Psychiatry - O. K. Napreyenko 2001

Propaedeutics of Psychiatry
Methods of Examination of Psychiatric Patients

Mental illnesses are diagnosed based on the physician's clinical reasoning, theoretical knowledge of psychiatry, and the results of a comprehensive psychiatric evaluation of the patient.

The psychiatric evaluation is conducted in accordance with the generally accepted medical principle that combines the primary clinical (psychopathological) method with a range of paraclinical assessments (experimental psychological, neurophysiological, neuroradiological, etc.).

Furthermore, psychiatry is closely intertwined with somatic medicine and draws extensively on the knowledge and Research Methods of related clinical disciplines, primarily internal medicine and neurology.

CLINICAL EXAMINATION

Identifying symptoms of mental disorders and diagnosing a condition require the physician, first and foremost, to have a deep theoretical understanding of their Clinical presentation. It is equally important to notice these disorders and accurately interpret the data gathered during the Clinical examination of the patient.

The primary methods of clinical (psychopathological) examination in psychiatry are simultaneous observation and interviewing of the patient. It is essential to constantly compare what is heard with what is seen—correlating interview data with observational findings, including facial expressions and pantomimic reactions to questions—even when the patient refuses to answer them.

While observing the patient, the physician pays attention to their appearance, goal-directedness or lack thereof, purposeless or stereotyped movements, outcries, facial expressions, reactions to the environment, speech patterns, and so forth. Nursing staff also monitor the patient's behavior in the inpatient Setting and maintain special observation logs, which the physician uses to assess the patient's mental status.

Certain symptoms of mental disorders (such as hallucinations, indicated by the patient listening intently, peering at something, or covering their Nose; or persecutory delusions) can be noticed or suspected from a tense and frightened appearance through careful observation. However, the majority of psychopathological symptoms can only be identified during the Patient interview (obsessive thoughts, depersonalization and derealization phenomena, delusional ideas, symptoms of psychic automatism, etc.).

The diagnostic value of information obtained during a conversation with a patient depends on the physician's knowledge of psychiatric symptomatology, their ability to select and interpret diagnostically relevant information, and their capacity to critically evaluate the ability of both the patient and their relatives or loved ones to accurately recount mental disturbances. The scope and quality of the information gathered regarding the patient's mental state depend on the degree of trust the patient has in the physician, as well as the clinician's ability to find an individual approach, establish rapport, and steer the conversation in the right direction. One must listen and observe simultaneously, sensing the situation in order to choose and ask appropriate questions at the right time. A crucial condition for establishing rapport between a psychiatric patient and the physician is adherence to deontological rules throughout the evaluation. Under no circumstances should the physician conceal their specialty; sooner or later, the deception will come to light, and trust in the physician will be lost. It is best to conduct the conversation in private, as the presence of relatives or third parties can hinder rapport.

One must never behave rudely toward a patient, even when mental disturbances and inappropriate behavior are glaringly obvious. The physician should remain tactful, benevolent, sympathetic, and attentive, refraining from irony even regarding the most absurd statements. At the same time, it is always advisable to maintain professional distance and avoid over-familiarity. During the interview, the clinician should be restrained, avoiding reprimands, moralizing, or displaying personal reactions (disapproval or agreement) toward delusional thoughts, preferring instead to maintain a neutral stance.

The clinical examination of psychiatric patients should follow the standard format of a medical history. In daily practice, however, achieving complete sequence is almost never possible; therefore, clinicians must constantly adapt their actions to the patient's mental state and their attitude toward the conversation.

The overall interviewing strategy, grounded in The ability to find an individual approach to each patient, should foster a friendly, professional atmosphere rather than feel like an interrogation.

It is best to begin the conversation with factual data, moving from the neutral and simple to the complex and sensitive. The initial steps involve introducing oneself, asking about the patient's age, education, place of residence, and occupation or studies.

Once rapport has been established, the physician explores the reason for seeking help from a psychiatrist or psychiatric clinic. Next, they ask whether the patient has any health Complaints. Responses can vary widely—from a complete denial of any complaints to the disclosure of psychological disturbances (insomnia, obsessive thoughts, fear, hallucinations, delusions, etc.). Therefore, this information must be clarified through follow-up questions. By listening attentively to the patient while observing their facial expressions and movements, the physician attempts to identify specific symptoms. If signs of mental disturbance are present, the conversation is steered in a specific direction to reveal The Nature and CHARACTERISTICS OF THE psychopathology. If the patient refuses to answer questions, the clinician may temporarily shift to assessing the somatic status; often, this interaction helps re-establish rapport with the physician.

When transitioning to gathering the Anamnesis, one must bear in mind that in psychiatry—more than in any other clinical discipline (perhaps with the sole exception of pediatrics, where an infant cannot speak for themselves)—the physician deals with two Components of the history of life and illness: subjective (information provided by the patient themselves) and objective (information from relatives, close acquaintances, and those who know the patient well, as well as medical records).

A patient in a psychotic state is best interviewed after obtaining objective Background information about them. In cases of non-psychotic (borderline) disorders, it is generally more appropriate to interview the patient first, as this helps build trust in the physician.

When collecting subjective and objective data for the life history, the physician first gathers details about the parents and close relatives. Attention is paid to family dynamics, parenting styles, and any history of suicide, individuals with difficult personalities, eccentricities, or substance abuse (alcohol or other mind-altering substances).

Next, the physician inquires about the Stages of the patient's physical and mental development (condition at birth; development During the first year, ages 1 to 3, and ages 4 to 16); personality traits; volitional drive; age of starting school, abilities, interests, academic attitude, school behavior, and any changes in character or behavior along with their causes; milestones of Puberty; post-school education; military service, employment history, marital status and family relationships at the onset of the illness and at the time of the examination; living conditions; past illnesses throughout life; surgical interventions; physical and psychological trauma; and bad habits.

The history of the present illness is compiled from the accounts of both the patient and their relatives. Attention is directed toward factors that may have preceded the onset of the illness or its relapse (various life events, psychological and physical trauma, infections, intoxication, childbirth, etc.), the pattern of pathological development (acute, subacute, gradual) and its manifestations (changes in personality, behavior, bizarre actions, cognitive impairment, emotional shifts, hallucinatory episodes, delusions, etc.), previous treatments (outpatient or inpatient) and their efficacy, reasons for hospitalization, and who brought the patient to the clinic.

During the collection of subjective and objective anamnestic data using a unified framework, all information is compared, evaluated, supplemented, and cross-checked. Relatives may not be aware of everything regarding the patient; therefore, It is important to ask the patient directly whether they are satisfied with their family and occupational status, what problems they are experiencing, and to explore significant life events and how they coped with them. The physician should screen for suicidal thoughts and attempts, and inquire about bad habits, past TRAUMATIC Brain INJURIES, Sexually Transmitted Infections, allergic tendencies, and more. However, the patient's statements should not always be taken at face value, as they may be unaware of, conceal, feel ashamed of, or fail to comprehend The Significance of certain deviations from the norm.

Objective anamnestic data should not be gathered in the patient's presence, since relatives may hold back information in front of them. Parents should be questioned in detail about the patient's early childhood development, family rearing conditions, and character traits. The physician must steer the conversation and gently curtail attempts by informants to impose their own opinions. While information is sometimes limited to a single informant, in other cases it is necessary to consult multiple people. It must be remembered that data obtained from relatives and the patient are not always sufficient to diagnose past psychiatric disorders. Therefore, when compiling the objective history, it is crucial to review certificates from medical institutions, discharge summaries, forensic expert reports, and other medical documents, and occasionally performance evaluations from workplaces or educational institutions. This allows for a retrospective Assessment of the onset and Clinical Features of the mental illness.

The assessment of the patient's mental status begins from the moment of the initial meeting with the clinician, through establishing contact and gathering complaints and background information. Aspects of the patient's appearance, complaints, specific statements, or notable details FROM THE HISTORY can serve as a springboard for a targeted conversation to identify a constellation of mental disorders. At the same time, objective information regarding the patient's mental disturbances must be used skillfully and cautiously to avoid straining relationships with family and loved ones. An experienced psychiatrist relies on interviewing techniques that naturally reveal all existing mental alterations, whereas a novice clinician may not know where to start the conversation or which direction to take. Consequently, the mental status examination should follow a structured framework, keeping in mind the absolute necessity of evaluating all domains of mental activity.

If a patient is severely agitated, has impaired consciousness, or is in a stupor, they should be interviewed only after their mental state improves. However, one must not resort to a silent standoff with the patient. Psychomotor agitation observed during the evaluation is, in itself, a symptom of mental disorders (such as altered states of consciousness, stupor, etc.).

The state of consciousness is indicated by the patient's orientation to place, time, and person. To assess this, specific questions are asked, such as: "What is your full name?" "Where are you right now?" "What is today's date, month, and year?" and so forth.

Perceptual disturbances are evaluated based on observations of the patient's behavior, facial expressions, and movements (such as covering their ears or nose, listening or peering intently, removing something from their Mouth, or brushing things off their body). It is important to remember that a patient will not always give a straightforward answer to a direct question; therefore, during the conversation, the clinician should casually inquire whether the patient has been experiencing any unusual sensations, whether they hear voices, and if so, when and what the content of those voices is.

Memory disorders concerning recent and past events are assessed as early as the initial collection of personal and anamnestic data. At this stage, the physician may observe the patient's inability to remember the doctor's full name or to recall current and past life events.

To evaluate a patient's intellect and its alignment with their education and life experience, clinicians examine their general knowledge, particularly professional expertise. Intellectual capacity and thinking processes are further reflected in the patient's ability to react appropriately to jokes and humor, and to grasp the meaning of proverbs, sayings, and metaphors.

During the preliminary conversation, attention is paid to The Nature of Thought Disorders (in terms of pace, form, and content). When identifying delusional ideas during direct contact or through the Analysis of the patient's letters, statements, or other writings, one must take into account their diverse thematic content (such as ideas of reference, influence, persecution, self-deprecation, or delusions of grandeur). Recognizing these symptoms is impossible without this contextual analysis.

For instance, it is recommended to ask the patient whether people's attitudes toward them have changed, whether they are being watched, whether poison is being added to their food, or whether various devices or rays are being used against them. Patients are also asked to explain any statements that raise suspicion of underlying mental disorders.

When examining the emotional sphere, primary focus should be directed to the patient's appearance, facial expressions, and clothing. Their current mood and the appropriateness of their emotional responses are also evaluated.

In assessing the motivational and volitional sphere, the main focus is placed on behavior and the capacity for independent, goal-directed activity. In patients with psychomotor and volitional disorders, spontaneous activity is severely impaired (e.g., they may be unable to care for themselves or may exhibit negativism). It is essential to ascertain from both the patient and those close to them whether there are any pathological drives or instinct-driven actions (concerning sex, Nutrition, or self-preservation). Inquiring about current and past suicidal thoughts and actions is mandatory.

To further examine the mental state, experimental psychological testing is also conducted using appropriate standardized methods.

It is equally important to determine the patient's attitude toward their pathological experiences and behavioral peculiarities. This may range from partial, unstable, or adequate insight to a complete lack of insight.

It should be kept in mind that patients, consciously or unconsciously and driven by various motives, may conceal or distort the manifestations of their illness, adopt a negativistic or conformist stance, deny everything, or simply agree with the clinician during questioning. Therefore, during the examination, it is crucial to adequately assess the patient's condition in terms of possible malingering, aggravation, or dissimulation of mental disorders. Aggravation, much like malingering, is more frequently encountered in forensic-psychiatric, military, and occupational evaluations, and manifests as the patient exaggerating their own symptoms. Since plausibly mimicking the clinical picture of a mental illness is practically impossible, specialists can readily identify such simulation.

Most commonly, psychiatrists encounter dissimulation, where patients attempt to conceal mental disturbances (such as delusions or suicidal ideation) and fabricate rationalizations for their actions and statements. If discharged prematurely from inpatient care, such patients may pose a danger to themselves or others. In these cases, as in detecting malingering and aggravation, it is necessary to compare the patient's statements with their actual behavior in the ward through continuous clinical observation.

The evaluation of somatic and neurological status plays a major role in the Diagnosis of mental illnesses. Detected somatic and neurological symptoms, along with altered laboratory findings, can be decisive in identifying the underlying cause of psychiatric disorders (such as a brain tumor, neurosyphilis, or HIV/AIDS). In other cases, somatoneurological disorders (e.g., tachycardia, Hypertension, anorexia) serve as manifestations of the mental illness itself (such as neurosis or manic-depressive psychosis).

As for the examination of somatic and neurological status, it follows the standard protocols used in general internal medicine and neurology clinics.

Somatic alterations in psychiatric patients possess certain distinctive features. Traces of physical trauma may be observed on the patient's body (such as hematomas, abrasions, scars from Burns, cuts, or injections, and ligature marks on the neck). These must be described in detail in the medical history. If an unidentified person is admitted without documents, their primary identifying features are recorded: height, body build, eye and Hair color, approximate age, birthmarks, tattoos, scars, and physical defects. Patients who are unable to voice any complaints require particularly thorough examination.

During the neurological examination, it is important to note any subtle microsymptoms (such as facial innervation Asymmetry or deep tendon reflex abnormalities), which may result from residual organic (post-traumatic or other) brain damage.

If a patient cannot be examined due to severe agitation or resistance, this fact must be explicitly documented in the medical history.

EXPERIMENTAL PSYCHOLOGICAL ASSESSMENT

During the clinical evaluation of psychiatric patients, difficulties may arise in diagnosing initial, subtle mental disorders and in assessing preserved personality traits, skills, and abilities. The purpose of psychological testing—conducted by a medical (clinical) psychologist or a physician specially trained in medical psychology, including a psychological physician—is to identify impairments in mental processes (perception, memory, attention, thinking, intellect) and overall personality Structure. When referring a patient for psychological testing, the clinician should formulate specific questions that are of primary interest (e.g., assessing the patient's intellectual level; determining whether Memory and Attention deficits characteristic of organic brain damage are present; or identifying thought disorders typical of Schizophrenia, personality traits in neuroses, etc.).

Intellectual level is most frequently assessed using the Wechsler Adult Intelligence Scale, yielding an Intelligence Quotient (IQ) officially recognized by the World Health Organization. An IQ of 100 is considered the statistical average, although in developed countries, the majority of the population scores higher. Scores ranging from 90 to 70 are considered low but within the normal range ("low average") and are not regarded as evidence of dementia. Values between 70 and 50 are characteristic of debility (mild intellectual disability), and down to 50, imbecility (moderate intellectual disability).

Attention disorders can be detected using cancellation tests (such as Bourdon-type letter cancellation). On a specialized form, the patient is asked to cross out two designated letters. The number of errors and the task completion time (in minutes) are calculated. To diagnose attention deficits, the Schulte table test is also utilized. The patient is asked to sequentially locate and point to numbers from 1 to 25 scattered across five different grids as quickly as possible. The time spent on each table is recorded (the normal range is 30–50 seconds). Another method is the Kraepelin continuous addition test. On a specialized worksheet, the patient must continuously add pairs of numbers and write down the sums. The number of operations performed within 15 seconds and the error rate in each row are recorded. These tests are also employed to detect fluctuations in attention, distractibility, fatigue, and the patient's attitude toward the task.

Memory assessment. Memory impairments can be evaluated using simple techniques such as the 10-word recall test using semantically unrelated words. The patient's ability to reproduce these words is tested immediately (short-term memory) and after 1–2 hours (long-term memory). Other methods assess whether the patient can "reproduce a story." After reading or listening to a short narrative, the patient must retell the content either orally or in writing. This simultaneously tests memory performance, sustained attention, and logical thinking (forgetfulness and gross errors are observed in organic brain lesions, whereas distortions and derailment of thought are characteristic of schizophrenia, etc.).

Assessment of thinking. A variety of psychological methods are used to detect thought pathologies. For instance, the patient is asked to describe the events depicted in a thematic picture. This technique evaluates the patient's comprehension, ability to discern the main idea, and emotional reaction.

"Arranging a sequence of events." Using a series of 3 to 6 pictures depicting a narrative event, the patient is asked to compose a coherent story.

"Association experiment." The patient is presented with words one by one from a standardized list (20–25 words) and is instructed to respond with a generalized superordinate concept. The latency period (normally 2–3 seconds) and the Nature of the response are recorded; this technique helps evaluate the ease or difficulty of associative processes and their semantic relevance.

The object Classification test (Protopopov-Rushkevich method) is used to assess Abstract thinking. Using a set of cards depicting various objects, the patient must complete a series of tasks, specifically: 1) name the depicted objects; 2) group them under a single general concept; 3) explain the concepts; 4) form a conditional response based on the dichotomy of "living vs. non-living"; 5) separate and group 16 items into 4 categories; 6) similarly group 16 words into 4 categories; 7) form a group of images while excluding the one that does not fit the given concept; 8) determine the relationship between concepts and select analogous groups; 9) distribute words into groups based on specific features; 10) explain proverbs and summarize their meaning; 11) draw logical Conclusions; and 12) form a comprehensive conceptual category. The test results are recorded on a specialized scoring sheet, which allows the clinician to evaluate not only the patient's thinking but also their attention, memory, and emotional sphere.

Method for assessing the emotional sphere. Self-evaluation is elicited in the following manner: on a straight line symbolizing a continuum of a universal human trait (such as health, intelligence, temperament, or happiness), the patient is asked to mark a point indicating their own standing and to explain the rationale behind this self-assessment. The characteristics of the patient's emotional reactions are also noted.

Various techniques can be used to detect hidden depression. The popular Luscher color test (Ilispeg) is widely used. Conclusions about a patient's emotional state are generally drawn from the sequence in which cards of specific colors are chosen. Certain questionnaires (such as those by Spielberger, Hamilton, and others) also feature specialized depression scales.

Methods for Assessing motor function. There are several approaches: assembling a labyrinth-like "chaotic" broken line from matches; constructing color mosaics with blocks; examining constructive-fingered actions; serial dynamometry; the multi-dot test; and assessing visuomotor coordination, among others.

For diagnosis, prognosis, and psychotherapy, it is crucial to identify psychotraumatic factors and painful experiences that patients often conceal. Projective methods are employed for this purpose. The most well-known is the sentence completion test, where patients are asked to finish phrases such as: "Married life seems to me..." or "A true friend is someone who...", and so on. The Thematic Apperception Test (TAT), introduced by H. Murray and C. Morgan (1935), is also utilized. The patient is asked to comment on 29 pictures depicting various situations and to compose a short story (for example, about a pedestrian splashed with mud by a car). According to the authors' hypothesis, the patient will talk about themselves or attribute their own knowledge, feelings, and experiences to the fictional characters.

Character traits are most frequently evaluated using the Minnesota Multiphasic Personality Inventory (MMPI), developed in the USA and adapted for our population. This helps identify predispositions to hypochondria, depression, hysterical, psychasthenic, and other traits. To diagnose personality accentuations in adults and children, the Smischek questionnaire is used, while adolescents are assessed using the PathsetCharacterological Diagnostic Questionnaire (PDQ) developed by N. Ya. Ivanov and A. E. Lichko.

NEUROPHYSIOLOGICAL EXAMINATION

Electroencephalography (EEG) is most commonly used to examine psychiatric patients, while reoencephalography (REG) and echo-encephalography (Echo-EEG) are employed less frequently. Sensitive equipment with computerized Data analysis helps quickly obtain accurate, objective results, and mathematical analysis makes it possible to identify specific patterns in brain function.

The EEG (a recording of the brain Cells' electrical currents) reflects metabolic processes taking place within the brain. These bio-currents are extremely weak (100–150 µV, 10–15 µV), requiring amplifiers for detection. This examination is vital for diagnosing Epilepsy AND EPILEPTIC psychoses: it reveals sharp waves, "spikes", "spike-wave" complexes, and other manifestations of seizure activity. Such activity can sometimes be recorded in individuals who have never experienced epileptic seizures but carry a very high risk of developing them ("latent epilepsy"). Conversely, some patients with epilepsy may show no signs of seizure readiness on their EEG between attacks. Hyperventilation (deep breathing in and out for 1–2 minutes) helps bring out these abnormalities, as they are provoked by a drop in Blood carbon dioxide levels. Anticonvulsants and certain psychotropic medications suppress seizure activity.

The EEG also aids in recognizing organic brain lesions. Mental disorders are typically accompanied by more frequent diffuse Changes in the brain's bioelectrical activity. Occasionally, these changes are more pronounced in the temporoparietal, frontal, or occipital regions of one or both hemispheres.

Endogenous depressions are characterized by EEG changes during Sleep (specifically, a shortening of the slow delta-wave phase). However, detecting these requires multi-hour nighttime recording. No specific EEG changes have been identified for other mental disorders.

REG involves recording the characteristics of cerebral blood flow by measuring fluctuations in the electrical resistance of HEAD Tissues. The REG curve is synchronous with the pulse. This examination helps detect vascular damage in the brain. In cerebral atherosclerosis, the waveform peaks become rounded rather than sharp and arced.

Echo-EEG is an ultrasound brain examination based on THE PRINCIPLE OF echolocation. It is used when a mental disorder is suspected to stem from a focal brain lesion, such as a tumor or hematoma. It reveals lateral Displacement of the midline brain structures toward the healthy side. If the atrophic lesion is large, the displacement may be directed toward its Location.

NEURORADIOLOGICAL EXAMINATION

Craniography is X-ray imaging of the cranial bones. It allows clinicians to infer the presence of organic brain damage through indirect signs. For instance, an intensification of digital impressions is a sign of chronically elevated intracranial pressure. Areas of excessive calcification often appear following traumatic brain injuries.

Pneumoencephalography (PEG). Brain X-rays are taken after a portion of the CEREBROSPINAL FLUID is drained and replaced with air or oxygen, which fills the cerebral ventricles and subarachnoid space. This method makes it possible to detect meningeal adhesions, certain tumors, and atrophic changes. With the advent of cranial computed tomography, this technique is now considered obsolete.

Angiography of the cerebral Vascular System. Contrast agents or radioactive substances are injected through the carotid artery, followed by X-ray imaging. This allows for the detection of cerebral vessel damage as well as localized brain injuries (such as tumors).

Computed tomography (CT) of the head is an automated cross-sectional X-ray Examination of brain tissue, featuring computer analysis of the data and the generation of a 3D image on a specialized monitor. It enables the precise localization of brain lesions and is prescribed to diagnose Brain Tumors, atrophic processes, abscesses, and other conditions.

Positron emission tomography (PET) is based on the differential breakdown rates of radionuclides used to label glucose, Neurotransmitters, or other administered compounds. It provides insight into local changes in brain METABOLISM, neuroreceptors, blood supply, and more. The data are synthesized using computer algorithms. It is one of the most promising diagnostic methods, with capabilities that are still being fully explored.

Laboratory tests

Diagnostic laboratory tests in psychiatry are ordered to assess the patient's somatic status at various stages of the Treatment and diagnostic process, as well as to identify physical illnesses caused or accompanied by psychoses.

The Objects of Study (blood, urine, cerebrospinal fluid, etc.), as well as most of the methodologies, are identical to those used in other medical fields.

General blood and urine tests are conducted primarily to rule out infectious or other systemic diseases. This is particularly important because psychiatric patients are less likely to complain about a deterioration in their general physical health.

It should be noted that acute schizophrenia (febrile form) is characterized by an elevated relative urine density, leukocytosis, an increased ESR, and toxic granularity of neutrophils, whereas chronic schizophrenic processes are more frequently accompanied by lymphocytosis. In epilepsy patients, a blood leukocytosis reaction can often be detected immediately after a seizure, along with protein and glucose in the urine.

Complications affecting the hematopoietic system and Kidneys during treatment with psychotropic drugs, though rare, do occur. For instance, cases have been described where treatment with chlorpromazine and other phenothiazine derivatives, as well as leponex (clozapine, azaleptine) and melipramine, led to agranulocytosis—a sharp decrease in blood neutrophils (up to their complete disappearance) accompanied by relative lymphocytosis. Prolonged haloperidol therapy can induce lymphomonocytosis.

Clinical urinalysis is essential for the timely detection of insidious, subclinical Kidney damage. Such pathology may serve as a contraindication for treatment with psychotropic agents and Insulin.

Biochemical changes in the blood and urine are observed across various mental illnesses. Psychomotor agitation, for example, is accompanied by hyperglycemia, elevated levels of corticosteroids and catecholamines, and other metabolic shifts.

Blood glucose levels are measured not only when Diabetes Mellitus is suspected or to detect hashish intoxication (hypoglycemia), but also during insulin coma therapy administered for psychoses.

If chlorpromazine treatment is prolonged, the prothrombin index should be determined (due to the risk of thromboembolic disease).

A hallmark of psychiatric clinical practice is monitoring blood lithium levels during the treatment of Affective Disorders with this medication. Regular determinations of its concentration in the blood are required (monthly at first, and subsequently every 2–3 months). The normal range is 0.6 to 1.2 mEq/L. Other psychotropic drugs are rarely studied in psychiatric patients, usually only within The Scope of scientific research.

Cerebrospinal fluid analysis is ordered when organic brain pathology is suspected (whether of syphilitic, neoplastic, inflammatory, or other origin). Lumbar puncture is performed only with the patient's consent, or—if the patient is unable to give consent due to impaired consciousness or a severe mental disorder—with the consent of relatives or close ones. The lumbar puncture is performed by a physician using a specialized needle (with a stylet). It is inserted into the terminal cistern of the Spinal Cord between the III and IV or IV and V lumbar vertebrae (in children, between the V lumbar and I sacral vertebrae) with the patient in a sitting or lateral recumbent position. After the puncture, the stylet is removed, and 4–8 mL of cerebrospinal fluid is collected for analysis. The outflow of cerebrospinal fluid in very frequent drops, let alone a continuous jet, indicates elevated intracranial pressure. In arachnoid and cerebral hemorrhages, the CSF resembles "meat washings." Fresh blood may enter the CSF from small vessels damaged during the puncture. Following the Procedure, the patient must lie flat for 2–3 hours without raising the head. Strict bed rest should be maintained for 24 hours. Cytosis (normally 3–5 cells per 1 µL of fluid) increases dramatically in acute Purulent meningitis (from 150 to several thousand cells per 1 µL; normally 0–5 cells, predominantly lymphocytes), and to a lesser extent in encephalitis and brain tumors. This indicator rises significantly in acute purulent processes, whereas chronic processes (arachnoiditis, neurosyphilis) exhibit a moderate lymphocytic reaction (10–100 cells per 1 µL).

Protein content (normally 0.15–0.3 g/L) increases during inflammatory processes and tumors. However, tumors that impede venous drainage from the brain are particularly characterized by "protein-cytological dissociation," where protein levels increase dozens of times while cytosis rises only slightly. In organic cerebral pathology, colloidal protein precipitation tests also become positive: the Nonne-Apelt test using ammonium sulfate, the Pandy test with carbolic acid, and the Weichbrodt test with mercuric chloride.

Lange's colloidal gold curve is particularly important for diagnosing syphilitic involvement of the brain. Normally, upon adding cerebrospinal fluid in various dilutions, the purple-red color of the solution remains unchanged in all 16 test tubes, whereas in pathology, the color may change to purple, blue with a reddish tint, blue, light blue, or the Contents of the test tube may even become completely decolorized. Specifically, cerebral Syphilis is characterized by moderate color changes in test tubes 2 through 5 (the "syphilitic zone"), while progressive paralysis causes a sharp color change (up to complete decolorization) in only the first 5–7 test tubes (the "paralytic curve"). The test results can be represented graphically or using a conventional numerical code corresponding to the color in each of the 16 test tubes. For example, a normal reaction type would appear as 1211111111111111, and a paralytic type as 7777764321111111.

Serological tests on CSF are performed to diagnose syphilitic brain lesions (Wassermann, Kahn, Sachs-Witebsky, Treponema pallidum immobilization [TPI], indirect immunofluorescence [IFA] tests, etc.), as well as for the diagnosis of cysticercosis (using cysticercus antigen).

Immunological studies. At The current stage of psychiatry's development, the mechanisms of interaction between the nervous and immune systems are being intensively investigated. The tasks of clinical immunology are related to the immunodiagnostics and Treatment of Mental Disorders. The patient's status is assessed based on the results of a comprehensive immunological study, taking into account factors of non-specific body reactivity (heterophile hemolysins, hemagglutinins, Complement system, levels of non-specific IMMUNOGLOBULINS), autoantigens and autoantibodies to brain Antigens detected in the patient's blood, and indices of neuroallergic reactions. It has recently been established that latent Viruses can persist in the human brain for prolonged periods. This may indicate the virus's involvement in the Pathogenesis of certain mental illnesses, particularly in the mechanisms driving autoimmune processes. Immune system dysfunctions in mental disorders underscore the rationale for pathogenetically sound psychoimmunorehabilitation of patients.

PSYCHIATRIC CASE HISTORY

Below is the outline for a psychiatric case history. Compared to the case history of a somatic patient, it possesses A number of distinct features.

1. General Patient Information: last name, first name, middle name; year of birth; nationality; occupation; if disabled, the disability group; place of work; place of residence; by whom referred and by whom delivered to the clinic; date of hospitalization; diagnosis (referring medical institution's diagnosis; admitting diagnosis; clinical diagnosis).

2. Patient's Complaints: if obtainable, they are described in detail for the current period of observation, while complaints upon hospitalization are transferred to the History of the illness; if the patient considers themselves healthy, this must also be recorded.

3. Objective Anamnesis (indicate the source, stating whose words and which documents are used):

a) anamnesis of life: living conditions and upbringing in the family; mental deviations and illnesses in close relatives; physical and mental Development of the patient during childhood, school years, and adolescence; academic performance; acquisition of a trade or profession; military service; employment; family life; personality traits; past illnesses; mechanical and psychological traumas; bad habits (smoking, alcohol, etc.); sleep; appetite; sexual function;

b) history of the illness: when, under what circumstances, and whether the deviations in the patient's experiences and behavior began acutely or gradually (describe in detail precisely how this manifested—from the initial symptoms throughout the course of the illness); if the patient has previously received treatment on an outpatient basis or in psychiatric hospitals, the chronological progression of the illness must be detailed, including treatments administered, outcomes, how this affected the patient's attitude toward their family and their work capacity, and what directly prompted the consultation with a psychiatrist and led to hospitalization. During the initial examination, it is necessary to indicate at whose initiative and for what reason the patient consulted a psychiatrist or was hospitalized. Not only the patient's address must be recorded, but also the full name, address, and telephone number of their closest relative. Information regarding the person who brought the patient to the psychiatric clinic should also be provided. The life and illness history of the psychiatric patient is gathered and described in detail (objective anamnesis).

4. Subjective Anamnesis: information regarding the patient's life and illness gathered directly from the patient, with a focus on their subjective experiences. Only data that Supplement or contradict the objective anamnesis are recorded.

5. Somatic Status: results of the examination of Organs and body systems (inquiry, Palpation, Percussion, Auscultation). Attention is paid to body constitution, pathological changes, bodily injuries, and febrile states.

6. Neurological Status: results of a complete neurological examination as conducted in a neurological clinic. Special attention is drawn to symptoms of brain lesions, cranial nerve involvement, and meningeal signs (aphasia, dysarthria, handwriting and gait disorders, apraxia, seizures, nuchal rigidity, Kernig's and Brudzinski's meningeal signs, etc.).

7. Laboratory and Other Paraclinical Investigations: clinical blood and urine tests, cerebrospinal fluid analysis, radiological, serological, and biochemical studies, psychological testing, neurophysiological, electrophysiological, and other specialized methods (fundus examination, ECG, EEG, etc.).

8. Mental Status. The patient's mental state is examined according to a structured plan:

a) appearance (clothing, hairstyle, accessories);

b) nature of contact—active, passive, easy to communicate with, difficult, productive (responds adequately to questions, stays on topic), formal, non-contact (does not respond or responds irrelevantly);

c) state of consciousness—orientation regarding place, time, surrounding environment, and self;

d) sensations, perception, and their disorders—weakening, intensification, distortion of sensations (visual, auditory, gustatory, olfactory, tactile, spatial body orientation, interoceptive). Cenesthopathies, metamorphopsia, body schema disorders. Illusions and hallucinations (by sensory modality). True hallucinations and pseudohallucinosis. Psychic automatism (Kandinsky-Clérambault syndrome). Derealization and depersonalization;

e) attention disorders—passive and active attention (span, concentration, selectivity, stability, switching, enhancement, impairment, distortion);

e) memory and its disorders — hypermnesia, hypomnesia, amnesia (anterograde, retrograde, anteroretrograde), paramnesias (pseudoreminiscences, confabulations, cryptomnesias);

f) thinking and its disorders — types of thinking (concrete, abstract); disorders of pace (accelerated, slowed), form (split, paralogical, overelaborate, detailed), content (obsessive, overvalued, and delusional ideas), and their themes (relations, persecution, influence, poisoning, control, jealousy, grandeur, inventiveness, eroticism, wealth, self-abasement, self-accusation, sinfulness, hypochondriacal, nihilistic, etc.);

g) intellectual disorders. They are established by identifying a discrepancy between the patient's store of knowledge and education, and their life experience. The capacity for mental operations is assessed, specifically regarding analysis (breaking down concepts into component parts), synthesis (combining parts into a single whole), comparison (identifying Similarities and differences, e.g., an airplane and a bird), generalization (apple, pear, plum), abstraction (understanding the figurative meaning of proverbs, metaphors, idioms, etc.), as well as concretization (applying abstract judgments to a specific situation). It is also important to determine whether the patient maintains a critical attitude toward their own pathological condition;

h) emotional sphere disorders — by intensity (euphoria, depression, apathy, emotional dullness, paralysis of emotions), mobility (lability, emotional lability/weakness, torpidity), adequacy (inadequacy, ambivalence, phobias, dysphoria, pathological affect); mood characteristics — morbidly elevated, depressed, indifferent, unstable;

i) Disorders of the motivational-volitional sphere and instincts: hypobulia (reduced activity); abulia (lack of activity); hyperbulia (increased activity); parabulias (stupor, mutism, active and negativism, passive negativism); stereotypy (of movements, speech, perseveration, verbigeration); catalepsy; waxy flexibility; echolalia; echopraxia; impulsive actions; obsessive states. Enhancement of instincts (aggression, bulimia, hypersexuality), weakening (lack of self-preservation reactions, anorexia, frigidity), distortion (suicidal acts, self-harm, coprophagia, Sexual Perversions, masochism, sadism, pedophilia, exhibitionism, etc.).

In a psychiatric case history, special attention is paid to the Description of the mental state, as it reveals psychopathological symptomatology. This description is initiated following a complete clinical examination, analysis and evaluation of the identified symptoms, and Determination of the Structural Features of the leading psychopathological syndrome.

Unlike the clinical investigation of the mental status, its written description does not typically follow a rigid scheme. Beginning with the patient's general appearance, posture, behavior, quality of rapport, and orientation in the environment and regarding their own identity, the report then focuses in detail on the most prominent manifestations of psychopathological symptoms (e.g., Specific features of emotional or thought disorders). A crucial condition for an objective portrayal of the patient's mental status is not mere assertion, but a descriptive account of the specific manifestations of disturbed mental activity. Attention is drawn to the patient's behavioral traits, facial expressions, movements, and the content of delusional thoughts. Characteristic statements made by the patient are quoted. The Use of shorthand psychiatric jargon is discouraged, such as: "the patient is depressed"; "auditory hallucinations were detected"; "expresses delusional ideas of jealousy", etc.

Only after a detailed description of the psychopathological symptoms should one briefly note the absence of other signs of mental disturbance (consciousness is clear, memory is intact, intellect corresponds to education and life experience, etc.). The syndromological diagnosis is thoroughly justified at the end of the description, with an emphasis on the individual Features of the psychopathological symptoms. This involves using psychiatric terminology followed immediately (in parentheses) by the specific manifestations of mental disorders that warranted the classification of that particular symptom.

9. Diagnosis and its justification. The diagnosis of the condition is substantiated based on the results of a complete clinical examination, analysis of the patient's complaints, subjective and objective history of life and illness, somatoneurological evaluation, laboratory data, and paraclinical research methods (psychological, electrophysiological). (Coexisting conditions are also noted — without detailed justification.)

10. Differential diagnosis. The primary disease is differentiated from other mental disorders that share similar clinical or course characteristics with the patient's psychopathological manifestations. First, the general and common symptoms shared by this pair of conditions are presented, followed by an enumeration of the differentiating features.

11. The final diagnosis is formulated after briefly summarizing the data directly pertaining to the primary condition. Comorbid diseases are also indicated (without justification).

12. Daily notes. These are maintained throughout the course of management (curation). They record the patient's statements, conclusions drawn from observing their behavior, a list of consultations, laboratory findings, and any modifications introduced into the treatment plan.

13. Treatment. All methods used to treat the patient are described. When necessary, prescriptions for the psychotropic medications administered are also provided.

14. Prognosis. The curator's assessment of the disease course in this specific patient is presented, along with expectations regarding their future quality of life.

15. Medical-social, military, and forensic-psychiatric evaluations.

16. Epicrisis. Upon the patient's discharge, the case history concludes with an epicrisis, in which the curator briefly summarizes all relevant data (anamnestic, clinical-psychopathological, laboratory, etc.) that substantiate the diagnosis, details the treatment methods, their outcomes, the prognosis of the condition, and vocational/occupational recommendations. A copy of the epicrisis serves as a medical document sent to the psychoneurological dispensary at the patient's place of residence and upon request by other psychiatric institutions.

The psychiatric case history serves not only as a medical and scientific document but also as a legal one. (Each entry is signed by the curator, consultant, or members of the medical-consultative commission, etc.) It is issued exclusively upon the demand of a prosecutor or court against a receipt signed by their representative.

Review Questions

1. Clinical psychiatric examination (interviewing, gathering subjective and objective anamnesis, observation).

2. The Role of pathopsychological evaluations in clinical practice.

3. Pathopsychological Methods for Investigating cognitive mental processes.

4. Pathopsychological methods for personality assessment.

5. Instrumental methods for investigating the functional state of the human brain.

6. Laboratory investigations and their diagnostic significance.

7. The case history and its structure.