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Behavioral disturbances of this type are common manifestations of all delirious-confusional states, particularly those of toxic-metabolic origin but also those due to more obvious structural disease of the brain The patient may be completely indifferent to all persons around him or the opposite when any approach may excite anger and aggressive action Family members may be treated with disrespect, regarded with suspicion, or falsely accused of harming the patient, stealing his possessions, or trying to poison him The embarrassment consequent on urinating in public or soiling the bed may be lost and, particularly in men, there may be lewd behavior toward the opposite sex In its most extreme form, usually seen in the later stages of dementing diseases, irascible behavior degenerates to kicking, screaming, biting, spitting, and an aversion to being touched, making it entirely impossible to approach the patient These aspects of disordered mental function are the most alarming to the family and are dif cult to manage in the hospital In contrast, docility and amiable social behavior characterize the Down and Williams syndromes (pages 863 and 888), and social indifference is a major feature of autism (page 889)
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Insight, the state of being aware of the nature and degree of one s de cits and their consequences, becomes manifestly impaired or abolished in relation to all types of cerebral disease that cause complex disorders of behavior Lack of insight is a far more complex phenomenon than this operational de nition suggests It might be noted that there are categories of disease, not attributable to obvious structured disease of the brain, in which individuals have a profound lack of insight into their own behaviors; included here are drug addiction, alcoholism, and sociopathy There are also many restricted forms of unawareness of particular neurologic de cits These are the agnosias, discussed in Chap 22 Patients with these diseases rarely seek advice or help for their illness; instead, the family usually brings the patient to the physician And, after the diagnosis has been made, the loss of insight may be re ected in a lack of compliance with planned therapy Thus, diseases that produce the aforementioned abnormalities of mentation also alter or reduce the patient s capacity to make accurate introspections concerning his psychic function
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To summarize, the entire group of acute confusional and delirious states is characterized principally by an alteration of consciousness and by prominent disorders of attention and perception, which interfere with the speed, clarity, and coherence of thinking, the formation of memories, and the capacity for performance of selfdirected and commanded activities Three major clinical syndromes can be recognized One is an acute confusional state in which there is manifest reduction in alertness and psychomotor activity A second syndrome, already alluded to as a special form of confusion, delirium, is marked by overactivity, sleeplessness, tremulousness, and prominence of vivid hallucinations, with convulsions often preceding or associated with the delirium These two illnesses tend to
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develop acutely, to have multiple causes, and, except for certain cerebral diseases, to remit within a relatively short period of time (days to weeks), leaving the patient without residual damage or with whatever defects were present before their onset The third syndrome is one in which a confusional state occurs in persons with some underlying, more chronic cerebral disease, particularly a dementia The cerebral disease may be focal or diffuse and, in the latter case, may dispose the patient to a superimposed acute confusional state or psychosis, which we have chosen to designate as a beclouded dementia From the neurologic perspective, the generic term psychosis applies to states of confusion in which elements of hallucinations, delusions, and disordered thinking comprise the prominent features An important point to be made here is that a large set of psychoses leaves the sensorium relatively unclouded and allows for normal attentions and high-level performance of many mental tasks These three syndromes and some aspects of psychotic confusion are elaborated below
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