Psychiatry: A Course of Lectures - V. S. Bitensky 2004
Disorders of Consciousness and Self-Awareness. Leading Psychopathological Syndromes
Consciousness
Consciousness is an integrative mental function that not only encompasses other, simpler mental states and Functions, but undoubtedly possesses its own specific attributes. It is crucial to formulate a comprehensive definition of consciousness that remains independent of ideological dogmas or methodological approaches; however, doing so makes it difficult to gauge the practical utility such a definition would offer to psychiatrists.
In seeking to approach an understanding of consciousness, one can define it as the capacity to realize and comprehend the state of affairs in one's surrounding environment, changes within it, and one's own state and experiences. Other mental functions often exhibit conscious properties. For instance, we are aware of what we perceive through our Senses, as well as a certain portion of our thoughts, emotions, and drives. Some experiences remain beyond the boundaries of consciousness (see «Id», «Ego», «Superego»).
Some psychiatrists believe that defining consciousness is possible only by way of contrast—that is, we speak of consciousness inasmuch as states of unconsciousness and lack of awareness exist. These occur when a person has no experiences, thoughts, sensations, or capacities. The field of consciousness is composed of interrelated mental processes that occur simultaneously and change over time. Within this field, There is a distinct center housing those mental images prioritized on The basis of prior experience and the specifics of a given situation, as well as a periphery of consciousness dominated by less intense images, the so-called «overtones» of consciousness. The threshold of consciousness serves as the boundary above which The Emergence of an image in the field of consciousness is recognized by the individual, while its lowering implies the image's departure from the field of consciousness. This applies both to the inner world of the personality (autopsychic orientation) and to the extrapersonal space surrounding the individual (allopsychic orientation).
Mention should also be made of another attribute without which consciousness is impossible. To isolate favored images and experiences within oneself or in the surrounding space, a state characterized by a distinctive sense of tension, known as attention, is necessary. Through attention, mental images shift from the center to the periphery of consciousness and vice versa, depending on prevailing goals and motives. It is precisely the execution of such transitions that requires a certain mental effort, namely attention. The stream of consciousness signifies the continuous connection between mental processes currently residing within or outside the field of consciousness. The object of consciousness consists of those external world objects and personal experiences that reside within the field of consciousness and toward which a person's attention is directed. If, say, I derive pleasure from a magnificent painting, the mental representations and experiences that arise within me constitute the content of consciousness, whereas the painting itself is merely the presented object of my consciousness. If we now attempt to picture these attributes of consciousness in action, following Karl Jaspers, we can compare consciousness to a stage traversed by individual mental phenomena, illuminated more brightly or dimly by the spotlight of attention. Unconscious processes (see «Id») can be visualized as occurring behind the scenes. This metaphor not only deepens our understanding of normal conscious activity but also illuminates the alterations that arise when consciousness is impaired.
An essential question concerns THE PLACE OF consciousness among other manifestations of mental life. Sigmund Freud believed that consciousness is intimately linked to personality. He argued that personality consists of three main components that interact and frequently conflict with one another: the «Id», the «Ego», and the «Superego». These components are not directly tied to anatomical Brain structures, but rather represent the fundamental operating principles of the psyche and consciousness in shaping human personality. Our psyche, especially its unconscious part, is a constant battlefield where the «Id», «Ego», and «Superego» endlessly contend. This internal conflict takes various forms in different individuals, reflecting in their consciousness and self-awareness.
The «Id», «Ego», and «Superego» occupy different levels of consciousness. The «Id» is entirely unconscious, and its contents are normally inaccessible to the individual. The Influence of the «Superego» extends across both conscious and unconscious levels, as well as the preconscious level, which houses thoughts, memories, and other experiences capable of crossing the threshold of consciousness through a certain voluntary effort and concentration of attention. Like the «Superego», the «Ego» can penetrate all three levels of consciousness, although the extent of its penetration into the unconscious is not as pronounced as that of the «Superego».
Let us examine the primary Properties of the «Id», «Ego», and «Superego».
The «Id» is that part of the personality representing unconscious psychic energy, which manifests in our inherited biological drives. Humans possess two primary drives: the drive for life preservation and reproduction, and the destructive, aggressive drive directed toward oneself or others. Freud named them Eros and Thanatos. Within the personality Structure, the «Id» is the most rudimentary part, yet it contains the source of energy for all other personality components. The «Id» operates in accordance with the «pleasure principle», which aims at the immediate gratification of any desires, regardless of the form they take. The clearest example is the mental life of an infant, for whom nothing exists save its desires, and no satisfaction exists apart from that derived from their fulfillment. Naturally, the «Id» disregards societal rules and values, though in certain situations it can be subject to the control of the «Superego».
If the «Id» is chaotic, poorly structured, and impulsive, the «Superego», by contrast, is highly organized. The «Superego» is the bearer of human moral values and encompasses the laws, norms, and sanctions of the society in which an individual lives. While the «Id» forms and functions immediately upon a person's birth, the «Superego» develops later as a component of personality, serving as a counterweight to the «Id». When the «Id» demands, «Do this immediately», the «Superego» objects, «Do not do this, it violates morality». The «Superego» comprises two parts: the «conscience» and the «ego-ideal». The «ego-ideal» consists of the standards of virtue that a person strives to attain. While the «Id» drives us to seek gratification in accordance with the pleasure principle, the «Superego» guides us toward the ego-ideal, initially personified by the figures of the mother and father. Gradually, the moral norms and sanctions that were previously external become internalized by the individual, becoming part of their consciousness. Their «Superego» opposes the sexual and aggressive drives of the «Id». A child who reaches for a piece of candy before dinner but then pulls their hand back upon feeling a sense of guilt is undoubtedly under METABOLISM/18.html">The Influence of the «Superego».
The «Ego» is predominantly a cognitive STRUCTURE OF THE personality engaged in Processing information about oneself and the external world. Consequently, the «Ego» acts as an intermediary between the individual and the external environment, and is responsible for our self-awareness. The «Ego» governs the personality and makes decisions regarding the moral sanctions that must be applied under the influence of the «Superego». The «Ego» also accounts for the constraints imposed by external reality; its primary operating principle is the reality principle, which consists partly in restraining the immediate gratification of the «Id»’s demands and choosing moderate pathways for their fulfillment, while simultaneously mitigating the demands and prohibitions of the «Superego». Thus, as the managerial agency of the personality, the «Ego», in S. Freud’s metaphor, is a battlefield and the scene of constant conflict: the beleaguered «Ego» feels hemmed in on three sides, faced with Three types of danger, and under heavy pressure reacts with mounting anxiety. Consequently, pushed by the «Id», restrained by the «Superego», and rebuffed by reality (the «cold shower of reality»), the «Ego» struggles to perform its vital task of harmonizing all the forces and influences acting within it and upon it; we can now understand why we so often cannot suppress the exclamation: «Life is not easy!» (S. Freud).
States of impaired or altered consciousness are highly diverse. They occur under physiological conditions, such as Sleep or dream-like states, as manifestations of human biological rhythms. In psychiatry, of course, greater significance is attached to various pathological variants, where the state of consciousness is altered or disrupted under the influence of toxic, traumatic, psychogenic, or endogenous factors. When consciousness is impaired, its characteristics change. Above all, the continuity and unity of consciousness are lost—that is, the uninterrupted stream of mental processes ceases to exist. Instead, mental life becomes fragmented, individual groups of experiences proceed without mutual connection, resulting in what amounts to a «disintegration of consciousness» (Karl Jaspers). For psychiatric Diagnostics, establishing the presence of clarity versus clouding (confusion) of consciousness is of paramount importance.
Karl Jaspers described the criteria for clouding of consciousness. Consciousness is considered clouded if the following features occur simultaneously: 1) alienation and a decrease in the quality of perception, its incompleteness, whereby surrounding reality is perceived vaguely, unrealively, as if from a distance, unclearly and dimly in every sensory modality—for example, visual perceptions become indistinct, blurred, and hazy, auditory perceptions become muffled and unclear, etc.; 2) Impairment of the continuity, sequence, and succession of mental processes, while basic mental functions such as thinking, volition, and emotions lose a sufficient degree of consistency and goal-directedness; 3) disorientation within one's own ego and in surrounding reality—autopsychic and allopsychic disorientation; 4) memory impairment, which primarily affects the retention of events that occurred during the period of impaired consciousness, while The ability to recall them disappears, resulting in amnesia, the severity of which (fragmentary or total) depends on the depth of the impairment of consciousness.
If a patient exhibits only some of the described criteria simultaneously, consciousness is formally considered clear (unimpaired). At the same time, the detection of phenomena such as mental alienation makes it possible to establish the presence of a disturbance in the reflection within a person's consciousness of subjective mental processes and their personality as a whole—that is, a disturbance of self-awareness, which manifests in a wide spectrum of psychopathological Disorders of the depersonalization-derealization type and phenomena of mental automatism. Therefore, it is advisable to differentiate between the pathology of consciousness and the pathology of self-awareness.
Syndromes of Disorders of Consciousness
Disorders of consciousness are defined as mental disturbances in which all 4 criteria of Karl Jaspers coexist. Insufficient consistency of thinking can also occur in certain mental illnesses, such as Schizophrenia, when consciousness is not clouded. Pronounced memory impairments are observed in memory disorder syndromes, such as Korsakoff's syndrome, but consciousness in these cases is likewise unimpaired.
The following variants of disorders of consciousness are distinguished:
a) clouding of consciousness;
b) confusional state (confusion);
c) paroxysmal twilight states of consciousness;
d) syncopal states;
e) sleep disorders.
Clouding of Consciousness
Clouded consciousness is characterized by a decrease in The activity of manifestations of consciousness, predominantly through quantitative impairments; depending on the depth of the clouding, the following syndromes can be distinguished.
The mildest degree of clouding of consciousness is nubilation (from Latin nubilis — cloudy). Consciousness at this time appears as if veiled by a cloud. Patients respond to questions and surrounding circumstances, and follow instructions, but visual perceptions become indistinct, sounds seem muted, and thinking becomes less consistent. Mild impairment of consciousness alternates with a state of clear consciousness. During nubilation, patients are able to speak, answer questions (after a pause), and ask them themselves. Their behavior is appropriate and orderly, although orientation to the environment is incomplete. Patients draw attention to themselves by experiencing difficulties when performing tasks, such as touching their left ear with their right hand.
Obnubilation most commonly occurs during febrile states, alcohol or drug intoxication, the acute period of traumatic brain injury, and cerebral tumor processes. Additionally, obnubilation may arise against the backdrop of initial somatovegetative disturbances During the first sessions of Insulin therapy in schizophrenia patients.
Obnubilation can be followed by somnolence. Overall, it is characterized by an elevated sensory threshold for external stimuli. Simple questions often elicit no response or a monosyllabic reply after a lengthy, often inappropriate, pause. Lethargy, sluggishness, and indifference to surroundings are observed. The formal correctness of thinking is impaired, and concentration is difficult. In A number of cases, there is a need for a differentiated Assessment of the syndrome.
In somnolence, patients provide verbal responses only to very simple questions. Allopsychic orientation is absent, behavior becomes inadequate, and patients do not understand complex phrases addressed to them. Drowsiness is frequently observed, with only sharp stimuli penetrating consciousness. Left to themselves, patients fall asleep quickly; if awakened after some time, they may resume answering questions, but signs of rapid mental exhaustion are prominent.
In stupor, as a rule, patients generally do not answer questions and cannot perform simple actions (such as showing the Tongue or giving a hand).
With a further deepening of stupor, altered consciousness reaches the level of sopor. In this state, patients lie with closed eyes and appear to be sleeping. They react only to strong stimuli (pain) with elementary motor acts (opening the eyes). Pupillary, corneal, and pharyngeal Reflexes can be elicited. Tendon and periosteal reflexes are diminished, and pathological reflexes may be observed. Occasionally, patients make purposeless movements. The ability to fixate the gaze on a shown object and follow the simplest instructions is lost. O. E. Lychko believes that the following reactions can be elicited in sopor: 1) a reaction to being loudly called by name, manifesting as facial, vocal, and vegetative responses; 2) the natural conditioned blinking reflex—reflexive eye closure upon the rapid approach of an object; 3) a reaction to words directed at a “painful point,” associated, for example, with a psychotraumatic situation or emotionally charged delusional experiences. This reaction will also be vegetative-mimic.
In coma, against the Background of the loss of all forms of orientation, reactions to any external stimuli and influences are absent. Dysfunctions of Internal Organs, swallowing disorders, pelvic organ dysfunction, respiratory arrhythmia, and collapse occur. In mild coma, reactions to strong pain stimulation and a weak pupillary reaction are possible. Starting from the Second Stage of coma, reflex reactions are absent. This state is transitional between life and death. In the 4th stage, the independent activity of vital organs—Respiration and heartbeat—is absent. Life support can be maintained only artificially. Coma belongs to terminal states. It is based on prolonged cerebral Hypoxia. A long-term comatose state leaves serious consequences; The Development of severe psycho-organic disorders up to apallic syndrome (E. Kretschmer) is possible, in which vital activity occurs at a vegetative level. Comatose states have a guarded prognosis.
Confused Consciousness
Confused consciousness is characterized by the emergence of qualitatively new productive psychopathological manifestations (hallucinations, delusions, etc.) against the background of disorientation, altered quality of perception, and impaired continuity, consistency, and succession of mental processes. Thus, Various Forms of confusion are characterized by a lowered level of consciousness (with the exception of physiological sleep), phenomena of stupor, and the unfolding of complex psychopathological phenomena on their basis.
Delirium
The most common variant of altered consciousness is delirium. It is characterized by an influx of vivid, sensory, predominantly visual hallucinations with more or less profound allopsychic disorientation and preserved orientation to one's own “I.” Delirium occurs in alcoholic psychosis (“delirium tremens”), atropine and hashish poisoning, and infectious diseases. In delirium, the depth of confusion typically fluctuates throughout the day. In the evening, disorientation is more pronounced, and hallucinations intensify. Delirium is frequently accompanied by somatovegetative disturbances: fever, tachycardia, falling or rising Blood pressure, acrocyanosis, tremor of the hands and entire body, and pallor of the Skin. Alcoholic delirium has a number of specific features: prominent somatovegetative and cardiovascular disorders, micro- and zoopsia, and hallucinations that are more often tinged with dark colors.
Clinical Case.
Patient R., 48 years old, was brought to the hospital by an ambulance. It is known that he had abused alcohol for more than 15 years, recently in the form of binge drinking. He consumed large quantities of alcoholic beverages for two weeks, and abstained for 3 days prior to hospitalization. He did not sleep the last night; with his eyes closed, he saw “dim” figures of people that disappeared when he opened his eyes. The patient felt anxious and occasionally experienced intense terror. Before dawn, he developed severe agitation, ran around the room, and claimed that Water was flowing down the walls, gathering in puddles on the floor and filling the room. He removed shoes from the floor “so they wouldn't get wet.” In the hospital, he is agitated, with a flushed, sweating face. He constantly tries to leap out of bed. He does not understand where he is, believes he is “in a dormitory,” and does not remember how long he has been in the hospital. He brushes something off a chair, saying that “there is some vermin — a snake,” and that cockroaches are crawling over his bed. He reaches for the nurse's station, claiming there is a box of cigarette butts on it and that he wants to smoke. He states his personal data correctly.
In delirium resulting from tetraethyllead poisoning, a sensation of a foreign body in the Mouth is characteristic. Atropine delirium is frequently accompanied by fragmentary visual hallucinations, often tinted yellow and predominantly non-frightening. The double symptom is characteristic of delirium in epidemic typhus. Epileptic delirium is characterized by delusions of persecution and physical destruction, and hallucinatory scenes of a religious-mystical content are not uncommon.
In its development, delirium goes through several stages (Liebermeister). The first period is characterized by loquacity, intensified memories, hyperesthesia, and unstable mood. Vivid, often frightening dreams are common during this period. At the second stage, visual illusions and pareidolias appear. Patients remain loquacious and restless, hyperesthesia is sharply pronounced, utterances are frequently incoherent, and Answers are inaccurate. Then, full-blown delirium sets in with all the aforementioned characteristic symptomatology. Sometimes a severe form is observed — muttering delirium with complete alienation from the environment, disorientation, incoherent speech, and uncoordinated hand movements. Muttering delirium can occur in very severe infections or intoxications. A variant of delirium is occupational delirium (or delirium of business), which is characterized by a greater depth of altered consciousness and peculiar motor production, where the patient's movements resemble their habitual professional or domestic activities.
Amentia is characterized by severe clouded consciousness, which, as a rule, is accompanied by certain sequelae. The main manifestations of amentia are the disruption of the coherence of all mental processes and their extreme inconsistency. Thinking consists of separate fragments of thoughts and ideas, speech is incoherent, and actions are extremely inconsistent: the patient alternately jumps up and lies down; restlessness in bed is frequent rather than agitation. The emotional state is characterized by the incoherence and inconsistency of individual emotional reactions. The patient alternately weeps, laughs, and experiences fear. The state of agitation is accompanied by toxicoses and exicosis (cracked Lips, halitosis, dehydration). With prolonged agitation and significant manifestations of toxicosis, a fatal outcome may occur due to secondary somatic disorders. Amentive syndrome has not been frequently encountered in recent years; it can be observed in severe exogenous, prolonged somatic, and infectious diseases (severe ones), as well as during endogenous mental illnesses, for example, in acute bouts of schizophrenia in adolescents. In the latter case, it is characterized by The addition of catatonic components, structural Thought Disorders, and the presence of incoherent delusional ideas. Such states are called amentiform. They are characteristic of febrile schizophrenia, which is distinguished by a relatively high mortality rate and requires special resuscitation and detoxification measures (hemisorption, lymphosorption, etc.).
Oneirism is a complex psychopathological syndrome that draws attention through the dissociation between A large number of morbid experiences and poverty of behavioral manifestations (up to complete immobility). In oneirism, all types of orientation are impaired. Unlike delirium, in oneirism there is no opposition of one's “I” to the psychopathological production, and therefore the patient is merely a spectator rather than a participant in the turbulent events generated by their diseased psyche. In its development, oneirism goes through several stages. Initially, general somatic disorders and affective fluctuations appear, with Complaints of weakness, “stupefaction,” forgetfulness, and lowered or elevated mood. Insomnia is very common, and a dreamy state resembling reverie often appears. Next, a delusional affect emerges with pronounced fear, anxiety, and a feeling of alteration of the “I.” Bewilderment is frequent here, interrupted by short periods of calm. The delusional affect transitions into a delusional perception of everything surrounding them. Under the influence of surrounding events or details, a special delusional synthesis arises, while the real picture of the world is preserved as a background, somewhere in the recesses of consciousness. Driven by a sharp intensification of imagination, the sensation arises that everything happening around is staged, resembling a massive, sometimes grotesque theater, and the environment fills with numerous false recognitions that progressively become more and more fantastic. The fantastic events happening to the patient gradually shift from the ideational sphere to the sensory one. Hallucinatory images obscure the real world, although the patient may periodically (less often permanently) exist in two worlds — the fantastic and the real. Such a state is called oneirism with double orientation. Finally, the culmination of development is the emergence of true oneiric altered consciousness, which in its psychopathological manifestations can be expansive (megalomaniacal) or depressive (nihilistic). Oneirism is observed in both exogenous and endogenous mental disorders.
Clinical Case.
Patient V., 23 years old, was admitted to the hospital on the referral of an ambulance doctor. According to roommates in the dormitory where the patient lives, over the past few days he became withdrawn, “somewhat pensive,” did not answer their questions, and spent a lot of time doing nothing, lying in bed or sitting on a chair. During the last 24 hours, he did not get out of bed, lay with open eyes, occasionally smiled, remained silent, and did not react when addressed by others. In the hospital, he was sluggish, refused food for three days, and drank only water if a cup was brought to his mouth. On the 4th day of hospitalization, after a pause, he began to answer individual questions and take food. From the patient's statements, it could be concluded that he did not understand where he is and was hallucinating. A week later, the patient's condition improved, and he became oriented to place, time, and his own personality. He recounted that he was in a huge hall with a floor covered in marble tiles. Stairs led into the hall, one set from above, another from below. Their ends were not visible. Angels descended the stairs from above, devils ascended from below, and a grandiose battle began in the hall, which the patient witnessed. He himself took no part in the battle of good and evil, but only observed it. All this was like a dream, only very vivid. The patient practically ceased to perceive the real environment back in the dormitory, did not remember how he got to the hospital, and how many days the morbid state lasted.
Mention should also be made of a state close to oneirism, called oneirism (or oneiric syndrome). This peculiar psychopathological syndrome develops in burn disease, Sepsis, and inflammatory disorders. Oneirism manifests as the patient failing to distinguish vivid dream images from reality upon waking, while the experiences felt during sleep seem to them to have occurred in real life. Critical attitude toward these experiences is quickly and fully restored. With a pronounced oneiric syndrome, it is sufficient for the patient to close their eyes to plunge into dream-like experiences. At the same time, the critical attitude toward the experiences vanishes, the patient is delirious while awake, and tries to walk somewhere. The content of the experiences is predominantly domestic or occupational; upon waking, the patient claims they were at work, tries to go out into the corridor, saying that relatives whom they recently saw are waiting for them there, etc. Perceptual disorders take the form of misidentification of surrounding persons. Hallucinations, as a rule, do not occur. The affective background is more often elevated and euphoric. When complicated by somatic illness, oneirism can transform into delirium.
If amentia has been quite rare in recent years, in infectious psychoses it has been superseded by oneirism and asthenic confusion (D. M. Isaev). Following the full unfolding of confusional syndromes, their reverse development is observed and, depending on the depth of the disorder, they may be replaced by Wernicke's transitional syndromes in the form of asthenia and residual delusions (after delirium), confabulations (after oneirism), and psycho-organic syndrome (after amentia).
After delirium subsides, the patient remains convinced for some time that certain people really came to see him and wanted to kill him. Following recovery from amentia, which can last several weeks, lasting cerebrasthenic disorders remain, and the development of psycho-organic syndrome is possible. Upon recovery from oneirism, patients generally retain memories of what they experienced, remembering the fantastic images that appeared at the moment of the morbid state. Real events are more frequently forgotten, or only partial memories of them are preserved.
Paroxysmal-Twilight Impairments of Consciousness
Paroxysmal-twilight impairments of consciousness most frequently combine features of clouding and confusion. In specific cases, there may be a predominance of qualitative or quantitative disorders of consciousness, but all of them, practically without exception, are characterized by suddenness, short duration, and an interruption of the stream of consciousness (G. Gruhle). There occurs, as it were, a narrowing of the field of consciousness to a certain sphere of perception, disrupting the connection with the continuous stream of experiences. As a rule, they are based on specific neurophysiological Changes in the CNS that determine their trigger, paroxysmal nature. The majority of paroxysmal-twilight disorders of consciousness occur in Epilepsy and epileptiform syndromes of exogenous-organic genesis, but they can also arise in hysteria, affective-Shock, and primitive-defensive reactions.
Twilight State
The classical variant of such disorders is the twilight state. Overall, during twilight states, the perception of the outside world is unclear and fragmentary, as if through a fog. There is affective engrossment, fixation by a complex of highly volatile experiences, which, due to tunnel-narrowed consciousness, can easily transform into frightening hallucinations or delusional ideas that may subsequently lead to senseless, violent actions. During twilight states, mood fluctuates from affects of anguish, anger, and fear to elevated mood up to an ecstatic state. The field of consciousness significantly narrows, leaving only a clear tunnel within the narrow circle of representations of which the possibility of elementary purposeful actions with the experience of automatisms is preserved. These states last from a few minutes to hours or days.
Twilight states are divided into simple (ambulatory automatisms), complex, and altered states of consciousness (auras).
Simple twilight states occur abruptly. Patients become detached from their surrounding reality, stop responding to questions, and communication with them becomes impossible. Spontaneous speech is either absent or limited to the stereotyped repetition of isolated words, exclamations, or short phrases. Movements are either impoverished and slowed down or punctuated by episodes of impulsive agitation. Sometimes the patients' actions remain sequential; they are consumed by a dominating sensation detached from the conscious content. When simple twilight states are accompanied by involuntary wandering, it is termed ambulatory automatism, which can be brief and accompanied by sharp, often nonsensical or chaotic motor agitation. A patient may suddenly start running or spinning in place (fugues), or wander aimlessly for a long time while performing actions that outwardly appear purposeful and orderly (trance). Ambulatory automatism occurring during sleep is known as sleepwalking or somnambulism (see Sleep Disorders). Sleepwalkers perform aimless, automatic actions. Their attention is focused on a very limited range of ideas and objects, and they cannot be awakened.
An absence seizure is a momentary loss of consciousness. During such moments, patients suddenly freeze with a vacant stare, as if losing their train of thought; if this happens during work, they drop their tool; while eating, a spoon; while smoking, a cigarette. Upon recovery from this state, which lasts mere seconds, they look around in bewilderment and cannot immediately gather their thoughts. The depth of impairment of consciousness in an absence seizure corresponds to a dazed state (obnubilation).
Complex twilight states are accompanied by hallucinations, delusions, and altered affect. The patients' perception of their surroundings is distorted due to productive symptoms. This can be gathered from the patients' spontaneous statements, as well as the fact that verbal communication with them may be partially preserved. The patients' words and actions reflect their underlying pathological experiences. Among hallucinations, visual ones predominate—vivid, sensory-rich, scenic, and terrifying in content. Auditory and olfactory hallucinations are simpler in content, yet invariably affectively significant and intense (rumbles, heavy footsteps, explosions, foul odors). Delusions are typically figurative, featuring ideas of persecution, grandeur, or mystical themes. Emotional experiences are equally intense and marked by high tension. Characteristic features include fear, intense rage, or ecstasy. Complete amnesia ensues after complex twilight states resolve. These conditions are extremely dangerous due to their unpredictability and the patients' frequent aggressiveness and malice.
One of the variants of twilight states of consciousness is pathological intoxication, in which mild alcohol intoxication triggers a narrowing of consciousness accompanied by hallucinatory and delusional experiences—most often of a threatening nature—leading patients to commit various inappropriate and socially dangerous acts. This condition resembles complex twilight states.
Sometimes complex twilight states can arise immediately following psychological trauma (Ganser syndrome). When faced with a complex situation that threatens life and safety, individuals with hysterical personality traits develop twilight states of consciousness. These serve as primitive defense mechanisms, expressing an instinctive urge to escape the burden of unbearable reality—an "escape into illness." Some of these patients appear profoundly demented (pseudodementia): they cannot state their name, the month, or the date, fail to count their fingers, give nonsensical ANSWERS TO QUESTIONS, and do not recognize or know how to use everyday objects. Occasionally, patients refuse to stand or walk, collapsing if placed on their feet, and frequently lapse into a stupor (pseudocatatonic stupor). Because their consciousness is clouded in the twilight manner, they exhibit characteristic symptoms such as vorbeireden (answering adjacent questions) and paraphasia (Ganser syndrome). A regression of behavioral patterns may be observed, wherein patients push actual reality out of their consciousness, evaluate their situation entirely without critical insight, and behave like children: babbling childishly, asking to be picked up, rejoicing over toys, and failing to apply their knowledge (puerilism).
A situation that threatened a person's safety may have occurred in the past, even the distant past. As a rule, this involves severe sexual trauma inflicted by parents or close relatives during childhood (incest or attempted rape). The outcome of such psychological trauma can be the emergence of alternating consciousness or multiple personality disorder. A splitting or even multiple personality disorder may occur, accompanied by the appearance of multiple states of consciousness. The content of mental life in each of these states seemingly differs from the others. The behavioral stereotype formed in one state changes significantly when the patient transitions to another. Consequently, the patient does not remember what happened to them or what they were just doing; however, upon returning to the previous state, they recall those responses, experiences, actions, and events (V. P. Osipov).
An interesting example of alternating consciousness is described in the book The Minds of Billy Milligan. He was accused of kidnapping and rape at the age of 22, but was found not guilty by reason of mental illness. Psychiatric examination revealed that he possessed 24 distinct personalities (states of consciousness), of which
2 were female and one was a young girl. One was British, alongside an Australian and a Yugoslav who spoke, read, and wrote in Serbian. One woman, a lesbian, was a poet, whereas the Yugoslav was an expert in weapons and ammunition, and the Briton was a sculptor. Alternating consciousness is a very rare pathological condition, with only a few hundred cases coming to the attention of psychiatrists over the past century.
Quite frequently, an aura assumes The structure of a twilight state—a disturbance of consciousness accompanied by peculiar sensations (sensory aura), movements (motor aura), or mental experiences (aura with psychopathological phenomena). An aura occurs immediately before an epileptic seizure. An aura with psychopathological phenomena is the closest to a twilight state; clinically, it manifests as vivid, often hallucinatory experiences that are expressive and colorful. In the absence of hallucinations, real objects are perceived with extraordinary contrast and clarity, yet "somehow differently"—everything surrounding the patient becomes alien, often accompanied by a feeling of déjà vu, during which patients sometimes try to recall something but fail to do so. In other cases, the aura is accompanied by psychosensory disorders, cenesthesias, or states of ecstasy with mystical penetration into the surroundings (the latter variant of aura was observed in F. M. Dostoevsky). Sometimes patients cannot clearly describe their psychopathological experiences. Several aura variants bear less resemblance to classical twilight states and more closely resemble altered states of consciousness (M. O. Gurevich).
Epileptic Phenomena
Many epileptic phenomena are paroxysmal in nature and are accompanied by quantitative and qualitative disturbances of consciousness. A classic example is the absence seizure—a momentary lapse of consciousness.
Convulsive seizures (generalized, focal) are likewise characterized by suddenly occurring, brief impairments of consciousness, up to its complete loss, equivalent in depth to a coma, accompanied by motor disorders, primarily in the form of convulsions. In addition to a critical termination, these seizures are distinguished by recurrence, paroxysmal nature, and stereotyped clinical manifestations—developing according to a "cliché" pattern.
Major convulsive seizures are characterized by a sudden onset of clouding of consciousness, a fall (typically forward), and a sequential transition from a shorter phase of tonic convulsions (up to 0.5 min) involving generalized Muscle tension, a thrown-back HEAD, and tightly clenched jaws (sometimes resulting in tongue biting) to a longer phase of clonic convulsions (1–2 min), as well as frequently (though not always) a post-ictal dazed phase that sometimes transitions into sleep. The onset of the seizure is occasionally preceded by prodromal signs such as general malaise, weakness, somatovegetative disturbances, and mood swings. Often, the seizure begins with an aura. The tonic convulsion phase is accompanied by an absence of pupillary light reflexes and urinary/fecal incontinence. Following the seizure, patients experience complete amnesia for the entire seizure period and sometimes for a brief interval preceding it. In many patients, general fatigue, headache, reduced work capacity and appetite, mood swings, and irritability persist for several hours after the seizure.
Psychomotor (temporal lobe) seizures are highly diverse in their clinical manifestations, but they share the sudden onset of various habitual automatic actions combined with twilight disturbances of consciousness, followed by amnesia for the seizure period. The simplest form of psychomotor paroxysms consists of oral automatisms, which manifest as brief episodes of swallowing, chewing, lip-smacking, and sucking, accompanied by hypersalivation. They can occur during sleep and are characteristic of childhood.
Fainting
Fainting (syncopal states) refers to suddenly occurring, short-term impairments of consciousness most commonly resulting from transient cerebral anemia. They exhibit certain Characteristic Features of paroxysmal disorders.
One group of fainting spells is reflex-mediated and occurs in response to intense pain or emotional triggers, upon transitioning to a vertical posture or changing body position, or due to increased vestibular excitability. The second group consists of symptomatic fainting spells, which arise from cardiac weakness, Heart rhythm disorders, respiratory failure, and impaired cerebral blood supply. Fainting is preceded by prodromal symptoms, the duration of which often depends on the intensity and Nature of the trigger. These may include dizziness, headache, sweating, muscle weakness, mild shortness of breath, seeing spots before the eyes, etc. Immediately prior to fainting, sharp pallor appears. During the loss of consciousness, this pallor persists, the skin becomes cold and covered in profuse sweat. The pulse is weak, sometimes barely palpable, and muscle tone is low. Deep reflexes are sluggish but elicitable. The pupils are dilated, and their reaction to light is somewhat sluggish. The loss of consciousness can vary in depth and duration—from a few seconds to several minutes. Convulsions and involuntary urination are not characteristic of fainting. Patients regain consciousness, and some weakness, nausea, and frequent urination are noted for a period following the attack.
Sleep Disorders
The description of sleep disorders within a chapter on disturbances of consciousness may raise doubts and objections. However, sleep itself is one of the altered states of consciousness, and its disorders—such as somnambulism, certain types of night terrors, and the like—are very closely related to epileptic seizures or represent psychiatric equivalents of seizures. Therefore, we consider it appropriate to discuss sleep disorders in this chapter.
There are many classifications of sleep disorders. Based on phenomenology, most researchers divide sleep disturbances into insomnias, hypersomnias (increased sleep duration), and parasomnias (various disturbances), as well as phenomena occurring during sleep. According to their duration, these types of disorders are classified into short-term (narcolepsy, Pickwickian syndrome, night terrors, hypnagogic/hypnopompic states) and long-term (lethargy, other hypersomnias) sleep disorders.
The Etiology of sleep disorders is diverse. Regarding psychological causes, one can distinguish reactive (associated with a traumatic life situation) and endogenous (associated with mental illness) factors. Disturbances may also arise from changes in environmental factors (jet lag, shift work, noise, Temperature fluctuations, etc.), somatic and neuroendocrine diseases that hinder normal physiological processes during sleep (e.g., nasal congestion) or are accompanied by pain syndromes, and The Use of neurotropic pharmacological agents and substances (psychostimulants, hypnotics). Particularly severe sleep disorders occur in organic lesions of brain structures involved in The regulation of sleep, as well as in primary genotypic impairment of cerebral mechanisms regulating sleep and its cyclicity (narcolepsy).
Insomnia
The term "insomnia" is imprecise because under pathological conditions, sleep is modified rather than disappearing entirely. In insomnia, the transition to sleep (sleep onset) and/or the maintenance of sleep is impaired, and total sleep duration may be reduced. This disorder is very common and occurs more frequently in elderly individuals.
Disturbances are classified into presomnic (difficulty falling asleep), intrasomnic (nighttime awakenings), and postsomnic (awakening disorders) categories.
When experiencing sleep-onset insomnia, patients often feel sleepy, go to bed, but sleep seems to "vanish into thin air." Falling asleep is hindered by thoughts of unresolved problems and unfinished tasks; time drags on endlessly, and every position in bed feels uncomfortable. Myoclonus (sudden muscle twitches) sometimes occurs. Sleep-onset difficulties cause patients severe distress even when the actual time it takes to fall asleep is relatively short (about 20 minutes).
Intra-sleep disorders include nocturnal awakenings, difficulty returning to sleep afterward, and a sense of insufficiently deep sleep. Post-sleep disorders are characterized by early morning awakenings accompanied by a feeling of unrefreshing sleep, lethargy, and a poor mood. Sometimes, a single patient may exhibit multiple types of sleep disturbances.
The causes of insomnia can vary widely. Among psychiatric conditions, it is triggered by depressive and anxiety states, neuroses, and the majority of psychoses.
Hypersomnias
Hypersomnias can be either paroxysmal (episodic) or protracted.
Narcolepsy is characterized by daytime sleep attacks, cataplectic episodes, hypnagogic and hypnopompic hallucinations, sleep-onset and awakening cataplexy, and nocturnal sleep disturbances. Excessive daytime sleepiness is the primary symptom. The patient experiences an irresistible urge to sleep under any circumstances, 3 to 5 times a day. The duration of sleep varies. Cataplexy manifests as a sudden loss of muscle strength and tone while consciousness remains completely clear. The patient may collapse, experience buckling knees, drooping of the head, or drop objects from their hands. Nocturnal sleep disruptions manifest as frequent awakenings and terrifying dreams. Just before falling asleep or waking up, patients may experience hallucinations, which are often frightening. Upon waking, the patient is frequently unable to make any movement at all (awakening cataplexy, or sleep paralysis). Narcolepsy arises from a disruption in the mechanisms regulating sleep and its cyclical nature. Its exact etiology remains unclarified.
Pickwickian syndrome predominantly occurs in individuals aged 40–50, more frequently in men. It manifests as daytime sleepiness, falling asleep in any situation, obesity, and sleep-related breathing disorders. Obesity, resulting from hypothalamic dysfunction, causes breathing difficulties—especially in the supine position—which can eventually lead to the development of Cor Pulmonale. Sometimes, Cheyne-Stokes respiration with apneic pauses develops during sleep. Consequently, patients' nighttime sleep is inadequate, and this sleep deficit is compensated for during the day. Furthermore, there are underlying impairments in the mechanisms of sleep regulation.
Hypersomnias are also observed in paroxysmal conditions (such as migraines and epilepsy). Quite prolonged periods of sleep (ranging from several hours to several weeks or even months) are classified as periodic hypersomnia or hibernation; these occur in patients with organic brain lesions (resulting from encephalitis, trauma, etc.) or are of psychogenic origin (lethargic states).
Permanent hypersomnias are observed rather rarely. An extension of nighttime sleep duration may be characteristic of healthy individuals as an individual trait, or it may occur temporarily as a defensive reaction to stress (especially in children), during neuroses and psychoses, with the use of medications (sedatives), as well as during the day due to insufficient nighttime sleep.
Parasomnias
Parasomnias encompass a wide array of phenomena whose manifestations are closely linked either to the sleep process itself or to partial, incomplete awakenings from it.
Motor Parasomnias
Somnambulism (sleepwalking) is one of the most striking motor disorders during sleep. It manifests as a person getting up during sleep, opening their eyes, and wandering aimlessly while performing coordinated movements without bumping into objects, sometimes even answering simple questions. During somnambulism, patients may engage in dangerous behaviors, such as climbing out a window or walking on a roof. Attempts to wake the patient are usually unsuccessful; the episode ends either with spontaneous awakening or by the patient returning to bed and continuing to sleep. Afterward, the episode is completely forgotten. Somnambulism is most common in childhood and adolescence and can occasionally be a manifestation of epilepsy.
Other motor phenomena during sleep may include somniloquy (sleep-talking), bruxism (Teeth grinding), head or body rocking, and leg movements. If such manifestations do not disrupt sleep and are not accompanied by psychopathological phenomena, they do not require Treatment and are not symptoms of a disease. However, it should be borne in mind that sleep-talking is quite frequently observed in epilepsy, while head or body rocking during sleep (jactatio) may indicate neuroses and neurotic personality development in the patient (these disorders are more characteristic of childhood).
Psychiatric Parasomnias
Night terrors are states of intense fear and motor agitation during nocturnal sleep. They occur predominantly in preschool and early school-aged children. There is evidence that night terrors arise against the backdrop of a narrowed state of consciousness (or a rudimentary twilight state), which is confirmed by the failure of attempts to wake the child and subsequent amnesia regarding these episodes. Night terrors manifest as a deeply sleeping child suddenly starting to scream and cry, with an expression of intense fear and open eyes. Children often call for their mother, yet fail to recognize their parents, push them away, and do not respond to questions. Fragmentary utterances indicate the presence of frightening dreams or hallucinations: "the black man is coming...", "chase her away...", "take them away from me...". Frequently, children sit up in bed, stand up, and perform automatic movements, much like in somnambulism. Such states last 15–20 minutes and are then followed by a return to sleep. In the morning, the child generally forgets the nighttime episode entirely. Night terrors tend to recur.
The psychopathology of night terrors remains insufficiently understood. At night, patients may experience overvalued fears (related to psychological trauma experienced during the day), delusional fears, and undifferentiated fears. A special place is occupied by paroxysmal, seizure-like fears that arise and cease abruptly, are tied to a specific time of night (1–2 hours after falling asleep), and tend to recur at regular intervals. Their Clinical presentation differs little from that described above. Night terrors occur in 4–5% of children, and are twice as common in children with epilepsy as in healthy peers. Paroxysmal fears are observed primarily in epilepsy, and less frequently in residual-organic brain lesions.
Nightmares can occur in both children and adults. They more commonly arise In the second half of the night or toward morning. In such instances, the person wakes up quickly and is generally able to recall the dream, which involved frightening images and experiences. Nightmares are more frequent in individuals prone to anxiety and depressive reactions.
Autonomic Parasomnias
Nocturnal enuresis, or involuntary urination during sleep, is the most common autonomic parasomnia, observed predominantly in childhood. Sleep in children with enuresis is typically deep, and involuntary urination mostly occurs during the first half of the night. Clinically, enuresis is classified into neurotic and neurosis-like forms.
Neurotic enuresis represents a form of systemic neurosis in children, whereas neurosis-like enuresis arises as a consequence of early organic Central Nervous system (CNS) damage. Pre-existing Urinary Tract diseases contribute to the onset of enuresis.
Respiratory Parasomnias
These can occur at any age, with their frequency increasing in the elderly. During sleep, against the background of slowed breathing, the tone of the Respiratory Muscles decreases, leading to a narrowing of the Airways; furthermore, the tone of the respiratory center diminishes. All these factors heighten the likelihood of sleep-related breathing disorders. The frequency of such disturbances increases in cases of obesity and cardiovascular and respiratory diseases. In infants, due to CNS immaturity and other physiological peculiarities (especially in newborns), the probability of respiratory disorders rises, and in the opinion of some authors, these may lead to sudden infant death syndrome (SIDS).
During sleep, alongside the aforementioned disorders, Cardiac Arrhythmias, angina pectoris, myocardial infarction, and certain gastrointestinal disturbances (such as gastroesophageal reflux) may also occur, while some patients experience migraine attacks while sleeping.
Mental disorders are one of the key etiological factors behind sleep disturbances. Neuroses are most frequently accompanied by insomnia, difficulty falling asleep, shallow nocturnal sleep, and frequent nighttime awakenings. In the morning, patients find it hard to wake up and feel unrefreshed. Hypersomnia is observed less often. Systemic neuroses accompanied by parasomnias (nocturnal enuresis, night terrors, and less frequently somnambulism or sleep-talking) are more characteristic of children. In schizophrenia, sleep disturbances are a frequent symptom; however, they receive less attention because patients voice fewer subjective complaints regarding sleep. Sleep may take on a paroxysmal character and is independent of the time of day. Often, following a brief period of deep sleep, patients may remain in a drowsy state for a long time. The total sleep duration in schizophrenia patients may decrease, but in some cases, both the duration and depth of sleep can increase.
In depressive and manic syndromes, sleep disturbances are a mandatory symptom and occur in the majority of patients. In depressed patients, the duration of nighttime sleep is significantly reduced due to difficulty falling asleep, frequent night awakenings, and, in endogenous depression, also early morning awakening. Since depressive symptoms tend to worsen in the morning, early awakenings are particularly distressing for patients. In a manic state, the duration of nighttime sleep is pathologically reduced (to 2–3 hours). The main characteristic of manic patients is that they feel no desire to sleep and do not voice any complaints. On the contrary, they remain full of energy at any time of the day.
In organic brain diseases, sleep disorders are diverse, with particularly severe disturbances occurring when structures involved in sleep regulation are damaged. A well-known example is lethargic encephalitis, where patients suffer from pronounced hypersomnia, as well as prolonged insomnia associated with diencephalic syndrome.
Epilepsy is characterized by seizures occurring during sleep, as well as parasomnias in the form of somnambulism, somniloquy (sleep-talking), or night terrors. In epilepsy, these disorders are typically paroxysmal, stereotyped, and recur at specific intervals.
Thus, virtually all mental illnesses present with some form of sleep disturbance, and in certain cases (such as manic or depressive states), sleep disruption serves as a crucial diagnostic symptom. In many borderline psychiatric disorders and in depression, sleep disturbances are so distressing to the patient that they become the primary complaint and require immediate correction.
Pathological prosonnic states (sleep drunkenness) belong to disorders of arousal, occurring when a patient, not fully waking from deep sleep accompanied by vivid and often terrifying dreams, cannot distinguish them from reality. Motor function is the first to be released from inhibition, and the patient may perform a series of actions—sometimes dangerous to themselves and others—which they subsequently do not remember.
Below is a generalized Overview of consciousness disorders.
Disorders of Consciousness
1. Clouding of consciousness:
1.1. Obnubilation
1.2. Somnolence
1.3. Stupor
1.4. Sopor
1.5. Coma
2. Confusional states
2.1. Delirium
2.1.1. Muttering delirium
2.1.2. Professional delirium
2.2. Amentia
2.3. Oneiroid syndrome
2.4. Oneirism
2.5. Asthenic confusion
3. Paroxysmal twilight states of consciousness
3.1. Twilight state
3.1.1. Simple twilight state
3.1.1.1. Fugues
3.1.1.2. Trance
3.1.1.3. Somnambulism
3.1.1.4. Absence
3.1.2. Complex twilight states
3.1.2.1. Hallucinatory
3.1.2.2. Delusional
3.1.2.3. Hysterical
3.1.3. Auras of consciousness
3.1.3.1. Sensory
3.1.3.2. Motor
3.1.3.3. With psychopathological phenomena
3.2. Epileptic phenomena
3.2.1. Absence
3.2.2. Generalized tonic-clonic seizures
4. Fainting (syncopal states)
4.1. Reflex
4.2. Symptomatic
5. Sleep disorders by phenomenology
5.1. Insomnias
5.2. Hypersomnias
5.3. Parasomnias
5.3.1. Movement parasomnias
5.3.2. Psychic parasomnias
5.3.3. Autonomic parasomnias
5.3.4. Respiratory parasomnias
Self-awareness
Self-awareness is an individual's conscious perception of their own "I" as a personality, recognizing bodily functions, mental acts, and spiritual processes as belonging to that "I." The development of self-awareness is a dynamic process. It begins with the emergence of self-sensations in a child during the first or second year of life. Subsequently, by the age of 12, The formation of body schema and concepts regarding bodily Organization is completed. This results in the emergence of self-esteem, that is, the ability to recognize one's own skills and distinct psychological qualities.
A higher stage of self-awareness is the formation of ego-identity, which represents a subjective sense of continuous sameness (E. Erikson). Ego-identity arises from the sum of roles accepted by an individual, As a result of the interaction between identifications and opportunities with the external world, as well as knowledge of how surrounding people react to these interactions. Clearly, ego-identity has a psychosocial nature and develops through a person's interaction with their environment. The formation of ego-identity is a complex process that occurs simultaneously at conscious and unconscious levels. It is inherently dynamic: it never reaches final completion nor remains static. It is a continuous process of expanding and deepening knowledge about one's "I," which refines self-awareness and self-knowledge. If the "I" suddenly perceives the inadequacy of its existing identity, a state of confusion naturally arises, accompanied by the desire and motivation to overcome it; the frustrating or conflicting situation is then investigated, and a search for new conditions of personal functioning is initiated. Ego-identity is considered optimal when a person feels an inner confidence in the direction of their life path. For ego-identity, what matters is not the specific content of individual experience at a given moment in time, but the capacity to perceive concrete situations as integral links in a single, continuous process. In many cases of mental pathology, a disruption of this continuity occurs, leading to conflicts akin to Shakespeare's tragedy ("The time is out of joint...").
The development of self-awareness is the formation of ego-identity in the form of a chain of crises and internal conflicts that trigger personal shifts and alterations in self-awareness.
Formation of Ego-Identity
E. Erikson identifies the following stages in the formation of ego-identity:
1. Development of basic trust. By the age of eighteen months, a child must acquire a sense of trust in the surrounding world, which serves as the foundation for developing positive self-feelings, a support for acquiring new experiences, and a motive for new types of activities. In a trust-fostering environment, a child feels loved, accepted, and protected. The feeling of trust gives concrete meaning to an infant's experience. The child learns to distinguish people and objects, and develops a first, vague sense of being a separate entity.
2. Development of autonomy. By the age of 3–4, a child recognizes their individual "I" as an active operating agent. Naturally, this "I" encounters disapproval. By overcoming it, the child transitions from complete dependence to relative independence, which gives them grounds to feel like an autonomous being capable of independent action. Hence the numerous cries of "I can do it myself." Persistent attempts by adults to limit a child's autonomy lead to conflicts and crises. How these are resolved determines whether further development proceeds in the direction of autonomy or toward insecurity, shame, and doubt.
3. Development of initiative. Up to the age of 7, an extremely important driving force is curiosity, characterized by energetic and persistent cognitive activity. This is driven by free mastery of one's own body, adequate speech development, a good grasp of events, an expanding social circle, and a desire to test the boundaries of what is permitted. Curiosity is repeatedly punished, which can lead to the formation of a sense of guilt and lack of initiative.
4. Development of industry. During the school years, a child masters systematic, organized activities, performing them independently or collaboratively. By engaging in these activities, the child strives for recognition and approval and becomes ready to adopt parental roles. Various schemes, toolsets, and stereotypes of standard activity are mastered, leading to a desire for self-expression. Diligence is shaped through independent activity. If an individual fails in this due to a lack of skills or poor performance, a sense of inferiority arises, causing the child to believe they are incapable of accomplishing what is expected of them, and consequently, that there is no point in even trying. The issue of competence is acutely pressing because there are too many mandatory requirements and too little freedom of action to achieve competence in another sphere.
5. Development of ego-identity. The main questions resolved by an individual at this stage are: "Who am I?", "What to believe in?", "How to relate to oneself?", "How to evaluate others?" The source of the sense of ego-identity lies in various identifications rooted in childhood. Initially, role models include parents, siblings, and peers; later, the number of identifications grows significantly. On this basis, the "ideal-self" and the set of roles adopted by the individual—which do not contradict the "ideal-self"—are formed. In the absence of ego-identity, role diffusion or a "pseudo-identity" based on rebellion and denial becomes prominent. The main dangers of this period include the blurring of the sense of "I," accompanied by uncertainty about how to live further, confusion, and bewilderment. The developmental trajectories of this state can vary: estrangement from family, inability to plan for the future, failure to effectively utilize one's potential, inability for productive labor, and a negativistic identity prone to deviant behavior.
6. Development of solidarity. By the age of 25, a person must master a sense of solidarity, realized through intense friendships with significant others or intimate relationships with a steady partner. Friendship, love, and sex become a guarantee of a person's solidarity with the world, allowing them to share these experiences with others and receive them in return. Without these feelings, a deeply dramatic isolation arises, which can lead to complete alienation.
7. Development of generativity. Up to the age of 50, an active creative drive continues, which holds vital significance for the individual. Through this, they can self-actualize outside the family in the professional sphere, improve society, or raise children. If such personal GROWTH AND DEVELOPMENT of self-awareness are absent, stagnation occurs, characterized by a fixation on satisfying one's own immediate needs, whims, and caprices.
8. Development of ego-integrity. The primary task after the age of 50 is the development and preservation of a sense of dignity and the value of the life lived. Without this, there is a severe risk of despair, fear of death, and a feeling that life has been lived in vain.
Disorders of Self-Awareness
At each stage of the development of self-awareness and ego-identity, disturbances may occur. These can manifest as individual conflicts (crises) or as psychopathological disorders. Three groups of self-awareness disorders are distinguished:
— states of perplexity;
— depersonalization-derealization states;
— states of psychic automatism.
All these Psychopathological Syndromes share at least one of Karl Jaspers' criteria for impaired consciousness. In perplexity, a feeling of psychic alienation arises; in depersonalization-derealization, there is a subjective awareness of the altered state of the "I" and the surrounding world; in states of automatism, these changes acquire the character of an external, objective force and extraneous coercion. Syndromes of impaired self-awareness are underpinned by a range of psychopathological disorders in perception (hallucinations, psychosensory disorders) and thinking (sperrung, flight of ideas, mentism), but when experienced as disorders within the mental "I," they acquire specific features characteristic of ego-identity psychopathology.
The syndrome of perplexity manifests as a painful incomprehension by the patient of their situation and/or condition, which appear unusual to them and imbued with a new, obscure meaning; it is frequently accompanied by anguish, anxiety, and fear. Karl Jaspers considered perplexity to be a "comprehensible reaction of a normal personality to the breakthrough of acute psychosis while retaining awareness of the ominous feeling of alteration." First and foremost, attention is drawn to the affect of incomprehension specific to the perplexity syndrome. It manifests in spontaneous or reflective statements by patients: "Something is happening to me," "I don't understand anything...", "I can't figure out my surroundings," "I think I'm going crazy." Speech is hesitant, rich in interrogative intonations, sometimes confused, occasionally incoherent, marked by latent pauses and prolonged paradoxical silence. Words and phrases of the interlocutor are frequently repeated. Some patients in a state of perplexity are hypokinetic and, left to themselves, sit in silence, whereas in other cases, impulsive agitation may occur. Patients' facial expressions are also changeable: one may observe a frozen mask of surprise, astonishment, concentration, or embarrassment, or these facial expressions may succeed one another. An important sign of perplexity is excessive distractibility (hypermetamorphosis); minor changes in the surrounding environment (sounds outside the window, water dripping from a tap) are immediately reflected by the patient through facial expressions, movements, or descriptive verbal utterances ("The wind blew," "The water is running," "It's ten o'clock now"). Perplexity fluctuates over short intervals of time. As a rule, it intensifies during conversation; as questions approach the period of illness onset, the patient's answers become increasingly hesitant until they ultimately lose the ability to recount anything about their current state. With the progression of the disease, perplexity may combine with various productive disorders: figurative delusions, verbal hallucinations, psychic automatisms, false recognitions, as well as clouding or confusion of consciousness. Deepening of the perplexity syndrome can lead to a state of torpor (ladenness), characterized by numerous psychopathological disorders with complete estrangement from the environment. Torpor can occur in Brain Tumors or during attacks of periodic schizophrenia. The perplexity syndrome rapidly disorganizes a patient's mental state and requires immediate psychiatric intervention.
Depersonalization-derealization states denote various variants of self-awareness disturbances in which voluntary acts, actions, emotions, thoughts, and bodily functions are experienced as subjectively alien, stripped of the quality of personal autonomy. Most notably, the alienation of the perception of the environment may occur—allopsychic depersonalization-derealization. The environment is perceived as altered, strange, ghostly, frozen, and devoid of life. Not only do the qualities of visual, auditory, and other sensory modalities change, but also the sense of time: it slows down, vanishes, stops, or, conversely, flows exceptionally fast. Derealisation manifests through symptoms of déjà vu ("already seen," "already heard," "already felt," "already experienced") or, conversely, jamais vu ("never seen," "never experienced"), etc. Derealisation often arises acutely as a logical continuation of the disturbance of self-awareness against the background of the perplexity syndrome. These disorders are short-lived and accompanied by an unpleasant emotional background. They can be observed in certain mental illnesses: schizophrenia, endogenous depression, epilepsy, organic brain diseases, and neuroses. Alienation may affect elementary forms of activity: the alienation of one's own movements, sensations, and bodily functions—somatopsychic depersonalization. The bodily component of the "I" seemingly gradually slips out of the control of self-awareness, resulting in a loss of the physical "I." Patients lose the sensation of pain; they no longer feel their heartbeat, breathing, urination, or body weight. This is typically accompanied by a depressed mood, often with anxiety and agitation. Emotional reactions, particularly higher emotions, may also become alienated. These, as is known, consist of two components: somatic (emotional expression) and psychic (emotional experience). With the intensification of depersonalization, emotional blunting reaches the point of a loss of the emotional "I" accompanied by a painful sense of "mournful numbness."
States of psychic automatism belong to the pathology of self-awareness because in them, the alienation of various properties and qualities reaches its utmost expression. They become seemingly completely severed, torn away from the "I," and exist independently of it. To the experience of alienation of these properties is added, for the first time, the component of the influence of an extraneous force, which is absent in phenomena of perplexity and depersonalization-derealization.
Associative, sensory, and motor psychic automatisms are distinguished.
Associative (ideational) automatism is accompanied by a sense of alienation of one's own thought processes. Initially, the patient experiences changes in thinking regarding its pace and structure, along with phenomena of mentism. At the same time, these symptoms are perceived by the patient as their own, with only a loss of control over them being present. Such a state is termed "minor psychic automatism" according to G. de Clérambault (1927). Subsequently, a sensation arises that thoughts, desires, and mental images originate externally and only thereafter become the patient's own (anticipatory experiences). A feeling may emerge that thoughts become known to everyone around (thought broadcasting syndrome). Sometimes it seems to the patient that others are repeating their thoughts (thought echo syndrome). With further elaboration of associative automatisms, "thought insertion," "telepathy," and "mental conversations" of a varied, predominantly unpleasant thematic content appear. This disorder, devoid of an acoustic component, is referred to as psychic hallucinations; they heighten the involuntary and alienated nature of mental processes. When an acoustic component joins the psychic hallucinations, the condition is described as "inner voices," that is, verbal pseudohallucinations.
Along with verbal pseudohallucinations, patients may experience other forms, most commonly visual ones. They develop a delusional conviction that an external force is involved in generating these pseudohallucinations (delusions of control). Sometimes, so-called pseudohallucinatory memories occur, where a memory of a pseudohallucination is perceived by the patient as a memory of a real event.
Sensory automatism manifests as unpleasant, distressing, and sometimes painful sensations in internal organs, accompanied by the firm belief that these feelings are 'made'—that they are artificially induced from the outside for a specific purpose (delusions of physical influence). Patients report feelings of constriction, twisting, pain, cold, and others. Sensory automatism also includes sensations of influence over the patient's physiological functions: they claim their appetite, SENSE OF SMELL, or taste is being spoiled, urination is delayed or provoked, or sexual arousal is artificially induced.
Motor automatism is the patient's conviction that their actions and deeds are driven by some external force. Initially, this presents as isolated, unwanted involuntary gestures or facial movements, brief states of immobility, and later progresses to more complex actions and behavior. Throughout this, patients remain entirely convinced that their actions are externally controlled: someone is 'moving their hands' or 'speaking with their tongue'.
The alienation of the 'I'—that is, the disruption of self-awareness in psychic automatism—is particularly vivid in delusions of forced transformation, where the subject believes they are being converted into another person, an individual of the opposite sex, an animal, or even an inanimate object. Along with Changes in external appearance, alterations in internal essence may also occur, thus giving rise to a specific subtype of delusion: metamorphosis.
Symptoms and Syndromes of Mental Disorders
Mental illnesses, much like other bodily diseases, possess their own specific indicators—symptoms. No single sign ever appears in isolation; as a disease develops, its manifestations are observed in complex combinations. A constellation of individual disease signs united by a common Pathogenesis and pattern of manifestation constitutes a syndrome.
A syndrome determines the qualitative features and the depth of a mental illness. Syndromes and their sequential evolution form the clinical picture of the disease and its progression. The illness as a whole represents a process manifested by the characteristics of emerging syndromes and their shifts—in other words, a 'chain reaction' characteristic of each specific disease. The Features of the pathological process determine the connections between the states that comprise it, while The Nature of these connections entails specific cause-and-effect relationships. The succession of syndromes—that is, the linkage of states acting as intermediate links for pathogenic causes—reveals the nosological features of the pathological process, as well as The Unity of etiology, pathogenesis, and cause-and-effect dynamics.
In psychiatry, syndromic analysis is of paramount importance due to the significant polymorphism of symptomatology in mental disorders. The precise definition of a syndrome facilitates the systematization of diverse disease manifestations, AIDS in Differential Diagnosis, and determines effective therapeutic and rehabilitative strategies for the psychiatric patient.
Syndromes can be minor (simple) or major (complex). For instance, asthenic syndrome frequently manifests with numerous neurasthenic features—irritability, increased fatigue, and tearfulness. Against the backdrop of an asthenic state, delusions, hallucinations, or altered consciousness may develop, indicating the emergence of major (complex) syndromes, which signifies the generalization of the pathological process.
The clinical picture of syndromes comprises positive and negative disorders. The former include hallucinatory-delusional, catatonic, and Affective Disorders, as well as confusion of consciousness (such as oneiroid states and delirium); the latter encompass emotional-volitional blunting, personality anomalies, and dementia. Positive and negative syndromes may manifest in close interrelation.
Depending on which sphere of mental activity is primarily impaired, syndromes are classified into neurotic, neurosis-like, affective, those involving pathologies of perception and thought, intellectual-mnestic disorders, disturbances of consciousness, and others.
Asthenic Syndrome
Its primary hallmark is irritability, manifesting as heightened excitability and agitation, combined with weakness and exhaustion. Patients complain of rapid physical and mental fatigue, as well as an inability to sustain prolonged effort. Quite characteristic are sleep disorders (difficulty falling asleep, superficial sleep, frequent waking, etc.), daytime sleepiness, and autonomic dysfunctions—most frequently vascular tone lability, transient fluctuations in blood pressure and pulse, and generalized or localized hyperhidrosis.
Hypersthenic and hyposthenic variants of asthenic syndrome are distinguished. The hypersthenic variant is characterized by a lowered excitation threshold, manifested as irritability, a sense of inner tension, phenomena of asthenic mentism, and restlessness. In the hyposthenic variant, phenomena of general weakness and exhaustibility come to the fore, accompanied by a substantial decline in work capacity.
Cenestopathic Syndrome
This syndrome is underpinned by poor overall well-being manifested through vivid pathological sensations in various PARTS OF THE body. Although patients describe these sensations as 'pains,' unlike true pain, they are dynamic, less distinct, unusual, and bizarre to the patient, and are accompanied by anxiety, apprehension, and fear. Unlike sensory disorders resulting from specific organ pathology, these do not depend on damage to those particular organs and represent disorders of the general sense (cenesthesia), in which the traits of bodily sensations and affects are inextricably intertwined. Patients describe such phenomena indirectly, through comparisons and spatial-tactile metaphors. However, they do not acquire the essential traits of perception, such as 'objectness,' retaining a quality of contingency—a 'as if' character (unlike visceral hallucinations in paranoid-hypochondriacal syndrome). Patients frequently complain of significant mental and physical distress accompanied by unusual bodily projections: 'anxiety in the legs,' 'fluttering in the abdomen,' and so on. Sometimes these pathological sensations closely resemble algias and are difficult to differentiate from them; some researchers refer to this type of cenestopathy as cenestalgia.
Patients do not voice spontaneous complaints regarding mood changes. When questioned, primary mood disorders are denied, while anxiety, agitation, and depression are experienced and evaluated by the patients as a natural, understandable reaction to poor physical health. Notions regarding the presence of any specific, serious illness are short-lived; patients do not insist on them and instead rely more on the physician's opinion. Behavior is predominantly driven by a desire to rid themselves of physical malaise rather than to establish a diagnosis. Cenestopathies are very frequently accompanied by autonomic disturbances.
Cenestopathic symptom complexes in their pure form are quite rare. More often, they are combined with overvalued hypochondriacal ideas or a depressive state, operating within the structure of other syndromes (such as cenesto-hypochondriacal syndrome or hypochondriacal subdepression) and forming their psychopathological core.
Cenesto-Hypochondriacal Syndrome
This state is defined by a complex of cenestopathies coupled with a pronounced overvalued hypochondriacal mindset. It is rooted in sickly well-being involving cenestopathies accompanied by apprehension, anxiety, and fear. As in cenestopathic syndrome, bodily sensations may resemble the feelings and pains associated with somatic diseases (homonymous sensations) or, conversely, differ significantly due to their unusual and bizarre nature (heteronymous sensations). Unlike paranoid-hypochondriacal syndrome, these bodily sensations do not acquire the character of cenesthetic hallucinations, and furthermore, there is no persistent, fixed idea regarding a specific disease that would require correction.
Unlike in cenestopathic syndrome, fears of a serious illness are not fleeting; rather, they are highly topical, affectively saturated, and dominate the patient's consciousness. Aligning with this motive, the patient's behavior is driven not so much by a desire to escape unpleasant sensations or 'pain,' but by an insistent search for a diagnosis in order to clarify it and prevent dangerous complications of the illness.
Primary mood disturbances, as in cenestopathic syndrome, are likewise denied by patients in this case. A poor state of health with a mixed subdepressive-anxious appearance, much like in hypochondriacal depression, is experienced and rationalized through general sickly well-being. Unlike hypochondriacal depression, this syndrome involves anxiety and apprehension, yet depression predominates, which is reflected in the pathological compulsion to seek out illness and clarify the diagnosis. Hence stems the patient's active drive toward diverse medical examinations.
Obsessive-Phobic Syndrome
This syndrome is defined by the coexistence of two interrelated phenomena: obsessions (intrusive thoughts) and phobias (fears), which frequently manifest as paroxysmal affective panic before later taking the form of moderate distress. Accordingly, phobic anxiety can vary in intensity from mild agitation to panic and terror. The content of such apprehensions and fears is diverse, yet, as a rule, it boils down to an imagined threat to existence.
From these core fears, various secondary obsessive apprehensions develop, linked to external objects and situations that are not actually dangerous. Examples include obsessive fears of darkness, solitude, confined or open spaces, sharp objects, traveling by train, bus, or airplane, as well as fears of blushing, making a faux pas, contamination, heights, and others. Obsessions and phobias in a patient are generally united by a singular underlying theme. Patients are usually well aware that the degree of danger or threat is exaggerated by them, particularly during bouts of phobic anxiety. However, this partial critical insight and the realization that others do not view the situation as genuinely dangerous do not make the phobias disappear. Consequently, patients typically avoid such situations and objects, sometimes out of fear of experiencing the fear itself (so-called phobophobia). Throughout clinical observation, phobic anxiety and the active efforts to cope with it fluctuate across a wide range. Sometimes the limiting impact of a phobia leaves the patient entirely housebound, venturing outside only when accompanied by relatives or acquaintances. The lack of immediate assistance or the inability to quickly exit a room or a vehicle is one of the key triggering mechanisms for many phobias.
The syndrome includes a vital asthenic or cenestopathic baseline that is overshadowed by more prominent symptoms, becoming apparent only during the remission of phobic attacks. In such cases, unpleasant bodily sensations appear or sharply intensify, most frequently in the cardiac region. Patients experience health-related anxiety, believing they are dying or that everything is over (thanatophobia). Dispyschophobia leads to a severe impairment in concentration and a disorganization of thinking, ranging from confusion and chaotic thoughts to mental blockage. As these phenomena intensify over a short period, patients develop not only fear but also a sense of losing their mind. Typically, this state subsides after a few days or even hours, only to return after some time.
Unlike overvalued hypochondriacal ideas—which are experienced as one's own—these apprehensions are accompanied during acute flare-ups by an awareness of alienation, while clear intervals bring a full understanding of their groundlessness.
Depersonalization-Derealization Syndrome
The core feature of this syndrome is a direct sense of one's own psychic alteration, reflecting qualitative disorders of self-awareness, or "I-disturbances"—the experience of the integrity, activity, and identity of the "I" in contrast to the external world. One's own mental processes lose their natural, immediate character and seem to become alien. As a rule, such disorders are predominantly expressed in one sphere, and accordingly, they are referred to as autopsychic or allopsychic disturbances. At this stage, however, there is no detachment or alienation of one's thoughts, actions, and deeds.
One's mental processes, bodily sensations, or external objects and surroundings appear qualitatively altered, distant, or operating automatically, almost unrealistically. Patients experience their feelings, thoughts, and drives as modified while simultaneously perceiving themselves from the outside, as it were. Quite often, patients complain of a feeling of self-duplication. The presence of introspective displacement and excessive reflection is typical. These states are experienced with considerable distress. Quite frequently, depersonalization overlaps with phenomena of derealization. Disorders of consciousness arising from depersonalization phenomena, alterations of one's own "I," and the external world are accompanied by a sense of detachment from the environment. In such cases, patients complain that they have begun to perceive the world differently; everything appears impoverished, lifeless, artificial, and unreal, as if in a dream. The retention of a sufficiently critical attitude toward these phenomena distinguishes this syndrome from Delusional syndromes of similar content. At the same time, there is an awareness of the pathological nature of what is happening and of the alteration in one's somatopsychic integrity. The fear of a profound mental disorder most often compels the patient to keep everything secret and avoid disclosing it. These pathological sensations are diffuse and uncertain, predominantly concentrated in the head, and muffled by an overarching sense of self-alteration. Accounts of one's well-being are generally detailed and verbose, accompanied by an Analysis of the disturbances troubling the patient. If the described experiences acquire an obsessive character and are accompanied by phobic paroxysms, this state should be classified as an obsessive-phobic condition.
This syndrome is rarely observed in its pure form. Mostly, this symptom complex is part of the structure of other syndromes, such as depressive, obsessive, and other syndromes involving altered consciousness (for instance, in epileptic aura).
Syndrome of Pathological Fears in Children
This definition encompasses a psychopathologically heterogeneous group. These are states of causeless fear occurring predominantly at night, especially right before waking up. The fear is accompanied by agitation, screaming, crying, a terrified facial expression, and autonomic reactions. The content of night terrors is poorly differentiated. Short-term fears may give way to more prolonged ones, with the fear persisting throughout the day. With the emergence of individual rational processing of real events, the instinctive fears typical of infants—such as sudden loud noises or loss of support—are replaced by fears of darkness, solitude, and abandonment. Pathological fears in children are characterized by significant inadequacy and can manifest as timidity and apprehension toward familiar objects and surrounding people (fear of a specific single object, such as insects, fur, etc.).
Such states should be distinguished, on the one hand, from fears of a prolonged nature that most commonly manifest as fear of death and hypochondriacal anxieties, and, on the other hand, from acutely arising fears accompanied by visual and elementary auditory hallucinations, agitation, and sleep disturbances, which share much in common with the residual delusional states of adults.
Tics and Motor Obsessions Syndrome in Children
Tics are characterized by the irregular recurrence of involuntary and purposeless movements in a single muscle or functional muscle group (excessive blinking, Nose-twitching, sniffling, shoulder shrugging, head jerking, etc.). Some of these involuntary movements take the form of more complex facial or motor acts accompanied by an experience of alienation. In such cases, they are classified as obsessions, which patients can inhibit for a short time by an effort of will. However, patients very quickly feel the urge to perform them again (smoothing Hair, tugging at clothes, etc.). Elementary motor automatisms, tics, and motor obsessions proper are accompanied by significant sensory-motor disturbances which, due to their vague and indefinite nature, are described by patients with great difficulty using imagery and comparisons as something bothersome and annoying.
The psychopathological picture of this syndrome is complemented by subdued dysthymic phenomena and, occasionally, rudimentary sensitive-type ideas of reference, the content of which is linked to an awareness of one's inferiority compared to peers. Sometimes, on the basis of primary doubts, apprehensions, and phobias, secondary obsessive movements develop that have the character of symbolic defense (motor and behavioral rituals), indicating the progression of the disease.
Affective Syndromes
Depressive Syndrome
This is a variant of depressive states characterized by a profound suppression of the triad's main components: affective, ideational, and motor. Patients are depressed, sorrowful, and akinetic, with a frozen expression of sadness on their faces. Visually, such patients appear dejected; their heads and shoulders are dropped, and they are often nearly hunched over. Their speech is slowed, and they complain of a depressed mood, a loss of the ability to think quickly, slowed and impoverished thoughts or a lack thereof, and memory decline. The depressed mood, especially pronounced in the morning hours, is accompanied by a heavy, painful sensation in the chest and, much less frequently, in the epigastric region, head, or other parts of the body. Thus, depression acquires vital characteristics. The body itself feels heavy or, conversely, completely unfelt, as if it were entirely absent. Concurrently, constipation, sleep disturbances, loss of appetite, and a decrease in potency and libido are generally observed.
The surrounding world is often perceived as having faded; sounds, smells, and colors have become muted, and taste has dulled or disappeared altogether. Patients evaluate their personality and abilities in a self-devaluing manner, diminishing everything positive and denying everything good. They speak of feelings of guilt and express unfounded ideas of guilt (primary ideas of guilt). Sometimes they punish themselves for real but minor misdeeds. They constantly accuse themselves of inactivity, and particularly often, of burdening the lives of their loved ones and everyone around them. They consider all of this to be their grave fault (secondary ideas of guilt). The future is viewed in bleak colors; patients believe that everything will be bad, that there will be no more joy, and that life is meaningless. Patients see no Prospects in life. Tendencies toward suicide manifest in various ways: from general statements about the futility of life to serious attempts.
Anxious Depression Syndrome
This type of depression is characterized by the predominance of anxiety and agitation. Motor retardation is absent. Mood depression recedes into the background; sometimes patients do not complain of a depressed mood at all. At the forefront is anxiety—often groundless—and a tense anticipation of catastrophe. Patients are unable to sit still; in mild cases, they simply pace back and forth, while in more severe cases, they rush around the ward, tear at their hair and clothing, sometimes attempt to smash their heads against the wall, grab at those around them, and beg for help or to be killed. At the peak of the disorder, a state of melancholic raptus may occur. In severe cases, the movements and utterances of patients become stereotyped: they sway on the bed, wring their hands, and repeat the same exclamations (The phenomenon of anxious verbigeration). Suicide attempts are quite frequent, sometimes occurring almost in the presence of medical staff. Patients do not conceal their suicidal intentions. Unlike the depressive-paranoid syndrome, this state is not characterized by the development of sensory delusions of depressive content and delusions of intermetamorphosis. If the latter is sufficiently pronounced, the syndrome should be classified as depressive-paranoid.
Manic Syndrome
The primary signs of manic syndrome are a pronounced elevation of mood, psychomotor agitation, and an accelerated flow of associative processes. Patients are extremely active, easily excitable, and plan a great deal; increased activity is observed, but it is coupled with a high level of distractibility by external stimuli. Very frequently, patients overestimate their capabilities, abilities, and personal traits. With the deterioration of the patients' condition, their activity loses its purposeful character, becomes disorganized, motor agitation grows, and distractibility intensifies. With the intensification of the manic state, agitation increases. Consequently, in response to any remark or prohibition, patients become extremely irritable and frequently angry (angry mania). A deepening of the malignant-irritable affect accompanied by a significant increase in psychomotor agitation constitutes raving mania. A particular acceleration of associative-ideational processes and high instability of attention is referred to as mania with flight of ideas. With extremely high lability of attention, patients become incapable of retaining impressions of their surroundings for long, their judgments become chaotic, and their speech correspondingly disjointed (confused mania).
In some cases of manic states, motor activity predominates over intellectual activity (unproductive mania). When the affect of elevated mood takes the form of exclusive enthusiasm, exaltation, or ecstasy, the agitation accordingly assumes the form of exalted mania. This category also includes manic states with senile-like features, frequently observed in patients aged 70 and older. In such a state, due to euphoric-silly behavior, patients resemble demented individuals, but the "dementia" vanishes after the pathological affective state subsides. Mania in the elderly may proceed with confusion, clouded consciousness, and speech disturbances (lack of coherence in speech). Such disorders are observed at the peak of the attack and are followed by subsequent amnesia.
Affective-Delusional Syndromes
Depressive-Paranoid Syndrome
This belongs to complex syndromes where, alongside affective disorders intertwined with anxiety and agitation, delusions are also present, the structure and plot of which have a depressive character with ideas of guilt and condemnation. Patients are constantly in a state of anxiety. They "hear" everyone around them condemning and cursing them, and preparing a terrible execution for them. Direct orientation in the environment is altered by delusional content (for example, a patient in a psychiatric hospital is convinced that they are in a prison disguised as a hospital, or in a judicial institution with guards posing as medical staff). The semantic perception of the environment is disrupted, although there are generally no clinical signs of clouded consciousness. A significant manifestation of this syndrome is the delusion of intermetamorphosis (staged scenarios), intertwined with verbal illusions and misidentification.
Syndrome of Depressive Paraphrenia
In this state, delusions of guilt and punishment, destruction and negation acquire a global, fantastic character, reaching the degree of megalomanic nihilistic delusions. Total disorders of self-awareness are characteristic, along with the experience of transforming into entities that personify world evil, animals, or inanimate matter, such as stone. Patients are convinced that their guilt and sinfulness are infinitely great, that the whole world is perishing because of them, and sometimes these experiences take on an absurd character. Patients claim that the world has perished, that it no longer exists, and that they do not exist either (the strictly nihilistic variant of Cotard's syndrome), or that their body has become empty, internal organs have rotted or turned to stone (the hypochondriacal variant of Cotard's syndrome). In some Variants of the syndrome, patients claim that they do not perish spiritually, but, on the contrary, remain in eternal immortality and are doomed to endless torment.
Manic-paranoid syndrome
In this state, against the background of a distinct elevation of mood, patients seem to understand everything happening around them in a new way. Everything around is illuminated by something festive and solemn. Patients are convinced that they are performing significant actions, fundamentally changing the outside world for the better. They feel exceptionally talented, capable, and happy. Accordingly, their speech becomes pathetic and ambiguous; they recite and sing. Marked psychomotor agitation is observed in patients, and a certain goal-directedness disappears from their activity. Pseudohallucinatory verbal surges with the impression of hypnotic influence on others are possible. At the same time, various false recognitions arise — everything is constantly changing, played out as if in a theatrical staging. Sometimes patients experience episodes of insight and clarity during this.
Syndrome of manic paraphrenia
This state is characterized by the predominance in the clinical picture of fantastic-paranoid disorders that occur against the background of an elevated mood with phenomena of ideational psychic automatism with unstable verbal pseudohallucinations, which, as a rule, are difficult to detect. Delusions can vary in content — fantastic ideas of grandeur, invention, reformism, noble birth, etc. Delusions are always distinguished by an acute sensory character, have no tendency to systematization, and are always intertwined with pronounced affective disorders. The fantastical nature of delusions and the Variability of their plot increase as the syndrome develops; delusions begin to be accompanied by false recognition and illusions, acquiring an antagonistic content (a struggle between two parties, a struggle between divine and demonic influences, etc.). Patients consider themselves mythical and historical heroes, scouts, the wealthy, and saints. Characteristic of this state are experiences of happiness, ecstasy, and vivid, figurative, affectively colored signs of psychic automatism. Sometimes a predominance of confabulatory phenomena is observed.
Delusional syndromes
Paranoid syndrome
This state is characterized by detachment from reality, a clear thematic focus of delusions, systematization and their detailed justification, and a significantly lower degree of severity of affective disorders. Alongside the main plot (jealousy, inventiveness), ideas of persecution are observed, which may predominate in the structure of the syndrome. In some patients, the delusional system forms gradually; in others, it may arise by the type of suddenly occurring thoughts or insights that are subsequently systematized, corrected, and reworked. Within the framework of the delusional system, patients interpret the actions and words of surrounding people, as well as minor, insignificant events (delusional interpretation). This also determines the patient's behavior and their relationships with other people. Along with this, viscosity and detail-oriented thinking are revealed. Such a state is mostly accompanied by a monotonous affective tension fixed on a morbid point. In The process of pathological creation, delusions gradually spread. Seeking a fair resolution of an issue, patients gradually include ever new people in the list of their enemies. They write numerous complaints and statements, carefully register their correspondence, and maintain multi-volume diaries.
As the disease progresses, changes and expansion of the delusional themes manifest in increasingly absurd and implausible ideas, although delusions always retain their limited, systematized, interpretive character. Patients who previously took only precautionary measures now embark on a path of active struggle against their pursuers. Such activity has an interpretive, ideological character rather than an anxious-panicked one. With the Development of the syndrome, the autization of patients also increases; they often live separately from their families, lose their ability to work, become increasingly conflicted, and cease to be interested in anything that does not fall within The Scope of their delusional ideas. Resontance and eccentricity grow, and eventually the delusional system blurs, its content changes, and its relevance is lost.
Paranoid syndrome occurring in late life is characterized by lesser "perfection" and systematization of delusional ideas, as well as greater concreteness of the plot (small-scale delusions). Persecutory delusions manifest in ideas of poisoning, accompanied by taste and olfactory illusions, and delusional interpretation of various somatic disorders is also observed.
Paranoid syndrome
This syndrome is expressed by fragmented, unsystematized ideas varying in theme (delusions of reference, persecution, influence, etc.). Morbid utterances are observed along with hallucinatory experiences. The structure of the syndrome often includes signs of mental automatism accompanied by pseudohallucinations and intrusive thinking (mentism). As a rule, auditory hallucinations predominate. Patients "hear" male, female, and children's voices, the voices of acquaintances and strangers, noises, whistles, screams, and cries transmitted via various apparatuses. Manifestations of depersonalization may also occur.
The presence of paranoid syndrome indicates a high progradient nature of the process compared to diseases accompanied by paranoid disorders.
Paranoid syndrome is part of the clinical picture of schizophrenia, epileptic psychoses, mental disorders resulting from the use of alcohol and narcotic substances, mental disturbances caused by severe stress, etc.
Paraphrenic syndrome
This syndrome manifests as grandiose delusions, which often have a fantastic character, as well as thematically related delusions of persecution and influence, with corresponding changes in the emotional sphere. The symptom of the double and false recognition (Capgras syndrome) may be observed. Producing delusional ideas, patients talk about their greatness, using fantastic comparisons: they consider themselves rulers of the Universe, commanders-in-chief of all the world's armies, and are confident that they possess immense strength and agility (declaring, in particular, that they can lift a steamship with one hand or leap across the Black Sea). Patients include numerous people and fantastic phenomena in their delusional statements. They review their past life based on their morbid notions. Their mood is very frequently elevated.
Paraphrenic syndrome is observed in schizophrenia, progressive paralysis, mental disorders resulting from alcohol use, and psychoses resulting from organic brain damage.
Hallucinatory syndrome
Conditionally, it can be assigned to the group of delusional syndromes. Unlike the previous syndromes, in hallucinosis, it is not delusional ideas that come to the forefront, but intense auditory, visual, olfactory, and tactile hallucinations. The patients' consciousness remains formally clear. They are oriented in their environment and in time. Depending on the content of the hallucinations, patients may express corresponding secondary delusional ideas of persecution, poisoning, jealousy, etc. Verbal hallucinosis is the most common, where a sick person hears voices commenting on their actions, giving orders, etc. Hallucinations intensify at night and in the evening. Sometimes patients are critical of them, but more often, under the influence of perceptual deceptions, they commit absurd acts and aggressive actions.
Hallucinosis can proceed both acutely and chronically, lasting for many months and even years. It is one of the variants of psychotic disorders in schizophrenia, mental disorders resulting from alcohol use, cerebral Syphilis, and epilepsy.
Syndrome of mental (psychic) automatism (Kandinsky-Clérambault syndrome)
This syndrome was studied and described by the Russian psychiatrist V. Kh. Kandinsky and the French scientist Clérambault. It is encountered in many mental illnesses (first of all, in schizophrenia). It consists of separate, interrelated psychopathologic symptoms.
First of all, monovocal (single-voiced) pseudohallucinosis should be mentioned. It is characterized by the presence of verbal pseudohallucinations. Patients feel that "voices" exist somewhere inside the head. The syndrome of mental automatism is also accompanied by a feeling of being possessed, the appearance of alien thoughts that arise coercively, as if imposed by some external force, contrary to the desire and will of the patient (mentism — coercive thinking).
A sick person gets the impression that their thoughts sound out loud and, as a consequence, are heard by surrounding people (the symptom of opened thoughts).
According to the patient's subjective perceptions, their mental activity is supposedly automatically controlled and directed by someone from the outside; therefore, the mental process in a sick person is often accompanied by loud, involuntary, coercive uttering of passing thoughts (the symptom of forced speech).
A patient may not articulate words, but subjectively experience contractions of the muscles involved in speech. Such disorders are referred to as muscular pseudohallucinations. This symptom is also characteristic of Kandinsky–Clérambault syndrome. Depending on the manifestation of various features of psychic automatism syndrome, several variants are distinguished.
Ideator (associative) automatism is characterized by forcible influxes of thoughts and images (mentism), independent of the patient's will, along with the involuntary expression of "alien" thoughts (the symptom of thought broadcasting). The patient's interests, thoughts, desires, and drives become alien, "known to everyone around them." Their thought process appears to be imposed from the outside.
Cenestopathic automatism occurs when the patient experiences compulsive sensations of burning, tingling, pain in internal organs, as well as emotional experiences of aversion, fear, anger, and a general feeling of malaise.
Motor (kinesthetic) automatism manifests as all the patient's actions taking on a seemingly externally imposed character. Against the patient's will, an alien force compels them to move, jerk their head, smile, or make grimaces.
The variants of Kandinsky–Clérambault syndrome do not occur in isolation, but rather represent stages in the development of the pathological process. If this process begins with ideator automatism, cenestopathic and subsequently kinesthetic variants should be expected to emerge. The manifestations of Kandinsky–Clérambault syndrome within the clinical picture of a particular disorder (e.g., schizophrenia) indicate a guarded prognosis.
Syndromes of Altered Consciousness
Delirium Syndrome
This syndrome is characterized by disorientation in the environment, an influx of vivid, scenic, primarily visual hallucinations (often of a terrifying nature), marked lability of affect corresponding to the patient's experiences, and the preservation of self-awareness—which notably distinguishes this syndrome from the oneiric state. In psychoses occurring without altered consciousness in elderly patients, evening exacerbations of the condition may manifest as delirious symptoms. Sometimes there is a paucity of visual hallucinations and a decreased intensity of affective disturbances. Frequently, the content of the delirium is occupational in nature or relates to the distant past. Partial amnesia for the endured psychosis is sometimes observed.
Twilight State Syndrome
Transitory disorders of consciousness characterized by a sharp transition boundary from clear consciousness to its clouding and back again. This state is accompanied by a tense affect (ecstasy, anguish, rage) featuring acute delusional and hallucinatory disorders, consecutive actions, and occasionally profound psychomotor agitation with aggression (epileptic excitement). Complete amnesia for the experiences occurring during the twilight state is observed.
Oneiric Syndrome
Oneiric syndrome predominantly develops within the clinical picture of pronounced catatonic disorders. Fully developed oneiric syndrome is characterized by dream-like, total disturbances of consciousness featuring fantastic delusions and complete identification of oneself with other persons. It arises as a consequence of deeper disturbances compared to the syndrome of oriented oneiroid state, and is characterized by total absorption in dream-like experiences with complete detachment from reality and the inability to establish contact with the patient. Patients are hypoactive; their facial expression is frozen and dreamy, or exhibits signs of fear or deep sorrow, in accordance with the content of their experiences. Concurrently, zonal cataleptic disorders—such as muscle tension in the upper shoulder girdle—and autonomic disturbances are observed.
Amentia Syndrome
Amentia syndrome is characterized by impairment of consciousness and self-awareness, confusion, impoverished speech, and purposeless agitation occasionally interrupted by stupor, alongside a lack of purposeful movements. Psychotic experiences, judging by disjointed, unconnected words, are fragmentary. Following the resolution of the acute state, amnesia is observed. Unlike other disorders of consciousness, the amentive state during the acute attack proceeds with significant somatic disorders: high fever, herpetic rash, dehydration, skin pallor or flushing, capillary fragility, and alterations in the blood count. Complete exhaustion (Stauder's lethal catatonia, febrile schizophrenia) quite frequently occurs.
Syndromes of Motor-Volitional Disorders
Catatonic-Hebephrenic Excitement
This syndrome is characterized by catatonic disorders featuring traits of infantilism and silliness, and always develops against a backdrop of euphoric mood. Patients frequently pull faces and grimace. Significant speech excitement is often observed, featuring incomprehensible utterances, primitive jokes, echolalia, incoherence of thought, and neologisms. Forced shouting occasionally occurs. Patients laugh, shriek, sing, and dance. Sometimes their movements resemble those of animals. In general, catatonic-hebephrenic excitement is characterized by chaos. Fragments of hallucinatory-delusional experiences and absurd utterances can be detected within it.
In certain cases, catatonic-hebephrenic excitement takes on the character of caricatured childish behavior. Patients act like small children, misbehave, and use baby talk. With the further development of this syndrome, the agitation evolves into simple catatonic excitement. In such a state, the patients' movements resemble gymnastic exercises with numerous stereotyped rhythmic repetitions. Motor agitation may be confined to the edges of the bed and not accompanied by complex actions and deeds.
During the transition of elementary catatonic excitement into impulsive movements, patients perform a series of unexpected, unmotivated acts, attack others, break objects, etc. Impulsive actions are characterized by speed and absurdity, and cannot be predicted. Alongside motor stereotypies, echopraxia and muscle tension are observed.
Catatonic Stupor
This term is used to designate states dominated by profound motor retardation, up to complete immobility. Typical of this state is the patient's adoption of monotonous, unnatural postures, often close to the fetal position. The "air pillow" sign, "hood" sign, and "proboscis" sign are noted. Passive and active negativism are pronounced, mutism is present, and muscle tone is sharply increased. Waxy flexibility (flexibilitas cerea) frequently occurs. The facial expression becomes fixed and mask-like. Saliva frequently accumulates in the mouths of such patients, urination and defecation are retained, and the skin appears greasy. Refusal of food is observed, often necessitating tube feeding. Upon detailed examination using amobarbital-caffeine disinhibition, it is sometimes possible to uncover pseudohallucinations and fragmentary delusional ideas.
Syndromes of Memory and Intellect Pathology
This syndrome is characterized by phenomena of fixation amnesia (impaired ability to learn new information) with mnemonic (substitutive) confabulations, or less frequently without them. Amnestic disorientation is characteristic, which in elderly patients is often observed with a Displacement of the situation into the distant past. Mood is elevated in the majority of cases, and lowered less frequently. Where the described disorders manifest in a more "pure" form, without pronounced dementia, insight into the illness is preserved. In such cases, Korsakoff's amnestic syndrome can be partially reversible. However, it should be noted that in old age, even in such instances, complete recovery of mental activity is not observed. When these disorders have subsided, signs of organic personality degradation generally persist. Korsakoff's syndrome within the framework of organic dementias cannot be compensated.
Lacunar Dementia Syndrome
This syndrome is characterized by the following features.
A dysmnestic type of memory impairment, in which memory retention disorders never reach the level of progressive amnesia, nor do recall disorders reach the level of fixation amnesia. A characteristic feature is the "unevenness" of mnestic function impairments. While chronological orientation is blurred, the chronological sequence of events is relatively well preserved: if a patient cannot recall a specific fact at a given moment, they tend to recall it at another time.
A sufficient degree of allopsychic and autopsychic orientation can almost always be detected.
Such patients are not characterized by shifting situations into the past or the presence of ekmestic confabulations.
As a rule, patients appear older than their years. Their movements are slowed and awkward. The same applies to their speech, which consistently reveals signs of dysarthria.
Patients withdraw into themselves, which manifests as a lack of reaction to surrounding events and an absence of initiative.
There is a varying degree of awareness of one's mental and, particularly, physical incapacity, and insight is often preserved as well.
Most commonly, this syndrome occurs in vascular dementia. It is frequently accompanied by mood changes involving anxious apprehension, irritability, forced crying, and emotional lability.
Global Dementia Syndrome
Its main features are as follows.
The presence of progressive amnesia, manifested by the sequential erasing of memory stores—primarily those acquired most recently—and the revival of memories belonging to the distant past. In severe cases, a disruption of all memory stores is observed.
The onset of fixation amnesia, which causes a loss of the ability to form new neural connections, i.e., to memorize. The presence of such amnesic disorders leads to complete autopsychic disorientation or false orientation in place, time, and surrounding individuals.
Progressive amnesia and the resurgence of past memories lead to so-called "living in the past," accompanied by ekmestic (borrowed from the past) confabulations, while the presence of fixation amnesia leads to so-called mnemonic (substitutive) confabulations.
The absence of not only insight, but even any awareness of illness.
Affects are blunted and indistinct, with a predominance of a carefree-euphoric, depressed-irritable, or malicious mood. The syndrome is observed more frequently in senile processes, which, in addition to those listed, are characterized by two more typical features:
a) even in the initial stages, one is struck by the dissociation between profound mental decay and a certain preservation of habitual external forms of behavior, a significant vocabulary, and preserved automated motor reactions;
b) patients' "outward orientation" and talkativeness; patients eagerly respond to all events happening around them and strive for unproductive activities.
Global dementia at the formative stage, when The breakdown of mental activity has not yet reached the degree of its complete disorganization, may exhibit certain features depending on the underlying cause. Therefore, the following variants of global dementia are distinguished:
— diffuse, in which, as shown in the works of V. S. Bitensky and co-authors, the leading impairment is attention deficit; in its Clinical Features, it approaches the psycho-organic (encephalopathic) syndrome (see Lecture 10) and occurs more frequently in prolonged intoxications (particularly alcohol-related); it may be partially reversible;
— concentric (epileptic), the main syndromal manifestation of which is bradyphrenia, followed by a narrowing of interests, increasing egocentrism, triviality, and the like;
— paralytic, characterized from the very beginning of the syndrome's development by an almost complete absence of insight against the background of the partial preservation of other operational components of intellect;
— senile (asemic), which has already been mentioned, but it should be noted that it is also accompanied by a progressive coarsening of personality with detachment, haughty irritability, persecutory delusions, and ultimately the reduction of all cognitive functions, including perception (various types of agnosia).
A separate category includes schizophrenic and functional dementias, which are not strictly dementias in the true sense of the word (these will be discussed in subsequent lectures).
Mental Retardation
Mental retardation is a state of arrested or incomplete mental development, characterized primarily by cognitive deficits and a limited capacity for Abstract thinking. This is most pronounced during the period of personality maturation, when the general level of intelligence—that is, the integral of human cognitive, speech, motor, and social functioning indices—is formed. Mental retardation is a multi-etiological disorder. It is caused by pre- and perinatal harmful influences on the child's brain, enzymatic disorders (phenylketonuria, mucopolysaccharidosis, etc.), early childhood illnesses, and Chromosomal aberrations (Down syndrome, sex chromosome trisomy, etc.). Mental retardation may be accompanied by emotional-volitional disorders that lead to maladaptive behavior as early as childhood. Regarding acquired skills or individual cognitive functions that comprise intelligence, the development or preservation of some of these does not negate the presence of signs of mental retardation in an individual. First and foremost, this concerns solving simple visuospatial tasks or memory. The latter in individuals with intellectual disabilities may even be superior to that of other people. Therefore, evaluation must encompass the entire complex of clinical data, behavioral adaptability, and performance on standardized psychometric tests, such as those by Wechsler, Cattell, Eysenck, etc. By the way, the first psychodiagnostic test, which marked the beginning of psychodiagnostics as a field of knowledge, was developed in the early 20th century by the French physiologist A. Binet precisely to assess the intellectual capabilities of mentally retarded children.
Intellectual disability is classified into the following degrees:
— mild (intelligence quotient ranging from 50 to 69); children with this condition can study in specialized schools and, with sensible guidance, even acquire a simple trade;
— moderate (intelligence quotient ranging from 20 to 49); care and training in basic types of work for individuals with this condition are typically provided in social care institutions, as they are mostly unsuited for independent living;
— severe;
— profound.
Last update: 08/08/2026
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