Diagnostic criteria for impaired consciousness
To confirm the diagnosis in psychiatry, the system of signs proposed by Karl Jaspers is used. A state is recognized as a disorder of consciousness only in the presence of four mandatory criteria, with disorientation, thinking problems, and memory issues being a direct consequence of the primary sign — detachment.
- Detachment from the surrounding world is the baseline symptom. The patient does not react to addressed speech, instructions, and questions, and does not perceive what is happening due to the suppression of both active and passive attention.
- Disorientation. It occurs in stages: first, the patient becomes disoriented in time (cannot name the time of day), then in place (does not understand where they are). The most severe form is disorientation in one's own personality (for example, in oneiroid state, a person considers themselves another being).
- Clouding of thought. The patient loses the ability to build logical connections and solve simple problems (for example, basic arithmetic). In severe cases, speech becomes completely incoherent (incoherence, or "word salad"). Unlike dementia, this symptom is reversible.
- Amnesia. The period of psychosis may be partially (events become confused) or completely omitted from memory.
Classification of disorders of consciousness (according to K. Jaspers)
Disorders can be divided into three key groups, differing by the presence or absence of productive symptoms (delusions, hallucinations):
- Reduction of the level (obnubilation/shutdown) of consciousness. Mental processes fade, productive symptoms are absent. Patients are lethargic or completely unresponsive. This is a continuum from mild clouding to deep coma.
- Clouding of consciousness (Delirious/twilight states). Acute psychoses in which reality is displaced by vivid fantasies and painful experiences. Productive symptoms and psychomotor agitation are characteristic. Patients are active and may pose a danger to themselves and others.
- Altered consciousness. The ability to perceive the world is preserved, but severely distorted. Attention is fixed on individual objects, derealization and psychosensory disorders occur. It manifests in paroxysms or under the influence of hallucinogens.
Syndromes of impaired (reduced level of) consciousness
These states occur in exogenous and organic brain lesions (intoxications, trauma, infections, hypoxia) and progressively worsen. In intensive care, their depth is assessed using the Glasgow Coma Scale.
- Clouding (Obnubilation). Slowed thinking, increased threshold of perception. The patient has difficulty understanding complex questions, but generally understands the situation (e.g., being in a hospital). Mild variants include obnubilation (detachment with motor activity) and somnolence (pathological drowsiness).
- Sopor (pathological sleep). Mental activity ceases, the patient cannot be awakened. Only basic reflexes and reactions to severe pain are preserved. Complete amnesia is observed after recovery.
- Coma. The most severe degree. Any reactions to stimuli disappear, unconditioned reflexes fade.
Attention disorders and pathology
Since disorders of consciousness are inextricably linked with impaired attention, it is important to distinguish its pathologies. Attention can be active (purposeful concentration) and passive (peripheral perception for safety).
- Hypoprosexia — weakening of attention, inability to concentrate for a long time. Typical for asthenic states.
- Aprosexia — complete loss of the ability to fixate attention. Occurs in disorders of consciousness and severe oligophrenia.
- Viscosity (pathological adhesion) — getting stuck on a single topic, inability to switch. Characteristic of epilepsy and organic brain lesions.
- Hyperprosexia — abnormal intensification of passive attention, extreme distractibility. Observed in acute psychoses (mania, delirium).
- Hypermetamorphosis — extreme degree of distractibility, typical for schizophrenia with oneiroid syndrome.
Briefly: answers to topical questions
What are the diagnostic criteria and clinical manifestations of oneiroid syndrome?
Oneiroid syndrome (oneiroid clouding of consciousness) is an acute, transient psychosis with a dynamic development. The following clinical manifestations and criteria are characteristic of this state:
- Dream-like experiences — painful fantasies that intertwine with reality, often combined with catatonic symptoms.
- Disorientation in one's own personality — the patient cannot say who they are, or perceives themselves in a distorted way (considers themselves a god, an alien).
- Ecstasy — extremely strong, exalted feelings.
- Hypermetamorphosis — especially marked distractibility.
The prognosis for oneiroid catatonia is considered favorable.
What psychosensory disorders are characteristic of altered consciousness?
Altered states of consciousness are characterized by psychosensory disorders, in which objects change their qualities, lose their naturalness, or become unusually bright. At the same time, object recognition is not impaired, but their physical properties are painfully transformed:
- Erythropsia — seeing in red.
- Xanthopsia — seeing in yellow.
- Macropsia — increase in size.
- Micropsia — decrease in size.
- Metamorphopsia — distortion of shape and surface.
- Polyopia — doubling or tripling of objects.
- Optical alloesthesia — rotation of the surrounding space by 90° or 180°.
They also include body schema disorders and disturbed time perception.
Jaspers' 4 criteria: ONE (Detachment [Otrešennost'], Disorientation, Clouding of thought [Nečetkost' myšlenija], Amnesia).
Class and exam questions
In what sequence does orientation become impaired during disturbances of consciousness?
Orientation in time is impaired first, followed by orientation in place. Orientation in one's own identity is lost last and is quite rare.
What is the difference between clouding of thought in a disorder of consciousness and dementia?
In disorders of consciousness, symptoms resembling dementia (inability to solve logical problems, incoherent speech) are completely reversible after relief of the acute state.
How does clouding of consciousness differ from its reduction/shutdown?
In reduced states (clouding, sopor, coma), mental processes fade, and there are no productive symptoms. In clouding of consciousness, conversely, vivid productive symptoms (delusions, hallucinations) and psychomotor agitation are observed.
What else to study on this topic
- Delirium, amentia, and twilight clouding of consciousness
- Oneiroid syndrome and its features
- Differential diagnosis of types of amnesia in psychoses
- Application of insulin coma therapy
- Glasgow Coma Scale assessment in psychiatric practice
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