General characteristics of consciousness and attention disorders
The fundamental signs of any disturbance of consciousness include disorientation. Such conditions most commonly develop against the background of organic lesions of the central nervous system (CNS), as well as various exogenous interventions.
Within isolated attention disorders, hypoprosexia is distinguished—a decrease in concentration that typically accompanies asthenic syndrome. However, the most profound disturbances of fixation and perception occur in acute psychoses. Decreased levels of consciousness (up to sopor and coma) are accompanied by a staged extinction of functions; during coma, even unconditioned reflexes are completely lost.
Oneiric catatonia and exogenous episodes
Oneiric syndrome most frequently manifests as an acute schizophrenic episode. Oneiric catatonia is considered one of the most prognostically favorable schizophrenic psychoses, as its outcome is a high-quality remission without marked personality changes in the patient.
In addition to endogenous causes, exogenous and somatogenic forms are distinguished:
- True exogenous oneiric states: develop against the background of hormonal drug use (glucocorticoids) or hallucinogens (ketamine, LSD, hashish).
- Fantastic delirium: a transitional state. From delirium, it adopts rapid development, evening worsening, and critical resolution via deep sleep. From oneiric states, it adopts pseudohallucinations and fantastic imagery.
Twilight state of consciousness
This condition represents a psychosis proceeding as an epileptiform paroxysm. It is characteristic of epilepsy, as well as brain tumors, head injuries, and cerebral atherosclerosis. It lasts from several tens of minutes to hours.
Key triad of signs:
- Sudden, sharp onset.
- Short duration with an equally sudden termination.
- Complete amnesia for the entire period of the episode (often ending in sleep).
The patient's behavior is completely detached from their personality, and moral control is lost. The patient responds only to accidental stimuli, and contact with them is practically impossible. In the hallucinatory-delusional variant, a malicious affect and unsystematized delusions arise. The patient poses an extreme danger: aggression is brutal in nature, and actions are characterized by absurdity and striking cruelty (for example, delivering blows without reacting to screams).
Ambulatory automatisms
This is a variant of the twilight state that occurs without marked motor agitation. Patients perform outwardly purposeful, habitual actions (may cross the street, answer simple questions), but do so completely unconsciously. Upon the episode's conclusion, complete amnesia sets in, and the person cannot explain how they ended up in another location.
Main types of automatisms:
- Fugues: last 1–2 minutes. The person suddenly runs, may tear off their clothes, or spin in place.
- Transes: prolonged aimless wandering. The patient may miss their stop, wander far from home, or even travel to another city (rarely).
- Somnambulism (sleepwalking): in adults, the first-time appearance of this symptom is an alarming sign. In epilepsy, it may precede or follow a convulsive seizure.
Hysterical twilight states and delirium
The twilight state should be distinguished from psychogenic reactions. Hysterical "twilight states" arise strictly at the moment of severe emotional stress. Behavior becomes foolish, infantile, and helpless (Ganser syndrome). Amnesia here has a different character: it may affect periods prior to the psychosis, and fragmented details are sometimes retained in memory. It resolves after the resolution of the psychotraumatic situation.
Delirium (Delirium): unlike twilight states, it lasts for several days. It is provoked by exogenous and organic brain lesions. It is characterized by a combination of pareidolic illusions and stage-like true hallucinations. In delirium, there is a high risk of fatal outcome due to the worsening of the somatic condition.
Briefly: answers to topical questions
What types of quantitative attention disorders are distinguished?
Pathology of attention includes the following disorders:
- Aprosexia — complete loss of the ability to direct and fixate attention.
- Hypoprosexia.
- Hyperprosexia — pathological enhancement of attention, considered a pathology when passive attention is disproportionately amplified.
- Hypermetamorphosis — especially marked distractibility.
What clinical signs are included in the structure of Ganser syndrome?
The structure of Ganser syndrome includes symptoms of pseudodementia and hysterical twilight disorder. The following clinical signs are distinguished:
- Helplessness — manifests when answering the simplest questions.
- Inability to name body parts — includes the failure to distinguish between right and left sides.
- Childishness of behavior and disorientation — combined with the aforementioned symptoms.
- Paraphasia (approximate answers) — incorrect answers that indicate an understanding of the meaning of the asked question.
- Hallucinations — the possible presence of hallucinatory imagery.
What stages of altered consciousness precede the development of coma?
Syndromes of depressed consciousness successively transition into one another as severity increases. Sources indicate obtundation and sopor among them; with further depression of consciousness, coma develops.
The twilight triad: "Sudden start — Short act — Blank slate (amnesia)".
Class and exam questions
What type of attention disorder is characteristic of asthenic syndrome?
Asthenic syndrome typically reveals hypoprosexia—a decreased ability to concentrate and sustain attention.
What is the main difference between hysterical twilight state and epileptic twilight state?
Hysterical states are provoked by emotional stress, accompanied by infantilism (Ganser syndrome), and amnesia may be incomplete. Epileptic states occur spontaneously, are accompanied by complete amnesia, and frequently by brutal aggression.
How does patient orientation change in delirium?
The patient is disoriented to their current location and time, but orientation to their own identity is completely preserved.
What is a fugue and how long does it last?
A fugue is a variant of ambulatory automatism. It is a brief episode (1–2 minutes) during which the patient may suddenly bolt, run, or begin spinning around, after which they remember nothing.
What else to study on this topic
- Febrile schizophrenic episode and management tactics
- Differential diagnosis of types of amnesia in psychoses
- Ganser syndrome in the structure of psychogenic conditions
- Epileptiform EEG activity in twilight states
- Specifics of pareidolic illusions in fantastic delirium
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