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by visual and auditory illusions or hallucinations and paranoid delusions (a veritable psychosis) are variable features These psychologic disturbances may appear in many contexts Confusion, as de ned in this way, is an essential ingredient of the singular state called delirium (discussed further on), in which a agitation, hallucinations, and sometimes convulsions and tremor accompany the core confusional state Also, as pointed out in Chap 17, a confusional state may appear at any stage in the evolution and resolution of a number of diseases that lead to drowsiness, stupor, and coma typically in the metabolic encephalopathies but also in diseases affecting the regions of the brain that maintain normal arousal It should be pointed out that confusion is also a characteristic feature of the chronic syndrome of dementia, where it is the product of a progressive failure of language, memory, and other intellectual functions; here it is mainly the long-standing and progressive nature of the mental confusion that differentiates the process from the acute confusional and delirious states that carry quite different implications Intense emotional disturbances, of either manic or depressive type, may interfere with attentiveness and coherence of thinking and thereby produce an apparent confusional state Finally, special forms of confusion may appear in association with certain focal cerebral lesions, particularly of the frontal, parietal, and sometimes the temporal lobe association areas Then, instead of a global inattention and incoherence, there may be unilateral neglect of self or of the environment, an inability to identify persons or objects, and sensorimotor defects Yet another unique form of confusion arises as a result of disordered language function, which apparently alters the stream of thought; this is usually a consequence of lesions in the specialized language areas of the left temporal lobe The many mental and behavioral aberrations that are seen in confused patients, and their occurrence in various combinations and clinical contexts, make it unlikely that they all derive from a single elementary psychologic abnormality such as a disturbance of attention While attention is near the core of confusion, phenomena as diverse as drowsiness and stupor, hallucinations and delusions, disorders of perception and registration, impersistence and perseveration, and so forth are not easily reduced to a disorder of one psychologic or physiologic mechanism More likely, a number of separable disorders of function are involved, all acute and usually reversible Indeed, one view of the confusional state that we nd attractive envisions confusion as a loss of the integrative functions among the elementary and localizable cerebral functions such as symbolic language, memory retrieval, and apperception All of these are often included under the rubric of the confusional states, for want of a better term We have reserved the term delirium, in distinction to the use of this term in psychiatric parlance, to denote a special type of confusional state In addition to many of the negative elements mentioned above, delirium is marked by a prominent disorder of perception; hallucinations and vivid dreams; a kaleidoscopic array of strange and absurd fantasies and delusions; inability to sleep; a.

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tendency to twitch, tremble, and convulse; and intense fear or other emotional reactions Delirium is distinguished not only by extreme inattentiveness but also by a state of heightened alertness ie, an increased readiness to respond to stimuli and by overactivity of psychomotor and autonomic nervous system functions, sometimes striking in degree Implicit in the term delirium are its nonmedical connotations as well intense agitation, frenzied excitement, and trembling All these positive aspects of disordered consciousness, after the classic studies of French authors, are designated by the term oneirism or oneiric consciousness (from the Greek oneiros, dream ) The twilight states are closely related disorders, but the clinical descriptions have been so diverse that the term now has little useful meaning It should be noted that this distinction between delirium and other acute confusional states is not universally accepted Many authors attach no particular signi cance to the autonomic and psychomotor overactivity and the dream-like features of delirium, or to the underactivity and somnolence that characterize certain other confusional states All such states are lumped together as confusion or, in the psychiatric literature, delirium, or under headings such as organic brain syndrome, acute organic reaction, toxic-infective psychosis, febrile delirium, exogenous psychosis, acute organic reaction, and symptomatic psychosis, with the implication that they are induced by toxic or metabolic disturbances of the brain (The term organic is unfortunate, for it implies the existence of other nonorganic confusional states) We set delirium apart from other nondescript confusional states because the two conditions are manifestly different and tend to occur in different clinical contexts, as indicated further on Nevertheless, implicit in both designations is the idea of an acute, transient, and usually completely reversible disorder modi ed, of course, by the underlying cause, clinical setting, and age of the patient An impairment of memory is often included among the symptoms of delirium and other confusional states, as discussed further on Registration and recall are indeed greatly impaired in the states under discussion, but they are affected in proportion to the degree of inattention and the inability to register new material The term amnesia, however, refers more precisely to a loss of past memories as well as to an inability to form new ones, despite an alert state of mind and normal attentiveness; the de nition further presupposes an ability of the patient to grasp the meaning of what is going on around him, to use language normally, and to maintain adequate motivation to learn and to recall Only if de ned this way does the term amnesia have any clinical usefulness The failure in the amnesic state is mainly one of retention, recall, and reproduction and must be distinguished from states of drowsiness, acute confusion, and delirium, in which information and events seem never to have been adequately perceived and registered in the rst place In the latter circumstances, as in genuine amnesia, the patient will, of course, be left with a permanent gap in memory for his acute illness In a similar way, the term dementia (literally, an undoing of the mind) denotes a deterioration of all intellectual or cognitive functions with little or no disturbance of consciousness or perception Implied by the word is the idea of a gradual enfeeblement of mental powers in a person who formerly possessed a normal mind Confusion can also be the result of dementia, but it is the chronicity of the latter that is most distinctive from the common acute confusional states Amentia, by contrast, indicates a congenital feeblemindedness more commonly referred to as mental retardation Dementia and amnesia are de ned more explicitly in Chap 21.

Type of BI Object (START_OBJECT_TYPE):

OBSERVABLE ASPECTS OF BEHAVIOR AND INTELLECTION IN STATES OF CONFUSION, DELIRIUM, AMNESIA, AND DEMENTIA