Lecture #5
DISORDERS OF CONSCIOUSNESS

Disorders of consciousness occur not only in mental patients. Can be, for example, with infections in children.

"Delirium tremens" - develops in every 20th patient with alcoholism. Impaired consciousness can be in drug addicts and substance abusers.

Classification of disorders of consciousness:

1. Disabled consciousness syndrome. The following stages are distinguished:

   - obnubilation,

   - coma - consciousness is absent.

2. Syndromes of darkened consciousness - consciousness is preserved, but in a new capacity - patients behave unusually. Then they do not remember or remember poorly what happened to them at the time of the clouding of the event. Experiences are vivid, outwardly incomprehensible.

Criteria of a clouded consciousness(according to K. Jaspers):

a) detachment from the real world

b) disorientation

c) amnesia - specific for each variant.

Jaspers described the staging of the development of delirium.

There are 4 main types of clouding of consciousness:

• delirious stupefaction - most often;
• oneiroid clouding of consciousness;
• amental clouding of consciousness;
• twilight clouding of consciousness.

Delirium- non-specific reaction of the psyche to the fact of intoxication. In most cases, delirium is of alcoholic origin. Acetaldehyde intoxication leads to meth-alcohol psychoses.

Delirium is one of the many alcoholic psychoses. It develops only at 2 or 3 stages of alcoholism. There are many symptoms.

"Delirium tremens" is preceded by alcohol withdrawal syndrome. According to WHO, alcohol withdrawal syndrome is a combination of somatovegetative neurological and psychopathological syndromes that occur with sudden deprivation of alcohol, and all these manifestations reduce their severity and intensity with the addition of new doses of alcohol. Abstinence is preceded by a binge, usually a true binge (5-7 days), after which the intake of alcohol suddenly stops, which leads to the appearance of symptoms.

Psychopathological manifestations of alcohol withdrawal syndrome:

a) sleep disturbances;

b) irritability;

c) anxiety, restlessness (possibly subdepressive mood);

d) rudimentary deceptive perception (phonemes, photopsies, phosphenes).

Neurological manifestations of alcohol withdrawal syndrome:

a) static and dynamic ataxia (violations of coordinating tests, instability in the Romberg position);

b) convulsive paroxysms are possible;

c) tremor (isolated or generalized).

Somatovegetative manifestations of alcohol withdrawal syndrome:

a) abdominal pain;

b) nausea, vomiting;

c) stool disorders;

d) lack of appetite;

e) cardialgia;

f) arterial hypertension (rarely hypotension);

g) tachycardia;

h) tachypnea;

i) increased body temperature (sometimes significant hyperthermia), especially in combination with infection;

j) hyperhidrosis;

k) the tongue is covered with a gray coating.

Of these 3 groups of symptoms, psychopathological gradually come to the fore, others fade into the background. For 2-3 days after the deprivation of alcohol, delirium develops closer to the night.

Clinical manifestations of delirium:

The patient lies fixed in bed, but tries to get up, the patient is unshaven, unwashed, "vegetative", the tongue is covered with a brown coating, there are perception disorders (microoptic zoophilic extracampal hallucinations), thinking disorders. The patient's behavior is determined by powerful hallucinatory experiences. The patient is oriented in his own personality, place, time. Disorders of perception are manifested by true hallucinations, all images with a negative connotation (devils, mice, rats, cockroaches). The emotional reaction of the patient is of great importance for the correct diagnosis. The patient actively defends himself, defends himself from hallucinatory images. By morning, the delirium is weakened - "lucid window" - a decrease in the severity of symptoms. Sometimes a non-lucid course of delirium is a less favorable option.

In the treatment of patients with delirium, it is important to achieve sleep, which will be the way out of delirium. For 2-3 months after leaving delirium - asthenic condition.

Keywords: psychiatry, lecture, consciousness, disorders of consciousness, delirium, oneiroid, loss of consciousness, clouding of consciousness, alcoholic delirium, alcohol withdrawal syndrome

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Voronezh State Medical Academy named after V.I. N. N. Burdenko

Department of Psychiatry with Narcology

SYNDROMES OF DISTURBED CONSCIOUSNESS

Voronezh 2004

1. Introduction

Consciousness is the highest form of reflection of objective reality, providing a link of knowledge for a systematic, naturally directed vigorous activity. Consciousness is inherent only to man and arose in the process of the historical development of social life and active labor activity of people. It is thanks to consciousness that we have the opportunity to navigate the environment, plan any activity, understand its goals and predict the final result.

The main characteristics of consciousness are considered to be the degree of its clarity (level of wakefulness), volume (breadth of coverage of the phenomena of the surrounding world and one's own experiences), content (completeness, adequacy and criticality of the assessment of the used stocks of memory, thinking, emotional attitude) and continuity (the ability to realize and evaluate the past, present and future). One of the most important components of conscious (conscious) and purposeful (volitional) activity is attention - the ability of conscious, voluntary or involuntary selective focusing of sensory, intellectual and motor activity on actual and individually significant external and internal phenomena.

Clarity of consciousness presupposes the correctness of the reflection of reality not in separate mental spheres (in perception, thinking, etc.), but in a generalized way, in a holistic mental act. That is why such mental disorders as hallucinations, delusions, obsessions, etc., are not formally classified as the pathology of objective consciousness, although they contain elements of disturbed consciousness.

Not only for a psychiatrist, but also for a general practitioner, it is very important to be able to identify violations of consciousness and properly organize therapeutic measures. Syndromes of disturbed consciousness indicate a severe impairment of mental activity, which can be caused not only by the actual mental, but also by somatic pathology (infections, intoxication, brain tumors, etc.).

Clinical task:

Patient Yu., 15 years old, student of the 9th grade. Transferred to a psychiatric clinic from a therapeutic hospital where she was being treated for severe follicular angina. For 3 days she hardly slept, complained of severe weakness, headache. The mood was changeable - sometimes unreasonably anxious, sometimes unusually upbeat. The last night in the therapeutic hospital was restless. The girl did not sleep, she felt fear, it seemed as if multi-colored spirals were coming from an electric light bulb, "screwing into her head." But in the dark, the fear was even more intensified. It seemed that vague threatening voices were heard outside the door, the door was being broken down, behind it one could see the flickering of lanterns, a crowd of people. Terrified, the girl jumped out of bed, tried to open the window and jump out into the street. By morning, under the influence of neuroleptic and hypnotic drugs administered, the patient fell asleep. After sleep, she felt overwhelmed, most of what she experienced during the night was preserved in the girl's memory. Questions for the task:

What causes the described mental disorders?

3. What therapeutic tactics would be appropriate to choose in this case?

The correct answers to the questions posed can be given on condition of knowledge of the basics of general psychopathology, its section "Syndromes of disturbed consciousness".

Lesson objectives:

be able to identify and correctly diagnose syndromes of disturbed consciousness;

master the tactics of helping patients with impaired consciousness syndromes.

To achieve this goal, it is necessary to solve the following tasks:

1) be able to identify the state of disturbed consciousness by the method of clinical targeted questioning and visual observation, also using data from the anamnesis of life and illness;

be able to qualify syndromic forms of disturbed consciousness;

master the tactics of providing medical assistance to persons who show signs of an upset consciousness.

The purpose of self-training:

learn to identify and diagnose typical symptoms and syndromes of disturbed consciousness using model tasks;

be able to theoretically, according to the situations proposed in the tasks, correctly make decisions on the provision of medical care and the implementation of measures that prevent socially dangerous actions.

2. Clinical manifestations

The clinical manifestations of disturbed consciousness are diverse, however, they all have common permanent signs. Only their joint presence makes the diagnosis of disturbed consciousness justified. These signs are called the criteria for disturbed consciousness (K. Jaspers, 1911).

Detachment from the environment. It is characterized by difficulty, fragmentation or complete impossibility of perception of the surrounding reality.

Disorientation. Violation of orientation in time, place, situation, surrounding persons, own personality.

Violation of thinking. Weakness or impossibility of judgment, insufficient understanding of the environment, incoherent thinking or the presence of delusional ideas.

Amnesia. Complete or partial loss from the memory of the events of the period of upset consciousness.

2.1 Syndromes of turning off consciousness

Syndromes of turning off consciousness (unproductive, non-psychotic forms of disturbed consciousness) are characterized by a decrease, up to complete disappearance, of the clarity of consciousness and the impoverishment of all types of mental activity.

Stun

It is characterized by an increase in the threshold to all stimuli, impoverishment of mental activity, motor inhibition, difficulty in associative processes. Stunning can be defined as a state in which the outside becomes the inside with difficulty, and the inside becomes the outside.

The patient is inactive, aspontanic, spends most of the time in bed, lying in a monotonous position. He is indifferent to the environment, his attention is drawn with difficulty, answers only simple questions asked in a loud voice, often after repeated repetition. The patient's answers are monosyllabic (olkgophasia), with significant latent periods (bradyphrenia), but always adequate. The voice is quiet, without modulations, the face is amimic. In the emotional sphere, indifference dominates, less often complacency. There is no critical assessment of one's condition. In his own personality, the patient is fully oriented, in the environment - “in general terms”.

After exiting the stun, partial amnesia is observed. Memories are fragmentary, poor, inconsistent. For example, the patient remembers that he was in the hospital, doctors and relatives came to him, but he does not remember what exactly they said, what diagnostic manipulations he underwent.

Obnubilation - (cloudy consciousness) - a mild form of stunning, characterized by alternating periods of impaired consciousness (clouding) and enlightenment, often in combination with euphoric affect and anosognosia. Attention is unstable, associations are superficial

Somnolence - (pathological drowsiness) - a deeper degree of stunning. Manifested by long periods of complete lack of contact with reality. It is possible to get the patient out of this state, but by means of an intense urge to verbal contact and for a short time, the patient, left to himself, "falls asleep" again. It should be remembered that, in some cases, "awakening" may result in acute psychomotor agitation with aggression (a variant of twilight stupefaction).

A more complete shutdown of consciousness than stun. Characterized by turning off the first signal system. In view of this, patients are completely inaccessible to verbal contact, and react only to strong stimuli (pain) with undifferentiated protective motor reactions. The patient is completely immobile. Corneal, conjunctival, gag, pupillary reflexes are preserved. Pathological reflexes may be noted. Upon exiting the stupor, complete amnesia is observed.

Complete shutdown of consciousness, lack of response to any stimuli. There are no pupillary and other reflexes, bulbar and pelvic disorders are observed. The activity of the vasomotor and respiratory centers is preserved. As the coma deepens, pathological forms of breathing occur, cardiac activity is disturbed, then death occurs.

Vegetative status - (apallic syndrome) - a state of relative stabilization of viscero-vegetative functions, starting after a coma with the first opening of the eyes, the possibility of wakefulness and ending with the first attempt to fix the gaze.

Unproductive forms of impaired consciousness are found in intoxications, metabolic disorders, traumatic brain injuries, brain tumors, vascular, and other organic diseases of the central nervous system. Switching off consciousness reflects the severity of the underlying disease and is a prognostically unfavorable sign.

2.2 Syndromes of obscuration of consciousness

Syndromes of confusion (productive, psychotic forms of disturbed consciousness), in addition to the presence of 4 signs of disturbed consciousness according to K. Jaspers, are characterized by the presence of productive psychopathological symptoms in the form of hallucinations, secondary delusions, affective disorders, inappropriate behavior and disorganized / pi mental activity in general .

Oneiroid

Oneiroid - dream-delusional, dream-like stupefaction. The development of oneiroid is usually preceded by a stage of affective-delusional disorders, which is characterized by non-specificity, polymorphism and variability of symptoms with intact consciousness.

Stage of affective-delusional disorders. Against the background of sleep disorders and various general somatic disorders, affective disorders are growing, manifested by manic states with a feeling of penetration and insight, or depressions with anxious depression and sensitivity. A diffuse delusional mood appears, the statements of patients (ideas of relationship, persecution, inferiority or overestimation of one's qualities, unusual abilities) are unstable and are in the nature of overvalued ideas and delusional doubts. There are massive depersonalization-derealization disorders, with a feeling of change in one's own mental and physical processes, a feeling of strangeness and unreality of the environment. The perception of time is disturbed, its course can be perceived by patients as extremely accelerated, intermittent, slowed down or stopped. These experiences are accompanied by an increase in polar fluctuations of affect (anxiety and exaltation reach a significant degree of severity) and the development of delusions of staging, special significance, intermetamorphosis, twins. Patients begin to claim that there is filming going on around or some kind of performance is being played out in which everyone has certain roles. Everything seems to be specially arranged, full of special meaning, which the patient guesses in other people's words, deeds, furnishings, real events acquire a symbolic meaning. There is a feeling of constant variability of the environment, objects sometimes disappear, then, as if by magic, reappear, people's faces are constantly changing, the same person takes on different looks (Fregoli's symptom), the patient recognizes his relatives in strangers, and considers his relatives to be figureheads ( Katra syndrome). The patient claims that the true essence of things has become available to him, that he is able to read thoughts, predict events or influence them in any way, he experiences extraneous influence on himself. Thus, the clinical picture becomes more complicated due to the appearance of illusions, pseudohallucinations, automatisms, after which antagonistic (Manichaean) delirium develops. Patients become the center of the struggle between the opposing forces of good and evil, the environment becomes the arena of this struggle, and people become its participants. Such a confrontation can be carried out outside the receptive field of the patient, but he has the "authority" to influence the course of historical events, the greatest achievements. The delusional plot acquires megalomaniac content: expansive (delusions of grandeur, messianism) or depressive (delusions of Kotard). Then a retrospective (confabulatory) delirium appears and the symptoms approach the paraphrenic syndrome.

The patient's behavior at the initial stages is due to the existing affective and delusional disorders. Gradually, it loses connection with the content of experiences, and then becomes formally ordered, however, the patient’s peculiar “enchantment” can betray the richness of inner experiences. Periodically, there are episodes of situationally conditioned delusional behavior, when the patient refuses to communicate with "made-up" relatives, resists a "staged" medical examination, and does not answer the questions of the "investigator" in the doctor's office.

Stage of development of the oriented oneiroid. At a certain moment, against the background of the described disorders, the patient develops a tendency to involuntary fantasizing, vivid dream-like representations, in which, thanks to a pathologically enhanced game of imagination, all past experience is processed in a bizarre way, not only personally experienced, but also borrowed from books and films. Any external impression or bodily sensation is easily included in the content of these fantasies, receiving a symbolic interpretation. At this stage, the phenomenon of "double orientation" appears.

The patient, as it were, simultaneously exists in two situations - real and fantastic, along with the correct orientation in his personality and place, he creates a delusional idea of ​​\u200b\u200bthe environment and his position in it. The environment is perceived as a historical past, an unusual situation of the present, or as a scene of fabulous and fantastic content, the surrounding faces turn into active characters of these unusual events. The patient may be fully aware that he is in a hospital and at the same time consider the medical staff as the crew of the spaceship, the patients as passengers, and himself as a starfleet admiral. Thus, there is a visualization of the products of the imagination, which the patient at first has the ability to control, but then the influx of images arises against his will.

The behavior of patients takes distinct catatonic features. In the ward, such patients may be almost invisible, or they may attract attention with ridiculous excitement and incoherent speech. They stereotypically and pretentiously perform religious and ritual actions, recite verses in a mannered manner, and freeze in sculptural and monumental poses. The phenomena of wax flexibility, negativism, echolalia, echopraxia, impulsive actions are episodically determined. Speech is rich in neologisms, thinking is resonant, sometimes broken. The face is mask-like or paramimic, it has an expression of mystical penetration, ecstasy, or seriousness, inadequate to statements. Contact is unproductive, it can be quite difficult to reveal the content of experiences.

The stage of development of a true oneiroid. It is characterized by a complete loss of contact with the surrounding reality, allo- and autopsychic disorientation. Involuntarily arising ideas take on the character of visual pseudo-hallucinations. The patient is captured by the contemplation of fantastic panoramas, scenes of grandiose events in which he himself occupies a central position, acts as an active character. At the same time, he, as it were, reincarnates into the heroes of unusual incidents, into the “world mind”, into animals, completely identifying himself with them, both on the mental and physical levels. In his painful experiences, he travels in time, the whole world history, pictures of the ancient world and the distant future flash before his “inner eye”. The patient visits distant planets, ancient civilizations, the underworld or other dimensions. He meets with their inhabitants, is at enmity with them or receives sacred knowledge from them. Some patients, being in oneiroid stupefaction, believe that they come into contact with representatives of extraterrestrial civilizations, are abducted by them, get on their aircraft, where they are subjected to experiments and research. Other patients see themselves traveling to distant or non-existent cities and galaxies, fighting future or past wars. Or they carry out social reforms, prevent world cataclysms, are participants in unprecedented experiments, explore the structure of the universe, unusual life forms, and themselves transform into fantastic creatures.

Despite the bizarre combinations, mergers, reincarnations observed in oneiroid, the incompleteness of individual images, visions are distinguished by extraordinary brightness, affective richness and sensual authenticity. Moreover, the events experienced are united by a common storyline. Each subsequent situation is meaningfully related to the previous one, i.e. the action unfolds dramatically. The patient can be (successively or simultaneously) a spectator, a main character, a victim or a perpetrator of the unfolding drama. According to the peculiarities of affect, expansive and depressive oneiroid are distinguished. In one case, the patient sees scenes of extraordinary beauty, experiences a sense of his exceptional significance, spiritual comfort and ecstatic inspiration. In the opposite situation, he witnesses the death of the world, the devastation of the planet, its crushing into fragments; experiences horror, despair, blames himself for what is happening (nonsense of evil power).

Catatonic disorders reach a significant degree of severity. The dissociation between the patient's behavior (stupor with waxy flexibility or bewildered pathetic excitement) and the content of painful experiences in which the patient himself is an active participant, acting on a planetary scale, deepens even more, verbal communication with patients is not possible. Vegetovisceral disorders are maximally expressed. In the case of febrile schizophrenia, the somatic condition becomes life-threatening, and the clinical picture approaches the amental syndrome.

The duration of the stage of affective-delusional disorders can reach several months. Oneiroid continues for days, weeks. Against the background of a true oneiroid, periods of double orientation are possible. The reduction of symptoms occurs in the reverse order of their appearance. Patients reproduce the content of psychopathological disorders in sufficient detail, the surrounding events, starting from the stage of oriented oneroid, are largely amnesiac, and for the period of clouded consciousness there is a complete amnesia of real events.

Depending on the predominance of certain leading symptoms in the clinical picture of oneiroid, the following forms are distinguished.

Affectivio-oneproid form. It is characterized by the predominance of outlined polar affective states throughout the psychosis. The content of delirium correlates with the pole of affect, catatonic symptoms are not pronounced.

Oneproid-delusional form. The largest share belongs to sensual figurative delirium and mental automatisms. This form has the longest duration with a gradual and slow complication of psychopathological symptoms.

Catatonic-oieirid form. It is distinguished by acute development, severity of vegetative-visceral disorders, early onset, syndromic completion and significant expressiveness of catatonic phenomena.

Oneiroid clouding of consciousness is the culmination in the development of an attack of schizophrenia, often observed with intoxication with cannabinoids, volatile organic solvents. Oneiroid is much less common in epilepsy, vascular diseases of the brain, in the structure of meth-alcohol psychoses and other mental disorders of exogenous organic origin.

The staging and symptomatology of oneiroid that occurs in schizophrenia does not occur in any other disease. Oneiroid-like states in symptomatic and organic mental disorders are characterized by faster development and short-term course, syndromic incompleteness, and outcome. In the initial period, psychopathological disorders reflect the characteristics of the corresponding nosological forms, the content of experiences is relatively primitive, devoid of megalomania and a single plot. Less pronounced or absent autopsychic disorientation, such as the patient traveling to exotic countries in a hospital gown. States of inhibition and excitation are devoid of catatonic features. The duration of such a oneiroid ranges from several minutes to several days, its reduction often occurs critically. After the restoration of consciousness, asthenia and psychopathological phenomena characteristic of organic brain damage are observed. Memories of the content of experiences are usually poor and fragmentary.

Delirium is an illusory-hallucinatory clouding of consciousness. Perceptual disturbances are the main psychopathological phenomenon in the structure of this syndrome and determine the delusional plot and the behavior of the patient. Delirious stupefaction develops, as a rule, in the evening and at night, and in its development it goes through a number of stages, which are conveniently considered using the example of alcoholic delirium.

In the first stage of delirium (the initial stage), against the background of asthenia and hyperesthesia, general anxiety, mood swings, and sleep disturbances increase. Patients experience increased fatigue, the bed seems uncomfortable to them, the light is too bright, and ordinary sounds are unbearably loud. Attention is easily distracted by external, insignificant events (the phenomenon of hypermetamorphosis). Patients are fussy, talkative, inconsistency in statements is noticeable. There are influxes of vivid figurative representations and memories (oneirgai). The mood is extremely changeable from touchingly good-natured, when patients demonstrate unmotivated optimism, to anxious and tense, with tearfulness, depression, and foreboding of trouble. There is always a peculiar irritability, capriciousness, resentment. Sleep superficial, with frequent awakenings, vivid nightmares that are confused with reality. In the morning, patients feel weak, claim that they did not sleep all night.

In the second stage (the stage of illusory disorders), the existing symptoms intensify even more. They are joined by elementary perceptual deceptions in the form of phonemes and acoasms - patients hear hails, doorbells, and various undifferentiated sounds. When trying to sleep, multiple kaleidoscopically changing hypnagogic hallucinations appear. With open eyes, illusory disorders occur. When they are closed, the interrupted hallucinatory episode develops further. Pareidolic illusions are characteristic - the revival of planar patterns. In the game of chiaroscuro, in the patterns of the carpet, wallpaper, patients see bizarre pictures, fantastic images that disappear when the light is increased. When attracting attention, unlike ordinary illusions, the picture does not disappear, but rather is supplemented with details, sometimes completely absorbing the real object. The snakes that crawl across the floor, however, disappear at the edge of the carpet. The attitude of the sick to the visions is a combination of fear and curiosity.

The course of delirium is undulating. A peculiar flickering of symptoms, with short intervals of a decrease in the intensity of psychopathological disorders, occurs already in the second stage. Periodically (usually in the morning hours), lucid (light) intervals can be observed. At this time, there are no psychotic disorders, orientation in the environment appears and even a critical assessment of the state, however, there is a readiness for hallucination. The patient can be asked to talk on a previously turned off phone (Aschaffenburg's symptom) or asked to carefully examine a blank sheet of paper and ask what he sees there (Reichard's symptom). The occurrence of hallucinations in such ("provoking") situations allows you to correctly assess the patient's condition.

Prognostically unfavorable signs of the course of delirium are an increase in stunning in the daytime and the development, following the third stage, of professional or exaggerated delirium (these forms are conditionally combined into the fourth stage).

Occupational delirium is accompanied by monotonous motor excitation in the form of habitual (professional) actions. In this state, patients hammer non-existent nails with a non-existent hammer, drive a car, type text on a computer, carry out resuscitation, a drug addict makes himself an intravenous injection. Excitation is realized in a limited space. Voice contact is not possible. External impressions practically do not reach the consciousness of patients.

Mumbling (muttering) delirium is an even deeper degree of clouding of consciousness. Uncoordinated, stereotyped actions, choreoform and athetosis-like hyperkinesis predominate here. Patients make grasping movements in the air, shake off something, feel it, sort out the bed linen with their fingers - a symptom of "robbing" (corphology). Excitation occurs within the bed, accompanied by a quiet slurred pronunciation of individual sounds. Patients do not react at all to external stimuli, are not available for verbal contact. The gaze is cloudy, directed into space. The somatic condition becomes life threatening. Possible transition to a coma and death.

The duration of delirium varies, on average, from three to seven days. If the delirium breaks off in the first or second stages, they speak of abortive or hypnagogic delirium. If the delirium lasts more than a week, it is called prolonged delirium. The disappearance of disorders often occurs critically, after a long sleep, less often lytically. In the latter case, residual delirium may occur. With this variant of the outcome, the patients, formally evaluating the transferred state as painful, are convinced of the reality of some episodes, for example, scenes of adultery. After a few days, a sudden appearance of full criticism is possible. After leaving delirium, asthenia is always observed, affective disorders (subdepressive or hypomanic) are characteristic. In severe cases of delirium, it is possible to develop Korsakovsky and psychoorganic syndromes.

Amnesia for the period of delirious stupefaction is partial. Memories of the experienced state are fragmentary and refer to psychopathological disorders, while real life events are not stored in memory. In patients who have undergone occupational and extenuating delirium, complete amnesia is observed.

Delirium occurs in alcoholism, substance abuse, infectious and acute somatic diseases accompanied by severe intoxication, craniocerebral injuries, vascular lesions of the brain, senile dementia, temporal lobe epilepsy.

In children, infectious delirium is more common, in adults alcoholic, in old age delirium of atherosclerotic origin. It is interesting that the content of psychopathological disorders arising in delirium reflects, sometimes in a symbolic, condensed form, the actual conflicts of patients, their desires and fears. Naturally, the deeper the degree of clouding of consciousness, the less individual, personal in the symptoms. Depending on the etiological factors of the delirious syndrome, perceptual disorders and other psychopathological phenomena may have some features.

The greatest difficulty in the differential diagnostic respect is delirium with pseudohallucinations and mental automatisms. In such cases, most often we are talking about the debut of an endogenous procedural disease, provoked by exogenous harmfulness (intoxication), or about the coexistence of both diseases. With delirium due to intoxication with substances with anticholinergics. properties (atropine, cyclodol, amitriptyline, azaleptin, chlorpromazine, diphenhydramine), metamorphopsia and other sensory synthesis disorders are common. Hallucinations are characterized by objectivity, simplicity, indifference of the content for patients (wire, sawdust, threads, etc.), with cyclodol intoxication, a symptom of a disappearing cigarette is described: when the patient feels a cigarette sandwiched between his fingers, which “disappears” when trying to bring it to his mouth ( Pyatnitskaya I. N.). In case of carbon monoxide poisoning, olfactory hallucinations dominate, cocaine - tactile (sensation of crystals), tetraethyl lead - oropharyngeal (feeling of a hair in the oral cavity). For infectious delirium, the phenomena of somatopsychic depersonalization are characteristic, patients feel floating in the air, a state of weightlessness, the disappearance of the body, the presence of a double next to them. Often there are vestibular disorders: a sensation of rotation, falling, rocking. In conditions accompanied by dehydration, water appears in painful experiences. Traumatic delirium is accompanied by experiences of the circumstances of the injury (the environment of the battle). In the formation of hallucinatory-delusional experiences in somatic diseases, painful sensations in various organs play an important role (it seems to patients that they are dying in a fire, being tortured, etc.). For senile delirium (pseudodeliry), the characteristic features are: ".life in prosyum", false recognitions, increased responsiveness to what is happening around, fussy businesslikeness, a symptom of "gathering for the road" - tying bedding into knots by patients, wandering with them. Such conditions have a chronic course, intensifying at night. A similar clinical picture has delirium in vascular diseases of the brain, its specificity is determined by the severity of the alarming component and dependence on the state of cerebral hemodynamics. With delirious disorders that occur against the background of an acute violation of cerebral circulation, among other things, violations of the body scheme can be observed. A feature of delirium that occurs in old age is the severity of mnestic disorders and the age-related theme of delusional statements (ideas of material damage). Epileptic delirium is characterized by a special brightness and fantastic hallucinatory images. Visions are frightening in nature, often painted in red and black and blue tones. Hallucinatory images approach the patient, crowd him. He hears a deafening roar, smells a disgusting smell. Experiences of apocalyptic and religious-mystical content are characteristic. In the latter case, the hallucinations may be extraordinarily pleasant and accompanied by an ecstatic affect.

Twilight clouding of consciousness

This kind of clouding of consciousness is often called pathologically narrowed consciousness or twilight. Due to some characteristic features and a variety of clinical manifestations, this syndrome is most difficult to differentiate. Its most common features are: sudden onset and cessation (paroxysmal), the ability to externally purposeful behavior, complete amnesia of this period.

Disorientation can be expressed in varying degrees. Along with deep disorientation in the environment and one's own personality, there are states of orientation “in general terms”, with a significant restriction of access to external impressions, a narrowing of the circle of actual ideas, thoughts and motives. The perception of the environment can be distorted by existing productive disorders. Their presence can be judged from spontaneous statements and actions of patients who, in a state of twilight stupefaction, are detached and gloomy, more often silent, their spontaneous speech is limited to short phrases. Patients are inaccessible to verbal contact, although their behavior gives the impression of a meaningful, purposeful, it is completely due to the existing psychopathological disorders. It is dominated by bright (often visual) scene-like hallucinations of frightening content, figurative delirium with ideas of persecution, physical destruction, and false recognitions are frequent. Affective disorders are intense and characterized by tension (anguish, horror, rage). Violent psychomotor agitation is often observed. These features make these patients extremely dangerous for themselves and others. They can give the impression of people with intact consciousness and, at the same time, show cruel blind aggression, crush everything in their path, killing and maiming relatives and strangers. Quite often, patients commit sudden and terrifyingly senseless auto-aggressive actions. Less common are twilight states with religious and mystical experiences and ecstatic affect.

The presented picture of twilight clouding of consciousness refers to its psychotic form. The latter, depending on the predominance of certain psychopathological disorders, is very conditionally divided into the following options. The delusional variant is characterized by the greatest external orderliness of behavior, in view of which, the aggressive actions committed are distinguished by a special suddenness and, accordingly, rigidity. The hallucinatory variant is accompanied by chaotic excitement with brutal aggression, an abundance of unusually vivid hallucinations of extremely unpleasant content. Oriented twilight stupefaction usually occurs at the height of dysphoria, when the growing tension with a melancholy-malicious affect receives a discharge in outwardly poorly motivated destructive acts, the memories of which the patient does not retain.

In the case of not so gross behavioral disorders, they speak of a non-psychotic (simple) form of twilight clouding of consciousness, implying the absence of hallucinations, delusions, and affective disorders. This point of view is not shared by all psychiatrists. Sudden suspiciousness, turning to a non-existent interlocutor, or the commission of especially ridiculous acts by the patient suggests the role of hallucinatory-delusional experiences in the origin of these phenomena.

Ambulatory automatism is a special form of twilight clouding of consciousness. Behavior is quite ordered, patients are able to perform complex motor acts, answer simple questions. Spontaneous speech is absent or stereotyped. On others, they give the impression of a thoughtful, focused or tired person. Usually engaged in some kind of activity before the attack, the patients unconsciously continue it, or stereotypically repeat one of the operations, being already in a state of clouded consciousness. In other cases, they commit actions that are in no way related to the previous ones and not planned by them before. Often this action is aimless wandering.

Trance - ambulatory automatism, lasting several days, weeks. In this state, patients wander around the city, make long journeys, suddenly finding themselves in an unfamiliar place.

Fugue - impulsive motor excitation, reduced to a blind and rapid striving forward. Manifested by sudden onset of aimless running, spinning in place, or withdrawal unrelated to the situation. Lasts 2-3 minutes.

Somnambulism (sleepwalking) is a twilight state that occurs in a dream. Manifested by sleepwalking, sleep-talking, paroxysmal night fears. A feature of this disorder is stereotyped repetition (like a cliché) and confinement to a certain rhythm. It is not possible to make verbal contact with a patient in this state; persistent attempts to awaken him may result in a generalized convulsive seizure or brutal aggression on his part. In the morning, the patient completely amnesiac night events, sometimes he feels weakness, weakness, emotional discomfort.

The course of twilight stupefaction can be continuous or alternating (with a short-term clarification of consciousness) and lasts from several minutes to 1-2 weeks. Disorder of consciousness breaks off suddenly, after a deep sleep. Amnesia after the patient's exit from the twilight state is complete. After clarification of consciousness, the attitude of patients to committed actions (murders, destruction, etc.) is defined as to other people's actions. In some cases, amnesia can be retarded, when fragments of experiences remain in the memory immediately after the psychosis, and then are lost within a few minutes or hours. The latter circumstance is of particular importance for the forensic expert assessment of the transferred condition.

Twilight confusion of consciousness occurs in epilepsy, pathological intoxication, epileptiform syndrome with organic brain lesions.

The paroxysmal nature of the occurrence of all twilight disorders makes it more likely to state the epileptic nature of these conditions. However, they must be differentiated from obscuration of consciousness of psychogenic origin and neurotic somnambulism. In the latter case, the occurrence of dreaming and dreaming is usually associated with emotional stress preceding falling asleep, a person in this state can be awakened, while he instantly has a critical assessment of the situation and accessibility to verbal contact, which is usually remembered in the morning.

Psychogenic forms of clouding of consciousness (affectively narrowed consciousness, hysterical twilight, clouding of consciousness of a dissociative type, dissociative psychosis) can be manifested by stuporous states or acute psychomotor agitation with speech confusion, fugiform reactions, pictures of pseudodementia, puerilism, personality regression ("savagery"), delusional fantasizing. They can have an acute or subacute course, but are always associated with a traumatic situation. The hallucinatory-delusional phenomena arising in these states are systematized and have a common plot, as a rule, opposite to the real situation. The affect is not so much tense as demonstrative, emphatically expressive. In the manifestations of hysterical (dissociative) psychosis, the patient's naive ideas about the picture of "insanity" are reflected. Behavioral models can be quite complex, but they are always “psychologically understandable” (K. Jaspers), i.e. by his actions, the patient, as it were, loses the theme of an unbearable situation for him, seeks to “resolve” it.

Amentia is a deep stupefaction of consciousness, the defining features of which are: incoherence (incoherence of associative processes), confusion and motor disorders. Motor excitation is intense, but non-purposeful and chaotic, limited to the bed. There is a breakdown of complex motor formulas, choreoform and athetosis-like hyperkinesis, symptoms of corphology. The patient makes rotational movements, scatters and rushes about in bed (yactation). Short-term catatonic phenomena are possible. The patient's spontaneous speech consists of individual words of ordinary content, syllables, inarticulate sounds, which he pronounces loudly, then barely audibly, then in a singsong voice; perseverations are noted. His statements are not clothed in grammatical sentences, they are incoherent (incoherence of thinking). The meanings of incoherent words correspond to the emotional state of the patient, which is characterized by extreme variability: sometimes depressed and anxious, sometimes sentimentally enthusiastic, sometimes indifferent. The affect of confusion, bewilderment, helplessness is constantly present. The patient's ability to analyze and synthesize is grossly impaired, he is not able to grasp the connection between objects and phenomena. The patient, like a person with broken glasses, perceives the surrounding reality in fragments, individual elements do not add up to a coherent picture. The patient is disoriented in all forms. Moreover, this is not a false orientation, but a search for orientation in its absence. Attention is extremely unstable, it is not possible to attract it. Speech contact is not productive, the patient does not comprehend the addressed speech, he does not answer in terms of the questions asked. Exhaustion is pronounced. Delusional ideas and hallucinations are fragmentary and do not determine the behavior of patients. Periodically, speech motor excitation subsides and then depressive affect and asthenia predominate, patients remain disoriented. At night, amentia may be replaced by delirium.

The duration of amentia is several weeks. After the restoration of consciousness, there is a severe prolonged asthenia, a psychoorganic syndrome. Amnesia after coming out of amental obscuration of consciousness is complete.

The amental state occurs in febrile schizophrenia, neuroleptic malignant syndrome, but most often in severe somatic conditions (neuroinfections, sepsis, acute disorders of cerebral circulation, etc.) and indicates an unfavorable development of the underlying disease.

A similar situation, as a rule, is observed when several aggravating factors are combined, for example, when an intercurrent infection (pneumonia, erysipelas, influenza) is added to a chronic asthenic somatic disease, or the development of sepsis in the early postpartum period. In the latter case, differential diagnosis with postpartum psychosis, as a variant of the onset of schizophrenia, is especially difficult. The absence of dissociation between incoherent speech and affect, depressive episodes, instability and variability of catatonic disorders, nocturnal delirium testify in favor of the exogenous nature of the amental syndrome.

3. Diagnosis and medical tactics

A disorder of consciousness is a non-specific reaction of the psyche to the action of a damaging factor of exceptional strength. Therefore, all forms of disturbed consciousness develop in close connection with somatic disorders that often threaten the patient's life, and even schizophrenia is no exception. Therefore, pathological conditions accompanied by a violation of the clarity of consciousness occur in patients of general somatic hospitals more often than in patients of psychiatric hospitals. The presence in the clinical picture of the disease of the syndrome of impaired consciousness is an indication for emergency medical care.

As can be seen from all of the above, various syndromes of clouded consciousness do not have a strict nosological specificity. Verification of the syndrome of clouded consciousness is more important for determining the severity of mental impairment, i.e. has not so much diagnostic as prognostic value. In terms of severity (depth), all syndromes of clouding of consciousness can be arranged in a certain sequence: oneiroid - delirium - twilight - amentia (V. A. Zhmurov). In this series, one can observe the deepening of congrade amnesia, the impoverishment of subjective experiences and the aggravation of behavioral disorders. This scale explains the existence of transient and mixed forms of disorders of consciousness, and allows you to evaluate their dynamics. Huck, for example, in the structure of the delirious syndrome, one can observe rudimentary manifestations of oneiroid in the form of oneirism, at the initial stages; a picture of professional delirium, with a severe course of psychosis, approaches twilight clouding of consciousness; Muscitating delirium is a life-threatening condition that is clinically similar to amentia in many ways. The end point of the dynamics of all syndromes of obscuration of consciousness is its shutdown and subsequent death.

It should be noted that the impact of several disease-causing factors, especially if the patient has signs of organic brain damage, increases the likelihood of developing a syndrome of impaired consciousness, aggravates its course and prognosis. So in children with minimal cerebral dysfunction (PED), infectious delirium occurs more often. In elderly patients, anticholinergic drugs (amitriptyline), even at medium therapeutic doses, can provoke vascular delirium. Pathological forms of alcohol intoxication are more common in persons who have suffered a traumatic brain injury. Mushing delirium usually develops against the background of a somatic disease, with nutritional deficiencies, the use of alcohol surrogates, etc.

In order to make a clinical diagnosis and select a hospital profile for the patient's hospitalization, it is necessary to collect as complete anamnestic information as possible (with the help of relatives or other persons) and correctly conduct a clinical examination. When collecting anamnestic information, it is necessary to find out about the patient's condition preceding the impairment of consciousness (alcohol withdrawal, inappropriate behavior, infectious or other somatic disease, traumatic brain injury, use of psychoactive substances or other drugs). From the patient's life history, it is necessary to find out about the tendency to abuse alcohol or other psychoactive substances, about the presence of a chronic somatic disease; traumatic brain injuries, neuro-infections, cerebrovascular accidents, the possibility of contact with industrial and domestic poisons, surgical interventions under anesthesia (their number and duration). Information is needed about the presence in the past of episodes of loss of consciousness of any origin, conditions similar to the present, indications of paroxysmal disorders. It is useful to find out about the possible facts of hospitalizations in psychiatric and other hospitals, their reason, duration.

During an objective examination, it is necessary to find out the nature and severity of vegetative-somatic and neurological disorders. In a mental state, establish the patient's ability to verbal communication, his orientation in time, place, surrounding persons, his own personality. To do this, you can ask the following questions: “What is your name? How old are you? What is the day of the week, month, year? Where are you at? What kind of people surround you? At the same time, it is necessary to evaluate the correctness of the answers, their adequacy to the questions asked, the stability of attention, the ability to make simple logical judgments, and to identify specific violations of thinking. Often, the answers to these questions also make it possible to clarify the content of experiences, the nature of the affect, the correspondence of the patient's statements and behavior to them. After a few minutes, the study of mental status is useful to repeat to assess the ability to remember current events, the variability of the content of painful experiences and the dynamics of the patient's condition as a whole.

The principal diagnostic criteria for the full development of typical syndromes of disturbed consciousness are presented in Table No. 1.

Hospitalization of patients with a clouded consciousness in a psychiatric hospital should be issued only on an involuntary basis in accordance with Art. 29 of the Psychiatric Care Act.

When assisting patients, the primary task is to relieve psychomotor agitation in order to prevent accidents and create the necessary conditions for pathogenetic therapy. For these purposes, the use of benzodiazepine tranquilizers (diazepam, phenazepam), anticonvulsants (phenobarbital, carbamazepine), neuroleptics (chlorpromazine, droperidol, haloperidol) in adequate dosages is shown.

Table 1.

Oneiroid	Delirium	dust	amentia
Orientation	Complete disorientation	Allopsychic disorientation	Complete disorientation	Lack of orientation
Perceptual disorders	Pseudo-hallucinations	true hallucinations	True and pseudo hallucinations	Rudimentary
Rave	Megalomanic	Physical and moral damage	Persecution and physical destruction	Rudimentary
Affect	Ecstasy or despair	Changeable from euphoria to fear	Yearning. Horror, fury	Confusion and bewilderment
Voice contact	Impossible, no spontaneous speech	Available. Speech products reflect the content of psychopathological disorders	Not possible. Spontaneous speech is jerky and stereotyped	Separate words, letters, syllables
Behavior	catatonic disorders	Severe psychomotor agitation	Brutal aggression with external ability for consistent actions	Chaotic excitement within the bed
Amnesia	Preservation of consistent memories of psychog1atological experiences	Fragmentary memories of psychopathological experiences	Complete amnesia	Complete amnesia
The content of experiences	Fantastic panoramas. Sequential development of events	Professional and domestic scenes. Changeable plot	Terrifying pictures of death and violence	Incoherence (incoherence)

In the case of the use of antipsychotics, which should be avoided if possible, preference should be given to drugs with a powerful antipsychotic effect (haloperidol), which, unlike drugs with a predominantly sedative effect (chlorpromazine, tizercin), reduce the threshold for convulsive readiness to a lesser extent and render! less effect on vegetative status. The use of drugs with a pronounced anticholinergic effect (azaleptin) should be excluded in states of impaired consciousness of unclear origin. The application of measures of constraint and retention must be carried out in strict accordance with Art. 30 of the Mental Health Act. It should be taken into account that the use of these measures in relation to patients with clouded consciousness sharply increases their fear and motor excitation, which, in conditions of limited mobility, leads to self-injury and adversely affects the somatovegetative status.

Only adequately conducted therapy of the underlying disease contributes to the speedy and complete reduction of psychopathological disorders.

4. Clinical tasks

Read the following tasks and determine which form of disturbed consciousness is described (syndrome).

Patient Zh., a student of a technical school. From the age of 10 he suffers from epileptic seizures. One morning I went to see a doctor at a psycho-neurological dispensary and disappeared. Despite an organized search, the patient could not be found anywhere. Three days later J. returned home. He was ragged, cold, without a coat. He behaved strangely: he did not say a word, did not answer questions, all the time he looked at the ceiling. Didn't sleep at all at night. The next day he began to talk, recognized his relatives. Gradually, the condition improved, and Zh. told the following: “I remember how I went to the dispensary for medicines. Then I don’t remember anything until I felt the railroad tracks under my feet. myself: 10 kilometers to Kazan, 10 kilometers. After that, I don’t remember anything again. I came to my senses somewhere near Kazan. I was sitting by the river under the bridge and washing my feet, which for some reason were red and burning. I was afraid. I thought: "I'll come home soon and tell my parents everything. Then again I don't remember anything." The acquaintances told their parents that they had seen Zh. a day after he disappeared from his house on the shore of a forest lake about 30 kilometers from the city. Zh. seemed to them somewhat strange, thoughtful, in response to the greeting of his acquaintances he nodded absently and went on.

Patient C, 40 years old, factory worker. She was admitted to a psychiatric hospital shortly after giving birth. She looks pale, emaciated, her lips are dry and parched. The mental state is extremely variable. At times the patient is agitated, tosses about in bed, tears off her underwear, assumes passionate poses. The facial expression is anxious, confused, attention is fixed on random objects. The patient's speech is incoherent; "You took my baby away from me ... It's a shame ... You think you should live with Vanya, but you need to live with God ... I'm the devil, not God ... You will all go crazy ... I have inhibition ... Aminazine , and then to the store ... "etc. From separate fragmentary statements it can be understood that the patient hears the voices of relatives coming from somewhere below, the cries and cries of children. Her mood is now deeply depressed, then enthusiastically - euphoric. At the same time, he is easily embittered, threatening to gouge out his eyes. The state of excitation is suddenly replaced by deep prostration. The patient becomes silent, powerlessly lowers her head on the pillow, looks around with longing and confusion. At this time, it is possible to make contact with the patient, get answers to simple questions. At the same time, it turns out that the patient does not know where she is, cannot name the current date, month, confuses the time of year, and cannot give almost any information about herself and her family. With a short conversation, he quickly becomes exhausted and stops answering questions.

Patient G., 39 years old, disabled person of group II. Admitted to a psychiatric hospital for the 6th time; attacks of the disease are similar, according to the type of "cliché". Upon admission to the hospital, contact is almost unavailable. Now excited, jumping, screaming, whistling, then wandering aimlessly along the corridor with an expression of detachment, at times laughing for no reason. After 3 weeks, there was a significant improvement in the condition, and the patient told the following about his experiences: “I understood that I was in the hospital, but somehow I didn’t attach any importance to it. Thoughts flooded into my head, everything was mixed up in my head. fantastic: I took the flowers on the window for Martian plants, it seemed that people had transparent blue faces and they moved slowly, smoothly - as if they were flying through the air. ", incorporeal, instead of hands she had tentacles, and I felt their cold touch. I lie down in bed - and immediately my thoughts take me far away. I imagine buildings with Corinthian columns, and I myself walk as if in a fairy-tale city among people dressed in ancient Roman clothes. Houses seem empty, uninhabited, monuments are seen everywhere. All this is like in a dream."

Patient V., 37 years old, mechanic. Three days ago, an incomprehensible anxiety, anxiety appeared. It seemed that his room was filled with people, some people were shouting from behind the wall, threatening to kill, calling "to go for a drink." I didn’t sleep at night, I saw a monster with horns and sparkling eyes crawling out from under the bed, gray mice, half-dogs, half-cats running around the room, I heard a knock on the window, cries for help. In extreme fear, he ran out of the house and rushed to the police station, fleeing from "persecution". From there he was taken to a psychiatric hospital. In the department he is excited, especially in the evening, rushes to the doors, to the windows. During a conversation, attention to the topic of conversation focuses with difficulty, trembles, looks around anxiously. Suddenly he starts to shake off something, says that he is shaking off insects crawling on him, sees "grimacing faces" in front of him, points at them with his finger, laughs out loud.

Answers to tasks

Task 1. Twilight state of consciousness.

The described condition in patient Zh. is one of the variants of twilight disorder of consciousness - an outpatient trance. The actions of the patient, outwardly quite ordered, in essence, go out of control of consciousness, become aimless, meaningless, automatic. His attention covers only a narrow circle of random objects and impressions from the outside world.

Everything else passes by the patient or is perceived by him vaguely, fragmentarily, "as in twilight." Hence the name of this syndrome. At the same time, all mental processes are emotionally brightly colored (an incomprehensible feeling of fear). The twilight state of consciousness arises unexpectedly, suddenly and usually lasts from several hours to several days. The whole period of his amnesia is completely or partially - as was observed in the described patient.

Task 2. Amentative syndrome.

This syndrome is characterized by a violation of the ability to navigate in place, time, one's own personality, disorderly excitement, incoherence of speech (incoherence). Equally fragmentary and unsystematic are hallucinatory experiences. However, despite the chaotic nature and fragmentation of internal experiences, actions and speech, they are constantly saturated with emotions that replace each other kaleidoscopically. All this is present in the behavior and experiences of the patient. Her attention is passively attracted for a moment by random objects, but the patient cannot connect them together, and, consequently, understand the surrounding situation, understand her attitude towards it. Symptoms unfold against the background of severe mental and physical weakness, asthenia.

Task 3. Oneiroid syndrome.

Attention is drawn to the acute nature of the attack of the disease, at the height of which there is a dream disturbance of consciousness with fantastic experiences. Patient G. has vivid visual pseudo-halluinations: he figuratively "imagines" fabulous cities, fantastic events, and he himself is a participant in them. Pareidolic illusions are noted: the flowers seem to be Martian plants, the doctor has tentacles instead of hands. These dream experiences fill the consciousness of the patient. At the same time, however, orientation in the environment is preserved - the patient understands that he is in the hospital, recognizes the doctor. Therefore, such a oneiroid is called oriented.

Task 4. Delirium.

In the above description, many of the signs that characterize the clouding of consciousness are not disclosed, and in particular, nothing is said about the patient's ability to navigate in place, time, in his own personality. We also do not know whether the patient subsequently developed amnesia for everything experienced during the period of illness. But still we can say that the patient has a clouding of consciousness in the form of delirium. This is supported by an abundant influx of hallucinations, mostly visual. The perception of real events is pushed into the background by bright hallucinatory images. Hallucinations are accompanied by sensual delusions of persecution, fear, psychomotor agitation. The patient's behavior is entirely determined by his hallucinatory-delusional experiences. Actual events are perceived and understood by the patient indistinctly, fragmentarily. Also characteristic is the increase in hallucinations and excitation in the evening.

5. Questions for test control

Brain function and mental clarity are the most important factors affecting the quality of life. If a person does not perceive reality, does not act consciously, then it is more difficult for him to adapt among people and society. Often, mental disorders and unusual human behavior are explained by a number of diseases. One of these is mental disorder. There are several types of such a state, one of which is called delusion. This is the predisposition of the human psyche to changeable states. It provokes a mental disorder that lasts from a few seconds to ten days.

Main features

• Detachment from the surrounding reality with manifestations of non-perception of time and reality.
• Non-perception of location, time space, etc.
• Disruption of communication in thinking, lack of clarity of thoughts, statements that do not correspond to reality.
• Unconscious brief seizures

For a confident statement of the correct diagnosis, doctors are based on the manifestation of all of the above signs.

Five fundamental stages of the delusion of human consciousness

• Stun.
• Delirium.
• Oneiroid.
• Amenia.
• Twilight darkness.

Stun

Stunning is a pathology that has a distinctive feature - mental impoverishment. The patient becomes more withdrawn in behavior, with slow coordination of movements, detached, in a state of prostration. He does not quite clearly understand the speech in the dialogue, answers inaccurately. But this stage of the disease does not have obvious mental disorders. The person does not experience aggression, there are no hallucinations, to a high degree, insomnia. If left untreated, this stage can become more difficult, causing the person to stop talking, then move, and fall into a coma. The initial stage of stunning is called nubilation.

Delirium

The delirium manifestation of changes in consciousness, the so-called, is a directly opposed diagnosis to stunning. The disease is active, the patient has visions that are not related to the surrounding reality, he lives in his own world of hallucinations. Greatness may appear. The patient sees non-existent persons, himself in the role of someone, participates in actions with fictional creatures from his visions. The patient can actively move, sparks appear in the eyes, porridge in the head. He may talk about people and activities that are not really there, but the patient will insist: "I hear voices!" Auditory and visual hallucinations occur throughout the course of the disease.

The patient understands who he is, but does not realize who surrounds him, twilight clouding of consciousness does not allow him to determine his location. The disease progresses at the end of the day and at bedtime. Such patients rarely have a clear mind. With an exacerbation of the disease, they go deep into their own consciousness, they say little, their speech is quiet, commenting on visions and actions outside of time and people who are nearby. With a long course of the disease, a person begins to make the same, abrupt movements, experiences delirium and hallucinations, but less, does not come into contact with others, moves little. After eliminating the causes and symptoms of the disease, he may not remember what happened to him.

Oneiroid

The oneiroid form of obscuration is a disorder of human consciousness, manifested by a state of delirium and carrying the same symptoms: porridge in the head, sparks in the eyes, fantastic visions and picturesque dreams that are far from reality. The state of the psyche is changeable, moving from detachment to hyperexcitation. The patient does not see or hear people nearby, lives in his own fantasy world.

Such people rarely have high activity, they can sit or stand in the same place for hours, not saying anything. The facial expression is stony, unemotional, sometimes frightening. After clarification of consciousness, such patients can talk about their travels and adventures, really perceiving their existence. Clarification of consciousness and a more realistic perception of reality comes to a person sometimes after a couple of weeks, but in some cases even after a couple of months.

Twilight clouding of consciousness

This is the shortest type of change in consciousness. It can last seconds, sometimes it is a matter of several days. The patient comes out of this state quickly, usually through a long phase of sleep. Often such a patient does not cause suspicion among others. Behaves detached and does not understand what is really happening.

But sometimes the disease manifests itself more actively. A person is haunted by a feeling of fear, anxiety, he may begin to show anger. It is expressed in movements, speech and actions. The patient may be accompanied, during which he attacks others, breaks furniture, destroys objects. He is under the influence of delusions and hallucinations. When the attacks subside, the person does not remember his actions.

Sleepy cloudiness

There is such a thing as prosonic twilight stupefaction. This is a manifestation of the disease during a sharp awakening of the patient from a state of sleep. There is a disturbance of consciousness. Symptoms: an attack of fear, the patient is afraid of the people around him, makes the same movements. The active phase lasts about 10-20 minutes, after which the patient falls into a long sleep. Rarely, but a person can remember vaguely what happened to him.

It must be understood that the clouding of consciousness in a person in the form of delirium, stunning, amenia in most cases is provoked by infectious diseases, poisoning due to chemical intoxication, encephalitis, etc.

The defeat of the vessels and the nervous system in the above diseases can lead to such forms of turbidity. Twilight dizziness can be a concomitant manifestation or a post-traumatic condition. Oneiroid is one of the manifestations of schizophrenia.

Prerequisites affecting the sharp clouding of consciousness

The clarity of consciousness can change dramatically and with high amplitude, from a complete lack of understanding of reality to mild disorders. This condition can occur in almost any person, regardless of existing diseases. The patient may suddenly say: "I hear voices" - and then withdraw into himself.

The main causes of clouding of consciousness

• Injuries received under certain circumstances in the head area.
• Impaired cerebral circulation, limited oxygen access to the brain.
• Stagnation of blood in the vessels of the brain.
• Pathological changes in brain tissues (for example, progressive Alzheimer's disease).
• High emotional stress.

• An increase or a sharp decrease in blood sugar levels, diabetic coma.
• Sudden loss of fluid in the human body.
• People of post-retirement age have progressive diseases of the genitourinary system.
• High body temperature.
• Infectious diseases of the brain - encephalitis, meningitis.
• Poisoning with drugs, including psychotropic ones.

The main signs of clouding of consciousness

• Lack of orientation.
• Ignoring surrounding people and objects.
• hallucinations.
• Overexcitation.
• Sudden mood swings.
• Previously uncharacteristic actions.
• Abstraction, lack of interest in the usual activities.
• Uncleanliness, lack of order.
• Speech, memory and hearing impairment.
• Slow and confused thought process.
• Lack of focus.

What measures to take in case of clouding of consciousness?

It is necessary to call for medical help in a timely manner. Especially when it comes to injuries, poisoning, epilepsy, infectious diseases. It is necessary to constantly contact the patient in order to maintain clarity of consciousness, to provide him with peace until the ambulance arrives.

Methods for the treatment of clouding of consciousness

If signs of such a form of the disease as twilight clouding of consciousness appear, the person must be taken for a consultation with a psychiatrist or placed for treatment in a psychiatric medical facility. You should not do it yourself, it is better to call an ambulance so that the patient is taken by paramedics. In case of aggressive behavior of the patient, ambulance staff administer sedative drugs, and then transport them to the clinic

It is not necessary to give the patient sedatives on their own. Depending on the severity of the disease and the manifestation of its signs, treatment can take from 3 weeks to many months. In acute attacks of aggression, the patient can be placed in a closed psychiatric hospital. For people with minimal mental changes, there are borderline medical centers. After undergoing treatment, a person can return to their previous lifestyle. But under a combination of negative circumstances, attacks of the disease can recur.

Basically, the patient is prescribed complex drug therapy with psychotropic drugs, antidepressants are prescribed. The patient is under the constant supervision of doctors in a medical facility. When his condition improves, he can be allowed to go home and take breaks in treatment. With an exacerbation of the disease, a second course of therapy is prescribed. With an aggressive course of the disease, a person is isolated from society for a long time.

After discharge from a medical institution, it is recommended not to overload the patient's psyche, not to create disease-provoking situations, and to protect him from emotional overload. Doctors advise at the end of the full course of treatment to undergo rehabilitation in order to adapt more easily after a period of isolation from society.

Unfortunately, clouding of consciousness may not be fully cured. On the contrary, the disease can develop into more severe forms, for example, various types of schizophrenia. With such mental illnesses, some patients never know the happiness of realizing reality. The deep disorientation of the patient for many years makes him undergo treatment in closed hospitals. Sometimes treatment with short breaks lasts a lifetime. Even being among people, such a patient behaves aloofly. The disease does not manifest itself actively, there is no aggression. But a person still leads an isolated lifestyle, has a detached behavior. The changes that have occurred in the psyche are irreversible, attacks of a vivid manifestation of the disease are stopped temporarily.

Stages of formation of consciousness:

• one). Up to 1 year (awake consciousness) - the first reactions to the environment appear.2). 1-3 years (objective consciousness) - the child's consciousness is enriched with ideas about objects, but he does not distinguish himself from the environment, lives in the present.
• 3). 3-9 years (individual consciousness) - the first ideas about space and time appear, which makes it possible to separate oneself from the environment.
• 4). 9-16 years old (collective consciousness) - ideas about relationships in the team appear.
• 5). 16-22 years old (reflexive consciousness) - the ability to reflect, to foresee the course of events and their consequences appears.

Criteria for impaired consciousness (according to Jaspers):

• 1. Detachment from the outside world(loss of the ability to perceive ongoing events, analyze, use past experience and draw appropriate conclusions, but more often manifests itself in a change in the perception of what is happening, expressed in fragmentation. Inconsistency in the reflection of events.)
• 2. disorientation(allopsychic, amnestic, autopsychic, delusional - false ideas about the environment, somatopsychic, double orientation).

Amnesia for the period of disturbed consciousness (total or partial).

Symptoms of confusion:

• 1). Detachment from the surrounding world.
• 2). disorientation in time and space, etc.
• a). Allopsychic - violation of orientation only in the environment.
• b). Amnestic - due to a memory disorder.
• v). Autopsychic - disorientation refers only to one's personality.
• G). Delusional - everything around is filled with a special meaning related to the patient.
• e). Somatopsychic - disorientation in parts of your body.
• e). Double orientation - the patient seems to be in 2 situations at the same time.
• 3). Anosognosia- denial of one's own illness.
• 4). Symptoms of the Never Seen and Already Seen.
• 5). Confusion- a state of acute senselessness, a painful inability to understand the situation.

Syndromes of turning off consciousness:

1). Stun- characterized by an increase in the threshold to all stimuli and the impoverishment of mental activity. Patients react only to loud questions, answer in monosyllables, but correctly.

Obnubilations(a veil on consciousness) - as with mild intoxication - absent-mindedness, slight euphoria.

• 2). Sopor- only simple mental reactions to external influences are preserved: when stabbed, he pulls his hand away, etc. Pupillary and other reflexes are preserved.
• 3). Coma- characterized by complete inhibition of mental activity, the absence of reflexes and the presence of bulbar and pelvic disorders.

Disturbance of consciousness

General concept of impaired consciousness

Under a disturbance of consciousness is understood disorders of consciousness, leading to a violation of an adequate reflection of objective reality.

The pathology of consciousness accompanies many mental and severe somatic diseases, but in all cases it fits into five syndromes of disturbed consciousness: stunning, delirium, oneiroid, twilight clouding of consciousness, amentia. Only the presence of all these symptoms indicates a clouding of consciousness, since the presence of one or two of the above states is also noted with a clear, undisturbed consciousness.

Criteria of a clouded consciousness

Following K. Jaspers, the following symptoms are considered to be the criteria for clouded consciousness:

o disorientation in time, place, situation;

o lack of a clear perception of the environment;

o different degrees of incoherent thinking;

o Difficulty remembering ongoing events and subjective painful phenomena.

Disorientation is expressed in violation of orientation in time, place and even one's own personality. Sometimes patients have the so-called double orientation, when the patient is simultaneously in two situations, places. He is convinced that he is in a Moscow hospital and at the same time is on a business trip to Sakhalin, that Ivanov Ivan Ivanovich is at the same time a "guinea pig" on whom the influence of cosmic dust on the biological objects of the Earth is being tested.

Detachment from the outside world manifests itself in a fuzzy and fragmented perception of reality, in the loss of the ability to adequately analyze the surrounding situation, one's own experience and draw appropriate clear conclusions.

Thinking disorder manifests itself in incoherence, slowness of the tempo of the associative process, weakness of judgment, the appearance of delirium.

memory impairment expressed in partial or complete amnesia of the entire period of disturbed consciousness.

To determine the state of stupefaction of consciousness, the establishment of the totality of all the above signs is of decisive importance. The presence of one or more signs cannot indicate clouding of consciousness (V. A. Gilyarovsky, A. V. Snezhnevsky).

Types of disorders of consciousness

Deafened state of consciousness. One of the most common syndromes of impaired consciousness is the stupor syndrome, which most often occurs in acute disorders of the central nervous system, in infectious diseases, poisoning, and traumatic brain injuries.

Under stunning understand the increase in the sensitivity threshold for all external stimuli; in this state, the perception and processing of information is difficult, patients are indifferent to the environment, usually motionless. Stunned consciousness is characterized by a sharp increase in the threshold of all external stimuli, the difficulty of forming associations. Patients answer questions as if "awakening", the complex content of the question is not comprehended.

Of the entire flow of information, only those stimuli evoke responses, the strength of which exceeds the threshold of perception that is usual for a person. As a result, most of the impressions of the surrounding reality are lost. Patients, not responding to speech at normal volume, perceive only very loudly and persistently uttered questions. The answers are extremely concise and monosyllabic, although correct. Such standard stimuli as moderate noise, a wet bed, cold or very hot food, do not cause any reactions, as they are outside the perceived. There is hypothymia, immobility, patients do not take an active part in anything and give the impression of dozing or sleeping.

There is slowness in movements, silence, indifference to the environment, the facial expression of patients is indifferent. Drowsiness sets in very easily.

There is also a disorientation in place and time. Reception also suffers significantly, which can lead to amnesia for many, and sometimes all, events occurring during stunning.

Most often occurs in acute disorders of the central nervous system, with infectious diseases, poisoning, craniocerebral injuries.

There are three degrees of stunning: obnubilation, sopor and coma.

Obnubilation is a mild degree of stunning, in this condition an oscillating tone of consciousness is noted - the patient either understands where he is, answers questions correctly, then is disconnected, confused, looks at others with bewilderment, does not understand the speech addressed to him. Euphoria and some excitement may suddenly set in, in sharp contrast to the lifelessness and detachment of the patient; the appearance of euphoria indicates the aggravation of the pathological process in case of intoxication, traumatic brain injury or brain tumor and the transition of obnubilation to stupor.

Sopor is expressed in deep stupor, in which it is absolutely impossible to make contact with the patient, he has no reactions even to strong stimuli. Patients give the impression of deep sleepers, only with very strong transcendental auditory stimuli they can open their eyes or turn their heads, but immediately again plunge into the abyss of stupor. With stupor, only a weak, short-term, poorly differentiated defensive reflex is preserved (with an injection, the patient withdraws his hand), as well as pain and tactile sensitivity, pupillary reflexes.

Coma is the most severe degree of stunning, it is a complete shutdown of consciousness. Pain sensitivity disappears, pupillary reflexes are not evoked.

The appearance of varying degrees of stunning is usually associated with an increase in intracranial pressure and anoxemia of the brain with brain tumors, hemorrhages, in some cases, stunning is associated with intoxication and infectious diseases.

Delirious state of stupefaction. In this state, orientation in the environment is also disturbed, but it does not consist in weakening, but in the influx of vivid ideas, continuously emerging fragments of memories. There is not just disorientation, but a false orientation in time and space.

Against the background of a delirious state of consciousness, sometimes transient, persistent illusions and hallucinations, delusions occur. Unlike patients who are in a stunned state of consciousness, patients in delirium are talkative. With an increase in delirium, the deceptions of the senses become scene-like: the patient's facial expressions resemble the reaction of a viewer following the events on the stage. The expression becomes either anxious or joyful, the facial expressions express fear or curiosity. Often in a state of delirium, patients become excited.

The first signs of incipient delirium are insomnia, diffuse, free-floating anxiety, causeless fear, pareidolic delusions, and hypnogogic hallucinations. As a rule, at night the delirious state amplifies. The patient hears voices threatening him with quartering, a monstrous painful execution, sees his persecutors or drinking companions outside the window or in the house. Hallucinations become scene-like, complex. In a state of delirium, the patient usually finds himself in the center of negative events for him, his behavior corresponds to the experienced hallucinations: he hides when he is persecuted, makes excuses when he is reproached or scolded, defends himself when attacked. Orientation in place and time is sharply disturbed. The patient at the same time lives and acts in his illusory-hallucinatory world. He does not perceive the events of the real world or treats them as secondary, insignificant. Perceptual disturbances are followed by a secondary delusion of persecution.

The intensity of hallucinatory, delusional and affective disorders (fears, anxiety) and, accordingly, the depth of confusion varies in degree

severity, and in accordance with this, the complex defensive behavior of patients changes. In the morning and daytime, all the psychopathological symptoms of delirium weaken, even reduce. Patients calm down, become available for productive contact. However, in the evening, all the symptoms intensify again and reach a maximum at night, when patients are extremely difficult to behave and can even be socially dangerous. Delirium lasts from a few hours to a week. Upon leaving this state, the patient does not remember (amnesiaze) real events, but clearly remembers his hallucinatory-illusory experiences. Sometimes, after delirium, residual (residual) delirium of persecution persists, when the patient is convinced for several more days that his neighbors on the landing wanted to kill him.

Delirium ends with a relatively short-term somato-psychic asthenia, during which "hallucinatory readiness" (positive Lipman's symptom) may persist. This is how a typical delirium proceeds.

There are the following types of delirious stupefaction:

o typical delirium (described above);

o abortive (non-expanded) delirium;

o occupational delirium;

o Mumbling (mumbling) delirium.

At abortive delirium against the background of intense illusory-hallucinatory experiences and a delusional or delusional interpretation of the environment, all types of orientation are preserved. Abortive delirium usually lasts only a few hours.

Professional delirium practically does not differ from the typical one, except that the patients are allegedly at their workplace. In this case, motor excitation manifests itself in the form of reproducing habitual professional movements (for example, a security guard "checks" everyone around for a pass to the factory, a turner "works" on a machine tool, a surgeon "operates", a policeman "catches" terrorists, checks motorists' licenses to drive a car etc.).

Mussitating delirium is characterized by a deep clouding of consciousness due to a severe physical illness. With this type of delirium, there is disorderly, chaotic, limited in a small space excitation, muttering, incoherent speech, senseless grasping movements of the hands (the patient, as it were, "looks", constantly sorting through the edge of the blanket or sheet, randomly squeezing and unclenching his fingers). Sometimes moussifying delirium ends in death or turns into amentia.

Delirious syndrome is most often observed with intoxication (alcoholic (delirium tremens, or "squirrel") and narcotic), infectious and vascular psychoses, as well as with skull injuries and some other organic brain lesions. In surgical practice, after major abdominal operations, in 3% of cases, a typical variant of delirium develops with severe disorientation: the patient can "confuse" the door of the ward with a window and try to "go out the window." In this case, intensive detoxification and verification of Lipman's symptom in dynamics is necessary. Lipman's symptom is expressed in light pressure on the eyeballs with simultaneous imperative suggestion to the patient of any visual images against the background of closed eyes; if the patient saw the image suggested to him, then Lipman's symptom is positive and indicates a high level of intoxication, therefore, delirium can be expected in the evening.

Oneiric state of stupefaction, first described by V. Meyer-Gross, is characterized by a bizarre mixture of reflections of the real world and bright sensual representations of a fantastic nature that abundantly pop up in the mind. Patients make interplanetary travel, are among the "inhabitants of Mars." Often there is fantasy with a character of enormity: patients are present "at the death of the city", they see "buildings collapsing", "subway collapses", "the globe splits", "disintegrates and is worn in pieces in outer space".

Sometimes the patient can stop fantasizing, but imperceptibly for him, such fantasies begin to arise again in the mind, in which all the previous experience emerges, shaping in a new way, everything that he read, heard, saw.

At the same time, the patient can claim that he is in a psychiatric clinic, that a doctor is talking to him. The coexistence of the real and the fantastic is revealed. K. Jaspers, describing such a state of consciousness, said that individual events of a real situation are obscured by fantastic fragments, that oneiroid consciousness is characterized by deep disorders of self-consciousness, patients not only turn out to be disoriented, but they have a fantastic interpretation of the environment.

If during delirium some elements of individual fragments of real events are reproduced, then with oneiroid, patients do not remember anything from what happened in a real situation, they sometimes only remember the content of their dreams.

Oneiroid clouding of consciousness (oneiric, dreamlike, dream-like disturbance of consciousness) resembles a waking dream - it is a clouding of consciousness with an influx of involuntarily advancing fantastic ideas. The figurative experiences of patients always have an internal projection, i.e., unlike delirium, with oneiroid, there is a predominance of pseudo-hallucinatory phenomena, unusually colorful and unusual. The environment is perceived as specially rigged, for the patient "a performance is played out" with figureheads (nonsense of staging, nonsense of a double). There is disorientation in place and time and a double orientation in one's own personality, the patient understands that he is in the hospital, but at the same time - the commander of a spaceship rushing to other galaxies, and the patients and medical personnel surrounding him are perceived as fellow astronauts and representatives of other civilizations meeting the ship. The behavior of a patient in a oneiroid state contrasts sharply with his fantastic pseudo-hallucinatory-delusional symptoms - he usually lies motionless in bed, closing his eyes, sometimes making "flying-smooth" movements with his hands, watching his fantastic adventures as if from the side. At the same time, the perception of time and the patient's own age is disturbed - it seems to him that he has been in flight for several light years, during this time he has died several times and was reborn by cloning, his last "I" is already several hundred years old. Sometimes the patient does not lie, but wanders thoughtfully around the department with an "enchanted smile", all turned into himself. At the same time, he can sometimes tell about some of his fantastic experiences in response to rather persistent questions.

At the height of the oneiroid, single catatonic symptoms may appear in the form, for example, of catalepsy or substupor. It should be emphasized that the theme of experiences during oneiroid is drawn from one's own experience, read books of a fantastic series, watched films of the corresponding content (this is probably why the plot of oneiroid experiences is different for everyone).

Upon exiting the oneiroid, the patient retains his fantastic experiences in memory, but amnesiazes the real events that occurred in his life during this painful attack. Residual delirium may persist for several days.

The duration of oneiroid is limited to several weeks or days. Most often, this pathology is noted in schizophrenia (oneiroid catatonia), but sometimes it is described with organic brain lesions and intoxications.

We present a clinical observation.

Patient E., aged 39, a geologist by education, was treated in a psychiatric hospital in the spring of 1996, was in a oneiroid state for five days, after which he reported that he was the commander of a space flight to Mars and at the same time acted as a geologist. On the way back, he wrote two accounts of this expedition, one of which is given without any changes.

Landing on Mars.

Appendix to the report on the flight "Earth-Mars-Earth" of the commander of the spacecraft "Argo-3".

In addition to the summary report dated August 11, 2000, I inform the Council of Intercosmos and the USSR Academy of Sciences: in accordance with the flight program, the Argo-3 spacecraft landed on Mars during the period corresponding to the time of maximum melting of the polar caps of Mars, i.e. e. at a time when the planet has the most favorable conditions for the development of the Martian flora.

The landing site was chosen at a point with coordinates corresponding in Martian latitude and longitude, similar to the coordinates of the city of Sochi, in the flat part of Mars. The first thing we saw when we landed on the surface of Mars was a vast, slightly hilly plain covered with coarse-grained sand, even gravel with a grain size of up to 1.5-2.0 mm. The composition of the gravel is oligomictic (homogeneous), siliceous-earthy, reddish-brown in color with frequent inclusions of mica (flagopite) of a light golden hue. Everywhere in the field of view on the surface of Mars, streams and rivers of various sizes are visible. Water in streams is exceptionally fresh in composition, even ultra-fresh. During the sampling of water for analysis, we saw creatures floating in the water that suddenly jumped out of the water and flew around us. These fish-birds, instead of fins, had folding membranous wings of a red hue. They attacked us, trying to bite, we had to fight them off with everything that was in our hands. (The patient, who was in a oneiroid, really constantly brushed something aside.) The teeth of these bird-fish resembled the teeth of piranhas. After a series of unsuccessful attacks, they dived into the water, so that after a while, as if gaining strength, they would resume the attack again. This continued until the entire team put on spacesuits, after which, as if on command, the attacks stopped, and only two observers remained in the air. All other natives returned to the water. From time to time, a fresh pair of fish-birds would fly out of the water and there would be a changing of the guard, but we were monitored throughout our stay on Mars. An attempt to capture at least one of these creatures was unsuccessful. Samples of local vegetation were collected - ukhorosy (like terrestrial cacti) and coniferous shrubs (like pine or Amur spruce), all of which had a brownish-purple color. Numerous species of bacteria and viruses have also been noted that have no direct analogues in terrestrial conditions.

08/12/2000 The commander of "Argo-3" is such and such.

A twilight state of stupefaction of consciousness. This syndrome is characterized by a sudden onset, short duration and an equally sudden cessation, as a result of which it is called transistorized, i.e. transient.

Twilight stupefaction is observed with organic brain damage, epilepsy, pathological intoxication and some other diseases.

An attack of a twilight state of consciousness ends critically, often with subsequent deep sleep. A characteristic feature of the twilight state of consciousness is subsequent amnesia. Memories of the period of obscuration of consciousness are completely absent. During the twilight state of consciousness, patients retain the ability to perform automatic habitual actions. For example, if a knife falls into the visual field of such a patient, the patient begins to perform the usual action with him - to cut, regardless of what is in front of him - bread, paper or a human hand. Often in a twilight state of consciousness, delusional ideas, hallucinations are observed. Under the influence of delirium and intense affect, patients can commit dangerous acts.

Hallucinatory-paronid stupefaction. This syndrome is characterized by a sudden onset, the presence of a pronounced intense affect of causeless anger and rage, illusory-hallucinatory symptoms, secondary delusions of persecution and attitude, disorientation in place and time. Just as at dusk a person sees relatively well only a small space in front of him, so a patient in twilight stupefaction of consciousness perceives as if a limited space in front of him, but exclusively in black and red tones (for example, a black train hung with corpses, from which red smoking blood is gushing ). Outside this space, the world does not exist for the patient and is not perceived absolutely. But even within the limits of space, the perception of the patient is illusory-hallucinatory, fueled by extreme malice and aggression. Therefore, the patient presents a random passer-by who "fell" into this space as an aggressor with a knife, intending to kill him. The patient, in a rage, attacks a passer-by in self-defense and brutally kills, inflicting many knife blows. However, since the patient's perception remains illusory-hallucinatory, he sees how a passer-by, pinching the wound with his hand, all red with blood, rises again and goes to him. In the end, the patient dismembers the passerby into pieces, but sees how the bloody meat slides into one piece and the revived passerby steps on the patient again. When this syndrome suddenly develops, especially in the evening, close relatives most often fall into the field of view of the patient, and it is they who become his first victim.

It lasts, as a rule, several minutes or hours, ending in pathological sleep. Memories of the experience are completely amnesic. Only in rare cases, in the first seconds after stopping the twilight clouding of consciousness, the patient can remember the most striking moments of the psychosis.

Ambulatory automatism- this is an ordered twilight clouding of consciousness without delirium, hallucinations and malice. A patient with a similar pathology suddenly leaves home, gets on the first bus that comes across, and goes somewhere. Usually he focuses his attention on one of the people and automatically copies his actions and deeds. After some time, the patient comes to his senses, discovers that he is in a completely unfamiliar place and does not understand how he got here. Patients with ambulatory automatism usually behave quite orderly and do not attract attention. After clarification of consciousness, memories of the past violation are not preserved. It usually lasts a few minutes, but a very prolonged state of ambulatory automatism has also been described. Thus, a patient in a state of ambulatory automatism sailed from England to India for a month and a half on a steamer, and all this time his consciousness was disturbed. One of the observed patients in a similar condition was traveling with a baby from Vladivostok to Moscow for eight days, and no one suspected anything, therefore, her behavior on the way was adequate.

Somnambulism (sleepwalking)- this is a nocturnal narrowing of consciousness, often observed in children with the consequences of organic brain damage within the framework of minimal brain dysfunction. It is clinically expressed in the fact that the patient in a sleepy state gets out of bed and wanders around the apartment with his eyes closed, without bumping into anything, goes out to the balcony without feeling any fear and with extraordinary dexterity can walk along the edge of the roof of a 20-storey building. The absence of fear is explained by a narrow strip of undisturbed consciousness and an absolute non-perception of everything else (that is, apart from the roof eaves, they no longer perceive anything, including the abyss on the left or right). The next morning the patient does not remember anything about his night wandering. In no case should patients be awakened while wandering, because, seeing themselves in an unusual environment (for example, on a roof), they may be frightened and fall. Somnambulism is always the result of organic damage to the brain.

Fugue- this is a short-term variant of ambulatory automatism, an irresistible impulse to escape, arising against the background of twilight clouding of consciousness. The fugue lasts for a few seconds or minutes, ending as suddenly as it begins. The patient always amnesizes his actions and deeds during the fugue. Most often, this disorder is noted in epilepsy and organic brain lesions.

It should be noted that the syndrome of twilight stupefaction can also be observed in functional disorders in the form of hysterical twilight stupefaction. It always develops after stressful situations quite sharply, does not last long. In this pathological state, the patient unconsciously "corrects" the traumatic situation in the direction necessary for himself (for example, a mother sees her dead child alive and alert, talks to him, cradles him). At the same time, elements of theatricality are clearly manifested: patients tear their shirt on their chest, throw their heads back in a picturesque way, "choke with grief", fall and roll on the ground or floor. Their consciousness is not turned off, but somewhat narrowed, so patients perceive and subsequently remember all the conversations of others about their condition.

A kind of twilight state of consciousness is pseudodementia. It can occur with severe destructive changes in the central nervous system and in reactive states and is characterized by acute onset disorders of judgment, intellectual-mnestic disorders. Patients forget the name of objects, are disoriented, hardly perceive external stimuli. The formation of new connections is difficult, sometimes illusory deceptions of perception, unstable hallucinations with motor restlessness can be noted.

Patients are apathetic, complacent, emotional manifestations are scarce, undifferentiated. The behavior often resembles a child's. So, a literate patient, when asked how many toes he has, takes off his socks to count them.

amentia(amental clouding of consciousness) - a deep degree of impairment of consciousness, characterized by the incoherence of all types of mental activity. There is a deep disorientation in time, place and self, the patients are anxious, confused, cannot understand what is happening around, do not know their name, address, their age, do not recognize themselves in the mirror, they have speech excitement. The environment is perceived fragmentarily. Hallucinations are devoid of any particular theme, they are incoherent, episodic. There may be incoherent fragmentary delusions. Emotions are inadequate, inconsistent, often change their polarity. Motor excitation is noted in a limited space (within the bed). The duration of amental stupefaction varies from several days to several weeks. Upon exiting amentia, patients completely amnesia their experiences during this period.

Amentia is most often observed in infectious, somatic and intoxication psychoses, but can also be observed in schizophrenia and organic psychoses.