[What is impaired consciousness? Revisiting impaired consciousness as psychiatric concept]

For decades, psychiatrists have considered that concepts of impaired consciousness in the study of psychiatry were inconsistent with those applied in the field of neurology, in which the usefulness of the concept of consciousness has long been seriously doubted. Gloor concluded that the concept of consciousness does not further the understanding of seizure mechanisms or brain function, which is the current representative opinion of most epileptologists. Loss of consciousness tends to be reduced to aggregates of individual impairments of higher cognitive functions, and the concept of consciousness is preferably avoided by neurologists by assigning various behavioral disturbances during disturbed consciousness to particular neuropsychological centers. In contrast, psychiatrists, especially those in Europe, are more likely to include phenomena involving problems related to phenomenological intentionality in impaired consciousness. For the present study, we first divided consciousness into vigilance and recursive consciousness, and then attempted to determine what kind of impaired consciousness would be an ideal candidate to represent pure disturbance of recursive consciousness. Then, 4 patients, 1 each with pure amnestic states followed immediately by complex partial seizures, an akinetic mutistic state caused by absence status, and mental diplopia as a manifestation of postictal psychosis, as well as a patient with Alzheimer's disease who gracefully performed Japanese tea ceremony, were studied. Based on our findings, we concluded that impaired consciousness as a generic term in general medicine does not indicate any unitary entity corresponding to some well-demarcated physiological function or constitute a base from which recursive consciousness emerges as a superstructure. From that, we stressed that a pure form of impairment of recursive consciousness could occur without the impaired consciousness named generically in general medicine. Second, following observation of an additional 3 cases, descriptions of naissance of the first word (taken from the autobiography of Helen Keller), visual object agnosia, and chronic schizophrenia with schizophasia were discussed to examine the relationship between impairments of recursive consciousness and semantic generation dysfunction. Attempts to bridge semantic generation and recursive consciousness, performed by psychopathologists such as Bin Kimura and Hiroyuki Koide, were also briefly discussed. In light of these case presentations and related discussions, we re-examined traditional theories of impaired consciousness, including Mayer-Gross's Gestalt theory, later replaced by Conrad and Henri Ey's theory related to intentionality. Furthermore, we attempted to link Denett's theory of consciousness to those traditional theories as well as to our own postulations, and neuropsychological data such as those of implicit memory and blindsight. Finally, the significance of Freud's unconsciousness in the framework of neuroscience was discussed.