4 Classification and assessment in psychiatry4.1 Descriptive psychopathology
4.1.2 Consciousness and its disorders
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic to the exams from January 2027.
Arousal, awareness and attention
Consciousness has two parts, and they can go wrong separately.
Arousal is how awake the person is.
Awareness is their experience of themselves and their surroundings.
The two are linked, but one can be more impaired than the other.
Attention is the ability to direct mental activity and keep it going. It can be disturbed even when the person's eyes are open and they seem awake.
Orientation covers person, place and time. Being correctly orientated does not on its own rule out delirium.
Delirium is an acute disturbance of attention and awareness that fluctuates. In hypoactive delirium the person is quiet and slowed. This can look like withdrawal even though there is an urgent medical cause.
Patterns of unresponsiveness
State | Wakefulness | Awareness and response |
|---|---|---|
Neurological stupor | Markedly reduced | Strong stimulation may rouse the person briefly |
Coma | Absent | No purposeful response and no eye opening |
Vegetative state, or unresponsive wakefulness syndrome | Sleep-wake cycles and eye opening are present | No reproducible behavioural sign of awareness |
Minimally conscious state | Present but variable | Definite signs of awareness, which may be inconsistent |
Locked-in syndrome | Preserved | Awareness is preserved despite severe motor paralysis |
In the minimally conscious state, signs of awareness include following a command or purposefully tracking something with the eyes. Repeated specialist assessment is needed to tell these apart from reflex responses.
Motor or sensory impairment can hide awareness. A lack of movement during one examination is not enough to conclude that awareness is absent.
Assessing reduced responsiveness
Immediate assessment. Deal first with airway, breathing, circulation, oxygenation and glucose. Escalate urgently if consciousness is reduced.
History. Ask about onset, substances, medicines, injury and seizures. Get information from witnesses or carers.
Examination. Record the response to voice and to stimulation, the pupils, movement, focal signs and physiological observations. Repeat the examination so that you can pick up change.
Structured tools support assessment but do not replace a diagnosis. They measure different things: the Glasgow Coma Scale records how responsive the person is, while the 4AT screens for delirium.
Important distinctions
Catatonic stupor. The person may be very still and unresponsive, but without the reduced wakefulness of coma. Look for other catatonic signs, and look for medical causes.
Dissociative unresponsiveness. This needs proper assessment. Do not assume it because the person has a psychiatric history.
Locked-in syndrome. Awareness is preserved despite severe motor paralysis. The person may be able to communicate through voluntary vertical eye movements or blinking.