patient from understanding them correctly).

The peculiarity of the patient's speech: shades of voice (timbre modulation - monotonous, loud, sonorous, quiet, hoarse, noisy, etc.), speech rate (fast, slow, with pauses or without stops), articulation (chanted, stuttering, lisping) , vocabulary (rich, poor), grammatical structure of speech (agrammatic, broken, confusing, neologisms), purposefulness of answers (adequate, logical, to the point or not to the point, specific, detailed, ornate, one-dimensional, diverse, complete, broken and etc.).

The availability or lack of accessibility of the patient should be noted. If the possibility of contact is difficult, reflect what caused it (active refusal of contact, impossibility of contact due to psychomotor anxiety, mutism, stunning, stupor, coma, etc.). If contact is possible, the patient's attitude to the conversation is described. It is necessary to emphasize whether the patient actively or passively expresses his complaints, what emotional and vegetative coloring they are accompanied by. It should be indicated if the patient does not complain about his mental state and denies any mental disorders in himself. In these cases, actively questioning the patient, the interpretation given by him of the very fact of hospitalization is described.

A holistic behavior is described, the correspondence (inconsistency) of the patient's actions with the nature of his experiences or the environment. A picture of unusual reactions to the environment, contacts with other patients, staff, acquaintances and relatives is given. General characteristics of a person with an assessment of his condition, attitude to loved ones, to treatment, immediate and distant intentions.

Following this, it is necessary to describe the behavior of the patient in the department: his attitude to eating, medicine, staying in the hospital, his attitude towards the surrounding patients and staff, his tendency to communicate or isolate himself. The description of the mental state ends with a presentation of the results of the study of attention, memory, thinking, intelligence and criticism of the patient in relation to the disease and the situation as a whole.

Adhering to the structural-logical scheme of mental status, it is necessary to describe four areas of mental activity. You can choose any sequence in describing these areas of mental activity, but you must follow the principle: without fully describing the pathology of one area, do not proceed to describe another. With this approach, nothing will be missed, as the description is consistent and systematized.

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

COGNITIVE SPHERE

Perceptual disorders

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

The presence and nature of hallucinations can be judged by observing the patient's behavior - he listens to something, plugs his ears, nostrils, whispers something, looks around with fear, brushes aside someone, collects something on the floor, shakes off something, etc. In the case history, it is necessary to describe in more detail such behavior of the patient. Such behavior gives rise to appropriate inquiries.

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

Senestopathy. The behavioral characteristics of patients experiencing senestopathies primarily include persistent appeals for help to somatic specialists, and later often to psychics and sorcerers. These surprisingly persistent, monotonous pains / unpleasant sensations are characterized by a lack of objectivity of experiences, in contrast to visceral hallucinations, often a peculiar, even pretentious shade and fuzzy, changeable localization. Unusual, tormenting, unlike anything "wander" through the abdomen, chest, limbs, and patients clearly contrast them with pain during an exacerbation of diseases known to them.

Where do you feel it?

Are there any features of these pains / discomforts?

Does the area where you feel them change? Is it related to the time of day?

Are they purely physical in nature?

Is there any connection between their occurrence or intensification with the reception

food, time of day, physical activity, weather conditions?

Do these sensations go away when taking painkillers or sedatives

Illusions and hallucinations. Inquiring about illusions and hallucinations, one should exercise special tact. Before embarking on this topic, it is advisable to prepare the patient by saying: "Some people have unusual sensations when they are upset." Then you can ask if the patient heard any sounds or voices at a time when no one was within earshot. If the medical history suggests the presence of visual, gustatory, olfactory, tactile or visceral hallucinations in this case, appropriate questions should be asked.

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

Visual hallucinations should be differentiated from visual illusions. If the patient does not experience hallucinations directly during the examination, then it can be difficult to make such a distinction, since it depends on the presence or absence of a real visual stimulus that could be misinterpreted.

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

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

next to you or you did not understand where they came from?

What they're saying?

hallucinations in the form of dialogue is a symptom in which the patient hears two or more voices discussing something concerning the patient.

What are they discussing?

Where do you hear them from?

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

Do you hear any assessments of your actions, thoughts?

Imperative hallucinations. Deceptions of perception, prompting the patient to a certain action.

spit something?

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

Are you familiar with the unusual sensations of touch in the absence of someone who could do it?

Have you ever experienced a sudden change in your body weight,

sensations of lightness or heaviness, immersion or flight.

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

Do you experience any unusual smells or smells that others don't? What are these smells?

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

Have you ever felt that ordinary food has changed its taste?

Do you experience any taste outside of meals?

- visual hallucinations. The patient sees shapes, shadows, or people

which do not exist in reality. Sometimes these are outlines or color spots, but more often they are figures of people or creatures similar to people, animals. These may be characters of religious origin.

Have you ever seen something that other people cannot see?

Did you have visions?

What did you saw?

What time of day did this happen to you?

Is it related to the moment of falling asleep or waking up?

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

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

Have you ever thought that an idea had already occurred to you that could not have arisen before?

Have you experienced the feeling that you have already heard something that you hear now for the first time?

Was there a feeling of unreasonable familiarity of the text when reading?

Have you ever seen something for the first time and feel like you've seen it before?

Phenomena never seen, heard, experienced, etc. (jamais vu, jamais vecu, jamais entendu and others). Patients seem unfamiliar, new and incomprehensible familiar, well-known. The sensations associated with the distortion of the sense of familiarity can be both paroxysmal and prolonged.

Did you have the feeling that you see the familiar environment in front of you?

Have you ever felt the strange unfamiliarity of what you should

have been many times heard before?

Thinking disorders

When analyzing the nature of thinking, the pace of the thought process is established (acceleration, slowdown, inhibition, stops), a tendency to detail, "viscosity of thinking", a tendency to fruitless sophistication (reasoning). It is important to describe the content of thinking, its productivity, logic, to establish the ability for concrete and abstract, abstract thinking, the patient's ability to operate with ideas and concepts is analyzed. The ability to analyze, synthesize, generalize is being studied.

One of the classic methods of studying thinking is the method of studying the understanding of stories. After listening to or reading a story, the subject is asked to reproduce the story. At the same time, attention is paid to the nature of the presentation (vocabulary, the possible presence of paraphasia, the rate of speech, the features of the construction of the phrase). It is essential to find out how accessible the hidden meaning of the story is to the subject, whether he connects it with the surrounding reality, whether the humorous side of the story is accessible to him.

For the study, you can also use texts with missing words (Ebbinghaus test). Reading this text, the subject must insert the missing words, in accordance with the content of the story. At the same time, it is possible to detect a violation of critical thinking: the subject inserts random words, sometimes by association with closely spaced and missing ones, and does not correct the ridiculous mistakes made. The identification of the pathology of thinking is facilitated by the identification of understanding of the figurative meaning of proverbs and sayings.

Relevance.

Schizophrenia is an endogenous disease with a progressive 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 before, 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:

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

MENTAL STATUS

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

ORIENTATION: in time, surrounding, own personality.

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

ATTENTION: passive, active. The ability to concentrate, stability, absent-mindedness, exhaustion, distractibility, weak distribution, inertia, pathological concentration, perseverations.

BEHAVIOR AND MENTAL ACTIVITY: gait, expressiveness of movements, adequacy of experiences, gesticulation, mannerisms, tics, twitches, stereotyped movements, angularity or plasticity, agility of movements, lethargy, hyperactivity, agitation, militancy, echopraxia.

SPEECH: (quantity, quality, speed) fast, slow, labored, stammering, emotional, monotonous, loud, whispered, slurred, mumbling, echolalia, intensity of speech, pitch, lightness, spontaneity, productivity, manner, reaction time, vocabulary .

ATTITUDE TO THE CONVERSATION AND THE DOCTOR: friendly, attentive, interested, sincere, flirtatious, playful, prepossessing, politeness, curiosity, hostile attitude, defensive position, restraint, alertness, hostility, coldness, negativism, posturing. Degree of contact, attempts to avoid conversation. Active desire for conversation or passive submission. The presence or absence of interest. The desire to emphasize or hide a painful condition.

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

EMOTIONAL SPHERE: prevailing mood (color, stability), mood swings (reactive, autochthonous). Excitability of emotions. Depth, intensity, duration of emotions. The ability to correct emotions, restraint. Anguish, hopelessness, anxiety, tearfulness, fearfulness, attentiveness, irritability, horror, anger, expansiveness, euphoria, a sense of emptiness, guilt, inferiority, arrogance, agitation, agitation, dysphoria, apathy, ambivalence. Adequacy of emotional reactions. Suicidal thoughts.

THINKING: thoughts, judgments, conclusions, concepts, ideas. Tendency to generalizations, analysis, synthesis. Spontaneity and aspontaneity in conversation. The pace of thinking, correctness, consistency, distinctness, purposefulness, switching from one topic to another. The ability to make judgments and inferences, the relevance of answers. Judgments are clear, simple, adequate, logical, contradictory, frivolous, complacent, indefinite, superficial, stupid, absurd. Thinking is abstract, concrete, figurative. Tendency to systematization, thoroughness, reasoning, pretentiousness. The content of thoughts.

MEMORY: violation of the functions of fixing, saving, playback. Memory for events of a past life, the recent past, memorization and reproduction of current events. Memory disorders (hyperamnesia, hypomnesia, amnesia, paramnesia).

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

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

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

PSYCHOPATHOLOGICAL PRODUCTS (deceptions of perception, delirium).

COMPLAINTS ON ADMISSION.