Thanks a lot, Leonhard. I read the article. Truly remarkable! In speaking of a disorder of consciousness it is always useful to pay attention to the presence of qualitative alterations of the sphere of consciousness. Consciousness must not be taken to be synonymous with the sphere of consciousness, and nor is it an ordered, circumscribed flow of processes. Being open-ended, consciousness transcends its own sphere of action. Precisely the unity of subjectivity and the world shows how the traditional distinction between the quantitative-categorial levels (attention, vigilance, sleep, coma) and qualitative-dimensional levels (subjective experiences such as sensations, thoughts, emotions) needs to be integrated with an analysis of the hierarchies and different types and degrees of consciousness, whether synchronic (sphere of consciousness) or diachronic (the ego or personality).

Each aspect of our relational life depends on the way in which consciousness integrates and transforms the data received from the environment. However, quite apart from its spontaneous capacity for transformation, consciousness can be strongly modified by our will, as when we concentrate on meditation or withdraw into contemplation. Only the crystal clear perception of our presence – that is, of it being we ourselves who are thinking, knowing, wanting, doing – guarantees a conscious psychic life: precisely what is missing, as we have seen, in those states characterised by sentiments of unreality and loss of familiarity vis à vis oneself and the world around, which obscure the outlines of the self, making them indistinct and indeterminate. 

Towards the end of the 19th century the ideas that experience of the self was only related to the sensorial-perceptive spheres had yielded to a more dynamic hypothesis. Pierre Janet, for example, formulated a model of the mind which comprised a complex hierarchy of levels. He considered depersonalization as an aspect of psychoasthenia, a syndrome characterised by a sensation of incompleteness and emptiness which invests perception, motor action, the emotions and the sense of self. It is in fact an authentic pathology of action: “the sensation of void is a problem of action, not of sensations or consciousness”. Janet distinguished between primary and secondary psychic activities: the former include the activities provoked by external stimuli (such as memories), forming a vital impression, while the latter represent an echo of the representations of primary acts and create the illusion of a continuous psychic stream.

Sure, Leonhard, send me your project as well. I'll read it with pleasure. Cordiali saluti dal mare di Napoli.

Silvia, very interesting your historical reconstruction. I have often heard patients say phrases like “as if it wasn’t me thinking”, “as if my feelings were no longer my own”, “as if I’d become an automaton” reflect surprise and disquiet, anguish and apprehension, feelings of being alien and of not belonging. In spite of these metamorphoses of feeling, including feeling part of the world, the critical appraisal of reality generally remains uncompromised, providing a check on the encroachment of the psychosis. The experience of time – in particular, the concordance between then and now – is altered. It is not unusual for memories themselves to appear alien, as if they no longer concerned the person who experienced them. In any case, the inability to live either in time or outside it is not linked to knowledge of time: rather, it concerns the experience of time. Past, present and future are seen as asymmetric. Feelings of unreality and discontinuity in time are the very essence of depersonalization.

Dear Mauro, I have argued in several places that ALL mental disorders are disorders of conscious processing, BUT have not been always successful - maybe because many psychistrists think that IF mental disease has a biological basis then it is NOT a disease of consciousness. In a Monist view the physical, informational and mental conscious aspects are aspects of the same reality, and therefore the Bleuler distinction is considered to be a mistake.

Dear Alfredo, you're right. It is a drift that has complex roots. The recent history of the DSM V is very eloquent! The worst risk is the cultural impoverishment of the new generations. We must return to discuss about psychopathology. consciousness and its disorders represent crucial issues.

Dear Mauro, I do not know the work of Ey. Does he distinguish the organization of the brain and the mind? Or does he think it is the same organization?

Dear Alfredo, Ey believed that consciousness is an activity whose expressions, degrees of reality and contents vary according to the circumstances of everyday life, with a hierarchy that can change quite freely. He argued that the whole spectrum of psychiatric illnesses can be seen as the consequence of a disorder of consciousness. In this conception, whichis strongly influenced by Jackson’s work, the de-structuring of consciousness can lead to a degeneration in the dynamic structure of the subjective experience. This process begins with a ‘de-temporalisation’ at various levels: first the projection into the future of the manic state and the withdrawal into the past of the depressive state; then the qualitative disorders of consciousness; and finally the disorientation in terms of time and space, seen in momentary fantasies, oneiric alterations combined with qualitative alterations, and formal disorders of the thought processes causing serious discriminative and cognitive alterations.

Ey brought to a close, we might say, the lengthy era of Victorian neurophysiology: no longer would it be possible to describe the nervous functions in terms of the old hierarchy of anatomical centres. The cerebral cortex becomes the locus for “optional exercises of the field of consciousness”, while the midbrain is the neuronal infrastructure for the vertical plane of the sphere of consciousness. The activity of the cortex is based on vigilance, which represents its "ouverture au monde".

Mauro (and others), so if consciousness has a state of "order" - how do we know it (define it) and could we at times misinterpret an initially disordered state as static, when in fact it might be part of a dynamic process that might eventually arrive at a state of (higher) order ?

As an example, I am now thinking about spiritual emergencies - Stan Grof's interpretation of certain episodes usually (mis)labelled as psychotic. 

Is anybody familiar with the enneagram ? I see each enneatype as a consciousness container (with defined size, volume, proportions...) and so I imagine it could be quite a nice template against which to "measure" various degrees of "order"...

Javi, I find your reasoning clever. In clinical settings you are needed from shared points. Generally speaking the meaning we project onto things is constantly changing. Things can prove to be more opaque or more transparent, more extraneous or more familiar. Sometimes, however, even what is closest to us can be an obstacle. A change in the relationship with things affects two aspects of everyday life: the stream of consciousness and our harmony with others. It is not a question of making a different value judgement but rather of attributing a different sense to things and other people. In these circumstances the meaning of things distances itself from our consciousness. Subject and object grow further and further apart. New judgements and categories give rise to a different system of values. Our existence gains in profundity but becomes removed from everyday life, which becomes dense with fantastic meanings and categories. The fault line between what the subject feels it is and what it has to be becomes increasingly evident.

Then there are experiences which can tend towards a radical inner metamorphosis (in the schizophrenic sense), deviating the flow of consciousness into obscure byways and suspending every achievement of meaning. In this climate of profound ambivalence, of radical inability to surpass oneself, it is impossible to re-connect and participate in past events. A radical crisis of presence ensues. The instigation of the “as if” modality – i.e. the urge to explain what can no longer be experienced – reveals all the ambiguity of an experience which is incapable of going any further except in a coercive sense.

In terms of consciousness alterations, I find the case of the Portugueese poet Fernando Pessoa emblematic. I do not think that his heteronyms were only literary constructions. At least it does not seem to be if we read some of his letters. Guess he was able to transform a significant problem in artistic wealth. On 13 January 1935, in reply to a letter from his friend Adolfo Casais Monteiro asking about the origin of his many heteronyms, Pessoa wrote: “The origin of my heteronyms is basically an aspect of hysteria that exists within me. I don't know whether I am simply a hysteric or if I am more properly a neurasthenic hysteric. I tend toward the second hypothesis, because there are in me evidences of lassitude that hysteria, properly speaking, doesn't encompass in the list of its symptoms. Be that as it may, the mental origin of heteronyms lies in a persistent and organic tendency of mine to depersonalization and simulation. These phenomena - fortunately for me and others - intellectualize themselves. I mean, they don't show up in my practical life, on the surface and in contact with others; they explode inside, and I live with them alone in me .... An urging of spirit came upon me, absolutely foreign, for one reason or another, of that which I am, or which I suppose that I am. I spoke to it, immediately, spontaneously, as if it were a certain friend of mine whose name I invented, whose history I adapted, and whose figure, face, build, clothes, and manner, I immediately saw inside of me. And so I contrived and procreated various friends and acquaintances who never existed but whom still today nearly thirty years later I hear, feel, see, repeat: I hear, feel, see and get greetings from them”.

Roberta, thanks for your interesting reflection. Generally speaking the meaning we project onto things is constantly changing. Things can prove to be more opaque or more transparent, more extraneous or more familiar. Sometimes, however, even what is closest to us can be an obstacle. A change in the relationship with things affects two aspects of everyday life: the stream of consciousness and our harmony with others. It is not a question of making a different value judgement but rather of attributing a different sense to things and other people. In these circumstances the meaning of things distances itself from our consciousness. Subject and object grow further and further apart. New judgements and categories give rise to a different system of values. Our existence gains in profundity but becomes removed from everyday life, which becomes dense with fantastic meanings and categories. The fault line between what the subject feels it is and what it has to be becomes increasingly evident.

Then there are experiences which can tend towards a radical inner metamorphosis (in the schizophrenic sense), deviating the flow of consciousness into obscure byways and suspending every achievement of meaning. In this climate of profound ambivalence, of radical inability to surpass oneself, it is impossible to re-connect and participate in past events. A radical crisis of presence ensues. The instigation of the “as if” modality – i.e. the urge to explain what can no longer be experienced – reveals all the ambiguity of an experience which is incapable of going any further except in a coercive sense. All the psychic energy is concentrated on the "I-world" identification.

There are perhaps no other human experiences able to reveal the conceptual drama of the unity of the person so starkly as derealization and depersonalization. Certainly, psychiatry and psychology remained ensnared in this dilemma for over a century. Not only do derealization and depersonalization call into question the world’s logical structure, transforming the ego into an enigmatic and disconcerting experience; ultimately they show up all the precariousness of rationality’s claim to being self-sufficient.

In the debate on psychopathology one often hears the famous and dramatic exclamation – recorded by Jaspers in his General Psychopathology – uttered by a woman from Sandberg at the onset of a delirious fit: “There’s something […]. Tell me, what is there? I don’t know. But something has happened”. It is not my intention to return to a discussion of schizophrenic premonition, which I have dealt with elsewhere. I just wish to point out how every boundary between the patient and the surrounding world has been dissolved. But if this boundary cannot be designated (whoever is asking cannot be the self, but nor its mirror, which obviously requires the self to exist), who is at the centre of this experience in which everything looms large, posing a terrible threat to the ego? What name can be given to this paradoxical and elusive revelation, this metamorphosis of sense, in which signifiant and signifié almost come to coincide, obscuring the “who” and “what” of a situation in which nothing has sense any more because everything can have a sense; in which language is a ciphered experience but the code has been lost, and every gesture is an attempt to find refuge in a shared “common sense” before the world ends, before we come face to face with the void?

Very interesting debate! Depersonalization was described in the first half of the 19th century as a set of experiences recurring in many psychiatric profiles, characterised by the loss of every sentiment and a sense of unreality vis à vis oneself and the world. To designate this latter aspect the term derealization was introduced in the first part of the 20th century. In current international psychiatric classifications, depersonalization is described as a persistent or recurring experience in which subjects feel themselves to be external observers of their mind and their body (as in a dream); while derealization is described as the sensation that the external world has become strange or unreal: as if the size or shape of objects and people have become mechanical and unfamiliar.

Dear Raffaele, the first descriptions of experiences similar to depersonalization can be found in nineteenth century medical literature. Griesinger records a letter written by a patient of the famous French psychiatrist Jean-Étienne Dominique Esquirol:

I continue to suffer constantly; I don’t have a moment of comfort, nor experience human sensations. Even though I am surrounded by all that can render life happy and agreeable, in me the faculty of enjoyment and sensation is waiting or have become physical impossibilities. In everything, even in the most tender caresses of my children, I find only bitterness, I cover them with kisses, but there is something between their lips and mine; and this horrid something is between me and the enjoyment of life. My existence is incomplete. The functions and acts of ordinary life, it is true, still remain to me; but in every one of them there is something lacking. That is, the sensation which is proper to them..Each of my senses, each part of my proper self is as if it were separated from me and can no longer afford me any sensation. This impossibility seems to depend upon a void which I feel in the front of my head and to be due to a diminished sensibility over my whole body, for it seems to me that I never actually reach the objects that I touch. I no longer experience the internal feeling of the air when I breathe...My eyes see and my spirit perceives, but the sensation of what I see is completely absent (Griesinger, 1845, p. 157)

interesting discussion, not only on the historical level! Wilhelm Griesinger had often come across similar cases in patients suffering from melancholy. Although they did not manifest any pathology, they complained about experiencing an unbridgeable gap between themselves and things, as if they were cut off from the outside world by a wall. Some years earlier Albert Zeller (1838) recorded five patients talking about an almost total lack of feelings: they felt as though they were dead, plunged into a bottomless abyss and with no possibility of seeing daylight ever again. The annotations of another French psychiatist, Ernest Billod, are also very interesting, describing a patient who reported similar experiences: "She claimed to feel as if she were not dead or alive, as if living in a continuous dream..objects [in her environment] looked as if surrounded by a cloud; people seemed to move like shadows, and words seemed to come from a far away world"

In reality, the first person to provide a systematic description of these experiences was Maurice Krishaber (1873), who described a total of 38 patients manifesting a mixture of anxiety, asthenia and melancholy. Over a third of them related disconcerting experiences, characterised by the loss of the awareness of reality. Whereas Jules Séglas described the singular case of a patient who lost all consciousness of her body each time she was out walking:

It seems to me as if I am split into two, I lose the awareness of my body, which feels as if it is in front of me, I walk, and I am aware of it but I do not have awareness of my own identity, that it is actually me who is walking. (Séglas)

Splendid description, Silvia! By the end of the 19th century the hypothesis that experience of the self was only related to the sensorial-perceptive spheres had yielded to a more dynamic hypothesis. Pierre Janet formulated a model of the mind, owing much to the theories of Jackson, which envisaged a psychological organization comprising a complex hierarchy of levels. He considered depersonalization as an aspect of psychoasthenia, a syndrome characterised by a sensation of incompleteness and emptiness which invests perception, motor action, the emotions and the sense of self. It is in fact an authentic pathology of action: “the sensation of void is a problem of action, not of sensations or consciousness”. The French researcher distinguished between primary and secondary psychic activities: the former include the activities provoked by external stimuli (such as memories), forming a vital impression, while the latter represent an echo of the representations of primary acts and create the illusion of a continuous psychic stream. 

In these patients, generally, there is a tendency to observe themselves, to separate the I-subject from the I-object. Things are wrapped in a sort of “dreamy numbness”, a mist, an aura of unreality. The sensation of being inanimate machines is projected onto objects, even the most familiar ones, which lose the quality of being known. And the same sensation invades the patients themselves. Phrases like “as if it wasn’t me thinking”, “as if my feelings were no longer my own”, “as if I’d become an automaton” reflect surprise and disquiet, anguish and apprehension, feelings of being alien and of not belonging. In spite of these metamorphoses of feeling, including feeling part of the world, the critical appraisal of reality generally remains uncompromised, providing a check on the encroachment of the psychosis.

The experience of time – in particular, the concordance between then and now – is altered. It is not unusual for memories themselves to appear alien, as if they no longer concerned the person who experienced them. In any case, the inability to live either in time or outside it is not linked to knowledge of time: rather, it concerns the experience of time. Past, present and future are seen as asymmetric. Feelings of unreality and discontinuity in time are the very essence of depersonalization.

It's true, Silvia. In the first half of the last century, Schilder insisted that depersonalization was typical of psychoses, and it was long believed to be the most frequent of the psychiatric syndromes. While Schilder emphasised the relationship between the corporeal projection and bodily awareness, highlighting the marked analogies between the disorders regarding parts of the body in depersonalised patients, Ey showed how such patients can see and touch their own bodies without ever being convinced that it is their own flesh and bones that are moving. They see their body without recognising it. The progressive estrangement of the body vis à vis the self is fostered by the alteration of the emotional sphere, which ensures the maintenance of the bodily image. If the image of our bodies is continually modelled by our sensations and perceptions, the emotional processes constitute the energy and determine that synthesising activity that has been completely lost in this formidable and mysterious experience.

I think it’s important to clarify that the disorders of consciousness are traditionally classed as either quantitative or qualitative. Among the former there are the conditions affecting attention, vigilance and other objectivizable spheres: confusional states, numbness, torpor, coma and cases with an organic basis. Qualitative disorders include those conditions which regard the contents of consciousness, the experience of self and the world around: depersonalization, derealization, dissociative phenomena with a psychogenous basis, oneiric and oneiroid states, confusional and crepuscular states. In reality, this is an artificial distinction. Quite often qualitative disorders are very contiguous to quantitative ones, making it difficult to arrive at a clear demarcation of the two. Of course this is not the place to set about formulating a meticulous (and highly complex) definition of the alterations of consciousness.

I agree. Nonetheless, in view of their crucial importance in a general consideration of consciousness, we need to outline a general classification. At least four levels of quantitative disorders of consciousness can be identified: 1) the first level comprises, among others, such clinical expressions as torpor, states of diminished consciousness, hypnoid alterations and others. In these conditions patients still distinguish themselves from the outside world, and fantasy from reality, recognising people and falling asleep normally. It is the first stage on the way to sopor, a sort of pre-coma. These conditions can be triggered by organic causes (cerebral traumas, grave metabolic alterations, tumours) or by the ingestion of alcohol and drugs; 2) the second level comprises, among others, the oneiric and oneiroid alterations, which involve both quantitative and qualitative associative anomalies, deformation of the appraisal of reality, and the presence of moments of delirium and hallucination. The distinction between reality and fantasy is still partially present. These alterations recur in confusional syndromes with an organic basis (delirium) and in acute phases of schizophrenia and mania.

3) the third level involves a shrinking of the sphere of consciousness. The onset will be abrupt, the symptomology has a limited duration, and generally the outcome is restitutio ad integrum. Patients appear to be totally wrapped up in themselves. They display a progressive inability to integrate temporal and spatial experiences. While there is no incoherence or numbness, they manifest fear, dysphoria, and mystic and ecstatic states. They have little memory of what has occurred. The activity of consciousness involves only a limited area of perceptions, representations, sentiments. The shrinking of the sphere of consciousness has a psychogenous basis and recurs in syndromes such as somatic conversion, post-traumatic stress and prolonged incarceration (Ganser’s syndrome). These quantitative disorders can also be caused by epileptic fits, cranial traumas and the ingestion of drugs; 4) the fourth level comprises, among other things, a confusional state in which the appraisal of reality is absent, there is linguistic incoherence, loss of temporal and spatial orientation, disorganization of language and thought processes, disorders of perception (illusions, hallucinations), alterations of the sleep-waking rhythm. It recurs in such cases as delirium or in acute and chronic organic confusional syndromes, traumas, dysmetabolic conditions, tumors and toxic states.

I would like point out that the qualitative disorders of consciousness include phenomena of derealization and depersonalization, disorders of dissociative identity (formerly known as multiple personality), psychogenous amnesia, somatic conversion syndrome, somatoform disorders, post-traumatic stress syndrome, acute psychoses and others. They can develop through medical causes (mostly following on from cerebral alterations) or psychic causes as the expression of a defence that intervenes in extreme situations (trauma) and unconscious conflicts that serve to contain a distress that cannot be organized in any other way.

In historical terms the psychopathological study of consciousness was of great importance. The formal features identified by Jaspers (1913) are still fundamental: 

•   sense of activity. Relational life is underpinned by an original activity which cannot be reduced to any other thing. The ego is conscious of thinking, acting and so on. This sense of the individual’s presence is lacking in states of depersonalization, where instead there is a radical perceptive estrangement, automatism of the will, a prevailing feeling of the absence of personal sentiments;

•   consciousness of uniqueness. I am a single whole at any given moment. The fact that the stability of the ego is beyond doubt, for all its extreme variability, is demonstrated by dissociations of personality; 

•   consciousness of identity. I am what I was yesterday through the flux of time; 

•   consciousness of the ego as opposed to the outside world and others. This aspect fully displays the unrepeatable originality of relational life. 

The harmonious development of these features – which according to Jaspers are at the basis of consciousness – is strongly altered by the ingestion of narcotic and psychedelic substances (cannabinoids and psilocybin, mescaline and lysergic acid, as well as more recent forms) and is manifested in phenomena such as the diffusion of thought (patients have the impression that their thoughts are projected onto the environment) and the sensation of fearful change with the onset of schizophrenia, feeling at the mercy of obscure forces, under hypnosis and other states. 

Raffaele, I think that whether these are identified as quantitative or qualitative disorders, their psychopathological study must always go hand in hand with analysis of the evolution and dissolution of the relationship between cortical and subcortical structures. For example, lesions of the ARAS, like the dysfunction of both cerebral hemispheres, can cause quantitative alterations of the state of consciousness. Alternatively, cortical lesions, in the absence of a bilateral dysfunction, produce modifications of the contents of consciousness matching their functional specialization.

believe that the study of correlations between neurobiological processes and dissociative phenomena is essential if you want to provide more strength to the psychopathological discourse.

it is necessary distinguish the primary eperienza of the sense of self (sense of activity etc ...) from the cognitive value of the sense of self. according to me the first is related to neurobilogici processes, the second is not related to them

A recent work compares the major physiopathological states linked with the absence of consciousness (deep sleep, coma/vegetative state, general anaesthesis, loss of consciousness during an epileptic fit). In particular it is shown how these states, although caused by a varied aetiopathogenesis, all share a series of objectivizable elements: regular electroencephalographic activity, a noticeable diminution of the metabolism in the frontoparietal regions, a generalised blockage of both cortico-cortical and talamo-cortical functional connections, and a state of “non respondence”. These effects of destructuring enable us to understand better some aspects of the temporal structure of consciousness and the related neural processes. For example, there are patients who can sleep well, be attentive and converse agreeably while showing no sign of consciousness disorders or altered syntony. And yet these are patients who often know very little of what they should know: where they are or where they have just come from. They often make mistakes, get lost easily, do not know the date or time or how old they are. Even in the state of full vigilance they are incapable (or only partially capable) of retrieving lost information.

Raffaele and Silvia, I agree. Anyway, although the debate on these highly sensitive issues is making great strides in the scientific community, in standard clinical practice alterations of the state of consciousness are still defined using the concepts of vigilance and consciousness. For example, if a patient involuntarily shuts their eyes, this is automatically classed as a withdrawal of consciousness from the world. If in a coma consciousness has disappeared and, in the most serious cases, the vital functions (such as breathing) have to be mechanically assisted, in the vegetative state the patient alternates periods when the eyes are opened and closed, often in correspondence with the sleep-waking cycles. Unlike in a coma, in the vegetative state there may be an unmotivated motor and facial mimicry activity. Although there are a large number of factors to be taken into consideration, before drifting into the vegetative state patients usually spend some weeks in the state of coma, after which the risk of non return becomes all too tragically probable.

In addition to the vegetative state there are states of minimal consciousness, and here the terminological and clinical situation becomes even more confused. The diagnostic criteria for this rather “all embracing” syndrome, characterised by severe alterations of consciousness, are different from those regarding the vegetative state. Consciousness is only minimally and discontinuously present. Patients appear to be able to interact, spontaneously or in response to precise stimulations, in an almost congruous way, albeit intermittently, with the outside world. However, their actions will not include the execution of complex tasks or last any length of time. In fact these two clinical conditions have notable elements in common, and they have been brought together in a clinical spectrum labelled “low level neurological state”, making it possible to dispense with such dated concepts as apallic syndrome, vigil coma and others.

Mauro, you have a background in psychiatry same as me. So from that field we know something, that could be called hardcore alterations. Alterations that are severe and persistent. Even applying medicaments may not cure these alterations but help people to work again or be able to live with their family. We also know about drugs, namely alcohol. The alterations from drugs may be softer and less persistent. They may be more harmful though.

The list is too long if we include what we know somewhat in comparison to really know. Neurosis is probably the most common in this small list. I am very skeptical as far as scientific knowledge from psychotherapy is concerned, but I can probably point to some knowledge with with more than 30 years of background as a practicioner and coming from teachers such as Fritz and Laura Perls. Neurosis has one main mechanism to alter conscious experience.

Influenced by neurosis we may perceive something different from what happens around us. Well establishey factors are defense mechanisms, prejudices etc. again the list is long and finding out what is knowledge and what is closer to guesswork is not easy.

Cheers

Hans

Hi Alfredo, 

I wanted to copy your comment, but my tablet is reluctant. So here a few remarks to your statement on page 1.

- disorders of conscious processing - is too vague. You basically must clarify if you address concerns regarding eteology, pathogenesis or symtoms of a malfunction. My "dear colleagues" will punish you for this. (I could give various explanations for this from the perspective of Medical Sociology) In a way this is understandable, because medicine had to fight for recognition as a science throughout most of the last century.

You keep missing on this distinction. So if a biological cause for a psychiatric malfunction is found, psychiatrists will defend this (some, frequently found) like a female lion its cubs. There may be multiple causation, biological, psychological, social, different kinds. They don't think in terms of consciousness, they rather think in terms of mind. Biological eteology means, pharmaceutic treatment is possible.

So unless a malfunction from consciousness is not detected safely as the main cause of the disease in question, it is better to look at the involvement of consciousness in pathogenesis, which follows eteology or symptoms. Not a safe way to make sure the establishment will listen though.

The even harder way would be to do research to clarify the position. I am basically out of the debates in psychiatry and social psychiatry since like 30 years, so I don't really know what is the situation these days.

Hope this helps anyway.

Cheers

Hans

Hans, it's true: although the debate on the consciousness is making great strides in the scientific community, in standard clinical practice alterations of the state of consciousness are still defined using the concepts of vigilance and consciousness. For example, recent works compares the major physiopathological states linked with the absence of consciousness (deep sleep, coma/vegetative state, general anaesthesis, loss of consciousness during an epileptic fit). In particular it is shown how these states, although caused by a varied aetiopathogenesis, all share a series of objectivizable elements: regular electroencephalographic activity, a noticeable diminution of the metabolism in the frontoparietal regions, a generalised blockage of both cortico-cortical and talamo-cortical functional connections, and a state of “non respondence”. These effects of destructuring enable us to understand better some aspects of the temporal structure of consciousness and the related neural processes. For example, there are patients who can sleep well, be attentive and converse agreeably while showing no sign of consciousness disorders or altered syntony. And yet these are patients who often know very little of what they should know: where they are or where they have just come from. They often make mistakes, get lost easily, do not know the date or time or how old they are. Even in the state of full vigilance they are incapable (or only partially capable) of retrieving lost information.