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Case History And Mental Status Examination ( MSE MSE ) Scheme for case taking Case taking in psychiatry is both a science and an art .to systematically systematically work up a case and obtain the most relevant information ,to arrive at a diagnosis and workout a management plan is an art which should be mastered over time .as in traditional medicine to a greater extent ,utmost ,utmost importance should by given to elicitation of history .this should should be supplemented by a systematically systematically carried out mental status examination and physical examination .the following is the scheme for case case tasking tasking . 1. History. 2. Ment Mental al stat status us exam examin inat atio ion n MSE MSE 3. Physical examination examination (S R will do ) 4. Summ Summar ary y ( part part of hist histor ory y) 5. Initial Initial formulat formulation ion (should (should be crisp crisp for initial initial diagnosis diagnosis 6. Invest Investiga igatio tions ns ,treat ,treatmen mentt and follow follow up 7. Fina inal form formul ulaation tion These components of case taking are described in the following pages .the material presented here is intended to enable students to follow a uniform method of case tasking it has not been possible to deal with all the areas exhaustively . Students are instructed to read texts cited in the end to become more proficient in case taking.
History taking NAME: AGE: SEX: ( TO NOT USE USE THE THE RE REAL AL NAME NAME FOR WRITING TO PROTE PROTECT CT TH THE E IDENT IDENTITY ITY OF TH THE E CLIEN CLIENT T DO NOT WRITING REPORTS BUT INITIALS ONLY ) EDUCATION:
OCCUPATION:
SOCIO ECONOMIC STATUS (SES): INFORMANT: INFORMANT : Mention here the source of information, relationship of the informant to the patient, intimacy and length of acquaintance with the patient and reliability of the information. It is often necessary to obtain information from more than one source. In certain types of illness like psychosis, relatives will be able to provide more reliable information, while in neurotic illness the patient would be the best informant .when information is collected from more than one source, do not collate the accounts of several informants into one, but record them separately. COMPLAINTS AND THEIR DURATION: Record the complaints verbatim in a chronological order. Do not write a long list of complaints, but present the salient disturbances in the different areas of functioning .while some patients / relatives may present an elaborate list of their complaints; others might not spontaneously report their difficulties unless more direct questions are posed. Hence use your skills and discretion in eliciting the complaints .about 5-6 \complaints should be taken verbatim. HISTORY OF PRESENT ILLNESS (HOPI): Give a detailed and coherent account of the symptoms from the onset to the time of consultation including their chronological chronological evolutions and course specify time and duration. . symptoms is acute (i.e. Developing within within few hours) sub acute (few days days to a)ONSET: )ONSET: Note if the onset of the symptoms few weeks) or gradual /insidious (few weeks to few months). b)PRECIPETATING b)PRECIPETATING FACTORS: Enquire about any precipitating events. These could be physical (e.g. a febrile illness) or psychological in nature (e.g. death/loss) .ascertain weather the e vents clearly preceded the illness or were consequences of the illness (e.g. job loss following the onset of a schizophrenic illness).
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2 COURSE OF THE ILLNESS: The course of an illness can be episodic (discrete symptomatic periods with intervening periods of normalcy) continuous or fluctuating (periodic exacerbations of a continuous illness).also a different pattern of symptoms may evolving a continuous illness. for example delusions, hallucinations and intense affects maybe prominent in the initial phases of a schizophrenic illness, while in the later stages apathy and emotional blunting might be prominent . Graphic presentation of the course of illness can often be very informative, as shown below.
Base line 2/12 ↓ (2 months in a year) ↓
2/12
Got married
2/12
2/12
Age 25 yrs Untreated
Age 27 yrs no definite precipitating factor treated with anti depressants
2/12 present episode Age 30 yrs
Touching baseline means the patient returned to normalcy. Exacerbations mean worsening of symptoms. c)ASSOCIATED DISTURBANCES: Enquiry should also be made of impairment in other areas of functioning. These include disturbances in sleep, appetite, weight, sexual life social life, and occupation the specific nature of the disturbances and the degree of disability should be recorded. Evidence of secondary gains qualify and are to be included in HOPI. NEGATIVE HISTORY: Lastly, certain historical details must be routinely enquired into, to rule out an organic etiology. These include: history of trauma, fever, headache, vomiting, confusion, disorientation, memory disturbance. History of present illness like hypertension / diabetes and history of substance abuse. While these details are important regardless of the nature of presentation, they are particularly important in the elderly. PAST HISTORY: Enquire about both past physical illnesses, and past psychiatric illnesses. Try to ascertain the nature and duration of symptoms, the nature of treatment received, and the pattern of response. In certain instances, it maybe more meaningful to describe the previous episodes in the history of present illness rather than in the past history (for example frequent episodes of manic –depressive illness AIDS? precipitating factor for past illness). FAMILY HISTORY: Give a description of the individual, family members(parents and siblings) .the description should include information as to whether they are living or dead , age (or age of death) , educati0on ,occupation , marital status , personality and relationship with the patient . Enquire about the physical and / or psychiatric illness in the family and record it in detail. Describe the socioeconomic condition of the family, leadership pattern, role functions and commnica6tions within the family (system support + expressed emotions i.e. hostility over involvement, aggression over intrusion). The information from the verbal account is represented diagrammatically on the genogram: ** find out information about the family up to 3 generations i.e. great grandparents and children if any
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Divorced/separated Affected male, female
Abortion
Unaffected Consanguinous union
Index patient Dead
PERSONAL HISTORY: BIRTH AND EARLY DEVELOPMENT: Record the details of prenatal, natal and post natal period’s .was the birth full term? Whether delivered in hospital or at home? Ask about any complications during delivery? Ask about any physical illness in the post natal period? Ascertain whether m ilestones were normal or delayed (check with informants amnesia? asphyxia). BEHVIOUR DURING CHILDHOOD: Enquire about sleep disturbances, thumb sucking, and nail biting, temper tantrum, bedwetting, stammering, tics, and mannerisms. Look for conduct disturbances in the form of frequent fights truancy, stealing, lying, and gang activities. Also enquire about relationship with parents, siblings and peers. PHYSICAL ILLNESS IN CHILDHOOD: Record physical illnesses suffered in childhood enquire specifically regarding epilepsy, meningitis and encephalitis. SCHOOL: Enquire about age of beginning and finishing school, type of school attended, scholastic performance, attitudes towards peers and teachers. OCCUPATION: Age of starting work; jobs held, in chronological order; work satisfaction, competence, future ambitions. MENSTRUAL HISTORY: Enquire about age of menarche > reaction to menarche; regularity of periods; dysmenorrhoea; menorrhagia /oligomenorrhoea; emotional disturbances in relation to menstrual cycle. SEXUAL HISTORY: Enquire about age at onset of puberty; level of knowledge regarding sex and mode of gaining the same, masturbatory practices; anxiety related to sexual fantasies/ practices. Homosexual and heterosexual fantasies, inclinations and experiences, extra- marital relationships. MARITAL HISTORY: Enquire regarding age at time of marriage ,whether arranged by elders or by self; was there mutual consent of the partners; age; education ;occupation, health and personality of the partner ; quality of marital relationships ,any separation or divorce .note the number of children ,their ages ,and health status . USE AND ABUSE OF ALCOHOL, TOBACCO AND DRUGS: Enquire about smoking and drinking pattern and abuse of other drugs like cannabis, opiates, barbiturates etc. PREMORBID PERSONALITY: Personality of a patient consists of those habitual attitudes and patterns of behavior which characterize an individual. Personality sometimes changes after the onset of an illness .get a description of the personality before the onset of an illness. Aim to build up a picture of the individual, not a type. Enquire with respect to the following areas.
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1)ATTITUDE TO OTHERS IN SOCIAL, FAMILY AND SEXUAL RELATIONSHIPS : Ability to trust others ;make and sustain relationships ,anxious or secure leader or follower ,participation ,responsibility ,capacity to make decisions ,dominant or submissive , friendly or emotionally cold, evidence of, any jealousy, suspiciousness guardedness etc. evidence of difficulty in role taking –gender ,sexual., familial ,parental and work. 2) ATTITUDE TO SELF: Egocentric, selfish, indulgent, dramatic , critical, deprecatory, over concerned, self conscious, satisfaction or dissatisfaction with work. Attitudes towards health and bodily functions. Attitudes to past achievements and failures and to the future. (Work related questions like satisfaction with work character attitude towards work response to challenges). 3) MORAL AND RELIGIOUS ATTITUDES AND STANDARDS: Enquire about evidence of rigidity or compliance, permissiveness or over conscientiousness, conformity or rebellion. Enquire specifically about religious beliefs. (Guilt induced by religion). 4) MOOD: Enquire about stability of d mood; mood swings, whether anxious irritable, worrying or tense .whether lively or gloomy. Ability to express and control feelings of anger, anxiety, depression (mainly stability band variants). 5) LEISURE ACTIVITES AND INTERESTS: Interests in reading, play, music, movies etc. Enquire about creative ability .Whether leisure time is spent alone or with friends .is the circle of friends large or small. 6)FANTASY LIFE: Enquire about content of day dreams and dreams .amount of time spent in day dreaming. 7)REACTION PATTERN TO STRESS: Ability to tolerate frustrations, losses, disappointments and circumstances arousing anger, anxiety or depression. Evidence for the excessive use of particular defense mechanisms such as denial, rationalization, projection etc. 8) HABITS: Eating, sleeping and excretory functions (sleep habits, regularity of functions).
Mental Status Examination ( MSE) A systematically conducted Mental Status Examination is an important component of case taking .it is essential to record the observations properly whenever positive findings are obtained, they should be described in detail .it is not adequate t o say ‘delusions present’ or ‘hallucinations ++’.MSE has to be repeated several times during the course of the illness to know the evolution of symptoms, effectiveness of treatment etc. The time frame covered by the MSE is not restricted to the hour of observation, but extends longer. While the following account highlights the major components of MSE, details should be obtained from other sources cited. GENERAL BEHAVIOUR: A description as complete, accurate, life like as possible, of the observations of ward staff and your own. The following points maybe considered, though not exclusively. Enquire about the way of spending the day, Eating; sleeping and cleanliness general, self care hair and dress. Behavior towards to other patient’s doctors and nursing staff .does the patient look ill? Note whether the patient is fully conscious, stuporose, or comatose .Is he in touch with surroundings? Is the patient relaxed or tense and restless? Is he slow or hesitant? How does he respond to various requirements and situations? Are there abnormal responses to external events .can his attention be held or diverted? Is the patient cooperative? Can adequate rapport be established? Does the patient maintain adequate eye contact? Does the patient’s behavior suggest that he id disoriented? Note the presence of any tics or mannerisms. Note the presence of any catatonic phenomena. PSYCHOMOTOR ACTIVITY: Note if the psychomotor activity is increased, decreased or normal both qualitative and quantitative aspects .
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5 Mannerism Tics Gestures Twitches
Echopraxia Hyperactivity Agitation Combativeness
Rigidity Gait Agility
Attitude towards the examiner (level of rapport established) Cooperative Interested Defensive Friendly Frank Contemptuous Attentive Seductive Perplexed Apathetic Evasive
Pacing Aimless/ purposeless activity
Hostile Playful Ingratiating
TALK: Note here the form of utterances rather than the content .does the patient speak spontaneously or only in response to questions .is the amount of speech little or excessive .is it high toned or low toned ?is the tempo fast or slow . Is the reaction time increased or decreased? Is the prosody of speech maintained? Is it relevant? Is it coherent? THOUGHT: Examine thought process with respect to STREAM: Flight of ideas, retardation of thinking, circumstantiality, perseveration, thought blocking. FORM: Presence of formal thought disorder. POSSESSION: Obsessions and compulsions, thought alienation .with respect to obsessions, elicit their nature – ideas, doubts, imagery, impulses and phobias .similarly clarify the nature of compulsive acts –checking, counting or washing .are these ‘controlling’ compulsions or ‘yielding’ compulsions. CONTENT: Look for the presence of overvalued ideas and delusions .before making an inference, a detailed description of the phenomenon must be given. now whether the delusion is single or these are multiple delusions, the type of delusion (grandiose ,persecutory ,nilhistic etc),the exact content of the delusions ,whether they are fleeting or fixed ,whether they are mood congruent or not .enquire about worries and peroccupatio0ons ,hypochondriacal, and somatic symptoms .depressive ideation , ideas of worthlessness, guilt ,hopelessness sand suicidal ideas must be enquired and recorded . MOOD: This should be assessed by both subjective report and objective evaluation .assessment should be both longitudinal (mood) and cross sectional (affect). Description should be given regarding the following components :the quality of emotion (happiness, sadness, anxiety etc),the intensity or depth of emotional experience ,the range of affective responses ,mobility ,reactivity (changes in emotion in relation to environmental factors ), diurnal variation, congruity (in relation to thought processes )and appropriateness (in relation to situations) .note any evidence of lability (rapid and extreme changes in emotion). PERCEPTION: Record the presence of illusions and hallucinations. Enquiry should be made into the following modalities; vision, hearing, smell, touch, taste pain and deep sensations, vestibular sensations and sense of presence. Record also the presence of special varieties of hallucinations like functional hallucinations, reflex hallucinations, extra campine hallucinations, synesthesia and autoscopy. Detailed descriptions of the actual experience should be obtained .for example with regard to auditory hallucinations Enquire whether the hallucinations are verbal or non verbal; continuous or intermittent; single voice or multiple voices; familiar voice/ unfamiliar; first person, second person or third person. Pleasant or unpleasant .if unpleasant whether commanding, abusive or threatening; relationship of hallucinations to time of the day, and daily activities; reaction to the hallucinations; whether mood congruent. Distinguish hallucinations from imagery and pseudo- hallucinations. Other perceptual disturbances that must be enquired into include heightened perception, dulled perception depersonalization/ derealization experiences, and disturbances in the perception of time. CONITIVE FUNCTIONS:
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C O C R V A I
= = = = = = =
Consciousness Orientation and memory Concentration and attention Reading and writing Visio spatial ability Abstractibility Information and intelligence
ATTENTION CONCENTRATION: Test for the ability to arouse and sustain attention .is there any distractibility? Concentration can be tested by asking the subjects to tell the days or months in reverse order or subtraction of serial sevens from 100(note answers and time taken). It could also be tested by giving the patient four to seven digits to repeat forward and backward. ORIENTATION: Record the patient’s answers to questions about his own name identity, the place where he is, the time of the day and the date. MEMORY: Test immediate, recent, remote memory .the digit repetition test is a test of immediate memory .to test recent memory, enquire about what patient had for breakfast the events of the day; and what he ate the previous night .patient’s recall the same after sometime .test remote memory by asking various personal and impersonal events .always attempt to verify from three informant. GENERAL INFORMATION: The tests should be varied according to the educational level and background of the patient .some common questions include −Name of the prime minister Major cities of India Name of the state capitals, chief minister Name of a few countries. INTELLIGENCE: Patients intelligence should be gauged from his educational level, occupational record, his general knowledge and supplemented by clinical tests appropriate to the background of the subject .more standardized tests maybe used if felt necessary. ABSTRACTIBILITY: Patient can be asked to explain the meaning of certain proverbs similarly patient can be asked to mention the similarities between certain objects e.g. a table and as chair. JUDGEMENT: Assess PERSONAL JUDGEMENT: What is the patient’s attitude to the present state; does he regard it as an a) illness? Does he think treatment is necessary?
b)
SOCIAL JUDGEMENT: Does the patient show appropriate behaviors in social situations? Is there any disinhibition?
c)
TEST JUDGEMENT: What would the patient do if a stamped, sealed and addressed envelope is found in the street? What would he do if the theater in which he is watching a movie caught fire? INSIGHT: Test the patient’s level of awareness of his illness. Does he think he is not ill at all (absence of insight)? Does he recognize the presence of illness but gives explanation in physical terms (partial insight) does he fully realize the emotional nature of his illness and the cause of his symptoms (insight present)? SUMMARY: The purpose of a summary is to provide concise description of all the important aspects of the case to enable others who are unfamiliar with the patient to grasp the essential features of the problem .the summary should be presented in the same format as described in the previous pages.
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INITIAL FORMULATION: This is the student’s own assessment of the case rather than a restatement of the facts. Its length, layout and emphasis will vary considerably from one patient to another .it should always include a discussion of the diagnosis, of the etiological factors which seem important, a plan of management and an estimate of the prognosis. Regardless of the uncertainty or complexity of the case, a provisional diagnosis should always be specified using the ICD. INVESTIGATIONS TREATMENT AND FOLLOW UP :Biochemical ,radiological or psychometric investigations should be carried out wherever appropriate .all aspect of management viz physical ,psychological and social intervention should be included in the treatment package though the r elative emphasis may differ from case to case .progress notes should be systematically recorded .(multi axial diagnosis ). FINAL FORMULATION: This is a revision of the initial formulation drawn up at the time of discharge .it should specify any divergences of opinion and should state the views of the consultant clearly .it should be written in the light of the patient’s response to treatment and other information becoming available since the time of admission .its length and layout will vary considerably but it should always include a final diagnosis, with amplifying comments and an estimate of the prognosis. REFERENCES
Hamilton. M (Ed) Fish’s Clinical Psychopathology: Signs and symptoms in Psychiatry John Wright and Sons Ltd Briston 1974. Hamilton, M (Ed) Outline Of Psychiatry John Wright and Sons Ltd Briston 1973. Jaspers,K General Psychopathology ( Translations by J. Hoenig and W. M. Hamilton )Manchester University Press ,1963. Strub, R.L. &Black,FW(Eds)the Mental Status Examination in Neurology F.A.Davis Company Philadelphia 1977. Kaplan and Saddock Mental Status Examination (MSE) Clinical Assessment of Cognitive Functions: Clinical assessment includes the areas of 1. ORIENTATION 2. ATTENTION CONCENTRATION 3. MEMORY 4. INTELLIGENCE 5. JUDGMENT 1) ORIENTATION:
Three aspects are described to time, Place and person, the following questions may be asked in the relevant areas: I) TIME: 1. Approximately what time of the day is it? (If the patient is unable to reply a more specific question maybe asked) 2. Is it morning, afternoon, evening or night? (In addition further questioning may be done to assess estimation of time) OR 3.What is the day today? (Day of week)
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8 4.What is the date (day of the month, month year) today? II) PLACE: 1. what place is this ?(if the answer is not forthcoming, a specific question is asked ) 2. is it a school ,office ,hospital ,restaurant etc(if the patient says hospital details maybe asked depending on background III) PERSON: 1. Orientation to self is tested by asking the of the patient 2. Enquiring about the identity of the patient’s relatives or family members 2) ATTENTION CONCENTRATION: Tests used in clinical situation include: I) Digit span test ii) Serial subtractions: iii) Days or months forward or backward. I) DIGIT SPAN TEST: a) FORWARD: The patient is given the following instructions “I will be saying some digits, listen to me carefully. When I finish saying them, you will have to recite them in the same order. The examiner after instructing the patient • Give an example (for e.g.- if I say 3-,7 you say 3,7 ) Give an example of 2 digits • Read each digit at the rate of one per second • • Note whether the immediate response of the patient is correct or incorrect • The following digits maybe used 5-7-3 4-1-7 5-3-8-7 6-1-5-8 1-6-4-9-5 2-9-7-6-3 3-4-1-7-9-6 6-1-5-8-3-9 7-2-5-9-4-8-3 4-7-1-5-3-8-6 4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4
• If the patient fails 3 digits give him 2 digits educational occupational level to be considered • The digit span is the highest number of digits repeated correctly • The same digits should not be repeated more than once If the patient cannot repeat a particular number of digits on one trial , a second trial with the same • number of digits and credit is given if the response is correct • Clinical judgment is required, write inferences when required b) Backward: “I will be saying some digits. Listen to me carefully. And repeat them after me in a reversed order, for example if I say 2-5 you have to say 5-2. • The procedure is the same as for digit forward. The same digits should not be used as for the forward test • • No digit should be repeated in a series presented • Change the phrasing if required
(Foot Notes: Attention can be aroused and maintained: main aim Attention cannot be aroused and maintained could not be tested adequately \grossly adequate \impaired .Familiarity with the task is important 1st Forward then Backward) II) SERIAL SUBTRACTIONS:
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9 Make sure the patient is comfortable while doing the task Increasingly difficult tasks are presented The examiner a. Instructs the patient. b. Gives an example of how to perform the task c. Notes the response verbatim and d. Notes the time taken in seconds Task Correct reposes and time limit 20 -1 20- 0 reversed in 15 secs 40 -3 40, 37, 34, 31, etc in 60 secs 100 -7 100, 93, 86, 79 etc in 120 secs • • • •
Time not to be used stringently Consider situational factors No feedback 3 errors generally
III) Days or months maybe asked for in forward or backward in a patient who is familiar with the correct order. (Inference based on clinical judgment why a patient may do differently on the 3 attention tasks) 3) MEMORY: Assessment includes IMMEDIATE, RECENT & REMOTE MEMORY I) IMMEDIATE MEMORY: Tested by digit span/ sentence completion (PGIMS) ii) RECENT MEMORY: Tested by Address test: in address consisting of about 4-5 facts, which is not known to the patient is slowly read to a. the patient after instructing him to attend to the examiner. He is engaged in conversation (to avoid rehearsal) and the response is noted verbatim. Recall is asked for after 3-5 minutes (this is a new test depends on the background of the patient. make sure there is registration .correct immediately. instruct about delayed recall.)
Asking the patient to recall events in the last 24 hours e.g. details of the time and amount in a meal or b. visitors to the hospital from an inpatient. Responses given should be noted down and cross checked from a reliable source. iii) REMOTE MEMORY: information on life events e.g. i. Date of birth or age ii. Number of children iii. Names and number of family members iv. Time since marriage or death of any family member v. Year of completing education 4 -5 facts maybe asked for relevant to the patient’s background and answers should be cross checked 4) INTELLIGENCE: This includes the areas of general information, comprehension, arithmetic and vocabulary GENERAL INFORMATION: information relevant to the patients literacy age or occupation I) maybe asked e.g. for literates: a) Name of prime minister. 5rivers, cities or states. b) Capitals of countries. c) d) Current events (major)
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a) b) c) d)
For illiterates: Seasons Crops or fruits grown in particular seasons Prices of food grains or food items Prices of land
ii) COMPREHENSION: the ability to understand questions asked during an interview is one index. Specifically the following questions of increasing difficulty maybe asked (sometimes answers can be peculiar. Focus on the patients understanding of the question) 1) What will you do when you feel cold? 2) What will you do if it rains when you start for work? 3) What will you do when you miss the bus when you are on a journey? 4) What will you do when you find on your way it will be late by the time you reach your work place? 5) Why do we need to stay away from bad company? iii) ARITHMETIC: The following maybe asked with increasing time units. 1) How much is 4 rupees and 5 rupees? (Total) 2) I borrowed 6 rupees from a friend and returned 2 rupees. How much do I still owe him? 3) If a man buys cloth for 11 rupees and gives a shopkeeper 20 rupees, how much change would he get back? 4) How many pencils can you buy for 2 rupees? If pone pencil costs a quarter of a rupees (or 25p) 5) If 18 boys are divided into groups of 6, how many groups will there be? Time limits: item 1 to 3 – 15 secs 4 to 5 -30 secs Correct answers: (1= 9,) (2= 4,) (3= 9,) (4= 8,) (5 =3) (2 step calculations / 3 digit ÷ns as and when required .Formulate easier questions as and when required) iv) ABSTRACTION: tested by differences similarities and proverbs test DIFFERENCES: the instructions are as follows the instructions are as follows “I will be giving you some pairs of words. Listen carefully and tell me in what way they are different from each other”. stone potato fly butterfly cinema radio iron silver praise punishment Use your own discretion and judgment to choose the number of differences sand similarities SIMILARITIES: the patient is given the following instructions “I will be giving you some pairs of words .You have to tell me in what way they are alike, what is common between them, or what is the similarity between them.” orange banana (fruits) dog – lion (animals) eye – ear (sense organs) north – west (directions) table – chair (items of furniture ) Correct responses i.e. abstract responses are given in brackets. Differences being an easier task, is always presented before similarities PROVERBS: before starting ask whether the patient knows ‘proverbs’ – you may change them according to culture and language The patient is asked the following questions a) whether he knows what a proverb is b) an example of a proverb and what it means
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11 If it is clear that the patient has the concept of a proverb the following maybe asked 1) Slow and steady wind the race 2) A barking dog never bite 3) As you sow, so shall you reap 4) All that glitters is not gold or all that is white is not milk 5) Where there is a will there is a way 6) Empty vessels make much noise 7) Every potter praises his pot 8) It is useless to cry over spilt milk The responses of the patient is to be noted verbatim and the answer is to be judged correct or incorrect (2 could suffice if there is a problem i.e. wrong interpretation explore further ask for situations where proverbs maybe used) 5) JUDGMENT:
It is assed in the following areas 1) Personal 2) Social 3) Test I) PERSONAL JUDGEMENT: judgment is assessed by inquiring about the patient’s future plans (realistic plans)
Social judgment is assessed by inquiring into the patient’s future plans with regard to occupation or other responsibilities (Judgment is adequate if a clear and realistic outline is given) III) TEST JUDGEEMENT: the following 2 problems are presented to the patient in a manner in which he can comprehend 1) FIRE PROBLEM: if the house in which you are catches fire, what is the first thing you will do? (Correct answer – try to put it off with water) 2)LETTER PROBLEM: if you are walking on the roadside you see a stamped and sealed envelope with a address on it which someone had dropped ,what will you do ?( correct answer – post it in a letter box or give it to the post man or leave it because the patient thinks it is a bomb )
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