Consciousness is the sum of various mental functions—in the words of Jaspers (69> 'the whole of present mental life'. Lipowski,(70) who regards the concept of consciousness to be 'completely redundant', describes what is commonly meant by clouding of consciousness on the basis of a number of behavioural features ( Table 2). In contrast with Lipowski's sceptical attitude, the concept of consciousness has recently elicited fresh interest in philosophy and clinical neurology. (See Chapter 2.1.2,)
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Table 2 Behavioural features indicating clouding of consciousness
Consciousness is a mode of relatedness between mind and world. Disordered consciousness may occur on a dimension of severity which ranges from lucidity to clouding and further towards unconsciousness. The latter represents a state of coma. In addition, consciousness may be assessed on a dimension of vigilance. (D Ey(71> regards consciousness as an attribute of wakefulness. Indeed, sleepiness implies a reduction in consciousness; however, consciousness may also be reduced despite normal vigilance. This is just one example of how consciousness is connected with other mental faculties. Likewise, consciousness is impaired by a disorder of memory, orientation or coherence, as in the clouded consciousness of delirium. Some authors have suggested that disturbed consciousness could be the basis for stupor.
When consciouness is impaired there is clouding of perceptions, ideas, and images. The intensity of perceptions is diminished and there is a disintegration of order in the perceptive field. Accordingly, patients are disoriented.
The term confusional state is merely a synonym for delirium that emphasizes thought disorder and disorientation. Disorientation may concern time, place, or person. Temporal and geographical disorientation are very common. Remote contents are more robust then recent ones; name or date of birth are usually more available than age or name of the hospital. It is useful, after a polite excuse, to ask direct questions concerning orientation, even if they sound rather trivial, since some patients are very skilful in avoiding topics that show the degree of their disorientation.
Another aspect is described by the term narrowing of consciousness, which means that awareness of a person's environment is restricted, for example owing to an abnormal affective or delusional state.
In epileptic aura or after taking certain drugs, consciousness may be experienced as heightened with increased intensity of awareness.
Twilight state is a well-defined interruption of the continuity of consciousness. Consciousness is clouded and sometimes narrowed. Despite the disorder of consciousness the patient is able to perform certain actions, such as dressing, driving, or walking around. Subsequently, there is amnesia for this state. Twilight states may occur in epilepsy, alcoholism (mania a potu is a twilight state), brain trauma, general paresis, and dissociative disorder. Mania a potu describes the situation where a person reacts extremely, namely by developing twilight state, to small amounts of alcohol. Often these patients have an increased vulnerability due to pre-existing organic brain pathology. Twilight state may lead to violent behaviour and therefore needs forensic assessment.
In an oneiroid state the patient experiences narrowing of consciousness together with multiple scenic hallucinations. Oneiroid states may occur in schizophrenia, but are also observed in patients under intensive care who have to be totally passive and dependent on others. The atmosphere is perceived as strange and dreamlike. Accordingly patients may be aloof and behave like dreamers.(72) Unlike twilight states, the contents of oneiroid states are often remembered.
Finally, it should be noted that the subconscious of psychoanalytical theory is not open to direct clinical examination. Disorders of attention and concentration
Attention and concentration both mean the directing of mental activities towards a particular object, with the exclusion of other objects. There is little difference between attention and concentration except that, in ordinary language, attention is associated with present alertness and concentration with longer-lasting achievement and performance. There is a distinction between selective and shared attention. Attention and concentration may be impaired by clouded consciousness or may be due to individual aspects of clouded consciousness such as sleepiness, incoherence, or memory deficits. However, there may be other reasons such as hallucinations or mood disturbances. Attention deficit is a permanent feature in the eponymous childhood disorder attention-deficit hyperactivity disorder.
Assessment of attention and concentration may consist of simple arithmetical tasks and include psychometric performance tests in addition to the clinical examination. Psychometric performance tests are also valuable tools in assessing disorder of memory and consciousness.
Disorders of sleep are described in ChapteL4J..4J..., Chapter.4:J4.2, ChapteE4:J.4.3, Chapter4.14.4, C.hapieL4J.4...5. and Chapter.4.14.6. Chapter References
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