Mental disorders in epilepsy

revealing the structural (meaningful) special features of the disturbances of the highest mental functions. The effectiveness of neuropsychological diagnostics with epilepsy is confirmed by the fact that with respect to the side of the defeat of the brain the neuropsychological conclusion coincides with the neurologic in 59%, with the data of psychopathological conclusion about the topical significance of the types of seizures – in 76%, with the data of EEG (focus paroxysmal manifestations of electrical activity) – in 80-83% of cases. The agreement of the results of neuropsychological diagnostics about the side the defeats of the brain with the results of neuroimaging, are achieved in 71-81% of cases taking into account the double-sided pathology.

These findings are consistent with the recently expressed opinion by P. Wolf (2011) about the fact that the thalamocortical circuit are up to now considered occupying central place in “generalized” ictogenesis. Other implicated subcortical structures include precuneus parietal cortical areas and areas of passive wakefulness, providing functions to maintain consciousness. Great significance have zones of cortex, which belong to the frontal and parietooccipital regions, and in them also can exist different local cortical drivers of rhythm. Nevertheless the cascade of the ictal events can begin variously, which in the case of epileptic reflector seizures are, apparently, the activity of the cortical circuits, which ensure physiological functions.

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Chapter 4

CLINIC OF MENTAL

DISORDERS OF EPILEPSY

As our studies showed, in general the pathokinesis in epileptic disease is characterized by the complication of clinical picture, worsening of mental activity and can be presented in a consistent detection of personality disorders often begin to manifest in patients even before the first manifestation of paroxysms, paroxysmal syndrome, psychotic disorders, epileptic dementia. Consecutively appearing, they overlap the previous special features of disease and with its development to a certain degree are reduced and cease to occupy key place in the clinical picture.

In contemporary prospective studies of the cohorts of patients with epilepsy the errors of primary diagnostics are outlined mainly from the position of the correspondence of the diagnosis of the last contemporary classification of epilepsy (1989), in essence of that oriented to the paroxysmal syndrome (W.F. Arts et al., 1997). The socalled behavioral problems, which are prolongedly considered basic with epilepsy, are traditionally explained to neurologists “basic neurologic disfunction”, “chronic disease”, “influence of sedative antiepileptic means” and “insufficient family regulation” (J.K. Austin et al., 1997; A. Izmeth, 1997; D.Taylor, 1997).

Some authors “from a series of psychiatric symptoms and reactions” call only depressions as “the attribute of epilepsy in the pure form” (G. Bogliun et al., 1997; E. Motta et al., 1997) or speak about “high risk of depressive disorders with epilepsy” (M. Robertson et al., 1987; M.S. Siffels et al., 1997; A. Kanner et al., 1999). Others to “steady signs of epilepsy in the course of its evolution” carry “worsening in the psyche as a whole” (A. Cerullo et al., 1997; G. Selukov, 1997) and “the types of behavioral disorders”, naming thus heavy psychiatric manifestations, including psychotic symptoms (P. Dodd et al., 1997; N. Holthausen, 1997), from which the depression “proves to be far from frequent” (K. Smith et al., 1997).

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In Great Britain and Canada the prevalence of depression in the patients with epilepsy during the entire life composes 22%, while in the general population – 12% (J. Edeh et al., 1987; J.F. TellezZenteno et al., 2005). According to a number of the authors, the prevalence of alarming disorders with epilepsy is from 5 to 30% (E.K. Silberman et al. 1994; L.L. Altschuler et al., 1999; G. Glosser et al., 2000; W.A. Swinkels et al., 2001; Jones, 2003).

The early formed special features of personality were in many instances outlined by us in patients on the entire course of disease, including its latest stages. With the advent of paroxysmal and psychotic disorders these special features underwent further emphasis and qualitative shift. With the formation of epileptic dementia gradually were consolidated the features of the so-called epileptic psyche, because of which were erased the individual or personal characteristics response.

The dynamics of individual characterological and personal manifestations in the course of the development of epileptic disease always interested not only psychiatrists, but also other specialists, especially psychologists and neurologists. In recent years in the literature in connection with the growth of interest in “psycho-social outcomes and quality of life” with epilepsy more frequently is discussed the presence in the patients with epilepsy “of the disorders of development in many regions of psychological functioning” (O. Aleksic et al., 1997; S. Jarvie et al., 1997), about the behavioral problems and the incorrect psychomotor development, that precede the first seizure (J.K. Austin et al., 1997, and F. Vigevano et al., 1997), and also about the need of examining each patient with epilepsy simultaneously along the I and II axes DSM-III-R (E.H. de Graaf et al., 1997). With this D. Fitzpatrick et al. (1997), D. Marinkovic et al. (1997), Z. Martinovic et al. (1997) and S. Spencer et al. (1997) consider that the appearance of epileptic seizures and behavioral disorders at the children’s and teenage period can render adverse effect on the subsequent development of personality and social functioning of patients. To the consequences of this type the authors carry limitations in the formation, “dependence of vital status and poor emotional and behavioral regulation”. S. Jarvie et al. (1997) and P. Wolf (1997) indicate the need of the attraction of the life experience of the patients with epilepsy to their solution “medical and psychological” of problems. In the same sense opine M. Inami et al. (1997), who consider that more adequate for studying the personal manifestations in the patients epilepsy are psychological, not medical criteria.

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On to the influence of the properties of the so-called epileptic personality to the creative activity of patients point L. Mouzitchouk et al. (1997) and M. Ttrimble (1997). G. O’Brien (l997), and also M. Popovic et al. (1997) examined “the detail of personal development” in the patients with epilepsy in the form of the formation in them of aggressiveness, sensitivity and dependence on others. According to the experimental-psychological study, carried out by N.G. Tokareva (1997), in 90% of patients these or other manifestations of rigidity were reflected in the dynamic, psycho-social and emotive structures of personality.

According to obtained by us data, paroxysmal disorders during their demonstrations, and then through the illness is characterized by the appearance of new forms. With the advent of the signs of psychosis and especially dementia they have a tendency toward the reduction.

On the relationship between the occurrence of paroxysmal symptoms and psychiatric disorders in patients with epilepsy modern authors suggest the following.

With repeated analysis of values of IQ in patients N. Adachi et al. (1997) revealed distinct correlation between them and with the frequency of seizures. J.E. Festen et al. (1997) assume that “the type and gravity of seizures influence cognitive development”. E. Sarac et al. (1997) note damage of the memory in patients with the primarily generalized seizures. G.L. Casaran et al. (1997) and O. Toidze (1997) report, that more than in half of examined by them patients the subclinical discharges by EEG decrease fulfillment of assignments for the vigilance and retention of attention. E. Milne et al. (1997) and E. Mojs et al. (1997) report that in many instances an improvement in the control over seizures correlates with the decrease in the patients of undesirable behavior and improves their capabilities for participation in the intelligent activity. In 81% of patients “with the heavy and deep mental backwardness” M. Derouaux et al. (1997) reveal “the very atypical and weakly expressed seizures. B.H. Landgrebe (1997) indicates the reciprocal relations between the seizures and the psychosis and cites the data about the development of the alternative schizophreniaform psychoses against the background of the decrease of the frequency of seizures and forced normalization of EEG.

T. Betts et al. (1997), on the contrary, assume that the beginning of mental disorders is rarely connected with the rapid stoppage of sei-

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zure. Presence in the patient of complex partial seizures T. Wolanczyk (1997) and M.L. Zupanc et al. (1997) connect with the higher probability of the occurence in them of mental disorders. R.G. Golodets (1997), without adhering to extreme views – “psychosis or seizure”, considers that if this connection in the part of the observations of sharp psychotic episode is outlined, then in the cases with the protracted and especially chronic course of psychosis interrelations between the paroxysms and the mental disorders are more complex.

V.A. Vasilenok (1997) in 35% examined children together with the complication of the paroxysmal disturbances of sleep notes hyperdynamic, astheno-depressive, hysteroform syndrome. According to the author, in anamnesis of such children are revealed the delay in the development of motivational directivity, the predominance of affective imagination above the cognitive. In 12% of observations of the author similar signs preceded the demonstration of epileptic seizures.

According to the epidemiological study, carried out by L.K. Khokhlov et al. (1997), in a population of patients with epilepsy in childhood observed by neurologists and psychiatrists, in cases when the seizures do not stop, persistent mental disorders are absent only in 1.9%.

According to our data, the types of epileptic psychosis by its length and shape of the flow can be reduced to three main groups: transient, schubweise and chronic. In this case, the clinical picture differs by extreme diversity.

Predominance in the individual case of the disease of the transitory, schubweise or chronic form of psychosis makes it possible to assume the certain readiness of individual for the specific duration of psychotic reaction to the pathologic harmfulness, which lies at the basis of epileptic process.

To the transitory epileptic psychoses with acute onset and rapid end, lasting from a few hours to a few days, we classified psychotic episodes of depression, mania, hypochondriacal states of anxiety relationships with ideas, poisoning, persecution, hallucinatory-delusional states, Lucid catatonic disorder catatonia with oneiric, twilight consciousness disorders, delirium.

Schubweise epileptic psychoses, which are characterized by a sprawling beginning and ending, lasting from several weeks to several months, were presented in our patients with affective, de- pressive-delusional, manic delusions, delusions, catatonic-delusional and catatonic attacks.

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In chronic epileptic psychoses we included affective-delusional states with the predominance of super-valuable ideas, the hallucinatory inclusions, state with predominantly querulant delusion in combination with the manifestations of second catatonia, to catatonic states with the affective-delusional inclusions.

According to our data, the structure of transitory, schubweise and chronic psychoses with epilepsy is found in the definite dependence on the preferred localization of epileptic process and degree of progressive course of disease.

4.1. Place of nonpsychotic mental disorders in the clinical picture of epilepsy

As adapted for use in domestic practice sections of the International Classification of Diseases, 9th and 10th Revision (ICD-9 and ICD -10 ) related to mental disorders, these disorders in epilepsy are only called but not described in detail. Meanwhile diagnostics of nonpsychotic mental manifestations with epilepsy is hindered not only in connection with the fact that it is something special, different, for example, from diagnostics of the disorders of a similar kind within the framework of the psycho-organic syndrome “nonepileptic” origin, but mainly as a result of the vagueness of the frequently used term “of change in the personality according to the epileptic type”.

Established by us in the course of the retrospective analysis of clinical data in 961 patients with epilepsy (478 men, 483 women) the so-called nonpsychotic mental disorders or the changes in the personality, which do not reach the degree of partial or total dementia, are examined in present chapter in the comparison with the disturbances of mental functions and the predominant type of psychotic disorders.

For the development of appropriate psychological and pathopsychological criteria were used methods aimed at identifying the ability to lock traces and volume of the perceived long-term storage (reproduction of 10 words after one hour), of safety of formal logical operations (mediation of concepts based on the example of pictogram, the classification of objects), of rate of tentative reactions (on Schulte’s tables), calculation, stability and switching capacity of attention, volume of the working storage (reading of 100 on 7), which designates the functions of speech (name of the generalized groups of ob-

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jects, phenomena), the mobilities of mental processes (passage from one form of activity to another), criticality (estimation of their own achievements in the experiment), endeavor of activity, design praxis (procedure of Koos, independent or from the model the construction of figure), movements.

The comparison of the revealed complex of the disturbances of the mental functions, which do not reach the degree of dementia (safety of speech, design praxis and motor reports, capability for reproduction not less than 7-10 words of 10 through the hour, the possibility of the correction of concrete-situational connections with classification and exception of objects, a sufficient switching capacity of mental processes and the mildly expressed disturbances of the endeavor of work in the experiment), with the revealed nonpsychotic mental disorders, which are combined in patients with the different forms of the course of epileptic psychosis (transitory, schubweise and chronic), made it possible to establish some differences in the formulation of the clinical picture of the remissions of disease on the stage of the appearance of psychotic disorders.

It turned out that the emphasis of the so-called premorbid features of personality occurred in our patients long before the demonstration of epileptic psychoses and most frequently – in the period of the active development of the paroxysmal manifestations of disease. In general the appearance of transitory and schubweise psychoses, independent from the predominances or the absences in their structure of affective, delusional or catatonic disorders, preceded the personal manifestations in the form of the combination of epileptoid and extravert features with sufficiently expressed sthenia and relative ease of adaptation. Changes in the personalities of the patients, which precede chronic epileptic psychoses, were more difficult to distinguish between the beginning of the psychosis.

In light of this, we are interested in the connection between personal characteristics, which were being most vividly demonstrated in patients in the period of the manifestation of the signs of psychosis, and by the dynamically structured characteristics of psychosis.

It was established that the affective and delusional disorders, which occupy the leading place in the structure of epileptic psychoses, in the purest form are, as a rule, observed in patients with the favorable and with the set aside exacerbation by the types of the course of epileptic process. To the formation of these disorders, first of all, contribute such personal special features of the patients with epi-

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lepsy noted still in the literature of the 19th century as tendency toward “the formation of interrupted false ideas and fantastic plans”, “suspiciousness together with the inadequacy, nonplasticity, changeability and explosive nature of affective reactions” (J. Falret, 1860). The clinical formulation of affective and delusional disorders and the small depth of negative disturbances hampered resolution of questions about the differentiation in our patients of the role of changes of the personality in the clinical picture of disease and premorbid personal manifestations in the appearance of the types of reactions characteristic of them.

By epileptoid manifestations were implied the tendency of patients toward the reactions of stress, selfishness, tendency toward the leadership, the increased exactingness of those surrounding, neglect of their opinion, touchiness and grudge. Alarming-over-anxious features were manifested in the patients in the indecision, the uncertainty to themselves, the tendency toward the doubts. The combination of irritability, increased sensitiveness with the manifestations of exhaustion entered into the circle of asthenic features. The changeability and the inconstancy of mood depending on the content of concrete situations predominated among the reactive-labile features. With the tendency toward the fantasies were combined the demonstrativeness, tendency toward the false charges of those surrounding, immaturity of psyche.

Epileptoidnye personality traits in cases of transient flow epileptic psychosis implemented in patients with acute tendency to affective reactions. For patients were characteristic active position with respect to their imaginary enemies, firm conviction in the validity of their conclusions. The reactions of anxiety more frequently occurred in the cases of the sharp hypochondriac states, basis for formation of which were senestopathias and psycho-sensory disorders. Alarming-over- anxious features and high reactive lability especially sharply were manifested in the cases of the predominance of transitory psychoses with the hallucinatory and pseudo-hallucinatory experiences.

Tendency toward the alarming fears, frequently in combination with the tension of passion were observed in patients in the cases of the development of sharp sensual delusion with the start of the elements of situation. In this case sensitivity also of the asthenic type of reaction in the larger measure were typical for the patients with the irregular depressions, which were being accompanied by the ideas of self-disparagement and relation. Characteristic of pa-

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tients epileptoid features caused, however, their effective resistance “to offender”. They usually did not hide from the imaginary enemies, openly they were turned with the complaints on them into different establishments.

In the periods of the remissions (as a rule, more than a year) of the special feature of personal manifestations sufficiently prolonged between the transitory psychoses, in the exaggerated form those appeared in the clinical picture of psychotic episodes, proved to be in patients sufficiently compensated.

The participation of personal factor in shaping of the clinical picture of disease occurred in patients and in the cases of the paroxismal course of epileptic psychosis. To the gradual development of psychosis here corresponded the tendency of patients to draw for the substantiation of its judgments of different kind real events, that did not exclude the possibility of the psychogenic “starting” and of the formulation of protracted psychotic paroxism. The structure of depressive-delusional states was in many respects caused by their duration. With the duration of psychosis in several months querulant and hypochondriac delusion became more systematized. The ideas of truth seeking with an increase in the duration of the psychotic schub acquired more autonomous nature. The tendency toward the fantasies noted even before the disease more frequently was manifested in patients with the protracted maniacal-delu- sional schubs. Together with the increased sociability for them was characteristic the tendency toward the interference in the matters of those surrounding, the tendency to teach, to actively inject its proposals and other. Alarming-timid passion predominated in the cases of the development of depressive-paranoid schub with the duration of 1-2 months. With the larger duration of psychosis the tension and anxiety proved to be less expressed.

Paroxismal psychoses were changed by sufficiently prolonged (from several months to 1 year) intermissions or remissions with the residual productive psychopathological disorders. Depending on this, the majority of patients due to the compensation or personal subcompensation of these symptoms continued their normal activities.

In the cases of the chronic course of psychoses fundamental importance for the adaptation of patients acquired their personal special features, such as egocentrism, mental rigidity, overstated selfappraisal and inadequate level of claims. Querulant delusion accompanied hypomanic passion. Conflicts with the administration, the

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members of family, medical workers and others they depended on the fight of patients with the imaginary encroachments of their rights, prestige, merit. In patients occurred steadfast conviction in their own infallibility and superiority over environment. With sufficient preservation in the part of them of professional habits and ability to attain the fulfillment of the narrowly stated goal this to a considerable extent hampered their stay in the sphere of social relations.

Thus, before the appearance in the patients signs of epileptic dementia a question about the place of the so-called nonpsychotic mental disorders in the general structure and the dynamics of clinical syndromes with the epileptic disease cannot, evidently, be examined without taking into account the possibility of the combination of personal and psychotic disturbances. Probably, precisely, because of emphasis and development of personal special features with epilepsy at the stages of disease, which precede the period of the formation of dementia, psychotic disorders have the greatest expressiveness. The difficulties of the differentiation of premorbid characterological and personal features with changes of the personality in the course of disease are, in our opinion, connected with the inspection of the adult patients with the fact that of a change in the personality they frequently precede the paroxysmal demonstration of epilepsy, which relates, as a rule, to the child and teenage period and that being been the most frequent occasion for the turning to doctor.

An analysis of the literature of recent years indicates an increase in interest in the studies of the structure and dynamics of mental disorders in epilepsy.

According to M.O. Abdulghani et al. (1997), who inspected 50 children with epilepsy and 20 of their contemporaries from the control group, children with anomalous EEG have distinct worsenings in the personal and behavioral regulation. This was the more expressed in patients with focal EEG by dysrhythmia. At the same time, according to the data of the authors, an intellectual decrease in the inspected by them patients was not connected with EEG with deviations.

O. Sugiyama et al. (1997) report that the preschoolers at the age between 3 to 6 years with epilepsy (n=37) reveal the delay of the formation of the investigating behavior and social experience independent of the state of their intellect.

In 23 school children with “normal intellect and unexpressed psychiatric and neurologic symptoms” O. Aleksic et al. (1997) re-

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