Types, causes, symptoms and treatment of confusion. Impaired consciousness

Types, signs, treatment of twilight stupefaction

Twilight disorder is a separate variant of qualitative disorders of consciousness. The twilight darkness is inherently psychotic disorder with productive symptoms.
Before today this type oppression of consciousness does not have an exact unambiguous definition. Some scientists indicate that with this disorder, the patient experiences a kind of dual “alternating” consciousness. This definition indicates the periodic variability of a person’s state: one moment the patient is in normal, clear functioning of the psyche, the next moment he experiences painful psychotic symptoms.
Such judgments of experts are based on the fact that, indeed, the leading distinguishing feature of twilight stupor from other qualitative disorders of consciousness is the unforeseen spontaneous occurrence of symptoms. This disorder is characterized by complete absence any factors that predict the development of the disorder. Symptoms of clouding of consciousness appear suddenly and are aggravated with lightning speed.

Another difference between this disorder and other forms of qualitative depression of consciousness is the transient nature of the illness episode. The attack of loss of clarity of consciousness is characterized by its short duration. For most people, symptoms of the disorder are recorded within a few minutes. At severe course disorder, an episode of loss of full functioning of the psyche lasts several hours. In isolated cases, symptoms of abnormal brain function are detected within a few days or weeks.
There is one more hallmark twilight stupefaction. This qualitative disorder ends as unexpectedly as it starts. The patient's painful symptoms suddenly disappear. The end of a psychotic episode marks the onset of deep terminal sleep.

Almost all people who have suffered an episode of twilight disorder experience a total loss of memory of events that occurred during the episode of illness. However, in some cases, the patient retains partial, often fragmented, memories of the events of the painful period. As a rule, the subject is able to reproduce the incident only for several minutes after the end of the attack. He remembers his thoughts, experiences, words. He talks about the content of hallucinatory images. Reports his actions and actions. However, after some time, the individual loses memory of the facts that occurred.

All researchers point out that when clear consciousness is restored, a person interprets the action he performed as an alien act committed by someone else. There is no complete connection between the actions performed by the subject and his self-awareness. The interruption of the phenomenon of self-awareness during the period of illness explains the patient’s inability to self-regulate behavior and determines the peculiarities of interpretation of the acquired experience.
One of the characteristic symptoms of twilight disorder is a person’s partial or complete detachment from the environment, his alienation from events occurring in reality. During the period of illness, a person perceives information about the phenomena of reality in the form of fragmented, distorted pictures. Or the patient’s perception of reality is completely distorted.

In twilight disorder, the psycho-emotional state is dominated by destructive emotions and feelings. At the same time, all his experiences reach the dimensions of affect and are perceived very painfully. Human thinking is subject to intense groundless obsessive fear. He is gripped by irrational anxiety and feels the uncertainty of his own future. He is haunted by difficult-to-define premonitions, thoughts of the inevitability of a catastrophe.

His soul is engulfed in black melancholy and oppressive melancholy. Corroding sadness, all-consuming despondency outwardly manifests itself as angry irritation towards everything that happens. The patient becomes conflicted and unfriendly. He behaves extremely hostilely and aggressively both with strangers and with close people. In twilight disorder, outbursts of rage occur spontaneously. Without any reason, a benevolent and sweet person suddenly becomes an unkind and malicious person. At the moment of an outburst of anger, an individual is capable of not only insulting and offending others, but also causing them physical harm.
Almost always, with twilight disorder, a person loses the integrity of self-awareness and is deprived of the opportunity to objectively navigate in self. Characteristic personality traits are partially or completely erased.
The patient is unable to plan and implement targeted actions, which would correspond to the current situation and would not be contradictory to the foundations existing in society. Often, being in a state of stupefaction, the subject experiences auto-aggression. He commits actions aimed at causing harm to himself. He may, contrary to the natural instinct of self-preservation, cause himself severe bodily harm or behave in such a way that it is likely that his life will end much earlier than the allotted time.

Often in the clinic of twilight disorder there are true hallucinations from various analyzers. Vivid visual, auditory, tactile, olfactory, and gustatory hallucinatory images appear. The patient perceives the emerging hallucinatory objects and phenomena as really existing components of reality. Plots of hallucinations completely displace real objects and events from the world of perception. Another symptom of some variants of clouding of consciousness is the emergence of illusions - distortions in the perception of reality. Often in patients, acute sensory delirium indicates a lack of clarity of consciousness. The delusional sayings uttered by the subject directly indicate how he perceives his own personality and the world around him. Most often, the delusional ideas expressed are devoid of connection with each other: they are inconsistent in content and contradictory in meaning.

In the manner of behavior of a person in a state of stupefaction, two styles can be determined. One group of patients acts illogically and unsystematically. They do some pretty strange things. Their behavior is chaotic and unfocused. The behavior of other patients looks quite normal outwardly. It seems to others that the person is behaving according to a pre-drawn plan. All his actions are perceived by people as consistent and logical. However, no matter what behavior a person demonstrates, his actions are determined by a painful psycho-emotional state and productive symptoms - hallucinations.

Twilight disorder: symptoms of certain variants of stupefaction
All cases of twilight stupefaction can occur in one of the following options, which have differences in etiological factors and occur with certain clinical symptoms. Psychiatrists distinguish the following types of disorders:

Human motor activity also undergoes changes. At one moment the patient's movements are slow and inhibited. In the next moment, he becomes excited: his facial expressions, gestures, and movements are chaotic and expressive. In some patients, active or passive negativism is determined. Whatever the subject is asked to do, he does the opposite. Or he doesn’t fulfill requests and demands at all. Typical symptom a simple variant of twilight stupefaction - loss of the ability to carry out purposeful motor activity.
In some cases, the patient experiences symptoms of ambulatory automatism: the subject performs illogical, inappropriate and useless actions. Without having to do so, he can leave the house, walk to a stop, get on a bus and travel a certain distance on it. Coming out of the bus, a person does not understand where he is, how he ended up here.

Paranoid (delusional) variant
Symptoms of the delusional form of stupefaction do not appear immediately, but arise gradually. The main difference between this option is the occurrence of acute delirium. Changes significantly psycho-emotional state patient: the predominant feelings are debilitating melancholy, furious anger, and withering anxiety. As the disorder worsens, the patient experiences hallucinations, most often visual and auditory. Hallucinatory images instill fear and horror. The stories that appear are very expressive and rich in content. All thinking and behavior of the patient is subordinated to painful obsessive experiences and perceived hallucinatory images.
A characteristic symptom of the paranoid variant of stupefaction is episodic affective outbursts. At such moments, the patient completely loses control over his actions. He behaves hostile and aggressive. Starts conflicts with others, starts fights. In a state of passion, the subject often commits criminal acts. It can cause harm to the health of both random strangers and loved ones.

It is not possible to establish normal contact with the patient. Since he is overwhelmed by delusional ideas, he does not respond to appeals addressed to him. The patient’s narratives tell about what experiences overcome him. In his stories, the patient mentions some offenders and ill-wishers. His painful conclusions are based on past events when someone accidentally offended and insulted him. He gets obsession that this mythical offender has developed a plan of revenge, the goal of which is the physical destruction of the patient. This is why a subject gripped by productive psychotic symptoms begins to take countermeasures.
His behavior fully reflects his condition inner world. However, the patient’s actions are often externally perceived by people around him as pre-planned actions. Indicates confusion of consciousness appearance person. He looks focused and collected. The absent look is noticeable. There is an unusual silence and isolation observed in the person.
The paranoid episode ends suddenly. Most often it hurts to fall into deep sleep. After awakening, he has no memories of the period of illness. He interprets the actions he has performed as actions performed by someone else. He completely denies his involvement in the offenses he committed.

Delirious (hallucinatory) variant
Symptoms of the hallucinatory form of stupefaction occur with lightning speed. Initially, the patient experiences a distortion of the perception of reality in the form of illusions. Hallucinations from the visual and auditory analyzers soon follow. The images that appear are filled with an ominous, frightening meaning. One storyline can be traced between individual hallucinations.
It is impossible to establish connections with the patient: he does not perceive stimuli from the outside and does not respond to changes in environment. The individual does not understand questions and requests. He is unable to adequately express his experiences. His speech is represented by sounds similar to mooing.

Because his mind is overwhelmed by terrible visions, the patient experiences overwhelming fear. He is extremely hostile towards others. From time to time he has outbursts of fierce anger for no reason. The patient ceases to control his actions. In this state, he can cause significant harm to himself and those close to him.
At the end of the attack, the memories of the events that occurred are completely erased. The person does not remember what he felt or how he behaved.

Oneiric (dream-like) variant
A dream-like form of clouding of consciousness is characterized by the patient’s emergence of absurd thoughts that have a mythical, fantastic content. The individual is transported into a world of illusions. The emotional state is dominated by inexplicable and uncontrollable fear. All of the subject's experiences are very intense and painful.
Visual hallucinations are soon added to the distorted perception of reality. The emerging images are represented by non-existent creatures, fairy-tale characters, and fantastic paintings. The person sincerely believes in the existence of such objects and phenomena. The person becomes a direct participant, and often the main character, of hallucinatory plots. The patient's behavior fully corresponds to the visible pictures.

A characteristic symptom of oneiric stupefaction is a change in motor activity. The patient most often remains in one position. He can stay in one position for days on end, without trying to move or change his body position.
After exiting the oneiric state, a person partially retains memory of events. He can tell you what hallucinatory images he had. However, his stories are fragmented.

Dysphoric (oriented) variant
Signs of a dysphoric type of disorder arise without any warning signs and become aggravated very quickly. Likewise, the end of an episode of illness is marked by a lightning-fast extinction of psychotic symptoms.
The difference between the dysphoric variant of depression of consciousness is the insignificant depth of the disturbances. A person understands who he is. He orients himself normally in space. He recognizes familiar faces.
In the dysphoric form of the disorder, the subject appears as if he is not fully awake. He is lethargic and sleepy. Speaks slowly, smoothly and quietly. He moves, swaying from side to side.
The foundation of the oriented variant of depression of consciousness is a pathologically low mood. Subject is anxious and irritable. He is exhausted by melancholy and anger towards others. It seems to outsiders that the person fiercely hates the whole world.

Hallucinatory images are not constantly present, appearing from time to time, putting a person in a state panic fear. Sizzling sadness and all-consuming hatred often reach the level of passion. At the moment of an attack, a person begins to destroy and destroy everything that is in his field of vision. At such a moment, he has no control over his emotions and actions at all.
After regaining clarity of consciousness, the patient retains memories for a short time. However, after two to three hours, there is a total loss of memory about the episode of the disorder.

Hysterical variant - Ganser syndrome
Hysterical stupefaction is formed against the background of long-term stress. Symptoms of Ganser syndrome occur after an extreme traumatic event. The impetus for depression of consciousness can be a person’s sudden exposure to unusual, uncomfortable, unsafe conditions.
In the hysterical variant of the disorder, complete alienation from real world. In most cases, the patient can be contacted. However, all his narratives boil down to a description of events that became tragic for him.
Characteristic sign Ganser syndrome is a kind of return of the patient to his childhood. His behavior and speech resemble those of children. He makes faces, grimaces, behaves as if he were a clown. The patient deliberately distorts the pronunciation of certain sounds. He may begin to lisp and be out of tune. He pretends that he cannot pronounce some words. He gives deliberately absurd answers to simple questions. For example, when asked how many fingers he has on his hands, he answers that there are eleven.

There is pronounced distortion when performing typical actions. The patient may diligently pull socks on his hands, and he will try to put gloves on his feet. Although he understands the purpose of these wardrobe elements. Some individuals do not show any reactions when exposed to pain receptors. They may not seem to feel pain, such as from a needle stick.
A complete loss of the ability to orientate oneself in time, place, and one’s own personality is recorded. Emotional condition the patient is fickle: emotions of joy instantly change to experiences of grief.
After the episode of confusion ends, the person has fragmentary memories of the events that occurred. After deep sleep The person's memory function is fully restored.

Twilight disorder of consciousness: urgent Care and treatment
If it is suspected that the subject has developed twilight stupefaction, people around them should immediately call a medical team. Delivery protocol medical services stipulates that in this situation a psychiatric team should arrive at emergency call within 10 – 20 minutes. Since a person’s behavior during twilight stupefaction can lead to unpredictable consequences, the patient is hospitalized in a psychiatric hospital, where he will be examined and subsequently treated.
Before the ambulance arrives, the main task of witnesses to the disorder is to ensure the safety of the patient and their own safety. It is necessary to isolate the individual from contact with society. The optimal course of action is to address the person in a calm, friendly tone and unobtrusively but persistently invite him to sit on the sofa.

If the patient demonstrates aggression and tries to leave the room, the front door should be closed. He must not be allowed to leave the room and come into contact with other people, since it is impossible to predict his behavior. Doctors recommend maintaining some distance when communicating with the subject. He may perceive being too close to a patient as threatening attacks against him.
It is necessary to ensure that there are no things, objects, liquids, or flammable substances near the patient, the use of which would involve causing physical harm. An individual in a state of stupefaction must not be allowed to come close to windows or go out onto balconies.
Considering that many patients with twilight stupefaction are in a state of pronounced psychomotor agitation and demonstrate aggressive and auto-aggressive tendencies, the main measure at the prehospital stage is to secure the patient by physical restraint.

To avoid causing harm to oneself and others, the patient is administered intramuscularly or intravenously the antipsychotic drug Aminazine in a dose of 2 ml of solution, which corresponds to 50 mg of chlorpromazine hydrochloride. 2 ml of aminazine solution is diluted in 20 ml of 5% or 40% glucose solution (Glucosum). Also, the patient, while maintaining normal indicators blood pressure intravenous or intramuscular injection Cordiamin (Cordiamin) in a dose of 2 ml of solution. To relieve (relieve) psychomotor agitation and anxious agitation, stabilize the heart rate, intramuscular or intravenous administration 2 ml of tranquilizer solution Seduxen. If twilight stupefaction is not accompanied by pronounced agitation, it is recommended to initial stage treatment, conduct psychostimulant therapy by subcutaneous administration 1 ml of caffeine-benzoate sodium solution for injections.

IN medical institution are carried out:

After completing a course of pharmacological therapy, all patients are recommended to undergo a course of psychotherapeutic treatment. If, during the period of a disorder of consciousness, a person committed a public dangerous action that violates the existing legal order and causes harm to other members of society, by court decision an outpatient commission forensic psychiatric examination is carried out to establish mental status patient.

Twilight Darkness consciousness - the most common form of disorder of consciousness in epilepsy, determined by disorientation in place, time, and self; accompanied by incorrect behavior. When only these symptoms predominate, we can talk about a simple form of twilight stupefaction. This form usually occurs acutely. The patient does not perceive his surroundings, and it does not affect his behavior. The patient can perform relatively complex purposeful actions, but more often these are individual automated movements. Speech is either absent or incoherent. It is impossible to enter into a conversation with the patient. The disorders disappear gradually. There is no memory of this painful episode. Twilight state ( simple form) lasts from several hours to several days. This form most often occurs in epilepsy with a predominance of grand mal seizures.

Twilight stupefaction may be accompanied by delusions, hallucinations, and altered affect. Hallucinatory-delusional forms of twilight stupefaction often develop gradually. The content of hallucinatory-delusional disorders is reflected in patients’ perception of the environment, their statements and actions. Speech contact with patients is preserved to one degree or another. Delusional ideas of persecution, personal and universal death, erotic-religious or expansive delusions (greatness, reformism, messianism) predominate. Visual and olfactory hallucinations are more common, auditory hallucinations are less common. Visual hallucinations are sensually bright, often colored in red, pink, yellow and other colors; usually it is war, disasters, murders, torture, religious, mystical and erotic visions.

Patients see a crowd crowding them, vehicles running into them, collapsing buildings, moving masses of water. From olfactory hallucinations The typical smell is of burnt feathers, smoke, rot, and urine. The frightening nature of delirium and hallucination is combined with an affect of fear, horror, anger, frenzied rage; states of ecstasy are much less common. Movement disorders in the form of excitement can be holistic and consistent, accompanied by actions requiring great dexterity and physical strength. Twilight stupefaction with productive disorders lasts from several days to a week or more. It is often accompanied by alternating consciousness with short-term clarity. Symptoms of psychosis may suddenly disappear. Along with complete amnesia, patients may first remember and then forget about their previous disorders (retarded amnesia). The degree of impairment of consciousness during twilight states can be very different - from deep darkness to a mild narrowing and slight stupor.

Particularly difficult to recognize are cases of the so-called oriented twilight consciousness, characterized by a shallow depth of clouding of consciousness, preservation in patients of the ability to basic orientation in the environment, recognition of loved ones, absence or appearance of a short time psychotic symptoms (delusions, hallucinations, affect of fear, anger). Patients in such conditions outwardly give the impression of people who are not completely awake - they have an unsteady, shaky gait, and slow speech.
Sometimes the content of statements during twilight states reflects past psychogenic influences, the patient’s hidden desires, and previous hostile relationships with others, which can influence his actions. For example, the patient includes the “offender” in hallucinatory delusional ideas and begins to pursue him. Outwardly, this may give the impression of meaningful, purposeful behavior.

If the picture of twilight stupefaction is dominated by scene-like visual hallucinations, related in content and successively replacing each other, then they speak of delirious confusion or epileptic delirium; if hallucinatory-delusional disorders have a fantastic content, but there is no complete amnesia, then the case is classified as epileptic oneiroid. Often it leaves behind residual delirium, transient or protracted.

During twilight stupor, with epileptic oneiroid, as well as with severe dysphoria, incomplete or complete immobility may occur - epileptic substupor and stupor. The latter never reaches deep degrees, for example, lethargy with numbness. Stuporous states last for hours, days, sometimes weeks.

Hallucinatory-delusional forms of twilight stupefaction, delirious confusion and oneiroid usually occur in epilepsy with a predominance of polymorphic paroxysms. The characteristics of delusions, hallucinations and affect that arise in these forms are often the reason for the behavior of patients that is very dangerous for others. Attacking imaginary enemies or defending their lives, patients destroy everything, maim and kill everyone in their path. Twilight states without delusions and hallucinations include ambulatory automatism and somnambulism.

Twilight stupefaction. This disorder occurs suddenly, usually not for long, and ends just as suddenly, which is why it is called transient, passing quickly. This syndrome is typically characterized by a combination of deep disorientation in the environment with the development of hallucinosis and acute figurative delusions, an affect of melancholy, anger and fear, frantic excitement or outwardly ordered behavior.

Under the influence of delirium, hallucinations and intense affect, the patient suddenly commits extremely dangerous acts: he brutally kills or maims close relatives and strangers who are taken for enemies; due to the rage that gripped him, he senselessly destroys everything that comes to hand, destroying animate and inanimate with equal malice.

An attack of twilight stupefaction often ends with subsequent deep sleep.

Memories of the period of clouding of consciousness are completely absent, the attitude towards the committed, sometimes serious crime (murder of relatives, children) is as someone else’s, and not as one’s own act. With twilight stupefaction, there are no memories not only of real events, but, in contrast to delirium and oneiroid, and of subjective experiences. In some cases of twilight stupefaction, the content of delirium and hallucinations is preserved in the first minutes after its end, but is subsequently completely forgotten (retarded, delayed amnesia).

The following variants of twilight stupefaction are distinguished.

Crazy option. The patient’s behavior is outwardly orderly, but attention is drawn to an absent look, special concentration and silence. Socially dangerous actions committed by patients in this state may give the impression of being premeditated and prepared. When clearing consciousness, patients treat the actions they have committed as alien to their personality. With careful questioning, you can obtain information about delusional experiences during the period of clouding of consciousness.

Hallucinatory variant accompanied by a predominance of hallucinatory experiences, a pronounced state of excitement with destructive tendencies, and aggression.

The depth of twilight stupefaction can vary widely. In a number of cases, patients retain basic orientation in their surroundings, they recognize people close to them, and fragments of self-awareness are discovered. Delusions and hallucinations may be absent or occur in the form of fleeting episodes. The affect of anger and fear is expressed. This type of confusion is called oriented (dysphoric) twilight stupefaction.

Twilight stupefaction occurs most often with epilepsy, traumatic brain lesions, organic brain lesions occurring with episyndrome, less often - with acute symptomatic ones, incl. intoxication psychoses.

TASK.

Patient K., 36 years old, police officer. Was taken to court psychiatric department hospitals from the holding cell. He has always been an efficient, hardworking and disciplined person. One morning, as usual, I got ready for work, took a weapon, but suddenly with a desperate cry: “Beat the bandits!” ran out into the street. Neighbors saw him running along the block with a pistol in his hands, continuing to shout something. Shots were immediately heard. Concerned about what happened, the neighbors called the police. The patient was detained in the next block, and showed violent resistance. He was excited, pale, and continued to shout threats against the “bandits.” Not far from him, three wounded passers-by were lying on the ground. About an hour later, the patient woke up in the police station. For a long time he could not believe that he had committed a serious crime. He remembered that he was at home, but subsequent events completely disappeared from his memory. Having become convinced of the reality of the events that had taken place, he reacted with deep despair, reproached himself for what he had done, and tried to commit suicide.

What kind of condition did the patient have?

SAMPLE CORRECT ANSWER

The described condition meets all the main signs of twilight disorder of consciousness. It began suddenly, did not last long, ended critically, followed by complete amnesia for the entire period of stupefaction. One can guess about the patient’s experiences during this period only by his behavior. The latter indicates that the disorder of consciousness was combined with vivid sensory delirium, possibly an influx of hallucinations. All this was accompanied by a strong affect of anger, rage and senseless aggressive actions. The presence of hallucinatory-delusional experiences and psychomotor agitation distinguishes this type of twilight state of consciousness from ambulatory trance.