Twilight blackout

Causes of development of mental disorder

The state of confusion develops against the background of organic or functional changes in the brain. Twilight disorder often accompanies epilepsy, which is associated with a disorder in the structure of certain groups of nerve cells. In addition to epileptic changes, intracerebral tumors, traumatic brain injuries, neuroinfections, etc. can be a provoking factor. Among the functional causes are hysterical psychosis and traumatic events that are unexpected for the patient.

Symptoms more often occur in adulthood, since these causes are observed less frequently in children. With hysteria and early manifestations of epilepsy, confusion may develop in children. A psychiatrist deals with the diagnosis and treatment of the disease, regardless of the patient’s age.

Varieties of the condition

In psychiatry, there are several variants of twilight stupefaction, which depends on the reasons that caused it:

psychotic – develops against the background of hysterical psychosis and other changes in the human mental sphere;
non-psychotic – associated with organic pathologies of the structures of the central nervous system.

Symptoms are heterogeneous. Depending on the predominant clinical manifestations, the following are distinguished:

delusional disorder – accompanied by the formation of delusions, which determines the patient’s behavior at the time of disturbance of consciousness;
dysphoric type - characterized by affective disorders, the patient expresses melancholy, fear or anger;
with the hallucinatory variant, the clinical picture is dominated by hallucinations and illusions, their nature can be different: auditory, visual, etc.

Oneiroid is classified as twilight. This is a condition accompanied by the appearance of colorful hallucinations with fantastic content. Against this background, there is a decrease in overall activity and the possible development of catatonia.

Psychiatrists divide non-psychotic disorders into four types:

ambulatory automatisms;
somniloquy;
somnambulism;
trance.

Somniloquy and somnambulia mean talking and sleepwalking, respectively. Outpatient automatism is a disturbance of consciousness with the occurrence of automatic actions of a different nature in the patient. If the patient does not regain consciousness for a long time at the time of the disorder, then they talk about trance.

Syndromes of clouded consciousness

A psychiatric understanding of consciousness implies an indispensable orientation in oneself, time and space. Self-orientation includes awareness of the Self, bodily, interpersonal, and projected elements. Orientation in time is purely calendar in nature, and orientation in space is formally territorial. In other words, the individual must say who he is, with whom he communicates, he must name the current date and place where he is. If he does this approximately, they speak of a narrowed consciousness. If he cannot name anything correctly at all, they speak of disorientation.

Syndromes of darkened consciousness include a number of conditions described by an individual’s loss of the integrity of “I” and the world, or a distortion of worldview.

The syndromes are formally grouped into the following subgroups (forms):

perverted (depersonalization, double consciousness and derealization);
non-paroxysmal (oneiroid, delirium, amentia, stunning, stupor, coma); paroxysmal (twilight state of consciousness, psychedelic states, convulsive syndromes);
inadequate (pathological intoxication and pathological affect).

Below they will be discussed in more detail.

Perverted forms of darkened consciousness usually occur against the background of a narrowing of consciousness. These include states of depersonalization, double consciousness and derealization.

Depersonalization (Latin de... - negative prefix + persona - personality) is a disorder of consciousness in which the individual has a feeling of loss of his own “I”, alienation from his own feelings, actions and thoughts, as well as from others. Accompanied by depression, melancholy, anxiety. Option: anesthetic depersonalization, characterized by emotional dullness, gradual loss of higher emotions (the ability to rejoice, be sad).

Double consciousness - an individual alternately plays two or more social roles, often having diametrically opposed qualities. A sense of personal identity is preserved in each of these states, however, being in one role, the patient denies his involvement in the others. In other words, memories are organized only in the context of one of the roles.

Derealization (Latin de... - prefix denoting separation + realis - real): the surrounding world is perceived as a whole as unreal or distant, lifeless, devoid of its colors; At the same time, individual object parameters are saved. Memory impairments often occur, often accompanied by states of “already seen” (de ja vu), “already heard”, “already experienced” or: “never seen”, “never heard”, “never experienced”.

In non-paroxysmal forms of darkened consciousness, two narrower subgroups are distinguished:

conditionally “qualitative” non-paroxysmal disorders, or stupefactions, which include: oneiroid, delirium and amentia;
conditionally “quantitative” non-paroxysmal disorders, or shutdowns, which include stupor, stupor and coma.

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The oneiric, or dreamlike, state (gr. oneiros - dream and eidos - view) is characterized by a bizarre combination of bright fantastic pictures with images of the real world. There are illusions, hallucinations and pseudohallucinations, disorientation in time and space, sensory affective delirium. A distinctive stigma is the patient’s inactivity, which is absolutely inconsistent with vivid experiences, his motor detachment from subjective and objective reality. It is most often observed in infectious and some mental diseases, with deep-seated brain tumors.

Delirium (Latin delirium - madness) can be figuratively described with the phrase: “The nightmare dragons of the subconscious take on the features of a frightening reality.”

Condition includes:

abundant frightening visual and partly auditory hallucinations and illusions, giving rise to affectively colored delusional experiences;
motor agitation and accompanying vegetative manifestations (palpitations, sweating, trembling, etc.);
a shallow disorder of consciousness with disorientation in place and time, but with preservation of orientation in one’s personality.

Delirium is characterized by brightness, mobility, and theatricality of terrible visions. They can be compared to the experiences of nightmares in reality. Habitual perception and thinking are narrowed and distorted. The patient is immersed in his chaotic fantasy world. If he perceives his surroundings, it is only for a short moment, and does not connect it with his past. A short-lived return to clear consciousness and a critical attitude towards painful manifestations is also possible. The intensity of manifestations and the degree of disturbance of consciousness intensify at night, then patients become more restless. Frightening hallucinations and the corresponding affective intensity often lead to actions that are dangerous for the patient. Patients run away in fear into the street, where they freeze, throw themselves into the river or jump out of a window, escaping the expected terrible torture and execution.

The duration of delirium usually does not exceed 3-4 days (sometimes it lasts only a few hours, much less often - 6-7 days). This is the most typical form of exogenous reaction inherent in acute toxic and toxic-infectious psychoses.

The onset of delirium is preceded by increasing insomnia, headache, increased sensitivity to noise and light with fearfulness, nightmares or hypnagogic hallucinations.

Sometimes the disease is limited to flickering clarity of consciousness, confusion, difficulty concentrating, fragmentary visions with experiences of fear for 1-2 days - the so-called abortive delirium.

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Amentia, or amentive syndrome (Latin amentia - meaninglessness), describes a state of severe clouding of consciousness. Characterized by incoherence of thinking (otherwise known as incoherence), associative confusion, disorientation in place, time and one’s own personality, confusion, misunderstanding and lack of understanding of surrounding events. An affect with disordered, chaotic excitement is possible, sometimes replaced by a long-term (hours, days) stupor (freezing in one position). At the end of the disorder, there is no memory of events (congrade amnesia).

Stunning is the mildest of this subgroup of disturbances in the functioning of consciousness. It is characterized by a certain difficulty in perception, inhibition of action and fragmented perception of information (only strong stimuli reach consciousness). Patients answer questions as if half asleep; the complex content of the question is not comprehended. There is slowness in movements, silence, and indifference to the environment. Dozing occurs very easily. Orientation to the environment is incomplete or absent. Occurs in acute disorders of the central nervous system, usually lasting from minutes to several hours.

Stupor is a deeper degree of loss of consciousness compared to stupor. Adynamia sets in, up to complete prostration. Orientation is completely absent, only mumbling speech and protective reflexes are preserved.

Coma is an extreme degree of switching off consciousness (with the complete disappearance of protective reflexes), characteristic of the terminal stages of life support. Coming out of a coma is often accompanied by so-called out-of-body experiences that resemble dream-like (oneiric) states.

In paroxysmal forms of darkened consciousness, two narrower subgroups are also distinguished:

conditionally “qualitative” paroxysmal disorders, or stupefactions, which include: twilight state of consciousness and psychedelic states;
conditionally “quantitative” paroxysmal disorders, or exclusions, which include convulsive syndromes, or episyndromes, or seizures.

Twilight stupefaction implies a sudden short-term deep disorientation in the surrounding world with relative preservation of the logical sequence of habitual actions. Disorientation is sometimes accompanied by vivid and frightening hallucinations, which causes strong affects of fear, anger and melancholy and a tendency to aggressive actions. A characteristic feature is subsequent amnesia. The twilight state of consciousness sometimes lasts for moments and is called absence (French absence). Another type of twilight state of consciousness is pseudodementia, which is characterized by acutely onset intellectual-mnestic disorders (judgment disorders). Patients forget the names of objects, are disoriented, and have difficulty perceiving external stimuli. Pseudodementia occurs in reactive states and with severe destructive changes in the central nervous system.

Read: Neurotic syndromes (asthenic, neurotic, hysterical)

During the twilight state, patients retain the ability to perform automatically habitual actions without their awareness. This is accompanied by amnesia and is called ambulatory automatism syndrome. For example, patients mechanically cross streets, travel somewhere in public transport, etc. From the outside, they give the impression of people immersed in their thoughts. When, against a background of excitement, a short-term (up to several seconds) unconscious primitive motor act occurs, they speak of a fugue. If we are talking about complex, consistent, externally ordered unconscious actions, long-term disturbances, up to several days, we talk about trance. Ambulatory automatism is common in epilepsy.

Psychedelic (hallucinatory) states (Greek psyche - soul + delia - illusion) are characterized by a change in the perception of the usual picture of the surrounding world. Hallucinations occur, and time and body patterns are often distorted (lack of bodily boundaries). The pace of thinking is disrupted (over-acceleration or over-slowing), and psychomotor disorders are present. A mandatory symptom is emotional stress. Emotional experiences are polar: from euphoria to fear. Exit from these states is possible along the path of crisis (quickly, through deep sleep) and lytically, in the form of slow regression. Psychedelic states are usually caused by the use of psychoactive drugs (psychedelics); they were modeled in many ancient cults.

Paroxysmal shutdowns (convulsive syndromes or episyndromes, or seizures) describe states of twilight consciousness that are accompanied by motor disturbances. Against the background of a fleeting (minute-long) complete shutdown of consciousness, various types of convulsions occur, in mild cases - simply stopping movement. Immediately before a seizure, many patients feel familiar signs of its onset.

These warning signs are called an aura. The aura is individual, but is always accompanied by psychosomatic tension. At the end of their seizures - congrade amnesia. Occurs in epilepsy, as well as acute intoxication.

Pathological intoxication is pronounced intoxication when consuming an inappropriately low, minimal dose of alcohol. Typical signs: a narrowed state of consciousness, aggression and unmotivated actions followed by amnesia.

Pathological affect is an inappropriately violent reaction to a minor negative stimulus. Thus, a seeming insult, a trifling nuisance, is subjectively incorrectly perceived as a serious threat to the existence of the individual. Accompanied by narrowed consciousness, aggression, auto-aggression.

Clinical manifestations of confusion

Dysphoric type

From the outside it looks like a set of ordered actions, however, the person is detached from what is happening around him. People around the patient note his absorption in his own thoughts. The facial expression is angry or reflects fear.

Contact with the patient is impossible. He ignores speech addressed to him, but may respond with stereotypical expressions that are completely meaningless. An important criterion for clouding of consciousness is the lack of criticism of one’s own behavior and its inadequacy. Some people remain spatially aware and can talk to familiar people. With disturbances of consciousness, short-term hallucinations, a feeling of the appearance of one’s own double, distorted perception of body parts, etc. may occur. As the mental disorder progresses, the patient may show aggression towards others and himself.

Delusional type

Delusions of persecution come first in the clinical picture. There is no contact with the patient, however, outwardly his actions appear purposeful and orderly. Due to the content of delirium, he may commit antisocial acts, trying to protect himself from others. The delusional type of disorder is characterized by the retention of memory of the period of stupefaction.

Hallucinatory disorder

Associated with the appearance of illusions and hallucinations. The latter are auditory or visual in nature, and are also accompanied by negative content. During the period of hallucinations, contact with the patient is completely impossible. He does not pay attention to speech, he can say certain words and make sounds meaninglessly. Due to perception disturbances, patients are aggressive, they are capable of committing serious crimes, attacking children, other patients, etc.

Outpatient automatisms

Manifested by automatic actions. Patients are capable of performing complex motor acts during the period of disorder: buying tickets for a bus or other transport, going to the store, etc. At the same time, when a person comes to his senses, he does not understand how he ended up in this place. This is associated with the development of complete amnesia. With outpatient automatisms, the patient is outwardly thoughtful, confused and perceived by people around him as a healthy person. Similar changes are characteristic of trance, but its duration can reach several days.

Hysterical twilight stupefaction

It has a number of clinical features:

contact with the patient is possible, which is due to his lesser detachment from the outside world;
in a conversation with the patient, the doctor can identify factors that provoke the development of psychosis;
After consciousness is restored, memories are partially preserved; hypnosis sessions can completely restore them.

The duration of the state during stupefaction is from several minutes to several hours. As a rule, the duration of symptoms is individual and can vary significantly even in one patient.

Syndromes of confusion

Syndromes of confusion.

Syndromes of clouded consciousness are a disorder of consciousness in which the reflection of the real world is disrupted not only in its internal connections (abstract cognition), but also in external ones. In this case, the direct reflection of objects and phenomena is upset. In these cases, they speak of a disorder of objective consciousness, meaning a simultaneous violation of sensory and rational cognition. Syndromes of stupefaction are different. At the same time, they have common characteristics (Jaspers): 1) detachment from the real world, expressed in an unclear perception of the environment, difficulty in fixation or complete impossibility of perception; 2) there is always a disorientation expressed to one degree or another in place, time, surrounding persons and situations; 3) thinking is more or less incoherent, judgment is extremely weakened, often excluded; 4) remembering ongoing events and subjective phenomena is difficult, memories of the period of stupefaction are fragmentary or absent altogether.

These include:

- stun

- delirium

-amentia

— oneiroid

-twilight stupefaction, etc.

Stun

- a symptom of switching off consciousness, accompanied by a weakening of the perception of external stimuli. Patients do not immediately respond to questions surrounding the situation. They are lethargic, indifferent to everything happening around them, inhibited. As the severity of the disease increases, stupor can progress to stupor and coma. A comatose state is characterized by the loss of all types of orientation and responses to external stimuli. When emerging from a coma, patients do not remember anything about what happened to them. Switching off consciousness is observed in renal, liver failure, diabetes and other diseases.

Delirium

- a state of darkened consciousness with difficult orientation in place, time, environment, but maintaining orientation in one’s own personality.

Patients develop abundant illusions of perception (hallucinations), when they see objects and people that do not exist in reality, or hear voices. Being absolutely confident in their existence, they cannot distinguish real events from unreal ones, therefore their behavior is determined by a delusional interpretation of the environment. There is strong excitement, there may be fear, horror, aggressive behavior, depending on the hallucinations. Patients in this regard can pose a danger to themselves and others. Upon recovery from delirium, the memory of the experience is preserved, while the events that actually occurred may fall out of memory. A delirious state is typical for severe infections and poisoning.

Oneiric state

(waking dream)—characterized by an influx of vivid scene-like hallucinations, often with unusual, fantastic content. Patients contemplate these pictures, feel their presence in the unfolding events (as in a dream), but behave passively, like observers, in contrast to delirium, where patients actively act. Orientation in the environment and one’s own personality is impaired. Pathological visions are retained in memory, but not completely. Similar conditions can be observed with cardiovascular decompensation (with heart defects), infectious diseases, etc.

Amentive state—- (amentia

- a deep degree of confusion of consciousness) is accompanied not only by a complete loss of orientation in the environment, but also in one’s own “I”. The environment is perceived fragmentarily, incoherently, and disconnectedly. Thinking is also impaired; the patient cannot comprehend what is happening. There are deceptions of perception in the form of hallucinations, which are accompanied by motor restlessness (usually in bed due to a severe general condition), incoherent speech. Excitement may be followed by periods of immobility and helplessness. The mood is unstable: from tearfulness to unmotivated gaiety. The amental state can last for weeks and months with short light intervals. The dynamics of mental disorders are closely related to the severity of the physical condition. Amentia is observed in chronic or rapidly progressing diseases (sepsis, cancer intoxication), and its presence, as a rule, indicates the severity of the patient’s condition.

Twilight stupefaction

- a special type of clouding of consciousness, acutely beginning and suddenly ending. Accompanied by complete loss of memory for this period. The content of psychopathological products can only be judged by the results of the patient’s behavior. Due to profound disorientation, possible frightening hallucinations and delusions, such a patient poses a social danger. Fortunately, in somatic diseases this condition is quite rare and is not accompanied by complete detachment from the environment, unlike epilepsy (see).

A feature of stupefaction syndromes in somatic diseases is their erasure, short duration, rapid transition from one state to another and the presence of mixed states.

Treatment.

It should be aimed, first of all, at the underlying somatic disease, because the mental state depends on its severity. Treatment can be carried out in the hospital where the patient is, but two conditions must be met.

Firstly, such a patient must be examined by a psychiatrist and give his recommendations. Secondly, if the patient is in acute psychosis, he is placed in a separate room with round-the-clock observation and care. In the absence of these conditions, the patient is transferred to the psychosomatic department. If a disease of the internal organs is not the cause of mental disorders, but only provoked the onset of a mental illness (for example, schizophrenia), then such a patient is also transferred to the psychosomatics department (in case of a severe somatic condition) or to a regular psychiatric hospital. Psychotropic medications are prescribed by a psychiatrist on an individual basis, taking into account all indications, contraindications, possible side effects and complications.

Prevention

: somatogenic disorders should be aimed at prevention, early detection and timely treatment of somatic diseases.

Possible complications

Psychiatrists divide the negative consequences of the disorder into two groups: those associated with the primary disease and those associated with inappropriate human behavior. Twilight stupefaction can occur against the background of organic pathology, and therefore characteristic complications may include:

With epilepsy, personality disorders develop - isolation, indifference to others. Gradually, apathy towards work and hobbies appears. This is due to organic changes in the nerve centers in the cerebral cortex, as well as side effects of long-term use of antiepileptic drugs.
With the growth of intracerebral tumors, the neurological deficit gradually increases. Sensory disturbances, movement disorders, blurred vision, etc. may occur. With rapid growth of the tumor, there is a risk of displacement of brain structures with their pinching in the foramen magnum, which can be fatal.

The main consequence of impaired consciousness is the patient’s antisocial behavior. Due to the development of hallucinations or delusions of persecution, he poses a threat to others and himself. Attempts at suicide, aggression towards loved ones, colleagues or strangers are possible. In some cases, patients commit brutal murders without remembering anything about what they did.

Somatogenic psychoses

Somatogenic psychoses (mental disorders due to somatic diseases). It is customary to distinguish between two broad groups: symptomatic psychoses and non-psychotic somatogenic disorders. According to various studies, the frequency of symptomatic psychoses varies from 0.5 to 1-1.2% of all somatic patients, i.e. very significant, given the high prevalence of internal diseases.

According to duration, somatogenic psychoses are divided into acute, or transient, subacute and protracted. Acute exogenous psychoses last from several hours to several days. These mainly include stupefaction syndromes: delirium, stupor, twilight stupefaction, amentia, oneiroid (rarely). Subacute symptomatic psychoses, lasting up to several weeks, include depression, manic-euphoric states, verbal hallucinosis, sensory delusions, hallucinatory-delusional, depressive-delusional states. Prolonged symptomatic psychoses, lasting up to several months, and in isolated cases - a year or more, can manifest themselves as chronic verbal hallucinosis, delusions with elements of systematization, catatonic-like disorders (rarely), persistent Korsakoff symptom complex. Of the acute symptomatic psychoses, the most typical is delirium in the form of abundant true visual hallucinations, illusions, false orientation, transient hallucinatory delusions, psychomotor agitation reflecting the content of hallucinatory-delusional experiences, and partial amnesia.

Mental disorders arising in connection with the pathology of internal organs and systems constitute a special branch of psychiatry - somatopsychiatry. Despite the diversity of psychopathological symptoms and clinical forms of somatic pathology, they are united by a common pathogenetic mechanisms and patterns of development.

The diagnosis of “somatogenic psychosis” is made under certain conditions: the presence of a somatic disease, a temporary connection between somatic and mental disorders, interdependence and mutual influence in their course.

Symptoms and course:

They depend on the nature and stage of development of the underlying disease, the degree of its severity, the effectiveness of the treatment, as well as on the individual characteristics of the patient, such as heredity, constitution, character, gender, age, the state of the body’s defenses and the presence of additional psychosocial harms.

Based on the mechanism of occurrence, there are 3 groups of mental disorders:

1. Mental disorders as a reaction to the very fact of the disease, hospitalization and the associated separation from the family and familiar environment. The main manifestation of such a reaction is varying degrees of depressed mood with one shade or another.

Some patients are full of painful doubts about the effectiveness of the treatment prescribed to them, about the successful outcome of the disease and its consequences. For others, anxiety and fear prevail over the possibility of serious and long-term treatment, before surgery and complications, and the likelihood of disability. Some patients are burdened by the very fact of being in the hospital and yearn for home and loved ones.

Their thoughts are occupied not so much with the illness as with problems at home, memories and dreams of being discharged. Outwardly, such patients look sad and somewhat inhibited. With a long, chronic course of the disease, when there is no hope for improvement, an indifferent attitude towards oneself and the outcome of the disease may arise. The patients lie indifferently in bed, refusing food and treatment - “it’s all the same.”

However, in such apparently emotionally inhibited patients, even with minor outside influence, anxiety, tearfulness, self-pity and a desire to receive support from others may occur.

2. The second, much larger group consists of patients in whom mental disorders are, as it were, an integral part of the clinical picture of the disease. These are patients with psychosomatic pathology, where, along with pronounced symptoms of internal diseases (hypertension, peptic ulcer, diabetes mellitus), neurotic and pathocharacterological reactions are observed.

3. The third group includes patients with acute mental disorders (psychosis). Such conditions develop either in severe acute diseases with high fever (lobar pneumonia, typhoid fever) or severe intoxication (acute renal failure), or in chronic diseases in the terminal stage (cancer, tuberculosis, kidney disease).

In the clinic of internal diseases, despite the wide variety of psychological reactions and more severe mental disorders, the most common are the following:

asthenic;
affective (mood disorders);
deviations in characterological reactions;
delusional states;
confusion syndromes;
organic psychosyndrome.

Treatment:
Should be aimed, first of all, at the underlying somatic disease, because the mental state depends on its severity. Treatment can be carried out in the hospital where the patient is, but two conditions must be met. Firstly, such a patient must be examined by a psychiatrist and give his recommendations.

Secondly, if the patient is in acute psychosis, he is placed in a separate room with round-the-clock observation and care. In the absence of these conditions, the patient is transferred to the psychosomatic department.

If the disease of the internal organs is not the cause of mental disorders, but only provoked the onset of a mental illness (for example, schizophrenia), then such a patient is also transferred to the psychosomatics department (in case of a severe somatic condition) or to a regular psychiatric hospital. Psychotropic medications are prescribed by a psychiatrist on an individual basis, taking into account all indications, contraindications, possible side effects and complications.

Prevention of somatogenic disorders should be aimed at prevention, early detection and timely treatment of somatic diseases.

Asthenia

Asthenia is a core or end-to-end syndrome in many diseases. It can be either a debut (initial manifestation) or the end of the disease.

Typical complaints include weakness, increased fatigue, difficulty concentrating, irritability, intolerance to bright light and loud sounds. Sleep becomes shallow and restless. Patients have difficulty falling asleep, difficulty waking up, and getting up unrested. Along with this, emotional instability, touchiness, and impressionability appear.

Asthenic disorders are rarely observed in their pure form; they are combined with anxiety, depression, fears, unpleasant sensations in the body and hypochondriacal fixation on one’s illness. At a certain stage, asthenic disorders can appear in any disease. Everyone knows that common colds and flu are accompanied by similar phenomena, and asthenic symptoms often persist even after recovery.

Emotional disturbances

Emotional disorders - somatic diseases are more characterized by a decrease in mood with various shades: anxiety, melancholy, apathy. In the occurrence of depressive disorders, the influence of psychotrauma (the disease itself is trauma), somatogenesis (the disease as such) and the personal characteristics of the patient are closely intertwined.

The clinical picture of depression varies depending on the nature and stage of the disease and the prevailing role of one or another factor. Thus, with a long course of the disease, depressed mood can be combined with dissatisfaction.

Stun

Stunning is a symptom of switching off consciousness, accompanied by a weakening of the perception of external stimuli. Patients do not immediately respond to questions surrounding the situation. They are lethargic, indifferent to everything happening around them, inhibited. As the severity of the disease increases, stupor can progress to stupor and coma.

A comatose state is characterized by the loss of all types of orientation and responses to external stimuli. When emerging from a coma, patients do not remember anything about what happened to them. Switching off consciousness is observed in renal, liver failure, diabetes and other diseases.

Delirium

Delirium is a state of darkened consciousness with false orientation in place, time, environment, but maintaining orientation in one’s own personality. Patients develop abundant illusions of perception (hallucinations), when they see objects and people that do not exist in reality, or hear voices.

Being absolutely confident in their existence, they cannot distinguish real events from unreal ones, therefore their behavior is determined by a delusional interpretation of the environment. There is strong excitement, there may be fear, horror, aggressive behavior, depending on the hallucinations. Patients in this regard can pose a danger to themselves and others. Upon recovery from delirium, the memory of the experience is preserved, while the events that actually occurred may fall out of memory. A delirious state is typical for severe infections and poisoning.

Oneiric state

The oneiric state (waking dream) is characterized by an influx of vivid scene-like hallucinations, often with unusual, fantastic content. Patients contemplate these pictures, feel their presence in the unfolding events (as in a dream), but behave passively, like observers, in contrast to delirium, where patients actively act.

Orientation in the environment and one’s own personality is impaired. Pathological visions are retained in memory, but not completely. Similar conditions can be observed with cardiovascular decompensation (heart defects), infectious diseases, etc.

Amentive state

An amental state (amentia is a deep degree of confusion of consciousness) is accompanied not only by a complete loss of orientation in the environment, but also in one’s own “I”. The environment is perceived fragmentarily, incoherently, and disconnectedly. Thinking is also impaired; the patient cannot comprehend what is happening. There are deceptions of perception in the form of hallucinations, which are accompanied by motor restlessness (usually in bed due to a severe general condition), incoherent speech.

Excitement may be followed by periods of immobility and helplessness. The mood is unstable: from tearfulness to unmotivated gaiety. The amental state can last for weeks and months with short light intervals. The dynamics of mental disorders are closely related to the severity of the physical condition. Amentia is observed in chronic or rapidly progressing diseases (sepsis, cancer intoxication), and its presence, as a rule, indicates the severity of the patient’s condition.

Twilight stupefaction

Twilight stupefaction is a special type of stupefaction that begins acutely and ends suddenly. Accompanied by complete loss of memory for this period. The content of psychopathological products can only be judged by the results of the patient’s behavior.

Due to profound disorientation, possible frightening hallucinations and delusions, such a patient poses a social danger. Fortunately, in somatic diseases this condition is quite rare and is not accompanied by complete detachment from the environment, unlike epilepsy.

Diagnostic measures

In identifying a disorder, psychiatrists rely on the clinical picture of the disorder and the testimony of loved ones, colleagues and other eyewitnesses. During twilight stupefaction, patients often commit crimes, so they undergo a forensic psychiatric examination. As a rule, it includes not only an examination by a psychiatrist, but also familiarization with the materials of the criminal case, etc.

To identify the immediate cause of the development of symptoms, a comprehensive examination is carried out:

Conversation with the patient and his relatives.
General examination and neurological examination. This makes it possible to detect diseases of the brain or internal organs that can cause mental disorders. It is important to establish the fact of past traumatic brain injuries, neuroinfections, as well as tumors in the structures of the central nervous system.
Electroencephalography (EEG), computed tomography or magnetic resonance imaging. The methods make it possible to study the state of the structures of the central nervous system and identify deviations in their structure. If atherosclerosis of the cerebral arteries is suspected, an ultrasound with Doppler sonography is performed.

Only a specialist - a psychiatrist or neurologist - should interpret the results obtained. Attempts at self-diagnosis can lead to progression of the underlying disease and the development of complications.

A differential diagnosis with delirium is mandatory. An important difference is the absence of memories of the period of impaired consciousness. They may partially persist if symptoms occur against the background of hysterical psychosis. In addition, the fact of a history of epilepsy and other organic diseases of the central nervous system testifies in favor of twilight disorder. Delirium is characterized by the appearance of symptoms when quitting alcohol and psychoactive substances. Patients experience psychomotor agitation, hallucinations, pseudohallucinations and delusions of persecution.

Syndromes of impaired consciousness in children and adolescents

In children, especially young children, stunning syndromes are more often observed. Stunning syndrome is characterized by a decrease in the activity of all mental processes, which is based on a decrease in the level of wakefulness. In children, mild stupor is more common - obstruction and somnolence.

A child in a state of nubulation looks lethargic, motorally inhibited, attention is not attracted immediately and is quickly depleted, the reaction to external influences and treatment is slow. The surroundings are perceived indistinctly, as if in a fog. Understanding the questions is difficult, but he names his first and last name correctly. Mood with a hint of apathy, decreased interest in toys, pictures, etc.

Upon exiting the state of numbing, memories are incomplete and fragmentary.

Somnolence is a deeper clouding of consciousness; the child resembles someone sleeping. You can only get a response with a loud sound. The child may follow some instructions, after which he again falls into a state of drowsiness. Memories of this period are not retained.

Stupor is an even deeper clouding of consciousness; only unconditioned reflex reactions are preserved: to painful stimuli, pupillary, corneal, pharyngeal, etc.

Comatose state is a complete loss of consciousness with a decrease in unconditioned reflex reactions and the appearance of pathological reflexes (Babinsky, Rossolimo, etc.) and decerebrate rigidity.

Among the syndromes of stupefaction with productive psychopathological symptoms, delirious syndrome, age-related variants of twilight stupefaction, and rarely amentive and oneiric states are more common.

Delirium is observed in children from 4-5 years of age. In the dynamics of delirium, several stages are distinguished: pre-delirium, hypnagogic delirium and the stage of true hallucinations.

In the pre-delirium stage, the child is motor restless, fearful, anxious, capricious, and tearful. Falling asleep is disturbed, sleep is superficial, with awakenings and terrible dreams.

Subsequently, a tendency to illusory perception with frightening visual illusions appears. Hypnagogic hallucinations are sometimes frightening, sometimes indifferent; they turn into dreams, and children of preschool and primary school age call them dreams.

Developed delirium is characterized by the appearance of small zooptic hallucinations. The child sees insects, snakes, worms, cats, dogs; the children try to drive them away, shake the insects off the bed and off themselves. Particularly vivid visual hallucinations are observed in cases of poisoning with henbane and drugs containing atropine.

In delirium of infectious and traumatic origin, true hallucinations are usually isolated, disorientation is not expressed, patients retain memories of hallucinations, and real events are not clearly remembered.

Delirium in children is usually short-term - from several hours to 1-2 days.

Amentive syndrome in young children manifests itself in the form of episodes of shallow mental confusion with an affect of bewilderment and difficulties in contact with others. Usually, complete disorientation and motor restlessness are detected.

S.S. Mnukhin called mild amental cloudings of consciousness asthenic confusion. In patients, it is possible to achieve short-term contact, after which mental exhaustion sets in.

Amental stupefaction occurs with severe cerebral and general infections and severe intoxication.

Oneiric syndrome is observed at puberty, it is expressed by detachment from the environment and immersion in the world of vivid imagery and fantastic pseudo-hallucinations. Patients, as a rule, see themselves as participants in fantastic events.

V., 14 years old, was admitted to the department with motor retardation, did not answer questions, refused to eat, sometimes got out of bed, walked slowly around the department with a detached expression, did not answer questions, sometimes spontaneously spoke several phrases, incoherent and incomprehensible to others . After coming out of this state, he said that he was taken to another planet, where everything is incredibly beautiful, painted in blue tones and people are also blue, they showed him animals, houses, offered to stay and marry a blue girl, but he refused, and he was returned to the ground.

In childhood, oriented oneiroid is more often observed. In the initial period, children experience confusion, anxiety, fears, false recognitions; double orientation is possible: the patient believes that he is at home and in the hospital at the same time.

The duration of oneiroid is from several hours to several weeks.

Twilight states of consciousness in children are very diverse. In preschool age, against the background of altered consciousness, oral automatisms are observed: chewing, swallowing, smacking and monotonous manual actions - fingering, patting, stroking, etc.

Children of primary school age experience sleepwalking and sleep-talking. With sleepwalking (somnambulism), the child gets out of bed during sleep, walks around the apartment, performs usual actions, does not answer questions, and does not remember anything in the morning.

Twilight states occur more often in children than in adults, but they are rudimentary, short-lived, and motor automatisms predominate in them.

Help during an acute period

Disorders of consciousness pose a danger to the patient and the people around him. This is due to inappropriate behavior against the background of delusions of persecution and hallucinations. In this regard, when symptoms appear, a number of simple measures should be taken to stabilize the condition.

It is necessary to call an ambulance. If possible, this should be a specialized psychiatric team capable of providing qualified treatment. While she is waiting, the patient is persuaded to sit down or lie down, and is not left alone. Sharp, piercing objects, as well as any dangerous substances, must be removed from the room. Windows and doors are closed. This helps reduce the risk of antisocial behavior.

Patients require hospitalization in a psychiatric hospital. Ambulance team specialists fix the patient and administer medicinal sedation. For this purpose, use Diazepam, Relanium, Sibazon or other drugs with a similar effect. At the beginning, a minimum therapeutic dosage is introduced, which allows you to suppress psychomotor activity. If the effect does not appear within 10-15 minutes, the administration of the drugs is repeated.

Combinations of antipsychotics with Diphenhydramine or Suprastin, as well as Aminazine, have a similar effect. When using such drugs, it is necessary to remember their hypotensive effect. These medications are contraindicated for people with low blood pressure.

In cases where symptoms of twilight stupefaction occur during epilepsy, they may be manifestations of an epileptic seizure. Therapy should include medications prescribed by a doctor to treat the underlying pathology.

Therapeutic principles

Antipsychotics are used as part of drug therapy. The drugs have a sedative effect, eliminate hallucinations, psychomotor agitation and other symptoms. Psychiatrists often use Aminazine and Tizercin, which have minimal side effects. If, while using antipsychotics, there is a decrease in blood pressure, Cordiamine is prescribed.

To relieve agitation, therapy is carried out according to the following scheme:

Intramuscular administration of Haloperidol, Olanzapine, Diazepam or Aminazine. Dosages of medications are selected individually.
With severe psychomotor agitation, intramuscular use of Midazolam at a dose of 5-10 mg is possible.
It is possible to use anesthetics: Hexobarbital or Propofol. The drugs are prescribed intramuscularly or intravenously.
After the excitement is removed, the form of the drugs is changed from injection to tablet. They are used until the symptoms are completely relieved.
If the course is prolonged, neuroleptics continue to be used until they are discontinued by a psychiatrist.

In parallel, therapy is carried out for the underlying disease that caused twilight stupefaction:

For epilepsy, antiepileptic drugs based on valproic acid are used. Patients must take them constantly, since refusal of medications leads to another relapse.
For the negative consequences of traumatic brain injuries or neuroinfections, nootropics (Piracetam, Phenotropil) and antioxidants (Dihydroquercetin, Tocopherol) are used to improve the functioning of nerve cells and protect them from negative effects. Medicines that improve blood flow in the cerebral vessels - Cerebrolysin, Actovegin, etc. - have a similar effect.

During the acute period of the disorder, the patient requires hospitalization. In a psychiatric hospital, relapse is stopped and constant medical supervision is established. As trance develops, the period of disturbed consciousness may persist for several hours or days. Repeated exacerbations may develop during hospitalization.

Of the non-drug methods, the key in the treatment of twilight disorder is psychotherapy aimed at achieving stable remission and preventing relapses. Patients are offered both individual and group sessions.

Forecast

Twilight disorder of consciousness is a symptom complex that is a sign of other diseases: hysterical psychosis, epilepsy, traumatic brain injury, etc. In this regard, the prognosis is determined by the root cause of the disorder and the timeliness of medical care.

With organic brain pathology, the prognosis is favorable if it is diagnosed in the early stages and the patient is prescribed comprehensive treatment. Identification of epilepsy, manifested in the form of automatisms and other mental symptoms, is an indication for the prescription of antiepileptic drugs. When taken regularly, the attacks disappear and the patient returns to normal life.

If the patient does not seek medical help for a long time, the disorder can lead to antisocial behavior. Incomplete medical and psychological examination in a criminal case leads to judicial punishment, including long-term arrest.