Mental disorders in epilepsy

B.A. Kazakovtsev

MENTAL DISORDERS

IN EPILEPSY

Moscow 2015

4.3.Structure and dynamics of mental disorders in patients with transitory form of epileptic psychosis 130

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PREFACE

For more than a hundred years the question of nosology conditionality of mental disorders in epilepsy is being discussed. However, the solution of this issue is more complicated for reason that up to date the place of mental disorders in the general structure and dynamics of clinical disease is not specified.

The presented results represent structural and dynamic analysis of mental disorders in epilepsy in the correlation with basic laws of the disease development accounting diversity and clinical prognostic value of these disorders.

The revealed conformity of the basic groups of mental disorders in the patients with epilepsy to the basic types of the clinical course of epileptic process, as well as nearly uniform distribution of these groups of disorders in the population indicate the existence of not just the continuum, but also “balance” of clinical and prognostic patterns in epilepsy.

The conducted research showed that the structure of epileptic psychosis is determined by predominance in clinical picture of one of the basic productive psychopathological syndromes: affective, delusional and catatonic. This fact to a greater extent than the current form of psychosis – transient, schubweise1 or chronic is connected to the type of flow of the epileptic process. These data suggests that the structure and syndromokinesis of productive and negative psychopathological disorders, as well as the main types of flow of the disease are related to the primary lesion considered as functional systems of mediobasal temporal lobe, temporal and frontal lobes of the brain as a whole.

During the conducting of the combined therapy of epilepsy, which takes place with the mental disorders, the reciprocal rela-

1 schubweise (germ.)

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tions between the functional systems of the brain in different development stages of epileptic process is noted. These relationships can be considered in the perspective, and possibly used as a basis for the formation of cerebral compensatory mechanisms and, consequently, as a biological premise of improving clinical and social prognosis in this disease.

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INTRODUCTION

Epilepsy – one of the repeatedly and multilaterally studied diseases. The enormous amount of literature, which concerns the questions of clinic, clinical course, pathogenesis, and prognosis, is dedicated to the disease. On an increasing interest in the problem of epileptic disease evidenced, for example, the fact that international and national medical publication abstracts along with general sections such as “neuroscience” and “psychiatry” for several years as an independent section included “epilepsy”.

The prevalence of epilepsy, according to World Health Organization, is from 3,66 to 12,59 for 1000 populations (WHO, 2005). According to D.S. Hesdorffer et al. (2011), one of 26 people develops epilepsy throughout life.

However, many aspects of the disease remain unclear. Although attempts to classify epileptic psychosis and dementia undertaken since 1838 (E. Esquirol), to date no comprehensive systematic description of their various manifestations. In recent years, with epilepsy, as with any chronic disease, especially felt the need for a more expanded diagnosis and multi-axial classification (H. Helmchen, 1980; ICD-10; M. Masato et al., 2000), which would satisfy the conditions of modern multidimensional diagnosis and prognosis, and contribute to the establishment of so-called bio-psycho-social correlations. The continuing tendency in the world literature of developing mostly the neurologic rather than the psychiatric divisions of the clinical picture of epilepsy prevents this need.

Experience shows that if such an approach can be justified and even necessary in the initial stages of the disease, then with the complexity of the clinical picture, due to its progressive course, multiple psychiatric disorders have to be analyzed with it. However, the tendency of many neurologists and psychiatrists to evaluate psychotic manifestations with epilepsy as comparatively rare and therefore

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alien to this illness, as the combination of epileptic and schizophrenic processes, leads to the fact that the statics and the dynamics of mental disorders with it are examined out of the connection with the assumed pathogenesis.

Therefore, with the development of the criteria of clinical and social prognosis basically the paroxysmal states and so-called widely and unclearly treated “changes in the personality” are considered. In addition, the current state of the doctrine of epileptic psychosis enables mainly to reflect and evaluate psychopathological disorders in epilepsy in static, while the dynamic classification of epileptic psychoses in most cases is limited to general terms inherited from the past century such as transient, prolonged and chronic – with the addition of a comprehensive term “schizophreniform”, while the relationship of the length of the psychosis with its structure remains actually little investigated.

Probably due to deficiency of the information on epileptic psychosis and epileptic dementia, most modern works on social rehabilitation of patients with epilepsy, despite the undeniably beneficial uses for these purposes of neuropsychological and personality characteristics of patients, have some sort of “anti-psychiatric” tone. Fairly objecting to hackneyed description of personal manifestations of epilepsy of the patients and recognition the majority of them as “imbeciles”, the authors tend to explain these features of the patient’s behavior mainly as the reaction of personality to the illness and the environment.

In the present study, based on an analysis of the literature and our own data, the possibility of studying the psychopathology of epilepsy compared with the basic laws of its flow is discussed. As the main method of systematization of diverse clinical features we used a structural and dynamic analysis of the major clinical manifestations of the disease, such as personality characteristics of patients, paroxysmal disorders, psychotic manifestations, dementia, which can be traced at all stages of the disease. Our proposed concept syndromokinesis options of mental disorders in epilepsy based on a study of the sequence and changing syndromes, their complexity and interconnection and changes in structure.

Considering the current ideas about the localization of the epileptic process we present a pathogenic interpretation of the dynamics of clinical disease. The typology of epileptic psychosis and epileptic dementia is presented with simultaneous systematization of pro-

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ductive and negative range of psychopathological disorders in their relationship. The rationale for the selection and use of combination therapies and rehabilitation activities, which promote the social integration of patients, is discussed.

Identified in the study data allowed to formulate recommendations for medical and social expert practice. The proposed method of epidemiological analysis of clinical manifestations of epilepsy, one of the most common diseases (according to the literature, in the world it affects 30 to 50 million people), to a certain extent can be used for planning and organizing assistance to the chronically ill with other types of pathology.

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Chapter 1

THE EVOLUTION OF THE VIEWS ON THE IMPORTANCE OF MENTAL DISORDERS IN EPILEPSY

FOR CLINICAL AND SOCIAL PROGNOSIS

Throughout entire of the period of the study of the clinic of mental disorders in epilepsy, researchers tended to distinguish two main features of these states: their structural characteristics and duration. This tendency still remains dominant nowadays. However, these two clinical signs are considered relatively rare in terms of their relation to the main characteristics of the disease – the type and stage of current epilepsy.

In accordance with the tasks of this work, we compared the literature data with the data, obtained in the course of our own studies. Meanwhile, we tried to examine structure and dynamics of mental disorders in epilepsy, correlating its productive and negative psychopathological manifestations and possibly using the current syndromes of the disease as the criteria of prognosis.

Analysis of the literature shows how gradually with the development of psychiatry in general, the views on the nosological specificity of these disorders and their relationship to other forms of epilepsy were formed. The detection of pathophysiological data was accompanied by attempts to establish links between psychopathological disorders. Also the treatments of epileptic psychoses were questioned. Based on the results of the research in these areas, the attempts to summarize the data on the clinical prognosis were undertaken.

Historically, in this regard, there are several major periods. First – a description of the structure of epileptic psychoses with

the transition from ascertaining their random combination with epilepsy to the approval of their belonging to the disease (from ancient times until the seventies of the last century).

Second – the allocation of core features of psychotic and nonpsychotic dynamics of mental disorders with epilepsy, with the discus-

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