Disorders of Disorders of consciousness and consciousness and experience of selfexperience of self

Presenter:Dr Mohd Osman Ali MBBS, DPMdr_osmanali@yahoo.com

Scheme of presentationScheme of presentation Introduction to consciousness--consciousness,

unconscious, preconscious, three dimensions , attention, concentration, orientation

Disorders of consciousness-psychopathological aspects --Quantitative lowering--clouding, drowsiness, coma

--Qualitative change—delirium, fluctuations, confusion

--other changes(restriction)– twilight state, dissociative fugue, mania a potu(pathological intoxication), automatism, dreamlike(oneroid) state, stupor, locked-in syndrome,

Introduction to attention

Disturbance of active attention

Scheme of presentation 2Scheme of presentation 2

Introduction to self and experience of self--ego and self, self concept and body

image, the body schema and cathexis, experience of self-four aspects

Disorders of experience of self

—of awareness of self activity – depersonalisation, derealisation, desomatisation, deaffectualisation, jamais vu, déjà vu

--of the immediate awareness of self unity --of the continuity of the self

--of boundaries of the self--of awareness of the body

Psychiatric aspects-- Theoey of mind (mentalisation)

INTRODUCTION INTRODUCTION TO TO CONSCIOUSNESSCONSCIOUSNESS

Study of consciousnessStudy of consciousnessThrough combining and sharing

the perspective of different disciplines: philosophy, psychology, medicine and neuroscience (Bock and Marsh, 1993)

Definition of Definition of consciousnessconsciousnessFor the purpose of descriptive

clinical psychopathology, consciousness can be simply defined as

-- a state of awareness of the self and the environment (Fish, 1967)

Consciousness is to be consciousness to know about oneself and the world. It is better used as an adjective than noun– a man does not posses consciousness--- -- the object of consciousness is its essential social dimension ( Sharfetter,1980)

preconsciouspreconsciousAmong unconscious, for which

there is a good evidence of their existence, frequency, and complexity, there are some which have been, or may yet become, conscious. This is what Freud called Preconscious (Frith, 1979)

conscious Vs conscious Vs preconsciouspreconscious Strict limit to the no of

items available

If stimulus is, only one interpretation is possible at one time

Very difficult to carry out more than one task

Flexible, strategic Conscious is executive in

nature and is dominant to and has the capacity to override the perceptions and functions of preconscious process

Very much more information is stored

Multiple meanings are available

Undertaking parallel task is usual

automatic

unconsciousunconsciousJasper(1957)- meaning of

unconsciousness --it is not an inner existence, does not occur as experience

--not thought as an object and has gone unregarded

--something which has not reached any knowledge of self

Clinicians use of Clinicians use of consciousness and consciousness and unconsciousnessunconsciousnessinner awareness

of experience

the subject reacting to objects intentionally

denotes a knowledge of conscious self

There is no subjective experience

Seen as conscious– unconscious continuum

Three dimensions of Three dimensions of consciousness and consciousness and unconsciousnessunconsciousness Vigilance(wakefulness)----

-drowsiness(sleep) axis

Lucidity ----clouding axis

Consciousness of self

Normal state of consciousness----- death(in a person suffering from serious brain disease)

Full wakefulness-----to deep sleep( in a person who is sleep)

Full vigilance ------total unawareness(in an alert and healthy person

The organic state of brain, as for instance, demonstrated by EEG, is utterly different in these three situations

Vigilence(wakefulness)---Vigilence(wakefulness)---drowsiness(sleep) axisdrowsiness(sleep) axisThe faculty of deliberately remaining

alert when otherwise one might be drowsy or sleep.It fluctuates

Factors influencing vigilance– interest, anxiety, extreme fear

or enjoyment (promotes vigilance)-- boredom( promotes

drowsiness) --the situation in the environment and the way the individual perceives the situation

Qualitative difference in the nature of wakefulness

--- the significant state of mind of a person scanning radar screen for possible enemy interceptor is very different from the rapt attention of music lover listening to a symphony

Lucidity--- clouding axisLucidity--- clouding axisConsciousness is inseparable

from the object of conscious attention: lucidity can only be demonstrated in clarity of thought on a particular topic

Lucidity Vs vigilance– unless the person is fully awake he cannot be clear in consciousness

Clouding denotes the lesser stages of a impairment on a continuum from full alertness and awareness to coma(Lishman,1997)

The pt may be drowsy or agitated, and is likely to show memory disturbance and disorientation

Most intellectual functions are impaired including attention, and concentration, comprehension and recognition, understanding, forming associations, logical judgment, communication by speech and purposeful action

Consciousness of selfConsciousness of selfAbility to experience self and

awareness of self that is both immediate and complex

DISORDERS OF DISORDERS OF CONSCIOUSNESS—CONSCIOUSNESS—PSYCHOPATHOLOGICAL PSYCHOPATHOLOGICAL ASPECTSASPECTS

Classification of disorders of Classification of disorders of consciousness (Fish)consciousness (Fish)Consciousness can be changed in

three basic ways it may be dream like,depressed, or restricted

Classification of Disorders Classification of Disorders of consciousness(Sims)of consciousness(Sims)

Quantitative lowering of consciousness

Qualitative change of consciousness

Normal(alert, vigilant, lucid)

Clouding DrowsinessSoporComa Death

DeliriumFluctuationsConfusion

Disorders of consciousnes Vs Disorders of consciousnes Vs dementiadementiaDisorders of consciousness are associated

with disorders of perception, attention, attitudes, thinking, registration and orientation

The pt with disturbance of consciousness usually shows, therefore, a discrepancy between their grasp of the environment and their social situation, personal appearance and occupation.

This lack of comprehension in the absence

of other florid symptoms of disordered consciousness may lead to a mistaken diagnosis of dementia

Disorders of consciousness Vs Disorders of consciousness Vs orientationorientationWhen consciousness disturbed it

tends to affect three aspects– time, place, and person in that order

If patient is disoriented for time and place, it is customary to say that they are confused

Most patients with confusion are

perplexed, but this sign is also seen in sever anxiety and acute schizophrenia in the absence of disorientation

QUANTITATIVE QUANTITATIVE heightening of heightening of consciousnessconsciousnessThere is a subjective sense of richer

perception: colours seem brighter, and so on.

There are changes in mood, usually exhilaration perhaps amounting to ecstasy

There is subjective experience of increased alertness and a greater capacity for intellectual activity, memory and understanding

May be associated with synaesthesia- a sensory stimulus in one modality resulting in sensory experience in another

--eg; hearing a finger nail drawn down a blackboard results in a cold feeling down the spine

Conditions seen are -- normal healthy people– esp

in adolescence or at times of emotional, social or religious crisis, when falling in love, on winning a large sum of money, at sudden religious conversion and so on

--drugs– notably with hallucinogens(LSD), CNS stimulant(amphetamine)

--occasionally in early psychotic illness, esp mania, or less often in schizophrenia

QUANTITATIVE QUANTITATIVE lowering of lowering of consciousness consciousness Impairment of consciousness is the primary

change in acute organic reactions and holds a fundamentally important place in the detection of acute disturbance of brain function and in assessment of severity(Lishman,1997)

Some conditions may produce a variable level of diminution of consciousness: that occurring with migraine: for example, may range from blunted awareness through lethargy and drowsiness to loss of consciousness(Lishman,1997)

clouding clouding

Lesser stage of consciousness associated with deterioration in thinking, attention, perception, and memory and usually drowsiness and reduced awareness of environment

although pts awareness is clouded, he may be agitated and excitable rather drowsy

The term clouding should be used for the

psychopathological statea)impairment of consciousness

b)slight drowsiness with or without c)and difficulty with attention and concentration

This will usually occur with organic impairment of function

Clouding Vs sleeping--There are important differences between the reduced wakefulness before falling sleep and clouding in an organic state (Liowski, 1967)

drowsinessdrowsinessNext level to clouding of consciousness

As a descriptive term simply means diminished alertness and attention which is not clear under the patients control

Pt is awake but will drift into sleep if left without sensory stimulation

Associated with--slow in action--slurred speech

--sluggish in intention--and sleepy on subjective

description

There is an attempt at avoidance at avoidance of painful stimuli; reflexes, including coughing and swallowing are present but reduced muscle tone is also diminished

These level of diminished consciousness are quite non-specific and occur whatever the nature of the cause

Conditions seen-- in the psychiatric practice this is commonly seen following

over dosage with drugs that have a central nervous depressant

effect. In such case interviewing the pt is impossible

comacomaPt is unconscious. In slight state, with

strong stimuli he may be momentarily arousable. In later stages pt is no longer arousable, he is deeply unconscious

There are no verbal responses or responses to painful stimuli

The righting response of posture has been lost. Reflexes and muscle tone are present but greatly reduced

Breathing is slow, deep and rhythmic. The face and skin may be flushed

Distinct stages of coma have identifiable physical signs ultimately culminating in brain death, (conference of medical royal college,1976)

Practical assessment of the depth and duration of impaired consciousness and coma has been quantified in the scale devised by Teasdale and Jennett(1974)

QUALITATIVE changes of QUALITATIVE changes of consciousnessconsciousness Definition of delirium Definition of delirium

Lishman– a syndrome of impairment of consciousness along with intrusive abnormalities of perception and affect

DSM-IV– in a global sense to describe a disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a pre-existing or evolving dementia. There is a reduction in the clarity of awareness of environment(DSM III term– acute brain syndrome, dementia is its chronic form)

ICD-10 (P. 54) an etiologically nonspecific syndrome characterised by concurrent disturbance of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycle

Symptoms of deliriumSymptoms of deliriumThere is some lowering of consciousness,

which is subjective experience of a rise in the threshold for all incoming stimuli

The pt is disoriented for time and place but not for person.

Thinking is disordered as it is in dreams and shows excessive displacement, condensation and misuse of symbols.

The pt is unable to distinguish between their mental images and perceptions, so that their mental images acquire the value of perceptions

Hallucinations in delirium Hallucinations in delirium Visual hallucinations– --often the outstanding

feature --usually of small animals and associated with fear or even terror

Elementary auditory hallucinations are common.

Rarely hallucinatory voices occur if they do– the change of consciouness and visual hallucinations often disappear in a few days, leaving behind an organic hallucinosis with little or no change in consciousness

Other hallucinations of touch, pain, electric feelings, muscle sense and vestibular sensations often occur

They may be associated with Lilliputian hallucinations (seeing little men), so that the pt describes little creatures walking over him--He feels their footsteps and hears them shouting obscene jokes(associated with feeling of pleasure) and abusive remarks in his ear

The patient is fearful and often misinterpretes the behaviour of others as threats. ----Thus a patient with delirium tremens said ‘Don’t hit me; please don’t hit me’ whenever anyone approached, although he had never been subjected to assault

Pt is highly suggestible to spoken comments and perceptual clues, but there is loss of grasp: misidentification and misinterpretation occur

Conditions of deliriumConditions of delirium One tests the patients orientation and if they are

disoriented there is prima facie case they have and organic disorder. (Exception to this may include the patient with chronic schizophrenia)

If this is of recent origin, then it is an acute organic state with disturbance of consciousness.

Although disorientation in an acute illness is strongly suggestive of disordered consciousness, the absence of this sign does not rule out an acute organic state with mild disorder of consciousness

Poor performance on intellectual and memory tasks, inability to estimate the passage of time, and changes in EEG may all suggest an acute organic state

Delirium Vs schiziophreniaDelirium Vs schiziophreniaIt is important to note that the patients

with schizophrenia, regardless of their history of institutionalisation, may also demonstrate significant disturbance of memory(McKenna et al,1990), including impairment of working and semantic memory(Kuperberg& Heckers,2000)

These impairments may also have a significant impact on social functioning

Mild degree of delirium/? Mild degree of delirium/? Toxic confusional stateToxic confusional stateGeneral lowering of consciousness during

the day and be incoherent and confused

At night delirium occurs with visual hallucinations and restlessness, but it improves in the morning(diurnal varation}

Pt may have inconsistent orientation, orientation may vary during 24 hours of the day

There may also be some restriction so that the mind is dominated by a few ideas, attitudes and hallucinations

The pt is usually restless and may carry out the customary actions of this trade; this is known as occupational delirium eg: an accountant may make out a long series of accounts or a bus conductor may ask other patients for their bus fares

This milder varieties of delirium may pass over into an amnestic state, torpor, severe delirium or a twilight state

fluctuations fluctuations Occurs in health, in

sleep and in fatigue.

In epileptics there is fluctuation in relation to fits

In delirious states there may be considerable diurnal fluctuation of consciousness

Also seen with drugs-- mescaline

confusionconfusionRefer to subjective symptoms and

objective signs indicating loss of capacity for clear and coherent thought

It is purely descriptive(of pt’s experience or doctors observation) term does not apply to clouding of consciousness

The term acute confusional state is often used as a synonym for acute organic psyho syndrome( or delirium in DSM IV and ICD 10) in medical literature. Here it refers to a more comprehensive syndrome with chaotic thinking and cognitive failure that includes delirium as sub category (Berrios, 1981)

It is seen in both organic(acute and chronic), and non-organic disturbance(associated with powerful emotions in neurotic disorders)

Confusion may be a prominent symptom in the acute toxic psychosis resulting from the use of high-potency cannabis(Ghodse,1986). It is then, of sudden onset and usually associated with delusions, hallucinations and emotional lability

Other states- Other states- RESTRICTION of RESTRICTION of consciousness- consciousness- Awareness is narrowed

down to a few ideas and attitudes that dominate

the patient’s mind

There is some lowering of level of consciousness

Disorientation in time and place occur

Twilight stateTwilight state

A well defined interruption of the continuity of consciousness (Sims et al,2000)

Restriction of the morbidly changed behaviourAnd relatively well oriented behaviour

It is characterised by a) abrupt onset and end; b)variable duration from a few hours to several weeks; and c)the occurrence of unexpected violent acts or emotional outbursts during otherwise normal, quiet behaviour (Lishman,1997)

ICD_10 includes twilight states under the heading of dissociative(conversion) disorder and when, criteria for organic etiology are met organic mental disorders

Consciousness may be markedly impaired or relatively normal between episodes

There may be associated dreamlike states, delusions, or hallucinations.

Ganser state is, in practice, a sort of twilight state, in which the organic element is often doubious

Different types described are—simple, hallucinatory, perplexed, excited, expansive, psychomotor and oriented twilight states

It is usually an organic condition and occurs in the context of

-- epilepsy, --alcoholism(mania a

potu), -- brain trauma -- and general paresis;

it may also occur with dissociative states.

The commonest twilight state is the result of epilepsy

Hysterical twilight stateHysterical twilight state Restriction of consciousness resulting from

unconscious motives

In some cases the subject sees to be deliberately running away from his troubles. It may be difficult to how much motivation of hysterical twilight is unconsciuos

In severe anxiety the patient may be so preoccupied by their conflicts that they are not fully aware of their environment and find that they have only a hazy idea of what has happened in the past hour or so

This may suggest to the patient that amnesia is a solution for their problems, so that they forget their personal identity and whole of their past a temporary solution for their difficulties

Dissociative fugueDissociative fugue Fugue– wandering state with some loss of

memory. May be of variable duration Conscious simulation of fugue may be difficult to

differentiate from dissociative fugue

Hysterical fugue may be more common in subjects who have previously had a head injury with concussion, possibly because they are familiar with the pattern of amnesia from their past experience of concussion and can therefore present it as a hysterical symptom

Depression Vs fugue--Not all fugues are hysterical-- Depression pts may start to kill themselves and wander about indecisively for some days before finding their home or being stopped by police

Mania a potu(pathological Mania a potu(pathological intoxication)intoxication)This is one type of twilight,

specially associated with alcoholism

It is important to distinguish this syndrome of acute pathological intoxication with alcohol from delirium tremens, which is a symptom of withdrawl.

Four components of pathological intoxication(Coid,1979)

a)the condition follows the consumption of a variable quantity of alcohol

b)senseless, violent behaviour then ensuesc)there is then prolonged sleep d)total or partial amnesia for disturbed behaviour occurs

Pathological reaction to alcohol is preferred term. The reaction is thought to be associated with exhaustion, great strain or hypoglycemia, and to occur esp in poorly defended against their own violent impulses (Keller,1997)

automatismautomatism Phenomenologically, it is action without any knowledge

acting.

It is a defense because mind does not go with what is being done(Kilmur,1963). Behaviour during automatism is usually purposeful and often appropriate

Violence is rare during automatism. When occur it fulfils the criteria for the definition of twilight state

Awareness of environment is impaired. Pt has no memory later what is done

Epileptic automatism---occur during,or immediately after, a seizure and during which individual retains control of posture and muscle tone and perform simple or complex movements

Dream-like(oneroid) stateDream-like(oneroid) stateAn unsatisfactory term not

clearly differentiated from delirium

The pt may appear to be living a dream world and so called occupational delirium

could be mentioned

It is important to look for other symptoms or organic states to make the important distinction between physical illness and a dissociative organic condition

stuporstupor names a symptom complex whose central feature is a

reduction in, or absence of, relational functions: that is, action and speech(Berrios, 1996)

The inability to initiate speech or action(mutism and akinesis) in a patient who appear awake and even alert

Usually occur with some degree of clouding of consciousness. The pt may look ahead or his eyes may wander, but he appear to take nothing in

Characteristic of lesions in the area of diencephalon and upper brain stem, and also frontal lobe and basal ganglia,

It is important to realise , however, that the syndrome of akinesis and mutism in a conscious patient also occur with schizophrenia, affective psychosis( bothe depressive and manic) and in dissociative states

Organic Vs functional stuporOrganic Vs functional stupor

The difference between psychogenic(so called functional) and neurological(organic)

--presence of clear consciousness in former

It is not possible at the time of observation to know whether consciousness clear or not; and even for functional stupor subsequent amnesia is common

After excluding consciousnes, diagnosis of stupor must then be followed by investigation of the differential diagnosis which include both organic and non-organic conditions

Locked-in syndromeA rare but specific condition

Involving the motor pathways in the ventral pons

There is full alertness and feeling but aphonia and total muscle paralysis apart from blinking, and jaw and eye movements(Plum and Posner,1972)

torportorpor The pt is psychologically benumbed

Without hallucinations, illusions, delusions, and restlessness

Pt is apathetic, generally slowed down, unable to express themselves clearly, and may perseverate.( may be mistakenly diagnosed as severe dementia)

Seen in severe infection such a typhoid and typhus, arteriosclerotic cerebral disease following a cerebrovascular accident

After some weeks there is a remarkably partial recovery and the patient is left with a mild organic deficit

INTRODUCTION TO INTRODUCTION TO ATTENTIONATTENTION

attentionattention The ability to focus on a particular sensory stimulus to

the exclusion of others

It can be--active----when the subject focuses their attention on some internal or external event--passive--- when the same events attract the subject’s attention without any conscious effort on their part

Active and passive attention are reciprocally related to each other, since the more the subject focuses their attention the greater must be the stimulus that will distract them( i.e. bring passive attention into action)

Attention is affected by an individuals mind set

Generally non rigid, and is altered in response to incoming information

Disturbance of Disturbance of active active attention--attention--distractabilitydistractabilitycan occurs in

--fatigue,-- anxiety,

(by anxious pre occupation)-- severe depression,

-- mania,-- schizophrenia

and organic states(may be result of a paranoid frame of mind)

schizophrenia and disturbance of active attention--In acute schizophrenia– as the result of formal thought disorder because the pt is unable to keep the marginal thoughts(which are connected with external objects by displacement, condensation and symbolism) out of their thinking, so that irrelevant external objects are incorporated into their thinking

Amnestic syndrome and attention--Pt’s thinking and observation are dominated by rigid sets, so that perception and comprehension are affected by selective attention

INTRODUCTION TO INTRODUCTION TO SELF AND SELF AND EXPERIENCE OF SELFEXPERIENCE OF SELF

Ego and selfEgo and selfFreud (1933) described ego as

standing for reason and good sense while id stands for the untamed passions

The ego has been modified by the proximity of the external world with its threat of danger. The poor ego has the masters and does what it can to bring their claims and demands into harmony with with one another------. Its three tyrannical masters are the external world, the super ego and the id(Freud,1933)

Self concept and body Self concept and body image image The body is unique in that it is experienced both

inside and outside; in both self and object. It is through our body that we have contact with the world outside our self: movement of the body relate us to external space

Self concept refers to the fully consciousness and abstract awareness of self.

Body image is more concerned with unconsciousness and physical matters: it includes experiential aspects of body awareness of self

Sometimes self concept is the same as body concept and at other times, conscious self is conceptualised as being independent of its cage: the body

The body schema and The body schema and cathexiscathexisThe body schema implies a spatial

element and is more than and usually bigger than the body itself. Eg; the body along with clothes, spectacles, instruments, car(while driving)

Cathexis implies the notion of power, force, libido– perhaps analogous to electrical change, the self that makes things happen

According to shield(1935) body images are never isolated, they are always encircled by the body images of others

At any one time the individual only perceives a small sample from a gallery of possible self images

It is the nature of the self and ego to be experienced as either subject of object

The central core of self image consists for a person his name, his body feelings, body images , sex and age

Experience of selfExperience of selfAlthough there is substantial

German literature on Ichbewusstsein or ego consciousness, both of these terms have now been replaced by the term ‘self-experience’

Disturbance is self experience has two aspects --awareness of existence and activity of the self --awareness of being separate from the environment

Four aspects of self-Four aspects of self-awareness(Jasper,1997) awareness(Jasper,1997)

the existence and ACTIVITY of the self

being a unity(SINGLENESS) at any given point of time

Continuity of IDENTITY over a period of time

being separate from the environment ( awareness of ego BOUNDARIES/DEFINITION)

Fifth dimension of ego vitality(Scharfetter,1981,1995) Previously this characteristic was incorporated within the awareness of activity, Which subsumed ‘being’ and existing with other principles

Awareness of Awareness of BEING OR BEING OR EXISTING, EGO VITALITYEXISTING, EGO VITALITY

“ I know that I exist” and this is fundamental to

awareness of self

Awareness of Awareness of ACTIVITYACTIVITY I do something and that I know that I

am doing itEverything I do, in everything I

experience, though every event that impinges upon me, I am aware that the experience has the unique quality of being mine.

“I pinched myself to make sure it was really happening to me” express the relationship we experience between reality and acitiviy

Awareness of Awareness of UNITY/SINGLENESSUNITY/SINGLENESSAt any given moment I know that

I am one personIn health, a person is integrated

in his thinking and behaviour, so that he does not have to be aware of feeling of unity

Awareness of Awareness of IDENTITY/CONTINUITYIDENTITY/CONTINUITY

I am who I was last week, or 30 years ago: I am who I will be next week, or in 10 years time

A feeling of continuity for oneself and one’s role is a fundamental assumptions of life without which competent behaviour cannot take place

Awareness of Awareness of BOUNDARIES BOUNDARIES OF SELFOF SELFI can distinguish what is myself

from the outside world, and all that is not the self

Awareness of Awareness of THE BODYTHE BODYThe ego is firstly the body ego

(Freud, 1933)The body schema the picture of our

body which we form in our mind, that is to say, the way in which the body appears to ourselves

not have abnormal body sensationsIn transsexual there is conflict

between ego and body image

DISORDERS OF DISORDERS OF EXPERIENCE OF SELF –EXPERIENCE OF SELF –ABNORMAL INNER EXPERIENCE OF I-NESS AND MY-ABNORMAL INNER EXPERIENCE OF I-NESS AND MY-

NESSNESS

Clinical range of Clinical range of disordered selfdisordered self In certain normal life experiences

in association with exhaustion, hunger, thirst, ecstasy, acute but appropriate anxiety, sexual arousal, hypnogogic states

In normal people in abnormal effects of pressure or gravity, in sensory deprivation and during hypnosis

Normal people taking drugsa) mild depersonalisation is very common with drugs Eg; tricyclic antidepressents

b) more marked change occur with cannabis, mescalin, LSD (Lysergic acid diethylamide)

In almost all neurotic conditions and related disorders complaints about self-awareness occur

In acute anxiety state, hypochondriacal disorder, dissociation with conversion symptoms, and anorexia nervosa, disturbance of self image is prominent

In psychosis, the self is self disturbed as a part of loss of reality judgment

The neurotic person, irrespective of type of neurosis, is very concerned with himself and how others see him

Disturbance of Disturbance of awarenessawareness of BEING OR of BEING OR EXISTINGEXISTING

All event that can be brought into consciousness are associated with a sense of personal possession, although this is not usually in the forefront of consciousness. This ‘I’ quality has been called personalisation (Jasper,1997) and may be disturbed in psychological disorders

There are two aspects to the sense of self activity -- the sense of existence

--the awareness of the performance of one’s action

Definition of Definition of depersonalisationdepersonalisation

A change in the awareness of one’s own activity occur when the pt feels that they are no longer their natured self and this is known as depersonalisation

Associated with a feeling of unnreality so that environment is experienced as flat, dull and unreal (derealisation)

Depersonalisation is the term used to designate a peculiar change in awareness of self, in which individual feels as if he is unreal (Sedman, 1972)

A subjective state of unreality in which there is a feeling of estrangement, either from a sense of self or from the external environment( Fewtrell, 1986)

Positive features of Positive features of Depersonalisation (Acner, 1954)Depersonalisation (Acner, 1954) Is always subjective, it is a disorder of

experience

The experience is that of an internal or external change, characterised by a feeling of strangeness, or unreality

The experience is unpleasant

Any mental functions may be the subject of change, but affect is invariably involved

Insight is preserved

Excluded from depersonalisation Excluded from depersonalisation (Acner, 1954)(Acner, 1954)The experience of unreality of

self, when there is delusional elaboration

The ego boundary disorder of schizophrenia

The loss of attenuation of

personal identity

Depersonalisation Vs delusionDepersonalisation Vs delusion

Depersonalisation (as if feeling) is not a delusion(experience of unreality that occur in psychosis)

It should be distinguished from nihilistic delusions

– mood congruent delusions occurring in the setting of severe depression -- in which pt denies that they exist or they are alive or that the world or other people exist

Components of Components of depersonalisation(Sierre depersonalisation(Sierre and Berris, and Berris, 2001)2001)

Emotional bluntingChanges in body experienceChanges in visual experienceChanges in auditory experienceChanges in tactile experienceChanges in gustatory experienceChanges in olfactory experienceLoss of feeling of agencyDistortions in the experience of timeChanges in the subjective experience of

memoryFeeling of thought emptinessSubjective feeling of an inability to evoke

imagesHeightened self-observation

Features most prevalent for Features most prevalent for diagnosis Seirra and Berrios(2001)diagnosis Seirra and Berrios(2001)

◦FOllowing four features are most prevalent for diagnosis

--emotional numbing --changes in visual perception

--changes in the experience of the body --loss of feeling of the agency

◦These are features of the disorder that are additional to the the symptom itself

Depersonalisation Vs dizzinessDepersonalisation Vs dizziness

The dizziness and depersonalisation are same experience described differently

Bipolar hypothesis– that two experiences form opposite ends of a dimension describing disturbed self/outside world relationships

Clinical features of Clinical features of depersonalisationdepersonalisationIt has been considered that after

depression, anxiety depersonalisation is the most frequent symptom to occur in psychiatry(Stewart, 1964)

When the pt first experiences the symptoms they are likely to find it very frightening and often think it is a sign that they are going mad. In the course of time they may become more or less accustomed to it.

Many pt who complain of depersonalisation also state that their capacity to feeling diminished

It frequently occurs in attacks which may be of any duration from seconds to months

Typically, in depersonalisation disorder , the altered state lasts for a few hours, in temporal lobe epilepsy for a few minutes and in anxiety disorder for a few seconds

Onset may be insidious and and with no known cause, or it may be in response to provocation

Conditions of depersonalisationConditions of depersonalisation

Organic brain disease– esp temporal lobe disorders (Matthew et al, 1993)

Substance misuse- cannabis, LSD, mescalin, marijuana

Depressive illness--Very occasionally, depersonalisation may be the outstanding feature in a patient with depressive state(DD-schizphrenia- examinar may be mislead by the bizarre description of the symptom)

Anxiety with agoraphobic symptoms, panic disorder, PTSD

Hysterical dissociation– depersonalisation as a symptom , is more frequently associated with depression and anxiety than dissociation

May also occur from time to time in individuals without mental illness, esp when severely tired

and with sensory deprivation Milder degree of dissociative depersonalisation occur

in moderately stressful situation, so that depersonalisation is quite common experience and is reported to occur in at least once in 30– 70 % of young individuals(Freeman, 1996)

True depersonalisation symptoms do occur in

schizophrenic patients, especially in the early stages of illness alongside definite schizophrenic psychopathology

It is also described as a side-effect with prescribed psychotropic drugs, such as tryiyclic anti depressants but because of the common association between depersonalisation and depression, it is difficult always to attribute cause

Depersonalisation symptom Vs Depersonalisation symptom Vs disorderdisorderIt is important to emphasize the

distinction between depersonalization as a symptom occuring associated with many psychiatric conditions or no disorder at al, and depersonalization as syndrome

While the epidemiology of depersonalisation disorder remains poorly understood, it is thought to be twice as common in women as in men (Kaplan& Sadock, 1996)

Depersonalisation disorder ICD-10 Depersonalisation disorder ICD-10 Vs DSM-IVVs DSM-IVClassinfied as

depersonalisation and derealisation syndrome

Occuring in a setting of clear consciousness with retention of insight

A disorder in which sufferer complain that his or her mental activity, body and

Depersonalisation disorder

Emphasis recurrent feeling of detachment, retention of reality testing, and resultant personal distress, all occuring in the absence of another mental disorder

Social and situational aspectsSocial and situational aspects

Frequently, the person feels that he is less able to himself, his personality, his behaviour than other people accept their own

There is barrier to his giving an account of his symptoms and this in turn is a barrier to communication in all areas of life.

Organic and psychological theories Organic and psychological theories of depersonalisationof depersonalisationThe relationship between brain pathology and

remains unclear. Depersonalisation is certainly not pathognomic of organic diseases, in fact there is no organic or psychotic abnormality in the vast majority of sufferers

The state of increased alertness observed in depersonalisation is considered by Sierra and Berrios (1998) to result from activation of prefrontal attention systems and reciprocal inhibition of anterior cingulate, leading to experience of ‘mind emptiness’ and indifference to pain

the lack of emotional colouring, reported as feelings of unreality, would be accounted for by a left-sided prefrontal mechanism with inhibition of the amygdala

derealisationderealisationFrequently depersonalisation is

accompanied by the symptoms of derealisation because– the ego and its environment are experienced as one continuous whole

The less a patient takes himself for granted the more unfamiliar and alien does the world around him become(Schrfer,1980)

desomatisationdesomatisationLocalisation to individualised

organ

Kuru, described by Yap(1965)- culture specific example, in which sufferer experiences acute anxiety, believes his penis is shrinking and fears that it will ultimately disappear

Distortion of timeDistortion of timeChange of feeling concerning the

body may be associated with distortion of time sense, the passage of time appears altered in some way: time both past and present, seems unreal to me, as if it had never happened and was never going to happen

Deaffectualisation--Loss of Deaffectualisation--Loss of emotional resonanceemotional resonanceNormal emotional resonance experiences

a series of positive and negative feeling as they encounter both animate and inanimate objects in the environment

An emotional crisis or a threat to life may lead to complete dissociation of affect, which can be regarded as an adaptive mechanism that allows the subject to function reasonably without being overwhelmed by emotion

Loss of emotional resonance is seen in—depression-depersonalisation

Depression and loss of emotional Depression and loss of emotional resonance resonance Pt has feeling that they cannot feel

Most marked when the pt with depression encounters their loved ones

If the pt has ideas of guilty, this apparent loss of feeling will make the pt feel even more guilty and morally reprehensible

Jamais vu and deja vuJamais vu and deja vuJamais vu – there is no sense of

previously having seen a well-known object

Déjà vu – where an unfamiliar object or experience seem to be familiar

These abnormalities are similar to depersonalisation and have common origin

Disturbance of awareness of Disturbance of awareness of SELF ACTIVITYSELF ACTIVITYPerception– a pt of endogenous depression

“I do not feel alive, my eyes stare like out of a corpse; I as if nowhere

Moving– a household wife suffering from a phobic neurosis said “ if I am in the street on my own, I panic, I feel as if I am falling over” schizophrenia-- delusion of control

Memorizing and imaging-- depression feels that he is unable to initiate act of memory or fantasy. Schiz this activiy when it occurs in not initiated by him but from outside himself

Loss of feeling– occurs as a common symptom in depression. “ I cannot love my husband. Nothing has happened to us. I have just lost my feeling for him”

Willing– schiz– no longer experiences his will as being his own. Commonly neurotic describe an inability to initiate activity, a feeling of powerlessness, of being ground down, in the face of life’s vicissitudes

Abnormalities of experience of one’s own activities are closely associated with mood: depressed patient believes that he is incapable of doing anything at all

Sometimes belief about initiation of activity changed(passivity experiences)

Disturbance in the Disturbance in the immediate awareness of immediate awareness of SELF-UNITY/SINGLENESS SELF-UNITY/SINGLENESS In dreams one sometimes sees

oneself, even perhaps with some surprise, in the drama

In some forms of transcendental meditation, by carrying out repetitive monotonous acts, the subject enters a self-induced trance in which he can observe himself carrying out the behavioiur

They feel as if they are two personsSeen in in psychogenic and depressive depersonlisation(the pt

may feel that they are talking and acting in an automatic way).this may lead to say as if they are two persons

individuals with appreciation needing personalities or with learning disability. May leave out the as if and say they are two persons

delusion of demonic possession( themselves and devil)

schizophrenia (may feel they are two or more people)

Autoscopy Autoscopy (heautoscopy/phantom mirror (heautoscopy/phantom mirror image)image)Autoscopy is complex psychosensorial

hallucinatory perception of one’s own body image projected into the external visual space (Lukianowicz, 1958)

“in this strange experience the pt sees himself and knows that it is he. It is not just a visual hallucination because kinesthetic and somatic sensation must also be present to give the subject that impression that the hallucination is he” (Fish, 1967 ).

The disturbance in visual perception is an essential feature. The loss of familiarity for oneself is prominent

Especially associated with disorders of parietal lobe

The double phenomenon: The double phenomenon: dopplegangerdopplegangerIt is an awareness of oneself as being both

outside alongside, and inside oneself: the subjective phenomenon of doubling

The experience occur with different conditions, or with no mental disorder et al

Six possible psychopathological explanations for phenomenon of non-organic, non-psychotic– fantasy, depersonalization, conflict, compulsive ideas, double personality(alternating states of consciousness), being doubled

dual, double or multiple dual, double or multiple personalitypersonalityVery rarely pt may complain of

experiencing multiple personalities---In multiple personality disorder(dissociative idetity disorders)

differential diagnosis– other dissociative disorders, schizophrenia, rapid cycling bipolar disorder, borderline personality disorder, malingering and complex epilepsy

Related termsDelusional misidentification or Capgras

syndromeDouble orientation; is the situation

where an individual appears to live in two worlds simultaneously– a psychotic world and the real world; for a confused patient on a psychogeriatric ward he believes both this man visiting him is the doctor and also the person come to marry him to his young wife

Disturbance of Disturbance of the the CONTINUITY/IDENTITY of CONTINUITY/IDENTITY of the selfthe selfThis disorder is characterised by changes in the

identity of self over timeThe complete alteration in the sense of identity is

exclusively psychotic A feeling of loss of continuity which is, of lesser

intensity than the psychotic change without element of passivity, may be experienced in health, and in neuroses and personality disorders

The person knows both people, before and after, are truly himself, but he feels very altered from what he was. This may occur following an overwhelmingly important life situation, or during emotional development without an outside event eg; adolescent

A part of continuity of self is accepting that the changes in one’s total state at present are due to illness. This is characteristic usually described in the mental status examination under the term insight (David, 1990)

The feeling of loss of continuity contribute to the inertia of the person with schizophrenia, and apathy of the depressive

Lack of clear sense of identity from the past continuity into the future is a strong disincentive to concerted activity

In schizophrenia They are not the same person that they

were before the illness (sense of change) may be described as--religious conversion or being born again

Following an acute shift of the illness, may describe how they seemed to pass from being one or personality to another

They may seem to be personifying natural events, seminars and historical event, animals and historical figures during the acute illness

The depressive secondary to disorder of mood, often sees no continuation into the future “everything is bleak, there is nothing to look forward to”

Possession statePossession stateAltered state of conscious awareness is

prerequisiteIt can occur in normal, healthy people in

unusual situations either as a group phenomenon(mass hypnosis) or individually

The difference between those conditions that constitute and those that may be considered as being within a cultural or religious context alone is that the former are unwanted, cause distress to the individual and those around, and may be prolonged the immediate event or ceremony at which it was induced

Near death experienceNear death experience

The most prominent clusters of symptoms seem to be depersonalisation, increased alertness and various descriptions of ‘mystic consciousness’. Out-of-body experience with autoscopy was frequent, as was passage of consciousness into a foreign region or transcendental experience

Disturbances of Disturbances of BOUNDARIES of the selfBOUNDARIES of the selfDisturbance in knowing where I ends and not I

begins One of the most fundamental of the experience is

the difference between one’s body and the rest of the world

Knowledge of what is body and what is not -- is based on the link between information from the extroceptors and the proprioceptors -- a link that is probably learned--has to be maintained constantly

The physiologic schema of the body and the continuity and integrity of memory and psychological function is the basis of awareness of the self

Seen in schizophrenia LSD intoxication– feeling of impending ego dissolution associated with the feeling of self ‘slipping away with considerable anxiety ( Anderson and Rawnsley, 1954)

Conditions disturbance of body image seen-hypnogogic state -depression(eg; face has become ugly)-schizophrenia-organic disorders

In schizophrenia In schizophrenia, the sense of invasion of

self appears to be fundamental to the nature of the condition as it experience

First rank symptoms have in common permeability of the barrier between the individual and his environment, loss of ego boundaries (Sims, 1993)

“Other people are doing things to me, events are taking place outside myself” the external observer finds a blurring or loss of the boundaries of self, which is not apparent to the patient himself

Passivity experience Passivity experience

Falsely attribute functions to not self influence from outside, which are actively coming from the inside self

Alienation of motor actions and feelings( passivity phenomenon/ made or fabricated experiences)

-- their actions are not their own-- attribute it to the hypnosis,

radiowaves, the internet, and so on--experiences these as being

made by outside influence --pt knows that all the

event around them as being made for their benefit (apophaneous experience)

In early stages of acute schizophrenia– changes in their awareness of their own activity that is becoming alienated from them(differential diagnoses: depersonalisation– they feel like machines as if their actions are carried out automatically, loss of control in obsessions and compulsions but belonging to pt)

Pt know that their actions and thoughts have excessive effects on the world around them and he experiences activity that is not directly related to them as having an effect on them

-- eg: a patient may believe that when they pass urine, they cause bad things to happen to other people

Auditory hallucinations and third Auditory hallucinations and third person auditory hallucinationperson auditory hallucinationAH confidently ascribed by the

patient to sensory stimuli outside the self, where as in fact they arise inside the self

3rd person AH– usually I think of myself n the first person singular. Occasionally I address myself in my thoughts in the second person, but I do not think about myself nor comment on my action in the third person

Hearing one’s own thoughts Hearing one’s own thoughts spoken aloud spoken aloud Implies locating one’s innermost

core experience as in distant past

Delusional perceptDelusional percept

Object of perception which is actually neutral and irrelevant to self, is delusionally interpreted as highly relevant, having intense personal meaning.

The implication is that meaning of the perception, although in reality outside self, has become incorporated within self

Thought broadcastingThought broadcasting

-- because the pt ‘knows’ that as he thinks the whole world is thinking in unison

Other alterations to Other alterations to boundaries of self– in states boundaries of self– in states of ecstasyof ecstasy Person might describe

feeling at one with universemerging with Nirvanaexperiencing unity with saints

or in oneness with GodOccur

in normal peoplein those with personality disorderas well as in sufferers from psychoses

This alteration in awareness in boundaries of self is different from that of schizophrenia. In ecstasy it is an as if experience and is mediated affectively( there is no loss of judgment, ability to discriminate)

PSYCHIATRIC PSYCHIATRIC APPLICATIONSAPPLICATIONS

Theory of mind Theory of mind (mentalisation)(mentalisation) refers to the ability of an

individual to infer or understand the mental states of others in given situation (Bentall, 2003)

Many of the disturbances in the experience of self may co-exist with deficits in theory of mind esp in the context of psychosis

Deficits in theory of mind have been particularly associated with-- autism(Baron, Cohen et al, 1993) --paranoid symptoms in psychotic illness(Frith,1992; Frith&Corcoran,1996)

Theory of mind prove valuable in informing other approaches to understanding the psychopathology of schizophrenia (Bentall,2003) or elucidating etiology

Schiffman et al (2004) - suggesting that some aspects of theory of mind may be impaired in these individuals prior to development of schizophrenia spectrum disorders

Sass & Parnas(2003) have proposed -- a unified account of symptoms in schizophrenia, in which they have emphasized the importance of abnormalities of consciousness -- argued that schizophrenia is fundamentally a self disorder characterised by particular distortions of awareness of aspects of the self. Eg: increased self-consciousness, diminished self affection

The study of consciousness, and the study of theory of mind are clearly related fields in schizophrenia research------may well play imp role in understanding clinical features of the illness

Disorders of the Disorders of the awareness awareness of the of the body(body image)body(body image)Undue concern with illness–

Hypochondriasis

Dislike of body– Dysmorphophobia, transsexualism

Undue concern with appearance– Narcissism

Distortion of body image– anorexia nervosa, obesity

referencesreferences

Andrew Sims. (2003)Symptoms in Mind ( 3rdedition). Saunders/Elsevier

Patricia Casey, Brenden Kelly.(2007) Fish’s Clinical psychopathology

(3rd edition). Gaskell

THANK YOU

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