Dr. Zainab from the Department of Psychiatry at KMCH Guntur presented on consciousness and its disorders. Consciousness refers to one's awareness of themselves and their environment. It can be altered in three ways - a dream-like state as seen in delirium, a depressed state, or a restricted state. Delirium involves a lowering of consciousness and disordered thinking similar to dreams, along with possible hallucinations and confusion about time and place. Consciousness levels range from alertness to lethargy, obtundation, stupor, and coma - with decreasing responsiveness at each level. Proper assessment of consciousness level is crucial for an accurate mental status examination.

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)