Disorders of Consciousness, Past, Present, and Future.

This paper, presented as the 2019 Cambridge Quarterly Neuroethics Network Charcot Lecture, traces the nosology of disorders of consciousness in light of 2018 practice guidelines promulgated by the American Academy of Neurology, the American College of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research. By exploring the ancient origins of Jennett and Plum's persistent vegetative state and subsequent refinements in the classification of disorders of consciousness-epitomized by the minimally conscious state, cognitive motor dissociation, and the recently described chronic vegetative state-the author argues that there is a counter-narrative to the one linking these conditions to the right to die. Instead, there is a more nuanced schema distinguishing futility from utility, informed by technical advances now able to identify covert consciousness contemplated by Jennett and Plum. Their prescience foreshadows recent developments in the disorders of consciousness literature yielding a layered legacy with implications for society's normative and legal obligations to these patients.

Coma and disorders of consciousness: scientific advances and practical considerations for clinicians.

Recently, neuroscientists and clinicians have seen the rapid evolution of diagnoses in disorders of consciousness. The unresponsive wakefulness syndrome-vegetative state, the minimally conscious state plus and minus, and the functional locked-in syndrome have been defined using new neuroimaging techniques. Diffusion tensor imaging, positron emission tomography, functional magnetic resonance imaging, electroencephalography, and transcranial magnetic stimulation techniques have all promoted important discoveries in the field of disorders of consciousness. This has led to a better understanding of these patients' condition and to the development of new prognosis, therapeutic, and communication tools. However, low sensitivity and artifacts problems need to be solved to bring these new technologies to the single-patient level; they also need to be studied in larger scale and randomized control trials. In addition, new ethics questions have arisen and need to be investigated.

Estados excepcionales de conciencia y consumo de sustancias psicotropas / No disponible

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Un modelo explicativo de la calidad de vida en la esquizofrenia: el papel de la velocidad de procesamiento y los síntomas negativos / An explanatory model of quality of life in schizophrenia: the role of processing speed and negative symptoms

Introducción. Mejorar la calidad de vida de los pacientes con esquizofrenia es un objetivo fundamental en una enfermedad que resulta devastadora, pero no hay acuerdo sobre qué factores predicen la calidad de vida (CV) en el curso de la enfermedad. Metodología. En el presente estudio se examinaron a165 pacientes hospitalizados con esquizofrenia. Se incluyeron medidas de síntomas psiquiátricos (PANSS, insight y síntomas afectivos) y cognitivas. Un análisis factorial confirmatorio estableció una estructura cognitiva compuesta de seis factores, que incluyen atención, velocidad de procesamiento, memoria verbal, fluidez, memoria de trabajo y funciones ejecutivas. La calidad de vida fue medida mediante la Escala de Calidad de Vida de Heinrichs-Hanlon-Carpenter. Resultados. La edad, tiempo de duración de la enfermedad, mayor gravedad de síntomas negativos y la mayoría de factores cognitivos correlacionaron significativamente con los indicadores de CV. Los análisis de regresión mostraron que, muy por encima de los demás factores cognitivos, la velocidad de procesamiento (VP) es un importante predictor de la CV. Además, la interacción de la VP con los síntomas negativos, la edad del paciente y el nivel de deterioro en funciones ejecutivas modificaron el efecto de la VP sobre la CV. Finalmente, los síntomas positivos y otros datos sociodemográficos no guardaron relación con la CV en nuestro estudio. Conclusiones. Nuestros hallazgos sugieren que la VP y los síntomas negativos predicen la CV en la esquizofrenia (AU)

Introduction. Improving the quality of life of patients with schizophrenia is a major goal in managing this devastating disorder, but agreement is lacking about the factors that predict quality of life (QoL) over the course of the disorder. Methods. We examined 165 hospitalized patients with schizophrenia in this study. We included measures for psychiatric (PANSS, insight and affective symptoms) and cognitive symptoms. Confirmatory factor analysis established a cognitive structure composed of the following six factors: attention, processing speed, verbal memory, fluency, working memory and executive functioning. Quality of life was assessed using the Heinrichs-Hanlon-Carpenter Scale. Results. Age, duration of illness, presence of more severe negative symptoms and most cognitive factors correlated significantly with QoL indicators. Regression analysis showed that processing speed (PS) was by far the most important cognitive factor that predicted QoL. Moreover, the interaction between PS and negative symptoms, patient age and executive functions modified the effect of PS on QoL. Finally, positive symptoms and other socio-demographic data were not related to QoL in the current study. Conclusions. Our findings suggest that PS and negative symptoms predict QoL in schizophrenia (AU)

Delirium e confusão mental no século XIX: uma história conceitual / Delirium and confusion in the 19th century: a conceptual history

O delirium permaneceu uma categoria psiquiátrica estável até oinício do século XIX, quando passou por uma redefinição etiológica efenomenológica, precipitando a transformação das insanidadesfuncionais em psicoses.A confusão, introduzida pelos franceses ao longo da segundametade do século, referia-se a uma síndrome mais ampla (porémincluindo) o delirium. Enfatizava o pensamento caótico e as falhascognitivas. A noção de turvação da consciência (e desorientaçãotemporoespacial) estabeleceu um denominador comum para as duasconcepções, enquanto Chaslin e Bonhoeffer redefiniram a confusão eo delirium como as manifestações estereotipadas da insuficiênciacerebral aguda.AU

Delirium remained a stable psychiatric category until the early 19th century whenit underwent aetiological and phenomenological redefinition, precipitating thetransformation of the functional insanities into psychoses. Confusion, introduced by theFrench during the second half of the century, referred to a syndrome wider than (butincluding) delirium. It emphasized chaotic thinking and cognitive failure. The notionof clouding of consciousness (and tempora-spatial disorientation) established acommon denominator for the two concepts, while Chaslin and Bonhoeffer redefinedconfusion and delirium asthe stereotyped manifestations of acute brain failure.AU

El delirium permaneció una categoría psiquiátrica estable hasta inicios de sigloXIX, cuando pasó por una redefinición etiológica e fenomenológica, precipitando latransformación de las insanias funcionales en psicosis.La confusión, introducida por los franceses a lo largo de la segunda mitad desiglo, se refería a un síndrome más amplio (pero incluyendo) o delirium. Enfatizaba elpensamiento caótico y las fallas cognitivas. La noción de turbación de la conciencia(y desorientación temporal-espacial) estableció un denominador común para las dosconcepciones, en cuanto Chaslin y Bonhoeffer redefinieron la confusión y el deliriumcomo as manifestaciones estereotipadas de la insuficiencia cerebral aguda.AU

Le délire était une catégorie psychiatrique stable jusqu’au début du XIXe siècle.Elle subi alors une redéfinition étiologique et phénoménologique précipitant latransformation des insanités fonctionnels dans les psychoses. La confusion, introduitepar les français au cours de la seconde moitié du siècle, renvoie à un syndrome plusample que le délire (et l’inclut). Elle met en relief la pensée chaotique et les échecscognitifs. La notion de trouble de la conscience (et de la désorientation temporospatiale)a établi un dénominateur commun pour les deux concepts, tandis que Chaslinet Bonhoeffer ont redéfini la confusion et le délire comme des manifestationsstéréotypées de la défaillance cérébrale aiguë.AU

Delirium e confusão mental no século XIX: uma história conceitual / Delirium and confusion in the 19th century: a conceptual history / Le délire et la confusion au XIX e siècle: une histoire conceptuelle / El delirium y la confusión en el sigo XIX: una historia conceptual

O delirium permaneceu uma categoria psiquiátrica estável até o início do século XIX, quando passou por uma redefinição etiológica efenomenológica, precipitando a transformação das insanidades funcionais em psicoses.A confusão, introduzida pelos franceses ao longo da segunda metade do século, referia-se a uma síndrome mais ampla (porém incluindo) o delirium. Enfatizava o pensamento caótico e as falhas cognitivas. A noção de turvação da consciência (e desorientação temporoespacial) estabeleceu um denominador comum para as duas concepções, enquanto Chaslin e Bonhoeffer redefiniram a confusão eo delirium como as manifestações estereotipadas da insuficiência cerebral aguda.

Delirium remained a stable psychiatric category until the early 19th century whenit underwent aetiological and phenomenological redefinition, precipitating the transformation of the functional insanities into psychoses. Confusion, introduced by the French during the second half of the century, referred to a syndrome wider than (butincluding) delirium. It emphasized chaotic thinking and cognitive failure. The notionof clouding of consciousness (and tempora-spatial disorientation) established acommon denominator for the two concepts, while Chaslin and Bonhoeffer redefined confusion and delirium asthe stereotyped manifestations of acute brain failure.

El delirium permaneció una categoría psiquiátrica estable hasta inicios de sigloXIX, cuando pasó por una redefinición etiológica e fenomenológica, precipitando latransformación de las insanias funcionales en psicosis.La confusión, introducida por los franceses a lo largo de la segunda mitad desiglo, se refería a un síndrome más amplio (pero incluyendo) o delirium. Enfatizaba elpensamiento caótico y las fallas cognitivas. La noción de turbación de la conciencia(y desorientación temporal-espacial) estableció un denominador común para las dosconcepciones, en cuanto Chaslin y Bonhoeffer redefinieron la confusión y el deliriumcomo as manifestaciones estereotipadas de la insuficiencia cerebral aguda.

Le délire était une catégorie psychiatrique stable jusqu’au début du XIXe siècle.Elle subi alors une redéfinition étiologique et phénoménologique précipitant latransformation des insanités fonctionnels dans les psychoses. La confusion, introduitepar les français au cours de la seconde moitié du siècle, renvoie à un syndrome plusample que le délire (et l’inclut). Elle met en relief la pensée chaotique et les échecscognitifs. La notion de trouble de la conscience (et de la désorientation temporospatiale)a établi un dénominateur commun pour les deux concepts, tandis que Chaslinet Bonhoeffer ont redéfini la confusion et le délire comme des manifestationsstéréotypées de la défaillance cérébrale aiguë.

Disorders of consciousness: what's in a name?

Following a coma, some patients may "awaken" without voluntary interaction or communication with the environment. More than 40 years ago this condition was coined coma vigil or apallic syndrome and later became worldwide known as "persistent vegetative state". About 10 years ago it became clear that some of these patients who failed to recover verbal or non-verbal communication did show some degree of consciousness--a condition called "minimally conscious state". Some authors questioned the usefulness of differentiating unresponsive "vegetative" from minimally conscious patients but subsequent functional neuroimaging studies have since objectively demonstrated differences in residual cerebral processing and hence, we think, conscious awareness. These neuroimaging studies have also demonstrated that a small subset of unresponsive "vegetative" patients may show unambiguous signs of consciousness and command following inaccessible to bedside clinical examination. These findings, together with negative associations intrinsic to the term "vegetative state" as well as the diagnostic errors and their potential effect on the treatment and care for these patients gave rise to the recent proposal for an alternative neutral and more descriptive name: unresponsive wakefulness syndrome. We here give an overview of PET and (functional) MRI studies performed in these challenging patients and stress the need for a separate ICD-9-CM diagnosis code and MEDLINE MeSH entry for "minimally conscious state" as the lack of clear distinction between vegetative state/unresponsive wakefulness syndrome and minimally conscious state may encumber scientific studies in the field of disorders of consciousness.

Kafka, paranoic doubles and the brain: hypnagogic vs. hyper-reflexive models of disrupted self in neuropsychiatric disorders and anomalous conscious states.

Kafka's writings are frequently interpreted as representing the historical period of modernism in which he was writing. Little attention has been paid, however, to the possibility that his writings may reflect neural mechanisms in the processing of self during hypnagogic (i.e., between waking and sleep) states. Kafka suffered from dream-like, hypnagogic hallucinations during a sleep-deprived state while writing. This paper discusses reasons (phenomenological and neurobiological) why the self projects an imaginary double (autoscopy) in its spontaneous hallucinations and how Kafka's writings help to elucidate the underlying cognitive and neural mechanisms. I further discuss how the proposed mechanisms may be relevant to understanding paranoid delusions in schizophrenia. Literature documents and records cognitive and neural processes of self with an intimacy that may be otherwise unavailable to neuroscience. To elucidate this approach, I contrast it with the apparently popularizing view that the symptoms of schizophrenia result from what has been called an operative (i.e., pre-reflective) hyper-reflexivity. The latter approach claims that pre-reflective self-awareness (diminished in schizophrenia) pervades all conscious experience (however, in a manner that remains unverifiable for both phenomenological and experimental methods). This contribution argues the opposite: the "self" informs our hypnagogic imagery precisely to the extent that we are not self-aware.

In a spin: the mysterious dancing epidemic of 1518.

In 1518, one of the strangest epidemics in recorded history struck the city of Strasbourg. Hundreds of people were seized by an irresistible urge to dance, hop and leap into the air. In houses, halls and public spaces, as fear paralyzed the city and the members of the elite despaired, the dancing continued with mindless intensity. Seldom pausing to eat, drink or rest, many of them danced for days or even weeks. And before long, the chronicles agree, dozens were dying from exhaustion. What was it that could have impelled as many as 400 people to dance, in some cases to death?

Affirming the right to care, preserving the right to die: disorders of consciousness and neuroethics after Schiavo.

In this article, I attempt to untangle some of the cultural, philosophical, and ethical currents that informed the Schiavo case. My objective is to better apprehend what the Schiavo case means for end-of-life care in general and to assert that our discourse about the ethical issues attendant to brain injury will be impoverished if we limit our discussions about disorders of consciousness solely to the vegetative state. If we ignore emerging developments in neuroscience that are helping to elucidate the nature of these disorders and fail to broaden the conversation about brain injury, beyond the unmitigated futility of the permanent vegetative state, we will imperil others who might improve and be helped. Through such efforts we can help mitigate the tragedy of the Schiavo case and overcome the rhetoric that marked the national discourse in March 2005. Once the complexity of disorders of consciousness is appreciated, rhetorical statements about a right to die or a right to life are exposed as being incompatible with the challenge of providing care to such patients. This is especially true as neuroscience brings greater diagnostic refinement to their assessment and management, a topic addressed in this article, which specifically focuses on the clinical and ethical implications of the recently described minimally conscious state. Instead of staking out ideological positions that do not meet the needs of patients or families, we should strive to both preserve the right to die for those who are beyond hope while affirming the right to care to those who might benefit from coming advances in neuroscience. If we can achieve that delicate balance, we will be able to transcend the partisan debate that shrouded the life and death of Theresa Marie Schiavo and begin to articulate a palliative neuroethics of care for those touched by severe brain injury and disorders of consciousness.

Pierre Janet and Félida Artificielle: multiple personality in a nineteenth-century guise.

In the wake of the recent epidemic of multiple personality phenomena, it is important to get a clear idea of what similar phenomena looked like in previous centuries. Pierre Janet's detailed description of his discovery, made during the 1880s, that he could cure hysteria by creating a healthy second personality offers a close look at a form of multiple personalities very different from what has recently been described. His description of the factors that influenced his discovery allow one to see his work in a historical context and to appreciate his confrontation with the paradoxes that this discovery revealed.

[The logical basis of mental confusion in Delasiauve, Bonhoeffer and Llopis versus DSM-III-R delirium]. / El fundamento lógico de la idea de confusión mental en Delasiauve, Bonhoeffer y Llopis, frente al del Delirium, en el DSM-III-R.

Delasiauve, Bonhoeffer and Llopis, conceived confusional scenes contrasting the theory of Unique Psychosis, Nosologic Unit, and Psychical Atomism respectively. The a-theoric DSM-III-R, doesn't establish any new concept, limiting itself to arrange in other way, that which was discovered by those and others authors, without rational justifications, having priority over clinical considerations, verbal definitions, with a practice and scientific value that may be debatable.

The predelusional state: a conceptual history.

The predelusional state (PDS) is defined as the set of psychopathologic events preceding the crystallization of delusions, and includes strange cognitions, moods, conations, and motor acts that may be fleeting and defy description. This review exclusively deals with the historic aspects of PDS. It is noted that during PDS the patient is expected to report experiences for which, on account of their novelty, he may not even have a name. Thus, it is quite likely that according to culture and personal codes and to the conceptual brief of the interviewer, similar experiences might be reported as depersonalization, bodily sensations, dysphoria, changes in perception of reality or time, dissolution of "ego boundaries," etc. It is therefore not surprising that since the 19th century, PDS has been considered a disorder of cognition, emotions, volition, and consciousness.