It is about Disorders of consciousness according to Textbook of Fish's Clinical psychopathology and Textbook of Sim's Symptom in the Mind. It also includes Attention and Orientation.

1. Disorders of
Consciousness
-Dr. Shibani Patade, Psychiatry JR

2. CONSCIOUSNESS
• Consciousness ‘is a state of awareness of the self and the
environment’.
• Characterized by :
• Subjective nature
• Privacy
• Qualia, that is recalcitrant to any external physical description. This is the
particular character of any object of our conscious experience, for example
the redness of the colour red as we perceive it.
• Intentional- it is directed towards objects; it has content – it is always about
something.
• Unified into a whole and not in fragments or unintegrated parts.

3. Basically, it refers to:
• The inner awareness of experience as opposed to the categorizing of
events as they occur.
• The subject reacting to objects deliberately.
• Knowledge of a conscious self.

4. UNCONSCIOUSNESS
• According to Jaspers (1959),
• ‘Means something that is not an inner existence and does not occur as an
experience
• Something that is not thought of as an object and has gone unregarded
• Something which has not reached any knowledge of itself ’.
• Seen in three different ways: (EEG different)
(have in common only the phenomenological element )(no subjective
experience)

5. Normal consciousness
Serious brain disease
Clouding
Drowsiness
Sopor
Coma
Sleep
Full
wakefullness
Reduced
wakefulness
Stages of sleep
N1
N2
N3
Deep
sleep
REM
Alert healthy
person
Full vigilance
Preconcious- not
readily available
Unconscious mind

6. Conscious
• Strict limit to the number of
items available , that are capable
of being memorized (Serial
Seven test)
• If ambiguous stimulus, only one
interpretation is possible.
• Difficult to carry out more than
one task at a time.
• Processes are flexible and
strategic
Preconscious
• More amount of information
stored at this level.
• If ambiguous stimulus, multiple
meanings are available.
• Undertake parallel tasks.
• Processes are automatic

7. DIMENSIONS OF CONSCIOUSNESS
Vigilance (Wakefulness)–
Drowsiness (Sleep)
-Deliberately remaining alert when
one might be drowsy/asleep.
-not uniform
-Promoted by:
>Interest
>Anxiety
>Extreme fear
>Enjoyment
-Demoted by : Boredom
- Also affected by how individual
perceives their environment
Lucidity–Clouding
- Related to
sensorium
-Clarity of
thought on a
particular topic.
Self-consciousness
-Ability to
experience and
be aware of
oneself
related

8. Pathology of
Consciousness
Lowering or
diminution of
consciousness
Quantitative
Qualitative
Heightened
consciousness
Synaesthesiae Twilight state Mania a potu Automatism
Dream-
like
oneiroid
state
Stupor

9. HEIGHTENED CONSCIOUSNESS
There is :
• Subjective sense of richer perception : colours seem brighter
• Changes in mood, usually exhilaration to ecstasy
• Increased alertness, intellectual activity, memory and understanding.
Seen in:
• Drug use
• The hallucinogens; LSD
• CNS stimulants; amphetamine.
• Early psychotic illness
• Mania
• Schizophrenia.

10. SYNAESTHESIAE
• A sensory stimulus in one modality resulting in sensory
experience in another
• Eg: Hearing fingernail drawn down blackboard results in cold
feeling down the spine.
Both heightening of consciousness and synaesthesiae, occur
in:
• Normal, healthy people;
• In adolescence
• Emotional, social or religious crisis
- When falling in love, on winning a large sum of money, at sudden religious
conversion.

11. QUANTITATIVE LOWERING OF
CONSCIOUSNESS
• Consciousness if considered as a continuum from full alertness and
awareness to coma, it may be regarded as quantitative.
Normal
consciousness:
alert, vigilant,
lucid
Clouding
-Drowsy/agitated
-memory
disturbance and
disorientation.
-Most intellectual
functions are
impaired.
Drowsiness
-Diminished
alertness and
attention .
-Not under the
patient’s control.
-Pt. ‘awake’ but will
drift into ‘sleep’ if
left without
sensory
stimulation.
Sopor
-Abnormally deep
sleep
Coma
-Pt. is unconscious
- No response to
painful stimuli
Death
- Permanent
cessation in
physical and
mental processes

12. Clouding of consciousness:
• Intellectual functions impaired are:
• Attention and concentration
• Comprehension and recognition
• Understanding
• Forming associations
• Logical judgement
• Communication by speech
• Purposeful action
• Reduced awareness of the environment

13. • Reduced wakefulness before falling asleep->different from
clouding in an organic state as pt. may be agitated and
excitable rather than drowsy.
• Seen in :
• Acute organic conditions
• Drug and alcohol intoxication
• Head injury
• Meningeal irritation caused by infection
• Cerebral tumour
• Raised intracranial pressure

14. Drowsiness
• Patient is:
• Slow in actions
• Slurred in speech
• Sluggish in intention
• Sleepy on subjective description
• Attempt at avoidance of painful stimuli
• Reflexes, including coughing and swallowing, are present but reduced
• Muscle tone diminished
• Interviewing such patient becomes next to impossible.

15. • Seen in:
• Overdosage with drugs that have a CNS depressant effect (TCAs)
• Head injury
• Tumour
• Epilepsy
• Infection
• Cerebrovascular disorder
• Metabolic disorder
• Toxic state

16. Coma
• Patient is:
• In lighter states->with strong stimuli-> momentarily arousable.
• No responses including verbal to painful stimuli.
• Righting response of posture lost.
• Reflexes and muscle tone present but greatly reduced
• Breathing->slow, deep and rhythmic
• Flushed face/skin

17. QUALITATIVE CHANGES OF
CONSCIOUSNESS
Delirium
-Transient organic mental syndrome of
acute onset
-Characterized by;
>Global impairment of cognitive
functions(thinking, memory)-
Disoriented
>Disturbances in perception, emotions
>Reduced level of consciousness
(diurnal fluctuation-in late evening and
lucid in morning)
>Attentional abnormalities
>Increased/decreased psychomotor
activity
>Disordered sleep–wake cycle
- Decrease in clarity of awareness of the
environment.
Fluctuation of
consciousness
-Occurs in:
>health- in sleep and fatigue
>Epilepsy: fluctuation in relation
to fits;occur before, during or
after the seizures
>Third-ventricle tumours with
variations in ICP
>Drugs like mescaline
- fluctuations of time sense seen
Confusion
- Subjective symptoms and
objective signs with loss of
capacity for clear and coherent
thought.
-Descriptive word-> disturbances
of thought ->the patient’s self-
experience or the doctor’s
observation
>Impaired consciousness in acute
organic states
>Thought process disruption d/t
brain damage in chronic organic
states
>Functional psychoses
>Powerful emotion in neurotic
disorders.
Related

18. Delirium
• Despite apparent unconsciousness, during partial states of
arousal->some memory functions and belief formation
present.
• Delirium is more of disturbance of the sleep-wake cycle than
disturbance of consciousness->the experience of delirium is
akin to dreaming->more in individuals with sleep
deprivation.

19. TWILIGHT STATE
• It is interruption of the continuity of consciousness.
• 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
• Consciousness impaired or relatively normal between episodes -
>associated with dream-like states, delusions or hallucinations.

20. • Forensic implications:
• Legal defence for violent behaviour for which the person had subsequent
amnesia.
• For that, it is important to demonstrate:
(a) the occurrence of similar episodes with inexplicable behaviour before
the key happening
(b) objective evidence of physical or mental illness.
The ganser state is a sort of twilight state in which the organic element is
often dubious.
• Associated with:
• Organic condition
• Epilepsy (the temporal lobe seizures)
• Alcoholism (mania à potu)
• Brain trauma
• General paresis
• Hysterical dissociation
• Acute reaction to massive catastrophe.

21. MANIA A POTU (Pathological intoxication)
• Type of twilight state associated with alcoholism.
• Distinguish this syndrome from delirium tremens, symptom of alcohol
withdrawal.
• Four components:
Consumption
of a variable
quantity of
alcohol
Senseless,
violent
behaviour
Prolonged sleep
Total or partial
amnesia for the
disturbed
behaviour

22. • Intoxication not always involved, so pathological
reaction to alcohol is the preferred term.
• Occurs in pt. with:
• Exhaustion
• Great strain
• Hypoglycaemia
• In people poorly defended against their own violent impulses

23. AUTOMATISM
• Action taking place in the absence of consciousness.
• It is:
• Involuntary behaviour over which pt. has no control. It is
inappropriate to the circumstances, and may be out of character
for the individual.
• Complex, co-ordinated, purposeful(continuing to dry the dishes)
and directed, though lacking in judgement.
• Pt. may have no recollection or partial and confused memory of
his actions.

24. • Behaviour during automatism is:
• Partly aware of being spoken to and does not reply appropriately
First-> activity is diminished, staring eyes and slumped posture
Becomes stereotyped, with repetitive movements, lip smacking, fumbling and
other actions
Finally, more complex purposeful behaviour like walking about, making irrelevant
utterances, removing clothing, etc.
Subsequent amnesia
• Some patients continue with whatever he was doing before, eg.- driving his car
• Violence is rare, mostly to resist restraint.

25. Epileptic automatism
• State of clouding of consciousness->occurs during or immediately
after seizure -> pt. retains:
• Posture control
• Muscle tone
• Performs simple or complex movements
• Actions without being aware of what is happening .
• Clinical part of psychomotor epilepsy -> d/t discharge in the temporal
lobes.
• Common in chronic epilepsy pts. ->resident in an epilepsy colony/
mental hospital.

26. • Aura
• First sign of an epileptic attack with temporal lobe automatism
• Manifested as:
• Abdominal sensations and in body esp. head
• Feelings of confusion with thinking
• Hallucinations or illusions (olfactory or gustatory)
• Motor abnormalities;
• Tonic contracture
• Masticatory movement
• Salivation or swallowing
• Speech automatism
• Utterance of identifiable words or phrases during the epileptic attack-
>patient has no memory later.

27. Dream-Like (Oneiroid) State
• Not clearly differentiated from twilight state or delirium.
• The patient is:
• Disorientated
• Confused
• Experiences elaborate hallucinations, usually visual (lilliputian)
• Impairment of consciousness
• Marked emotional change, terror or enjoyment of the
hallucinatory experiences; auditory(elementary commonly) or
tactile hallucinations.

28. • Patient can be fearful and misinterprets the behaviour of others as
threats. Eg.- Delirium tremens pt. said ‘Don’t hit me; please, don’t hit
me’ whenever anyone approached, although he had never been
subjected to assault.
• Living in a dream world and carry out the customary actions of this
trade; this is known as ‘occupational delirium’.
• Eg.- Bus conductor may ask other patients for their bus fares
• It is important to look for other symptoms or organic states to
differentiate between physical illness and a dissociative non-organic
condition.

29. Stupor
• It is a reduction in, or absence of, relational functions: that is, action
and speech’ (Berrios, 1996).
• It is distinct from coma, does not lie on a continuum from
wakefulness to coma.
• Occurs in:
• Syndrome in which mutism and akinesis; the inability to initiate speech or
action in a patient who appears awake and even alert.
• some degree of clouding of consciousness.
• The patient look ahead blankly or his eyes may wander, but he appears to
take nothing in.
• It is followed by subsequent amnesia.

30. • Seen in:
Organic stupor:
• Akinetic mutism- lesions in the area of the diencephalon and upper
brainstem, and frontal lobe and basal ganglia
• Locked-in syndrome-
• Lesion in motor pathways in the ventral pons
• Quadriplegia and anarthria
• Preserved consciousness
• Vertical eye movement
Functional stupor:
• Schizophrenia
• Affective psychoses (both depressive and manic)
• Dissociative states.

31. ATTENTION
• It is the active or passive focusing of consciousness on an experience
such as sensory inputs, motor programmes, memories or internal
representations.
• It enhances some information and inhibits others, allowing us to
select some information for further processing.
• This overlaps with alertness, awareness and responsiveness.
• Attention is a different function from consciousness, but it is
dependent on it.

32. Types of attention:
Voluntary/active :
when the subject focuses his
attention on an internal or
external event
Involuntary/passive :
when the event attracts the
subject’s attention without his
conscious effort.

33. • Components of attention include:
• Orientating to sensory events
• Detecting signals for focused processing
• Maintaining a vigilant and alert state
• Concentration
• It is one aspect of attention.
• It involves focused or selective attention.
• Serial sevens is employed to assess this.
• Automatic cognitive processes
• Occur without intention, are involuntary and do not interfere with other
ongoing activities and exist in parallel with those that require attentive
processes

34. • Digit span test
• Influenced by: fatigue, depression, brain
injury

35. ALTERATION OF THE DEGREE OF ATTENTION
• Attention is affected by an individual’s mind-set;
• in the absence of mental illness, is generally non-rigid and is altered in
response to incoming information.
• In the amnestic syndrome, thinking and observation are dominated by rigid
sets, so that perception and comprehension are affected by selective
attention.
• Impairment of focused attention and concentration denotes an
inability to exercise attention on an object in a purposeful way,
implying weakening of the determining tendency.
• feature of mania and hypomania
• organic states

36. • Distractibility
• It is disturbance of active attention such that the patient is diverted
by almost all new stimuli, and habituation to new stimuli takes
longer than usual.
• Occur in:
• Fatigue
• Anxiety- active attention made difficult by anxious preoccupations
• Severe depression
• Mania and hypomania
• Schizophrenia-
• Paranoid schizophrenia- result of a paranoid frame of mind.
• Acute schizophrenia- result of formal thought disorder because patient is unable to
keep the marginal thoughts (which are connected with external objects by
displacement, condensation and symbolism) out of their thinking, so that irrelevant
external objects are incorporated into their thinking.
• Organic states

37. • Decreased in:
Normally;
• Sleep
• Dreams
• Hypnotic states
• Fatigue
• Boredom
• Pathologically;
• Organic states(with lowering of consciousness):
• Head injury
• Acute toxic confusional states such as drug- and alcohol-induced conditions
• Epilepsy
• Raised intracranial pressure
• Brainstem lesions
• Psychogenic states
• Hysterical dissociation
• Hyperkinetic disorders in childhood and adult life

38. • Narrowing of attention:
• The ability of the subject to focus on a small part of the field of
awareness.
• Occurs in conditions in which involuntary attention is directed
elsewhere:
• By delusions
• By hallucinations
Eg.- In conversation schizophrenia pt, in which she repeatedly ignored
questions and said, ‘I wish you would not interrupt when I am being given
my instructions’
• By strong emotion- depressive illness-> morbid mood state results in
attention limited to a restricted themes – mostly unhappy.

39. ORIENTATION
• It is capacity of an individual to accurately gauge time, place and person in his
current setting.
• When consciousness is disturbed it tends to affect these three aspects in that
order.
Orientation in time
• requires an individual should maintain a continuous awareness of what goes on
around them and be able to recognise the significance of those events that mark
the passage of time.
• Labile.
• Easily disturbed by rapt concentration, strong emotion or organic brain factors
(alcoholic intoxication).
• Milder degrees of disorientation: inaccuracy of more than half an hour for the
time of day or duration of interview.
• In advanced states- incorrect day of the week, year or period of day, season of
the year is seen progressively.

40. Orientation for place
• It is retained more easily because the surroundings provide some
clues.
• disturbed later in the disease process than time.
• Disorientation in time and place are evidence of an organic mental
state; earliest signs in a dementing process.

41. Orientation for person
• It is lost with greatest difficulty because the persons themselves provide the
information that identifies them.
• The disoriented patient fails to remember his own name.
• occurs at a very late stage of organic deterioration.
• Loss of intellectual grasp (apprehension) occurs in organic states as a form of
disorientation.
• They cannot understand the context of their present situation and connects
outside objects and events with himself.
• Disorientation occur with disturbance of:
• consciousness
• Attention
• Perception
• intelligence
• In severe intellectual defect and severe disturbances of memory, orientation is
impaired but with clear consciousness.

42. Disorientation
• Orientation fluctuate in organic conditions
• Eg.- acute toxic state pt. associated with congestive cardiac failure
disorientated in time every evening but quite clear mentally in the morning.
• Disorientation in time and loss of intellectual grasp (situational
disorientation) usually occur first in a progressive illness;
disorientation in place occurs later and, in person, is last.

43. Delusions that Mimic Disorientation
• Disorientation is usually associated with other organic features, such
as lowering of consciousness or disturbance of memory.
• Delusions of misorientation have the features of a delusion-
• Eg.-a person on the ward may believe himself to be in prison

44. Dissociation and Disorientation
• Definite, undisputed disorientation is indicative of acute organic brain
syndrome, if coupled with lowering of consciousness, or chronic
organic deterioration.
• Hysterical dissociation may mimic this but with apparent
disorientation.
• Although apparently disorientated, he actually showed an
abnormality of memory as part of a dissociative.

45. Thank You