Perplexity
Perplexity is a state of bewilderment or puzzlement in which a person feels unable to make sense of their own experiences or surroundings, often appearing outwardly confused, hesitant, or searching, as though struggling to grasp something that keeps slipping out of understanding. As an abnormal expression of emotion, it reflects the person's emotional response to overwhelming or bewildering experience, rather than a primary disturbance of thought or consciousness itself.
This has traditionally been noted as a common accompaniment to acute and rapidly evolving psychotic states, where a person's emotional response to bewildering new experiences, such as the early stages of delusion formation, is itself a puzzled, searching bewilderment rather than fear, sadness, or anger.
Recognition features
- An outward appearance of bewilderment, hesitancy, or being unable to make sense of what is happening
- The person may describe feeling puzzled or confused by their own thoughts, perceptions, or surroundings
- Often accompanies acute, rapidly changing psychotic experiences, particularly in the early stages
- Distinct from a primary disturbance of consciousness, since the person's alertness and basic orientation may otherwise be intact
Eliciting it at interview
- Observe for a puzzled, searching quality in the person's manner and speech, and ask directly whether they feel confused or unable to make sense of what is going on
- Ask what specifically feels confusing or hard to understand, since this can help reveal underlying abnormal experiences the person is struggling to process
- Distinguish from disorientation by checking basic orientation to time, place, and person, which is typically preserved in perplexity
Distinguishing features
- Differs from disorientation, a sign of impaired consciousness, in that basic orientation to time, place, and person is typically preserved
- Differs from anxious foreboding, which is a sense of impending misfortune, whereas perplexity is specifically a bewildered inability to make sense of experience
- Often accompanies, and can be a useful clue toward, other underlying abnormal experiences such as delusional mood or perceptual disturbance
Common misconceptions
- That perplexity indicates an organic confusional state; it is commonly seen in acute primary psychiatric presentations and does not by itself suggest an organic cause
- That a perplexed manner is simply vagueness or evasiveness in answering questions; it usually reflects a genuine, distressing inability to make sense of what the person is experiencing
Related phenomena
Abnormal Expression of Emotion · Delusional Mood · Disorientation
Practice this
A patient in the early stages of an acute psychotic episode appears outwardly bewildered and hesitant, repeatedly saying she cannot make sense of what is happening around her or of her own thoughts, though she remains fully alert and correctly oriented to time, place, and person. What is this? · A patient describes, with full clarity and coherent understanding of her circumstances, a persistent and distressing feeling that something terrible is about to happen to her family, though she cannot say what or why, and she otherwise makes complete sense of her surroundings. Before revealing the answer: is this perplexity? · A patient seems confused during assessment. Before revealing the answer, decide what distinguishes disorientation from perplexity. · A patient appears distressed and unsettled about their current experience. Before revealing the answer, decide what distinguishes perplexity from anxious foreboding. · A patient appears outwardly confused and hesitant during the interview. Before revealing the answer, decide how you would explore whether this is perplexity. · Explain why perplexity is considered a useful clinical clue toward other underlying abnormal experiences, rather than simply a nonspecific sign of distress.
Illustration
A 22-year-old man in the early stages of a first psychotic episode repeatedly stops mid-sentence, frowning and shaking his head, saying he can't quite explain it but that everything around him lately feels strange and unsettled in a way he can't put his finger on, though he knows exactly what day it is and where he is.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 6, 'Disorders of Emotion'.