Definition Classification levels

1. -PRESENTOR- Dr. ZAINAB(1st yr PG)
-MODERATOR- Dr. MEGHANA(2nd yr PG)
-DEPARTMENT OF PSYCHIATRY
-KMCH GUNTUR

2. DEFINTION OF CONSCIOUSNESS
 A STATE OF AWARENESS OF THE SELF AND THE
ENVIRONMENT .
 Disorders of consciousness are associated with
disorders of perceptions, attention, attitudes,
thinking,registration, orientation.

3. CLASSIFICATION
 Consciousness can be changed in 3 basic ways .
 It may be
- Dream like change of consciousness
-Depressed
-Restricted

4. Dream like change of
consciousness
 It is the main feature of DELIRIUM
 There is some lowering of consciousness ,which is
the subjective experience of rise in threshold for all
the incoming stimuli.
 The patient is Disoriented for TIME &PLACE BUT
NOT PERSON
 Here THINKING IS DISORDERED as it is in dreams
and show excessive displacement ,condensation and
misuse of symbols.

5. HALLUCINATIONS IN DELIRIUM
 VISUAL Hallucinations –usually of small animals and
associated with fear or even terror
 Pt is unable to distinguish between their mental
images and perceptions so that their mental images
acquire the value of perceptions.
 ELEMENTARY AUDITORY HALLUCINATIONS are
common ,but continuous voices are rare
 Other hallucinations of touch , pain ,electric feelings,
muscle sense, vestibular sensations often occur.

6. There may be
assoc with
LILLIPUTIAN
hallucinations
(seeing little
men).he feels
their footsteps
&hears them
shouting jokes
and abusive
remarks in ear

7.  The pt is fearful and often misinterpret the behaviour
as threats . Thus a pt with DELIRIUM TREMENS said
“don’t hit me ;please don’t hit me” whenever anyone
approached although he had never been subjected to
assault

8. Occupational delirium
 Pt is usually restless and may carry out the customary
actions of this trade .
 Examples-
 1)bus conductor may ask other patients for bus fare
 2)accountant may make out long series of accounts .

9. SUBACUTE DELIRIOUS STATE/TOXIC
CONFUSIONAL STATE
 It is the mild degree of delirium
 General lowering of consciousness during day and be
incoherent and confused.
 At night visual hallucinations & restlessness but it
improves in morning.
 Pt may have inconsistent orientation ,orientation may
vary during 24hrs of the day.
 These milder varieties may pass over into Torpor,
severe delirium ,twilight states

10. TORPOR(LOWERING OF
CONSCIOUSNESS)
 General lowering of consciousness WITHOUT
HALLUCINATIONS, illusions,delusions,restlessness.
 The pt is APATHETIC,slowed down, can’t express
themself clearly and may persevrate
 Now a days seen in arteriosclerotic cerebral disease
following CVA.
 In past its result of severe infections such as
typhoid&typhus.
 After some weeks there is remarkable partial recovery
and left with mild organic defect

12. TWILIGHT STATE
 FEATURES
 1)Restriction of morbidly changed consciousness
 2)break in the continuity of consciousness
 3)relatively well ordered behaviour
Usually seen in EPILEPSY(MOST COMMON )
ALCOHOLISM
BRAIN TRAUMA

13. Characters of twilight state(sims)
 Abrupt Onset and end
 Variable duration from few hrs to several weeks
 Occurrence of unexpected violent acts/emotional
outbursts during otherwise quite behaviour
 ICD-10 includes twilight states under headings of
dissociative (conversion)disorders &when criteria for
organic etiology are met ,organic mental disorders

14. HYSTERICAL TWILIGHT STATE
 Restriction of consciousness resulting from
unconscious motives.
 In severe anxiety the pt is so preoccupied by their
conflicts that they r not fully aware of their
environment& they have only hazy idea of what has
happened in the past hour or so
 This may suggest to pt that amnesia is solution for
their problems so that they forget their personal
identity& whole of his past as temporary solution for
their difficulties

15. FUGUES
 WANDERING STATES WITH SOME LOSS OF
MEMORY –called as FUGUES
 May be of variable duration
 Seen in DEPRESSION
 HYSTERICAL FUGUE – it is common in subjects who
have previously HEAD INJURY WITH CONCUSSION
 Icd-10 includes fugues under dissociative (conversion)
disorders

16. ATTENTION
 It can be active or passive
 Active-when subject focus their attention on some
internal or external event
 Passive – when same events attract subjects attention
without conscious effort
 Disturbance of active attention shows itself as
DISTRACTIBILITY,so that the pt is diverted by all new
stimuli and habituation to new stimuli can take longer
than usual.

17. distractability
 Can occur in
-Fatigue
-anxiety
-severe depression
-mania
-Schizophrenia
-Organic states

18. LEVELS OF CONSCIOUSNESS
 An alteration in level Of consciousness is an imp
factor of BRAIN DYSFUNCTION and is usually caused
either by primary neurologic disease or systemic
medical illness .
 The term consciousness is multifaceted, it is imp to
distinguish between CONTENT& AROUSAL of
consciousness
 CONTENT-refers to higher cognitive and emotional
functioning
 AROUSAL- refers to activation of cortex from
ascending activating system(AAS)

19. Basic levels
 ALERTNESS
 LETHARGY OR SOMNOLENCE
 OBTUNDATION
 STUPOR OR SEMICOMA
 COMA

20.  ALERTNESS-pt is AWAKE &fully aware of normal
external &internal stimuli
 LETHARGY-pt is not fully awake &tends to drift off to
sleep when not actively stimulated.in conversation pt
looses train of thought
 -Eg-pt name is called in normal tone of voice ,pt opens
his eyes ,starts mumbling –”WHY YA BOTHERING”
ME? Then closes eyes and sleeps

21.  OBTUNDATION-transitional state between lethargy and
stupor
 -pt is difficult to arouse and when aroused he is confusional
-constant stimulation is required to elicit marginal
cooperation
-meaningful MSE is usually FUTILE
-the obtunded pt is ,by our definition -Acute confusional
state or quiet delirium.
-Here pt responds to loud voice ,restless movements
,brief eye opening,speech
mumbled,incoherent,disoriented,pt returns to sleep

22.  STUPOR &SEMICOMA-pt donot responds to loud
voice .
 but responded shaking of shoulders ,accompanied by
loud calling of pts name with groan ,aimless
movement of extremities ,eyes remained closed
 Here pt has extensive brain dysfunction and due to
reduced level of consciousness MSE is not meaningful.

23.  COMA-Pt is completely unarousable and eyes remain
closed.
 Its an absolute end point on the scale of consciousness
 Pt responds neither to external or internal stimulation
nor spontaneously.

24. Hysterical coma like state
 Its state of pyschogenic unresponsiveness
 Constitutes 1% of all pts presenting to medical
emergency room in unresponsive state
 Here normal –HR,RR,B.P.
 BULBAR REFLEXES INTACT.
 Muscle reflexes are symmetric .
 Should not be diagnosed too hastily.

25. SUMMARY
 As consciousness is most rudimentary of all mental
functions. its level should be determined FIRST in any
MSE (mental status examination )
 Any alteration in level of consciousness decreases the
efficiency of cortical functioning & there by decreases
the validity of susequent steps in MSE.

26. REFERENCES
1)FISH’S clinical psychopathology- 3rd edition
(pages-81 to 85)
2)The mental status examination in neurology -4th
edition- by STURB AND BLACK
(pages-29 to 32;38;39)