DISORDERS OF CONSCIOUSNESS

 Consciousness: a state of awareness of the self & the environment

 In the fully awake subject, the intensity of consciousness varies considerably
 Attention
1. Active: when the subject focuses their attention on some internal or external event
2. Passive: when the same events attract the subject’s attention without any conscious
effort on their part.
 Distractibility: disturbance of active attention

Can occur in:

- Fatigue, anxiety, severe depression, mania, schizophrenia and organic states.

- Abnormal and morbid anxiety anxious preoccupations distractibility
- Organic and paranoid schizophrenia states paranoid frame of mind distractibility
- Acute schizophrenia formal thought disorder distractibility (the 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
objects are incorporated into their thinking.
- Amnestic syndrome rigid mind sets selective attention
 Disorders of consciousness are associated with disorders of perception, attention,
attitudes, thinking, registration and orientation.
 The patients with disturbance of consciousness usually show, a discrepancy between the
grasp of the environment and their social situations, personal appearance and occupation.
 This lack of comprehension in the absence of other florid symptoms of disordered
consciousness may lead to a mistaken diagnosis of dementia.
 Clinical test for disturbance of consciousness
- The date, the day of the week, the time of the day, the place, the duration of their stay
in that place, etc.
- Orientation test disoriented prima facie case that they have an organic disorder.
- Recent origin an acute organic state with disturbance of consciousness
- Exception: chronic schizophrenia who has been institutionalized on a long-term basis
(may also demonstrate significant disturbances of memory, including impairments of
working and semantic memory, which may also have a significant impact on social
functioning)
 Orientation is normally described in terms of time, place and person. When consciousness
is disturbed, it tends to affect these 3 aspects in that order.

 Consciousness can be changed in 3 basic ways:

1. Dream-like change:
 Some lowering of level of consciousness, which is the subjective experience of a rise in
the threshold for all incoming stimuli.
 The patient is disoriented for time and place, but not for person.
 Disordered thinking: excessive displacement, condensation and misuse of symbols.
 Visual hallucinations:
- Outstanding feature: presence of visual hallucinations, usually of small animals and
associated with fear or even terror;
- the patient is unable to distinguish between their mental images and perceptions, so
that their mental images acquire the value of perceptions.
- Occasionally, Lilliputian hallucinations also occur and are associated with feelings of
pleasure.
 Auditory hallucinations:
- Elementary A.H. are common
- Continuous voices: rare
- Organized A.H.: take the form of odd disconnected words or phrases
- Rarely hallucinatory voices occur in association with a dream-like change in
consciousness, and if they do, the change of consciousness and the visual
hallucinations often disappear in a few days, leaving behind an organic hallucinosis
with little or no change in consciousness.
 Other hallucinations:
- Of touch, pain, electric feeling, muscle sense and vestibular sensations often occur.
 Acute delirium:
- Outstanding feature: dream-like change of consciousness
- The patient is fearful and often misinterprets the behaviour of others as threats.
- Occupational delirium: the patient is often is restless and may carry out the
customary actions of his trade.
2. Lowering of consciousness
 General lowering of consciousness without hallucinations, illusions, delusions and
restlessness.
 The patient is apathetic, generally slowed down, unable to express themselves clearly and
may perseverate.
 Term designated ‘torpor’.
 The state was very often the result of severe infections like typhoid and typhus
 Presently, more commonly seen in the context of arteriosclerotic cerebral disease
following a cerebrovascular accident
3. Restriction of consciousness
 Awareness is narrowed down to a few ideas and attitude that dominate the patient’s mind
 Some lowering of level of consciousness
 Disorientation for time and place occurs
 Twilight state:
- A restriction of the morbidly changed consciousness, a break in the continuity of
consciousness and relatively well-ordered behaviour.
- Commonest T.S. is the result of epilepsy
- Non-epileptic twilight states with convulsive manifestations can occur following a
febrile seizure.
- Any condition with real or apparent restriction of consciousness
 Simple T.S.
 Hallucinatory T.S.
 Perplexed T.S.
 Excited T.S.
 Expansive T.S.
 Psychomotor T.S.
 Oriented T.S.
- ICD-10: includes T.S. under the heading dissociative disorders and when criteria for
organic etiology are met, organic mental disorders
- Hysterical T.S.: restriction of consciousness resulting from unconscious motives.
 Severe anxiety: the patient may be so preoccupied by their conflicts that they
aren’t fully aware of their environment and find that they have a hazy idea of
what has happened in the past hour or so. This may suggest to the patient that
amnesia is a solution to their problems, so that they ‘forget’ their personal
 identity and the whole of their past as a temporary solution for their
difficulties.
- Fugue:
 Wandering states with some loss of memory
 Not all fugues are hysterical
 Hysterical fugue: 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.
 Fugue states may have variable duration, with some fugue states persisting for
extremely long periods of time.
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