Types of disturbances of consciousness. Stupidity: what types are there? Criteria for stupefaction

Disturbances of consciousness are among the least developed issues. Despite the fact that all psychiatry textbooks describe various forms of disturbance of consciousness, the definition of this concept encounters difficulties. This happens because the concept of consciousness in psychiatry is not based on a philosophical and psychological interpretation.

Consciousness can be considered in different aspects. In philosophy, it has a broad meaning, being used in terms of contrasting the ideal with the material (as secondary to the primary), from the point of view of origin (a property of highly organized matter), from the point of view of reflection (as reflecting the objective world).

In a narrower sense, consciousness is a human reflection of existence, a reflection in socially developed forms of the ideal. Marxism associates the emergence of human consciousness with the emergence of labor in the process of transformation of a monkey into man. The impact on nature in the course of collective work activity gave rise to an awareness of the properties and natural connections of phenomena, which was consolidated in the language formed in the process of communication. In work and real communication, self-awareness arose - awareness of one’s own relationship to the natural and social environment, an understanding of one’s place in the system of social relations. The specificity of the human reflection of existence is that “human consciousness not only reflects the objective world, but also creates it” [1, 29, 194].

When solving the problem of consciousness in psychology, Soviet scientists proceed from the provisions of Marxist-Leninist philosophy. Consciousness is considered as the highest function of the brain associated with speech, reflecting reality in a generalized form and purposefully regulating human activity.

S. L. Rubinstein paid much attention to the problem of consciousness in psychology [159; 160]. Saying that consciousness is the process of the subject’s awareness of the objective existence of reality, he emphasized that consciousness is the knowledge of how an object opposes the knowing subject. The problem of the connection between consciousness and activity is also given attention in the works of A. N. Leontyev. He directly points out that consciousness can be understood “as a subjective product, as a transformed form of manifestation of those relations that are social in nature, which are carried out by human activity in the objective world... It is not the image that is imprinted in the product, but precisely the activity - the objective content that it objectively carries within itself" [113, 130].

Consciousness includes not only knowledge about the world around us, but also knowledge about oneself - about one’s individual and personal properties (the latter presupposes awareness of oneself in the system of social relations). In contrast to the traditional use of the concept of “self-awareness,” A. N. Leontyev proposes to use this term in the sense of awareness of one’s personal qualities. He says that self-consciousness, the consciousness of one’s “I,” is awareness in the system of social relations and does not represent anything else.

The problem of self-awareness is given a lot of research (S. L. Rubinshtein, B. G. Ananyev, L. I. Bozhovich, etc.), analysis of its methodological aspect (I. I. Chesnokova, E. V. Shorokhova), the connection of self-awareness with cognition other people (A. A. Bodalev, I. S. Kon, V. V. Stolin, etc.). An extremely large amount of research has been devoted to the problem of self-awareness, the “I-image” in the works of foreign neo-Freudian authors and representatives of humanistic psychology (K. Rogers, A. Maslow). The literature on the problem of self-consciousness and the unconscious is also rich (F.V. Bassin, A.E. Sherozia). A number of works are devoted to the problem of self-regulation and self-awareness (I. Kon, B.V. Zeigarnik, L. Festinger). Beginning with James, particular problems are also highlighted as the relationship between self-awareness and the physical image of the self (I. I. Chesnokova, A. A. Bodalev, M. A. Kareva, etc.).

It is not possible in this book to dwell on all aspects of consciousness. I would just like to remind you that 1) in psychology this problem is developed from different positions and aspects, both theoretically and phenomenologically: 2) that no matter how different the ways of studying consciousness, all domestic psychologists proceed when solving even its particular problems from Marxist-Leninist philosophy the position that consciousness reflects the objective outside of us existing world that it has the property not only to reflect, but also to create it.

The concept of consciousness in psychiatry does not coincide with its philosophical and psychological content. It is rather "working". Leading modern psychiatrist A.V. Snezhnevsky says that “if we approach consciousness in a philosophical sense, then we naturally must say that with any mental illness, the highest form of reflection of the world in our brain is disrupted” [173, 99-100]. Therefore, clinicians use the conventional term disturbance of consciousness, meaning special forms of its disorder.

S. L. Rubinstein also agrees with this position, speaking about the advisability of “separating” mental disorders from disorders of consciousness, as having specific characteristics.

The concept of consciousness, which A. V. Snezhnevsky defines as “conditional,” is based on the views of the German psychiatrist K. Jaspers, who views consciousness as the background against which a change of various mental phenomena occurs. Accordingly, with mental illness, consciousness can be impaired regardless of other forms of mental activity and vice versa. Thus, in medical histories one can find expressions that the patient has delirium with clear consciousness, impaired thinking against the background of clear consciousness, etc. Metaphorical signs of “clarity” and “stupidity” of consciousness, introduced by K. Jaspers, have become defining for the characteristics of consciousness in psychiatry textbooks to this day. Following K. Jaspers, the following are taken as criteria for darkened consciousness:

1. disorientation in time, place, situation;
2. lack of a clear perception of the environment:
3. different degrees of incoherent thinking;
4. difficulty remembering current events and subjective painful phenomena.

To determine the state of darkened consciousness, it is crucial to establish the totality of all of the above signs. The presence of one or more signs cannot indicate confusion [55, 173].

In psychiatry, different forms of consciousness disorders are distinguished.*

* Although we generally do not use the conceptual apparatus of psychiatry, for some sections (in particular, consciousness) it should be covered.

Stunned state of consciousness. One of the most common syndromes of impaired consciousness is stunned syndrome, which most often occurs in acute disorders of the central nervous system, infectious diseases, poisoning, and traumatic brain injuries.

A stunned state of consciousness is characterized by a sharp increase in the threshold for all external stimuli and difficulty in forming associations. Patients answer questions as if “awake”; the complex content of the question is not comprehended. There is slowness in movements, silence, and indifference to the environment. The patients' facial expressions are indifferent. Dozing occurs very easily. Orientation to the environment is incomplete or absent. The state of unconsciousness lasts from minutes to several hours.

Delirious confusion. This state is very different from being stunned. Orientation in the environment is also disturbed, but it does not consist of a weakening, but rather an influx of vivid ideas and continuously emerging fragments of memories. What occurs is not just disorientation, but false orientation in time and space.

Against the background of a delirious state of consciousness, sometimes transient, sometimes more persistent illusions and hallucinations, delusional ideas arise. Unlike patients in a stunned state of consciousness, patients with delirium are talkative. As delirium increases, the deceptions of the senses become stage-like: facial expressions resemble a spectator watching the scene. The facial expression becomes either anxious or joyful, facial expressions express either fear or curiosity. Often, in a state of delirium, patients become agitated. As a rule, the delirious state intensifies at night. A delirious state is observed mainly in patients with organic brain lesions after injuries or infections.

Oneiric (dreaming) state of consciousness(first described by Mayer-Gross) is characterized by a bizarre mixture of reflections of the real world and vivid sensory ideas of a fantastic nature abundantly emerging in the mind. Patients “commit” interplanetary travel and “find themselves among the inhabitants of Mars.” One often encounters fantasy with a huge character: patients are present “at the death of a city,” they see “buildings collapsing,” “the metro is collapsing,” “the globe is splitting apart,” “breaking up and floating in pieces in outer space” [173, 111].

Sometimes the patient’s fantasizing stops, but then, unnoticed by him, fantasies of this kind begin to arise in his consciousness again, in which all his previous experience, everything he read, heard, and saw, emerges, forming in a new way.

At the same time, the patient can claim that he is in a psychiatric clinic, that a doctor is talking to him. The coexistence of the real and the fantastic is revealed. K. Jaspers, describing such a state of consciousness, said that individual events of a real situation are obscured by fantastic fragments, that oneiric consciousness is characterized by a deep disorder of self-awareness. Patients are not only disoriented, but they have a fantastic interpretation of their surroundings.

If during delirium certain elements, individual fragments of real events are reproduced, then with oneiroid patients do not remember anything from what happened in a real situation; they sometimes only remember the content of their dreams.

Twilight state of consciousness. This syndrome is characterized by a sudden onset, short duration and equally sudden cessation, as a result of which it is called transistor, i.e. transient.

An attack of the twilight state often ends critically. followed by deep sleep. A characteristic feature of the twilight state of consciousness is subsequent amnesia. Memories of the period of stupefaction are completely absent. During the twilight state, patients retain the ability to perform automatic, habitual actions. For example, if a knife comes into the field of vision of such a patient, the patient begins to perform the usual action with it - cutting, regardless of whether there is bread, paper or a human hand in front of him. Often, in a twilight state of consciousness, delusions and hallucinations occur. Under the influence of delirium and intense affect, patients can commit dangerous acts.

The twilight state of consciousness, occurring without delirium, hallucinations and changes in emotions, is called “outpatient automatism” (involuntary wandering). Patients suffering from this disorder, leaving the house with specific purpose, suddenly, unexpectedly and incomprehensibly, they find themselves at the other end of the city. During this unconscious journey, they mechanically cross streets, ride in public transport and give the impression of being lost in thought.

The twilight state of consciousness sometimes lasts for an extremely short time and is called absence (absence - French).

Pseudo-dementia. A type of twilight state of consciousness is pseudodementia. It can occur with severe destructive changes in the central nervous system and in reactive states and is characterized by acutely occurring disorders of judgment, intellectual-mnestic disorders. Patients forget the names of objects, are disoriented, and have difficulty perceiving external stimuli. The formation of new connections is difficult; at times, illusory deceptions of perception, unstable hallucinations with motor restlessness can be noted.

Patients are apathetic, complacent, emotional manifestations are scanty and undifferentiated. Behavior often resembles deliberately childish. Thus, an adult patient, when asked how many toes he has, takes off his socks to count them.

We have focused only on some forms of impairment of consciousness. In reality, their manifestations in the clinic are much more diverse, but it was important for us to acquaint the reader with the concepts in which disorders of consciousness are interpreted and described in the clinic.

Along with. various forms disturbances of consciousness as a reflection of the surrounding reality, a unique form of disturbance of self-cognition is encountered in the clinic - depersonalization.

Depersonalization. It is characterized by a feeling of alienation from one’s own thoughts, affects, actions, one’s “I”, which are perceived as if from the outside. A frequent manifestation of depersonalization is a violation of the “body schema” - a violation of the reflection in consciousness of the basic qualities and ways of functioning of one’s own body. its individual parts and organs. Similar disorders, called “dysmorphophobia,” can occur in various diseases - epilepsy, schizophrenia, after traumatic brain injury, etc.

Dysmorphophobia syndrome has been described in detail by many psychiatrists, starting with the works of the Italian psychiatrist Morseli (Morseli, 1836-1894). Patients with this syndrome believe that they have “an ugly nose, protruding ears, and they smell bad.” Patients strive to take measures to eliminate the “interfering defect”, insist on surgical intervention, they stand in front of the mirror for hours (mirror symptom), and constantly look at themselves.

This syndrome is described in particular detail in the works of M.V. Korkina, who writes that this syndrome can be considered as a triad consisting of: a) the idea of ​​a physical disability with an active desire to get rid of it: b) the idea of ​​relationships and c) low mood.

The expressed, obsessive or delusional desire of patients to correct an imaginary defect gave the author grounds to talk about dysmorphomania. This is not about the discrepancy between the meaningful reflection of the ideal idea of ​​the external appearance of the “I” and the present, but about rejection of oneself, i.e. about unconscious rejection.

In psychology, the problem of “self-image” was considered within the framework of the problem of self-consciousness, starting with W. Wundt and A. Pfender, who identified the concept of “I” and the concept of “subject”. In a different aspect, this problem is posed by W. James (1911), who distinguished between the empirical “I” (the mental world of the subject, which is supplemented by self-esteem) and the pure “I” ( thinking man). The problem of “self-image” was the subject of analysis of various psychological schools of Freudianism and neo-Freudianism, understanding, humanistic psychology, etc.

In Russian psychology, this problem appears already in L. Groth and I. M. Sechenov, who linked the problem of “I” with “warm feelings” and interorceptions. The dependence of the physical image of the “I” on many aspects was shown, especially self-esteem and the assessment of others (I. S. Kon, A. A. Bodalev, S. L. Rubinstein, etc.). S. L. Rubinstein directly pointed out that the problem of studying personality “ends with the revelation of the individual’s self-awareness” [158, 676-677]. A number of works are devoted to changing the “image of self” in mentally ill patients (R. Federi, S. Fischer, etc.). Many studies have been devoted to the study of disturbances of the “I” in patients with schizophrenia (Vekovich, Sommer).

The work of B.V. Nichiporov, devoted to this problem, shows that dysmorphophobia syndrome is associated with low self-esteem. Such patients avoid society, seclude themselves, and often experience their imaginary ugliness so strongly that it can cause suicide attempts. Moreover, their self-esteem is based not on the content of the idea of ​​​​the ideal image of the external “I”, but on the rejection of their physical “I”.

We find the most general answer to the question about the nature of this phenomenon in I.M. Sechenov, who emphasized the role of muscle sensations in the implementation of body movements and acts of perception, pointed to the existence of “dark”, undifferentiated feelings emanating from the internal organs, creating a “sensual lining” " of our "I" and serving as the basis of self-awareness.

“Dark” interoceptive sensations, due to their constancy and monotony, as well as inductive inhibition due to the outward direction of the subject’s activity, are usually not recognized, but are a necessary background for the normal flow of all mental activity. Based on these sensations, the child, in the process of development, learns to distinguish himself from the world around him.

I.M. Sechenov argued that the synthesis of sensations emanating from the internal sense organs and the so-called external sense organs is the core of the formation of self-awareness: “A person continuously receives impressions from own body. Some of them are perceived in the usual ways (one’s own voice by hearing, body shapes by the eye and touch), while others come, so to speak, from inside the body and appear in consciousness in the form of very vague dark feelings. Sensations of the latter kind are companions of processes occurring in all the main anatomical systems of the body (hunger, thirst, etc.), and are rightly called systemic feelings. A person cannot, in fact, have any objective sensation that is not mixed with a systemic feeling in one form or another... The first half of feelings is, as they say, objective in nature, and the second is purely subjective. The first corresponds to objects of the external world, the second - the sensory states of one’s own body, self-awareness" [171, 582-583].

Normally, a person does not need proof that his body belongs to his own person and mental experiences. In some pathological cases, this sensory “lining” of self-awareness is disrupted, and as direct knowledge, a feeling of alienation, imposition, and suggestibility of one’s own thoughts, feelings, and actions may appear.

A modern researcher of the problem of depersonalization A. A. Mehrabyan, showing the inconsistency of explaining this psychopathological phenomenon from the positions of associationism, phenomenological direction, anthropological psychology, psychoanalysis, connects it with a disorder of special “gnostic feelings” - systemic automated feelings, merged in a normal state with the reflective component of mental images

Gnostic feelings, according to A. A. Mehrabyan, exhibit the following properties: 1) generalize previous knowledge about an object and a word in a concrete sensory form; 2) provide a sense of belonging of mental processes to our “I”; 3) include an emotional tone of one color or another and intensity.

The role of gnostic feelings in cognition and self-knowledge becomes especially noticeable in cases of pathology that gives rise to phenomena of mental alienation [130, 131].

Violation of gnostic feelings can lead not only to a disorder of self-knowledge, but also to personality changes. This is convincingly shown in the work of V.I. Belozertseva. Based on the work of the school of V. M. Bekhterev, the author revealed how an altered sense of self in the course of the reflective activity of the diseased brain gives rise to a new activity for the subject - the activity of self-perception. This activity, due to the constancy of unusual feelings and their special significance for a person, becomes meaning-forming, leading in the hierarchy of other types of activity. Patients abandon their previous affairs and cannot think about anything except their own unusual conditions and the reasons for their occurrence.

Many case histories cited in the works of V. M. Bekhterev and his colleagues illustrate how the desire to comprehend the results of distorted self-perception leads patients to a delusional interpretation of their condition. In search of the “enemies” influencing them, patients observe the behavior of others, analyze relationships with them, perform real actions in order to “liberate” from the supposed hypnotic influence, and again analyze their state and the behavior of the “enemies”.

In the course of this activity and real relationships with people, delirium influences the mental sphere acquires new and new details, distorting the perception of the environment and influencing the behavior and lifestyle of patients, rebuilding the system of their relationships with people, changing their personality.

V.I. Belozertseva concludes that if in a healthy person the sense of self is not related to his personal characteristics and self-awareness in the system of social relations, then in a patient it can bring to the fore an activity that previously did not exist or acted only as individual actions in the system of other activities, - the activity of self-perception. Regardless of the personality (whether a person wants it or not), it becomes meaning-forming. The main motive shifts to the goal, and the “detachment” of the hierarchy of activities from the state of the body, characteristic of a healthy subject, is disrupted. In the case of pathology, the biological begins to play a different role than in the life of a healthy person.

This, of course, does not mean that the disease itself, as a biological factor, determines the restructuring of the hierarchy of motives and self-awareness. The motive for the activity of self-perception is generated by the awareness of the unusualness, changes in the sensations of one’s own mental experiences, and an active attitude towards them. Consequently, the disease has a destructive effect on the personality not directly, but indirectly, through activity learned in the course of human social development.

We present these clinical data to show that pathological change psyche, its self-awareness is carried out, like normal development, in ontogenesis, in the practical activity of the subject, in the restructuring of his real relationships - in this case, under the influence of a delusional interpretation of his state that develops in the course of self-perception, affecting a person’s place among other people.

Thus, I. I. Chesnokova writes that the material of clinical observations of disorders of self-awareness, expressed mainly in the depersonalization syndrome, is the actual substantiation of theoretical provisions about self-awareness as the central “former” of personality, linking together its individual manifestations and features.

Syndromes of switching off consciousness.

Classification of disorders of consciousness.

Criteria for impaired consciousness.

The concept of consciousness.

Disorders of consciousness and desires.

LECTURE 5.

1. The concept of consciousness.

2. Criteria for impaired consciousness.

3. Classification of disorders of consciousness.

4. Syndromes of switching off consciousness.

5. Syndromes of stupefaction.

6. Desire disorders.

7. Suicidal behavior of mentally ill people and its prevention.

8. Refusal of food in mentally ill people and help with it.

Consciousness - the highest form of reflection by the human brain of objectively existing reality.

Consciousness integrates everything mental processes and ensures their interaction. Consciousness ensures the ability of the individual to give himself a clear account of the environment, present and past times, make decisions and manage his behavior in accordance with the situation.

Disorders of consciousness are an indicator of the significant severity of the disease.

K. Jaspers proposed 4 criteria. We can talk about disorders of consciousness only if all criteria are met.

1. Detachment from the environment (the patient does not react to what is happening)
2. Disorientation (in time, place of stay, self)
3. Incoherent thinking
4. Amnesia for a period of impaired consciousness (congrade amnesia)

I. Switching off consciousness (simple syndromes)

1. Stunned
2. Sopor

II. Confusion (complex syndromes)

1. Delirium
2. Oneiroid
3. Amentia
4. Twilight stupefaction

Stunned.

The patient's threshold of perception increases. He only reacts to strong stimuli (loud sound). The patient is accessible to contact - he can answer simple questions asked in a loud voice in monosyllables. The facial expression is sleepy, the look is confused. Left to his own devices, the patient falls asleep.

Sopor.

More severe condition. Contact with the patient is impossible, but the reaction of the pupils to light and the reaction to painful stimuli are preserved.

Coma.

Mental activity is completely suppressed. Protective reflexes and indicative reactions fade away, painful stimuli are not perceived. Pathological reflexes appear.

Turning off consciousness is a universal reaction of the brain to external harm. It occurs in severe infections and intoxications, head injury, severe somatic diseases, metabolic disorders, etc.

Delirium.

Starts in the evening or at night. It occurs in 3 stages.

1. initial stage. IN evening time The patient develops hyperesthesia, irritability, emotional lability, sleep disturbances (difficulty falling asleep, nightmares). Anxiety may appear.

2. Illusory stage. Pareidolic illusions and hypnagogic hallucinations.

3. Hallucinatory stage. Multiple true hallucinations. Prevail visual images(zoological, religious-mystical, anthropomorphic). Auditory (voices) and tactile hallucinations also occur. The patient's behavior is determined by the content of hallucinations. Most often, hallucinations are frightening. At the height of delirium, orientation in time and place of stay is disrupted.

Delirium lasts from several hours to several days. A wave-like course is typical - during the daytime the patient’s condition improves, but increased hallucinatory readiness remains (reading from a blank sheet of paper, talking on a switched off phone). At the exit from delirium, partial amnesia remains: they remember hallucinations well and poorly remember real events.

Variants of delirious stupefaction:

1) abortive delirium – mild form, lasts several hours, no disorientation at the place of stay, fragmentary hallucinations;

2) professional delirium and excruciating delirium – severe forms, characterized by a long course (up to 2 weeks), absence of light intervals, and depletion of hallucinatory symptoms; with professional delirium, the patient performs the usual professional or everyday actions, with mussitative delirium - agitation in the bed, circling movements, unintelligible muttering.

Delirium occurs in alcohol withdrawal syndrome, somatic and infectious diseases with severe intoxication (lobar pneumonia, cancer, typhoid fever), and head injury.

Oneiroid.

Dreamlike stupefaction with visual fantastic pseudohallucinations (flights into space, travel to fairy-tale lands). Orientation in time, place of stay and one’s own personality is disrupted. Behavior does not depend on hallucinations; their content can be guessed from the facial expression of the patient, who is in a stupor. Duration - from several weeks to several months. The result is partial amnesia (remembers hallucinations, but does not remember real events).

Occurs in recurrent type of schizophrenia.

Amentia.

A severe disorder of consciousness that develops with severe somatic diseases (cancer cachexia, sepsis). Hallucinations are practically absent, complete disorientation. Excitement within the bed or crucified position. Contact with the patient is impossible due to severe incoherence of thinking (speech is a meaningless collection of words). The duration of amentia ranges from several weeks to several months. The result is complete amnesia. The prognosis is unfavorable and depends on the course of the underlying disease

Twilight stupefaction.

This is a paroxysmal disorder of consciousness, i.e. it begins and ends suddenly and does not last long. There is a tendency to repeat them. A common feature of twilight disorder is the preservation of orientation in a small part of space in the immediate vicinity of the patient. At severe forms orientation in time and one's own personality is disturbed. The result is complete amnesia.

1. Classic shape . Against the background of clouding of consciousness, frightening visual hallucinations and delirium appear, which leads to the development of frantic motor excitement with destructive actions (the patient defends himself). The condition is short-term (minutes-hours), after its completion - severe asthenia.

2. Dysphoric (oriented) variant . Darkening of consciousness of lesser depth. Occurs against the background of severe dysphoria.

3. Outpatient automatisms . The mildest form of twilight disorder. Patients perform stereotypical automated actions. Types of outpatient automatisms:

1) somnambulism (sleepwalking)

2) trances (somnambulism while awake, the patient does not remember how he ended up in a given place)

3) fugues (quick stereotypical actions against the background of a detached facial expression).

Twilight disorder of consciousness occurs in epilepsy, organic brain damage.

Lecture No. 5
DISORDERS OF CONSCIOUSNESS

Disorders of consciousness occur not only in mental patients. May occur, for example, with infections in children.

“Delirium tremens” develops in every 20th alcoholic patient. Drug addicts and substance abusers may have disturbances of consciousness.

Classification of disorders of consciousness:

1. Syndrome of switched off consciousness. The following stages are distinguished:

   – nullification,

   – coma – no consciousness.

2. Syndromes of clouded consciousness - consciousness is preserved, but in a new quality - patients behave unusually. Then they don’t remember or don’t remember well the events that happened to them at the moment of darkness. The experiences are vivid, outwardly incomprehensible.

Criteria for darkened consciousness(according to K. Jaspers):

a) detachment from the real world

b) disorientation

c) amnesia – specific for each option.

Jaspers described the stages of development of delirium.

There are 4 main types of confusion:

• delirious stupefaction - most often;
• oneiric stupefaction;
• amental clouding of consciousness;
• twilight stupefaction.

Delirium– a nonspecific mental reaction to the fact of intoxication. In most cases, delirium is of alcoholic origin. Acetaldehyde intoxication leads to metal-alcohol psychosis.

Delirium is one of many alcoholic psychoses. Develops only at stages 2 or 3 of alcoholism. There are many symptoms.

Delirium tremens is preceded by alcohol withdrawal syndrome. According to WHO, alcohol withdrawal syndrome is a set of somatovegetative neurological and psychopathological syndromes that occur with sudden deprivation of alcohol, and all these manifestations reduce their severity and intensity with the addition of new doses of alcohol. Withdrawal is preceded by a binge, usually a true binge (5-7 days), after which the drinking of alcohol suddenly stops, which leads to the appearance of symptoms.

Psychopathological manifestations of alcohol withdrawal syndrome:

a) sleep disorders;

b) irritability;

c) anxiety, restlessness (possibly subdepressive mood);

d) rudimentary deceptive perception (phonemes, photopsies, phosphenes).

Neurological manifestations of alcohol withdrawal syndrome:

a) static and dynamic ataxia (violations of coordination tests, instability in the Romberg position);

b) convulsive paroxysms are possible;

c) tremor (isolated or generalized).

Somatovegetative manifestations of alcohol withdrawal syndrome:

a) abdominal pain;

b) nausea, vomiting;

c) stool disorders;

d) lack of appetite;

e) cardialgia;

e) arterial hypertension (occasionally hypotension);

g) tachycardia;

h) tachypnea;

i) increased body temperature (sometimes significant hyperthermia), especially in combination with infection;

j) hyperhidrosis;

k) the tongue is covered with a gray coating.

Of these 3 groups of symptoms, psychopathological ones gradually come to the forefront, while others fade into the background. On the 2-3rd day after deprivation of alcohol, delirium develops closer to night.

Clinical manifestations of delirium:

The patient lies in bed, fixed, but tries to get up, the patient is unshaven, unwashed, “vegetative”, the tongue is covered with a brown coating, perception disorders are observed (microptic bestial extracampal hallucinations), and thinking disorders. The patient's behavior is determined by powerful hallucinatory experiences. The patient is oriented in his own personality, place, time. Perception disorders manifest themselves as true hallucinations, all images with a negative connotation (devils, mice, rats, cockroaches). The emotional reaction of the patient is of great importance for making the correct diagnosis. The patient actively defends himself, protects himself from hallucinatory images. By the morning, delirium weakens - the “lucid window” - a decrease in the severity of symptoms. Sometimes the silent course of delirium is a less favorable option.

In the treatment of patients with delirium, it is important to achieve sleep, which will be a way out of delirium. For 2-3 months after recovery from delirium, an asthenic state occurs.

Keywords: psychiatry, lecture, consciousness, disorders of consciousness, delirium, oneiroid, blackout, stupefaction, alcoholic delirium, alcohol withdrawal syndrome

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Blurred consciousness refers to its qualitative disorders and is a sign of serious problems with the functioning of the brain. There are several types of darkness, differing in the depth and content of pathopsychological symptoms. Identification and treatment of such disorders in patients is most important for psychiatrists, narcologists, neurologists, toxicologists and resuscitation specialists, but doctors of other specialties may also encounter this problem. What types of clouding of consciousness exist will be discussed in this article.

What happens during clouding of consciousness

Clouding of consciousness is its disintegration with a decrease in the level of perception of external stimuli and the filling of a person’s “internal space” with pathological psychoproductive phenomena. At the same time, a person’s behavior changes, which is determined by the depth of immersion in one’s own experiences and the visible response to them.

The main clinical signs of confusion are:

• detachment from the outside world, while the perception of ongoing events is fragmented and inconsistent, and the analysis of these external stimuli is sharply reduced;
• disorientation in space and time due to the patient’s immersion in his experiences, it is noted that the patient partially or completely does not recognize familiar people and familiar surroundings;
• disturbances in thinking with its incoherence, inconsistency, amorphism, fragmentation;
• memory deterioration to varying degrees, up to amnesia of everything that happens during the period of darkened consciousness, including one’s own experiences.

To diagnose confusion, all 4 of the above signs must be present. Hallucinatory and secondary delusional disorders are also often detected. Experiences during the period of stupefaction are perceived by the patient as real. They replace the events of the surrounding world or are felt as more vivid, absorbing all the patient’s attention. Sometimes this is accompanied by a lack of self-awareness and a feeling of alienation.

Individual memories of the experiences experienced may persist for some time, their vividness and detail depend on the type of disorder suffered. Subsequently, they lose relevance, but criticality towards them almost never reaches a sufficient level. But in some cases, the exit from the state of darkened consciousness is accompanied by complete amnesia for this period; the patient may note a failure in personal perception of time.

Stupidity: classification

Qualitative disorders of consciousness are divided into:

• delirium (delirious stupor or state), including the so-called professional delirium;
• (oneiric, or dream stupefaction);
• amentia (amentive darkness);
• twilight states of consciousness (twilight), including several varieties;
• special states of consciousness: various types of aura, which is a paroxysmal form of clouding of consciousness.

It is not always possible to carry out an adequate differential diagnosis during the initial examination of a patient with confusion. The primary task is to exclude quantitative disorders (stunning, etc.). Clarification of the type of stupor is sometimes carried out on the basis of dynamic observation and retrospective analysis with the patient’s self-report.

Delirium

Delirious stupefaction is characterized by the presence of predominantly psychoproductive symptoms. These include abundant hallucinatory and illusory disorders and the acute sensory delirium determined by them. In this case, true visual hallucinations predominate, although tactile and auditory deceptions of perception are also possible. Their content is usually unpleasant for the patient and is threatening in nature. These can be monsters, beasts of prey, skeletons, small animals and insects, small humanoid creatures. Hallucinations quickly replace each other; wave-like influxes of visions are characteristic.

Behavior is subordinated to emotions, patients are usually restless motorly up to the development of psychomotor agitation. Aggression is directed at hallucinatory images and can affect others. Affect is variable and determined by the content of hallucinations. Generally, anxiety, anger, and fear predominate, but transient states of curiosity and enthusiasm are possible. Preoccupation with hallucinations leads to complete or partial disorientation, and false orientation in space and time is often noted.

Delirium is a wave-like condition. It is characterized by lucid windows: spontaneous periods of lucidity, when the patient’s perception of the environment and the overall level of brain functioning improve. The condition also worsens in the afternoon with an increase in hallucinatory influxes in the evening and at night. Lucid windows most often occur after awakening; during them, the person is asthenized, partially oriented and moderately critical. In addition, delirium is characterized by stages of development, with each stage being reversible.

At the first stage, there are no hallucinations yet, but there are influxes of vivid memories, increased and uncontrollable associations, and distracted attention. The person is talkative, affectively unstable, not critical enough and is not always clearly oriented. His behavior becomes inconsistent, and his sleep is restless and superficial, with disturbing, overly vivid dreams.

At the second stage, illusions and pareidolia appear, disturbances of attention are aggravated with difficulty in perceiving the environment. The third stage of delirium is characterized by multiple true hallucinations and associated sensory delusions. Even when scene-like visual hallucinations appear, the feeling of their alienness remains. The patient does not become involved in imaginary events, but observes them or opposes himself to them. Behavior is subject to emotions, orientation deteriorates sharply.

The fourth stage is a severe disintegration of thinking with complete immersion in experiences and detachment from the outside world. Delirium at this stage is called muttering. The man shakes something off himself, makes picking movements, fidgets with the bed, and mutters for a long time. Verbal activity is practically independent of external factors; strong sound and painful stimuli lead to a temporary increase in the volume of pronounced sounds and words.

A special form of delirious stupefaction is occupational delirium, in which hallucinatory-delusional disorders are fragmentary in nature and do not determine behavior. Against the background of deep detachment and disintegration of thinking, stereotypically repetitive movements appear, which are associated with the automation of the patient’s professional activity. This could be imitation of working on a machine, sweeping, using abacus, knitting. It is also possible to repeat simple gestures and body movements typical for a given person.

Oneiroid

Oneiroid is a more severe form of clouding of consciousness. In this case, the defining feature is a dream-like delirium of fantastic content, which unfolds dramatically and leads to a violation of the patient’s level of self-awareness. Visions are perceived as if by the inner eye; they absorb almost all of a person’s attention and draw him into the illusory world. The scenes are large-scale, fantastic, colorful and dynamic. The patient feels like a different person or being, with unusual capabilities and the ability to influence everything that happens. It is as if he controls world wars, discovers new galaxies, collects plants of extraordinary beauty, meets historical figures or even becomes them.

Unlike the oneiroid, all these vivid experiences have practically no effect on the behavior of the person in the oneiroid. He may appear distracted, lethargic, or simply freeze periodically. His movements are usually elaborate, meager, and slow. From them and from their frozen facial expressions it is almost impossible to guess the content of the visions. At the same time, it is sometimes possible to obtain simple answers to questions about the patient’s experiences and imaginary place of stay.

Such clouding of consciousness can occur in stages:

1. Another controlled fantasy with an influx of images;
2. Delirium of intermetamorphosis with a feeling of unreality and staging of events, false recognitions, developing into sensual delirium of fantastic content;
3. Oriented oneiroid, when dream-like experiences are combined with partial orientation in the environment;
4. A deep oneiroid with detachment from the real world; when leaving it, there is complete amnesia of the actual events that have occurred.

Sometimes oneiric stupefaction is diagnosed after its completion. At the same time, the patient has a detailed, vivid description of fantastic experiences combined with a paucity of memories of what is happening around him and bewilderment about the dissonance regarding the duration of the episode and his own personal identity.

Amentia

With this type of darkness, a person is confused, helpless, he does not comprehend the events taking place and is deeply disoriented in place, time and even his own personality. There is a pronounced disintegration of all components of thinking, the process of analysis and synthesis is disrupted, and self-awareness disintegrates. Hallucinatory and delusional disorders are fragmentary and in this case do not determine the patient’s behavior.

Speech production is increased. Statements mainly consist of individual incoherent words, but at the same time their content corresponds to the existing affect. The mood is unstable, the patient experiences alternating states of enthusiasm and tearfulness. Quite clearly defined episodes of low mood with classic psychomotor signs of depressive syndrome are possible.

The behavior is characterized by agitation in the bed, which sometimes resembles catatonic and for a short time can be replaced by a substuporous state. Movements are unfocused, inconsistent, and often sweeping. Revitalization of fine motor skills is not typical.

Amental stupefaction is a profound disorder of consciousness and can last up to several weeks. There are no periods of lucidity, but in the evening and at night, amentia is often replaced by transient delirium. After emerging from the state of stupefaction, the patient becomes completely amnesic of both his experiences and the events of the surrounding world.

Twilight

Twilight states of consciousness are transient and heterogeneous disorders. They are characterized by intense affect, disorientation and complete amnesia during the period of stupefaction. Depending on the type of twilight, a person may also experience delusions, hallucinations, automated movements, or agitation. There are delusional, affective (dysphoric), and oriented variants of the twilight state of consciousness. There is a separate form with various ambulatory automatisms, including trance and fugue.

People around us do not always recognize the onset of a person’s twilight state of consciousness. Suspicious signs are a state of self-absorption that is inadequate to the situation, indifference to current events, stereotypic movements or ridiculous unexpected actions. Moreover, actions can be criminal, causing physical harm to other people, including murder.

Aura

An aura is a special type of clouding of consciousness; most often it occurs before deployment. At the same time, the person experiences vivid and memorable experiences, and real events are perceived fragmentarily and unclearly or do not capture the patient’s attention at all. There may be a feeling of a change in the body diagram, depersonalization and derealization, visual, gustatory and olfactory hallucinations, senestopathies, bright color photopsia, increased contrast and coloring of real objects.

The affect is usually intense, and dysphoria or ecstasy often occur. During an aura, a person may freeze, experience anxiety, and become immersed in his unusual sensations. Memories of these experiences displace from memory information about what is happening in the outside world, and they are not subject to amnesia even with the subsequent development of a generalized convulsive seizure.

It is currently believed that confusion occurs due to disruption of cortical interneuron connections. Moreover, these changes are not structural, but functional in nature; they are associated with an imbalance of the main neurotransmitters. The reason for this may be endogenous mental disorders, various intoxications, and other conditions. And determining the type of clouding of consciousness a patient has is an important point in diagnosis, often determining the tactics of further treatment.

Psychiatrist I.V. Zhuravlev gives a lecture on the topic “Disorders of consciousness and self-awareness”:

Voronezh State Medical Academy named after. N. N. Burdenko

Department of Psychiatry with Narcology

SYNDROMES OF DISTURBED CONSCIOUSNESS

Voronezh 2004

1. Introduction

Consciousness is the highest form of reflection of objective reality, providing the connection of knowledge for systematic, naturally directed active activity. Consciousness is inherent only to man and arose in the process historical development social life and active labor activity of people. It is thanks to consciousness that we have the opportunity to navigate our environment, plan any activity, understand its goals and predict the final result.

The main characteristics of consciousness are considered to be the degree of its clarity (level of wakefulness), volume (breadth of coverage of the phenomena of the surrounding world and one’s own experiences), content (completeness, adequacy and criticality of the assessment of the used reserves of memory, thinking, emotional attitude) and continuity (the ability to recognize and evaluate the past, present and future). One of the most important components of conscious (conscious) and purposeful (volitional) activity is attention - the ability of conscious, voluntary or involuntary selective concentration of sensory, intellectual and motor activity on relevant and individually significant external and internal phenomena.

Clarity of consciousness presupposes the correct representation of reality not in individual mental spheres (in perception, thinking, etc.), but generally, in a holistic mental act. That is why mental disorders such as hallucinations, delusions, obsessions, etc. are not formally classified as pathologies of objective consciousness, although they contain elements of impaired consciousness.

Not only for a psychiatrist, but also for a doctor general practice It is very important to be able to identify disorders of consciousness and correctly organize therapeutic measures. Syndromes of impaired consciousness indicate a severe disturbance of mental activity, which can be caused not only by mental pathology itself, but also by somatic pathology (infections, intoxication, brain tumors, etc.).

Clinical task:

Patient Yu., 15 years old, 9th grade student. She was transferred to a psychiatric clinic from a therapeutic hospital, where she was being treated for severe follicular tonsillitis. For 3 days I hardly slept, complained of severe weakness, headache. The mood was changeable - sometimes unreasonably anxious, sometimes unusually elated. The last night in the therapeutic hospital was hectic. The girl did not sleep, she felt fear, it seemed as if multi-colored spirals were emanating from the electric light bulb, “screwing into her head.” But in the darkness the fear intensified even more. It seemed that vague threatening voices were heard behind the door, the door was being broken down, behind it one could see flickering lanterns and a crowd of people. In horror, the girl jumped out of bed, tried to open the window and jump out into the street. By morning, under the influence of the administered neuroleptic and hypnotics, the patient fell asleep. After sleep, she felt overwhelmed; most of what she experienced during the night was preserved in the girl’s memory. Questions for the problem:

What causes the described mental disorders?

3. Which one therapeutic tactics would it be advisable to choose in this case?

Correct answers to the questions posed can be given provided you know the basics of general psychopathology, its section “Syndromes of impaired consciousness.”

Lesson objectives:

be able to identify and correctly diagnose syndromes of impaired consciousness;

master the tactics of providing assistance to patients with syndromes of impaired consciousness.

To achieve this goal, it is necessary to solve the following tasks:

1) be able to identify states of impaired consciousness using the method of clinical targeted questioning and visual observation, also using data from the anamnesis of life and illness;

be able to qualify syndromic forms of disordered consciousness;

master the tactics of providing medical care persons who show signs of disordered consciousness.

Goal of self-training:

learn to identify and diagnose using model tasks typical symptoms and syndromes of impaired consciousness;

be able to theoretically, based on the situations proposed in the tasks, make correct decisions to provide medical care and carrying out measures to prevent socially dangerous actions.

2. Clinical manifestations

Clinical manifestations of impaired consciousness are varied, however, they all have common constant signs. Only their joint presence makes the diagnosis of impaired consciousness justified. These signs are called criteria for upset consciousness (K. Jaspers, 1911).

Detachment from the environment. Characterized by difficulty, fragmentation or complete impossibility of perceiving the surrounding reality.

Disorientation. Impaired orientation in time, place, situation, surrounding persons, and one’s own personality.

Thinking disorder. Weakness or inability to judge, lack of understanding of the environment, incoherent thinking, or the presence of delusional ideas.

Amnesia. Complete or partial loss from memory of events during the period of upset consciousness.

2.1 Syndromes of switching off consciousness

Syndromes of switching off consciousness (non-productive, non-psychotic forms of impaired consciousness) are characterized by a decrease, even complete disappearance, in clarity of consciousness and impoverishment of all types of mental activity.

Stun

It is characterized by an increase in the threshold to all stimuli, impoverishment of mental activity, motor retardation, and difficulty in associative processes. Stunning can be defined as a condition in which the external has difficulty becoming internal, and the internal - external.

The patient is inactive, spontaneous, spends most of his time in bed, lying in a monotonous position. He is indifferent to his surroundings, it is difficult to attract his attention, he answers only simple questions asked in a loud voice, often after repeated repetition. The patient's answers are monosyllabic (olkgophasia), with significant latent periods (bradyphrenia), but always adequate. The voice is quiet, without modulation, the face is mimic. IN emotional sphere indifference dominates, less often complacency. There is no critical assessment of one's condition. The patient is completely oriented in his own personality, and “in general terms” in his surroundings.

After recovery from stun, partial amnesia is observed. Memories are fragmentary, poor, inconsistent. For example, a patient remembers that he was in the hospital, doctors and relatives came to him, but he does not remember what exactly they said, what diagnostic procedures were performed on him.

Obnubilation - (cloudy consciousness) - a mild form of stunning, characterized by alternating periods of impaired consciousness (fogging) and enlightenment, often in combination with euphoric affect and anosognosia. Attention is unstable, associations are superficial

Doubtfulness - (pathological drowsiness) - a deeper degree of stunning. It manifests itself as long periods of complete lack of contact with reality. It is possible to bring the patient out of this state, but through intensive stimulation to speech contact and for a short time, left to himself, the patient “falls asleep” again. It should be remembered that, in some cases, “awakening” may result in acute psychomotor agitation with aggression (a variant of twilight stupefaction).

A more complete shutdown of consciousness than stunning. Characterized by turning off the first alarm system. Because of this, patients are completely inaccessible to verbal contact, and react only to strong stimuli (painful) with undifferentiated protective motor reactions. The patients are completely motionless. Corneal, conjunctival, gag, and pupillary reflexes are preserved. Pathological reflexes may be observed. Upon recovery from stupor, complete amnesia is observed.

Complete loss of consciousness, lack of reaction to any stimuli. Pupillary and other reflexes are absent, bulbar and pelvic disorders are observed. The activity of the vasomotor and respiratory centers is preserved. As the coma deepens, pathological forms of breathing arise, cardiac activity is disrupted, and then death occurs.

Vegetative status - (apallic syndrome) - a state of relative stabilization of viscero-vegetative functions, beginning after a coma with the first opening of the eyes, the possibility of wakefulness and ending with the first attempt to fixate the gaze.

Unproductive forms of impaired consciousness occur with intoxication, metabolic disorders, traumatic brain injuries, brain tumors, vascular tumors, and others. organic diseases CNS. Loss of consciousness reflects the severity of the underlying disease and is a prognostically unfavorable sign.

2.2 Syndromes of confusion

Syndromes of stupefaction (productive, psychotic forms of impaired consciousness), in addition to the presence of 4 signs of disordered consciousness according to K. Jaspers, are characterized by the presence of productive psychopathological symptoms in the form of hallucinations, secondary delusions, affective disorders, inappropriate behavior and disorganized/pi mental activity in general .

Oneiroid

Oneiroid is a dream-delusional, dream-like clouding of consciousness. The development of oneiroid is usually preceded by a stage of affective-delusional disorders, which is characterized by nonspecificity, polymorphism and variability of symptoms with preserved consciousness.

Stage of affective-delusional disorders. Against the background of sleep disturbances and various general somatic disorders, affective disorders are increasing, manifested by manic states with a feeling of penetration and insight, or depression with anxious depression and sensitivity. A diffuse delusional mood appears, the patients’ statements (ideas of attitude, persecution, inferiority or overestimation of one’s qualities, unusual abilities) are unstable and have the nature of overvalued ideas and delusional doubts. Massive depersoptional-derealization disorders arise, with a feeling of alteration of one’s own mental and physical processes, a feeling of strangeness and unreality of the environment. The perception of time is disrupted; patients may perceive its flow as extremely accelerated, intermittent, slow or stopped. These experiences are accompanied by an increase in polar fluctuations of affect (anxiety and exaltation reach a significant degree of severity) and the development of delusions of staging, special meaning, intermetamorphosis, doubles. Patients begin to claim that a movie is being filmed around them or some kind of performance is being played out in which everyone has certain roles. Everything seems specially arranged, filled with a special meaning, which the patient guesses in other people’s words, actions, and furnishings; real events acquire symbolic meaning. There is a feeling of constant variability in the environment, objects either disappear or appear again as if by magic, people’s faces are constantly changing, the same person takes on different appearances (Fregoli’s symptom), the patient recognizes his loved ones in strangers, and considers his relatives to be dummies ( Quatre's syndrome). The patient claims that the true essence of things has become available to him, that he is able to read thoughts, predict events or influence them in some way, and is experiencing external influences on himself. Thus, the clinical picture becomes more complicated due to the appearance of illusions, pseudohallucinations, automatisms, after which antagonistic (Manichaean) delusions develop. Patients become the center of the struggle between the opposing forces of good and evil, the environment turns into the arena of this struggle, and people become its participants. Such a confrontation can take place outside the patient’s receptive field, but he has the “power” to influence the course of historical events and greatest achievements. The delusional plot acquires megalomaniac content: expansive (delusions of grandeur, messianism) or depressive (delusions of Cotard). Then retrospective (confabulatory) delusions appear and the symptoms approach paraphrenic syndrome.

The patient’s behavior at the initial stages is determined by existing affective and delusional disorders. Gradually it loses connection with the content of experiences, and then becomes formally ordered, however, the patient’s peculiar “fascination” can reveal the wealth of internal experiences. Periodically, episodes of situationally determined delusional behavior occur when the patient refuses to communicate with “made-up” relatives, resists a “staged” medical examination, and does not answer the questions of the “investigator” in the doctor’s office.

Stage of development of the oriented oneiroid. At a certain moment, against the background of the described disorders, the patient develops a tendency to involuntary fantasizing, vivid dream-like ideas in which, thanks to a pathologically enhanced play of the imagination, all past experiences, not only personally experienced, but also borrowed from books and films, are bizarrely processed. Any external impression or bodily sensation is easily included in the content of these fantasies, receiving a symbolic interpretation. At this stage, the phenomenon of “double orientation” appears.

The patient seems to simultaneously exist in two situations - real and fantastic; along with the correct orientation in his personality and place, he creates a delusional idea of ​​​​the surroundings and his position in it. The surrounding environment is perceived as the historical past, an unusual situation of the present, or as a scene of fairy-tale-fantastic content; the surrounding persons turn into active characters in these unusual events. The patient may be fully aware that he is in a hospital and at the same time consider the medical workers to be the crew of a spaceship, the patients to be passengers, and himself to be a starfleet admiral. Thus, the visualization of the products of the imagination occurs, which the patient initially has the ability to control, but then the influx of images arises against his will.

The behavior of patients takes on distinct catatonic features. In the department, such patients may be practically invisible, or they attract attention with absurd agitation and inconsistent speech. They perform religious and ritual actions in a stereotypical and pretentious manner, mannerly recite poetry, and freeze in sculptural and monumental poses. The phenomena of waxy flexibility, negativism, echolalia, echopraxia, and impulsive actions are occasionally detected. The speech is rich in neologisms, the thinking is resonant, sometimes torn. The face is mask-like or paramimic, it shows an expression of mystical penetration, ecstasy, or seriousness that is inappropriate for statements. Contact is unproductive; identifying the content of experiences can be quite difficult.

Stage of development of a true oneiroid. It is characterized by a complete loss of contact with the surrounding reality, allo- and autopsychic disorientation. Involuntarily arising ideas take on the character of visual pseudohallucinations. The patient finds himself captivated by the contemplation of fantastic panoramas, scenes of grandiose events, in which he himself occupies a central position, acting as an active character. At the same time, he seems to be reincarnated into the heroes of unusual incidents, into the “world mind”, into animals, completely identifying himself with them, both mentally and physically. physical level. In his painful experiences, he travels through time; everything flashes before his “inner eye.” world history, pictures of the ancient world and the distant future. The patient visits distant planets, ancient civilizations, the afterlife or other dimensions. Meets their inhabitants, quarrels with them, or receives sacred knowledge from them. Some patients, being in oneiric stupefaction, believe that they come into contact with representatives of extraterrestrial civilizations, find themselves abducted by them, end up on their aircrafts where they undergo experiments and research. Other patients see themselves traveling to distant or non-existent cities and galaxies, fighting in future or past wars. Or they carry out social reforms, prevent global cataclysms, take part in unprecedented experiments, explore the structure of the universe, unusual forms of life, and themselves transform into fantastic creatures.

Despite the bizarreness of the combinations, mergers, transformations observed in the oneiroid, and the incompleteness of individual images, the visions are distinguished by their extraordinary brightness, affective richness and sensory authenticity. Moreover, the events experienced are united by a common storyline. Each subsequent situation is meaningfully connected with the previous one, i.e. the action unfolds dramatically. The patient can be (sequentially or simultaneously) a spectator, a main character, a victim or a perpetrator of the unfolding drama. According to the characteristics of affect, expansive and depressive oneiroid are distinguished. In one case, the patient sees scenes of extraordinary beauty, experiences a feeling of exceptional significance, spiritual comfort and ecstatic inspiration. In the opposite situation, he witnesses the death of the world, the devastation of the planet, its fragmentation into fragments; experiences horror, despair, blames himself for what is happening (delirium of evil power).

Catatonic disorders reach a significant degree of severity. The dissociation between the patient’s behavior (stupor with waxy flexibility or confused-pathetic excitement) and the content of painful experiences in which the patient himself is an active participant operating on a planetary scale deepens even more; verbal communication with patients is not possible. Vegetovisceral disorders are most pronounced. In the case of febrile schizophrenia, the somatic condition becomes life-threatening, and the clinical picture approaches amentia syndrome.

The duration of the stage of affective-delusional disorders can reach several months. Oneiroid lasts for days, weeks. Against the background of true oneiroid, periods of double orientation are possible. Reduction of symptoms occurs in the reverse order of their appearance. Patients reproduce the contents in sufficient detail psychopathological disorders, surrounding events, starting from the stage of oriented oneroid, are largely amnesic, and during the period of darkened consciousness, complete amnesia of real events is observed.

Depending on the predominance of certain leading symptoms in the clinical picture of oneiroid, the following forms are distinguished.

Affective-oneproid form. Characterized by a predominance of defined polar affective states throughout the psychosis. The content of delirium correlates with the pole of affect, catatonic symptoms are not sharply expressed.

Oneproid-delusional form. Largest specific gravity belongs to sensual figurative delirium and mental automatisms. This form has the longest duration with a gradual and slow complication of psychopathological symptoms.

Catatonic-oieriid form. It is distinguished by its acuteness, severity of vegetative-visceral disorders, early appearance, syndromic completion and significant expressiveness of catatonic phenomena.

Oneiric clouding of consciousness is the culmination in the development of an attack of schizophrenia, often observed during intoxication with cannabinoids and volatile organic solvents. Oneiroid is much less common in epilepsy, vascular diseases of the brain, in the structure of alcohol-induced psychosis and other mental disorders of exogenous-organic origin.

The phasing and symptomatology of oneiroid occurring in schizophrenia is not found in any other disease. Oneiroid-like conditions in symptomatic and organic mental disorders are characterized by more rapid development and short-term course, syndromic incompleteness, as well as outcome. In the initial period, psychopathological disorders reflect the characteristics of the corresponding nosological forms; the content of experiences is relatively primitive, devoid of megalomania and a single plot. Autopsychic disorientation is less pronounced or absent, for example, a patient travels to exotic countries in hospital clothes. States of inhibition and excitement are devoid of catatonic features. The duration of such oneiroid varies from several minutes to several days, its reduction often occurs critically. After restoration of consciousness, asthenia and psychopathological phenomena characteristic of organic brain damage are observed. Memories of the content of experiences are usually poor and fragmentary.

Delirium is an illusory-hallucinatory clouding of consciousness. Perception disorders are the main psychopathological phenomenon in the structure of this syndrome and determine the delusional plot and behavioral characteristics of the patient. Delirious stupefaction develops, as a rule, in the evening and at night and in its development goes through a number of stages, which can be conveniently considered using the example of alcoholic delirium.

In the first stage of delirium (initial stage), against the background of asthenia and hyperesthesia, general anxiety, mood swings, and sleep disturbances increase. Patients experience increased fatigue, the bed seems uncomfortable to them, the light is too bright, and ordinary sounds are unbearably loud. Attention is easily distracted by external, unimportant events (the phenomenon of hypermetamorphosis). Patients are fussy, talkative, and there is noticeable inconsistency in their statements. Influxes of vivid figurative ideas and memories (oneirgai) arise. The mood is extremely variable from tender-compassionate, when patients demonstrate unmotivated optimism, to anxious-tense, with tearfulness, depression, and apprehension of trouble. There is always a kind of irritability, capriciousness, and touchiness. The sleep is superficial, with frequent awakenings, vivid nightmares that are confused with reality. In the morning, patients feel exhausted and claim that they did not sleep all night.

In the second stage (the stage of illusory disorders), the existing symptoms intensify even more. They are joined by elementary deceptions of perception in the form of phonemes and acoasms - patients hear calls, doorbells, and various poorly differentiated sounds. When trying to sleep, multiple kaleidoscopically changing hypnagogic hallucinations appear. When the eyes are open, illusory disorders occur. When they are closed, the interrupted hallucinatory episode develops further. Pareidolic illusions are characteristic - the revival of planar patterns. In the play of chiaroscuro, in the patterns of the carpet, and wallpaper, patients see bizarre pictures, fantastic images that disappear when the lighting increases. When attracting attention, unlike ordinary illusions, the picture does not disappear, but rather is supplemented with details, sometimes completely absorbing the real object. The snakes crawling across the floor, however, disappear at the edge of the carpet. The attitude of patients towards visions is a combination of fear and curiosity.

The course of delirium is wavy. A peculiar flickering of symptoms, with short intervals of decreasing intensity of psychopathological disorders, occurs already at the second stage. Periodically (usually in the morning), lucid (light) intervals may be observed. Absent at this time psychotic disorders, orientation in the environment and even a critical assessment of the state appears, however, there is a readiness to hallucinate. The patient can be asked to talk on a previously switched off telephone (Aschaffenburg's symptom) or asked to carefully examine a blank sheet of paper and ask what he sees there (Reichard's symptom). The occurrence of hallucinations in such (“provoking”) situations allows us to correctly assess the patient’s condition.

Prognostically unfavorable signs of the course of delirium are the increase in stunning in the daytime and the development following the third stage of professional or excruciating delirium (these forms are conventionally combined into the fourth stage).

Occupational delirium is accompanied by monotonous motor agitation in the form of habitual (professional) actions. In this state, patients hammer non-existent nails with a non-existent hammer, drive a car, type on a computer, carry out resuscitation measures, a drug addict gives himself an intravenous injection. Excitation is realized in a limited space. Voice contact is not possible. External impressions practically do not reach the consciousness of patients.

Mumbling (mumbling) delirium is an even deeper degree of clouding of consciousness. Uncoordinated, stereotypical actions, choreoform and athetosis-like hyperkinesis predominate here. Patients make grasping movements in the air, shake something off, palpate, and finger the bed linen - a symptom of “robing” (corphology). Excitation occurs within the bed, accompanied by a quiet, indistinct utterance of individual sounds. Patients do not react at all to external stimuli and are not accessible to verbal contact. The gaze is cloudy, directed into space. The somatic condition becomes life-threatening. Possible transition to a coma and death.

The duration of delirium ranges, on average, from three to seven days. If delirium ends in the first or second stages, they speak of abortive or hypnagogic delirium. If delirium lasts more than a week, it is called prolonged delirium. Disappearance of disorders often occurs critically, after prolonged sleep, less often lytically. In the latter case, residual delirium may occur. With this type of outcome, patients, formally assessing the condition suffered as painful, are convinced of the reality of some episodes, for example scenes of adultery. After a few days, there may be a sudden appearance of full criticism. Upon recovery from delirium, asthenia is always observed, and affective disorders (subdepressive or hypomanic) are characteristic. In severe cases of delirium, it is possible to develop into Korsakovsky and psychoorganic syndromes.

Amnesia for the period of delirious stupefaction is partial. Memories of the experienced state are fragmentary and relate to psychopathological disorders, while real-life events are not retained in memory. In patients who have suffered from occupational and excruciating delirium, complete amnesia is observed.

Delirium occurs in alcoholism, substance abuse, infectious and acute somatic diseases accompanied by severe intoxication, traumatic brain injury, vascular lesions of the brain, senile dementia, and temporal lobe epilepsy.

In children, infectious delirium is more common, in adults, alcoholic delirium, and in old age, delirium of atherosclerotic origin. It is interesting that the content of psychopathological disorders that arise in delirium reflects, sometimes in a symbolic, condensed form, the actual conflicts of patients, their desires and fears. Naturally, the deeper the degree of clouding of consciousness, the less individual, personal in the symptoms. Depending on the etiological factors of delirious syndrome, perception disorders and other psychopathological phenomena may have some features.

The greatest difficulty in differential diagnostic terms is delirium with pseudohallucinations and mental automatisms. In such cases, most often we are talking about the debut of an endogenous-processual disease, provoked by exogenous harmfulness (intoxication), or the coexistence of both diseases. For delirium due to intoxication with anticholinergic substances. properties (atropine, cyclodol, amitriptyline, azaleptine, aminazine, diphenhydramine), metamorphopsia and other sensory synthesis disorders are common. Hallucinations are characterized by objectivity, simplicity, indifference of content for patients (wire, sawdust, threads, etc.); during intoxication with cyclodol, the symptom of a disappearing cigarette is described: when the patient feels a cigarette squeezed between his fingers, which “disappears” when he tries to bring it to his mouth ( Pyatnitskaya I. N.). In case of carbon monoxide poisoning, olfactory hallucinations dominate, with cocaine - tactile (sensation of crystals), tetraethyl lead - oropharyngeal (sensation of hair in the oral cavity). Infectious delirium is characterized by the phenomena of somatopsychic depersonalization; patients feel floating in the air, a state of weightlessness, the disappearance of the body, the presence of a double next to them. Vestibular disorders are common: sensations of spinning, falling, swaying. In conditions accompanied by dehydration, water appears in painful experiences. Traumatic delirium is accompanied by experiences of the circumstances of injury (battle situation). In the formation of hallucinatory-delusional experiences in somatic diseases, they play an important role painful sensations V various organs(patients feel like they are dying in a fire, being tortured, etc.). For senile delirium (pseudodelirium) characteristic features are: “...life in progress”, false recognitions, increased responsiveness to what is happening around, fussy businesslikeness, a symptom of “getting ready for the road” - patients tying bedding in knots, wandering with them. Such conditions have a chronic course, worsening at night. Delirium in vascular diseases of the brain has a similar clinical picture; its specificity is determined by the severity of the anxiety component and dependence on the state of cerebral hemodynamics. In delirious disorders that occur against the background of an acute cerebrovascular accident, among other things, disturbances in the body diagram may be observed. A feature of delirium that occurs in old age is the severity of mnestic disorders and the age-related themes of delusional statements (ideas of material damage). Epileptic delirium is characterized by particularly vivid and fantastic hallucinatory images. The visions are frightening in nature, often colored in red, black and blue. Hallucinatory images approach the patient, crowding him. He hears a deafening roar and smells a disgusting smell. Experiences of apocalyptic and religious-mystical content are characteristic. In the latter case, hallucinations can be unusually pleasant and accompanied by ecstatic affect.

Twilight stupefaction

This type of clouding of consciousness is often called pathologically narrowed consciousness or twilight. Due to some characteristic features and diversity clinical manifestations This syndrome is the most difficult to differentiate. Its the most common features are: suddenness of onset and cessation (paroxysmal), the ability for externally purposeful behavior, complete amnesia during this period.

Disorientation can be expressed to varying degrees. Along with deep disorientation in the environment and one’s own personality, there are states of orientation “in general terms”, with a significant restriction of access to external impressions, a narrowing of the range of current ideas, thoughts and motives. Perception of the environment may be distorted by existing productive disorders. Their presence can be judged from the spontaneous statements and actions of patients who, in a state of twilight stupefaction, are detached and gloomy, often silent, their spontaneous speech is limited to short phrases. Patients are inaccessible to verbal contact, although their behavior gives the impression of being meaningful, purposeful, it is completely determined by existing psychopathological disorders. Here, vivid (usually visual) scene-like hallucinations of frightening content, figurative delirium with ideas of persecution, physical destruction, and false recognitions are common. Affective disorders are intense and characterized by tension (sadness, horror, rage). Frenzied psychomotor agitation is often observed. The listed features make these patients extremely dangerous to themselves and others. They can give the impression of people with intact consciousness and, at the same time, show cruel, blind aggression, crush everything in their path, killing and maiming relatives and strangers. Often patients commit sudden and terribly senseless auto-aggressive actions. Less common are twilight states with religious and mystical experiences and ecstatic affect.

The presented picture of twilight stupefaction refers to its psychotic form. The latter, depending on the predominance of certain psychopathological disorders, is very conventionally divided into the following options. The delusional variant is characterized by the greatest external orderliness of behavior, in view of which the aggressive actions committed are particularly sudden and, accordingly, harsh. The hallucinatory variant is accompanied by chaotic excitement with brutal aggression, an abundance of unusually vivid hallucinations of extremely unpleasant content. Oriented twilight stupefaction usually occurs at the height of dysphoria, when increasing tension with a melancholy-angry affect is discharged in outwardly poorly motivated destructive acts, the memories of which are not retained by the patient.

In the case of less severe behavioral disorders, they speak of a non-psychotic (simple) form of twilight stupefaction, implying the absence of hallucinations, delusions, and affective disorders. This point of view is not shared by all psychiatrists, because sudden suspicion, turning to a non-existent interlocutor, or the patient committing particularly ridiculous acts suggests the role of hallucinatory-delusional experiences in the origin of these phenomena.

Outpatient automatism is a special form of twilight stupefaction. Behavior is quite orderly, patients are capable of performing complex motor acts and answering simple questions. Spontaneous speech is absent or stereotypical. They give the impression of a thoughtful, focused or tired person to others. Usually engaged in some activity before the attack, patients unconsciously continue it, or stereotypically repeat one of the operations, already in a state of darkened consciousness. In other cases, they commit actions that are in no way related to the previous ones and were not previously planned by them. Often this action is aimless wandering

Trance is an outpatient automatism that lasts several days or weeks. In this state, patients wander around the city, make long journeys, suddenly finding themselves in an unfamiliar place.

Fugue is an impulsive motor excitation that boils down to a blind and rapid striving forward. It manifests itself as sudden aimless running, spinning in place, or walking away unrelated to the situation. Lasts 2-3 minutes.

Somnambulism (sleepwalking) is a twilight state that occurs during sleep. It manifests itself as sleepwalking, sleep-talking, and paroxysmal night terrors. A feature of this disorder is stereotypic repetition (like a cliché) and confinement to a certain rhythm. It is not possible to enter into verbal contact with a patient in this state; persistent attempts to awaken him can result in a generalized convulsive seizure or brutal aggression on his part. In the morning, the patient has complete amnesia for the events of the night and sometimes feels weak, overwhelmed, and emotionally uncomfortable.

The course of twilight stupor can be continuous or alternating (with short-term clarity of consciousness) and lasts from several minutes to 1-2 weeks. The disorder of consciousness ends suddenly, after deep sleep. Amnesia after the patient emerges from the twilight state is complete. After clearing consciousness, the attitude of patients to the committed actions (murders, destruction, etc.) is determined as to the actions of others. In some cases, amnesia can be retarded, when immediately after experiencing psychosis, fragments of experiences remain in the memory, and then are lost within a few minutes or hours. The latter circumstance is of particular importance for the forensic expert assessment of the transferred condition.

Moderate stupefaction occurs in epilepsy, pathological intoxication, epileptiform syndrome with organic brain lesions.

The paroxysmal occurrence of all twilight disorders makes it more likely to establish the epileptic nature of these conditions. However, they must be differentiated from clouding of consciousness of psychogenic origin and neurotic somnambulism. In the latter case, the occurrence of sleepwalking and sleep-talking is usually associated with emotional stress preceding falling asleep; a person in this state can be awakened, and he immediately develops a critical assessment of the situation and is accessible to verbal contact, of which memories are usually retained in the morning.

Psychogenic forms of clouding of consciousness (affectively narrowed consciousness, hysterical twilight, clouding of consciousness of a dissociative type, dissociative psychoses) can manifest as stuporous states or acute psychomotor agitation with speech confusion, fugiform reactions, pictures of pseudodementia, puerilism, personality regression (“wildhood”), delusional fantasies. They can have an acute or subacute course, but are always associated with a traumatic situation. The hallucinatory-delusional phenomena that arise in these states are systematized and have a common plot, usually the opposite of the real situation. The affect is not so much intense as it is demonstrative, emphatically expressive. The manifestations of hysterical (dissociative) psychosis reflect the patient’s naive ideas about the picture of “insanity.” Behavioral models can be quite complex, but they are always “psychologically understandable” (K. Jaspers), i.e. Through his actions, the patient seems to play out the theme of a situation that is intolerable to him, and strives to “resolve” it.

Amentia is a deep clouding of consciousness, the defining signs of which are: incoherence (incoherence of associative processes), confusion and motor impairment. Motor arousal is intense, but unfocused and chaotic, limited to the bed. There is a disintegration of complex motor formulas, choreoform and athetosis-like hyperkinesis, and symptoms of morphology. The patient makes rotational movements, throws himself around and rushes about in bed (yactation). Short-term catatonic phenomena are possible. The patient’s spontaneous speech consists of individual words of everyday content, syllables, inarticulate sounds, which he pronounces either loudly, sometimes barely audible, or in a sing-song monotonous voice; Perseverations are noted. His statements are not expressed in grammatical sentences and are incoherent (incoherence of thinking). The meaning of incoherent words corresponds to the emotional state of the patient, which is characterized by extreme variability: sometimes depressed-anxious, sometimes sentimentally-enthusiastic, sometimes indifferent. There is a constant feeling of confusion, bewilderment, and helplessness. The patient's ability to analyze and synthesize is grossly impaired; he is unable to grasp the connection between objects and phenomena. The patient, like a person with broken glasses, perceives the surrounding reality in fragments; individual elements do not add up to a complete picture. The patient is disoriented in all forms. Moreover, this is not a false orientation, but a search for orientation in the absence of it. Attention is extremely unstable, it is impossible to attract it. Speech contact is not productive, the patient does not comprehend the addressed speech, and does not answer in terms of the questions asked. Exhaustion is sharply expressed. Delusions and hallucinations are fragmentary and do not determine the behavior of patients. Periodically, speech motor excitation subsides and then prevails depressive affect and asthenia, patients remain disoriented. At night, amentia may give way to delirium.

The duration of amentia is several weeks. After restoration of consciousness, severe prolonged asthenia and psychoorganic syndrome are observed. Amnesia after emerging from amentive stupefaction is complete.

An amental state occurs in febrile schizophrenia, neuroleptic malignant syndrome, but most often in severe somatic conditions (neuroinfections, sepsis, acute cerebrovascular accidents, etc.) and indicates the unfavorable development of the underlying disease.

A similar situation is usually observed when several aggravating factors are combined, for example, when an intercurrent infection (pneumonia, erysipelas, influenza) joins a chronic asthenic somatic disease, or the development of sepsis in the early postpartum period. In the latter case it is especially difficult differential diagnosis With postpartum psychosis, as a variant of the onset of schizophrenia. The absence of dissociation between incoherent speech and affect, depressive episodes, instability and variability of catatonic disorders, and nocturnal delirium indicate the exogenous nature of the amentia syndrome.

3. Diagnostics and medical tactics

A disorder of consciousness is a nonspecific reaction of the psyche to the action of a damaging factor of exceptional strength. Therefore, all forms of impaired consciousness develop in close connection with somatic disorders, often threatening the patient’s life, and even schizophrenia is no exception. Therefore, pathological conditions accompanied by impaired clarity of consciousness occur in patients in general somatic hospitals more often than in patients in psychiatric hospitals. The presence of impaired consciousness syndrome in the clinical picture of the disease is an indication for emergency medical care.

As can be seen from all of the above, various syndromes of clouded consciousness do not have strict nosological specificity. Verification of the clouded consciousness syndrome is more important to determine the severity of the mental disorder, i.e. has not so much diagnostic as prognostic significance. According to the degree of severity (depth), all clouding syndromes can be arranged in a certain sequence: oneiroid - delirium - twilight - amentia (V. A. Zhmurov). In this series, one can observe a deepening of congrade amnesia, an impoverishment of subjective experiences and a worsening of behavioral disorders. This scale explains the existence of transitional and mixed forms of disorders of consciousness and allows us to assess their dynamics. So, for example, in the structure of delirious syndrome one can observe rudimentary manifestations of oneiroid in the form of oneirism, in the initial stages; the picture of occupational delirium, with severe psychosis, approaches twilight gloom consciousness; delirium delirium is a life-threatening condition that is clinically similar to amentia. The end point of the dynamics of all clouding syndromes is its shutdown and subsequent death.

It should be noted that the impact of several pathogenic factors, especially if the patient has signs of organic brain damage, increases the likelihood of developing the syndrome of impaired consciousness, complicating its course and prognosis. Thus, in children with minimal cerebral dysfunction (MCD), infectious delirium occurs more often. In elderly patients, anticholinergic drugs (amitriptyline), even in moderate therapeutic doses, can provoke vascular delirium. Pathological forms alcohol intoxication are more common in people who have suffered a traumatic brain injury. Delirium delirium usually develops against the background of a somatic illness, nutritional deficiency, consumption of alcohol substitutes, etc.

In order to make a clinical diagnosis and select a hospital profile for hospitalization of the patient, it is necessary to collect anamnestic information as completely as possible (with the help of relatives or other persons) and correctly conduct a clinical examination. When collecting anamnestic information, it is necessary to find out about the patient’s condition preceding the impairment of consciousness (alcohol withdrawal, inappropriate behavior, infectious or other somatic disease, traumatic brain injury, use of psychoactive substances or other medications). From the patient’s life history, it is necessary to find out about the tendency to abuse alcohol or other psychoactive substances, about the presence of a chronic somatic disease; suffered traumatic brain injuries, neuro-infections, cerebrovascular accidents, the possibility of contact with industrial and household poisons, suffered surgical interventions under anesthesia (their number and duration). Information is needed about the presence of past episodes of loss of consciousness of any origin, conditions similar to the present, and indications of paroxysmal disorders. It is useful to find out about possible cases of hospitalization in psychiatric and other hospitals, their cause, duration.

During an objective examination, it is necessary to determine the nature and severity of vegetative-somatic and neurological disorders. In a mental state, establish the patient’s ability to communicate verbally, his orientation in time, place, surrounding persons, and his own personality. To do this, you can ask the following questions: “What is your name? How old are you? What day of the week, month, year is it now? Where are you at? What kind of people surround you? In this case, it is necessary to evaluate the correctness of the answers, their adequacy to the questions asked, stability of attention, the ability to make simple logical judgments, and identify specific thinking disorders. Often, the answers to these questions also make it possible to clarify the content of the experience, the nature of the affect, and the correspondence of the patient’s statements and behavior to them. After a few minutes, it is useful to repeat the mental status examination to assess the ability to remember current events, the variability of the content of painful experiences and the dynamics of the patient’s condition as a whole.

The principal diagnostic criteria for the full development of typical syndromes of impaired consciousness are presented in Table No. 1.

Hospitalization of patients with clouded consciousness in psychiatric hospital should be issued only in an involuntary manner in accordance with Art. 29 of the Law on psychiatric care.

When providing care to patients, the primary task is to relieve psychomotor agitation in order to prevent accidents and create necessary conditions for pathogenetic therapy. For these purposes, the use of benzodiazepine tranquilizers (diazepam, phenazepam), anticonvulsants (phenobarbital, carbamazepine), antipsychotics (aminazine, droperidol, haloperidol) in adequate dosages is indicated.

Table 1.

Oneiroid	Delirium	Twilight	Amentia
Orientation	Complete disorientation	Allopsychic disorientation	Complete disorientation	Lack of orientation
Perceptual disorders	Pseudohallucinations	True hallucinations	True and pseudohallucinations	Vestigial
Rave	Megalomanic	Physical and moral damage	Persecution and physical destruction	Rudimentary
Affect	Ecstasy or despair	Variable from euphoria to fear	Yearning. Horror, rage	Confusion and bewilderment
Voice contact	Not possible, no spontaneous speech	Available. Speech production reflects the content of psychopathological disorders	Not possible. Spontaneous speech is abrupt and stereotyped	Individual words, letters and syllables
Behavior	Catatonic disorders	Severe psychomotor agitation	Brutal aggression with external ability for consistent actions	Chaotic excitement within the bed
Amnesia	Retention of sequential memories of psychopathological experiences	Fragmentary memories of psychopathological experiences	Complete amnesia	Complete amnesia
Content of experiences	Fantastic panoramas. Consistent development of events	Professional and domestic scenes. Changeable plot	Horrifying images of death and violence	Incoherence (incoherence)

In the case of the use of antipsychotics, which should be avoided if possible, preference should be given to drugs with a powerful antipsychotic effect (haloperidol), which, unlike drugs with a predominantly sedative effect (aminazine, tizercin), reduce the threshold of convulsive readiness to a lesser extent and have! less impact on vegetative status. The use of drugs with a pronounced anticholinergic effect (azaleptin) should be excluded in states of impaired consciousness of unknown origin. The use of restraint and restraint measures must be carried out in strict accordance with Art. 30 of the Psychiatric Care Act. It should be taken into account that the use of these measures in relation to patients with clouded consciousness sharply increases their fear and motor agitation, which, in conditions of limited mobility, leads to self-injury and adversely affects the somato-vegetative status.

Only adequate therapy for the underlying disease contributes to the speedy and complete reduction of psychopathological disorders.

4. Clinical objectives

Read the following problems and determine what form of impaired consciousness is described (syndrome).

Patient J., a technical school student. Since the age of 10 he has suffered from epileptic seizures. One morning I went to see a doctor at a neuropsychiatric dispensary and disappeared. Despite organized searches, the patient could not be found anywhere. Three days later J. returned home. He was ragged, cold, without a coat. He behaved strangely: he didn’t say a word, didn’t answer questions, and looked at the ceiling all the time. I didn't sleep at all that night. The next day he began to talk and recognized his relatives. Gradually, the condition improved, and Z. said the following: “I remember how I went to the dispensary for medicine. Then I don’t remember anything until I felt the railway rails under my feet. I remember that I walked past some booth, and kept repeating about myself: 10 kilometers to Kazan, 10 kilometers. After that, I don’t remember anything again. I came to my senses somewhere near Kazan. I sat by the river under the bridge and washed my legs, which for some reason were red and burning. I felt very strongly about something I was afraid. I thought: “I’ll come home soon and tell my parents everything. Then again I don’t remember anything.” Acquaintances told the parents that they saw Zh. the day after he disappeared from his house on the shore of a forest lake about 30 kilometers from the city. J. seemed somewhat strange and thoughtful to them; in response to the greetings of his acquaintances, he nodded absentmindedly and moved on.

Patient S, 40 years old, factory worker. She was admitted to a psychiatric hospital shortly after giving birth. She looks pale, exhausted, her lips are dry and parched. Mental condition extremely changeable. At times the patient is excited, rushes about in bed, tears off her underwear, and takes passionate poses. The facial expression is anxious, confused, attention is fixed on random objects. The patient's speech is incoherent; “You took away my baby... It’s a shame... You think of living with Vanya, but you need to live with God... I’m a devil, not a god... You’ll all go crazy... I have inhibition... Aminazine , and then to the store..." etc. From some fragmentary statements one can understand that the patient hears the voices of relatives coming from somewhere below, the screams and cries of children. Her mood is sometimes deeply depressed, sometimes enthusiastic - euphoric. At the same time, he easily becomes embittered and threatens to gouge out his eyes. The state of excitement suddenly gives way to deep prostration. The patient falls silent, powerlessly lowers her head onto the pillow, and looks around with melancholy and confusion. At this time, it is possible to come into contact with the patient and get answers to simple questions. It turns out that the patient does not know where she is, cannot name the current date or month, confuses the time of year, and cannot give almost any information about herself and her family. During a short conversation, he quickly becomes exhausted and stops answering questions.

Patient G., 39 years old, disabled group II. Enters a psychiatric hospital for the 6th time; The attacks of the disease are similar, of the “cliché” type. Upon admission to the hospital, contact is almost impossible. Either he is excited, jumping, screaming, whistling, or he is wandering aimlessly along the corridor with an expression of detachment, and at times he laughs for no reason. After 3 weeks, there was a significant improvement in his condition, and the patient spoke about his experiences as follows: “I understood that I was in the hospital, but somehow I didn’t attach any importance to it. Thoughts came into my head in a flood, everything was mixed up in my head. Everything around was strange, fantastic: I took the flowers on the window for Martian plants, it seemed that people had transparent blue faces and they moved slowly, smoothly - as if flying through the air. I immediately recognized my doctor, with whom I was being treated for the third time, but she also seemed ethereal to me , ethereal, instead of hands she had tentacles, and I felt their cold touch. I lay down in bed - and immediately my thoughts are carried away far away. I imagine buildings with Corinthian columns, and I myself seem to be walking through a fairy-tale city among people dressed in ancient Roman clothes. The houses seem empty, uninhabited, monuments are seen everywhere. All this is like a dream."

Patient V., 37 years old, mechanic. Three days ago, an incomprehensible anxiety and restlessness appeared. It seemed that his room was filled with people, some people were shouting from behind the wall, threatening to kill, calling him to “go have a drink.” I didn’t sleep at night, I saw a monster with horns and sparkling eyes crawling from under the bed, gray mice, half dogs, half cats, were running around the room, I heard knocking on the window, cries for help. In extreme fear, he ran out of the house and rushed to the police station, fleeing the “persecution.” From there he was taken to a psychiatric hospital. In the department he is excited, especially in the evening, rushing to the doors and windows. During a conversation, it is difficult to concentrate attention on the topic of conversation, trembles, and looks around with anxiety. Suddenly he begins to shake something off himself, says that he is shaking off insects crawling on him, sees “grimacing faces” in front of him, points his finger at them, laughs loudly.

Answers to problems

Task 1. Twilight state of consciousness.

The described condition in patient Zh. is one of the variants of twilight disorder of consciousness - ambulatory trance. The patient’s actions, outwardly quite orderly, essentially go beyond the control of consciousness, become aimless, meaningless, and automatic. His attention covers only a narrow circle of random objects and impressions from the outside world.

Everything else passes by the patient or is perceived by him vaguely, fragmentarily, “as in twilight.” This is where the name of this syndrome comes from. At the same time, all mental processes are emotionally brightly colored (an incomprehensible feeling of fear). The twilight state of consciousness occurs unexpectedly, suddenly and usually lasts from several hours to several days. Throughout his entire period, he is amnesic either completely or partially - as was observed in the described patient.

Task 2. Amentive syndrome.

This syndrome is characterized by a violation of the ability to navigate in place, time, one's own personality, erratic arousal, and incoherence of speech (incoherence). Hallucinatory experiences are just as fragmentary and unsystematic. However, despite the chaotic and fragmented nature of internal experiences, actions and speech, they are constantly saturated with emotions that kaleidoscopically replace each other. All this is present in the patient’s behavior and experiences. Her attention is passively attracted for a moment by random objects, but the patient cannot connect them together, and, consequently, understand the surrounding situation, or understand her attitude towards it. Symptoms develop against the background of severe mental and physical weakness, asthenia.

Task 3. Oneiric syndrome.

Noteworthy is the acute nature of the attack of illness, at the height of which a dream-like disturbance of consciousness with fantastic experiences occurs. Patient G. has vivid visual pseudo-halluilations: he figuratively “imagines” fairy-tale cities, fantastic events and he himself is a participant in them. Pareidolic illusions are noted: flowers seem to be Martian plants, the doctor has tentacles instead of hands. These dream experiences fill the patient's consciousness. At the same time, however, orientation in the environment is preserved - the patient understands that he is in the hospital and recognizes the doctor. Therefore, such an oneiroid is called oriented.

Task 4. Delirium.

The above description does not reveal many of the signs that characterize clouding of consciousness, and in particular, nothing is said about the patient’s ability to navigate in place, time, or in his own personality. We also do not know whether the patient subsequently developed amnesia for everything he experienced during the illness. But we can still say that the patient has clouding of consciousness in the form of delirium. This is supported by the abundant influx of hallucinations, mainly visual. The perception of real events is pushed into the background by vivid hallucinatory images. Hallucinations are accompanied by sensory delusions of persecution, fear, and psychomotor agitation. The patient's behavior is entirely determined by his hallucinatory-delusional experiences. Actual events are perceived and understood by the patient vaguely and fragmentarily. Intensification of hallucinations and agitation in the evening is also characteristic.

5. Questions for test control