Disorder of Consciousness

What is a Mental Disorder?

In psychiatry, consciousness is defined as the ability to concentrate and orientate in oneself, time and one’s own personality (I). Quantitative and qualitative disorders of consciousness are distinguished. Quantitative disorders: stunning, stupor and coma. Qualitative disorders: delirium, onyroid, amentia, twilight disorders of consciousness, ambulatory automatism, fugue and trance, double orientation. Special states of consciousness include psychosensory disorders against the background of a narrowing of consciousness. Exceptional states of consciousness: pathological intoxication, pathological affect, special ethnic changes in consciousness (amok, low, koro, etc.). Multiple consciousness is also distinguished in case of multiple personality disorder.

Background, norm and evolution

Consciousness in the 19th century was defined as a combination of knowledge and experience (consciousness – aggregate knowledge). However, Heraclitus argued that consciousness should be associated with a turbulent river, along which a person floats, and when he emerges, he can fix what is happening on the shore, but after a while he falls back into the water, and then the shore does not exists. S.S. Korsakov believed that consciousness contains an active side – the attitude of the I to the outside world. Currently, there are up to 200 definitions of consciousness, and therefore we can only talk about its models.

Psychologists believe that consciousness is a picture of the World that manifests itself in our experiences. Models of consciousness in different cultures and at different times are different. Therefore, the consciousness of the past can be reconstructed through all the symbols of culture. The founder of experimental psychology W. James points out that from a pedagogical point of view, consciousness is built from association, integration and bias, but he reflects on consciousness in the style of Heraclitus.

The primary concrete fact that belongs to the inner experience is the belief that conscious processes take place in this experience. States of consciousness are replaced in it one after another. Just as we express impersonally: “it grows light”, “it gets dark”, we can characterize this fact best of all with the impersonal verb “think”.

Consciousness, according to W. James has 4 properties:

  1. Each state of consciousness seeks to be part of personal consciousness.
  2. Within the boundaries of personal consciousness, his states are variable.
  3. Every personal consciousness represents a continuous sequence of sensations.
  4. “It readily accepts some objects, rejects others and, in general, all the time makes a choice between them.”

K. Marx believed that consciousness is “my attitude to my activity”, emphasizing that all consciousness is derived from activity. Such was the point of view of most Soviet activity psychologists. In this definition, the existence of the I is important – relationships and actions, therefore the “inactive” does not reveal its consciousness. L.S. Vygotsky wrote that all mental functions are mediated through tools and signs, his view of the problem of consciousness, from the point of view of A.N. Leont’ev, was to evaluate this function as a systemic and semantic, moreover, as a function developing in the history of culture.

The development of consciousness takes place in ontogenesis and the history of culture, and consciousness can be studied from the indirect data of objective culture and signs, like psychological tools.

In “General Psychopathology” K. Jaspers argued that “consciousness is a scene through which individual psychic phenomena pass, now stronger, then weaker than illuminated by a spotlight of attention.”

From this it is clear that consciousness exists due to concentration of attention, and it is clear that if a spotlight with the same intensity of light concentrates on one object (narrowed consciousness), all boundary psychic phenomena appear in darkness, if it is wide – a lot of psychic phenomena are noticeable, but they are in the zone of distracted attention. K. Jaspers has consciousness, firstly, the actual experience of mental life, secondly, the dichotomy of the subject and object, thirdly, knowledge of one’s own conscious self.

In the 30s and 40s of the 20th century, psychiatrists believe that consciousness exists in an integrated form, which is ensured by a synthesis of experiences and in a state of disintegration, an example of which is sleep, hypnosis, meditation (alternating consciousness). Awakening is reintegration, and pathology is pathological integration, this is the invasion of sleep into reality. Perhaps earlier such an “invasion” was normative, since many peoples have an idea of ​​the exceptional value of sleep information and the belief that it is dream that is real life, and reality is actually insignificant, such, in particular, representations of Australian Aborigines .

S.S. Korsakov believed that changing internal mental processes have a subjective and some “at least to a minimum degree sign of consciousness”. K. Conrad writes about consciousness as a “changing field of experience”, but he denies the objective connotation in consciousness. V.A. Gilyarovsky is confident that consciousness contains the subjective and objective sides. The subjective side – “the inner insight of emotional experiences, self-penetration, so to speak, internal transparency”, objectively – these are properties that appear in the mental pattern as a series of “inhibited reflexes”. For E. Kretschmer, consciousness is a “spherical order” phenomenon that includes almost all areas of the psyche.

S. Freud, approaching all mental phenomena from the perspective of topography, dynamics, and economics, also applied to consciousness, which he accordingly understood structurally consisting of I, Ono, and Super-I. I and the Super-I arise in the ontogenesis of It.

C.G. Jung believes that individual consciousness is part of the collective unconscious, which is archetypal, that is, there are universal constructions of consciousness that are common for representatives of different nations. Such constructions embodied in myths (mythologies), according to C.G. Jung, exists 16. They are united by more general mythologies, such as the Self, Shadow, Anima, Animus.

E. Erikson believes that consciousness contains all the experienced levels of identity crises, and therefore a person can be in a structurally different consciousness at any given moment, depending on the identity path she has traveled.

K. Popper talks about the world of objective content of thoughts that exists, although it is the result of activity of thinking. The products of this world (books, theories) can be studied in isolation from ideas about how to create them. According to him, World III – the world of subjective ideas, consciousness and behavior – World II, the physical world – World I. There is some correspondence between the worlds, and the evolution in World III is somewhat similar to that in World II and I, for example, in all Worlds there is natural selection (of objects, ideas, behavior). L. Wittgenstein (1922) believes that consciousness should be considered the world given in language, that is, consciousness finds itself through symbols and signs, otherwise it simply does not exist.

From a biological point of view, all stages of phylogenesis from the consciousness of reptiles (brain stem) to the consciousness of birds, mammals (subcortical structures) and primates (cortex) are included in human consciousness. Orientation in ontogenesis develops in the following stages: orientation in place – orientation in time – orientation in one’s own personality (I). An indicator of the formation of self is an interest in one’s own body.

Symptoms of a Disorder of Consciousness

Separate quantitative and qualitative disorders of consciousness. Quantitative include stunning, stupor and coma. Qualitative ones include delirium, oneirroid, amentia, twilight disorders of consciousness, ambulatory automatism, fugue and trance, double orientation. Special states of consciousness include psychosensory disorders against the background of a narrowing of consciousness. Exceptional states of consciousness: pathological intoxication, pathological affect, special ethnic changes in consciousness (amok, low, koro, etc.). Multiple consciousness is also distinguished in case of multiple personality disorder, and second life syndromes, which are characterized by radical changes in the self without amnesia of the previous self.

Stunning (raush) is preceded by drowsiness (doubtfulness), in which the patient slowly answers questions, sometimes with half-closed eyes, he is inhibited and sleepy. Actually, all the minimal symptoms of impaired consciousness are characteristic of stunning, that is, passivity of attention, blurred perception, weakening of memorization and memory, impaired understanding, decreased ability to make judgments and conclusions. Euphoria and fussiness are possible.

It is the state of this kind M.O. Gurevich called the disintegration of consciousness. Sometimes they resemble the processes of physiological falling asleep.

Sopor is a further violation of consciousness disorders. It is characterized by disorientation, grasping and proboscis movements, mumbling speech, uncoordinated movements. Pain sensitivity, pupillary, conjunctival and corneal reflexes are present.

Coma – complete shutdown of consciousness. It is characterized by muscle atony, areflexia, mydriasis with the absence of pupillary reactions. Quantitative disorders of consciousness relate to exogenous disorders and are noted in case of vascular disorders, severe intoxications, endocrine disorders, epilepsy (epileptic coma), after traumatic brain injuries and in the terminal stages of dying (vegetative coma). An assessment of the severity of brain damage using a coma scale is given in the Appendix.

The exit from a coma is often characterized by the so-called out-of-body experiences, which resemble dreamlike (oneiric states).

Delirium (delirious syndrome) is characterized by a disorientation of orientation in place and time while maintaining orientation in one’s own personality, an influx of terrifying visual, less often auditory hallucinations, and fear. Hallucinations are often zooptic (animals, especially reptiles, devils). Patient behavior is determined by the content of hallucinatory images. After exiting delirium, amnesia is absent. It occurs with organic disorders and intoxications, is considered an exogenous syndrome.

Amentia (amentia syndrome) is characterized by complete disorientation, incoherence of speech (thinking), sweeping movements and partial or complete amnesia after leaving amentia. With the transition of delirium to amenia, one of the first symptoms is a mumble and sweeping movements (mussitic delirium). It occurs with organic disorders and intoxications, also refers to exogenous syndromes.

Twilight disorders are characterized by a narrowing of consciousness with an influx of visual hallucinations, often colored in yellow and red (erythropsia) and partial or complete amnesia after exiting twilight. More common in epilepsy.

Oneyroid (oneiric syndrome) – a disorder of consciousness with complete disorientation, an influx of cosmic or apocalyptic visual hallucinations, exit from the neuroid without amnesia. It is characteristic of catatonic schizophrenia, sometimes it occurs with intoxication with psychoactive substances and epilepsy. It is considered mainly an endogenous syndrome.

Outpatient automatism is characterized by a shutdown of consciousness with automatic actions and amnesia. If such actions are accompanied by excitement, but last up to several seconds (jogging, slamming the door), they talk about fugue, if for a long time (several days), they talk about trance. Meet with epilepsy.

A double orientation is characteristic of delirium, for example delirium of greatness, when the patient calls himself both a significant personality and his name, or in the delirium of staging, claims that although he is in this place, he still considers it not genuine, staged.

Special states of consciousness include psychosensory disorders in the form of derealization, depersonalization against the background of a narrowing of consciousness.

Exceptional states of consciousness include pathological intoxication and pathological affect. Pathological intoxication – a narrowed state of consciousness, noted when drinking a minimum dose of alcohol, aggression or other unmotivated acts with subsequent amnesia.

Pathological affect is an inadequate strong reaction to insult, humiliation, loss with constricted consciousness, aggression, auto-aggression. Special ethnic changes in consciousness (Amok, Low, Mirriri) also relate to pathological affect. According to the description of ethnographers, the Indian custom of self-immolation of widows after the death of a spouse was often associated precisely with an affective narrowing of consciousness.

Multiple consciousness is also distinguished in case of a multi-personality disorder, which is characterized by the transition of the personality to another personality with other habits, behavior, name and amnesia of the previous personality.

Diagnosis of Consciousness Disorder

The psychiatric model of consciousness is quite simple – it equates consciousness with orientation in itself, time and space. Orientation in itself includes self-awareness, bodily, interpersonal (interpersonal) and projected elements, time orientation is purely calendar in nature, and spatial orientation is formally territorial. A person must say who he is, with whom he communicates, he must name the current date and place. If he does this approximately, they speak of a constricted consciousness. If you can’t name something correctly, they talk about disorientation. To determine the features of attention, it is important to establish the degree of passivity of attention, the clarity of perception (the patient looks closely or listens, interrogates), the degree of weakening of memorization and memory, impaired understanding, decreased ability to make judgments and conclusions. In speech with minimal disturbances of consciousness, one can identify repetitions (perseverations), repetitions of a question (echolalia), an increase in the distance between words, an increase in the number of words such as “yes”, “here”, “well”, and under-finishing of word endings.