Disturbances of

Consciousness
The criteria of determining impaired
consciousness
Jaspers criteria
• Distraction from the real outside world. This is expressed by the fact
that the patient fragmentarily, unclearly, perceives reality
• Disturbance of orientation of time, place, situation, and rarely of
one's own personality.
• Disturbance of framing thought right up to incoherence.
Amnesia disorder of ability to store the ongoing events in memory
during the disturbance of consciousness.
Confusion
syndromes
 Clouding of consciousness
(Obnubilation)
● It is reflected by the increased threshold of perception of all analyzers and thought blocking.
● Patient cannot understand the conversation quickly.
● He often asks to repeat the question or requests to speak louder so that he hears the question and
understands the meaning of it.
● In this condition he is not able to analyze different questions even after repeating many times.
● Orientation of time and place is disturbed.
● He cannot answer the name of the hospital, where he is brought.
● Frequently he cannot tell the accurate time (confuses morning with evening).
● But the general understanding of the situation is not disturbed.
● He understands that he is surrounded by doctors, he is in a clinic.
● Remembrance about the period of clouding is fragmented, though complete amnesia is generally not
observed.
● When the condition worsens - somnolence
 Sopor
● profound disorder of consciousness with complete cease of
psychological activities.
● The patient sleeps so deep that he cannot wake up.
● Some basic reactions and reflexes are secured in the presence of
strong stimuli.
● like, a patient can talk if he feels pain.
● In case of cold he pulls the blanket towards him.
● Opens eyes if he hears his name spoken loudly by the doctor.
● But no contact can be made with the patient. He doesn't hear and
doesn't follow the instructions.
● He doesn't answer; not even by the signs or movements.
During remission from the sopor, complete amnesia is observed.
 Coma
● This is the most severe stage of deterioration of consciousness.
● In this case, not only the contact with the patient is impossible, but
there is also absence of reflex and reaction in strong stimuli.
● Causes of these symptoms may be different exogenous and somatic
or organic defects of the brain (intoxication, infection, trauma,
hypoxia, hypoglycemia, and electrolytes imbalance, increased
intracranial pressure due to brain tumor or hematoma).
● When the condition worsens - death.
 Delirium
• Delirium is a clinical syndrome characterized by the acute onset of fluctuating cognitive
impairment in the presence of clouded consciousness.
• Patients with delirium experience mental symptoms, such as confusion and hallucinations,
as a consequence of a range of physical problems, all of which affect brain functioning.
• Although it is common in patients admitted to general hospitals, delirium is often missed
because the symptoms fluctuate.
• Additionally, in patients with dementia or an intellectual disability, symptoms may be
mistakenly attributed to their pre-existing dementia or intellectual disability.
• Prompt identification and treatment of delirium is important to reduce the complications,
which include longer hospital stays, falls and death.
• Delirium has many causes
 Epidemiology
• Around 10% of general hospital patients have a period of delirium, either developed during admission,
or that they already had when they presented.
• Incidence increases with age and is higher in those w/:
• Pre-existing dementia
• A head injury or stroke
• Terminal illness, e.g. terminal cancer
• Problems with vision or hearing
• Recent surgery, particularly emergency operations or hip fracture repairs
• Alcohol misuse
• Polypharmacy: being prescribed multiple medications, particularly opioid analgesics,
benzodiazepines, antiparkinsonian medications and steroids
• A move to a new environment
 Clinical features
• An acute onset of confusion
• A fluctuating course
• Impaired, or clouded, consciousness
• Cognitive impairment, including impaired attention,concentration or short-term memory
• Abnormalities of the sleep-wake cycle
• Abnormalities of perception, which can include hallucinations
• Agitation
• Emotional lability
• Diagnostic approach
• A thorough history, mental state examination and mini mental state examination are vital to
differentiate delirium from other conditions that present in similar ways.
• These include depression and, in older people, dementia.
• A full physical examination should identify potential causes.
• These commonly include urine infection, chest infection, dehydration and constipation.
• Comprehensive investigations are required to exclude the many causes of delirium.
 Management
• Management involves treating the underlying cause and environmental
measures using physical, psychological and social strategies to reduce
the patient's confusion and resulting anxiety,
• Medication
• The underlying cause of the delirium is treated with the appropriate
medication.
 Oneyroid
● A dreamlike state in a condition of wakefulness.
It is also called a dreamlike state and is defined by the fantastic psychological suffering.
● It is characterized by ambivalent, contradictory speech, senses global changing, catastrophe, and
celebration simultaneously.
● Oneiroid is frequently met with vivid hallucination and illusion which are perceived not as a real fact
in the world but as a presentation, like a movie.
● Sitting in his own room the patient experiences fantastic adventures and events.
● His behavior represents the occurrence of catatonia, stereotypical speech, mutism, negativism,
extreme agility, impulsive attempts.
● Sometimes the speech of the patient is not understood.
● When they answer, it can be found that there is presence of disorientation.
● Only in oneiroid, there is double personality orientation, i.e. the patient may simultaneously think
that he is a normal patient and also a king (or something else according to his grandiose delusion).
●
Amentia
This is a rough obscured consciousness with:
● incoherent thought,
● complete disorientation, unavailability for contact,
● isolated deception of perception signs of sudden physical exhaustion.
● Patients in amentia generally lie in spite of having chaotic excitements.
● His movement reminds about some action which is observed in early stages of hallucination, but frequently it is
absolutely senseless, stereotypical and automatic.
● Patient tries to show something but it is impossible to understand what he wants.
● Words of the patient are not framed in phrases, and are represented by isolated speech (incoherent thought).
● Patient reacts with the doctor's question but cannot answer his question, cannot follow his instruction.
● Unavailability of the patient doesn't allow following up his orientation.
● Physical weakness does not let him get up from the bed.
● Amentia follows somatic disease.
● Duration of the psychosis in this case is longer than the delirium.
● Severity of the physical condition of the patient indicates the possibility of death.
● Even if the life is saved, there is formation of organic defects (dementia, Korsakoff's syndrome, asthenia
condition.).
 Twilight state: trance, fuge
• They are present in typical epileptic paroxysm.
• Psychosis is characterized by sudden onset, very short duration and abrupt end with total amnesia for the total period of disorder of consciousness.
• Symptoms may be different for different patients. But some common factors are present.
• Perception of the surrounding is partial; the patient snatches out from the surrounding irritated facts and reacts to them unpredictably.
• Affect is characterized by crudeness, aggressiveness, antisocial behavior is not rare.
• Sometimes positive symptoms are present.
• During the psychosis, conversation with the patient is absolutely impossible.
• Hallucination can be understood by the behavior of the patient.
• During remission remnants of the psychosis are not present.
• Sometimes psychosis ends with deep sleep.
• Twilight states includes:
• Consciousness with positive symptoms (delusional and hallucination variant)
Delusional and hallucination variants of twilight states can be presented by different symptoms with abrupt psychomotor excitement, brutal aggression,
and crude affect.
• Patient represents serious harm for the surrounding.
• His aggressive movement is odd and rude.
• He may even kill.
● He won't listen to request, pray, ery and crick
 Consciousness with automatic
movements (ambulatory automatism)
• Ambulatory automatism lasts for a shorter period of time without abrupt excitement but with the possibility to do automatic
movements.
• Patient may take off his clothes or the opposite, go on the street, look at the sides, and cross the road.
• If he meets a person, he may answer his questions.
• When he goes out of the psychosis, he cannot remember how he went out, crossed the road, whom he met. He cannot explain his
actions.
• This state can be divided further into the followings:
Fuga:
● Very short period of twilight state episode (1-2 min).
• During fuga, the patient suddenly runs, takes away or wears clothes.
After 1-2 min, he comes to himself, but cannot remember what had happened in that 1-2 min, what he did and how he did it.
• Trans:
• It is a little longer in duration.
• The episode is of senseless roaming.
• Patient may go far from the home, where the disorder of consciousness occurred; he got up to a vehicle on his way to work, missed
some stations, then he realized suddenly that he missed his station.
• Very rarely it is observed that a patient goes to another city, stays there for a few hours, roaming around helplessly, then gets back to
 Somnambulism: Sleepwalking

● Purposeful moving, usually but not always including walking, while in a deep stage of sleep.
● These activities can be as benign as sitting up in bed, walking to the bathroom, and cleaning, or as
hazardous as cooking, driving, violent gestures, grabbing at hallucinated objects, or even homicide.
● Sleepwalkers often have little or no memory of the incident, as their consciousness has altered into a state
in which it is harder to recall memories.
● Although their eyes are open, their expression is dim and glazed over.
● Sleepwalking may last as little as 30 seconds or as long as 30 minutes.
● Twilight states, like other paroxysms, are typical presentations for epilepsy and other organic diseases of
the brain (tumor, cerebral atherosclerosis, head injury etc.).
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