Oneiroid

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, often of unusual content, similar to fantastic dreams, usually connected by one storyline, which unfold in the subjective mental space of the patient. And if in his fantastic-illusory world he is an active participant in what is happening, then in reality his behavior is dissonant with the content of the experienced pseudo-hallucinations. The overwhelming majority of patients are passive spectators of visions, detached from the surrounding events. The patient with developed oneiroid is completely disoriented, that is, he is not able to correctly perceive either himself or the surrounding environment. Contact with him at this time is impossible, but after exiting the state, the patient can quite coherently retell the events he dreamed about, although what happened next to him in reality during this period remains outside his perception.

Epidemiology

There are no statistics on the frequency of occurrence of oneiroid syndrome in various diseases. There is evidence that it most often occurs in patients with paroxysmal catatonic schizophrenia. [ 1 ] As for age, fragmentary manifestations that fit the clinical picture of oneiroid syndrome may be observed in children. True, full-blown oneiroid can be confidently diagnosed already in adolescence, mainly in stuporous states. In old age, oneiroid syndrome rarely develops.

Causes oneiroid

Oneiroid refers to syndromes of impaired consciousness, occurs 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, most often schizophrenia, and somewhat less often bipolar disorder. The oneiroid state is inherent in the catatonic form of schizophrenia; previously, it was even considered a variant of stupor. In the most common paranoid form, oneiroid is often accompanied by the syndrome of mental automatism (Kandinsky-Clerambault). True, stage-developing, prolonged illusory-fantastic oneiroid is observed mainly in schizophrenics. It is often the culmination of an attack of periodic catatonic or fur-like form of the disease, after which a residual period occurs. [ 2 ]

Risk factors

Oneiroid may have an exogenous-organic genesis. The risk factors for its occurrence are varied. Oneiroid syndrome is one of the typical exogenous reactions of the brain (according to K. Bonhoeffer) to:

• head injuries;
• accidental poisoning with toxic substances or their intentional use;
• pathologies of the central nervous system - epilepsy, brain tumors, cerebrovascular insufficiency;
• collagenoses - severe forms of lupus erythematosus, scleroderma, rheumatoid arthritis;
• changes in the metabolism of neurotransmitters in decompensated liver, kidney, 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 oneiroid 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 established that its occurrence, in particular in schizophrenia, is caused by hyperactivity of the mesolimbic dopaminergic system. Increased dopamine release is associated with weakness of the glutamatergic and GABAergic systems, however, all neurotransmitter systems are interconnected, their influence on each other is still being studied. Oneiroid syndrome is a consequence of the disruption of complex mechanisms of neurochemical interaction related to 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 the relationship of oneiroid clouding of consciousness with other psychoses has not yet been fully revealed. Many issues remain to be resolved in the future.

Symptoms oneiroid

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

Researchers also describe oneiroid with a predominantly sensory component of consciousness disorder, when visual pseudohallucinations are weakly expressed, or even absent altogether. Patients with this type of syndrome have tactile, auditory and kinesthetic disorders, which, together with the patients' interpretation of their sensations, allow the attack to be classified as oneiroid. Kinesthetic symptoms are represented by flights in outer space (patients felt the pressure of a spacesuit on their body); falling down stairs (they were not seen, but felt) into the underworld; a feeling that the entire apartment with furniture and relatives was moving to another planet. Sensory symptoms manifested themselves in the sensation of cold or heat of other planets, air movement, heat from hellish furnaces; auditory - patients heard the roar of spaceship engines, the blazing of a 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, how claws, tails or wings grew.

The disturbance of perception is pseudo-hallucinatory in nature, the patient is disoriented in time and space, as well as in his own personality. Verbal contact with him is impossible in most cases, real events remain outside his zone of perception, although those around him in the stage of oriented oneiroid can be included in the experienced fantastic plot. After exiting this state, the patient, as a rule, remembers and can retell his dream-like experiences, the memory of real events is amnesic.

The classic stage-by-stage development of oneiroid syndrome is observed in schizophrenics, it is even called schizophrenic delirium. According to experts, there is no true delirium in schizophrenia. Most cases of oneiroid are characterized by the patient's passivity. He is a spectator of dynamic fantastic visions. Outwardly, the patient is in a stuporous 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 amnesia, and later - as a variant of catatonic stupor. It is believed that a patient with oneiroid syndrome can very rarely be in a state of psychomotor agitation.

The main manifestation of oneiroid is the patient’s detached state, pronounced depersonalization and derealization, dream-like fantastic visions connected with a certain plot and replacing reality.

The stages of development of oneiroid disorder have been described by representatives of different psychiatric schools and, in principle, there are no major differences in these descriptions.

The first signs appear in emotional disorders. This may be emotional instability, duality or a pronounced one-sided change in sensory reactions, for example, a relatively stable dissatisfied or ecstatic state. Inadequate emotional reactions and the so-called "affect incontinence" may be observed. Pathological changes in the emotional state are accompanied by general somatic and vegetative disorders: attacks of tachycardia, heart or stomach pain, sweating, loss of strength, sleep disorders, headaches, even digestive disorders. These symptoms precede oneiroid and can be observed for a very long time - for several weeks or even months. However, emotional disorders in themselves are not yet oneiroid.

The next stage is delusional mood - a precursor to 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 an elevated mood. Such a mood can last for several days, gradually transforming into delusions of staging, false recognition, transformation, reincarnation. At this stage, the first speech disorders appear in the form of slowing down or speeding up speech, mental ideational automatisms. The delusional stage can last from several days to several weeks. Bulgarian psychiatrist S. Stoyanov called this stage affective-delusional depersonalization/derealization.

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

The stages of oneiroid can last from several hours to several days. The culmination is a dream-like oneiroid, when contact with the patient becomes impossible. He is completely in the power of his dream experiences, most often distinguished by an unusual plot. Despite the vividness of the events experienced (conspiracies, uprisings, universal catastrophes, interplanetary wars), there is almost always a dissonance between the real and imaginary behavior of the patient. Psychomotor agitation develops extremely rarely. In most cases, the patient lies in a stupor, 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 in the stage of oriented oneiroid the patient has scattered attention, but at least somehow reacts to external stimuli, then in the stage of dream-like oneiroid it is impossible to attract his attention.

Symptom reduction occurs in the reverse order: the dream-like oneiroid is replaced by an oriented one, then only delirium remains, which gradually folds and the patient comes out of the oneiroid state. Memory disorders, in particular, partial amnesia, are noted by many authors. The patient does not remember the real events that occurred during the oneiroid, the memory of painful experiences is often preserved. In addition, amnesia in oneiroid is expressed to a lesser extent than in delirium.

According to the nature of the affect, the following are distinguished: expansive oneiroid with delusions of grandeur and megalomaniacal fantasies, which are characterized by an accelerated flow of time; depressive oneiroid with a tragic, melancholy-anxious plot of pseudo-hallucinations with a feeling of a slow flow of time, sometimes it simply stops. Mixed oneiroid is also distinguished, when the depressive state is replaced by expansion.

It is not always possible to trace the stage-by-stage development of oneiroid. In the classical sequence, it can develop in bipolar disorder and senile psychoses.

Oneiroid syndrome of exogenous-organic genesis develops quite quickly, as a rule, in the acute period, bypassing the long prodromal and delusional stage. Especially in acute intoxications and head injuries, the development of oneiroid occurs lightning fast, the culmination stage unfolds almost immediately, which proceeds approximately according to the same scenario as in schizophrenia. It lasts from several hours to five or six days.

For example, in case of closed head injuries (contusions), oneiroid syndrome occurs in the first days after the injury, characterized by absolute disorientation, both personal and objective, in the behavior of the victim, euphoric or ecstatic affect prevails. 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 - experiences of acceleration or deceleration of the flow 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 sopor and coma.

Oneiroid syndrome caused by smoking or inhaling drugs (cannabinoids, Moment glue) occurs as an atypical course of mild drug intoxication. It manifests itself as a state of stupefaction, immersion in a world of delusional fantasies, often of amorous-erotic or retrospective nature (feelings of past real events that once caused strong emotional experiences in the patient emerge). Rich facial expressions are characteristic - the expression changes from ecstatic to complete despair, the patient is visited by pseudo-hallucinations, visual and auditory, of a frightening nature. Contact with the outside world is absent.

Oneiroid states may occasionally occur in infectious diseases that occur without pronounced toxicosis (malaria, rheumatism, etc.). They usually last several hours. They occur in the form of an oriented oneiroid with a relatively shallow clouding of consciousness. Patients report the content of their experiences after the psychosis has passed. They manifest themselves in a typical way - vivid visual images, scene-like experiences with a fairy-tale theme, patients actively participate or "watch" them from the outside. The patient's behavior is characterized by inhibition and partial detachment from the environment.

Epileptic oneiroid, unlike the syndrome in schizophrenia, also occurs suddenly. Fantastic dream-like images, verbal hallucinations appear against the background of a pronounced disturbance of affect - delight, horror, anger reach the level of ecstasy. Personal disorientation is characteristic of epileptics. Impaired consciousness in this form occurs with symptoms of catatonic stupor or excitement.

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

Complications and consequences

If oneiroid in schizophrenia is only part of the positive symptoms and, as experts note, has a prognostically favorable character, then exogenous-organic oneiroid indicates the severity of the patient's condition. It is essentially a complication of trauma, intoxication or disease, developing in severe cases. The consequences depend on the depth of the brain damage: the patient can fully recover or remain disabled. Exogenous-organic oneiroid itself is not a prognostic marker.

Diagnostics oneiroid

In the initial and even delirious stage, no one would dare to predict that the condition will end in oneiroid. The stages of 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, about a head injury suffered the day before, a brain tumor, or drug use. If the cause of the oneiroid syndrome is unknown, the patient requires a full examination, laboratory and instrumental, using laboratory tests and instrumental methods. Personal and family history is taken into account during diagnosis. [ 3 ]

Oneiroid syndrome is diagnosed directly based on the clinical picture. In psychiatric practice, the visible presence of catatonic symptoms is more often noted; manifestations of oneiroid symptoms can only be established if there is at least partial contact with the patient. If the patient is unavailable for contact, then the presumptive diagnosis is made based on a survey of relatives.

Differential diagnosis

Differential diagnosis is carried out with disorders of consciousness: oneiric syndrome, delirium, confusion, somnolence.

Oneiric syndrome (oneirism) is a condition in which an individual identifies his dream with real events, because upon waking up, he does not feel that he was sleeping. Accordingly, the patient's behavior after waking up is determined by the content of the dream; he continues to live in the reality that he dreamed of. Criticism of his condition appears in some people after a short time (hours, days), and in others it does not appear at all.

Delirium is manifested by pronounced derealization, disturbance of object orientation, while personal orientation is preserved. 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 the patient, the latter cannot immediately understand the essence of the question, often answer inappropriately, however, self-awareness is present. The difference between oneiroid and delirium is precisely in the preservation of personal orientation. Although behavior in most cases is different, with oneiroid the overwhelming majority of patients are in a stuporous numbness, and with delirium in a state of speech-motor agitation, 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 is significantly different. With professional delirium, the patient mechanically and silently performs his usual actions, he does not have pronounced hallucinations and delusions, outbursts of excitement are limited spatially and are verbally expressed in separate words or phrases. Mussifying (quiet) delirium is characterized by uncoordinated motor activity within the bed. Usually these are grasping or shaking 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 oneiroid have a number of other significant differences. According to the etiological sign, the causes of delirium are often external, while those of oneiroid are internal. In terms of duration, the symptoms of delirium in most cases are reduced faster.

Delirium has a wave-like course: during the day there are lucid intervals, at night the psychopathological symptoms intensify. The psychopathological symptoms of oneiroid do not depend on the time of day, its course is stable.

In delirium, the patient has true hallucinations that occur in the present tense and relate to everyday or professional topics. Distorted perception of the sizes and shapes of surrounding objects (macropsia, micropsia) is typical. The patient's behavior corresponds to delusional-hallucinatory experiences. In oneiroid, the patient sees fantastic panoramic images of the past or future with his inner eye, but his behavior and facial expressions do not correspond to the experiences.

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

In a state of stupefaction and somnolence, the behavior of patients may outwardly resemble an oriented oneiroid; they are inhibited, sedentary, and difficult to attract their attention, but they do not have 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, thereby singling out from schizophrenia separately patients suffering from oneiroid clouding of consciousness. But this proposal did not catch on. Oneiroid syndrome may also, although much less frequently, develop in other psychoses. Differential diagnostics presents certain difficulties, in addition, oneiroid in schizophrenia, as psychiatrists believe, often remains unrecognized, which is facilitated by the peculiar behavior of the patient and his lack of desire to share his experiences with the doctor.

The patient's state of memory also helps differentiate oneiroid from other cloudings of consciousness. After exiting oneiroid, limited amnesia is usually observed - the patient has no memory of real events, but the memory of pathological experiences during the attack is preserved. The patient can retell his "adventures" quite coherently, and when the condition improves, the memory of events preceding 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 those who have experienced oneiroid, amnesia is expressed to a much lesser degree than in such disorders of consciousness as delirium or stunning.

Treatment oneiroid

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 carried out; in case of severe infections, they are treated first; the disturbed metabolism is restored; in case of injuries, cerebrovascular diseases and tumors, surgical treatment may be necessary.

Productive symptoms of oneiroid and catatonic symptoms are relieved with neuroleptics. These same drugs are the main drugs for the treatment of schizophrenia and other pathopsychological conditions in which oneiroid disorder develops. At present, preference when choosing a drug is given to second-generation or atypical neuroleptics, with the use of which, especially short-term, drug-induced parkinsonism associated with the effect on the dopaminergic system develops less often. In addition, many of the atypicals are more powerful than typical ones and are able to quickly relieve productive symptoms.

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

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

Along with atypicals, traditional neuroleptics are also used. Haloperidol and fluphenazine have high antipsychotic activity. The main undesirable effects of classical neuroleptics are symptoms of Parkinsonism. In addition, all neuroleptics reduce blood pressure, disrupt the functioning of the heart, to a greater or lesser extent affect hematopoiesis, the endocrine and hepatobiliary system, 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 easy occurrence of endocrine, cardiovascular, hematological disorders, classical (typical) neuroleptics are preferable, patients with a high probability of developing neurological disorders are prescribed atypical neuroleptics. 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; enhance cholinergic conductivity, protein and phospholipid synthesis. Cinnarizine, piracetam, cerebrolysin, the antihypoxant actovegin, and the herbal preparation Memoplant based on ginkgo biloba can be prescribed.

In case of drug resistance, electroconvulsive therapy is used.

Prevention

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

Patients with schizophrenia and bipolar disorder need to follow the medication regimen and behavioral and lifestyle restrictions recommended by the doctor.

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 fully restore the patient's mental health, although in general, the prognosis depends on the course and severity of the underlying disease. Endogenous oneiroid is also usually resolved even without treatment, however, the state of mental health usually remains impaired due to the underlying disease.