Psychiatry - H.T. Sonnyk 2003

General Psychopathology and Symptomatology of Mental Illness
Disorders of Consciousness

Consciousness is a function of the human Brain that consists in reflecting the objective properties of objects and phenomena of the surrounding world, processes occurring within it, and regulating human interactions with nature and social reality.

A.V. Snezhnevsky distinguished 4 signs of clear consciousness:

1) adequate, correct perception of the surrounding world (non-illusory, non-delusional, etc.);

2) correct orientation in place, time, and surrounding persons;

3) sequential thinking, absence of phenomena of disorganization or incoherence;

4) preservation of memory.

To the above, one more sign of normal consciousness should be added—The ability to establish adequate verbal and reflexive contact. If all these 4 signs are altered, it indicates a disturbance of consciousness.

At any given moment, a person's mental life may exhibit varying degrees of consciousness, ranging from fully clear to unconscious. Despite significant differences, clouded consciousness syndromes share four general features (K. Jaspers) that are inherent to each of them to varying degrees:

1) blurred perception of surrounding reality;

2) disorientation in place, time, and situation;

3) Various Forms of thinking impairment;

4) memory impairment (the patient completely or partially forgets what happened to them during the pathological state).

Individually, each of these signs does not yet indicate a disorder of consciousness. Torpor (obtundation), for example, can occur in Schizophrenia.

Clouding of consciousness can occur suddenly or develop gradually. The gradual onset (e.g., delirious) is preceded by a state of perplexity, the core of which is hypermetamorphosis—a state of excessive distractibility where every new stimulus immediately captures the patient's attention. The patient loses the dominant line of behavior, attention constantly shifts, and actions acquire a chaotic character. This syndrome was first described by Wernicke. A.V. Snezhnevsky believed that this phenomenon is based on a pathological intensification of the orienting reflex.

Non-psychotic (negative) disorders of consciousness.

These disorders are also referred to as exclusion of consciousness. They are characterized by the simultaneous impairment of rational and sensory cognition due to the exclusion of consciousness resulting from a lesion of the Brainstem system.

Obtundation — in this state, only strong (physical or psychic) stimuli reach the consciousness. Perception of the surroundings is unclear and blurred, and memories are sharply limited or absent. Orientation in place and time is severely impaired or absent, and emotions are diminished. Motor activity is absent or reduced. Patients' facial expressions are inexpressive; they typically sit or lie in a single position. Occasionally, phenomena of euphoria are observed.

Nubilation — a mild, short-term form of obtundation with moments of lucidity, when consciousness returns to the patient for a short time and then becomes clouded again.

Somnolence — a deeper degree of obtundation that can progress into sopor and coma.

Sopor — a syndrome of generalized impairment of consciousness. Patients lie motionless, sometimes with chaotic movements. Only very strong external stimuli, such as pain, are perceived. Reflex activity is diminished. Pathological Reflexes and autonomic disorders may be observed. Memories of the soporose period are not retained.

Coma — complete loss of consciousness, absence of reactions to external and internal stimuli, and disappearance of reflexes. During coma, Respiration, cardiovascular activity, and the function of the Autonomic Nervous system are disrupted. Coma is followed by complete amnesia for the period of unconsciousness.

Psychotic (productive) disorders of consciousness.

Such disorders are also called clouding of consciousness. They are characterized by the disintegration of mental activity As a result of cortical lesions.

Delirious syndrome is represented by massive productive psychosymptomatology. Multiple, mobile, plot-driven hallucinations are observed, predominantly visual and tactile. Delusional ideas of reference and persecution are unstable and associated with hallucinations and metamorphopsia illusions. The patient's emotional state and behavior correspond to the content of the hallucinations. The Development of delirious syndrome involves 4 stages:

Stage I — increased talkativeness, a rush of associative, concrete-sensory images and vivid representations, hypermnesia, with vivid recollection of pictures from the past—sometimes recent, sometimes distant. Speech is disorganized and incoherent. The syndrome of hypermetamorphosis is clearly manifested. A characteristic change in the patient's mood and behavior occurs. If such perceptual anomalies are pleasant, the mood rises, but terrifying hallucinations are more frequently observed, leading to an affect of anxiety and fear. Towards evening, the patient's condition worsens—perceptual disorders intensify. Sleep is superficial with nightmares. Patients jump up, try to run somewhere, and are disoriented. In the morning, as a rule, they fall asleep, sleep becomes deep, and they wake up with a feeling of fatigue and weakness.

Stage II – deepening of delirium. More massive floods of illusions and pareidolia appear, along with increasing hypermetamorphosis and sensory hyperesthesia. Patients react sharply to stimuli and are anxious. They often answer questions incorrectly, and heightened distractibility is observed. Consciousness is impaired, sometimes with lucid "windows"—resembling "windows into the real world"—accompanied by a sense of morbid alteration. At such moments, the patient Answers questions better and begins to recognize those around them, only to plunge back into the world of illusory perception. Sleep becomes even more superficial, accompanied by increasingly terrifying dreams. Patients fall asleep only in the morning, for just 2–3 hours.

Stage III – the aforementioned symptoms are joined by vivid, scene-like, kaleidoscopic visual hallucinations with extraprojection, causing the patient to behave in accordance with their content. Hallucinations may be complex in nature (visual + auditory). At night, the onslaught of hallucinations intensifies, complete disorientation develops, and patients often do not sleep at all. Lucid "windows" are short-lived or entirely absent.

Stage IV – complete disorientation is observed, and speech is incoherent—the patient utters individual words without any sequence and does not respond to questions. Bed-bound motor agitation is accompanied by muttering, attempts to tear off clothing, pick "threads" from the body, and move the blanket or pillow. Sometimes hyperkinesia and the "wiping" sign (prognostically unfavorable) appear. The gaze is dull and bewildered. Subsequently, sopor, coma, and death may ensue.

Following the delirious state, quite vivid but not always coherent memories are retained. Morbid experiences remain etched in memory much more clearly than real events.

Occupational and muttered delirium have been described as variants of delirious syndrome characterized by a more severe course.

Occupational delirium – due to hallucinatory-paranoid experiences caused by delirium, the patient behaves as if performing their professional duties: a driver simulates steering a car, a musician "plays" a trumpet, a turner "machines" a part on a lathe, etc.

Muttering (mussitant) delirium – bed-bound agitation, "picking" at small objects supposedly stuck to the body and clothing, quiet and unintelligible speech in the absence of reaction to external stimuli.

Most commonly, delirious syndrome occurs in chronic alcoholism (alcoholic delirium or delirium tremens). It is also observed in connection with poisoning by henbane Alkaloids (atropine delirium), tetraethyllead (tetraethyllead delirium), in various acute infections (infectious or febrile delirium), and as a variant of epileptic psychoses (epileptic delirium), etc.

Oneiroid state – manifested by sparse hallucinations of a fantastic, supernatural content in which the patient does not participate, but feels a special responsibility for everything that happens. Hallucinations blend with real reality to form a single whole (double orientation). Reality is generally diminished in its significance or entirely unperceived by the patient. Illusory-hallucinatory perception of the surrounding world and emotional tension (fear, anticipation) are observed.

The patient's behavior is characterized by oneiroid stupor or aimless, senseless agitation. Memories after recovery are fragmentary in nature.

As a variety of the oneiroid syndrome, some authors distinguish the oriented oneiroid, in which complete (usually double) orientation is observed.

Amentia – characterized by profound impairment of perception and orientation, predominantly auditory hallucinations, disjointed delusional ideas, fragmentary reflection of the environment, amentiform incoherence of speech, motor agitation, feelings of fear, helplessness, and bewilderment. This symptomatology is primarily caused by a disturbance of synthesis, as a result of which the patient cannot comprehend their surroundings. Complete amnesia ensues following the amential syndrome, less frequently fragmentary memories.

Amentia predominantly occurs in severe somatic diseases. Amential syndrome may manifest within various nosological forms as a sign of an unfavorable disease course. Some authors view amentia as a variant of delirium.

Twilight state – a syndrome of clouded consciousness accompanied by profound disorientation in the environment, hallucinations, disjointed ideas of reference, influence, and persecution, affective reactions of fear and anger, and motor agitation. Twilight states arise suddenly and cease rapidly, sometimes leading the patient to motiveless acts and aggressive behavior. This state terminates in deep sleep and amnesia.

Twilight disorder of consciousness has five differential features:

1) brief duration – from a few minutes to several days;

2) onset – sudden and critical;

3) emotional tension, pronounced affect of anger and malice;

4) purposeful actions – deeds are sequential, sometimes making it impossible to suspect a disturbance of consciousness;

5) presence of acute sensory delusions or hallucinations.

Depending on the predominance of individual component parts of twilight consciousness, hallucinatory, delusional, and dysphoric variants are distinguished.

1. Delusional (paranoid). Characterized by orderly, consistent behavior, but determined by sensory delusions and tense affect. Patients can frequently be socially dangerous.

2. Hallucinatory. Hallucinations predominate in the clinical picture. Patients are agitated and aggressive. Such a state is often a manifestation of an epileptic equivalent.

3. Dysphoric (oriented). Phenomena of partial orientation are observed. The patient is elementally oriented in place and as to their own person, but a tense affect and aggressive destructive actions are also possible.

As a variety of twilight states (twilight with orderly behavior), the following are distinguished:

Ambulatory automatism: while in a twilight state, patients perform outwardly orderly actions, traveling from place to place, sometimes quite far. At the same time, they behave appropriately to the situation and communicate with others if necessary, yet leave the impression of being somewhat bewildered and preoccupied individuals. Actions committed during an ambulatory automatism are generally amnesic.

Somnambulism: a state of altered consciousness characteristic of ambulatory automatism that occurs during sleep, when a patient gets out of bed at night, performs a series of complex actions at home or outside, exhibiting motor agility that is sometimes inaccessible in a normal state, and then falls asleep again and in the morning remembers nothing of these events.

Prosomnic state (sleep drunkenness): a mild form of consciousness disorder resembling the state a person experiences when suddenly woken up at night, when the "Ego" has returned, but orientation in time, place, and environment is still lacking. In a healthy person, such a state is short-lived (seconds, minutes), whereas in mentally ill patients it persists for a long time.

Trance: a mental disorder characterized by automatic behavioral acts during a state of clouded consciousness or a narrowed field of consciousness.

Fugue: a state of narrowed consciousness. In this condition, the patient, unaware of their surroundings, performs a series of actions (usually in an agitated manner), such as spinning in place, suddenly starting to run, or taking off clothing on a trolleybus. The person acts automatically and unconsciously.

CONTROL QUESTIONS:

1. Name the non-psychotic and psychotic forms of consciousness disorders.

2. What is obtundation (clouding of consciousness) and what are its clinical characteristics?

3. Cytology/practical/136.html">Differential Diagnosis OF stupor and coma.

4. General characteristics of psychotic forms of altered consciousness.

5. Provide a description of delirium syndrome.

6. Describe the Selection/3.html">Stages of development of delirium syndrome.

7. Provide a description of oneiric syndrome.

8. Clinical characteristics of amhentia.

9. Twilight states of consciousness and their characteristics.

10. Clinical Variants of the course of twilight states of consciousness.

11. What is ambulatory automatism?

12. Provide a Description of the prosomnic state, trance, and fugue.