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Subjective sensory perceptions in the absence of relevant external stimuli. The person may or may not recognize the experiences as false. Hallucinations may be auditory, visual, olfactory, gustatory, tactile, or somatic. (False perceptions associated with dreaming, falling asleep, and awakening are not classified as hallucinations.)

Illusions may occur in grief reactions, delirium, acute and posttraumatic stress disorders, and schizophrenia.

Hallucinations may occur in delirium, dementia (less commonly), posttraumatic stress disorder, schizophrenia, and alcoholism.

Patients with psychotic disorders often lack insight into their illness. Denial of impairment may accompany some neurologic disorders.

Judgment may be poor in delirium, dementia, mental retardation, and psychotic states. Judgment is affected also by anxiety, mood disorders, intelligence, education, socioeconomic options, and cultural values.

Disorientation occurs especially when memory or attention is impaired, as in delirium.

Insight and Judgment. These attributes are usually best assessed during the interview.

Insight. Some of your very first questions to the patient often yield important information about insight: "What brings you to the hospital?" "What seems to be the trouble?" "What do you think is wrong?" More specifically, note whether or not the patient is aware that a particular mood, thought, or perception is abnormal or part of an illness.

Judgment. You can usually assess judgment by noting the patient's responses to family situations, jobs, use of money, and interpersonal conflicts. "How do you plan to get the help you'll need after leaving the hospital?" "How are you going to manage if you lose your job?" "If your husband starts to abuse you again, what will you do?" "Who will attend to your financial affairs while you are in the nursing home?"

Note whether decisions and actions are based on reality or, for example, on impulse, wish fulfillment, or disordered thought content. What values seem to underlie the patient's decisions and behavior? Allowing for cultural variations, how do these compare with mature adult standards? Because judgment is part of the maturational response, it may be variable and unpredictable during adolescence.

Orientation. By skillful questioning you can often determine the patient's orientation in the context of the interview. For example, you can ask quite naturally for specific dates and times, the patient's address and telephone number, the names of family members, or the route taken to the hospital. At times—when rechecking the status of a delirious patient, for example—simple, direct questions may be indicated.

"Can you tell me what time it is now . . . and what day is it?" In either of these ways, determine the patient's orientation for the following:

■ Time (e.g., the time of day, day of the week, month, season, date and year, duration of hospitalization)

■ Place (e.g., the patient's residence, the names of the hospital, city, and state)

■ Person (e.g., the patient's own name, and the names of relatives and professional personnel)

Attention. These tests of attention are commonly used:

Digit Span. Explain that you would like to test the patient's ability to concentrate, perhaps adding that people tend to have trouble with that when they are in pain, or ill, or feverish. Recite a series of digits, starting with two at a time and speaking each number clearly at a rate of about one per second. Ask the patient to repeat the numbers back to you. If this repetition is accurate, try a series of three numbers, then four, and so on as long as the patient responds correctly. Jotting down the numbers as you say them helps to ensure your own accuracy. If the patient makes a mistake, try once more with another series of the same length. Stop after a second failure in a single series.

Causes of poor performance include delirium, dementia, mental retardation, and performance anxiety.

In choosing digits you may use street numbers, zip codes, telephone numbers, and other numerical sequences that are familiar to you, but avoid consecutive numbers, easily recognized dates, and sequences that possibly are familiar to the patient.

Now, starting again with a series of two, ask the patient to repeat the numbers to you backward.

Normally, a person should be able to repeat correctly at least five digits forward and four backward.

Serial 7s. Instruct the patient, "Starting from a hundred, subtract 7, and keep subtracting 7. ..." Note the effort required and the speed and accuracy of the responses. (Writing down the answers helps you keep up with the arithmetic.) Normally, a person can complete serial 7s in minutes, with fewer than four errors. If the patient cannot do serial 7s, try 3s or counting backward.

Poor performance may be due to delirium, the late stage of dementia, mental retardation, loss of calculating ability, anxiety, or depression. Also consider the possibility of limited education.

Spelling Backward. This can substitute for serial 7s. Say a five-letter word, spell it, e.g., W-O-R-L-D, and ask the patient to spell it backward.

Remote Memory. Inquire about birthdays, anniversaries, social security number, names of schools attended, jobs held, or past historical events such as wars relevant to the patient's past.

Remote memory may be impaired in the late stage of dementia.

Recent Memory (e.g., the events of the day). Ask questions with answers that you can check against other sources so that you will know whether or not the patient is confabulating (making up facts to compensate for a defective memory). These might include the day's weather, today's appointment time, and medications or laboratory tests taken during the day. (Asking what the patient had for breakfast may be a waste of time unless you can check the accuracy of the answer.)

New Learning Ability. Give the patient three or four words such as "83 Water Street and blue," or "table, flower, green, and hamburger." Ask the patient to repeat them so that you know that the information has been heard and registered. This step, like digit span, tests registration and immediate recall. Then proceed to other parts of the examination. After about 3 to 5 minutes, ask the patient to repeat the words. Note the accuracy of the response, awareness of whether or not it is correct, and any tendency to confabulate. Normally, a person should be able to remember the words.

Recent memory is impaired in dementia and delirium. See Table 16-5, Delirium and Dementia, p. 603. Amnestic disorders impair memory or new learning ability significantly and reduce a person's social or occupational functioning, but they do not have the global features of delirium or dementia. Anxiety, depression, and mental retardation may also impair recent memory.

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