1. Disorders of consciousness and
experience of self
Presenter:
Dr Mohd Osman Ali MBBS, DPM
dr_osmanali@yahoo.com

2. Scheme 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

3. Scheme 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)

4. INTRODUCTION TO
CONSCIOUSNESS

5. Study of consciousness
Through
combining and sharing the
perspective of different disciplines:
philosophy, psychology, medicine and
neuroscience (Bock and Marsh, 1993)

6. Definition of consciousness
For
the purpose of descriptive clinical
psychopathology, consciousness can be
simply defined as
-- a state of awareness of
the self and the environment
(Fish, 1967)

7. 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)

8. preconscious
Among
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)

9. conscious Vs preconscious

Strict limit to the no of items
available

Very much more information is
stored

If stimulus is, only one
interpretation is possible at one
time

Multiple meanings are available

Very difficult to carry out more
than one task

Undertaking parallel task is usual

Flexible, strategic

automatic

Conscious is executive in nature
and is dominant to and has the
capacity to override the
perceptions and functions of
preconscious process

10. unconscious
Jasper(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

11. Clinicians use of consciousness and
unconsciousness
inner
awareness of
experience
subject reacting
to objects
intentionally
There
is no
subjective
experience
the
denotes
a knowledge
of conscious self
Seen
as conscious–
unconscious
continuum

12. Three dimensions of consciousness
and unconsciousness

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

13. Vigilence(wakefulness)--drowsiness(sleep) axis
The
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

14. 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

15. Lucidity--- clouding axis
Consciousness
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

16. 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

17. Consciousness of self
Ability
to experience self and awareness
of self that is both immediate and
complex

18. DISORDERS OF
CONSCIOUSNESS—
PSYCHOPATHOLOGICAL
ASPECTS

19. Classification of disorders of
consciousness (Fish)
Consciousness
can be changed in three
basic ways it may be
dream like,
depressed,
or restricted

20. Quantitative lowering of
consciousness
Qualitative change of consciousness
Normal(alert, vigilant,
Delirium
lucid)
Clouding
 Drowsiness
Sopor
Coma
Death
Fluctuations
Confusion
Classification of Disorders of
consciousness(Sims)

21. Disorders of consciousnes Vs
dementia
Disorders
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

22. Disorders of consciousness Vs orientation
When
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

23. QUANTITATIVE heightening
of consciousness
There
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

24. 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

25. 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

26. QUANTITATIVE
lowering of 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)

27. 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 state
a)impairment of consciousness
b)slight
drowsiness with or without
c)and
difficulty with attention and concentration

28. 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)

29. drowsiness
Next
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

30.  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

31. coma
Pt
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

32. 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)

34. QUALITATIVE changes of
consciousness
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 preexisting 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

35. Symptoms of delirium
 There
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

36. 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

37.  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

38. 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

39. Conditions 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

40. Delirium Vs schiziophrenia
It
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

41. Mild degree of delirium/? Toxic
confusional state
 General
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

42. 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

43. fluctuations
Occurs
in health,
sleep and in fatigue.
in
In
is
epileptics there
fluctuation in relation to fits
In
delirious states there may be
considerable diurnal fluctuation of
consciousness
Also
seen with drugs-- mescaline

44. confusion
Refer
to subjective symptoms and
signs indicating loss of capacity for
coherent thought
objective
clear and
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)

45. 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

46. Other states- RESTRICTION
of consciousnessAwareness
is narrowed
down to a few ideas
attitudes that dominate
the patient’s mind
and
There
is some lowering of level of
consciousness
Disorientation
in time and place occur

47. Twilight 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)

48.  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

49. 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


50. Hysterical twilight state
 Restriction
motives
of consciousness resulting from unconscious
 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

51. Dissociative 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

52. Mania a potu(pathological
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.

53.  Four
components of pathological
intoxication(Coid,1979)
a)the condition follows the consumption of a
variable quantity of alcohol
b)senseless, violent behaviour then ensues
c)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)

54. automatism

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

55. Dream-like(oneroid) state
An
unsatisfactory term not
clearly differentiated
delirium
The
pt may appear to be
dream world and so called
occupational delirium
could be mentioned
It
from
living a
is important to look for other symptoms or
organic states to make the important distinction
between physical illness and a dissociative organic
condition

56. stupor

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


57. Organic 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

58. Locked-in syndrome
A rare but specific condition
Involving
pons
There
the motor pathways in the ventral
is full alertness and feeling but
aphonia and total muscle paralysis apart
from blinking, and jaw and eye
movements(Plum and Posner,1972)

59. torpor
 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

60. INTRODUCTION TO
ATTENTION

61. attention

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

62. Disturbance of active
attention--distractability

can occurs in
--fatigue,
-- anxiety,(by anxious pre occupation)
-- severe depression,
-- mania,
-- schizophrenia and organic
states(may be result of a paranoid frame
of mind)

63. 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

64. INTRODUCTION TO
SELF AND EXPERIENCE
OF SELF

65. Ego and self
Freud
(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)

66. Self concept and body 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

67. The body schema and cathexis
The
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

68.  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

69. Experience of self
Although
there is substantial German
literature on Ichbewusstsein or ego
consciousness, both of these terms have
now been replaced by the term ‘selfexperience’
Disturbance
is self experience has two
aspects --awareness of existence and
activity of the self --awareness of being
separate from the environment

70. Four aspects of selfawareness(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

71. Awareness of BEING OR
EXISTING, EGO VITALITY
“
I know that I exist”
and this is fundamental to awareness of self

72. Awareness of ACTIVITY
I do something and that I know that I am
doing it
Everything 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


73. Awareness of
UNITY/SINGLENESS
At
any given moment I know that I am
one person
In health, a person is integrated in his
thinking and behaviour, so that he does
not have to be aware of feeling of unity

74. Awareness of
IDENTITY/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

75. Awareness of BOUNDARIES OF
SELF
I
can distinguish what is myself from the
outside world, and all that is not the self

76. Awareness of THE BODY
The
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 sensations
In transsexual there is conflict between
ego and body image

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

78. Clinical range of disordered 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 drugs
a) mild depersonalisation is very common with drugs
Eg; tricyclic antidepressents
b) more marked change occur with cannabis, mescalin,
LSD (Lysergic acid diethylamide)

79.  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

80. Disturbance of awareness
of BEING OR EXISTING
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

81. Definition of depersonalisation
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)

82. 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)

83. Positive features of 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

84. Excluded from depersonalisation (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

85. Depersonalisation 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

86. Components of depersonalisation(Sierre
and Berris, 2001)
Emotional blunting
Changes in body experience
Changes in visual experience
Changes in auditory experience
Changes in tactile experience
Changes in gustatory experience
Changes in olfactory experience
Loss of feeling of agency
Distortions in the experience of time
Changes in the subjective experience of memory
Feeling of thought emptiness
Subjective feeling of an inability to evoke images
Heightened self-observation

87. Features most prevalent for 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

88. Depersonalisation 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

89. Clinical features of depersonalisation
It
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

90. 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

91. Conditions 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

92.  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

93. Depersonalisation symptom Vs disorder
It
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)

94. Depersonalisation disorder ICD-10 Vs
DSM-IV
 Classinfied
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

95. Social 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.

96. Organic and psychological theories of
depersonalisation
 The
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

97. derealisation
Frequently
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)

98. desomatisation
Localisation
Kuru,
to individualised organ
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

99. Distortion of time
Change
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

100. Deaffectualisation--Loss of
emotional resonance
Normal
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

101. Depression and loss of emotional
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

102. Jamais vu and deja vu
Jamais
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

103. Disturbance of awareness of SELF
ACTIVITY
Perception–
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

104. 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

105. 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)

106. Disturbance in the immediate
awareness of SELFUNITY/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

107.  They
feel as if they are two persons
Seen 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)

108. Autoscopy (heautoscopy/phantom
mirror 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

109. The double phenomenon:
doppleganger
It
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

110. dual, double or multiple
personality
Very
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

111. Related
terms
Delusional misidentification or Capgras
syndrome
Double 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

112. Disturbance of
the CONTINUITY/IDENTITY
of the self
 This
disorder is characterised by changes in the identity
of self over time
 The 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

113. 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

114. 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

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

116. Possession state
Altered
state of conscious awareness is
prerequisite
It 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

117. Near 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

118. Disturbances of
BOUNDARIES of the self
 Disturbance
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

119. 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)-schizophreniaorganic disorders

120. 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

121. 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)

122.  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

123. Auditory hallucinations and third person
auditory hallucination
AH
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

124. Hearing one’s own thoughts spoken
aloud
Implies
locating one’s innermost core
experience as in distant past

125. Delusional 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

126. Thought broadcasting
--
because the pt ‘knows’ that as he
thinks the whole world is thinking in
unison

127. Other alterations to boundaries of
self– in states of ecstasy
Person
might describe
feeling at one with universe
merging with Nirvana
experiencing unity with saints
or in oneness with God
Occur
in normal people
in those with personality disorder
as 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)

128. PSYCHIATRIC
APPLICATIONS

129. Theory of mind (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

130.  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

131. 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

132. Disorders of the awareness
of the body(body image)
Undue
concern with illness–
Hypochondriasis
Dislike
of body– Dysmorphophobia,
transsexualism
Undue
concern with appearance–
Narcissism
Distortion
obesity
of body image– anorexia nervosa,

133. references
Andrew
Sims. (2003)Symptoms in
Mind ( 3rdedition). Saunders/Elsevier
Patricia
Casey, Brenden Kelly.(2007)
Fish’s Clinical psychopathology
(3rd edition). Gaskell

134. THANK YOU

135. Floor discussion