11: The Patient's Mental Status and Higher Cerebral Functions

INTRODUCTION

I. THE MENTAL STATUS EXAMINATION: A NONPROGRAMMED INTERLUDE

A How to derive the mental status information

1. Most of the data for judging the patient's (Pt's) mental status emerge as a natural consequence of the questions posed during the standard medical history, which this text does not cover. Although you do the basic Neurologic Examination (NE) by a set routine, you should probe the Pt's mental status unobtrusively and flexibly. If you blurt out questions obviously designed to test the mental status, such as, "Do you hear voices?" the Pt may respond with annoyance, sullen silence, or outright anger. Nevertheless, just such a question, introduced at the proper time, encourages the disclosure of distressing thoughts. The Pt then may describe the voice that repeats, "You have a duty to kill your family." Because your personal characteristics and interview techniques condition what the Pt can and will disclose, you must remain flexible, empathetic, and nonjudgmental. This is the first point: the interview technique is everything.

2. By monitoring the Pt's responses, you determine which questions to use and how far to pursue any particular line of inquiry. As long as the Pt talks productively, continue the line of inquiry. If the Pt changes the subject or becomes evasive, flustered, or silent, you have pressed too hard. The Pt isn't ready to talk about that. Try another tack. A mentally ill Pt may permit a full NE but completely resist inquiries obviously designed to disclose thoughts. Patients will talk about whatever problems and anxieties occupy their thoughts, if they can tolerate the thought and its communication. This is the second point: Pts will disclose their mental state, particularly their worries and concerns, if you provide a free opportunity. Nathaniel Hawthorne (1804–1864) marvelously described the correct interview technique in The Scarlet Letter:

   So [Dr.] Roger Chillingworth—the man of skill, the kind and friendly physician—strove to go deep into his patient's bosom, delving among his principles, prying into his recollections, and probing everything with a cautious touch, like a treasure-seeker in a dark cavern. Few secrets can escape an investigator, who has opportunity and license to undertake such a quest, and skill to follow it up. A man burdened with a secret should especially avoid the intimacy of his physician. If the latter possess native sagacity, and a nameless something more—let us call it intuition; if he show no intrusive egotism, nor disagreeably prominent characteristics of his own; if he have the power, which must be born with him, to bring his mind into such affinity with his patients' that this last shall unawares have spoken what he imagines himself only to ...