Psychiatry - G.T. Sonnyk 2003

Methods of examining psychiatric patients
Clinical examination of a mental patient

At the beginning of the examination, after establishing rapport with the patient, one should ask about their general Complaints regarding their health status. These may be of both psychological and somatic nature. It is essential to listen to the patient attentively without interruption, and only then, based on the information obtained, clarify the complaints. Subsequent targeted questions help determine the presence of complaints related to major Organs and systems. Primary attention is given to complaints concerning specific spheres of the psyche, largely taking into account the patient's impaired ability to make an adequate self-assessment.

Mental illness can lead to an anosognosic or dysgnosic internal picture of the disease (failure to recognize, rejection, distortion), resulting in the patient's denial of any mental health problems, a stubborn unwillingness to clarify the state of certain mental spheres, or attributing hospitalization to somatic causes ("headache"; "Stomach ache", etc.). Furthermore, the patient may be in a state of altered consciousness and unable to communicate effectively with the physician.

The specific nature of gathering anamnestic data in psychiatric practice lies in the necessity of separating subjective and objective anamneses. Initially, data obtained through direct communication with the patient are evaluated — this is the "subjective Anamnesis." It should be kept in mind that mental illness leaves an imprint on a person's worldview and often results in a distorted presentation of the anamnesis due to impairments in memory, perception, or logical thinking, etc. The patient may intentionally distort Answers, avoid certain topics in the hope of hastening discharge, or influence the diagnostic or therapeutic process. Therefore, the subsequent stage — the "objective anamnesis" — is critically important. It includes data regarding the patient's life and illness obtained independently of the patient. This should include:

a) records made by the physician who first witnessed the onset of the illness: most often this is the psychiatrist from the psychoneurological dispensary who referred the patient to the inpatient facility;

b) data from observation, interview, and Description of the objective status by the inpatient physician during the initial patient examination;

c) data obtained from documents available to the patient (passport, correspondence, reference letters, outpatient record data, discharge summaries, etc.);

d) entries in current medical history progress notes and notes from archival medical histories;

e) information regarding the patient's life and illness obtained from their relatives and acquaintances (spouse, parents, friends, children).

When determining anamnestic data regarding the patient's illness, one should evaluate the dynamics of the current mental illness throughout its entire course, from the first appearance of morbid manifestations in the past to the present hospitalization.

The patient may entirely deny having any mental illness. In such cases, one should limit the inquiry to recording the dates of past hospitalizations and politely ask how the patient explains their causes, paying special attention to the current hospitalization.

An important role in the psychiatric clinic is played by the examination of the somatic and neurological status. Sometimes the identified somatic and neurological symptoms can be of decisive importance in recognizing the cause of a mental illness (Brain tumor, AIDS, etc.), while in other cases, somato-neurological disorders may be one of the manifestations of the mental illness. The examination of somatic and neurological statuses is carried out According to the standard protocols used in therapeutic and neurological clinics.

When examining and describing the mental status in the medical history, objectivity and a certain consistency of presentation should be maintained, guided by the following Scheme for the mandatory sequential coverage of all spheres of the patient's mental activity. Data from medical observation and interviewing are presented for each sphere of the psyche. The interview is conducted in a targeted manner to identify specific psychopathological symptoms.

The sequence of describing mental spheres:

✵ general appearance of the patient: facial expression, mimicry, its plasticity, expressiveness; gait characteristics; posture;

✵ degree and adequacy of facial and verbal contact with the examiner: good, when the patient readily answers questions and meaningfully talks about themselves; formal, when the patient's answers are sparse, monotonous, or monosyllabic; absence of contact — the patient is silent, turns away, avoids eye contact ("gaze negativism"), and refuses to converse;

✵ state of consciousness: orientation to place, surroundings, time, and own personality;

✵ perceptual disorders: according to identified complaints, examination by sensory analyzers, and behavioral observation. Questioning can determine the presence of illusions, hallucinations, and psychosensory disturbances. They should be described in detail regarding sensory modalities, complexity, projection, completeness of development, and the individual's subjective attitude. If the patient tends to conceal certain disorders, attention is paid to behavioral features that, reflecting hallucinations or other perceptual flaws, help objectify them. In auditory hallucinations, patients may listen to "voices," converse with them, and sometimes attempt to escape them by blocking their ears with fingers, cotton wool, etc. In visual hallucinations, the patient may turn their HEAD toward the hallucinatory scene, intently track it, and exhibit a characteristic facial expression. Sometimes movements reflect contact with hallucinatory images (grasping, brushing things off a table or clothing, pressing against oneself, etc.). Preoccupied with olfactory hallucinations, patients may plug their Nose with cotton wool or squeeze it with their fingers; with gustatory hallucinations, they may grimace or spit. In tactile hallucinations, scratching or sudden withdrawal of limbs may occur, among other signs;

✵ Thought Disorders: by pace — normal, accelerated, slowed; by coherence (consistency) and form of associations — incoherence, disorganization, paralogia, circumstantiality/zernerism, pathological detailing, perseverations, pathological symbolism, ambivalence of thinking, neologisms; by adequacy of associations — obsessions, overvalued ideas, delusions. The latter should be characterized in detail by theme (e.g., "delusions of jealousy," "ideas of worthlessness and guilt," "ideas of persecution, special significance, and grandeur") and Structure (paranoid, paranoid-hallucinatory, or paraphrenic nature of delusions), illustrating the account with the patient's direct speech; the level of critical insight into their own morbid symptoms and the course of the disease. Features of the patient's speech: voice inflections and modulations, expressiveness, pauses, and characteristic facial accompaniments of specific (delusional, falsely held) statements;

✵ attention disorders: difficulty shifting attention; difficulty engaging attention; pathological distractibility; reduced or absent attention span (illustrated with Examples of observations of the patient's behavior and speech);

✵ intellectual impairments: correspondence to overall age and general educational level (grades in the certificate, general knowledge of school subjects, response to questions about favorite subjects); level of judgment and reasoning, vocabulary size; ability to Abstract; handling abstract concepts and mathematical categories; ability to correct statements upon prompting; reading and writing skills; understanding of humor; ability to comprehend questions and instructions correctly — immediately or with repetitions and prompts, etc.;

✵ memory impairments: intensification; decline; identification of memory gaps with detailed characterization; qualitative disorders — confabulations, pseudoreminiscences, cryptomnesia;

✵ emotional state: predominant mood Background, stability, manifestations of mood disturbances; emotional reactions during the interview with the physician (e.g., significant mood swings, periodic irritability, anger, lack of emotional reaction to anything, flat and sparse emotions, extreme emotional excitability when discussing a specific topic, animation of emotions in response to a specific question or action by the physician), Disorders of emotion in terms of intensity, lability, and adequacy. CHARACTERISTICS OF THE patient's emotional reactions toward significant individuals (relatives, friends, medical staff, individuals targeted by the patient's delusions). Observations should be illustrated in the medical history by describing mimicry and physiological manifestations of specific emotional reactions in response to verbal or behavioral stimuli from the physician;

✵ state of the effector-volitional sphere: adequacy, speed, voluntariness, and purposefulness of movements; presence or absence of involuntary movements (tics, stereotypies, etc.); presence of convulsive manifestations, paresis, astasia-abasia, and other movement disorders. Manifestations of the patient's goal-directed activity (future plans — adequacy, sincerity, feasibility; in case of disability — degree of asthenia; in Schizophrenia — possible abulic manifestations, etc.); features of the patient's motor-volitional activity in the hospital ward according to staff observations — compliance with ward rules, degree of cooperation with medical staff, adherence to instructions, physical activity, leisure time, personal hygiene, tendency to escape or other violations of ward regulations, and information from staff regarding delusional, hallucinatory, dysphoric, apatho-abulic, psychopathic, negativistic, or other behaviors. It is important to identify the features of the patient's adaptive behavior: it is usually harmonious, conflict-prone, regressive, or indifferent. Presence of alterations in lower and higher drives — enhancement, attenuation, or perversion, with detailed characterization. Special attention should be paid to socially aggressive and suicidal manifestations. Questions regarding aggressive drives toward others or oneself should be formulated particularly carefully and cautiously, monitoring and excluding the possibility of inducing the patient with one's own fantasies, choosing an appropriate time, and striving for maximum clarity;

✵ personal attitude toward the fact of hospitalization and Treatment: positive, with critical awareness of their morbid state and a desire to cooperate with medical staff for recovery; or negative, lacking critical insight into the illness; or indifferent, or with formal criticism of the illness (to be quoted in the patient's direct speech).

Experimental psychological examination.

The purpose of an experimental psychological assessment is to identify impairments in mental processes (such as perception, attention, thinking, memory, and emotions) and the personality as a whole. A practicing psychiatrist should primarily focus on a general evaluation of the patient's mental status and the diverse aspects of their mental activity. Therefore, all methodological groups should be utilized, and the examination protocol must document not only the patient's answers but also their behavioral features during the test, their statements, and their attitude toward the examination.

During testing, the physician should be concise. However, providing certain types of assistance to the examinee is entirely permissible. It is important to keep in mind that patients sometimes react poorly to their own failures encountered during the testing process. In such cases, the purpose of the study should be explained, and the patient should be reassured that the observed difficulties are temporary.

When explaining the purpose of the study, it should be noted that for most people, it is psychologically more acceptable to test "memory," "attention," or "the state of nervous activity" rather than "intelligence," "IQ," or "abilities." Presenting patients with overly simple tasks can sometimes give the wrong impression, leading them to think they are being considered "foolish" or "psychiatric cases." Therefore, it is better to start the evaluation with more complex tasks that can engage the patient's interest. If the patient feels insecure or is afraid of revealing incompetence, a few simple tasks or questions will help put them at ease.

Below are only a few of the Methods that can be applied to investigate mental Functions.

I. Assessment of Sensation and Perception.

1) Recognition of images in pictures (perception of ordinary pictures, recognition of images when only certain elements are present—such as contours, silhouettes, main strokes, or distracting elements that complicate recognition). The examinee is asked to look at the images row by row and name them. Initially, simpler pictures with clear details are shown, followed by smaller, contour, silhouette, crossed-out, overlapping, and more complex ones. Contour drawings depicting a dog are shown one by one from left to right, and the examinee is asked to "fill in" in their imagination what is missing. Other tables are used to assess optical agnosia. Impairments in image recognition are most frequently observed in patients with symptoms of mental weakness and altered states of consciousness (asthenic, amuretic, and amuretic-like states), as well as in children with pronounced intellectual deficits. Depending on the severity of the impairments, simpler images close to real objects are perceived correctly, whereas silhouette, contour, unfinished, crossed-out, or overlapping drawings are difficult to perceive.

2) Assessment of sensory excitability and Autonomic Nervous system responses during the perception of complex patterns. The patient is asked to look closely at tables depicting "moving squares" and, subsequently, a "wavy background." When viewing the first table, the second is covered with a white sheet of paper, and vice versa. While gazing at the second table, the examinee must count the squares in the first row. Factors taken into account include the time spent counting the squares in each row, as well as autonomic reactions and complaints arising from the initial glance at the mottled background and the perceived direction of the squares' "rotation." On another table, the examinee is asked to alternately count indistinctly drawn circles, squares, and triangles scattered against a background of wavy lines. During this process, attention is paid to how the examinee perceives the wavy background, what subjective sensations arise, and whether they attempt to rotate the picture so that the wavy lines become vertical, which facilitates visual inspection.

In various psychopathological states (delirium and predelirium, hyperesthetic emotional lability, sensory encephalitis, consequences of arachnoiditis, etc.), emotional and autonomic reactions clearly predominate at the onset of the cognitive process. Upon first glancing at the mottled or wavy background, patients with pronounced sensory excitability exhibit autonomic reactions, illusory stereoscopic effects (waves appear more convex), unpleasant sensations akin to motion sickness, visual flickering, and so forth. This assessment helps to "objectivize" subjective complaints and serves as a differential diagnostic criterion for toxic and organic brain lesions.

II. Assessment of Thinking.

1) Conceptual generalization. The patient is asked to name images or various items using a single, generalizing superordinate concept. This task engages the secondary signaling system: it evaluates the capacity for synthesis and the retrieval of associations from past life experience among narrower generalized Definitions. For example, name in a single word: a) poetry, music, painting, cinema; b) cow, horse, donkey, pig; c) physics, chemistry, mathematics, botany.

2) Conceptual categorization. The patient is asked to name familiar types of animals, plants, fabrics, and so on. This assesses the logical process inverse to conceptual generalization. The task addresses the secondary signaling system and primarily requires analytical Processing.

3) Definition and differentiation of concepts. The patient is asked to explain what a cat, life, snow, horizon, truth, etc., are, and to define the differences between a child and a dwarf, stinginess and thrift, a pine tree and a birch, a bee and a fly, and so forth. This evaluates the complex analytical-synthetic activity of the secondary signaling system, which is based on The ability to isolate essential concepts. It relies on identifying common essential features of objects and phenomena and reflecting those features in verbal responses.

4) Concept exclusion. The patient is asked to identify, from a group of items united by a common category, the item that does not belong. This task requires the Cerebral Cortex to distinguish complex stimuli based on general and essential features within homogeneous complexes. These form the basis for object Classification, as they have been reinforced through past life experience. For example: a) bold, brave, angry, courageous, resolute; b) minute, second, day, hour, evening; c) success, victory, luck, tranquility, win (which word must be excluded to leave only homogeneous items).

5) Analysis of conceptual relations. This test evaluates the ability to establish and generalize relationships between concepts. The extraction of relationships is ensured by the integrity of cortical analysis, with the leading role played by the secondary signaling system. The examinee is asked to select, from a series of relationships, one analogous to the first relationship in the given set. For example, corresponding to the relationship "library" (book), the examinee should select "forest" (trees), guided by the general whole/part concept.

6) Comprehension of the figurative meaning of proverbs and metaphors. From a physiological standpoint, a proverb is a complex verbal stimulus possessing two main aspects: a literal and a figurative meaning. The second aspect is derived from the first through The Mechanism of temporary connections (associations) formed by past life experience. Failure to comprehend the figurative meaning of a proverb is caused by the exhaustion or inhibition of this connection. Misunderstanding can also occur As a result of a hypnotic state of the cortex. In this case, the more specific feature—the figurative meaning—elicits an inhibitory effect, whereas the less essential feature—the literal meaning—acts positively. Understanding the figurative meaning of an unfamiliar proverb relies on abstracting from the literal meaning through the reactivation of life-experience connections between broad and narrow generalizing terms. When unable to grasp the figurative meaning, patients select expressions that share a superficial similarity with the proverb. This indicates impaired abstract thinking with a fixation on general, secondary details. When assessing the understanding of metaphors (e.g., "hare's Heart," "heavy person," "wolfish appetite," "barren steppe," "stone heart"), the patient is asked to explain the figurative sense in which these expressions are used. The interpretation of the results is similar to that for proverbs. Thus, disturbances in processes of abstraction and generalization can be explained by an insufficient reserve of temporary connections formed in past life experience (in oligophrenia); a persistent loss of temporary connections (in cortical Cell damage resulting from organic brain diseases); or disorders in the processing of temporary connections against the background of widespread cortical inhibition (in schizophrenia).

7) Assessment of comprehension. a) Understanding the plot of narrative pictures. Picture reproductions are presented so that the examinee can inspect them and sequentially describe what is depicted. The task consists of identifying significant details of the picture and determining its main theme. This evaluates complex forms of analytical-synthetic brain activity involving both signaling systems. In pronounced asthenic states, altered consciousness syndromes, and certain other conditions, There is a diminished capacity for narrative comprehension. In such cases, patients isolate only individual objects and details depicted in the picture, missing the semantic connections and relationships between them. This test provides a basis for assessing the patient's premorbid personality status through their emotional response to the picture's theme and depicted events; b) Narrative based on sequentially developing picture sequences. The patient is asked to examine a series of pictures with a sequential plot and construct a story. Here, as in case "a," the analysis and Synthesis of the complex stimulus complex are primarily carried out by the visual analyzer of the primary signaling system, accompanied by the analytical-synthetic work of the secondary signaling system, which is expressed through specific judgments and Conclusions.

8) Syllogisms. These are inferences in which a third judgment, called the Conclusion, is derived from two categorical premises linked by a common term, with the middle term absent in the conclusion. For example: All liquids are elastic. Water is a liquid. Therefore, water is elastic. From a physiological perspective, the crucial part of the premise is the term that repeats in both premises and serves as the connecting link: in our example, this is the word "liquid." The test includes two premise-assertions and 4 conclusions, of which only one is correct. Example: No planet shines with its own light. Some celestial bodies shine with their own light. Therefore: given the options a) all celestial bodies are planets; b) no celestial body is a planet; c) some celestial bodies are planets; d) some celestial bodies are not planets—the correct conclusion is the last one (d).

III. Assessment of Memory.

1) 10-word recall test: tests mechanical auditory memory. The examinee is read 10 semantically unrelated words 3 times. After each reading, they are asked to repeat all the words in any order, while the examiner records the accuracy of the responses in the protocol. After one hour, the patient is asked to recall the remembered words, which are again recorded in the protocol. Under normal conditions, by the third repetition, the subject reproduces 9 or 10 words. Example word lists: a) Needle, rose, border, cat, grief, memory, book, wine, saw; b) son, tea, mushroom, smoke, moose, oak, Blood, swarm, laughter, steam; c) sea, book, field, autumn, theater, dove, war, science, sun, hero; Russian word lists: a) дом, труд, спорт, хлеб, дождь, звук, боль, жизнь, лес, пакт; b) дом, Вода, лес, окно, мед, брат, стул, гриб, конь, игла.

2) Text memorization. A text containing a specific number of semantic units is read aloud. Short-term immediate memory and retention functions are assessed. During reproduction, both the quantity and the sequence of the recalled associations are taken into account. Healthy individuals easily master the text after 2-3 readings. Pronounced impairments are observed in organic brain lesions of various etiologies.

3) Pictogram test. Used to study mediated memorization as well as thinking functions. The patient is given a blank sheet of paper and asked to make a simple drawing to help remember 12 words read aloud to them, while numerical and letter markings are forbidden. Initially, words with more concrete meanings are usually given; once it is clear that the subject can perform the task, the examiner moves on to more abstract concepts. Examples of words: warm evening, hungry child, brave act, toothless grandfather, happiness, victory, hostility, wealth, dream, intellect, boredom, hope. Russian word list: Веселый праздник, глухая старушка, сердитая учительница, девочке холодно, болезнь, разлука, развитие, ПОБЕГ, надежда, зависть, сожаление, мечта. Protocol format for "Pictogram": * Target expressions * Drawing * Patient's explanation * Recall.

After completing the task, the protocol with the drawings is set aside, other tests are conducted, and an hour later the patient is asked to recall the target words using the drawings. Depending on the symbols used by the examinee to memorize the word, conclusions can be drawn not only regarding mediated memory but also about The Nature of their associations. Healthy individuals typically draw imagined concepts quickly, concisely, adequately, and often stereotypically symbolizing the presented words. Such drawings can usually be "read" even without knowing the target words. Patients with organic intellectual deficits and mild oligophrenia find it easier to create images for concrete words (merry holiday, tasty dinner, etc.) and experience difficulties representing abstract words (doubt, thought, etc.). Their drawings are characterized by concreteness and a lack of "conventionality." In patients with Epilepsy, the content of the drawings has a pronounced egocentric character. Pictograms produced by schizophrenia patients often lose their object meaning, appearing pseudo-abstract (arrows, mathematical symbols, etc.), paradoxical, and repetitive, while the words recalled from them often do not correspond to the original items.

4) Digit span test (forward and backward). Assesses working memory. The patient is read two-digit numbers with progressively increasing lengths, first in the forward order and then backward. Correct reproduction characterizes the capacity of working memory. Under normal conditions, its value is 7±2 elements.

5) Narrative reproduction. Evaluates the capacity for involuntary and voluntary text reproduction, as well as retention. The test material consists of a set of short stories (fables) ranging from 50 to 100 words in varying complexity. The examinee is asked to read a story aloud (without instructions to memorize it) and then reproduce it (involuntary memory). To assess voluntary memory, the patient is asked to read and intentionally memorize the story. The evaluation covers completeness of recall, speech tempo, sentence structure, vocabulary, conciseness or verbosity, and comprehension of the story's meaning. The completeness of recall after 1 hour is particularly informative.

6) Memorization of geometric shapes and simple or complex drawings. Evaluates the ability to form and immediately reproduce multiple lasting connections linked to stimuli of the 1st signaling system (visual complexes—unfamiliar and familiar, relatively simple and more complex). The examinee is asked to carefully examine and memorize geometric shapes on a table for 10 seconds (the other half of the table is covered), and then locate them among the figures displayed on the larger half of the table. Normally, subjects remember at least 5-6 figures. The assessment of fruit or other object recognition is conducted in a similar manner using corresponding tables.

IV. Investigation of Attention

1) Sequential and complex subtraction of numbers, recitation of months and days. The patient is asked to consecutively and mentally subtract an odd number from 100—usually 17 or 7, with 13 or 3 being easier alternatives. When evaluating the results, errors in units indicate combinatorial disorders, while errors in tens point to attentional deficits. The patient may also be asked to count numbers, list the months and days of the week in both forward and reverse orders while skipping every second and fourth number or name.

2) Number cancellation and tracing. Schulte tables are used to examine the pace and span of attention. Typically, five different tables are used, featuring numbers from 1 to 25 scattered randomly across Cells. A stopwatch and a pointer are required. The subject is asked to find and point to the numbers in ascending order from 1 to 25. The examiner monitors the correctness of the actions and records the time using a stopwatch. A normal result ranges from 30 to 50 seconds (averaging 40–42 seconds) per table, whereas, for instance, in pronounced cerebral atherosclerosis, a single table may take up to 2–3 minutes.

3) Bourdon letter cancellation test and Kraepelin work curve. These assess attention stability, concentration capacity, fatigability, and shifting. The test is performed using special sheets with rows of letters or columns of numbers. The subject must either cross out one or two specific letters chosen by the examiner, or rapidly add up numbers in a Column and write the sum at the bottom. Every 30 or 40 seconds, a mark is made on the sheet to indicate where the subject is currently working. The total time spent on the operation is also recorded. The evaluation takes into account the number of errors per unit of time, the execution pace, and the distribution of errors throughout the test. Practice effects on this test are minimal, allowing it to be administered repeatedly and used to assess state changes under METABOLISM/18.html">The Influence of medication.

V. Assessment of Intellect.

When assessing intellect, it should be kept in mind that its level depends on the condition of the underlying functions, which include perceptual accuracy, attention, memory, motor skills, and cognitive activity.

1) Evaluating the correlation between existing knowledge and education, their consistency with life experience and the nature of occupational activity. To this end, a series of questions is proposed that must be tailored to the patient's education and estimated level of intellectual development. Failure to account for this may disrupt subsequent rapport with the patient—especially if an educated patient is asked elementary questions, or conversely, if overly complex questions are posed to someone lacking the appropriate background. The questions should test the patient's orientation and behavior in everyday life situations (e.g., how the patient would act in the event of a fire, getting lost in the forest, making a purchase at a market, etc.). Subsequently, based on the patient's intellectual load, appropriate tasks are administered to test analysis and synthesis capabilities.

2) Picture assembly from segments. The patient is asked to piece together 6 cut-up pictures of increasing complexity. The first three pictures are cut into 4 parts, while the others are divided into a larger number of pieces. The first and fourth pictures are identical, but cut differently. For re-testing, several analogous sets are required. The picture segments are presented to the subject unordered and face-down, without a complete reference sample. The evaluation considers not only the time spent and the final outcome, but crucially, the specific mechanics of task execution. Successful completion initially requires an Analysis of the provided material, followed by a sequential, methodical assembly of the image. The ability to identify key structural details plays a vital role here. In intellectual deficit, such analysis is absent; patients attempt to assemble the picture by haphazardly pushing segments together via trial and error, indicating a lack of a coherent plan. Critical thinking may also be impaired, as the subject leaves incorrectly placed segments uncorrected.

3) Comprehension of stories. The results reflect the patient's narrative comprehension and memory status. Special stories are selected, most often of a didactic nature, akin to parables. When the patient retells a story, attention is paid to the style of delivery (vocabulary, speech rate, sentence structure, conciseness versus excessive detail). Of substantial significance is whether the subject grasps the hidden meaning, relates it to real life, or appreciates the humor of the theme. In cases of intellectual impairment, understanding of hidden and figurative meanings is often lacking, despite a text-accurate retelling. Certain narratives help reveal verbosity (rezonerstvo) and other pathological judgment patterns. To this end, texts of varying difficulty should be prepared in advance.

4) Ebbinghaus completion test (fill-in-the-blanks). The subject reads a text with missing words and must fill them in based on the context, typically after skimming the subsequent phrases. This test can reveal impaired critical thinking when the subject inserts arbitrary words—sometimes driven by prior associations—and fails to correct glaring errors even after the examiner points them out.

5) Concept exclusion test (examining the level of generalization, abstraction, and the ability to isolate significant attributes of objects and phenomena).

6) Comprehension of the figurative meaning of proverbs and metaphors.

7) Pictures and texts containing absurdities. The understanding of humor provides a very subtle reflection of the capacity for abstraction and critical evaluation of reality. The analytical and synthetic activity of signaling systems is investigated, characterized by a highly refined analysis of complex stimuli (distinguishing all details in pictures with "odd" elements) and the presence of all temporal connections that reflect regular relations between objects and phenomena. On The basis of these connections, a new temporal judgment regarding correspondence or discrepancy with reality emerges.

8) Raven's Progressive Matrices. Based on the ability to fill in missing details in visual patterns. The test consists of 60 graphic designs divided into 5 sets of increasing difficulty; problems are solved both within a set and from set to set. It investigates the analytical and synthetic activity of the brain and the concentration degree of the excitatory process within the visual analyzer, with orienting oculomotor reactions playing a major role in comparison and Selection. In this context, the second signaling system is crucial, operating first to comprehend the assigned task and subsequently to execute the logical operations required to determine the underlying principle of the next problem.

9) Solving mathematical problems using multiplication tables, and questioning on school subjects based on abstract categories of thinking (mathematics, geometry, physics, chemistry). For example: 10 pencils cost 70 kopecks. How much do 3 pencils cost? What is the chemical formula of water? Of sulfuric acid? How do you measure floor area? Which is greater—the radius or the diameter?, etc.

VI. Investigation of Emotions.

1) Dembo-Rubinstein self-esteem technique. On a vertical line representing a certain human quality (health, intelligence, character, happiness, etc.), the subject is asked to mark their position with a point and provide a verbal explanation. This captures the level of self-esteem, the rationale, and the specific emotional reactions.

2) Luscher color choice test. This requires a set of 8 colored cards, which the subject must twice arrange in descending order from the most appealing color to the least appealing. By choosing or rejecting certain colors, the patient projects their subconscious moods, drives, and issues onto them, which can then be subjected to subsequent interpretation.

3) Verbal association experiment using emotionally charged stimulus words. In a simplified version, a series of words carrying special emotional significance for the patient is singled out. The patient is asked to utter the first words that come to mind in response to the stimuli. The examiner then inquires into the meaning of the association words, conducting psychotherapeutic correction of shifts if they fall within the neurotic register.

4) There are several indirect METHODS FOR STUDYING emotional activity: the association experiment, the Rosenzweig picture-frustration test, the Rorschach test, the Spielberger anxiety questionnaire, and the SAN scale (a questionnaire assessing well-being, activity, and mood).

VII. Investigation of the Motor-Volitional Sphere.

In clinical practice, when examining the motor component of the effector-volitional sphere, attention is paid to facial expression, posture, bed posture, nature of movements (stiff, slow, sweeping, rapid), voice intonation, and response latency to questions. The ability to perform object-directed actions (lighting a match, demonstrating how to use a key, opening and closing a briefcase, hammering a nail) is evaluated. When establishing a psychopathological Diagnosis, the clinician seeks to determine whether the patient can perform objectless actions (jumping, whistling) and autokinetic movements (clenching a fist, sticking out the Tongue), or repeat demonstrated movements. Tasks from pathopsychological test batteries focusing on combinatorial skills, habits, and constructive actions are utilized. These include: a) forming meaningful words from letters; b) filling in missing letters in words; c) assembling pictures from segments; d) arranging square picture tiles into ornaments according to a model; e) Raven's Progressive Matrices; f) writing a phrase or copying a text, etc. The speed and accuracy of task completion are evaluated, along with how success depends on task complexity. Among rating scales, the Dembo-Rubinstein self-esteem test is employed. These probes provide insight not only into the integrity of practical skills but also into the patient's intellectual status. Movement discoordination may be observed in vascular lesions, while parapraxias and The breakdown of skills occur in degenerative brain diseases, etc.

Account is taken of the patient's willingness to cooperate with medical staff to accelerate recovery, readiness to follow instructions and prescriptions, activity level within the ward, degree of involvement in work therapy, appropriateness of responses during conversation, behavior, sociocultural interests, hobbies, aspirations, plans, and goal-achievement strategies. The Nature of the subject's needs, goals, and motivational drivers is determined, along with the ability to sustain focus during goal pursuit, autonomic reactions to emotionally significant stimuli and remarks, and responses to disagreement on subjectively important matters.

Certain volitional disorders, such as Sexual Perversions, are not easily understood, identified, or studied, which also complicates corresponding expert diagnostic evaluations.

VIII. Investigation of Personality, Temperament, and Character.

1) Existing personality questionnaires based on the evaluation and self-assessment of specific traits in the subject (such as MMPI, Cattell's and Eysenck's questionnaires, PDO, etc.) are standardized inventories containing anywhere from 54 to 565 statements with which the subject can either agree or disagree. All questions are formulated so that, by answering them, the subject informs the examiner about their well-being, typical behavioral patterns under various circumstances, and evaluates their own personality from different Perspectives, highlighting the specifics of their interpersonal relationships, and so on. Due to time constraints that usually prevent a patient from completing a questionnaire assessment, it is more practical when compiling a medical history to focus on the outcomes of direct diagnostic interviews and behavioral observations to outline character traits.

2) Projective methods. Whether consciously or unconsciously, the subject executing these tests projects their thoughts, feelings, and dominant needs onto external objects (the Rorschach test, sentence completion test, TAT, psychodynamic play/psychodrama, human figure, house, and non-existent animal drawing tests, Lücher color test, Rosenzweig picture-frustration study, etc.).