Consciousness is an attribute of the pure self, or the ultimate reality.

1. Disorders of
Consciousness
DR CH PAVANA SANDHYA
DEPARTMENT OF PSYCHIATRY

2. definition
 consciousness can be defined as
 a state of awareness of the self and the environment.
 In the fully awake subject the intensity of consciousness varies considerably.
 If someone is carrying out a difficult experiment their level of consciousness will be at its
height,
 they are sitting in an armchair glancing through the newspaper the intensity of their
consciousness will be much less.
 In fact, when subjects are monitoring a monotonously repetitive set of signals, short
periods of sleep may occur between signals and are not recognised by the subject, but are
shown clearly by changes in the electroencephalogram (EEG).

3.  first to the inner awareness of experience
as opposed to the categorizing of events
as they occur.
 Second, it refers to the subject reacting to
objects deliberately.
 Third, it denotes a knowledge of a
conscious self

4. UNCONSCIOUSNESS
 Unconscious, according to Jaspers (1959),
‘means something that is not an inner
existence and does not occur as an
experience
 secondly, something that is not thought of
as an object and has gone unregarded
 thirdly, it is something which has not
reached any knowledge of itself ’

6.  disorders of consciousness
 deal with the possibly confounding issue of attention.
 Attention can be active when the subject focuses their attention on some
internal or external event
 passive when the same events attract the subject’s attention without any
conscious effort on their part.
 Active and passive attention are reciprocally related to each other, since the
more the subject focuses their attention the greater must be the stimulus
that will distract them (i.e., bring passive attention into action).

7. Distractibility:
 Disturbance of active attention
 the patient is diverted by almost all new
stimuli and habituation to new stimuli takes
longer than usual.
 fatigue, anxiety, severe depression, mania,
schizophrenia and organic states

8.  Disorders of consciousness are
associated with disorders of
 perception
 Attention
 Attitudes
 Thinking
 Registration
 orientation

9. clinical test for disturbance of
consciousness is
to ask the patient
 the date
 the day of the week
 the time of day, the place
 the duration of their stay in that place and
so on

10.  acute organic state
 performance on intellectual and memory tasks, inability to
estimate the passage of time and changes in the EEG may all
suggest an acute organic state.
 chronic schizophrenia
 institutionalised on a long-term basis and may be indifferent or
reject all contact, and so seem disoriented.

11.  If a patient is disoriented for time and place, it is customary to
say that they are confused.
 Unfortunately, this word is used in everyday speech to mean
 ‘muddled’
 ‘bewildered’
 ‘perplexed’.
 In fact, most patients with confusion are perplexed, but this
sign is also seen in severe anxiety and acute schizophrenia in
the absence of disorientation

12. Vigilance (Wakefulness)–
Drowsiness (Sleep)
 deliberately remaining alert
 Factors
 Interest
 Anxiety
 extreme fear or enjoyment
 whereas boredom encourages
drowsiness

13. Lucidity–Clouding
 lucidity can be demonstrated only in
clarity of thought on a particular topic.
 The sensorium, the total awareness of all
internal and external sensations
presenting themselves to the organism at
any particular moment, may be clear or
clouded

14. Clouding
 denotes the lesser stages of impairment of
consciousness on a continuum from full alertness and
awareness to coma (Lishman, 1997)
 drowsy or agitated
 memory disturbance
 disorientation.
 In clouding, most intellectual functions are impaired,
including attention and concentration,
 comprehension and recognition, understanding, forming
associations, logical judgement, communication by
speech and purposeful action.

15. Pathology of Consciousness

17.  Consciousness can be changed in three
basic ways:
 it may be dream-like
 depressed
 restricted.

18. Dream-Like Change of
Consciousness
 there is some lowering of the level of
consciousness, which is the subjective
experience of a rise in the threshold for all
incoming stimuli.
 patient is disoriented for time and place,
but not for person.

19.  visual hallucinations,
 Lilliputian hallucinations occur and are
associated with a feeling of pleasure.
 Elementary auditory hallucinations
 hallucinations of touch, pain, electric feelings,
muscle sense and vestibular sensations

20. Lowering of Consciousness
 lowering of consciousness the patient is psychologically benumbed and there is a
general lowering of consciousness without hallucinations, illusions, delusions and
restlessness.
 The patient is apathetic, generally slowed down, unable to express themself clearly
and may perseverate. There is no accepted term for this state that is best designated
as ‘torpor’.
 In the past, this type of consciousness was very often the result of severe infections
such as typhoid and typhus.
 Nowadays, it is more commonly seen in the context of arteriosclerotic cerebral
disease following a cerebrovascular accident.
 If the history of the illness is not clear, the general defect in intelligence, in the
absence of hallucinations, may be mistakenly diagnosed as severe dementia, but
after some weeks there is a remarkable partial recovery and the patient is left with a
mild organic deficit.

21. Restriction of Consciousness
 With restriction of consciousness,
awareness is narrowed down to a few
ideas and attitudes that dominate the
patient’s mind.
 There is some lowering of the level of
consciousness, so that in some cases the
patient may only appear slightly bemused

22.  uninformed bystanders may not realise that they are confused.
Disorientation for time and place occurs. Some of these patients are
relatively well-ordered in their behaviour and may wander, but
usually they are not able to fend for themselves, like the patient with
a hysterical twilight state.
 The term ‘twilight state’ describes conditions in which there was a
restriction of the morbidly changed consciousness, a break in the
continuity of consciousness and relatively well-ordered behaviour. If
one keeps strictly to these criteria, then the commonest twilight state
is the result of epilepsy.
 In addition, nonepileptic twilight states with convulsive
manifestations can occur following a febrile seizure and may be
misdiagnosed as prolonged seizures resulting in overtreatment
(Miyahara et al., 2018).
 However, this term has been used for any condition in which there
is a real or apparent restriction of consciousness, so that simple,
hallucinatory, perplexed, excited, expansive, psychomotor and
orientated twilight states have been described.

23.  ICD-10 includes twilight states under the
headings of dissociative (conversion)
disorders

24. severe anxiety
 preoccupied by their conflicts
 not fully aware of their environment and find that they have only a hazy
idea of what has happened in the past hour or so.
 This may suggest to the patient that amnesia is a solution for their
problems, so that they ‘forget’ their personal identity and the whole of their
past as a temporary solution for their difficulties.
 This restriction of consciousness resulting from unconscious motives has
been termed a ‘hysterical twilight state’. It may be difficult to decide how
much the motivation of a hysterical twilight state is unconscious because in
some cases the subject seems to be deliberately running away from his
troubles

25.  Wandering states with some loss of memory have also been called
fugues, but not all fugues are hysterical;
 for example, some individuals with depression may start out to kill
themselves and wander about indecisively for some days before
finding their way home or being stopped by the police.
 Hysterical fugue may be more common in subjects who have
previously had a head injury with concussion, possibly because they
are familiar with the pattern of amnesia from their past experience of
concussion and can therefore present it as a hysterical symptom.
 The ICD-10 includes dissociative fugue under the heading of
dissociative (conversion) disorders and notes that conscious
simulation of fugue may be difficult to differentiate from true
dissociative fugue (World Health Organization, 1992).

 Fugue states may be of variable duration, with some fugue states
persisting for extremely long periods of time.

26. QUALITATIVE CHANGES OF
CONSCIOUSNESS
 Delirium
 Lipowski (1990) defines delirium as ‘a
transient organic mental syndrome of
acute onset, characterized by global
impairment of cognitive functions, a
reduced level of consciousness,
attentional abnormalities, increased or
decreased psychomotor activity and a
disordered sleep–wake cycle’

27. Fluctuation of Consciousness
 Alterations of consciousness level are described with
third-ventricle tumours associated with variations in
intracranial pressure (Sim, 1974).
 diurnal fluctuation of consciousness.
 Characteristically, the patient becomes more
disorientated
 disturbed in mood and distracted perceptually with
illusions and hallucinations in the late evening and
shows greatest lucidity mid-morning

28. Confusion
 France (confusion mentale) and later in
Germany (Verwirrtheit)

29. OTHER TERMS

30. Twilight State
 well-defined interruption of the continuity of consciousness (Sims et al.,
2000).
 It is usually an organic condition and occurs in the context of epilepsy,
alcoholism (mania à potu), brain trauma and general paresis; it may also
occur with dissociative states.
 It is characterized by
 (a) abrupt onset and end
 (b) variable duration, from a few hours to several weeks
 (c) the occurrence of unexpected violent acts or emotional outbursts during
otherwise normal, quiet behaviour (Lishman, 1997).

31.  forensic implications of this condition are
therefore important, and it has been used
as a legal defence for violent behaviour for
which the person had subsequent
amnesia.

32. Mania à Potu (Pathological
Intoxication)
 This is one type of twilight state specifically associated with alcoholism.
 Keller (1977) has defined mania à potu as:
 an extraordinarily severe response to alcohol, especially to small amounts,
marked by apparently senseless violent behaviour, usually followed by
exhaustion, sleep and amnesia for the episode.
 Intoxication is apparently not always involved and for this reason
pathological reaction to alcohol is the preferred term. The reaction is
thought to be associated with exhaustion, great strain or hypoglycaemia,
and to occur especially in people poorly defended against their own violent
impulses.

33. Coid (1979) describes four components:
■ the condition follows the consumption of a
variable quantity of alcohol
■ senseless, violent behaviour then ensues
■ there is then prolonged sleep
■ total or partial amnesia for the disturbed
behaviour occurs.

34. Automatism
Automatism implies action taking place in the absence of
consciousness.
It has been defined by Fenwick (1990) as follows: An automatism is an
involuntary piece of behaviour over which an individual has no
control.
The behaviour itself is usually inappropriate to the circumstances, and
may be out of character for the individual.
It can be complex, co-ordinated, and apparently purposeful and
directed, though lacking in judgement.
Afterwards, the individual may have no recollection, or only partial and
confused memory, of his actions.

35.  Epileptic automatism
 aura may be the first sign of an epileptic
attack with temporal lobe automatism and
may be manifested as abdominal
sensations; feelings of confusion with
thinking; sensations elsewhere in the
body, especially the head; hallucinations
or illusions (especially olfactory or
gustatory); and motor abnormalities such
as tonic contracture, masticatory
movement, salivation or swallowing.

36.  Speech automatism occurs when there is
utterance of identifiable words or phrases

37. Dream-Like (Oneiroid) State
disorientated, confused and experiences elaborate
hallucinations, usually visual.
There is impairment of consciousness and
marked emotional change, which may be terror
or enjoyment of the hallucinatory experiences;
there may also be auditory or tactile
hallucinations.
The patient may appear to be living in a dream
world, and so-called occupational delirium

38. Stupor
 ‘Stupor names a symptom complex whose central feature is a reduction in,
or absence of, relational functions: that is, action and speech’ (Berrios,
1996).
 lesions in the area of the diencephalon and upper brainstem, and also the
frontal lobe and basal ganglia, and the term akinetic mutism
 A rare but specific condition involving the motor pathways in the ventral
pons is called the locked-in syndrome, in which there is quadriplegia and
anarthria with preserved consciousness and vertical eye movement (Plum
and Posner, 1972; Smith and Delargy, 2005).
 symptoms of akinesis and mutism in a conscious patient also occur with
schizophrenia, with affective psychoses (both depressive and manic) and in
dissociative states.
 The difference between psychogenic (so-called functional) and neurological
(organic) causes of stupor can be clinically extremely perplexing.
Psychiatric definitions have demanded that the condition occurs when there
is ‘a complete absence, in clear consciousness, of any voluntary
movements’ (Wing et al., 1974).

39.  1984 film Paris, Texas provides a vivid depiction of a
man with a dissociative fugue state.
 Written by Sam Shepard and directed by Wim Wenders,
Paris, Texas focuses on the story of Travis, a middle-
aged man who reappears in Texas after wandering for
four years in a desert on the border between the United
States and Mexico.
 Despite being apparently mute and amnesic, Travis
manages to locate his brother and gradually starts to re-
integrate with society.
 The film provides a valuable demonstration of the
features of dissociative fugue states, as well as a useful
exploration of the difficulties that can result from them.

40. 1984 film Paris, Texas