MAJOR A.N. MUKHERJI, M.Sc., M.B. (CAL., UNIV.).
Method of examination of Psychiatric cases differ considerably form that of Physical cases. As accurate systematic form of examination is essential. In examining a psychiatric patient, a great deal depends upon the method of approach. The following form of examinations is at present thought to be the best.
1. Family History.
2. Personal History
3. History of the present illness.
4. Examination of the patient-
(a) examination of his physical condition
(b) examination of his Mental condition.
This is very important as regards prognosis and treatment, but it is very difficult to get a reliable statement of the family history. The relatives are usually sensitive about their position and have a great tendency to conceal anything that may affect the reputation of the family. They usually put very little importance to the family history, even history of grave insanity in direct relatives are described in a very light and insignificant way. Sometimes maternal sides blames the paternal side and vice versa.
It is better to obtain personal history from several different sources e.g. Father, mother, brother, sister or from other intimate relatives and friends. The personal history should include history from the time of conception up to the present illness. Then the social circumstances of the parents and the history of childhood of the patient; whether he learned to walk or speak or cut teeth at the normal time, whether he suffered from any childhood ailments or prolonged bed-wetting, etc.
Later inquires should be made about his school career and intellectual attainments, his hobbies and interests and also about his addiction to alcohol, Cannabis Indica (Gunja) or other intoxicants. Finally inquiries should be made about his sex life. In this connection he should be asked about his love affairs, masturbation or any tendency towards perversion. Any previous attack of mental illness should also be carefully enquired.
HISTORY OF PRESENT ILLNESS.
It is of great value to find out how the disease started, whether the onset is insidious and gradual or sudden, whether there is any precipitating cause responsible for his breakdown. Sometimes the relatives feel that one factor is more important than another, whereas the fact which has been thought to be of least importance has later on been found to be the chief aetiological factor.
EXAMINATIONS OF THE PATIENT.
Physical- A thorough physical examination should be made in all mental cases. This will not be described in this article.
Mental- Mental examination is usually performed as follows:-
1. General behaviour
2. The stream of Mental activity.
3. Emotional Reaction (Affect).
4. Mental Trend (Content of Thought).
9. School and General knowledge
10. General Intelligence
11. Insight and Judgement.
It is usually the first indication to the relatives of the patient. Any deviation from the normal behaviour causes suspicion, the facial expression, the dress and the peculiar attitude often tell at a glance that the underlying state of mind is far from normal. Then the following to be noted whether there is elation or depression, talkativeness or apathy and listlessness, whether there is anxiety and agitation or stereotypes in action or speech, whether he declines to take normal bath or food.
THE STREAM OF MENTAL ACTIVITY.
This can be easily determined from the patients response and reaction to a number of simple questions, e.g. “Who are you?” “What is your name?” “How old are you?” “What is your occupation?” “Why have you came here?” “What ails you?” etc. The response to such questions to be noted, whether it is over talkativeness or mutism. Whether the answer tends to go into much detail with flight of ideas and distractibility. Sometimes the patient takes considerable time or requires coaxing to reply (retardation) or at other times answers very promptly but the answer may not be relevant or coherent.
EMOTIONAL REACTION (Affect).
From the facial expression we can guess about the emotional state of the patient, but it can be better ascertained from the patients own statements about his feelings especially after some specific questions e.g. “How do you feel?” and then according to the reply this can be followed up by “Are you happy?” and then “Why?” or “Are you sad or melancholy or out of sorts or worried?” and again “Why?” After this the patient should be asked to tell his story from the beginning, and he should be kept to the topic without any interruption from the physician.
The points to be noted are the intensity of emotion, whether it varies with the different parts of his story or whether it is in harmony with the ideas expressed. When the patient does not respond to any question his affective state may be determined by his physical conditions like pallor, flushings, perspiration, and pulse rate.
MENTAL TREND CONTENT OF THOUGHT
A psychiatric patient when describes his story usually expresses out the contents of his thought. He should not be interrupted, rather be encouraged to express out his ideas. In order to continue his story, it is better to ask questions like “Have attempts been made to poison or injure you?” “Do you believe that your movements are watched by the Police or anybody else?” “Have you got any proof to suspect your wife?”
Physician should determine whether his experiences appear to be real or imaginative due to lack of insight. Some times some patients get “compulsive” thought or ideas to do some particular action inquiry should be made whether these thoughts come with insistent force and dominate the patients mind completely.
For time, place and person are usually tested by the following questions “What day is it?” “What time of day is it?” “What month is it?” “What year is it?” “Do you know the date?” “What place is this?” “Where have you been born?” “Can you tell me how you will go to your native place?” “Who am I?” “What is my occupation?” “Why have you been brought to me?”.
This is tested for (i) Recent events (ii) Remote events and (iii) for his power of retention.
Recent Events- This can be tested by some questions as “When did you come here?” “With whom?” “Where from?” “What have you taken this morning?” etc.
Remote events- This is usually tested by asking the patient to tell some important events of his childhood or to give a chronological account of his life, e.g. “When he joined the school?” “When he left the school?” “When married?” “Names and ages of his children?” etc. These answers should be verified with those of the patients relatives.
Retention- When something is sensed the image persists for sometime after removal of the impressing object this is called Retention. Retention is tested by asking the patient to remember something presented to him and to reproduce after sometime. He may be asked to remember some objects such as house, carriage, river or some digits or letters etc.
“The process through which any content is brought to clear comprehension we call apperception” This is tested as follows The patient is given a short story or paragraph to read, then is asked to give the gist of what he has read.
SCHOOL AND GENERAL KNOWLEDGE.
Patients educational qualification and level and his general knowledge should be tested. This can be done by simple questions in arithmetic, in history and in geography.
This is usually estimated by the general character of the responses. Whether the patient can under stand or answer general questions correctly. In some cases Intelligence quotients are found out by the special methods of Intelligence Tests.
INSIGHT AND JUDGEMENT.
Here the questions are put to see whether he realises about his own condition? Whether he realises that he is ill and needs treatment? Does he understand that his ideas are due to diseased mental state? Can he be made to believe that his ideas and suspects have no material basis? His judgement as regards family and society responsibility should also to be tested.