Mental disorders in epilepsy

vealed “plural signs of the disorders of development in many regions of psychological functioning, including ticks, enuresis, fears, headaches”.

According to the evidence of S. Ehlers et al. (1997), that is based on the materials of the inspection of 75 children with Lennox-Gastaut syndrome, diagnosed in the period between 1992 and 1995, almost for all patients had typical social and behavioral disturbances in their mental development.

D. Fitzpatrick et al. (1997) although establishing the differences between the personal special features in 20 patients with epilepsy and in 20 control patients with diabetes mellitus, however consider questionable assertion about the influence of epilepsy of the childhood on further development of personality in patients. P. Ноаге (1997); also comparing children with epilepsy (n=62) and diabetes mellitus (n= 91), notes that in the first more frequently take place the disorder of behavior and less expressed a feeling of self-esteem.

According to V.A. Vasilenok (1997), noted since the beginning of the learning in 120 sick with epilepsy children the depletion of interests, impulsiveness, conversion episodes and other neurotic symptoms contribute to the formation in them of steadfast school desadaptation.

R. Lossius et al. (1997) in 12 out of 16 inspected young (1425 years) people with epilepsy revealed the behavioral and emotional problems, which created for them difficulties in the school and in the family. E. Pavlou et al. (2011) note that among the reasons, connected with the health, epilepsy on its negative influence on the school learning occupies the second place.

M. Pose et al. (2011) in the course of a comparative study of the data of the interrogation of the relatives of 16 patients with frontotemporal dementia and of 19 patients with Alzheimer’s disease about the nature of the noted by them changes in the personality in patients establish the following. In patients with frontotemporal dementia occur the reliably significant differences with the premorbid personality in the plan of regress on such aspects as persistence, activity, emotionalism, openness, honesty, consciousness, self-discipline. In patients with Alzheimer’s disease reliably significant, in comparison with the premorbid stage, changes in the personality are evinced by the growth of anxiety, hostility, depressiveness, impulsiveness, vulnerability and reduction in the honesty, persistence, activity.

N.G. Neznanov and M.Ya. Kissin (2010, 2011) divide personal disorders in the patients with epilepsy into the obligatory and the fac-

111

ultative. In obligatory disorders the authors include viscosity and explosiveness. Viscosity (F. Minkowska, 1923) is manifested in the form of difficulty of movement, sluggishness, heaviness. Such patients are typical “condensed, sticking, sticking to the surrounding objects affectivity”. Secondary with the respect to viscosity are pedantry and accuracy, in the measure the growth of dementia having tendency for decrease. Explosiveness is manifested in the irascibility, the irritability, the aggressiveness. With the explosiveness are connected changes in the personality in the form of grudge, vindictiveness, state of conflict, which have a tendency toward the decrease in proportion to the formation of dementia. Formation of the facultative disorders of the personality in the form of paranoiac, schizoid, psychasthenic and hysteroid features can be caused by heredity, by course of epileptic process, by localization of epileptic focus, by influence of medicinal therapy, by psychogenic factors, by environmental factors. According to M.V. Usyukina et al. (2009), of primary importance in making a fi- nal judgment on the diagnostic supplies psychosis has the character personality changes.

4.2. The clinico-pathopsychological criteria of structure and dynamics of epileptic dementia

As showed the results of the investigations conducted by us, depending on the rate of progressive course of epilepsy the development of psychopathological disorders with it can prolongedly remain at that stage, when cognitive functions in patients clinically remain not changed, either with one or other speed or another are passed the stages of disease with shaping of the picture of epileptic dementia: at first with gradual reduction in the creative abilities, working storage, appearance of the expressed plosive disorders, then – with the sluggishness, the viscosity, the objectively-concrete nature of thinking and finally with the the oligophasia, by the expressed mnesticointellectual decrease, by aspontaneity.

As was already noted above, psychotic symptoms to a certain degree are reduced at the stages of the formation of epileptic dementia in proportion to the deepening of intellectual defect. Clinically this is expressed in the fact that the affective reactions in patients become less sharp, delusional manifestations acquire the thickening forms, is lost the urgency of delusional experiences, the catatonic

112

disorders, entering the structure of polymorphous psychopathological formations, become more elementary, predominate the phenomena of sub-stupor.

According to our data, the examination of the clinico-prognostic aspect of the problem of the course of epilepsy with psychosis and dementia assumes the need for the analysis of the factors of hereditary, biographical, personal, cerebral-organic, paroxysmal and psychopathological circle, which participate in the structuration of mechanisms and clinical picture of disease.

The results of the observations of two large groups of patients, who live in different removed from each other regions of the country, proved to be completely similar and they showed that the type of the course of disease, which in different degree reflects the general destructive tendency of epileptic process, appears basic determinants of clinical prognosis at all stages of disease.

Since the productive psychopathological disorders in the majority of the observed by us cases of disease were combined in patients with the negative psychopathological disorders, the account of the corresponding material to us was expedient to begin from the clinical characteristic of the latter. We assumed that with this approach the principle of the dynamic study of mental disorders with epilepsy can be sustained most clearly.

The concepts of partial and total are used in relation to dementia as well as the definition of its extent, depth, intensity, etc. In the current domestic and foreign textbooks on psychiatry, is often given the term progressive dementia. The enumerated circumstances, however, insufficiently are considered from the positions of psychiatry of flow, which assumes dynamically structured approach to understanding of the nature of the connection between the productive and negative psychopathological syndromes. Meanwhile precisely this connection relate, apparently, to the discharge of nosologically specific and, as show our observations, are the clinical reflection of pathogenesis.

Regarding the scientific group of WHO (1987), the dementia by the, being “acquired global disturbance of all highest cortical functions, including memory, the ability to solve the problems of daily life, the fulfillment of complex actions, the correct application of social habits, all aspects of language and contact, checking of the emotional reactions in the absence of the roughly expressed loss of consciousness”, nevertheless “almost always progresses” and “the substanti-

113

ated diagnosis of dementia can be placed only after the statement of worsening in the mental functions in the course of time”.

As for epileptic dementia, our special study was devoted to the clinico-catamnestic study of its dynamically structured special features in the aspect of prognosis in its time (1976). It was established, in particular, that the formation of epileptic dementia passes the specific stages in accordance with the predominance to the clinical picture of the expressed affective disorders, disturbances of thinking or reduction in the cognitive functions.

The undertaken by us subsequently with the use of the named criteria clinico-epidemiological study of the wider spectrum of mental disorders with epilepsy showed that among the located on the psychiatric observation adult sick with epilepsy persons with the signs of epileptic dementia they compose 51,8%. In the total number of cases of dementia the portion of the cases with its initial manifestations, that is with the domination of affective disorders in the form of “fire excitability”, composed 22,2% of cases, with the predominance in the clinical picture of sluggishness, difficulty of movement, viscosity and the objectively-concrete nature of thinking -60,5%, and the cases with total dementia in the form of the combination of the expressed mnestico-intellectual defect with the aspontaneity – 17,3%.

Taking into account our own data and literature data (K. Luedorf et al., 1986) about the determining influence of dementia on the social functioning of the patients with epilepsy, for refining the diagnostic and expert criteria to us was necessary to conduct the comparison of the clinically revealed in patients tendency toward the progression of the epileptic defect of psyche with the data of experimentalpsychological study.

In the course of the intensified clinical study of material on the dispensary and stationary histories of the disease of 450 patients there was confirmed the previously expressed by us position about the fact that the structure and the dynamics of epileptic defect is essential diagnostic and prognostic signs.

It was confirmed, for example, that with the increase of the signs of the defect of psyche at first they exaggerate characteristic of patients prior to the beginning of the paroxysms of feature personalities, and then begins “the consolidation” of the features of the so-called epileptic personality, because of which seemingly are erased the specific features of reaction. Such “consolidated” manifestations included the polarity of passion, straightness and

114

arbitrariness of the judgments of patients, their emphasized executiveness, accuracy, assiduity.

In the course of our study not only the differential-diagnostic signs of epileptic dementia were refined, but were also established the factors of the risk of the appearance of the specific rate of progressive course of the epileptic process, in accordance with which to the development of one or other stage of the formation of dementia contributes diagnostics of the specific types of the paroxysmal and psychotic disorders.

Combination in the clinical picture of vegetative paroxysms and affective psychoses proved to be possible to estimate as the sign, which associates the favorable course of disease, not leading to the development of dementia (120 patients). On the contrary, strengthening the paranoic features of personality, as a rule, noting in the third decade of life, was the sign of the set aside exacerbation of process with the frequent appearance of hallucinatory-delusional disorders and statement in the majority of the cases of the first or second stage of the formation of dementia (154 patients). The duration of the first stage of the formation of dementia (with the predominance of affective disorders) in this case on the average was 5,95+/-0,7 years. Finally, indication of appearance at the young age in the patients generalized tonicoclonic seizures and polymorphous psychoses with the catatonic manifestations made it possible for us to prognosis the early (into the first 5-10 years of disease) appearance of signs of dementia, which consecutively passed, according to our observations, all three stages of its formation (176 patients). The duration of the first stage of the formation of epileptic dementia, according to obtained by us data, on the average was equal to 5,6+/-0,75 years, the second – 8,25+/-1,1 year.

For the development of the reliable clinical criteria of diagnostics of epileptic dementia, not only general, but also predominantly relating to each of the stages of its formation, we carried out the ex- perimental-psychological study of 200 patients by epilepsy (135 men, 65 women), of whom 50 composed the group of patients with the presence of epileptic changes in the personality without the signs of dementia, 50 – group with the presence of epileptic dementia with the predominance in its structure of affective disorders, 50 – group with the presence of epileptic dementia, which is characterized by predominance in the patients of disorders of thinking and 50 – group with the presence of the clinical signs of total epileptic dementia.

115

Already with the comparison of the groups of patients with absence or presence of the clinical signs of dementia it was possible not only to isolate its basic differential-diagnostic criteria, but also to outline comparatively less significant for the diagnosis or facultative signs of dementia, which relate to one or other stage of its formation.

Obtained by us data show that as basic, noted more than in half of the cases, criteria of the epileptic changes in the personality, which do not reach the degree of dementia, can be used absence in the patients disturbances of speech, safety of design praxis and motor reports, capability for reproduction is at least 7-10 words of 10 through the hour, the possibility of the correction of concrete-situation 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.

To the discharge of the pathopsychological criteria of syndrome of epileptic dementia of general order, noted more than in half of the clinically verified cases, first of all related the inadequate and noncritical ratio of patients to their behavior and situation of experiment, nonpurposefulness of activity, predominance of the noncorrective concrete-situation solutions with the classification of objects, rough disorders of design praxis, bradykinesia.

As facultative components, which can be used for refining the dynamics of the manifestations of the syndrome of epileptic dementia, according to our data, should be considered oligophasia, insolvency with the fulfillment of assignments for the reading, duration of the search for the numbers on one table of Schulte of more than two minutes, the incomprehension of instruction in the procedure for the exception of objects, the reproduction in the hour less than two words of ten.

Obtained data allowed us to arrive at the conclusion about the possibility of using some “insubstantial” signs of dementia (“partial to dementia”) as the material, suitable for the interpretation of the nature of compensating or adaptive mechanisms.

It proved to be possible to divide the pathopsychological characteristics of epileptic dementia at the stages of its formation into the inherent either in any one of them and those because of this utilized for diagnostics of this stage or which simultaneously belong to two consecutive stages. Existence of similar characteristics indicates the possibility of evaluating the growth of the manifestation of the syndrome of dementia as steady with the accumulation of various struc-

116

tural special features and of the probability of establishing the signs of the known compensation for this syndrome in proportion to the decrease of the manifestation of its separate characteristics.

The first stage of the formation of epileptic dementia is characterized, according to obtained by us data, by the reliable predominance of the signs of the partiality of the defeat of the mental functions, first among which is a violation of focus in the work because of emotional inadequacy of patients, to a certain extent due to the increasing affective disorganization in cases arising from difficulties in the assimilation of instructions, and also as a result of the noted the patients have tendency toward the stickings and the concretesituation solutions, which are more frequent revealed in the conditions of applying the procedures for the exception of objects and the establishment of simple analogies.

The characteristic manifestation of the second stage of the formation of dementia, as showed our studies, is combination of the signs of partiality and totality of the defeat of mental functions. Among the first – expressed tendency of patients toward the mediation of concepts by concrete connections (that more frequent revealed with the study by the method of pictogram), the establishment of concretesituational connections with the classification of objects, and also difficulty of nomination. By the signs of the deeper defeat of mental functions, which indicates the progression of dementia, at this point its formation should be considered not only an increase in the cases of complete incomprehension as the patients of instructions, but also the incomprehension of the being contained in them conditionality, the deceleration of the rate of tentative-search reactions, the contraction of the volume of attention, the appearance of disorders of constructive praxis, the loss of endeavor in the work under the conditions of the experiment, bradykinesia.

The third stage of the formation of dementia is characterized by further accumulation in the patients signs of total dementia. Among characteristic of this stage it is possible to note not only incomprehension by the patients of instructions with an attempt at the detection in them of the preservation of formal logical operations, capability for generalization, abstracting, isolation of essential sign, but also in general inadequate relation to a study, the expressed sluggishness of mental processes, to oligophasia.

Thus, the obtained in the course studies pathopsychological data allowed us to confirm the need of examining the syndrome of epilep-

117

tic dementia in its dynamics for purposes of the establishment of the chronological and pathogenetic connection between the signs of partiality and totality of the defeat of mental functions, development of the continuum of negative psychopathological manifestations with the epileptic disease, approximations to understanding of the mechanisms of adaptation and compensation at its distant stages, refinements of the differential-diagnostic criteria of changing the personality without the signs of dementia and strictly dementia.

In recent years more attention is given to questions of a neuropsychological study of cognitive functions with epilepsy out of their connection with the conducted medication treatment.

Cognitive deficiency in the sphere of memory and attention is revealed by O. Aleksic et al. (1997) in 23 schoolboys with epilepsy together with the insufficient verbal, compared with perceiving, manipulative ability. In comparison with the control, in 27 patients with epilepsy of O. Dogu et al. (1997) memory was evaluated considerably below. G.L. Casaran et al. (1997) ound that subclinical EEG discharges in 11 children aged 7 to 13 years in 58 % of cases have a negative impact on the performance of tasks for vigilance and retention of attention. In comparison with its contemporaries, N. Krstic et al. (1997) revealed in 16 patients with IQ > 85 on Wechsler Intelligence Scales for Children discovered common thin and diffuse disorder in various spheres of the cognitive process, including clinical expression of attention deficit mnemonic and executive functions with a decrease in the ability to allocate resources, the reduction of cognitive flexibility and dynamic organization products. In 66 patients with epilepsy, in comparison with 105 healthy persons, in the absence the signs of intellectual insufficiency S.-L. Lai et al. (1997) revealed “many disturbances of the neurobehavioral functions”, including “of the speed of motions, visual-engine performance, attention, memory, instruction and mood”. A.M. Weber et al. (1997) in 36 patients aged between 2 to 17 years soon after the appearance in them of the first seizure revealed the disorders of speech, visual-constructive thinking and motor-speed coordination. S. Malagold et al. (1997) in majority of 22 examined patients with “youthful epilepsy” revealed the disorders of logical memory, into 2/3 cases – disturbance of the smoothness of speech, in this case in half of the cases in patients remained abstract thinking, nonverbal intellect, visual- three-dimensional organization, there are no disorders of free call (episodic memory). The same number of patients with the same form of the disease V. Sofia

118

et al. (1997) with most typical of the cognitive disorders considers the scarcity of short-term memory and calculation. In 72 patients with epilepsy “with the favorable focal syndromes, with the average (65%) and above average (35%) by intellect” H. Mayer et al. (1997) approximately in 30% of cases established the disturbances of capability for instruction in the letter, orthographies and vocal functioning, in 35% of cases – disorders in the form of the scarcity of attention, in 35% of cases – emotional disorders. The same authors in other study (1997) come to the conclusion that with favorable epilepsy of the childhood (n=69) the cognitive scarcity can be observed in third of cases and serve as a reason for school nonproficiency. To difficulties in the pre-school and school periods in the patients with epilepsy, according to the data of M. Sato et al. (1997), contributes scarcity in the attitude and the three-dimensional memory. Based on the example of 30 patients A. Piazzini et al. (1997) established that the semantic memory more frequently is surprised with temporal epilepsy than with the frontal. E. Sarac et al. (1997) report that in patients with the well controlled seizures all tests by the memory are reduced.

Given data in literature attest to the fact that the damages of cognitive functions in the patients with epilepsy, less expressed in comparison with the revealed by us signs of partial dementia, can serve as early diagnostic and prognostic criteria with this disease.

Obtained by us data, and also given literatures illustrate he complex situation of promising clinical and experimental psychological development to find an answer to the question of how disrupted is the “course (that is structure) of mental processes” (Yu.F. Polyakov, 1983) in the cases of detecting various trends in the development of chronic psychic illnesses.

In order to approach the understanding, of how close in the course of the development of the versions of epileptic dementia is possible the combination of personal, nonpsychotic mental and psychotic manifestations and manifestations of epileptic defect, here, apparently, is expedient to cite some obtained by us clinical data about so-called paranoid epileptic dementia.

The purpose of the work was the study of the special features of structure and dynamics of this type of dementia, the determining adaptive possibilities patients. In each case of the disease (n=66) was conducted retrospective analysis of the development of epileptic process in general, including according to archive data of stationary and dispensary inspections. Period of catamnesis – from 1 year

119

to 12 years. For the period of the inspection of 6 patients – the disabled of the third group were occupied with labor under the conditions of special shop, 27 patients – the disabled of the second group worked in the usual production and 33, being as the disabled of the first group, worked nowhere.

The analysis of the clinical picture of epileptic dementia, which is combined with the chronic delusional disorders, allowed us to single out its three versions, that are distinguished not only by the depth of intellectual defect, but also by the structure of delusional formations.

In these patients the complexity of working adaptation appeared already in the cases of the mildly expressed reduction in the formal intellectual functions when in structure present the defect of the expressed affective (explosive) disturbances and fixed super-valuable formations (first version – 12 people). The average duration of disease in this case was equal to 25-30 years. To the indicated period in patients considerably was reduced critical functions. They overestimated their possibilities and social role, vocation, they required the acknowledgement of their imaginary abilities. In the series of observations were noted the super-valuable ratio of patients to their responsibilities for work. In this case the contact with them for those surrounding became extremely difficult as a result of their captiousness, meanness, state of conflict, rigidity.

Incremental changes in thinking (stiffness, propensity to detail, a kind of vagueness, uncritical, monotonous judgment, inability to comprehend adequately assess the situation in general) contributed to the fact that patients with minor deficiencies in the organization of production interpreted in special way, they evaluated extremely negatively, affectively, they were fixed on them and began “news fight”.

In the unusual situation, for example, under steady survey, in patients was revealed the clearly expressed polarity of affect and method of reaction. In these cases for them became typical such manifestations, as extreme strength , explosiveness , suspicion , distrust , vulnerability and at the same time a sense of complacency , superiority , self-reassessment, infallibility. In the contact with the unknown people the patients were obsequious and at the same time intolerant, incapable to establish any steady contacts with those surrounding, in spite of expressed tendency to arrange them toward themselves. This desire is quickly replaced by attempts to subjugate others to themselves, their interests. Impatience, irritability, rude-

120