Arousal, attention and awareness #
Consciousness can be described through level of arousal and the content of awareness. Assess whether the person is alert, drowsy or difficult to engage, then examine attention, orientation and coherence. Historical descriptive terms can overlap; record actual responsiveness and fluctuations in ordinary language.
Disturbed arousal or attention changes the interpretation of other mental-state findings. A perceptual experience during acute confusion should not be assessed as though it occurred in a consistently alert state. New altered consciousness requires medical evaluation and is not explained by a psychiatric label alone.
Several dimensions of self-experience #
| Dimension | Question |
|---|---|
| Identity | Does the person experience continuity in who they are? |
| Ownership | Does a thought, feeling or bodily experience feel like their own? |
| Agency | Do they experience themselves as initiating or controlling an action? |
| Reality or familiarity | Does self or environment feel ordinary, real or familiar? |
| Body representation | How are body parts, size, boundaries or position experienced? |
A change in one dimension does not establish a change in all of them. Preserve the person’s words and ask for a concrete example. Metaphorical expressions such as “I am not myself” often describe ordinary distress rather than a specific psychopathological phenomenon.
Depersonalization and derealization #
Depersonalization concerns a feeling of detachment or unreality relating to oneself, one’s mental activity or body. Derealization concerns the surroundings feeling unreal, distant or altered in their experiential quality. The person may describe an “as if” quality while recognizing that they or the environment have not literally changed.
| Experience | Clarification |
|---|---|
| “I feel like an observer of myself.” | Explore detachment, emotional colouring and retained recognition. |
| “The room feels dreamlike.” | Explore environmental unreality, arousal and perceptual detail. |
| “Someone controls my movements.” | Explore externally imposed agency rather than assuming detachment. |
| “I no longer exist.” | Clarify whether this is figurative distress, unreality or a firmly held nihilistic belief. |
Detachment can occur with stress, anxiety, trauma-related states, sleep loss, substances and other conditions. A symptom description alone does not establish a depersonalization–derealization disorder. Assess persistence, distress, impairment, reality appraisal and alternatives.
Ownership and passivity experiences #
Passivity experiences involve thoughts, feelings, impulses, bodily sensations or actions experienced as imposed by an external influence. Clarify what is altered: the sensation itself, its explanation, the impulse to act, or the sense of directing the action. Thought insertion is distinct from an unwanted thought that is still recognized as one’s own.
Do not infer agency disturbance from a person regretting an action or saying they felt compelled by social pressure. The precise subjective experience matters. These phenomena require the complete clinical context rather than automatic classification.
Body experience and neurological context #
People may report altered size, shape, ownership or presence of body parts. Separate a sensory experience, a belief about the body, an appearance preoccupation and a neurological recognition problem. Sudden changes, focal deficits, seizures or headache can change the assessment priority.
Older named body-schema phenomena can be difficult to distinguish from brief accounts. Describe laterality, duration, sensory and motor findings, awareness and the person’s interpretation. Avoid assigning a rare label simply because one word in the account resembles its definition.
Context and documentation #
- Clarify onset, duration, recurrence, triggers and the last usual state.
- Establish arousal, attention and orientation during the experience.
- Ask about sleep, medicines, substances, trauma and physical or neurological symptoms.
- Examine ownership, agency, reality appraisal and emotional response separately.
- Document functional impact, distress and behaviour in response.
- State which descriptions are reported and what was observed.