Consciousness and experience of self

Attention, awareness and orientation

Consciousness in clinical description concerns awareness of self and surroundings. Attention concerns how information is selected and sustained. Orientation describes awareness of aspects such as time, place and person. These are related findings, but one should not stand in for all the others.

Assess changes against the person’s usual functioning and the course over time. An orientation answer can be influenced by circumstances; preserved orientation does not exclude every disturbance of awareness or attention. Describe the pattern and setting rather than relying on the word confused.

Detachment and unreality

Depersonalisation concerns an altered experience of oneself, often described as detachment or not feeling like the usual self. Derealisation concerns the surroundings seeming unreal or altered. Clarify whether the person describes a feeling of unreality or a firm belief that reality has actually changed.

These experiences can be difficult to put into words. Ask for a recent example, the circumstances, duration, distress and how the person understands it. Retained recognition that an experience is a feeling differs from a fixed belief; record that distinction without assuming a diagnosis.

Do not combine unlike findings

Reduced alertness, distractibility and a subjective sense of detachment require different descriptions. Include relevant illness, substance exposure, fatigue and mood context. An unfamiliar expression should be explored before it is interpreted as a psychotic symptom.

A new, rapidly changing disturbance of attention or awareness requires clinical assessment. This educational article is not a triage tool and does not determine the cause or certify a person’s safety.

For your next supervision discussion

Compare difficulty sustaining attention with a feeling of detachment in an otherwise alert encounter. How would you document the difference without allowing a single ambiguous word to stand for both?