Classification of oppression of consciousness (A.I.

Distinguish the following types consciousness: clear, clouded, stupor, stupor, coma, delirium, hallucinations.

In therapeutic clinics, patients are more likely to have clear consciousness. At the same time, the patient is fully oriented in the environment, clearly answers questions.

Darkened (unclear) consciousness manifests itself in the indifferent, indifferent attitude of the patient to his condition; He answers questions correctly, but late.

At stupor (stun) the patient is poorly oriented in the environment, sluggishly, slowly answers questions, sometimes not to the point, and immediately begins to doze off, fall asleep: he falls into a state of stupor.

Sopor- deep stupefaction of consciousness (stupefaction). In this case, the patient is in a state of "hibernation". Only a loud cry, painful effects (pricks, pinches, etc.) can bring him out of this state, but for a very short time; soon he falls asleep again.

Coma (deep sleep)- complete loss of consciousness. The patient does not respond to shouting, painful irritations and inhibitions. In coma, there are no reflexes. Coma indicates a significant severity of the disease. It develops, for example, severe course diabetes mellitus, with renal and hepatic insufficiency, with alcohol poisoning, etc.

At diabetes in case of metabolic disorders, mainly carbohydrates and fats, due to a lack of insulin in the body, hyperglycemic (diabetic) coma occurs. It develops slowly. It is usually preceded by malaise, loss of appetite, headache, nausea, vomiting. Further, muscle tone decreases, dryness of the skin develops, their turgor decreases, the face becomes pink, the eyeballs become soft, tendon reflexes partially or completely disappear, noisy breathing (Kussmaul breathing) is noted, a characteristic smell of acetone (fruity) is felt in the exhaled air, pulse slows down, blood pressure drops.

With adrenal insufficiency, as well as with an overdose of insulin and for a number of other reasons, as a result of a sharp decrease in blood sugar, a hypoglycemic coma occurs. It starts quickly. Sometimes it is preceded by a feeling of hunger, weakness, sweating. The skin with this disease becomes pale, moist, muscle rigidity, body trembling, convulsive twitches are noted, the pupils dilate.

Due to severe diffuse liver damage as a result of complete insufficiency its function develops hepatic coma. In this case, there is a sharp weakness, drowsiness, alternating with periods of excitement. The skin becomes icteric, scratching is noted on them, " spider veins", hemorrhages. Muscle twitches are also observed, a sweetish (liver) smell from the mouth is felt. Breathing is noisy (Kussmaul), pupils are motionless, dilated, arterial pressure is lowered, urine is dark yellow, feces are discolored.

In patients with chronic disease kidneys, accompanied by severe functional insufficiency them, a uremic coma occurs. Initial signs her are general weakness, headaches, nausea, vomiting (especially in the morning, before meals), general anxiety, insomnia. Then comes the loss of consciousness. The skin becomes pale yellowish, dry, with traces of scratching and hemorrhages. The mucous membranes of the oral cavity also become pale and dry, Cheyne-Stokes breathing, less often Kussmaul type, muscle tone increases, an ammonia smell (smell of urine) is felt from the mouth.

For the sick alcoholic coma are characterized by a cyanotic face, dilated pupils, hyperemic sclera of the eyes, shallow, hoarse breathing, the smell of alcohol from the mouth, Cheyne-Stokes type breathing, a small rapid pulse, low blood pressure.

In the case of an anemic coma, "dead" pallor, sticky sweat, deafness of heart sounds, a thready pulse, and a decrease in blood pressure are noted.

In some diseases (especially infectious ones with severe intoxication), poisoning with alcohol, sleeping pills and other drugs, patients experience excitation of the central nervous system, i.e., a state opposite to that described above. Such patients are restless, excited.

In addition, there may be a violation of consciousness, leading to delirium. Rave- this is an objectively false, absolutely uncorrectable judgment. With violent delirium, patients are extremely excited, jump out of bed, run somewhere, they have hallucinations.

hallucinations there are auditory, visual, tactile (sensation of crawling over the body of worms, insects, microbes, etc.).

During auditory hallucinations, the patient talks to himself or to an imaginary interlocutor.

With visual hallucinations, patients see something that is not really there, for example, mice that rush at them, devils, etc. This often happens with alcoholism.

Silent delirium is also characterized by unrealistic ideas, hallucinations, only patients behave outwardly calmly, often in a state of stupor or stupor, mutter something, utter incomprehensible and incoherent phrases.

Disturbances of consciousness are among the least developed issues. Despite the fact that all textbooks of psychiatry describe various forms of impaired consciousness, the definition of this concept encounters difficulties. This happens because the concept of consciousness in psychiatry is not based on a philosophical and psychological interpretation.

Consciousness can be considered in different aspects. In philosophy, it has a wide meaning, being used in terms of opposing the ideal to the material (as secondary to the primary), from the point of view of origin (a property of highly organized matter), from the point of view of reflection (as reflecting the objective world).

In a narrower sense, consciousness is a human reflection of being, a reflection in socially developed forms of the ideal. Marxism connects the emergence of human consciousness with the emergence of labor in the process of turning apes into humans. The impact on nature in the course of collective labor activity gave rise to an awareness of the properties and regular connections of phenomena, which was fixed in the language that was formed in the process of communication. In work and real communication, self-consciousness arose - awareness of one's own attitude to the natural and social environment, an understanding of one's place in the system of social relations. The specificity of the human reflection of being is that "human consciousness not only reflects the objective world, but also creates it" [1, 29, 194].

In solving the problem of consciousness in psychology, Soviet scientists proceed from the principles of Marxist-Leninist philosophy. Consciousness is considered as the highest function of the brain associated with speech, reflecting the reality in a generalized form and purposefully regulating human activity.

S. L. Rubinshtein paid much attention to the problem of consciousness in psychology [159; 160]. Saying that consciousness is the process of the subject's awareness of the objective existence of reality, he emphasized that consciousness is the knowledge of how the object opposes the cognizing subject. The problem of the connection between consciousness and activity is also given attention in the works of A. N. Leontiev. He directly points out that consciousness can be understood "as a subjective product, as a transformed form of manifestation of those relations that are social in nature, which are carried out by human activity in the objective world ... It is not the image that is imprinted in the product, but precisely the activity - the subject content that it objectively carries in itself" [113, 130].

Consciousness includes not only knowledge about the surrounding world, but also knowledge about oneself - about one's individual and personal properties (the latter involves awareness of oneself in the system of social relations). In contrast to the traditional use of the concept of "self-consciousness", A. N. Leontiev proposes to use this term in the sense of awareness of one's personal qualities. He says that self-consciousness, the consciousness of one's "I", is awareness in the system of social relations and does not represent anything else.

The problem of self-consciousness is given a lot of research (S. L. Rubinshtein, B. G. Ananiev, L. I. Bozhovich and others), the analysis of its methodological aspect (I. I. Chesnokova, E. V. Shorokhova), the connection of self-consciousness with cognition other people (A. A. Bodalev, I. S. Kon, V. V. Stolin, etc.). An extremely large amount of research has been devoted to the problem of self-consciousness, the "I-image" in the works of foreign neo-Freudian authors, representatives of humanistic psychology (K. Rogers, A. Maslow). The literature on the problem of self-consciousness and the unconscious is also rich (F.V. Bassin, A.E. Sheroziya). A number of works are devoted to the problem of self-regulation and self-awareness (I. Kon, B. V. Zeigarnik, L. Festinger). Starting with James, particular problems are also singled out as correlations of self-consciousness and physical image-I (I. I. Chesnokova, A. A. Bodalev, M. A. Kareva, etc.).

It is beyond the scope of this book to deal with all aspects of consciousness. I just wanted to remind you that 1) in psychology, this problem is developed from different positions and aspects, both in theoretical and phenomenological terms: 2) that no matter how different the ways of studying consciousness are, everything domestic psychologists when solving even its particular problems, they proceed from the Marxist-Leninist philosophy of the position that consciousness reflects the objective outside of us existing world that it has the property not only to reflect, but also to create it.

The concept of consciousness in psychiatry does not coincide with its philosophical and psychological content. It is rather "working". The leading modern psychiatrist A. V. Snezhnevsky says that “if we approach consciousness in a philosophical sense, then we naturally must say that with any mental illness highest form the reflection of the world in our brain is disturbed" [173, 99-100]. Therefore, clinicians use the conditional term of impaired consciousness, meaning special forms his disorders.

S. L. Rubinshtein also agrees with this provision, speaking about the expediency of "breeding" mental disorder and disturbances of consciousness, as possessing specific features.

The concept of consciousness, which A.V. Snezhnevsky defines as "conditional", is based on the views of the German psychiatrist K. Jaspers, who considers consciousness as a background against which various mental phenomena change. Accordingly, in mental illness, consciousness can be disturbed independently of other forms of mental activity, and vice versa. So, in the case histories one can find expressions that the patient has delirium with clear consciousness, thinking is disturbed against the background of clear consciousness, etc. The metaphorical signs of "clarity" and "clouding" of consciousness, introduced by K. Jaspers, have become decisive for the characterization of consciousness in psychiatry textbooks to this day. Following K. Jaspers, the following are taken as criteria for a clouded consciousness:

1. disorientation in time, place, situation;
2. lack of a clear perception of the environment:
3. different degrees of incoherent thinking;
4. difficulty remembering current events and subjective painful phenomena.

To determine the state of clouded 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 [55, 173].

In psychiatry, various forms of impaired consciousness are distinguished. *

* Although basically we do not use the conceptual apparatus of psychiatry, however, for some sections (in particular, consciousness) it should be highlighted.

Stunned state of mind . 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, with infectious diseases, poisoning, traumatic brain injury.

The stunned state of consciousness is characterized by a sharp increase in the threshold for all external stimuli, the difficulty in forming associations. Patients answer questions as if "awakening", the complex content of the question is not comprehended. There is slowness in movements, silence, indifference to the environment. The facial expression of patients is indifferent. Drowsiness sets in very easily. Orientation in the environment is incomplete or absent. The state of stunned consciousness lasts from minutes to several hours.

Delirious clouding of consciousness. This state differs sharply from stunned. Orientation in the environment with him 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, there are sometimes transient, sometimes more persistent illusions and hallucinations, delusional ideas. 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: facial expressions resemble a viewer watching the scene. Facial expression becomes either anxious or joyful, facial expressions express fear or curiosity. Often in a state of delirium, patients become excited. As a rule, at night the delirious state amplifies. A delirious state is observed mainly in patients with organic lesions of the brain after injuries, infections.

Oneiric (dreaming) state of consciousness(first described by Mayer-Gross) is characterized by a bizarre mixture of reflection real world and abundantly popping up in the minds of vivid sensual representations of a fantastic nature. Patients "commit" interplanetary travel, "find themselves among the inhabitants of Mars." Quite 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 rushes in pieces in outer space" [173, 111].

Sometimes the patient's fantasizing is suspended, but then, 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 a deep disorder of self-consciousness. Patients are not only disoriented, but they have a fantastic interpretation of the environment.

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

Twilight state 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.

An attack of a twilight state ends critically, often. followed by 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, patients retain the ability to perform automatic habitual actions. For example, if a knife enters the field of vision of such a patient, the patient begins to perform the usual action with him - to cut, regardless of whether there is bread, paper or a human hand in front of him. Quite often at a twilight state of consciousness crazy ideas, hallucinations take place. Under the influence of delirium and intense affect, patients can commit dangerous acts.

The twilight state of consciousness, proceeding without delirium, hallucinations and changes in emotions, is called "ambulatory automatism" (involuntary wandering). Patients suffering from this disorder, leaving the house for a specific purpose, suddenly, unexpectedly and incomprehensibly to themselves, find themselves at the other end of the city. During this unconscious journey, they mechanically cross the streets, ride in vehicles and give the impression of people immersed in their thoughts.

The twilight state of consciousness sometimes lasts an extremely short time and is called absence (absence - French).

pseudodementia. 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 acutely advancing judgment disorders, 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. Behavior often resembles deliberately childish. So, an adult patient, when asked how many toes he has, takes off his socks to count them.

We stopped only on some forms of violation of consciousness. In reality, their manifestations in the clinic are much more diverse, but it was important for us to acquaint the reader with the concepts in which impairments of consciousness are interpreted and described in the clinic.

Along with. various forms of impaired consciousness as a reflection of the surrounding reality in the clinic there is a peculiar form of violation of self-knowledge - depersonalization.

Depersonalization. It is characterized by a feeling of alienation of one's own thoughts, affects, actions, one's "I", which are perceived as if from the outside. A frequent manifestation of depersonalization is a violation of the "body scheme" - a violation of the reflection in the mind of the main qualities and ways of functioning of one's own body. its individual parts and organs. Similar disorders, called "dysmorphia", can occur when various diseases- with epilepsy, schizophrenia, after traumatic brain injury, etc.

The dysmorphic syndrome has been described in detail by many psychiatrists, starting with the work of the Italian psychiatrist Morseli (Morseli, 1836-1894). Patients with a similar syndrome believe that they have "an ugly nose, protruding ears, they smell bad." Patients seek to take measures to eliminate the "interfering deficiency", insist on surgical intervention, they stand for hours in front of a mirror (a symptom of a mirror), constantly looking at themselves.

This syndrome is described in particular detail in the works of M. V. Korkina, who writes that this syndrome can be considered as a triad consisting of: a) the idea of ​​a physical defect with an active desire to get rid of it: b) the idea of ​​relationships and c) low mood.

The pronounced, obsessive or delusional desire of patients to correct an imaginary defect gave the author grounds to speak of dysmorphomania. This is not about the discrepancy between the meaningful reflection of the ideal idea of ​​the external appearance of the "I" and the present, but about the rejection of oneself, i.e. about unconscious rejection.

In psychology, the problem of "self-image" was considered within the framework of the problem of self-consciousness, starting with W. Wundt and A. Pfender, who identified the concept of "I" and the concept of "subject". In a different aspect, this problem is posed by W. James (1911), who distinguished between the empirical "I" (the mental world of the subject, which is supplemented by self-esteem) and the pure "I" ( thinking person). The problem of "image-I" was the subject of analysis of various psychological schools of Freudianism and neo-Freudianism, understanding, humanistic psychology, etc.

In domestic psychology, this problem appears already in L. Grot, I. M. Sechenov, who linked the problem of "I" with "warm feelings", interoreptions. The dependence of the physical image of the "I" on many points was shown, especially self-esteem, evaluation of others (I. S. Kon, A. A. Bodalev, S. L. Rubinshtein, etc.). SL Rubinshtein directly pointed out that the problem of studying personality "ends with the disclosure of self-consciousness of personality" [158, 676-677]. A number of works are devoted to changing the "self-image" in mentally ill patients (R. Federi, S. Fisher, and others). Many studies are devoted to the study of the violation of the "I" in patients with schizophrenia (Vekovich, Sommer).

In the work of B. V. Nichiporov, devoted to this problem, it is shown that dysmorphic syndrome is associated with low self-esteem. Such patients avoid society, retire, often experiencing their imaginary deformity is so strong that it can cause suicidal attempts. At the same time, their self-esteem is based not on the content of the idea of ​​the ideal image of the external "I", but on the rejection of their physical "I".

We find the most general answer to the question about the nature of this phenomenon in I. M. Sechenov, who emphasized the role of muscle sensations in the implementation of body movements and acts of perception, pointed out the existence of "dark", undifferentiated feelings emanating from internal organs, creating a "sensual lining" of our "I" and serving as the basis of self-awareness.

"Dark" interoreceptive sensations, due to their constancy and uniformity, as well as induction inhibition due to the outward orientation of the subject's activity, are usually not recognized, but are a necessary background for the normal course of all mental activity. Based on these sensations, the child in the process of development learns to distinguish himself from the world around him.

I. M. Sechenov argued that the synthesis of sensations emanating from the internal sense organs and the so-called external sense organs is the core of the formation of self-consciousness: “A person constantly receives impressions from his own body. bodies - by eye and touch), while others go, so to speak, from within the body and appear in consciousness in the form of very indefinite dark sensations. Sensations of the latter kind are companions of processes occurring in all major anatomical systems body (hunger, thirst, etc.), and rightly called systemic feelings. A person cannot, in fact, have any objective sensation, which would not be mixed with a systemic feeling in one form or another ... The first half of feelings has, as they say, an objective character, and the second is purely subjective. The first corresponds to the objects of the external world, the second - the sensual states of one's own body, self-perceptions" [171, 582-583].

Normally, a person does not need proof that his body belongs to his own person and mental experiences. In some pathological cases, this sensual "lining" of self-perception is violated, and as direct knowledge, a feeling of alienation, imposition, suggestion of one's own thoughts, feelings, actions can appear.

The modern researcher of the problem of depersonalization A. A. Megrabyan, showing the inconsistency of explaining this psychopathological phenomenon from the standpoint of associationism, phenomenological direction, anthropological psychology, psychoanalysis, connects it with the disorder of special "gnostic feelings" - systemic automated feelings, merged in a normal state with the reflective component of mental images.

Gnostic feelings, according to A. A. Megrabyan, reveal the following properties: 1) they generalize previous knowledge about the subject and the word in a concrete-sensory form; 2) provide a feeling of belonging of mental processes to our "I"; 3) include an emotional tone of a particular color and intensity.

The role of gnostic feelings in cognition and self-knowledge becomes especially noticeable in cases of pathology that gives rise to the phenomena of mental alienation [130, 131].

Violation of gnostic feelings can lead not only to a disorder of self-knowledge, but also to personal change. This is convincingly shown in the work of V. I. Belozertseva. Based on the work of the school of V. M. Bekhterev, the author revealed how an altered self-perception in the course of the reflective activity of a sick brain generates a new activity for the subject - the activity of self-perception. This activity, due to the constancy of unusual feelings and their special significance for a person, becomes meaning-forming, leading in the hierarchy of other types of activity. Patients abandon their former affairs and can think of nothing but their own. unusual states and the reasons for their occurrence.

Many case histories cited in the works of V. M. Bekhterev and his colleagues illustrate how the desire to comprehend the results of a distorted self-perception leads patients to a delusional interpretation of their condition. In search of "enemies" that affect them, patients observe the behavior of others, analyze relationships with them, perform real actions in order to "liberate" from the alleged hypnotic influence, and again analyze their state and the behavior of "enemies".

In the course of this activity and real relationships with people, the delusion of influencing the mental sphere acquires new and new details, distorting the perception of the environment and influencing the behavior and lifestyle of patients, rebuilding the system of their relationships with people, changing their personality.

V. I. Belozertseva concludes that if a healthy person’s sense of self is not related to his personal characteristics and awareness of himself in the system of social relations, then in a patient it can bring to the fore an activity that did not exist before or acted only as separate actions in the system of other activities, the activity of self-perception. Regardless of the personality (whether the person wants it or not), it becomes meaningful. There is a shift of the main motive to the goal, the “detachment” of the hierarchy of activities from the state of the organism, which is characteristic of a healthy subject, is violated. Biological in the case of pathology begins to play a different role than in the life of a healthy person.

This, of course, does not mean that the disease itself is biological factor determines the restructuring of the hierarchy of motives and self-consciousness. The motive for the activity of self-perception is generated by the awareness of the unusual, altered sensations of one's own mental experiences, an active attitude towards them. Consequently, the disease acts destructively on the personality not directly, but indirectly through activities acquired in the course of human social development.

We have presented these clinical data to show that pathological change psyche, its self-consciousness is carried out, like normal development, in ontogenesis, in the practical activity of the subject, in the restructuring of his real relationships - in this case, under the influence of the delusional interpretation of his state that develops in the course of self-perception, affecting the place of a person among other people.

So, I. I. Chesnokova writes that the material of clinical observations of self-consciousness disorders, expressed mainly in the depersonalization syndrome, is a factual justification theoretical provisions about self-consciousness as the central "forming" personality, linking together its individual manifestations and features.

Impairment of consciousness is a complex of mental and neurological changes in which the relationship between a person and the outside world is disrupted or completely absent.

There are key signs of disturbed consciousness:

• Perceptual disturbance. Sensory cognition is turned off, visual, auditory or tactile perception deceptions occur, which distort the picture of the outside world.
• Disorientation in place, time, or self. The patient may not know the location and time. In other cases, he is falsely, distortedly aware of himself, representing an unreal environment.
• Violation of rational cognition. A person with impaired consciousness does not understand the connections between objects and phenomena due to the inability to make judgments.
• Difficulty remembering. As a rule, a patient with impaired consciousness loses memory of events and his actions after leaving the unconscious episode. This manifests itself in the form of congrade amnesia. Sometimes memories are fragmentary, indistinct.

Types of disturbed consciousness

Violation of consciousness is divided into two groups: productive and unproductive. In the first case, the patient has hallucinations, perceptual delusions, fictitious objects and objects, which occurs in the case of mental disease states. Unproductive disorders of consciousness are the result of severe somatic diseases, injuries or infections that affect the nervous system, so they are observed not only in psychiatry.

Unproductive disorders of consciousness (turning off consciousness)

Stun

This condition is characterized by the fact that only intense stimuli cause a reaction in the patient (the threshold for responding to external stimuli rises). The patient understands the informational meaning of the stimuli, but it is difficult to orientate in time and the environment in combination with psychomotor retardation. In addition, mental activity slows down. Speech contact with the patient is difficult. A person answers with simple phrases, he is indifferent, drowsy, reacts to any stimuli for a long time.

Light forms of stun:

- Nubilation. Patients become fussy, excited. The clarity of consciousness fluctuates, a person can be included in the situation for a short episode, and then be absent again. Also characteristic is the lack of criticism of one's own condition. This is well illustrated by car accident victims who fussily help others in a state of shock, oblivious to their own injuries.

— Doubt- this is a form in which a person falls into a state of prolonged sleep, from which it is difficult to wake him up. When trying to wake the patient, aggression can be provoked. After a short awakening comes instant falling asleep. Somnolence is observed in patients after leaving an epileptic coma or a series of seizures.

Sopor

Sopor is a more serious condition than stunning. Consciousness is not completely turned off, but the patient does not understand the meaning of the addressed speech. Only elementary manifestations of mental activity are observed, only the most primitive reactions to stimuli are preserved. For example, when an injection is given, the patient will grimace in pain, and respond to a loud appeal only by turning his head. Muscle tone is lowered, reflexes are weak, the reaction of pupils to light is slow.

Fainting

Fainting is observed when consciousness is completely turned off and the patient does not respond to any stimuli (with ischemia - acute oxygen starvation bark).

Coma

Coma is a serious condition, which is characterized by complete inhibition of mental activity. There is a deep degree of disorder of consciousness - a complete shutdown of consciousness and shutdown of reflexes (absence of pupillary and corneal reflexes). Muscles completely lose their tone, reflexes are absent. The patient does not respond to external stimuli, any stimuli.

Productive disturbances of consciousness or clouding of consciousness

Delirium

This condition appears with intoxication (alcohol, atropine). Also, the cause of delirium can be an infection (typhoid, influenza), craniocerebral injury (TBI).

Delirium is characterized by a loss of orientation in place and time, while maintaining it relative to oneself. Accompanied by bright, lively and mobile visual hallucinations (rarely auditory). Patients are full of fear, anxiety, fussy, restless.

Characteristic appearance perceptual disturbances. The patient has hallucinations, and illusions may also be present.

Hallucinations during delirium are observed more often visual and tactile, less often - auditory. Often the patient sees animals (rats, small animals - zoohallucinations), demons, excessively large or small objects (more often - microhallucinations). Tactile hallucinations are also observed (for example, the presence of small creatures under the skin), the patient sees nets, cobwebs, wires. A striking example – thread symptom. A patient with alcoholic delirium may see an imaginary thread between the doctor's fingers. For various intoxications, there are specific symptoms. So, with cocaine delirium, a symptom of Manyan is observed, when the patient has tactile hallucinations in the form of the presence / sensation under the skin of small foreign bodies or insects, as well as crystals.

Sometimes the images acquire a scene-like character, like a movie.

In addition to distorted perception impaired thinking and memory. A person expresses unstable delusional ideas, sees false images of people. After leaving the delirium, fragmentary, torn memories of past events are observed.

Orientation is specific. The patient is aware of his identity, but is lost in place and time. If we talk about emotional changes, then there is affective instability. Fear, exorbitant horror, surprise or sudden aggression, tearfulness change each other dramatically. Sometimes the patient shows a humorous attitude to the events taking place ("the hangman's laughter"). The behavior of the person suffering from delirium is also sharply disturbed. He is fussy, restless, defending himself from something, running somewhere. Motor excitation is observed, the patient is difficult to control.

The intensity of delirious disorders increases in the evening and at night, and decreases during the day.

Oneiroid

Delusional, fantastic disturbance of consciousness, similar to a long dream.

Oneiroid is a condition that patients describe as a dream. This is an involuntary influx of pictures of fantastically delusional content, which have a complete plot and replace one another. The patient acts as a spectator. Dual orientation can be observed when a person is in two places at the same time. This applies not only to place, but also to time.

Symptoms of oneiroid are polymorphic (varied). The patient can see himself in oneiroid scenes, feels an involuntary flow of vivid thoughts and images. Experiences are scene-like. It is noteworthy that the images and psychopathological disorders are within the same plot, that is, they are systematized and have a peculiar plot, in contrast to delirium.

Orientation in the personality is sharply violated. The patient does not realize himself, he becomes a participant in events and influences the picture of a fictional world, which does not happen with delirium, where a person plays the role of an observer.

In the literature, two variants of oneiroid are distinguished: depressive(there are scenes of hell, torment, cataclysms) and expansive(visions take on the character of distant travels, space flights, magical scenes). The patient feels himself in a different world, which may have a different affective coloring depending on the above-described variants of the oneiroid. Much more often in practice, an expansive oneiroid is observed, in which an ecstatic affect is typical, when the patient experiences a feeling of delight, happiness. After leaving such a state, patients sometimes want to return back to oneiroid sensations.

Twilight clouding of consciousness

This is a special state that has an abrupt onset and a sudden end. The name of this violation is due to the fact that when it occurs, the circle of motives, ideas and thoughts narrows, which resembles a violation of seeing objects in the dark.

Elementary actions are observed, but the integrity of perception suffers. Consistent thinking and ordinary activity are not possible. Behavior is not conditioned by all external stimuli, but only by separately snatched stimuli. The perception of objective reality is observed in fragments, and the responses are perverted. The disorientation is aggravated by the fact that selective phenomena are mixed with hallucinatory and even fantastic images. The external movements of the patient are more often ordered, but not realized, the patient's actions are not predictable and therefore especially dangerous. Often during the twilight episode, people become extremely agitated, and may engage in dangerous, antisocial acts, destruction, and self-mutilation. The personality is disoriented, and after leaving the twilight there is a complete or fragmentary amnesia with a critical attitude, less often - the preservation of pathological experiences with delusional interpretation (residual delirium) for some time in the mind.

The twilight state is more often observed with epilepsy, sometimes with pathological intoxication and hysteria.

amentia

Amentia is a violation of consciousness, in which there is an extreme confusion of the patient, his disorientation in place, time, self. Thinking is inconsistent, without logical connection, and movements are chaotic. Speech contact is virtually impossible, speech is devoid of grammatical construction. It resembles a person who is frightened, agitated within the confines of the bed, cannot eat on his own, and spits out food when feeding. At the same time, the emotional state is extremely labile; in a person, sadness turns into joy, passivity into aggression. The hallucinations are fragmentary, they quickly replace each other. The patient may fall into a stupor or motor excitement.

Amentia is observed with TBI, severe intoxication, infectious lesions or schizophrenia.

conclusions

A patient with impaired consciousness needs urgent medical assistance. Productive disorders of consciousness require urgent psychiatric care. Hospitalization and assistance are necessary, even on a forced basis, since such a patient may pose a danger to others or himself. Therefore, if your relatives, friends or close people have characteristic signs of impaired consciousness, immediately consult a doctor.

Options for impaired consciousness

The following are some of the concepts used to refer to disorders of consciousness. The definitions of these concepts by different authors may not completely coincide.

Acute and subacute disturbances of consciousness

Darkening of consciousness - with a slight decrease in the level of wakefulness, the perception and assessment of the environment is reduced and distorted. Excitation, delirium, hallucinations, various affects are possible, in connection with which the patient may perform inappropriate actions. Typical for intoxications, psychoses. May precede the development of a coma.

Confusion of consciousness is characterized by a violation of the sequence and a slowdown in all thought processes, memory, and attention. Typical disorientation in place, time, personal situation. The level of wakefulness is reduced slightly. May be due to intoxication intracranial hypertension, acute and chronic circulatory disorders and other conditions.

Twilight consciousness is a kind of state when the perception and awareness of the surrounding reality is sharply limited or completely absent, but the patient is able to perform a series of unconscious sequential habitual actions. The most typical example is an epileptic seizure in the form of complex automatisms. Similar conditions can also be found in acute transient circulatory disorders (conditions like global amnesia).

Delirium - acute disorder consciousness, manifested primarily by excitement, disorientation in the environment and impaired perception of sensory stimuli, dream-like hallucinations, during which the patient is absolutely inaccessible to contact. A patient in a state of delirium may be aggressive, verbose, suspicious. The course of a delirious state is undulating, with relatively light intervals, during which elements of contact and criticism appear. The duration of the delirious state usually does not exceed 4-7 days. Occurs with exogenous and endogenous intoxications, including alcohol, as well as with severe traumatic brain injury in the stage of recovery from a coma.

Stunning is a condition in which the level of wakefulness is significantly reduced in the absence of productive symptoms. Speech contact with the patient is possible, but it is significantly limited. The patient is lethargic, drowsy, mental processes are slowed down. Disturbances of orientation, memory are characteristic. At the same time, the patient performs various motor tasks, the physiological position in bed is preserved, and complex habitual motor acts are preserved. Typical fast exhaustion.

Distinguish between moderate and deep stunning. The boundary between these states is very arbitrary.

• At moderate stunning preserved speech activity the patient in the form of answers to questions, although the speech is monosyllabic, there is no emotional coloring, the answers are slow, often they can be obtained only after repeated repetition of the question.
• At deep stun the decrease in wakefulness increases, the patient's speech activity is practically absent, but the understanding of inverted speech is preserved, which is manifested in the performance of various motor tasks. When differentiating the state of stunning, it should be remembered that the cause of speech impairment may be a focal lesion of the temporal lobe of the dominant hemisphere.

Sopor is a state that in translation means "deep sleep". A soporous state is usually understood as a deep depression of consciousness with the development of pathological sleep. Instructions are not followed. Nevertheless, the patient can be "awakened", that is, to get the reaction of opening the eyes to sound or pain. Vital functions are usually not significantly impaired. The mimic and purposeful coordinated motor response to the corresponding strong irritation, for example, to a painful stimulus, is preserved. Various stereotyped movements, motor restlessness in response to irritation are possible. After the action of the stimulus ceases, the patient again plunges into a state of unresponsiveness.

Stupor is a concept in English literature that is almost similar to sopor. It is also used to refer to psychogenic unreactivity, which occurs as an element of a complex symptom complex in catatonia (catatonic stupor).

Coma (coma). The main manifestation of a coma is the almost complete absence of signs of perception and contact with the environment, as well as mental activity (areactivity). The patient lies with eyes closed, it is impossible to “wake him up” - there is no reaction of opening the eyes to sound or pain. For all other signs (position in bed, spontaneous motor activity, reaction to various stimuli, degree of preservation of stem functions, including vital ones, condition reflex sphere etc.) comatose states are extremely diverse. The neurological symptom complex of a comatose patient consists of various symptoms of irritation and prolapse, depending on the etiology of the damage, its localization and severity.

Not every brain injury, even a very extensive one, causes a coma. Necessary condition development of this state - damage to the structures that provide wakefulness. In this regard, coma in supratentorial pathological processes is possible only with significant bilateral damage involving activating conduction systems that go from the reticular formation and thalamus to the cerebral cortex. Coma develops most rapidly when exposed to a damaging factor on the medial and mediobasal sections. diencephalon. When the subtentorial structures are damaged, coma develops as a result of a primary or secondary dysfunction of the brain stem and is primarily due to the impact on the oral sections of the reticular formation. The close functional connection of the reticular formation with the nuclei of the cranial nerves, which provide vital functions (respiratory and vasomotor centers), causes a rapid violation of breathing and blood circulation, typical for stem damage. The development of coma is typical for acute pathological processes in the brain stem (circulatory disorders, traumatic brain injury, encephalitis). With slowly progressive diseases, long-term compensation is possible (tumors and other volumetric processes of the posterior cranial fossa, including the brain stem, multiple sclerosis, syringobulbia).

Chronic disorders of consciousness

Chronic disorders of consciousness are usually called conditions that form as a result of acute disorders. There is no clear time boundary between acute, subacute and chronic disorders of consciousness. A chronic condition is considered to be a condition that has formed approximately one month after the violation of consciousness appeared. criterion chronic disorder one should also consider the stabilization of the state at a certain level and the absence of changes in one direction or another for a rather long (at least several days) period of time.

Vegetative state (vegetative status, waking coma, apallic syndrome). The above terms describe a state characterized by the relative preservation of stem functions in the complete absence of signs of the functioning of the cerebral hemispheres. A vegetative state usually develops as the outcome of a coma. Unlike the latter, it is characterized by a partial, stable or non-permanent recovery of the awakening reaction in the form of spontaneous or induced opening of the eyes, the appearance of a change in sleep and wakefulness. Spontaneous breathing is preserved and the work of the cardiovascular system is relatively stable. There are no signs of contact with the outside world. Other symptoms can be highly variable. So, motor activity can be completely absent or manifested by a mimic or non-purposeful motor reaction to pain; chewing, yawning, involuntary phonation (groaning, screaming), reflexes of oral automatism, and a grasping reflex may persist. Various changes possible muscle tone pyramidal or plastic type. Clinical picture corresponds morphological changes of the brain, the absence of microfocal changes in the trunk is characteristic with pronounced extensive bilateral changes in the telencephalon, especially its anteromedial sections, or these changes are insignificant.

A vegetative state can be a stage in the patient's exit from a coma. In such cases, as a rule, it is short-term, soon contact with the patient becomes possible (the first signs are fixation of the gaze, tracking, reaction to addressed speech). Nonetheless full recovery mental functions in a patient who has survived a vegetative state, it almost never occurs.

In the absence of positive dynamics, the vegetative state can persist for many years. Its duration depends mainly on good patient care. The death of the patient usually occurs as a result of infection.

Akinetic mutism is a condition in which a patient, who has all the signs of a fairly high level of wakefulness, the preservation of stem functions, elements of contact with the outside world (awakening reaction, change of sleep and wakefulness, fixation of gaze, tracking of an object), does not show any signs of motor and speech activity, both spontaneous and in response to a stimulus. At the same time, there are no signs of damage to the motor pathways or speech zones, which is proved by cases of complete restoration of motor and speech activity with a favorable outcome of the disease. The syndrome develops, as a rule, with a bilateral lesion of the medial parts of the hemispheres with the involvement of the reticulocortical and limbic-cortical pathways.

Dementia is a condition when, with intact high level wakefulness reveal gross stable or steadily progressive disorders of mental activity (content, cognitive component of consciousness). Dementia is the outcome of many extensive and diffuse organic lesions of the cerebral cortex (outcomes of traumatic brain injury, acute and chronic circulatory disorders, prolonged hypoxia, Alzheimer's disease, etc.).

isolation syndrome (locked-in) described by F. Plum and J. Posner in 1966. Occurs with extensive infarcts of the brain stem at the base of the bridge. It is characterized by a complete absence of voluntary motor activity, with the exception of eye movements in the vertical direction and blinking. These movements provide contact with the patient. The syndrome in the strict sense of the word is not classified as a disorder of consciousness, but it must be known, since the state of isolation is often confused with a coma or a state of akinetic mutism.

There are many different diseases that lead to impaired consciousness. Before touching on the causes of the disorder of consciousness, we should briefly dwell on the brain structures responsible for the state of clear consciousness.

A person is characterized by a change in periods of clear consciousness (wakefulness) and sleep. There is also an intermediate state - slumber. The ascending reticular formation located in the upper sections of the brain stem (mainly in the midbrain) is responsible for controlling the cyclic rhythm of sleep-wakefulness - the formation of the brain connecting the cerebral hemispheres with the long brain.

Types and symptoms of impaired consciousness

According to the depth of disturbance of consciousness, coma, stupor and stunning are distinguished.

Coma is an extreme degree of impairment of consciousness:

• there are no reactions to irritations (speech,);
• there is no alternation of sleep-wakefulness;
• eyes are closed.

Sopor(in foreign literature, the term stupor is more often used) - a milder degree of impaired consciousness compared to coma. With controversy:

• the patient cannot be fully awakened, but there is a reaction to pain (a non-directed protective motor reaction is preserved, for example, pulling back the hand when painful irritation is applied to it);
• reaction to speech is either weak (with mild stupor) or absent;
• after a short awakening (with mild stupor), the patient quickly again falls into unconsciousness, does not remember the moments of awakening in the future.

Stun- a state of incomplete wakefulness, which is characterized by the loss or impairment of varying degrees the severity of the coherence of thoughts and actions due to a gross disorder of attention, drowsiness.

Stunning should be distinguished from delirium (the most common cause of which is), in which stunning is combined with psychomotor agitation, delirium, hallucinations, and activation of the sympathetic nervous system (increased blood pressure, sweating, trembling, tachycardia).

With coma and deep stupor, in addition to impaired consciousness, other symptoms are observed:

Violation of the normal rhythm of breathing, in severe cases, breathing becomes chaotic; there may even be respiratory depression.

Impaired pupillary response to light.

Impaired eye movements (observed when lifting the eyelids): or floating movements, fixing the gaze.

A variety of pathological activities can be observed: epileptic seizures, muscle twitches (myoclonus), parakinesis (involuntary movements, reminiscent of arbitrary in nature - according to the popular expression: “before death, it is robbed”).

There may be a sharp increase in muscle tone or, conversely, its decrease ("atonic coma").

Glasgow scale

eye opening

Spontaneous - 4

Opening for speech - 3

Opening for pain - 2

Missing - 1

motor response

Follows a verbal command - 6

Localizes pain - 5

Withdraws the limb with its bending in response to pain - 4

Pathological flexion of all limbs from pain (decortic rigidity) - 3

Pathological extension of all limbs from pain (decerebrate rigidity) - 2

No movement - 1

Preservation of verbal responses

Oriented and talking - 5

Confused speech - 4

Says incomprehensible words - 3

Inarticulate sounds - 2

No speech - 1

The total score is the sum of the scores of the three groups. 15 points - clear consciousness, 14-13 - slight stun, 12-11 - severe stun, 10-8 - stupor, 7-6 moderate coma, 5-4 - deep coma, 3 - pulp death, transcendental coma.

Diagnostics

It is important to establish not only the degree of impairment of consciousness, but also its cause. In addition to the anamnesis, which may remain unknown either in the absence of the patient's relatives or because of their ignorance, additional studies help clarify the diagnosis.

Blood and urine tests - general analysis, analysis for blood, urine glucose, blood electrolytes, creatinine, calcium, phosphates, biochemical parameters of liver function, blood osmolality.

Screening toxic substances(carried out in specialized toxicological laboratories).

Electrocardiography (ECG).

Chest x-ray

X-ray of the skull (if TBI is suspected)

CT and MRI of the brain, revealing the presence of a stroke, the consequences of TBI (brain contusion, subdural hematoma, epidural hematoma, mixing of brain structures), encephalitis.

Lumbar puncture with subsequent examination of cerebrospinal fluid in case of suspected meningitis, subarachnoid hemorrhage.

Electroencephalography (ZEG), which makes it possible to distinguish coma from mental "reactivity (with hysteria, catatonia).

The reasons

Disturbances of consciousness (coma, stupor) can be caused by various causes neurological, metabolic (diabetes mellitus, hypothyroidism, adrenal insufficiency, uremia, hyponatremia, liver failure), poisoning, hypoxia (asphyxia, severe heart failure), sunstroke and heatstroke.

Neurological causes of impaired consciousness:

• with damage to the reticular substance of the midbrain and associated subcortical formations (primarily the thalamus);
• with extensive lesions of the cortex;
• with combined damage to the cerebral cortex and midbrain.
• TBI: concussion or contusion of the brain, hematoma, traumatic intracerebral hemorrhage, diffuse axonal damage;
• stroke;
• brain tumors (impaired consciousness can be caused by blockade of the CSF pathways, hemorrhage into the pituitary tumor, increasing with compression of the brain stem),
• status epilepticus,

diabetic coma

Hypoglycemic and diabetic (ketoacidotic) coma occur in diabetes mellitus. The first takes the 3rd place, and the second coma - the 5th place in the structure of the com. Hypoglycemic coma occurs more often in type 1 diabetes on the background of insulin therapy (and in those patients with type 2 diabetes receiving insulin) with fasting blood glucose at the level of 3 mmol / l.

Provoking factors:

• insulin overdose,
• skipping meals or not eating enough
• excessive alcohol intake

Medications can also cause a hypoglycemic state. These include: blockers, sulfonamides, salicylates, anabolic hormones, tetracycline, lithium carbonate, monoamine oxidase inhibitors, calcium-containing drugs.

Symptoms develop quickly (more often within minutes, less often hours). The first symptoms include profuse sweating, blanching of the skin, a feeling of severe hunger, hand tremors, weakness, and sometimes dizziness. Show up fairly quickly inappropriate behavior, psychomotor agitation (sometimes with aggression), impaired coordination of movements, further confusion, development of coma, sometimes convulsions.

At the first sign of hypoglycemia, the patient should eat a piece of sugar (a tablespoon of granulated sugar) or candy and drink a cup of very sweet tea. Coma is stopped by intravenous jet injection of 60 ml of 40% glucose, not more than 10 ml per minute. Then 5% glucose is injected intravenously (up to 1.5 liters per day) under the control of blood glucose.

Diabetic (most often it is ketoacidotic) coma when taking insufficient doses of hypoglycemic drugs or skipping insulin with unauthorized drug withdrawal and non-compliance with the diet. Physical activity, alcohol abuse, taking certain drugs (steroids, oral contraceptives, calcitonin, saluretics, adrenoblockers, diphenin, lithium carbonate, diacarb) can act as provoking factors. Diabetic hyperglycemic coma develops more slowly than hypoglycemic coma.

With moderate ketoacidosis, asthenia and thirst increase; there are dyspeptic phenomena, weight loss, in the exhaled air - the smell of acetone. In the future, a precomatous state occurs, characterized by stunning, an increase in dyspeptic phenomena (anorexia, vomiting, pain in the abdomen), shortness of breath, a decrease in mouse tone and eye turgor, and dry skin. On examination - tongue with brown coating, decrease in pressure, temperature, absence of tendon reflexes.

Data helps diagnose laboratory research: hyperglycemia and glucosuria, increased blood ketone bodies, acidosis.

In the precoma stage, the glucose level reaches 28 mmol / l, in the coma stage - 30 mmol / l and more.

Necessary urgent measures for diabetic coma include elimination of dehydration (dehydration), hypovolemia (decrease in circulating blood volume) and prevention of possible hemorrhagic complications, normalization of glucose and blood levels.

An intensive infusion therapy- saline solution 1 l/hour (up to 5-7 l) under the control of blood pressure, pulse rate, diuresis. If necessary, oxygen therapy and warming are carried out. For the prevention of thrombosis, 500 IU of heparin (preferably low molecular weight heparin) is administered intravenously. Insulin therapy is carried out with the control of blood glucose.

Coma with sunstroke

Often faced with coma that arose earlier healthy people as a result of solar (or thermal) stroke. Sunstroke can occur during heavy physical work under the scorching sun with an uncovered head, with prolonged sunbathing on the beach. The risk factor is excessive alcohol intake. Symptoms can occur not only directly during exposure to the sun, but also a few hours after insolation. In relatively mild cases (without loss of consciousness) and in a precomatous state, redness of the skin of the face, increased sweating, fever (in severe cases up to 41 ° C), tachycardia, and shortness of breath occur. In the future, tachycardia is replaced by bradycardia, breathing becomes arrhythmic, convulsions, delirium and impaired consciousness may occur.

Immediate measures for sunstroke include:

• placing the patient in a cool atmosphere;
• a cold compress (or ice pack) on the head of the patient and wrapping the body with a sheet soaked in cold water;
• intravenous injection of 500 ml of saline, subcutaneous injection of 1-2 ml of 10% caffeine, 1-2 ml of cordiamine.

The development of heat stroke is associated with a general overheating of the body, which occurs when staying in a hot and humid room, during intensive work in stuffy conditions, during long hikes (military, tourist) in the heat.

apalic syndrome

Coma is distinguished from such a special state of impaired consciousness as apalic syndrome (synonyms: vegetative state, chronic persistent vegetative state, "awake" coma). An apalic state is a total disorder of the function of the cerebral cortex with the preserved work of the trunk (including the midbrain), which is characterized by:

• as in coma - lack of consciousness, reactions to pain, sound irritations;
• unlike coma, the alternation of wakefulness and sleep is preserved (but their random change), during wakefulness there is no fixation of the gaze on any object and tracking of others.

In some patients, then there may be a partial (and sometimes quite good in apalic syndrome of traumatic genesis) recovery of consciousness. In the transitional stage, fixation of the gaze and tracking of others, primitive emotional reactions and purposeful movements occur.

isolation syndrome

The “isolation” syndrome (synonyms: the “locked up” syndrome) is sometimes perceived by the patient’s relatives as a gross violation of consciousness and intellect. This syndrome occurs with extensive heart attacks of the base of the brain stem. It is characterized by:

• total immobility (tetraplegia - paralysis of the arms and legs);
• lack of speech as a result of anarthria;
• preservation of consciousness and intellect;
• the preservation of voluntary eye movement and blinking, with the help of which communication with the patient is possible (for example, using Morse code, which is taught to the patient and the person caring for him).

Violation of consciousness in the form of coma and stupor should be differentiated from some mental states, outwardly resembling a coma: with conversion (hysterical) and catatonic (with schizophrenia) stupor. With a psychogenic disturbance of consciousness, there are no involuntary slow eyeballs, the eyes are often open, there is no change in muscle tone and changes in the EEG.

First aid for impaired consciousness

A general practitioner who finds a patient in a coma must:

• call ambulance for the purpose of speedy hospitalization of the patient;
• find out from relatives or acquaintances of the patient anamnestic data for making a preliminary presumptive diagnosis;
• measure blood pressure, pulse rate, respiratory rate, measure body temperature, and in the presence of a glucometer - blood glucose;
• emphasize on skin, turgor of the eyeballs and muscles of the limbs, the size of the pupils, the reaction to light;
• inject intravenously 60 ml of 40% glucose (not dangerous even if the patient has a hyperglycemic coma) with 100 mg of vitamin B1.