Psychiatry - H.T. Sonnyk 2003

General psychopathology and symptomatology of mental illnesses
Psychotic syndromes of altered consciousness

Depersonalization and derealization syndromes represent a combined disturbance in the perception of one's own self and external reality, which is consciously experienced and causes significant distress.

Either of these disorders—depersonalization or derealization—may predominate within the syndrome, and in some cases, they occur in isolation.

Depersonalization is a disorder of self-awareness characterized by the sensation that certain or all mental processes (such as sensations, thoughts, mental images, memories, and attitudes toward the environment) have changed.

In the mildest cases of depersonalization, patients experience a sense of altered mental processes due to the weakening or loss of the imaginative component. The surroundings begin to be "perceived by the mind alone," becoming an "detached concept" or "mere thought." Moral and ethical categories—such as good, evil, duty, and justice—are reduced to Abstract concepts for the patient. The ability to perceive the emotional reactions of others is diminished or lost, leading patients to feel like outsiders among people. They report emotional and intellectual impoverishment, often feeling as though their speech and actions are performed automatically.

In more severe cases, the patient's spiritual "self" loses its unity and integrity, being experienced instead as a collection of disjointed parts. Many patients speak of a splitting of their "self," and some may even experience a complete disappearance or dissolution of their "self" among others. Memories of the past fade, and what remains is perceived only as fragmented elements disconnected from the present. While insight into the illness is typically preserved in these patients, critical evaluation of their own condition is impaired.

Another variant of severe depersonalization is the estrangement of higher emotions, manifested as a profound sense of blunted emotional responsiveness to surrounding events, people, nature, and oneself. As depersonalization intensifies, these dulled feelings may culminate in a complete loss of affect, accompanied by the previously described symptom known as anaesthesia psychica dolorosa.

Derealization is a disorder of self-awareness accompanied by the feeling that animate and inanimate objects, the environment, and natural phenomena have fundamentally changed.

In derealization, the environment is perceived as altered, strange, blurred, alien, ghostly, frozen, and lifeless. It appears as though viewed through a fog, a film, or translucent Glass, frequently losing its three-dimensionality and perspective, while objects seem stripped of their spatial arrangement. In some instances, patients note that their surroundings resemble a stage set or a photograph. The colors of surrounding objects change, losing their saturation and brightness. Conversely, derealization sometimes makes the environment appear unusually sharp and vivid. The perception of time is also altered: it may slow down, stop, or seem to vanish entirely, though at other times patients experience a sensation of time rushing by rapidly.

Derealization encompasses the phenomena of déjà vu, déjà éprouvé, déjà entendu (already seen, experienced, or heard) and jamais vu, jamais éprouvé, jamais entendu (never seen, experienced, or heard).

Delirium syndrome is a hallucinatory clouding of consciousness dominated by true visual hallucinations and illusions, vivid delusions, labile affect characterized primarily by fear, and motor agitation.

The Development of this disorder unfolds in several stages.

The symptoms of The First stage typically become noticeable by evening, marked by generalized restlessness. Patients are talkative, and their speech easily slips into incoherence. They experience surges of vivid, visually concrete memories from the past, and their movements acquire an exaggerated expressiveness. Hyperesthesia is present across visual, tactile, auditory, and gustatory modalities. The mood is labile, and Sleep is superficial and interrupted, accompanied by vivid and often terrifying dreams, anxiety, and fear.

In the second stage, against the backdrop of intensifying previous disturbances, visual illusions emerge in the form of pareidolias. Episodic disorientation in time and place may occur, and hypnagogic hallucinations appear upon closing the eyes just before falling asleep.

The Third Stage is characterized by true visual hallucinations, which may be single or multiple, static or moving, colored or uncolored, and reduced, normal, or enlarged in size. Depending on the etiological factor, visual hallucinations can exhibit distinct features; for instance, zoopsia is characteristic of alcohol and cocaine delirium, whereas microptic hallucinations are typical of delirium induced by opiate poisoning, among others.

In delirium, the patient is invariably an engaged spectator of everything happening around them, and their affect and actions closely mirror the content of their perceptual disturbances. They are gripped by curiosity, bewilderment, rapture, fear, or terror. Auditory, tactile, and olfactory hallucinations, as well as fragmentary figurative delusions, may also emerge during the third stage. The patient struggles to comprehend questions put to them and frequently gives irrelevant Answers.

Orientation to the environment is impaired, and patients are typically misoriented. However, self-awareness—the awareness of one's own "self"—remains intact at all times. At night, patients experience either complete insomnia or shallow, interrupted sleep that only arrives toward morning.

An unfavorable progression of the underlying condition (whether somatic, infectious, or toxic) can lead to severe forms of delirium, namely professional and muttering delirium.

Professional delirium is characterized by a predominance of monotonous motor agitation manifesting as routine, everyday actions—such as eating or cleaning—or actions directly related to the patient's profession. Hallucinations and delusions are either absent or rudimentary, and verbal contact is frequently impossible.

Muttering delirium involves uncoordinated motor agitation confined to the bed, lacking completed actions yet monotonous in its manifestations. Patients make picking, shaking, or grabbing motions. Verbal agitation is expressed through quiet, unintelligible sounds and syllables. Communication with these patients is impossible, as they are entirely detached from their surroundings. Muttering delirium typically succeeds professional delirium.

Depending on the underlying Etiology, delirium may be accompanied by autonomic and neurological disturbances, such as tachycardia, tachypnea, diaphoresis, Blood pressure fluctuations, muscular hypotonia, hyperreflexia, tremor, and ataxia.

Oneiric syndrome (oneirism) is a clouding of consciousness marked by an influx of spontaneously arising fantastic imagery that incorporates modified fragments of previously perceived experiences—sometimes isolated, sometimes bizarrely intertwined with distorted details of the real world. The resulting mental scenes resemble dreams, unfolding in a specific sequence where one event seems to flow seamlessly into another (i.e., exhibiting a theatrical, scenario-like quality). Persistent affective (depressive or manic) and motor disturbances, including catatonic symptoms, are invariably present.

The initial stage is defined by affective disturbances: depressive states are accompanied by lethargy, helplessness, capriciousness, irritability, and motiveless anxiety, whereas manic states invariably carry an imprint of ecstasy, a sense of insight and penetration, thus presenting symptoms typical of ecstasy. These affective disturbances are accompanied by sleep and appetite disorders, headaches, and unpleasant sensations in the cardiac region.

Later, a stage of delusional mood (delusional preparedness) emerges. The environment appears to the patient altered, incomprehensible, and pregnant with a hidden, threatening significance. Unconscious fear or a premonition of danger and catastrophe arises, accompanied by unsystematized delusions, predominantly of persecution, illness, and ruin.

This is followed by the stage of delusions of staging, significance, and intermetamorphosis. Patients note that events are unfolding around them like a movie or play, in which they either play specific roles themselves or watch with rapt attention as spectators; at times, individuals transform into one another. Periods of psycho-motor agitation alternate with states of psychomotor retardation.

Further clinical evolution is marked by the development of true oneirism. The patient's consciousness is dominated by visualized, fantastic imagery (dream-like delusions) tied to their inner world, with visual pseudohallucinations serving as their foundation. In this oneiric state, scenes of grandiose events pass before the patient's "mind's eye," with the patient acting as the central protagonist. A frequent dissociation is observed between the content of consciousness and the motor sphere, which is dominated by catatonic stupor symptoms—variable in intensity but generally mild—that are briefly interrupted by episodes of pathetic or absurd agitation. Patients are typically mute, and verbal communication with them is impossible.

The reduction of oneiric symptoms occurs gradually in the reverse order of their onset. Patients can recall the content of psychopathological disorders during the clouded consciousness period in considerable detail.

Twilight state syndrome. A twilight state of consciousness is a sudden and short-lived (lasting minutes, hours, days, or rarely longer) loss of clear consciousness, characterized by complete detachment from the environment or its fragmented and distorted perception, while familiar automated actions are preserved.

Based on their Clinical Features, twilight states are divided into simple and "psychotic" forms, though no sharp boundaries exist between them.

The simple form has a sudden onset. Patients disconnect from reality, and establishing contact with them is impossible. Spontaneous speech is either absent or limited to the stereotypical repetition of isolated words or short sentences. Movements may be impoverished and slowed, or punctuated by episodes of impulsive agitation accompanied by negativism. In some cases, sequential, often relatively simple yet outwardly purposeful actions are preserved. When accompanied by involuntary wandering, this is referred to as ambulatory automatism. If it lasts for minutes, it is called a fugue or trance; ambulatory automatism occurring during sleep is known as somnambulism or sleepwalking. The simple form of twilight clouding usually lasts from a few minutes to several hours and is followed by complete amnesia.

The "psychotic" form of twilight clouding is accompanied by hallucinations, delusions, and altered affect, and develops relatively gradually.

Visual hallucinations with terrifying content predominate. They are frequently vivid, scenic, colorful, and brilliant. Characteristic features include moving visual hallucinations, such as approaching groups of people or animals, a car speeding toward the patient, collapsing buildings, and so on. Auditory hallucinations consist of phonemes, often deafening, such as thunder, footsteps, or explosions. Olfactory hallucinations are typically unpleasant, resembling the smell of burning, urine, or carrion.

Figurative delusions prevail, featuring themes of persecution, physical destruction, grandeur, and messianism; religious and mystical delusional statements are common. Delusions may be accompanied by illusions of recognition.

Affective Disorders are intense and marked by high tension: fear, fury, hatred, and ecstasy. Motor disturbances most commonly manifest as agitation involving senseless destructive actions directed at inanimate objects or other people.

The disappearance of pathological disorders is often sudden. Amnesia following a twilight state accompanied by productive symptoms may be partial, retarded, or complete.

Amentia syndrome is a form of clouded consciousness characterized by incoherent speech, motor disturbances, and perplexity.

The speech of patients consists of isolated everyday words, syllables, or sounds uttered quietly, loudly, or chanted with monotonous intonation. Perseverations are frequently observed. The patients' mood is labile, shifting from depressed and anxious to somewhat elevated with euphoric features, or entirely indifferent.

Motor agitation in amentia typically occurs within the confines of the bed. It is limited to isolated motor acts that do not form a completed movement: patients toss about, arch their backs, startle, and so forth. Verbal contact cannot be established with them. Delusions in amentia are fragmented, and hallucinations are sparse.

Based on the predominance of specific disorders—such as stupor, hallucinations, or delusions—distinct forms of amentia are identified: catatonic, hallucinatory, and paranoid. The amentic state is subject to complete amnesia. Upon recovery, amentia is succeeded either by persistent asthenia or by a psycho-organic syndrome.

CONTROL QUESTIONS.

1. Classification of Psychopathological Syndromes According to the predominant impairment of individual mental spheres.

2. Classification of psychopathological syndromes by the depth of mental impairment.

3. Clinical manifestations of Hallucinosis syndrome.

4. Clinical manifestations of Korsakoff's Amnestic Syndrome.

5. Clinical manifestations of paranoid syndrome.

6. Clinical manifestations of Kandinsky-Clérambault syndrome.

7. Clinical manifestations of paranoiac syndrome.

8. Clinical manifestations of paraphrenic syndrome.

9. Clinical characteristics of psychophysical infantilism syndrome.

10. Clinical manifestations of encephalopathic and demented syndromes.

11. Clinical characteristics of neurotic syndromes.

12. Clinical characteristics of catatonic syndrome.

13. Clinical characteristics of manic and depressive syndromes.

14. Clinical presentation of delirium syndrome.

15. Clinical presentation of oneiric syndrome.

16. Clinical presentation of ammentive syndrome.