Psychopathology: disturbances of consciousness, orientation, and psychomotor activity – characteristics and clinical conditions

01Disturbances of consciousness

Consciousness is the awareness of oneself and one's surroundings. Clinically it has two parts. Its level, wakefulness or arousal, is kept up by the reticular activating system of the brainstem and the thalamus. Its content, what is experienced and how clearly, depends on the cortex. Disturbances are therefore described as quantitative, a lowered level, or qualitative, an altered content or field of awareness, and in practice the two often go together.

Quantitative disturbances

The words are used differently from country to country, so the level is better recorded with the Glasgow Coma Scale, in its three parts (eye opening 1 to 4, verbal response 1 to 5, motor response 1 to 6, a total of 3 to 15). A score of 8 or less is coma and puts the airway at risk. The opposite of clouding, a heightened alertness and vigilance with a sense of sharpened perception, is seen in stimulant and hallucinogen intoxication, mania, early psychosis and severe anxiety.

Qualitative disturbances

Delirium is the commonest by far. ICD-10 (F05) defines it by clouding of consciousness and attention, a global disturbance of cognition, psychomotor disturbance, a disturbed sleep-wake cycle and emotional changes, coming on quickly and fluctuating. It is hyperactive, hypoactive or mixed: hypoactive delirium, quiet and withdrawn, is the form most often missed and is easily mistaken for depression. Delirium from alcohol withdrawal is delirium tremens (F10.4), covered in alcohol use disorders.

Pathological intoxication (F10.07) is a twilight state brought on by an amount of alcohol that would not intoxicate most people: a sudden outburst of aggression, unlike the person when sober, followed by amnesia. It is disputed for lack of evidence and appears in neither ICD-11 nor DSM-5-TR, and in court it is a claim to be tested against how much was really drunk. The twilight states matter in forensic psychiatry, because acts done in them may not be under the person's control.

02Disturbances of orientation

Orientation is knowing where one stands in time, in place, among other people and in the situation. It needs clear consciousness, attention, perception and memory, which is why it is so sensitive to organic disease and so seldom lost in primary psychiatric disorders.

Disorientation follows a typical order as organic impairment deepens: time, then place, then other people, and own identity only in the most severe states. A patient who has lost his own name and history while alert and otherwise oriented almost always has a dissociative disorder or is feigning, not an organic one.

Kinds of disturbed orientation

• Disorientation: missing or wrong answers, as in delirium (fluctuating, worse at night), dementia (progressive, time first), intoxication and after seizures or ECT.
• Misorientation with confabulation: wrong answers given confidently, the gaps filled with false memories, as in Korsakoff syndrome (see memory), sometimes taking the hospital for a familiar place.
• Double orientation (double bookkeeping): a correct and a delusional orientation held side by side without the contradiction troubling the patient: "This is the general hospital, it is Tuesday, and it is also the fortress where the secret service holds me." It is typical of schizophrenia and paraphrenia.
• Delusional (false) orientation: the delusional version replaces the real one, as when a patient insists he is in a palace and is its king.
• Approximate answers: wrong but near answers ("two and two make five") in the Ganser syndrome, a dissociative state usually under great stress, such as in prisoners on remand.

Orientation is usually kept in depression, mania, schizophrenia and the anxiety disorders. When it is lost in them, an organic cause or a very severe state (delirious mania, catatonia) is likely.

03Disturbances of psychomotor activity

Psychomotor activity is the outward, motor expression of mental life: the amount and speed of movement, its purpose and quality, posture, gesture, facial expression and speech. It can be increased, decreased or qualitatively abnormal.

Increased activity: agitation and excitement

Psychomotor agitation is excessive, mostly purposeless activity driven by inner tension: pacing, wringing the hands, inability to sit, plucking at clothes. Its severe forms, psychomotor excitement, differ by cause:

Agitation can also be akathisia, a side effect (below). Hyperactivity in hyperkinetic disorder is different again: poorly regulated restlessness from early childhood, in every setting.

Decreased activity: retardation and stupor

Psychomotor retardation is slowing of movement, speech and thought: few gestures, a fixed face, a long delay before each answer, a quiet monotonous voice and a sense that everything is an effort. It is a core sign of melancholic depression, and also comes with hypothyroidism, parkinsonism (including drug-induced), the negative symptoms of schizophrenia, sedation and subcortical disease.

Its extreme is stupor: no movement and no speech, little or no response to the surroundings, with consciousness preserved.

Stupor is told apart from coma (unrousable), the locked-in syndrome (awake and trying to communicate with vertical eye movements and blinks), akinetic mutism from frontal or midbrain lesions and non-convulsive status epilepticus, which needs an EEG. A patient in stupor stops eating and drinking: dehydration, pressure sores, pneumonia and venous thromboembolism make it an emergency.

Catatonia

Catatonia, described by Kahlbaum in 1874, is a psychomotor syndrome with many causes, not a subtype of schizophrenia alone. It is found in up to about one in ten patients in mental health services when it is looked for systematically, and in far fewer case records, because it is under-recognised. It comes more often with mood disorders, especially mania, than with schizophrenia, and also in autism and many medical conditions, which are behind about a fifth of cases overall and most in older and medically ill patients. DSM-5-TR diagnoses it with 3 of 12 signs; ICD-11 gives it a grouping of its own, whatever the cause; ICD-10 places it in catatonic schizophrenia (F20.2), organic catatonic disorder (F06.1) and the mood disorders' stupor.

The Bush–Francis Catatonia Rating Scale rates 23 signs; 2 or more of its first 14 make a positive screen. The causes to look for include mood disorders, schizophrenia, autism, encephalitis (including autoimmune, anti-NMDA receptor encephalitis), non-convulsive status, metabolic and endocrine disease, drugs (antipsychotics, and withdrawal from benzodiazepines or clozapine) and neuroleptic malignant syndrome.

Malignant catatonia, catatonia with fever, autonomic instability (tachycardia, labile blood pressure, sweating), rigidity, a rising creatine kinase and clouding, is life-threatening. Neuroleptic malignant syndrome is closely related and is often seen as a drug-induced form of it (see antipsychotics).

1. 1

   Recognise

   Look for the signs, rate them, and check temperature, pulse, blood pressure, hydration and the skin.
2. 2

   Find the cause

   Full history from informants, examination, blood tests with creatine kinase, and as indicated a urine drug screen, brain imaging, EEG, lumbar puncture and autoantibodies.
3. 3

   Lorazepam challenge

   1 to 2 mg of lorazepam intravenously or intramuscularly, or 2 mg by mouth. A fall of about half in the catatonic signs within minutes to half an hour supports the diagnosis.
4. 4

   Treat

   Regular lorazepam, titrated: usually a few milligrams a day, and up to 16 mg a day or more when needed, above the licensed maximum, before it is judged to have failed. ECT if benzodiazepines fail within days, and early in malignant catatonia.
5. 5

   Protect

   Fluids, nutrition, thromboprophylaxis, pressure care. Avoid antipsychotics where there is no psychotic disorder, use them cautiously when there is one, and stop all dopamine antagonists in malignant catatonia.

Most patients respond to benzodiazepines or ECT, those with acute catatonia and mood disorders best.

Other abnormal movements

Akathisia is the one most often confused with a psychiatric sign:

Mistaking akathisia for psychotic agitation and raising the antipsychotic makes it worse. It is distressing, a common reason for stopping treatment, and linked with suicidal and aggressive acts.