Consciousness is the ability to perceive oneself and the external world, as well as to report on events occurring in the external world and form one’s own reaction in response to these events.
Consciousness allows you to navigate the environment, time and your own personality. The formation of human consciousness occurs in several stages:
- Waking consciousness . The presence of such consciousness allows you to choose the most favorable environment for yourself. So, a child under 1 year old understands that he is more comfortable in his mother’s arms than just on the soft surface of the crib;
- Subject consciousness . Such consciousness is typical for the ages of 1-3 years, it allows the formation of a basic idea of objects - “cat”, “dog”, “grandfather”, “grandmother” and others;
- Individual consciousness . This type of consciousness is formed in the period from 3 to 9 years. The child receives basic ideas about space and time, and, thanks to this, distinguishes himself from the environment;
- Collective consciousness . In the period from 9 to 16 years, a teenager develops a collective consciousness that combines a basic idea of himself with a basic idea of other people and builds initial interpersonal interactions;
- Reflective consciousness . This is the most mature form of consciousness, it is formed from 16-22 years old and onwards. Such consciousness allows for introspection and deep analysis of the world around us, establishing complex cause-and-effect relationships and making predictions for the future.
Pathologies of consciousness are a very important branch of neuroscience. Every doctor must be able to determine the degree of lucidity of the patient, because many emergency conditions are very closely related to disturbances of consciousness. Universal criteria that allow one to suspect disorders of consciousness were proposed by the German psychiatrist Karl Jaspers . These criteria are the basic diagnostic tool to this day:
- Detachment from the outside world;
- Disorientation in time, space and self;
- Thinking disorders;
- Amnesia.
Let's look at them separately, this is a fundamentally important point.
Detachment from the outside world means a state in which the patient does not perceive (does not fully perceive) everything that happens around him. It is always difficult to establish contact with such a patient; he does not hear or perceive speech addressed to him, he ignores the gestures and facial expressions of the interlocutor with normally functioning organs of vision and hearing. In order to get an answer from the patient, the doctor has to repeat the question very loudly and several times. Often contact with such patients is generally impossible. Detachment is the main criterion for clouding of consciousness.
Disorientation is a lack of understanding and/or misconception. As you remember, within the framework of our symptom complex, disorientation in time, space and one’s own personality is distinguished. Time disorientation is a condition in which the patient ceases to understand what time of day it is, what day of the week, month or even year. As a rule, the first symptom of clouding of consciousness is disorientation in time.
Disorientation in space is the patient’s lack of understanding of where he is now. A person in a hospital may believe that he is in a store, office center or stadium. Disorientation in space and time is classified as allopsychic disorientation.
The most severe mental disorders are accompanied by disorientation in one's own personality . It is also called “autopsychic disorientation.” During personality disorientation, the patient experiences difficulty in self-identification - he cannot say who he is, what he does and what his name is. Also, such disorientation manifests itself in situations when the patient begins to perceive himself pervertedly - he may consider himself a supernatural being, a demon, an alien from another world, an animal, an inanimate object or phenomenon - a black hole, a magical amulet.
Thinking disorders during disorders of consciousness are manifested by a variety of symptoms. The most common is fragmented thinking, which turns into incoherence. This is expressed, as you remember, in the patient’s speech, which becomes similar to the pronunciation of individual words and interjections that are in no way connected with each other.
Amnesia is a complete loss of memory of any period. In the case of disorders of consciousness, we are talking about loss of memory of the period of the illness itself. If we are talking about a mild disorder, the patient may remember some events that occurred during the illness, but without any details and with a broken sequence.
Impairments of consciousness are also divided into qualitative and quantitative.
Quantitative disorders of consciousness
Quantitative disorders of consciousness include conditions in which consciousness, without being distorted, fades more and more depending on the pathology. In this list, I will arrange quantitative disorders of consciousness in exactly this way - from the state with the least loss of consciousness to the state when it is completely absent:
- Stun
- Sopor
- Coma
In a state of stunning, the patient has an increase in the threshold of perception of all analyzers. That is, he does not perceive normal speech, it needs to be louder. Even very loudly and clearly spoken phrases will be understood by the patient only if they are simple and monosyllabic. The patient will not react at all to any intricate phrases or narration. Visually, he perceives only very sharp changes in the image or situation - if, for example, a chair or armchair is placed directly in front of him, the patient will not react in any way. The patient will also not pay any attention to mild physical impacts; only slight movements of the eyelids are possible in the case of, for example, an unsuccessful and extremely painful injection.
A patient in a state of stupor, as a rule, understands that he is in a hospital, but there are always problems with further orientation - he cannot say which hospital he is in, what time it is and in which department he was placed.
There are also separate types of stunning - obnubilation and somnolence. Numbulation is a mild degree of stunning, in which the patient occasionally gets out of bed and walks around the ward, but detachment from everything around him is clearly noticeable. Somnolence is a stupor in which the patient always wants to lie down and sleep. If he is awakened, he will be able to answer a few simple questions, but after the end of the conversation he immediately falls asleep, regardless of the presence of noise or other stimuli.
Stupor is a much more severe disturbance of consciousness, in which the patient gives the impression of being deeply asleep. Mental activity in this state completely stops. It is impossible to completely awaken or in any way rouse such a patient. Sometimes it is possible to produce subtle responses, such as opening the eyes slightly in response to a very loud speech next to the ear or a dull groan in response to the infliction of very severe pain.
Most of the simplest reflexes (tendon, skin) may be suppressed, but not absent - this is often what distinguishes stupor from coma. Therefore, stupor is also called “precoma.” When leaving the state of stupor, a person will not remember anything from the period of illness.
Coma is the most severe quantitative disorder of consciousness. In other words, it is a complete lack of consciousness. A patient in a coma lies motionless; a response on his part cannot be evoked by any irritants. There are no unconditioned reflexes, except for the pupillary and corneal (corneal) ones.
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Qualitative disturbances of consciousness
You are probably already accustomed to this simple classification of pathologies of mental functions in psychiatry. Almost all violations of all functions are divided into quantitative (strengthening and weakening) and qualitative (perversion). Today’s topic will be no exception - qualitative disorders of consciousness are a perverted version of normal consciousness, not reduced quantitatively.
The main qualitative disorders of consciousness are delirium, amentia, twilight stupor and oneiroid.
Delirium
Delirium is a severe disturbance of mental activity, which is expressed in confusion, true hallucinations, illusions, severe psychomotor agitation and disturbance of orientation in place, time and (sometimes) in personality.
Delirium begins with a feeling of anxiety, restlessness and increased sensitivity to light, sounds and other stimuli (hyperesthesia). The patient suffers from insomnia, trying in vain to relax and fall asleep. Then anxiety increases, reaching panic. At the same time, perception disorders appear - first illusions, and then hallucinations. Illusions in this state are closely related to the surrounding environment - the glare of light from street lamps forms ominous human faces, the branches of a house plant become hooked paws, and the patterns on the carpet turn into streams of running insects.
Then mental disorders increase, and hallucinations join the general fun. In the overwhelming majority of cases, these are true frightening hallucinations - patients see rotting impersonal corpses, blood, dead relatives, hostile supernatural beings.
At the peak of delirium, scene-like hallucinations appear, that is, the entire situation changes - patients, while in the hospital, see themselves in a cemetery, in their own crypt, on board a spaceship, in the bowels of another planet, etc. The patient experiences extreme fear or rage, he tries to interact with the hallucinations - to hit them, push them away, or flee. In this state, patients show extraordinary strength, they destroy furniture and overturn heavy objects, they can jump out of a window, without realizing that they are putting their lives at risk.
The patient cannot sleep until the delirium resolves. Typically, the state of delirium lasts 2-4 days, after which the patient falls soundly asleep and, after half a day of deep sleep, wakes up in a normal mental state.
In modern psychiatry, special types of delirium are distinguished:
- Abortive delirium . Such delirium resolves within a few hours, orientation is only partially impaired, and proceeds relatively easily;
- Delirious delirium . The more common term is “muttering delirium.” This type of delirium is characterized by a more profound impairment of consciousness. Here there is chaotic excitement within the bed, indistinct muttering and shouting of individual words or fragments of phrases. There are senseless grasping movements;
- Occupational delirium is a condition similar to ordinary delirium, however, with all other similar symptoms, the patient is convinced that he is at his workplace and performs stereotypical actions related to his work (hammering non-existent nails, signing non-existent contracts, etc.).
A fundamentally important point is that with delirium, orientation in one’s own personality is not disturbed Interaction with hallucinations occurs in accordance with the patient’s temperament - brave and courageous people rush in rage at “demons” or “living dead”, while more cautious people run away in horror or try to hide.
Amentia
Amentia is a clouding of consciousness, very similar to ordinary delirium. However, with amentia, the patient does not leave the bed; periods of excitement alternate with periods of complete rest (amnestic lacunae). His thinking is incoherent, and his speech consists of separate words.
With amentia, orientation in the individual is disrupted. Patients are not available for contact. Also, with amentia, hallucinations, unlike delirium, are scanty and ephemeral. An important feature of amentia is severe physical exhaustion . As a rule, amentia indicates a long-term debilitating disease.
Twilight stupefaction
Twilight stupefaction (twilight state) is a sudden, deep disorientation in the surrounding space while maintaining the usual automatic actions. Here we are talking about a condition when a “failure” in consciousness suddenly occurs and the patient completely ceases to control and feel himself. I remember the story of my propaedeutics teacher about one of his patients.
This was a young woman who, for the first time in her life, experienced an attack of twilight stupefaction. She came home after a long day of work, closed the door behind her and lost consciousness before she had time to take off her coat and hat (it was late autumn). When she woke up, this young woman experienced a chilling horror, because when she opened her eyes, she saw that she was standing in front of the mirror in an evening dress and with bright makeup.
There is a triad of signs characteristic of the twilight state:
- Paroxysmality is a sudden onset and an equally sudden end;
- The behavior of patients is determined by the nature of their experiences;
- Complete amnesia for the entire painful period.
Clinically, two large groups of states of twilight consciousness are distinguished: ambulatory automatism and delusional-hallucinatory (sometimes separately delusional and hallucinatory) twilight consciousness.
Outpatient automatism
Outpatient automatisms are short periods of confusion during which the patient performs habitual, automatic actions. There is no violent behavior or socially dangerous acts here. Being in a state of darkened consciousness, “oblivion,” patients can move around the streets, stop in front of a red traffic light, and briefly answer questions from others. After the end of the attack of twilight consciousness, the patient does not understand how he ended up in this or that place, and does not remember his words and actions at all. I considered a typical example of ambulatory automatism a little higher, when we were talking about a young girl who suddenly found herself in a dress. Outpatient automatisms are classified into fugues, trances and somnambulism.
Fugues (from the Latin “fugas” - “to run”) are sharp, short-term attacks of stupefaction, during which the patient, unexpectedly for those around him, breaks away and rushes to run in bizarre directions, which he himself, after emerging from the attack, cannot explain. The fugue lasts, as a rule, no more than 2-5 minutes.
Trances are states in which the stupefaction of consciousness lasts longer than during fugues. During trance, the patient can leave the house, use public transport, or even leave the boundaries of his city. When the attack passes, the patient finds himself disoriented in an unfamiliar place and has no idea how he got there.
Somnambulism is exactly what our grandparents called “sleepwalking.” Attacks of somnambulism occur during sleep. The patient, in the presence of a minor irritant (the light of the moon or a night lamp), gets out of bed, performs automatic actions - walks, straightens the bed, overcomes obstacles, after which he returns to bed and continues the interrupted sleep. The next morning the patient does not remember anything from the night's incident and listens with surprise to stories about his attack.
There are a number of recommendations for patients suffering from somnambulism - when choosing real estate, choose apartments located on the ground floor, do not store cold and loaded firearms at home, and, if possible, install alarms on the doors.
