Oneyroid

A true oneiroid is a mental disorder, a form of altered consciousness, most often of endogenous organic origin. It is characterized by pronounced productive symptoms in the form of an influx of vivid scene-like images, sensations, more often of unusual content, similar to fantastic dreams, as a rule, connected by one storyline, which unfolds in the patient's subjective mental space. And if in his fantastically illusory world he is an active participant in what is happening, then in reality his behavior is discordant with the content of the experienced pseudogallucinations. The overwhelming majority of patients are passive spectators of visions, detached from the surrounding events. A patient with a developed oneiroid is completely disoriented, that is, he is not able to correctly understand either himself or the environment. Contact with him at this time is impossible, but after leaving the patient's state, he can retell the dreamed events quite coherently, although what happened next to him in reality during this period remains outside his perception.

Epidemiology

There is no statistics on the incidence of oneiroid syndrome in various diseases. There is evidence that it most often occurs in patients with paroxysmal catatonic schizophrenia. [1] As for age, children may experience fragmentary manifestations that fit the clinical picture of oneiroid syndrome. A true deployed oneiroid can be diagnosed with confidence already in adolescence, mainly in stuporous conditions. In old age, oneiric syndrome rarely develops.

Causes oneyroid

Oneyroid refers to syndromes of impaired consciousness, arises in the clinical picture of psychoses of various origins and does not directly indicate the nosological cause of the pathology.

It can be a manifestation of mental endogenous diseases more often - schizophrenia, somewhat less often - bipolar disorder. The oneiric state is inherent in the catatonic form of schizophrenia; earlier it was even considered as a variant of stupor. With the most common paranoid form, oneyroid is often accompanied by a syndrome of mental automatism (Kandinsky-Clerambo). A true, stage-by-stage development of a long-term illusory-fantastic oneiroid is observed mainly in schizophrenics. It is often the culmination of an attack of a periodic catatonic or fur-like form of the disease, after which a residual period begins. [2]

Risk factors

Oneyroid can be of exogenous organic origin. The risk factors for its occurrence are diverse. Oneiric syndrome is one of the typical exogenous reactions of the brain (according to K. Bongeffer) to:

• head trauma;
• accidental poisoning with toxic substances or their deliberate use;
• pathologies of the central nervous system - epilepsy, brain neoplasms, cerebrovascular insufficiency;
• collagenoses - severe forms of lupus erythematosus, scleroderma, rheumatoid arthritis;
• changes in the metabolism of neurotransmitters in decompensated hepatic, renal, cardiovascular failure, diabetes mellitus, pellagra, pernicious anemia, infectious and other severe somatic diseases leading to general intoxication of the body.

Pathogenesis

The pathogenesis of the development of oneiric syndrome corresponds to the mechanism of development of the underlying disease. This type of altered consciousness refers to productive psychotic symptoms. Modern neuroimaging methods have made it possible to establish that its appearance, in particular in schizophrenia, is caused by hyperactivity of the mesolimbic dopaminergic system. An increase in dopamine release is associated with weakness of the glutamatergic and GABA-ergic systems, however, all neurotransmitter systems are interconnected, their influence on each other is still being studied. Oneiric syndrome is a consequence of a violation of complex mechanisms of neurochemical interaction, concerning changes in the rate of biosynthesis of neurotransmitters, their metabolism, sensitivity and structure of the corresponding receptors. To date, the psychopathology of oneiroid remains not fully understood, as well as its pathogenesis, and also the connection of oneiroid clouding of consciousness with other psychoses has not yet been fully disclosed. Many issues remain to be resolved in the future.

Symptoms oneyroid

Oneiroid is a qualitative disorder of consciousness with an influx of dreamlike scenes and visual images of fantastic content, intertwined with reality, in which the patient feels himself in the thick of events, observing the oneiroid scenes unfolding in front of him, sometimes he does not actively participate in them, while experiencing his passivity, because feels responsible for what is happening, and sometimes is an active participant and even the main character. The theme of experiences is fabulous and unreal - these are witches' sabbaths, and travel to other planets, to heaven or hell, to the seabed, etc. The patient does not even always imagine himself as a man, he can transform into an animal, inanimate objects, a cloud of gas.

Researchers also describe a oneiroid with a predominantly sensory component of a disorder of consciousness, when visual pseudo-hallucinations are little or even absent. In patients with this type of syndrome, tactile, auditory and kinesthetic disorders are present, which, together with the patients' interpretation of their sensations, make it possible to attribute the attack to oneroid. Kinesthetic symptoms are represented by flights in open space (patients felt the pressure of the spacesuit on the body); falling down the stairs (they were not seen, but felt) into the underworld; the feeling that the whole apartment with furniture and relatives moved to another planet. Sensory symptoms were manifested in the sensation of cold or warmth of other planets, air movement, heat from hellish furnaces; auditory - the patients heard the roar of the starship engines, the blazing fire, the speech of aliens, the singing of birds of paradise. Reincarnation also took place, the patients did not see it, but felt how their skin turned into fur or scales, claws, tails or wings grew.

Perceptual impairment is of a pseudo-hallucinatory nature, the patient is disoriented in time and space, as well as in his own personality. Verbal contact with him in most cases is not possible, real events remain outside the zone of his perception, although those around him at the stage of an oriented oneyroid can be included in the experienced fantastic plot. After recovering from this state, the patient, as a rule, remembers and can retell his dreamlike experiences, the memory of real events is amnestied.

The classic phased development of oneiric syndrome is observed in schizophrenics, it is even called schizophrenic delirium. Experts believe that there is no true delirium in schizophrenia. For most cases of oneyroid, the patient's passivity is characteristic. He is a spectator of dynamic fantastic visions. Outwardly, the patient is in a stupor state and does not demonstrate expressive facial expressions or motor restlessness. For a long time, oneiroid clouding of consciousness in psychiatry was considered as melancholy with unconsciousness, and later - as a variant of catatonic stupor. It is believed that it is extremely rare for a patient with oneiric syndrome to be in a state of psychomotor agitation.

The main manifestation of oneyroid is the detached state of the patient, pronounced depersonalization and derealization, dreamlike fantastic visions associated with a specific plot and replacing reality.

The stages of development of oneyroid are described by representatives of different psychiatric schools and, in principle, there are no big differences in these descriptions.

The first signs appear in emotional disorders. This can be emotional instability, ambivalence, or a pronounced one-sided change in sensory responses, for example, a relatively stable dissatisfied or ecstatic state. Inappropriate emotional reactions and so-called "passion incontinence" can be observed. Pathological changes in the emotional state are accompanied by general somatic and autonomic disorders: tachycardia attacks, heart or stomach pains, sweating, loss of energy, sleep disturbances, headache, even digestive disorders. These symptoms precede the oneyroid and can be observed for a very long time for several weeks, or even months. However, emotional disorders in themselves are not yet a oneiroid.

The next stage is a delusional mood - a harbinger of a disorder of thinking, characterized by confusion, a premonition of an imminent threat, a feeling of change in oneself and the surrounding reality. There may be a premonition and expectation of something joyful and desirable, pleasant against the background of high spirits. Such a mood can last for several days, gradually transforming into delirium of staging, false recognition, transformation, reincarnation. At this stage, the first speech disorders appear in the form of slowing or accelerating speech, mental ideatorial automatisms. The delusional stage can last from several days to several weeks. Bulgarian psychiatrist S. Stoyanov called this stage affective-delusional depersonalization / derealization.

Then comes the stage of an oriented oneyroid, when there is still a partial orientation in the surrounding reality and contact with the patient is possible, but against the background of a shallow clouding of consciousness, fantastic scene-like pseudo-hallucinations, introspective or Manichean delirium (the patient sees scenes from the past or the future, becomes a witness to the struggle of angels) with demons or battles with alien creatures).

Oneyroid stages can last from several hours to several days. The culmination is a dreamlike oneiroid, when contact with the patient becomes impossible. He is completely at the mercy of his dreaming experiences, most often characterized by an unusual plot. Despite the brightness of the events experienced (conspiracies, uprisings, universal catastrophes, interplanetary wars), there is almost always a dissonance between the patient's real and imaginary behavior. Psychomotor agitation is extremely rare. In most cases, the patient lies in a daze, with a frozen, expressionless face, completely detached from what is happening outside of his subjective experiences. Only in his imagination is he an active participant in fantastic events.

If at the stage of oriented oneyroid the patient has scattered attention, but he at least somehow reacts to external stimuli, then at the stage of the dreamlike it is impossible to attract his attention.

Reduction of symptoms occurs in the reverse order: the dreamlike oneiroid is replaced by an oriented one, then only delirium remains, which gradually collapses and the patient leaves the state of the oneiroid. Memory disorders, in particular, partial amnesia, have been noted by many authors. The patient does not remember the real events that occurred during the oneyroid, the memory of painful experiences is often retained. In addition, amnesia with oneiroid is less pronounced than with delirium.

By the nature of the affect, there are: an expansive oneiroid with delusions of grandeur and fantasies of megalomnic content, which is characterized by an accelerated flow of time; a depressive oneiroid with a tragic, sadly alarming plot of pseudogallucinations with a feeling of a slowed-down flow of time, sometimes it just stops. A mixed oneiroid is also distinguished, when the depressive state is replaced by expansion.

It is not always possible to track the phased development of oneyroid. In the classic sequence, it can unfold in bipolar disorder and senile psychosis.

Oneiric syndrome of exogenous organic genesis develops rather quickly, usually in the acute period, bypassing the long prodromal and delusional stage. Especially with acute intoxications and with head injuries, the development of oneyroid occurs with lightning speed, the culmination stage almost immediately unfolds, which proceeds approximately according to the same scenario as in schizophrenia. Lasts from several hours to five to six days.

For example, with closed head injuries (contusions), oneiric syndrome occurs in the first days after the injury, is characterized by absolute disorientation, both personal and objective, euphoric or ecstatic affect prevails in the victim's behavior. The course is mixed: chaotic excitement with individual pathetic cries is replaced by short periods of external immobility and mutism. Typical manifestations of depersonalization are autometamorphopsia, derealization - the experience of accelerating or slowing down the passage of time.

In case of alcohol poisoning, the victim goes into a state of oneiroid from delirium. This is expressed in the fact that he becomes inhibited, detached, stops responding to attempts to establish contact with him, falls into a stupor, which can develop into stupor and coma.

Oneyroid syndrome caused by smoking or inhalation of drugs (cannabinoids, Moment glue) occurs as an atypical course of mild drug intoxication. It manifests itself as a state of stunnedness, immersion in the world of delusional fantasies, more often of a love-erotic or retrospective nature (sensations of past real events that once caused strong emotional experiences in the patient emerge). A rich facial expression is characteristic - the expression changes from enthusiastic to complete despair, the patient is visited by pseudo-hallucinations of visual and auditory frightening content. There is no contact with the outside world.

Oneiric conditions can occasionally occur in infectious diseases that occur without severe toxicosis (malaria, rheumatism, etc.). Their duration is usually several hours. They flow in the form of an oriented oneyroid with a relatively shallow stupefaction. Patients report the content of their experiences after psychosis has passed. They are typically manifested - vivid visual images, scene-like experiences with a fairy-tale theme, patients actively participate or "watch" them from the side. The patient's behavior is characterized by lethargy and partial detachment from the environment.

Epileptic oneiroid, in contrast to the syndrome in schizophrenia, also occurs suddenly. Fantastic dreamlike images, verbal hallucinations appear against the background of a pronounced disturbance of affect - delight, horror, anger reach the degree of ecstasy. For epileptics, personal disorientation is characteristic. Impairment of consciousness in this form proceeds with symptoms of catatonic stupor or excitement.

Oneiroid is a rare complication of exogenous genesis, delirium is typical.

Complications and consequences

If the oneiroid in schizophrenia is only part of the positive symptomatology and, as experts say, has a prognostically favorable character, then the exogenous organic indicates the severity of the patient's condition. He, in essence, is itself a complication of trauma, intoxication or illness that develops in severe cases. The consequences depend on the depth of the brain damage: the patient can fully recover or remain disabled. By itself, an exogenous organic oneiroid is not a prognostic marker.

Diagnostics oneyroid

In the initial and even delusional stage, no one will undertake to predict that the state will end with oneiroid. The stages of the development of the syndrome were described on the basis of retrospective. Often the patient already has a diagnosis of schizophrenia, bipolar disorder, or is known, for example, of a head injury, brain tumor, or drug use suffered the day before. If the cause of the oneiroid syndrome is unknown, the patient needs a complete examination, laboratory and instrumental, using laboratory tests and instrumental methods. The diagnosis takes into account personal and family history. [3]

Oneiric syndrome is diagnosed directly according to the clinical picture. In psychiatric practice, the visible presence of catatonic symptoms is more often noted, the manifestations of oneiric symptoms can be established only if there is at least partial contact with the patient. If the patient is not available to contact, then the presumptive diagnosis is made on the basis of a survey of relatives.

Differential diagnosis

Differential diagnosis is carried out with impaired consciousness: oniric syndrome, delirium, stunning, dubiousness.

Oniric syndrome (onirism) is a condition in which an individual identifies his dream with real events, since upon waking up, he does not feel that he was sleeping. Accordingly, the patient's behavior after awakening is determined by the content of the dream, he continues to live in the reality that he dreamed of. For some, criticism of their condition appears after a short time (hours, days), and for some it does not appear at all.

Delirium is manifested by pronounced derealization, a violation of subject orientation, while the personal one persists. The patient's brain produces vivid true hallucinations (visual, auditory, tactile) and figurative sensory delirium, the content of which corresponds to the patient's behavior. The patient's facial expressions reflect his mood, and the affect of fear prevails in delirium, often accompanied by psychomotor agitation. When trying to establish contact with a patient, the latter cannot immediately understand the essence of the question, they often answer inappropriately, however, self-awareness is present. The difference between oneyroid and delirium is precisely in the preservation of personal orientation. Although the behavior in most cases is different, with oneiroid the vast majority of patients are in stupor stupor, and with delirium in a state of speech-motor excitement, but in some cases these conditions are not met. More severe forms of delirium, which develop with an unfavorable course of the underlying disease, are similar to oneiroid in the absence of verbal contact with the patient. But the behavior itself differs significantly. In professional delirium, the patient mechanically silently performs his usual actions, he does not have pronounced hallucinations and delirium, outbursts of excitement are spatially limited and verbally expressed in separate words or phrases. Mussitious (quiet) delirium is characterized by uncoordinated motor activity within the bed. Usually these are grasping or shaking off movements. After extensive delirium and its severe forms, amnesia is always complete, if delirium is limited to one stage, then partial memories of psychosis may remain.

In addition, delirium and oneyroid have a number of significant differences. On the etiological basis, the causes of delirium are often external, in the oneyroid - internal. In most cases, delirium symptoms decrease faster in duration.

Delirium has an undulating course: during the day there are lucid intervals, by night the psychopathological symptoms intensify. The psychopathological symptomatology of oneyroid does not depend on the time of day, its course is stable.

With delirium, the patient has true hallucinations that arise in the present tense and relate to household or professional topics. Distorted perception of the size and shape of surrounding objects (macropsia, micropsia) is characteristic. The patient's behavior corresponds to delusional-hallucinatory experiences. With oneiroid, the patient sees with his inner gaze fantastic panoramic images of the past or future, while the behavior and facial expressions do not correspond to the experiences.

Muscle tone in delirium is not changed, with oneiroid it often corresponds to catatonic disorder.

In a state of stunning and dubiousness, the behavior of patients may outwardly resemble an oriented oneiroid, they are inhibited, inactive, it is difficult to attract their attention, but they have no affective tension (since there is no productive symptomatology) and symptoms of catatonic disorder.

Schizophrenia and oneiroid may well coexist in the same patient. This is a common combination. Even in the middle of the last century, it was proposed to introduce the term oneirophrenia into everyday life, thereby isolating from schizophrenia separately patients suffering from oneiric confusion. But this proposal did not catch on. Also, oneiroid syndrome can, albeit much less often, develop with other psychoses. Differential diagnosis presents certain difficulties, in addition, oneiroid in schizophrenia, according to psychiatrists, often remains unrecognized, which is facilitated by the patient's peculiar behavior and his lack of desire to share his experiences with the doctor.

The patient's memory state also helps to differentiate the oneiroid from other obscurations of consciousness. After exiting the oneyroid, limited amnesia is usually observed - the patient has no memory for real events, but memory for pathological experiences during an attack is preserved. The patient can retell his "adventures" quite coherently, and when the condition improves, the memory of the events that preceded the oneiroid returns. Only that part of reality that the patient did not perceive, being in a state of detachment, falls out of memory. In survivors of Oneiroid, amnesia is expressed to a much lesser extent than in such disorders of consciousness as delirium or stunning.

Treatment oneyroid

Since oneiroid syndrome develops due to various reasons, the main treatment is the elimination of the etiological factor. In case of intoxication, detoxification therapy is performed; in the case of severe infections, they are treated first; restore disturbed metabolism; for injuries, cerebrosvascular diseases and tumors, surgical treatment may be required.

The productive symptoms of oneyroid and catatonic symptoms are stopped with the help of antipsychotics. These same drugs are the main drugs for the treatment of schizophrenia and other pathopsychological conditions in which oneiric disorder develops. Currently, when choosing a drug, preference is given to second-generation or atypical antipsychotics, with the use of which, especially short-term, rarely develops drug parkinsonism associated with an effect on the dopaminergic system. In addition, many of the atypicals are more powerful than typical ones and are able to quickly stop productive symptoms.

For example, leponex (clozapine), the first antipsychotic drug that does not cause acute extrapyramidal side effects, has powerful anti-delusional and anti-hallucinatory effects. However, as a result of its use, violations of hematopoiesis (agranulocytosis, neutropenia) are often observed, there may be convulsions, disturbances of the heart. Patients feel lethargic, sleepy, unable to respond appropriately.

Olanzapine is highly effective in relieving productive symptoms and arousal. However, it also induces strong sedation and also increases appetite, which leads to rapid weight gain. Risperidone and amisulpiride are considered moderate drugs, but hyperprolactinemia is a key side effect.

Along with atypics, traditional antipsychotics are also used. Haloperidol and fluphenazine have high antipsychotic activity. In classical antipsychotics, the main undesirable effects are the symptoms of parkinsonism. In addition, all antipsychotics lower blood pressure, disrupt the work of the heart, to a greater or lesser extent affect hematopoiesis, the endocrine and hepatobiliary systems, and also have a number of other side effects. Therefore, the approach to the choice and dosage of the drug is strictly individual. For example, for patients with an initial readiness for the mild occurrence of endocrine, cardiovascular, hematological disorders, classical (typical) antipsychotics are preferable, for patients with a high probability of developing neurological disorders, atypical antipsychotics are prescribed. The doctor must take into account and compare many factors: compatibility with drugs for the treatment of the underlying pathology, the functionality of the excretory organs, the presence of relative contraindications.

To normalize the metabolic processes of the brain and improve its integrative activity, nootropic drugs are prescribed. They improve cellular nutrition, in particular, the absorption of glucose and oxygen; stimulate cellular metabolic processes; increase cholinergic conductivity, synthesis of proteins and phospholipids. Cinnarizine, piracetam, cerebrolysin, antihypoxant actovegin, the herbal preparation Memoplant based on gingko biloba can be prescribed.

For drug resistance, electroconvulsive therapy is used.

Prevention

The main preventive measure for the development of oneyroid is a healthy lifestyle, in particular, the absence of alcohol and drug addiction in it, which significantly reduces the risk of mental disorders and craniocerebral trauma. People who are responsible for their health usually have good immunity, therefore, they can more easily tolerate infectious diseases, less often encounter metabolic disorders and other chronic pathologies, have high stress resistance, and consult a doctor in a timely manner to prevent complications. [4]

Patients with schizophrenia and bipolar disorder should follow the medication regimen and behavioral and lifestyle restrictions recommended by the physician.

Forecast

Modern methods of treatment are able to provide a favorable prognosis in most cases of the development of oneiroid syndrome with exogenous organic genesis of the disorder and completely restore the patient's mental health, although in general, the prognosis depends on the course and severity of the underlying disease. An endogenous oneiroid also usually resolves even without treatment, however, mental health usually remains impaired due to the underlying disorder.