Скачати 43.99 Kb.
Зміст1. Actuality Aim Psychiatry studies etiology, pathogenesis, clinic, diagnostics, treatment, prophylaxis and examination of menta
4. List of disciplines necessary
5. Content of the theme
Mental state examination
5.2. Theoretical questions
5.3. Practical training during the tutorial
Ministry of Health of Ukraine
Bukovynian State Medical University
on the methodical meeting
of the Department of neurology, psychiatry
and medical psychology nm. S.M.Savenko
“____” ___________ 2009 (Report № __).
Chief of the Department
Professor V.M. Pashkovsky
for 4-th year students of medical faculty №2
(the speciality “medical affair”)
for independent work during preparing to practical class
Theme 2: Methods of psychiatric research. Psychonosology, concept of psychopathological symptom, syndrome and disease, registers of mental disorders.
MODULE 1. GENERAL QUESTIONS OF PSYCHIATRY AND NARCOLOGY. GENERAL PSYCHOPATHOLOGY
Topical module 1. General questions of psychiatry and narcology
A narcology is clinical discipline, which studies etiology, pathogenesis, clinic, diagnostics, treatment, prophylaxis and examination of diseases which arose up as a result of the use of alcohol and psychoactive substance.
2. Hours: 2
3. Teaching goal
The students must know:
and be able to:
Assimilate practical skills
for learning theme 1
A basic method of research in psychiatry is clinical method. It include clinical interview and observation (Pose (natural – unnatural; symmetric – asymmetric, closed – opened etc.). Gestures: communicative and expressive. Mimicry is the co-coordinated motions of muscles persons, which represent emotions, mood, sense).
The examination of the patient include:
The patient's complaints and his/her behaviour at the moment of hospitalisation. If he (she) considers himself mentally healthy (sane), how does he explain his internment to the inpatient psychiatric department? Does he/she want to be treated? If the patient has no complaints, describe the reasons of his/her hospitalisation.
Information about the parents: their age, education, profession. Age at the moment of marriage. Diseases they suffered, specific features of character. If the parents are alive, their present occupation. Information about close relations: mental and neurological disorders, mental retardation, fits, suicides, strange behavior, peculiarities of character. Did any member of the family have serious illnesses: tuberculosis, syphilis, vascular disorders, alcoholism, drug addiction? Were there any cases of stillborn children or spontaneous abortions in the family?
Relationships between the family members: warm, sincere, or hostile. Conflicts, quarrels, separations, divorces, etc. The parents' attitude towards patient in childhood: methods of punishment, child neglect, connivance or excessive control, excessive fondling or cruelty, injustice, uneven attitude towards children.
The patient's life history: Mother's state of health during pregnancy, delivery, its characteristics. Patient's development in early childhood (when had he/she learnt to walk, speak, etc.). Illnesses in childhood. Enuresis, night terrors, sleepwalking, sleep-talking, stammering, increased nervousness, convulsive fits, or strange forms of behavior in childhood.
Characteristic features of behavior in childhood: lively, active, inquisitive, or slack, shy, and reserved; capricious; naughty; affectionate, etc.
Age of entering school. School achievements, which subjects were easy for the patients, and which were difficult. What hobbies did he/she have? Character at school age (communicative or reserved, hard-working or not, accurate, industrious, dreamy, shy, etc.). Relationships with the family and with peers. Changes in character in adolescence and youth. Features of sexual maturation. Illnesses the patient had at school age.
Employment and social activities. Military service. Relationships at the place of employment. Working discipline. Living conditions and their changes during the period of working activities (nutrition, outdoors activities, sports, dwelling conditions).
Personality features in adulthood: sociability or reserve, frequent changes in mood, weak will, good or bad coping capacities, etc.
Time of marriage. Sexual and family life (sexual excesses or perversions). For women: number of pregnancies, deliveries, abortions. Family situation at present. Number of family members, their health, relationships.
Illnesses the patient had in adulthood, intoxication (including alcohol), traumas in chronological order, their consequences (temporary inability to work, disability, personality changes, etc.). Psychological trauma (traumatic events), their nature, attitude towards them, consequences. Specific features of somatic and neuro-psychological reactions to different harmful influences, traumatic events, difficult and stressful situations.
Harmful habits (alcohol and drug abuse, smoking, etc.).
History of Mental Disorder. The first manifestations of the present mental disorder must be described in the chronological order. Mention external and internal harmful factors that preceded the onset of the disorder. If the disease is chronic and the patient is suffering a relapse, find out what was his/her state between the relapses. The information on the patient's treatment (outpatient, inpatient, what kinds of treatment was used, what were the results). Describe the further course of the disorder.
Qualified psychological assessment requires special training; it is usually carried out by a clinical psychologist. You are to implement only short psychological tests that will help you to assess the patient's mental functions.
I. Investigation of attention.
Specific features of concentration, switching over of attention, its exhaustion (by the end of the interview).
Test of active attention: ask the patient to subtract in the successive order in sevens from 100 and name the obtained numbers. Draw a graph of attention exhaustion.
Conclusion: normal attention; attention is: easily distracted; unstably exhausted; rigid (switching over from one subject to another is difficult)
2. Investigation of memory.
Memory of the past life events, dates if important historical evenl holidays.
a) test of memorizing: suggest the patient to memorize 10 words (noun i Read them aloud to the patient three times. The patient is to repeat the w< he/she remembers in any order every time after you read them to him Normal memory: after the first reading the patient should remember no less than 7 or 8 words.
b) memory for numbers:
— name three two-digit figures — ask the patient to repeat them (27, 49, 51).
— name three three-digit figures — ask the patient to repeat them (472, 138, 659).
c) test of associative memory: select 10 pairs of words, according to then meaning, for instance: rocket — space, hand — finger, rain — umbrella, etc Read the pairs out aloud once to the patient. Then read the first word of the pair (for instance, "rocket"), and the patient should tell you the second word ("space").
Assessment: normal associative memory means 8 or more correct answers.
Conclusion: general assessment of memory (for example: recollections of past experience are normal, but ability to remember new information is insufficient); normal memory; hypomnesia; amnesia.
3. Investigation of thinking.
Test of the ability to generalize. For example: table, chair, bed, wardrobe. Answer: furniture (3 groups of words).
a) test of capacity to analysis and synthesis: what is similar and what are the differences between: a child and a dwarf (a fly and a bee; a bird and an airplane; a river and a lake, etc. — 3 examples).
b) test of the capacity to form abstract concepts: cite 3 well-known idiomatic expressions to the patient and ask him/her to explain them. For example: "it's raining cats and dogs," etc.
c) test of capacity to abstract thinking: cite 3 proverbs to the patient and ask him/her to explain them. For instance: "It's no use crying over spilt milk."
Conclusion: general assessment of the patient's thinking (for example: capacities to generalization and comparison are normal, but the level of abstract thinking is decreased).
4. Assessment of judgment (critical capacity).
Tell the patient an absurd story and ask him/her to comment on it. For example: "A hen can live for three years, and how long can a half of a hen live?"
Conclusion: assessment of judgment.
All the tasks and the patient's answers are written down in the case history in details (where appropriate — literally), and after the test of each mental function a conclusion is made. When you describe the patient's mental state, the data obtained in testing are taken into account: the conclusions about the qualities of attention, memory, and thinking are added to the appropriate parts of the mental state description.
The mental state examination should be orderly and systematic.
The patient's appearance and behavior. Mimic movements — lively; inexpressive; sorrowful; inadequate (paramimia); affectation. Facial expression — indifferent, tense, mask like. lies, convulsive movements of facial muscles. Expression of eyes lively; lackluster; anxious, sad, angry. Posture — free, natural; theatrical; rigid; drooping. Movements — quick, free; impulsive; uncertain; angular; chaotic; strange; monotonous. General slowness of movements, manifestation! of stupor. Psycho-motor agitation.
Features of communication with the patient. The contact is established quickly, easily, with difficulty, gradually, or was not established at all. Communication superficial, formal; the patient answers your questions inadequately, etc.
State of consciousness. Orientation in time, place, self and other people. Type of consciousness disorder (clouding, delirium, amentia, twilight state, or oneiroid)
Perception. Clearness of perception. Changes in intensity of perception (hyperesthesia, hypesthesia, anesthesia). Changes in the quality of perception: depersonalization, senesthopathias disturbances of sensory synthesis (distorted perception of environment, body image or time perception disorders), deja vu. Illusions. Hallucinations (visual, auditory, olfactory, taste, tactile sensations, deep sensations, complicated) and pseudohallucinations. Characteristics of hallucinations or pseudohallucinations: indifferent, imperative, commenting, or hostile; single or multiple; episodic or constant; hypnagogic. The patient's attitude towards hallucinations: deeply emotional (they frighten him, make him sad, or he enjoys them), indifferent, or critical. Objective signs of hallucinations in the patient's behavior.
Attention. Prevalence of active or passive attention. Insufficient stability of concentration, distraction to internal or external stimuli. Concentration on external environment or on the patient's own inner experiences (for example, delusions, emotions, etc.). Insufficient capacity to switching over from one subject to another. Exhaustibility of attention. Signs of absent-mindedness in behavior. Decrease of the volume of attention.
Memory. Insufficiency of registration (memorizing), retention (keeping in memory) or recall. General weakening of memory — hypomnesia, fixation (registration) or progressing amnesia, anterograde, retrograde total amnesia. Paramnesia: kryptomnesia confabulation, pseudoreminiscence. The Koi sakofTs (Wernicke-Korsakoff, amnestic) syndrome (anterograde and retro grade amnesia, fixation amnesia (recent memory severely impaired), amnestic disorientation (in time and space), confabulations and pseudoreminiscenes).
Speech. Too slow or too quick, affected, disarthric, oligophasia, inadequate stops, stammering, etc.
Voice. Quiet, loud, hoarse, intonation — emotional or toneless, etc.
Thinking. Stream of thought: excitation (acceleration) of thought (flight of ideas, pressure of thought), or retardation (slowing down) of thought (thought blocking, perseveration and stereotypy, pathological thoroughness). Disorders of the form (structure) of thought (paralogic, symbolic, autistic thought), loosening of associations, incoherence of thought Neologisms, inadequate answers to questions, "estrangement" of ideas, "someone else's" thoughts, openness of thoughts.
Obsession ideas, their content, the patient's attitude towards them.
Delusional ideas, their content: delusions of grandeur, richness, power, invention, erotic delusions; delusions of persecution, special meaning, poisoning, physical influence, jealousy; delusional ideas of self-accusation, self-humiliation, sinfulness, detriment, hypochondriac delusions. Residual, or induced delusions; transformation of delusions. Structure of delusions: paranoiac, paranoid, paraphrenic or other (detailed description of the syndrome). Systematization of delusions. Dependence of delusions on affective and perception disorders.
Mental automatism (Clerambault-Kandinsky) syndrome: pressure of thought, estrangement of ideas, "echo of thoughts", "insertion" or "taking away" of thoughts, "control" over the patient's thoughts on somebody else's part, "artificial recollections" (associative automatism). Pseudohallucinations "made" by somebody (perception automatism). Kinesthetic automatism (somebody moves the patient's limbs, speaks with his tongue, etc.).
Intelligence. Correspondence of the patient's level of mental development to his/her age, educational level and social environment. General erudition. The patient's capacity to use acquired knowledge and professional skills. Mental retardation — innate intelligence deficiency, or dementia — acquired intelligence deficiency. The patient's critical assessment of his/her mental state. Organic brain damage syndrome.
Volition. Hyperbulia, hypobulia, abulia. Behavior: psycho-motor excitation, motor retardation, impulsive movements; impulsive actions (cleptomania, pyromania, dromomania, etc.). Different kinds of stupor. Catatonic manifestations: affectation mannerisms, stereotypy (posture, pose, place), automatic submission ornegativism (active and passive), waxy flexibility of muscles, echopraxia. Motor speech disturbances: mutism, perseveration, echolalia, stereotypies of speech.
Convulsive fits: grand mal, petit mal (epileptic fits), hysterical fits.
The patient's behavior in the department, according to the observations of the personnel: communicative or reserved, behavior caused by hallucinations or delusions; rituals, compulsive actions. Tendency to escape from the department, suicidal ideation and/or actions, refusal to eat and its reasons. Sleep disorders. Tendency to asocial behavior (steeling, vandalism, falsity, etc.).
Emotions. External manifestations of emotions: facial expression, posture, gesticulation. Prevailing mood: eutimic, euphoric, sad, labile, angry, benevolent, anxious, etc. Qualitative features of mood disorder: prevalence of depression; malice; anger; excessive gaiety, euphoria. Depressive or manic syndromes. Increased sensitivity and intensity of emotions: irritability sensitivity; exhaustibility of emotional tonus, timidity. Decreased sensibility of emotions: emotional coldness (blunting, flattening), apathy. Inadequacy of emotions. Anxiety, fear. Polarity of emotions. Ambivalence. Parathymia. Overwhelming emotions (affects): malice, depression, fear. Pathologic affect. Physiological manifestations of affect (vascular and other). Phobias.
Instincts and drives. Disturbance of the self-preservation instinct: fear of death, infection, patient's excessive worrying over the state of his/her health; suicidal thoughts and attempts; self-harm. Eating disorders: overeating (bulimia), anorexia (decreased appetite); eating inedible objects. Sexual drive disorders (increase, decrease, perversions).
1. Clinical observation of the behavior of the mentally ill patient.
2. Clinical interview.
3. Acquaintance with a mental hospital.
5.4. Materials for self-control
A. Questions for self-control:
Prepared by assistant S.D.Savka
|Ministry of public health of ukraine ministry of education, science, youth and sports of ukraine||Ministry of health of ukraineministry of health of ukraine|
|Ministry of Health of Ukraine||Ministry of health of ukraine|
|Ministry of Health of Ukraine||Ministry of Health of Ukraine|
|Ministry of Health of Ukraine||Ministry of health of ukraine|
|The Health Ministry of Ukraine||Ministry of Health of Ukraine|