Twilight state of consciousness. Quantitative and qualitative disturbances of consciousness: twilight stupefaction, stupor and others. Providing medical care

Syndromes of stupefaction (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 generally.

Oneiroid

Oneiroid is a dream-delusional, dream-like clouding of consciousness. The development of oneiroid is usually preceded by a stage of affective-delusional disorders, which is characterized by nonspecificity, polymorphism and variability of symptoms with preserved consciousness.

Stage of affective-delusional disorders. Against the background of sleep disturbances and various general somatic disorders, affective disorders are increasing, manifested by manic states with a feeling of penetration and insight, or depression with anxious depression and sensitivity. A diffuse delusional mood appears, the patients’ statements (ideas of attitude, persecution, inferiority or overestimation of one’s qualities, unusual abilities) are unstable and have the nature of overvalued ideas and delusional doubts. Massive depersoption-derealization disorders arise, with a feeling of alteration of one’s own mental and physical processes, a feeling of strangeness and unreality of the environment. The perception of time is disrupted; patients may perceive its flow as extremely accelerated, intermittent, slow 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 meaning, intermetamorphosis, doubles. Patients begin to claim that a movie is being filmed around them or some kind of performance is being played out in which everyone has certain roles. Everything seems specially arranged, filled with a special meaning, which the patient guesses in other people’s words, actions, and furnishings; real events acquire symbolic meaning. There is a feeling of constant variability in the surroundings, objects either disappear or appear again as if by magic, people’s faces are constantly changing, the same person accepts different appearances(Fregoli's symptom), the patient recognizes his loved ones in strangers, and considers his relatives to be dummies (Quatre's 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 some way, and is experiencing external influences on himself. Thus, the clinical picture becomes more complicated due to the appearance of illusions, pseudohallucinations, automatisms, after which antagonistic (Manichaean) delusions develop. Patients become the center of the struggle between the opposing forces of good and evil, the environment turns into the arena of this struggle, and people become its participants. Such a confrontation can take place outside the patient’s receptive field, but he has the “power” to influence the course of historical events and greatest achievements. The delusional plot acquires megalomaniac content: expansive (delusions of grandeur, messianism) or depressive (delusions of Cotard). Then retrospective (confabulatory) delusions appear and the symptoms approach paraphrenic syndrome.

The patient’s behavior in the initial stages is determined by existing affective and delusional disorders. Gradually it loses connection with the content of experiences, and then becomes formally ordered, however, the patient’s peculiar “fascination” can reveal the wealth of internal experiences. Periodically, episodes of situationally determined delusional behavior occur 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 ideas in which, thanks to a pathologically enhanced play of the imagination, all past experiences, not only personally experienced, but also borrowed from books and films, are bizarrely processed. 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 seems to simultaneously exist in two situations - real and fantastic; along with the correct orientation in his personality and place, he creates a delusional idea of the surroundings and his position in it. The surrounding environment is perceived as the historical past, an unusual situation of the present, or as a scene of fairy-tale-fantastic content; the surrounding persons turn into active characters in these unusual events. The patient may be fully aware that he is in a hospital and at the same time consider medical workers crew of a spaceship, patients as passengers, and himself as a starfleet admiral. Thus, the visualization of the products of the imagination occurs, which the patient initially has the ability to control, but then the influx of images arises against his will.

The behavior of patients takes on distinct catatonic features. In the department, such patients may be practically invisible, or they attract attention with absurd agitation and inconsistent speech. They perform religious and ritual actions in a stereotypical and pretentious manner, mannerly recite poetry, and freeze in sculptural and monumental poses. The phenomena of waxy flexibility, negativism, echolalia, echopraxia, and impulsive actions are occasionally detected. The speech is rich in neologisms, the thinking is resonant, sometimes torn. The face is mask-like or paramimic, it shows an expression of mystical penetration, ecstasy, or seriousness that is inappropriate for statements. Contact is unproductive; identifying the content of experiences can be quite difficult.

Stage of development of a true oneiroid. Characterized by total loss contact with the surrounding reality, allo- and autopsychic disorientation. Involuntarily arising ideas take on the character of visual pseudohallucinations. The patient finds himself captivated by the contemplation of fantastic panoramas, scenes of grandiose events, in which he himself occupies a central position, acts as an active actor. At the same time, he seems to be reincarnated into the heroes of unusual incidents, into the “world mind”, into animals, completely identifying himself with them, both on the mental and physical level. In his painful experiences, he travels through time; the entire world history, pictures of the ancient world and the distant future flash before his “inner eye”. The patient visits distant planets, ancient civilizations, the afterlife or other dimensions. Meets their inhabitants, quarrels with them, or receives sacred knowledge from them. Some patients, being in oneiric stupefaction, believe that they come into contact with representatives of extraterrestrial civilizations, find themselves abducted by them, end up 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 in future or past wars. Or they carry out social reforms, prevent global cataclysms, are participants in unprecedented experiments, explore the structure of the universe, unusual shapes life, they themselves transform into fantastic creatures.

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

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

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

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

Affective-oneproid form. Characterized by the predominance of delineated polar affective states throughout the course of psychosis. The content of delirium correlates with the pole of affect, catatonic symptoms are not sharply expressed.

Oneproid-delusional form. The greatest 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-oieriid form. It is distinguished by its acuteness, severity of vegetative-visceral disorders, early appearance, syndromic completion and significant expressiveness of catatonic phenomena.

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

The phasing and symptomatology of oneiroid occurring in schizophrenia is not found in any other disease. Oneiroid-like conditions in symptomatic and organic mental disorders are characterized by more rapid development and short-term course, syndromic incompleteness, as well as 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. Autopsychic disorientation is less pronounced or absent, for example, a patient travels to exotic countries in hospital clothes. States of inhibition and excitement are devoid of catatonic features. The duration of such oneiroid varies from several minutes to several days, its reduction often occurs critically. After 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. Perception disorders are the main psychopathological phenomenon in the structure of this syndrome and determine the delusional plot and behavioral characteristics of the patient. Delirious stupefaction develops, as a rule, in the evening and at night and in its development goes through a number of stages, which can be conveniently considered using the example of alcoholic delirium.

In the first stage of delirium (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, unimportant events (the phenomenon of hypermetamorphosis). Patients are fussy, talkative, and there is noticeable inconsistency in their statements. Influxes of vivid figurative ideas and memories (oneirgai) arise. The mood is extremely variable from tender-compassionate, when patients demonstrate unmotivated optimism, to anxious-tense, with tearfulness, depression, and apprehension of trouble. There is always a kind of irritability, capriciousness, and touchiness. Superficial sleep, with frequent awakenings, vivid nightmares that are confused with reality. In the morning, patients feel exhausted and 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 deceptions of perception in the form of phonemes and acoasms - patients hear calls, doorbells, and various poorly differentiated sounds. When trying to sleep, multiple kaleidoscopically changing hypnagogic hallucinations. At open eyes illusory disorders arise. When they are closed, the interrupted hallucinatory episode receives further development. Pareidolic illusions are characteristic - the revival of planar patterns. In the play of chiaroscuro, in the patterns of the carpet, and wallpaper, patients see bizarre pictures, fantastic images that disappear when the lighting increases. 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 crawling across the floor, however, disappear at the edge of the carpet. The attitude of patients towards visions is a combination of fear and curiosity.

The course of delirium is wavy. A peculiar flickering of symptoms, with short intervals of decreasing intensity of psychopathological disorders, occurs already at the second stage. Periodically (usually in the morning), lucid (light) intervals may be observed. At this time, there are no psychotic disorders, orientation in the environment and even a critical assessment of the state appears, however, there is a readiness for hallucination. The patient can be asked to talk on a previously switched off telephone (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 us to correctly assess the patient’s condition.

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

Occupational delirium is accompanied by monotonous motor agitation 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, conduct resuscitation measures, a drug addict makes himself 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 (mumbling) delirium is an even deeper degree of clouding of consciousness. Uncoordinated, stereotypical actions, choreoform and athetosis-like hyperkinesis predominate here. Patients make grasping movements in the air, shake something off, palpate, and finger the bed linen - a symptom of “robing” (corphology). Excitation occurs within the bed, accompanied by a quiet, indistinct utterance of individual sounds. Patients do not react at all to external stimuli and are not accessible to 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 ranges, on average, from three to seven days. If delirium ends in the first or second stages, they speak of abortive or hypnagogic delirium. If delirium lasts more than a week, it is called prolonged delirium. Disappearance of disorders often occurs critically, after prolonged sleep, less often lytically. In the latter case, residual delirium may occur. With this type of outcome, patients, formally assessing the condition suffered as painful, are convinced of the reality of some episodes, for example scenes of adultery. After a few days, there may be a sudden appearance of full criticism. Upon recovery from delirium, asthenia is always observed, and affective disorders (subdepressive or hypomanic) are characteristic. In severe cases of delirium, it is possible to develop into Korsakovsky and psychoorganic syndromes.

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

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

In children, infectious delirium is more common, in adults, alcoholic delirium, and in old age, delirium of atherosclerotic origin. It is interesting that the content of psychopathological disorders that arise 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 Delirious syndrome, perception disorders and other psychopathological phenomena may have some features.

The greatest difficulty in differential diagnostic terms is delirium with pseudohallucinations and mental automatisms. In such cases, most often we are talking about the debut of an endogenous-processual disease, provoked by exogenous harmfulness (intoxication), or the coexistence of both diseases. For delirium due to intoxication with anticholinergic substances. properties (atropine, cyclodol, amitriptyline, azaleptine, aminazine, diphenhydramine), metamorphopsia and other sensory synthesis disorders are common. Hallucinations are characterized by objectivity, simplicity, indifference of content for patients (wire, sawdust, threads, etc.); during intoxication with cyclodol, the symptom of a disappearing cigarette is described: when the patient feels a cigarette squeezed between his fingers, which “disappears” when he tries to bring it to his mouth ( Pyatnitskaya I. N.). In case of poisoning carbon monoxide olfactory hallucinations dominate, cocaine - tactile (sensation of crystals), tetraethyl lead - oropharyngeal (sensation of hair in oral cavity). Infectious delirium is characterized by the phenomena of somatopsychic depersonalization; patients feel floating in the air, a state of weightlessness, the disappearance of the body, the presence of a double next to them. Vestibular disorders are common: sensations of spinning, falling, swaying. In conditions accompanied by dehydration, water appears in painful experiences. Traumatic delirium is accompanied by experiences of the circumstances of injury (battle situation). In the formation of hallucinatory-delusional experiences in somatic diseases, painful sensations in various organs play a large role (patients feel as if they are dying in a fire, being tortured, etc.). For senile delirium (pseudodelirium) characteristic features are: “...life in progress”, false recognitions, increased responsiveness to what is happening around, fussy businesslikeness, a symptom of “getting ready for the road” - patients tying bedding in knots, wandering with them. Such conditions have a chronic course, worsening at night. Delirium in vascular diseases of the brain has a similar clinical picture; its specificity is determined by the severity of the anxiety component and dependence on the state of cerebral hemodynamics. In delirious disorders that occur against the background of an acute cerebrovascular accident, among other things, disturbances in the body diagram may be observed. A feature of delirium that occurs in old age is the severity of mnestic disorders and the age-related themes of delusional statements (ideas of material damage). Epileptic delirium is characterized by particularly vivid and fantastic hallucinatory images. The visions are frightening in nature, often colored in red, black and blue. Hallucinatory images approach the patient, crowding him. He hears a deafening roar and smells a disgusting smell. Experiences of apocalyptic and religious-mystical content are characteristic. In the latter case, hallucinations can be unusually pleasant and accompanied by ecstatic affect.

Twilight Darkness consciousness

This type of clouding of consciousness is often called pathologically narrowed consciousness or twilight. Due to some characteristic features and diversity clinical manifestations This syndrome is the most difficult to differentiate. Its most common symptoms are: suddenness of onset and cessation (paroxysmality), the ability to engage in externally goal-directed behavior, and complete amnesia during this period.

Disorientation can be expressed to varying degrees. Along with deep disorientation in the environment and one’s own personality, there are states of orientation “in general outline", with a significant restriction of access to external impressions, a narrowing of the range of current ideas, thoughts and motives. Perception of the environment may be distorted by existing productive disorders. Their presence can be judged from the spontaneous statements and actions of patients who, in a state of twilight stupefaction, are detached and gloomy, often silent, their spontaneous speech is limited to short phrases. Patients are inaccessible to verbal contact, although their behavior gives the impression of being meaningful, purposeful, it is completely determined by existing psychopathological disorders. Here, vivid (usually visual) scene-like hallucinations of frightening content, figurative delirium with ideas of persecution, physical destruction, and false recognitions are common. Affective disorders are intense and characterized by tension (sadness, horror, rage). Frenzied psychomotor agitation is often observed. The listed features make these patients extremely dangerous to 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. Often patients commit sudden and terribly senseless auto-aggressive actions. Less common are twilight states with religious and mystical experiences and ecstatic affect.

The presented picture of twilight stupefaction refers to its psychotic form. The latter, depending on the predominance of certain psychopathological disorders, is very conventionally 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 particularly sudden and, accordingly, harsh. 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 increasing tension with a melancholy-angry affect is discharged in outwardly poorly motivated destructive acts, the memories of which are not retained by the patient.

In the case of less severe behavioral disorders, they speak of a non-psychotic (simple) form of twilight stupefaction, implying the absence of hallucinations, delusions, and affective disorders. This point of view is not shared by all psychiatrists, because sudden suspicion, turning to a non-existent interlocutor, or the patient committing particularly ridiculous acts suggests the role of hallucinatory-delusional experiences in the origin of these phenomena.

Outpatient automatism is a special form of twilight stupefaction. Behavior is quite orderly, patients are capable of performing complex motor acts and answering simple questions. Spontaneous speech is absent or stereotypical. They give the impression of a thoughtful, focused or tired person to others. Usually engaged in some activity before the attack, patients unconsciously continue it, or stereotypically repeat one of the operations, already in a state of darkened consciousness. In other cases, they commit actions that are in no way related to the previous ones and were not previously planned by them. Often this action is aimless wandering

Trance is an outpatient automatism that lasts several days or weeks. In this state, patients wander around the city, make long journeys, suddenly finding themselves in an unfamiliar place.

Fugue is an impulsive motor excitation that boils down to a blind and rapid striving forward. It manifests itself as sudden aimless running, spinning in place, or walking away unrelated to the situation. Lasts 2-3 minutes.

Somnambulism (sleepwalking) is a twilight state that occurs during sleep. It manifests itself as sleepwalking, sleep-talking, and paroxysmal night terrors. A feature of this disorder is stereotypic repetition (like a cliché) and confinement to a certain rhythm. It is not possible to enter into verbal contact with a patient in this state; persistent attempts to awaken him can result in a generalized convulsive seizure or brutal aggression on his part. In the morning, the patient has complete amnesia for the events of the night and sometimes feels weak, overwhelmed, and emotionally uncomfortable.

The course of twilight stupor can be continuous or alternating (with short-term clarity of consciousness) and lasts from several minutes to 1-2 weeks. The disorder of consciousness ends suddenly, after deep sleep. Amnesia after the patient emerges from the twilight state is complete. After clearing consciousness, the attitude of patients to the committed actions (murders, destruction, etc.) is determined as to the actions of others. In some cases, amnesia can be retarded, when immediately after experiencing psychosis, fragments of experiences remain in the memory, 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.

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

The paroxysmal occurrence of all twilight disorders makes it more likely to establish the epileptic nature of these conditions. However, they must be differentiated from clouding of consciousness psychogenic origin and neurotic somnambulism. In the latter case, the occurrence of sleepwalking and sleep-talking is usually associated with emotional stress preceding falling asleep; a person in this state can be awakened, and he immediately develops a critical assessment of the situation and is accessible to verbal contact, of which memories are usually retained in the morning.

Psychogenic forms of stupefaction (affectively narrowed consciousness, hysterical twilight, stupefaction of a dissociative type, dissociative psychoses) can manifest as stuporous states or acute psychomotor agitation with speech confusion, fugiform reactions, pictures of pseudodementia, puerilism, personality regression (“wildness”), delusional fantasizing. They can have an acute or subacute course, but are always associated with a traumatic situation. The hallucinatory-delusional phenomena that arise in these states are systematized and have a common plot, usually the opposite of the real situation. The affect is not so much intense as it is demonstrative, emphatically expressive. The manifestations of hysterical (dissociative) psychosis reflect the patient’s naive ideas about the picture of “insanity.” Behavioral models can be quite complex, but they are always “psychologically understandable” (K. Jaspers), i.e. Through his actions, the patient seems to play out the theme of a situation that is intolerable to him, and strives to “resolve” it.

Amentia is a deep clouding of consciousness, the defining signs of which are: incoherence (incoherence of associative processes), confusion and motor impairment. Motor excitation is intense, but unfocused and chaotic, limited to the bed. There is a disintegration of complex motor formulas, choreoform and athetosis-like hyperkinesis, and symptoms of morphology. The patient makes rotational movements, throws himself around and rushes about in bed (yactation). Short-term catatonic phenomena are possible. The patient’s spontaneous speech consists of individual words of everyday content, syllables, inarticulate sounds, which he pronounces either loudly, sometimes barely audibly, or in a sing-song voice; Perseverations are noted. His statements are not expressed in grammatical sentences and are incoherent (incoherence of thinking). The meaning of incoherent words corresponds to the emotional state of the patient, which is characterized by extreme variability: sometimes depressed-anxious, sometimes sentimentally-enthusiastic, sometimes indifferent. There is a constant feeling of confusion, bewilderment, and helplessness. The patient's ability to analyze and synthesize is grossly impaired; he is unable 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 complete picture. The patient is disoriented in all forms. Moreover, this is not a false orientation, but a search for orientation in the absence of it. Attention is extremely unstable, it is impossible to attract it. Speech contact is not productive, the patient does not comprehend the addressed speech, and does not answer in terms of the questions asked. Exhaustion is sharply expressed. Delusions 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 give way to delirium.

The duration of amentia is several weeks. After restoration of consciousness, severe prolonged asthenia and psychoorganic syndrome are observed. Amnesia after emerging from amentive stupefaction is complete.

An amental state occurs in febrile schizophrenia, malignant neuroleptic syndrome, but most often in severe somatic conditions (neuroinfections, sepsis, acute cerebrovascular accidents, etc.) and indicates the unfavorable development of the underlying disease.

A similar situation is usually observed when several aggravating factors are combined, for example, when an intercurrent infection (pneumonia, erysipelas, influenza) joins 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, and nocturnal delirium indicate the exogenous nature of the amentia syndrome.

Twilight stupefaction is manifested by a violation of orientation in the surrounding world with ordered motor activity, which is often accompanied by fear, melancholy or rage. At the end of the attack, the memory of the events that occurred is completely absent. Stupefaction develops against the background of hysterical psychosis and other brain diseases. The basis of treatment is taking medications that normalize the functioning of the central nervous system and the patient’s behavior.

Causes of development of mental disorder

The state of confusion develops against the background of organic or functional changes in the brain. Twilight disorder often accompanies, which is associated with a violation of the structure of certain groups nerve cells. In addition to epileptic changes, intracerebral tumors, traumatic brain injuries, neuroinfections, etc. can be provoking factors. functional reasons distinguish hysterical psychosis and traumatic events that are unexpected for the patient.

Symptoms more often occur in adulthood, since these causes are observed less frequently in children. With hysteria and early manifestations of epilepsy, confusion may develop in children. A psychiatrist deals with the diagnosis and treatment of the disease, regardless of the patient’s age.

Varieties of the condition

In psychiatry, there are several variants of twilight stupefaction, which depends on the reasons that caused it:

psychotic – develops against the background of hysterical psychosis and other changes in the human mental sphere;
non-psychotic – associated with organic pathologies of the structures of the central nervous system.

Symptoms are heterogeneous. Depending on the predominant clinical manifestations, the following are distinguished:

delusional disorder – accompanied by the formation of delusions, which determines the patient’s behavior at the time of disturbance of consciousness;
dysphoric type - characterized by affective disorders, the patient expresses melancholy, feelings of fear or anger;
with the hallucinatory variant, the clinical picture is dominated by hallucinations and illusions, their nature can be different: auditory, visual, etc.

Oneiroid is classified as twilight. This is a condition accompanied by the appearance of colorful hallucinations with fantastic content. Against this background, there is a decrease in overall activity and the possible development of catatonia.

Psychiatrists divide non-psychotic disorders into four types:

ambulatory automatisms;
somniloquy;
somnambulism;
trance.

Somniloquy and somnambulia mean talking and sleepwalking, respectively. Outpatient automatism is a disturbance of consciousness with the occurrence of automatic actions of a different nature in the patient. If the patient is in distress long time does not regain consciousness, then they talk about trance.

Clinical manifestations of confusion

Dysphoric type

From the outside it looks like a set of ordered actions, however, the person is detached from what is happening around him. People around the patient note his absorption in his own thoughts. The facial expression is angry or reflects fear.

Contact with the patient is impossible. He ignores speech addressed to him, but may respond with stereotypical expressions that are completely meaningless. An important criterion for clouding of consciousness is the lack of criticism of one’s own behavior and its inadequacy. Some people remain spatially aware and can talk to familiar people. With disturbances of consciousness, short-term hallucinations, a feeling of the appearance of one’s own double, distorted perception of body parts, etc. may occur. As the mental disorder progresses, the patient may show aggression towards others and himself.

Delusional type

Delusions of persecution come first in the clinical picture. There is no contact with the patient, however, outwardly his actions appear purposeful and orderly. Due to the content of delirium, he may commit antisocial acts, trying to protect himself from others. The delusional type of disorder is characterized by the retention of memory of the period of stupefaction.

Hallucinatory disorder

Associated with the appearance of illusions and hallucinations. The latter are auditory or visual in nature, and are also accompanied by negative content. During the period of hallucinations, contact with the patient is completely impossible. He does not pay attention to speech, he can say certain words and make sounds meaninglessly. Due to perception disturbances, patients are aggressive, they are capable of committing serious crimes, attacking children, other patients, etc.

Outpatient automatisms

Manifested by automatic actions. Patients are capable of performing complex motor acts during the period of disorder: buying tickets for a bus or other transport, going to the store, etc. At the same time, when a person comes to his senses, he does not understand how he ended up in this place. This is due to the development of complete. With outpatient automatisms, the patient is outwardly thoughtful, confused, and is perceived by people around him as healthy man. Similar changes are characteristic of trance, but its duration can reach several days.

Hysterical twilight stupefaction

It has a number of clinical features:

contact with the patient is possible, which is due to his lesser detachment from the outside world;
in a conversation with the patient, the doctor can identify factors that provoke the development of psychosis;
After consciousness is restored, memories are partially preserved; sessions can completely restore them.

The duration of the state during stupefaction is from several minutes to several hours. As a rule, the duration of symptoms is individual and can vary significantly even in one patient.

Possible complications

Psychiatrists divide the negative consequences of the disorder into two groups: those associated with the primary disease and those associated with inappropriate behavior person. Twilight stupefaction can occur against the background of organic pathology, and therefore characteristic complications may include:

With epilepsy, personality disorders develop - isolation, indifference to others. Gradually, apathy towards work and hobbies appears. This is due to organic changes in the nerve centers in the cerebral cortex, as well as side effects of long-term use of antiepileptic drugs.
With the growth of intracerebral tumors, the neurological deficit gradually increases. Sensory disturbances, movement disorders, blurred vision, etc. may occur. With rapid growth of the tumor, there is a risk of displacement of brain structures with their pinching in the foramen magnum, which can be fatal.

The main consequence of impaired consciousness is the patient’s antisocial behavior. Due to the development of hallucinations or delusions of persecution, he poses a threat to others and himself. Possible suicide attempts, aggression towards loved ones, colleagues or strangers. In some cases, patients commit brutal murders without remembering anything about what they did.

Diagnostic measures

In identifying a disorder, psychiatrists rely on the clinical picture of the disorder and the testimony of loved ones, colleagues and other eyewitnesses. During twilight stupefaction, patients often commit crimes, so they undergo a forensic psychiatric examination. As a rule, it includes not only an examination by a psychiatrist, but also familiarization with the materials of the criminal case, etc.

To identify the immediate cause of the development of symptoms, a comprehensive examination is carried out:

Conversation with the patient and his relatives.
General inspection and neurological examination. This makes it possible to detect diseases of the brain or internal organs which can cause mental disorders. It is important to establish the fact of having suffered traumatic brain injuries in the past, as well as tumors in the structures of the central nervous system.
Electroencephalography (EEG), computed tomography or magnetic resonance imaging. The methods make it possible to study the state of the structures of the central nervous system and identify deviations in their structure. If atherosclerosis of the cerebral arteries is suspected, an ultrasound with Doppler sonography is performed.

Only a specialist - a psychiatrist or neurologist - should interpret the results obtained. Attempts at self-diagnosis can lead to progression of the underlying disease and the development of complications.

Differential diagnosis with . An important difference is the absence of memories of the period of impaired consciousness. They may partially persist if symptoms occur against the background of hysterical psychosis. In addition, the fact of a history of epilepsy and other organic diseases of the central nervous system indicates in favor of twilight disorder. Delirium is characterized by the appearance of symptoms when quitting alcohol and psychoactive substances. Patients experience psychomotor agitation, hallucinations, pseudohallucinations and delusions of persecution.

Help during an acute period

Disorders of consciousness pose a danger to the patient and the people around him. This is due to inappropriate behavior against the background of delusions of persecution and hallucinations. In this regard, when symptoms appear, a number of simple measures should be taken to stabilize the condition.

It is necessary to call an ambulance. If possible, this should be a specialized psychiatric team capable of providing qualified treatment. While she is waiting, the patient is persuaded to sit down or lie down, and is not left alone. Sharp, piercing objects, as well as any dangerous substances, must be removed from the room. Windows and doors are closed. This helps reduce the risk of antisocial behavior.

Patients require hospitalization in a psychiatric hospital. Ambulance team specialists fix the patient and administer medicinal sedation. For this purpose, use Diazepam, Relanium, Sibazon or other drugs with a similar effect. At the beginning, a minimum therapeutic dosage is introduced, which allows you to suppress psychomotor activity. If the effect does not appear within 10-15 minutes, the administration of the drugs is repeated.

Combinations of antipsychotics with Diphenhydramine or Suprastin, as well as Aminazine, have a similar effect. When using such drugs, it is necessary to remember their hypotensive effect. These drugs are contraindicated for people with low level blood pressure.

In cases where symptoms of twilight stupefaction occur during epilepsy, they may be manifestations of an epileptic seizure. Therapy should include medications prescribed by a doctor to treat the underlying pathology.

Therapeutic principles

Within drug therapy neuroleptics are used. The drugs have a sedative effect, eliminate hallucinations, psychomotor agitation and other symptoms. Psychiatrists often use Aminazine and Tizercin, which have minimal side effects. If, while using antipsychotics, there is a decrease in blood pressure, Cordiamine is prescribed.

To relieve agitation, therapy is carried out according to the following scheme:

Intramuscular administration Haloperidol, Olanzapine, Diazepam or Aminazine. Dosages of medications are selected individually.
With severe psychomotor agitation, intramuscular use of Midazolam at a dose of 5-10 mg is possible.
It is possible to use anesthetics: Hexobarbital or Propofol. The drugs are prescribed intramuscularly or intravenously.
After the excitement is removed, the form of the drugs is changed from injection to tablet. They are used until the symptoms are completely relieved.
If the course is prolonged, neuroleptics continue to be used until they are discontinued by a psychiatrist.

In parallel, therapy is carried out for the underlying disease that caused twilight stupefaction:

For epilepsy, antiepileptic drugs based on valproic acid are used. Patients must take them constantly, since refusal of medications leads to another relapse.
For the negative consequences of traumatic brain injuries or neuroinfections, nootropics (Piracetam, Phenotropil) and antioxidants (Dihydroquercetin, Tocopherol) are used to improve the functioning of nerve cells and protect them from negative impacts. Similar action have medications that improve blood flow in the cerebral vessels - Cerebrolysin, Actovegin, etc.

During the acute period of the disorder, the patient requires hospitalization. In a psychiatric hospital, relapse is stopped and constant medical supervision is established. As trance develops, the period of disturbed consciousness may persist for several hours or days. Repeated exacerbations may develop during hospitalization.

Of the non-drug methods, the key in the treatment of twilight disorder is psychotherapy aimed at achieving stable remission and preventing relapses. Patients are offered both individual and group sessions.

Forecast

Twilight disorder of consciousness is a symptom complex that is a sign of other diseases: hysterical psychosis, epilepsy, traumatic brain injury, etc. In this regard, the prognosis is determined by the root cause of the disorder and the timeliness of medical care.

With organic pathology of the brain, the prognosis is favorable if it is diagnosed in the early stages and the patient is prescribed complex treatment. Detection of epilepsy, manifested in the form of automatisms and other mental symptoms, is an indication for use. When taken regularly, the attacks disappear and the patient returns to normal life.

If the patient does not seek medical help for a long time, the disorder can lead to antisocial behavior. Incomplete medical and psychological examination in a criminal case leads to judicial punishment, including long-term arrest.

Prevention options

Prevention consists of primary and secondary measures. Primary is carried out before the onset of the disease, and secondary is aimed at preventing relapses.

Primary prevention is based on following the rules healthy image life and general medical advice:

Activities associated with increased risk receiving traumatic brain injuries;
when visiting areas endemic for neuroinfections (etc.), routine vaccination against them should be carried out;
nutrition should be rational and contain the required amount of proteins, vitamins and microelements;
it is necessary to eliminate bad habits and addictions: smoking, drinking alcohol and drug addiction;
You should exercise regularly, etc.

If there is a history of mental or organic diseases with brain damage, as well as cases of twilight disorder, a person needs secondary prevention:

stressful situations are excluded;
complied with mandatory prescribed therapy for the treatment of the primary disease (in no case should you change medications, their dosage or even refuse to take them);
If any disturbances in perception occur, immediately seek medical help.

The patient's loved ones play an important role in preventing relapses. They should create a favorable atmosphere in their home and work environment. Conflict situations must be excluded.

Disorders of consciousness of a qualitative and quantitative nature occur against the background of diseases of the internal organs and brain. They have various clinical manifestations - from slight inhibition to hallucinations. Patients require a comprehensive examination and adequate therapy.

Quantitative disorders of consciousness

Quantitative disorders include syndromes of switching off consciousness:

nullification;
stun;
doubtfulness;
coma.

They differ from each other in the depth of clinical manifestations. In some conditions (traumatic brain injury, intracerebral hemorrhages etc.), disorders can successively replace each other.

Nullification - least serious violation. Psychiatrists call it “cloudy” consciousness. The main symptoms include general absent-mindedness, inability to focus on any activity, and errors when answering simple questions. The mood is labile and inadequate to the surrounding environment. Nubilization lasts several minutes, but can last several hours if it develops against the background of malignant formations in the structures of the central nervous system or severe intoxication.

Stunning is the second most profound disturbance of consciousness. The patient's threshold of excitability for any stimuli increases. Patients perceive speech addressed to them poorly and only understand simple sentences. The speed of thinking is slowed down. The answers use few words. Motor activity is also suppressed, and movements are made with errors. Memory also suffers - patients have difficulty remembering and reproducing information. An important difference from qualitative violations is associated with the absence productive symptoms: delirium, hallucinations, etc. After emerging from stupor, the sufferer does not remember the period of the disorder.

Doubtfulness is similar to drowsiness, in which a person does not open his eyes for a long time. The patient answers simple questions quickly and correctly. However difficult questions are ignored due to a violation of their comprehension. With strong external influence(scream, bright light), the symptoms of somnolence and deafness temporarily disappear.

Stupor - when it develops, the patient is completely immobilized. There is no facial expression, and the eyes are closed. Verbal contact is impossible. When exposed to strong stimuli, in contrast to doubtfulness, stereotypical speech and motor reactions occur. The latter are protective in nature.

Coma is the most severe quantitative disturbance of consciousness. Occurs with severe intoxication with alcohol, drugs, organic lesions of the central nervous system and metabolic disorders. Consciousness, as well as reaction to external stimuli, is completely absent.

Therapy quantitative violations consciousness is based on the elimination of the original causes. For this purpose, an examination is carried out for organic brain pathology or intoxication.

Qualitative disturbances of consciousness

Syndromes of clouding of consciousness occur in people of different ages and against the background of a wide range of diseases. Precise definition for this concept No. However, a number of experts note the criteria for making a diagnosis:

The presence of disorientation in time, place and self.
Disturbances in the perception of surrounding reality, including delusions, hallucinations, etc.
Incoherent thinking, accompanied by asthenic phenomena and speech disorder.
At the end of the symptoms, the patient partially or completely forgets the events and thoughts of the acute period. Memories of psychopathological phenomena are often retained: delusions and hallucinations.

It is important to note that the first three signs are observed in various mental and neurological disorders. For example, disorientation is characteristic not only of qualitative disorders of consciousness, but also of dementia, as well as delusional syndromes. Incoherent thinking is a manifestation of manic states, dementia, etc. In this regard, doctors diagnose clouding of consciousness only if all four signs are present.

In neurology and psychiatry, the following types of stupefaction are distinguished: delirium, oneiroid, amentia and twilight stupefaction. They have a specific clinical picture, which facilitates diagnosis.

Symptoms of amentia

Amentia - manifests itself as a combination of incoherent thinking, disturbances in the motor sphere and confusion. Speech changes are characteristic: it is represented by inarticulate sounds, as well as individual words and syllables. Patients speak either softly or loudly. Perseverations are possible. This is a forced repetition of the same words. The mood is changeable - from anxiety and aggression to enthusiasm or indifference to the environment. It determines the emotional coloring of speech.

The patient lies down more often. He exhibits motor agitation in the form of shuddering, flexion, and extension of his arms and legs. He can take the pose of a fetus or a crucified Christ. During some periods of attention, excitement is replaced by stupor and complete immobility.

Speech contact is impossible in most cases. Many patients have pronounced speech motor arousal, which makes it possible to assess the course of the existing affect (usually depressive). Clarifications of consciousness are not typical. Single hallucinations and fragments of delirium may occur.

Delirious syndrome

acute onset in the absence of mental and neurological precursors;
the duration does not exceed several hours, unlike other qualitative disorders;
pronounced emotional background - a feeling of fear, anger or melancholy;
the predominance of disorientation in one’s own personality (the patient is not able to perform purposeful activities and fully communicate with people around him);
delusions of perception and true visual hallucinations;
twilight darkness ends abruptly with a long sleep;
the patient completely or partially forgets what happened.

Unlike quantitative ones, qualitative disorders of consciousness more often arise against the background of mental illness. In connection with this issue, their diagnosis and treatment should be dealt with by a psychiatrist. The specialist uses antipsychotics, tranquilizers and other groups of psychoactive drugs. After removal acute symptoms Attendance at individual or group psychotherapy is indicated.

The prognosis for disorders of consciousness depends on the type of disorder and the severity of the underlying disease. If you seek medical help in a timely manner at the initial stages of the development of the syndrome, it does not pose a danger to the person or people around him. The presence of affect in the form of anger or rage, as well as delusions of persecution, can cause antisocial behavior. Self-medication for blackout and blackout syndromes is unacceptable.

Blurred consciousness refers to its qualitative disorders and is a sign of serious problems with the functioning of the brain. There are several types of darkness, differing in the depth and content of pathopsychological symptoms. Identification and treatment of such disorders in patients is most important for psychiatrists, narcologists, neurologists, toxicologists and resuscitation specialists, but doctors of other specialties may also encounter this problem. What types of clouding of consciousness exist will be discussed in this article.

What happens during clouding of consciousness

Clouding of consciousness is its disintegration with a decrease in the level of perception of external stimuli and the filling of a person’s “internal space” with pathological psychoproductive phenomena. At the same time, a person’s behavior changes, which is determined by the depth of immersion in one’s own experiences and the visible response to them.

Main clinical signs clouding of consciousness are:

detachment from the outside world, while the perception of ongoing events is fragmented and inconsistent, and the analysis of these external stimuli is sharply reduced;
disorientation in space and time due to the patient’s immersion in his experiences, it is noted that the patient partially or completely does not recognize familiar people and familiar surroundings;
disturbances in thinking with its incoherence, inconsistency, amorphism, fragmentation;
memory deterioration to varying degrees, up to amnesia of everything that happens during the period of darkened consciousness, including one’s own experiences.

To diagnose confusion, all 4 of the above signs must be present. Hallucinatory and secondary delusional disorders are also often detected. Experiences during the period of stupefaction are perceived by the patient as real. They replace the events of the surrounding world or are felt as more vivid, absorbing all the patient’s attention. Sometimes this is accompanied by a lack of self-awareness and a feeling of alienation.

Individual memories of the experiences experienced may persist for some time, their vividness and detail depend on the type of disorder suffered. Subsequently, they lose relevance, but criticality towards them almost never reaches a sufficient level. But in some cases, the exit from the state of darkened consciousness is accompanied by complete amnesia for this period; the patient may note a failure in personal perception of time.

Stupidity: classification

Qualitative disorders of consciousness are divided into:

delirium (delirious stupor or state), including the so-called professional delirium;
(oneiric, or dream stupefaction);
amentia (amentive darkness);
twilight states of consciousness (twilight), including several varieties;
special states of consciousness: various types of aura, which is a paroxysmal form of clouding of consciousness.

It is not always possible to carry out an adequate differential diagnosis during initial examination patient with confusion. The primary task is to exclude quantitative disorders (stunning, etc.). Clarification of the type of stupor is sometimes carried out on the basis of dynamic observation and retrospective analysis with the patient’s self-report.

Delirium

Delirious stupefaction is characterized by the presence of predominantly psychoproductive symptoms. These include abundant hallucinatory and illusory disorders and the acute sensory delirium determined by them. In this case, true visual hallucinations predominate, although tactile and auditory deceptions of perception are also possible. Their content is usually unpleasant for the patient and is threatening in nature. These can be monsters, beasts of prey, skeletons, small animals and insects, small humanoid creatures. Hallucinations quickly replace each other; wave-like influxes of visions are characteristic.

Behavior is subordinated to emotions, patients are usually restless motorly until the development psychomotor agitation. Aggression is directed at hallucinatory images and can affect others. Affect is variable and determined by the content of hallucinations. Generally, anxiety, anger, and fear predominate, but transient states of curiosity and enthusiasm are possible. Preoccupation with hallucinations leads to complete or partial disorientation, and false orientation in space and time is often noted.

Delirium is a wave-like condition. It is characterized by lucid windows: spontaneous periods of lucidity, when the patient’s perception of the environment and the overall level of brain functioning improve. The condition also worsens in the afternoon with an increase in hallucinatory influxes in the evening and at night. Lucid windows most often occur after awakening; during them, the person is asthenized, partially oriented and moderately critical. In addition, delirium is characterized by stages of development, with each stage being reversible.

At the first stage, there are no hallucinations yet, but there are influxes of vivid memories, increased and uncontrollable associations, and distracted attention. The person is talkative, affectively unstable, not critical enough and is not always clearly oriented. His behavior becomes inconsistent, and his sleep is restless and superficial, with disturbing, overly vivid dreams.

At the second stage, illusions and pareidolia appear, disturbances of attention are aggravated with difficulty in perceiving the environment. The third stage of delirium is characterized by multiple true hallucinations and associated sensory delusions. Even when scene-like events appear visual hallucinations the feeling of their alienness remains. The patient does not become involved in imaginary events, but observes them or opposes himself to them. Behavior is subject to emotions, orientation deteriorates sharply.

The fourth stage is a severe disintegration of thinking with complete immersion in experiences and detachment from the outside world. Delirium at this stage is called muttering. The man shakes something off himself, makes picking movements, fidgets with the bed, and mutters for a long time. Verbal activity is practically independent of external factors; strong sound and painful stimuli lead to a temporary increase in the volume of pronounced sounds and words.

A special form of delirious stupefaction is occupational delirium, in which hallucinatory-delusional disorders are fragmentary in nature and do not determine behavior. Against the background of deep detachment and disintegration of thinking, stereotypically repetitive movements appear, which are associated with the automation of the patient’s professional activity. This could be imitation of working on a machine, sweeping, using abacus, knitting. It is also possible to repeat simple gestures and body movements typical for a given person.

Oneiroid

Oneiroid is a more severe form of clouding of consciousness. In this case, the defining feature is a dream-like delirium of fantastic content, which unfolds dramatically and leads to a violation of the patient’s level of self-awareness. Visions are perceived as if by the inner eye; they absorb almost all of a person’s attention and draw him into the illusory world. The scenes are large-scale, fantastic, colorful and dynamic. The patient feels like a different person or being, with unusual capabilities and the ability to influence everything that happens. It’s as if he controls world wars, discovers new galaxies, collects plants of extraordinary beauty, meets historical figures or even becomes them.

Unlike the oneiroid, all these vivid experiences have practically no effect on the behavior of the person in the oneiroid. He may appear distracted, lethargic, or simply freeze periodically. His movements are usually elaborate, meager, and slow. From them and from their frozen facial expressions it is almost impossible to guess the content of the visions. At the same time, it is sometimes possible to obtain simple answers to questions about the patient’s experiences and imaginary place of stay.

Such clouding of consciousness can occur in stages:

Another controlled fantasy with an influx of images;
Delirium of intermetamorphosis with a feeling of unreality and staging of events, false recognitions, developing into sensual delirium of fantastic content;
Oriented oneiroid, when dream-like experiences are combined with partial orientation in the environment;
A deep oneiroid with detachment from the real world; when leaving it, there is complete amnesia of the actual events that have occurred.

Sometimes oneiric stupefaction is diagnosed after its completion. At the same time, the patient has a detailed, vivid description of fantastic experiences combined with a paucity of memories of what is happening around him and bewilderment about the dissonance regarding the duration of the episode and his own personal identity.

Amentia

With this type of darkness, a person is confused, helpless, he does not comprehend the events taking place and is deeply disoriented in place, time and even his own personality. There is a pronounced disintegration of all components of thinking, the process of analysis and synthesis is disrupted, and self-awareness disintegrates. Hallucinatory and delusional disorders are fragmentary and in this case do not determine the patient’s behavior.

Speech production is increased. Statements mainly consist of individual incoherent words, but at the same time their content corresponds to the existing affect. The mood is unstable, the patient experiences alternating states of enthusiasm and tearfulness. Quite clearly defined episodes of low mood with classic psychomotor signs of depressive syndrome are possible.

The behavior is characterized by agitation in the bed, which sometimes resembles catatonic and for a short time can be replaced by a substuporous state. Movements are unfocused, inconsistent, and often sweeping. Revitalization of fine motor skills is not typical.

Amental stupefaction is a profound disorder of consciousness and can last up to several weeks. There are no periods of lucidity, but in the evening and at night, amentia is often replaced by transient delirium. After emerging from the state of stupefaction, the patient becomes completely amnesic of both his experiences and the events of the surrounding world.

Twilight

Twilight states of consciousness are transient and heterogeneous disorders. They are characterized by intense affect, disorientation and complete amnesia during the period of stupefaction. Depending on the type of twilight, a person may also experience delusions, hallucinations, automated movements, or agitation. There are delusional, affective (dysphoric), and oriented variants of the twilight state of consciousness. There is a separate form with various ambulatory automatisms, including trance and fugue.

People around us do not always recognize the onset of a person’s twilight state of consciousness. Suspicious signs are a state of self-absorption that is inadequate to the situation, indifference to current events, stereotypic movements or ridiculous unexpected actions. Moreover, actions can be criminal, causing physical harm to other people, including murder.

Aura

An aura is a special type of clouding of consciousness; most often it occurs before deployment. At the same time, the person experiences vivid and memorable experiences, and real events are perceived fragmentarily and unclearly or do not capture the patient’s attention at all. There may be a feeling of a change in the body diagram, depersonalization and derealization, visual, gustatory and olfactory hallucinations, senestopathies, bright color photopsia, increased contrast and coloring of real objects.

The affect is usually intense, and dysphoria or ecstasy often occur. During an aura, a person may freeze, experience anxiety, and become immersed in his unusual sensations. Memories of these experiences displace from memory information about what is happening in the outside world, and they are not subject to amnesia even with the subsequent development of a generalized convulsive seizure.

It is currently believed that confusion occurs due to disruption of cortical interneuron connections. Moreover, these changes are not structural, but functional in nature; they are associated with an imbalance of the main neurotransmitters. The reason for this may be endogenous mental disorders, various intoxications, and other conditions. And determining the type of clouding of consciousness a patient has is an important point in diagnosis, often determining the tactics of further treatment.

Psychiatrist I.V. Zhuravlev gives a lecture on the topic “Disorders of consciousness and self-awareness”:

All types of clouding of consciousness have a number of common features:

1) detachment from the outside world;
2) disorientation in place, time and surrounding persons, sometimes in one’s own personality;
3) incoherence of thinking along with weakness or impossibility of judgment;
4) complete or partial amnesia during the period of stupefaction.
1. Stunned state of consciousness (drowsy, somnolent). Orientation in the environment is incomplete, in one’s own personality it can be preserved, but in time it is disrupted. Slowness of movements, silence, and indifference to surrounding stimuli are noted. The condition is characterized by a sharp increase in the threshold for all external stimuli and difficulty in forming associations. The person answers questions as if “awake”. The depth of stun can be different (light, medium, deep). Deep stun is dangerous because it can turn into sopor.

: often this state of consciousness can occur both after intense mental trauma (sudden intense enemy shelling, hostage taking, etc.) and physical (traumatic brain injury).

In addition, such a violation of consciousness can occur during intoxication stages somatic diseases(infections, poisoning, diabetes, peritonitis, typhus, anemia).

2. Delirious stupefaction. In such a state of consciousness, a person can be completely disoriented in place, time and self. In contrast to stupor, a person in this state is fussy, mobile, talkative at random, facial expressions do not correspond to the situation: he expresses fear, then joy, laughter or curiosity. Not always, but appearance may change: observed severe redness face, sweating, trembling of limbs against a background of high temperature, sloppiness. With targeted questioning, it is possible to identify visual and auditory deceptions (hallucinations), and delusional ideas. That is, a person sees, hears and feels what others do not see or hear, and comes into contact with the invisible world (answers questions, performs actions under the influence of “voices” heard only by him). In this state, he can commit auto- and hetero-aggressive actions. At the same time, at times he can answer questions correctly, but then attention and orientation in the environment are disrupted again.

In the practice of a clinical psychologist: this state of consciousness can develop in persons who have consumed alcohol, drugs or their substitutes, against the background of intense stress, after traumatic brain injuries and infections.

3. Oneiric (dreaming) state of consciousness. This state is characterized by influxes of fantastic experiences, often intertwining pictures of reality. Fantastic experiences have the nature of vivid dreams, without motor excitement, since the person himself is not always an active participant in the events he experiences. Often all experiences are perceived as if from the outside, while he has a double orientation. Often a person sees himself on other continents, planets, lives in other historical eras, participates in atomic wars, is present at the death of the Universe. Although very dynamic events may unfold before your eyes, behavior may remain inhibited. Upon recovery from this state, amnesia, as a rule, does not occur. A person can draw or describe in sufficient detail what he saw, but at the same time he will have difficulty remembering the real situation around him.

Sometimes oneiroid can be in the form of excitement or stupor, expansive or depressive.

In the practice of a clinical psychologist: oneiroid can occur against the background of intense exposure to psychotraumatic factors in persons predisposed to psychosis or who have previously had sluggish, latent forms of disorders: with schizophrenia, epileptic disease, organic diseases of the brain, tumors, etc.

4. Twilight state of consciousness (TSC). In this state, disorientation in the environment is combined with the development of hallucinosis and acute sensory delirium with an affect of melancholy, anger and fear, frantic excitement or, very rarely, outwardly ordered behavior. CVS develops suddenly and ends just as suddenly; its duration varies - from several hours to several days or more. In this state, a person may show aggressiveness, characterized by extreme cruelty, due to an anxious and angry affect and the presence of hallucinations or delusions. Depending on their predominance in the structure of disturbed consciousness, the CVS has three clinical variant: delusional, hallucinatory, dysphoric. With the latter option, amnesia of experienced events can be delayed: immediately after the resolution of the SSS, the person, although indistinctly, for several minutes or hours, remembers the events and his behavior during a period of darkened consciousness, and amnesia subsequently develops. CVS occurs in epilepsy, organic brain diseases, and tumors.

Also in the structure of the cardiovascular system, mention should be made of such disorders as obnibulation, pseudodementia, depersonalization and derealization, states of ambulatory automatism.

Obnibulation - consciousness seems to become foggy for a few seconds, covered with a light cloud, while all types of orientation are preserved, amnesia does not occur.

Pseudo-dementia is characterized by a short-term impairment of intellectual-mnestic abilities in literate people (for example, a person cannot answer the question of how many fingers or toes he has, but at the same time he can correctly answer a complex question).

Depersonalization characterized by a feeling of alienation or splitting of one’s own “I”, a violation of the “body diagram” (for example, a person thinks that one leg reaches the size of a two-story building, the size of the stomach extends to the whole body, etc.).

Derealization- a state in which the world, the surrounding environment is perceived indistinctly, unclearly, as something unreal. Often a person can perceive a familiar environment as “never seen”, and an unfamiliar one as “already seen” (“ja mé vu” and “de ja vu”).

Amentia - confusion of consciousness with a predominance of incoherent speech-motor excitation against a background of confusion, affect of anger and fear, followed by complete amnesia.

In the practice of a clinical psychologist: such conditions can develop in persons who have suffered severe head injuries, stress, predisposition to mental illness, after severe intoxication and infectious diseases.

5. State of ambulatory automatism. This condition is characterized by automated forms of behavior (somnambulism, sleepwalking, trance). In these states, a person can perform purposeful actions without being aware of what is happening (travelling by transport, leaving his place of residence); when leaving it, he cannot understand how he found himself in this or that situation.

In the practice of a clinical psychologist: This condition develops in many people after hysterical and epileptic seizures- predisposed to vascular and other psychoses, who have received traumatic brain injuries, as well as against the background of exposure to intense stress factors (crisis situations of a socio-political nature, emergency situations of a man-made, environmental and natural nature, emergency situations of a criminal nature).