Delirium

Georget introduced the term stupidité (stupor) to replace Esquirol's term acute dementia to indicate a state in which a person appears to have no ideas or cannot express them. The term was adopted by German as well as French authors. Baillarger(!) suggested that patients with this syndrome were melancholic, and the term 'melancholy with stupor' became widely accepted despite problems with differential diagnoses. According to Griesinger: (2)

Melancholy with stupor has not only a great theoretical importance due to the strongly marked psychic symptoms and characteristic brain injuries existing in some cases, but also due to the fact that they are easily and frequently mixed up with dementia, which can lead to great errors in relation to the prognosis and treatment; for this they have also a great practical interest.

This controversy resembles that surrounding the term 'depressive pseudodementia' today. Other authors, while accepting that melacholy with stupor existed, thought that most cases of stupor were independent.

Chaslin(3) included stupidité under the term mental confusion. Both the concept and many of the clinical features correspond to Bonhoeffer's exogenous reaction type (die exogenen Reaktionstypus),(4) which he classified into three groups:

1. characteristic forms, which comprised amentia, delirium, twilight states, and hallucinosis;

2. homonymous forms, i.e those with manifestations similar to schizophrenia, mania, and depression;

3. a residual group including hyperaesthetic, sensory, or neurastheniform disorders together with Korsakoff's syndrome.

Two properties are essential: the manifestations lack specificity, and they share a disturbance of consciousness ( Bewusstsein). Kraepelin(5) attempted to study organic or exogenous psychoses using the medical aetiological model, believing that each aetiology corresponded to a specific aetiopathogenic mechanism and a characteristic symptomatology. This view was contradicted by Bonhoeffer,(4) who pointed out that in the characteristic forms each aetiology could give rise to any syndrome, and each syndrome could be caused by any aetiological factor.

Characteristic forms are characterized by a disorder of the consciousness; amentia, delirium, and twilight states are due to a decrease of consciousness, whereas hallucinosis is due to an increased clarity of consciousness.(6)

All Bonhoeffer's characteristic forms are included in the current classifications under the term delirium, but this is an error. Firstly, the disturbance of consciousness is not sufficiently emphasized and, secondly, syndromes which should be separated because of their different psychopathological characteristics appear together. In amentia, there is little decrease in consciousness; indeed, it may even go unnoticed although it is always present. Amentia is characterized by incoherent thought and severe motor disorder, whereas delirium is characterized by a more severe disturbance of consciousness with oneirism, hallucinations, and delusions (frequently occupational). In a twilight state, the level of consiousness is intense but fluctuating. It may occur with a decrease of the 'awake' consciousness ( Bewustsein), but without any alteration in 'reflexive' consciousness' (Ey's conscience de soi(7)). Finally, in hallucinosis increased clarity of consciousness is accompanied by anxiety, auditory hallucinations, and a tendency to paranoid ideas.

Some consider that all four syndromes described by Bonhoeffer should be mantained mainly to avoid diagnostic errors. Amentia, with little change of consciousness, is sometimes mistaken for schizophrenia or, in older people, dementia. The patient is perplexed, makes false identification, and is depersonalized. These manifestations of amentia may also be present in acute endogenous disorders such as the cycloid psychoses. Sometimes these subconfusional manifestations are chronic, with a long evolution when it is easy to mistake them with dementia. The possibility that enhanced amentia in the old may be of psychogenic origin (psychogenic unresponsiveness) has to keep in mind.

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