Mental disorders in epilepsy

ness, bluntness, a tendency to exaggerate mundane facts, egocentrism, ignoring logic, failure distance patients produced for the environment the repellent impression, also, during several days, inspite of “sociability”, hey found themselves essentially outside society. Appeared typical in these cases of the complaint of patients of the hostile attitude towards them from the side of those surrounding. Patients began to search for “protection” in doctor, nurses, in relatives, they required immediate discharge from the hospital.

In a production environment dismissed from their work, which is incompatible with their behavior, or transferred into another group, patients with difficulty were thrown to the new forms of activity, sharply they reacted to the least changes in the prevailing stereotype. Their transfer into the work into the conditions of special shop or therapeutic-working workshops was practically impossible as a result of their rigid installation to return to the old work under the conditions of usual production, extremely negative reaction to the proposal work among the mentally sick. Their failure they accompanied frequently by the stimulation of situational activity, by acts of aggression.

In private life patients, as a rule, were retained better than at work; however, they behaved themselves extremely uneven: they were first thoughtful with respect to the close ones, then they were irascible and aggressive. Many patients knew how to subordinate their relatives to themselves.

With this version of dementia the sharpness of affective disturbances, and also the polymorphism of paroxysmal states indicated the relatively high activity level of pathologic process. From the paroxysmal disorders dysphorias were most frequent and expressed. In a smaller number of cases were noted vegetative-visceral, psychomotor and psycho-sensory seizures, are still thinner frequent-absenc- es and abortive convulsive seizures. The general frequency of the enumerated paroxysms fluctuate at patients between 2-3 per month to 3-4 per year.

The average daily dose of the antiepileptic drug, which were assigned to the patient, was equal, in the conversion to phenobarbital, 0,2-0,3 g. An increase in this dose did not contribute to reaching complete therapeutic remission (curtailment of seizures), reduction in the dose led to the aggravation of state. During the treatment patients more frequently treated by luminal and diphenine, from the psychotropic means – aminazine, propazine, levomepromazine.

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Patients with the described pathology needed different forms of social aid, in particular, in solving of conflict situation and the search of the possibility to at least partially satisfy their requests in the plan of working device, search for way for one or other compromise.

In proportion to further growth of dementia (second version) on the average of 30-35 years after the beginning of the disease occurred the complication of delusional formations (28 patients). The querulant activity, which lasted many years and begun most frequently from the fight for the restoration at the previous place of work, frequently acquired in patients inadequate nature. After attaining the required (6 people), patients, as a rule, proved to be completely not suitable to the systematic working activity. They could not work also in the specially created conditions (special shop, therapeutic-working workshops).

In the clinical picture of these patients affective disorders were represented differently from those described above with the first version of dementia. Appears the attack of the apparent complacency, special euphoria. Affective reactions were less brutal, more monotonic and prolonged. The extremely expressed affective viscosity caused in patients the exceptionally persistent and stereotype nature of querulant behavior.

To this contributed gross disturbances of thinking. Viscosity, perseverations, extreme concreteness of judgments were combined in them with floridity and verboseness of response reactions, use of neologisms, noncriticality and paralogicality of thinking, and in the cases of accelerating the associations – with its inconsistency, diffusion, which reaches the degree of incoherence.

Installation to the labor in patients was in the essence formal. Fight for the restoration “of prestige”, its “rights” was transformed in their fight of the wider plan: for the punishment of all guilties, the reconstruction of society.

In the process of infinite walkings on different instances patients develop an elaborate unique and typical for them style of behavior. In the absence of clearly expressed affective explosiveness, by their “prudence”, apparent validity of the complaints, confirmed by a number of facts, patients frequently evoked sympathy in those, who were involved in the consideration of their complaints. This sympathy convinced patients in their rightness even more and impelled them to the stimulation of their querulant activity. They infinitely “reminded of themselves” by telephone calls, daily “they appeared

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to the appointments”, they required “the accelerations of the matter”, manifesting extreme egocentrism, importunity, the tendency by any price to attain thier goal. The attitude toward them of those, who participated in their situation, patients one way or another evaluated depending on that, agreed those with them in everything or not. Least objection was received by them as “the unwillingness to understand” them, “irresponsible and careless relation to its responsibilities” from the side of officials or even as hostile to them relation. In this case patients, continuing a struggle in the previous direction, began especially persistently “to attain their goal” in the instance, which refused to them, by means of the threats, the presentations “of categorical demands”, the immediate complaints into the higher establishments.

Mental aggression bore in this case stereotype nature .

The delusional estimation of thir allegedly salient abilities (fighters for the validity, inventors and other) were combined in many of the patients of this group with the delusional ideas of relation, pursuit, jealousy, the hypochondriac ideas. The unique disturbances of the motor activity in the form of affectation and angularity of gestures supplemented the clinical picture of paranoid epileptic dementia.

In private life these patients were extremely heavy. The expressed egocentrism, the tendency engage in their fight close ones, to subordinate to thier interests their entire life contributed so the fact that many patients lost their families.

In many cases in patients were noted the phenomena, close to anosognosia. They were noncritical to their behavior and possibilities, paid no attention to the paroxysms, frequently they reject any treatment.

A certain increase of paroxysms was noted in part of the patients in connection with this. However, in general phenobarbital coefficient did not exceed 0,15-0,2 g. Both the increase and the certain reduction in this dose did not significantly change the picture of disease. As a result of the transformation of seizures into the abortive became typical their “small polymorphism”. The frequency of the appearance of paroxysms did not exceed 1-2 per month.

During the treatment of the patients of this group were used phenobarbital, diphenine, benzonal, hexamidin, carbamazepine, and also neuroleptics.

Treatment was, as a rule, stationary and prolonged.

The inclusion of patients in labor, increase the effectivenesses of remediation, achievement by them of the higher level of social-

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working adaptation became possible in the third version of dementia (25 people), which was formed usually in 3-4 decades of the course of the disease, when with the deepening of mnestico-intellectual disturbances were observed the depletion of emotional life, reduction in the tension of affect and disintegration of querulant-paranoiac syndrome. Patients, to that prolongedly recognized as disabled and not working, returned to the work to the special workshop (4 people) and even to the usual production conditions (12 people).

The ideas of relation, infidelity, pursuit although little changed in their content however they lost their affective saturation. Hypochondriac ideas were substituted by stereotype complaints of the indeterminate unhealthy sensations.

Patients become obsequious, unctuous, while remaining extremely annoying. Speech became less loquacious, more distinct were manifestations of oligophasia. With the increasing poverty of speech remained its pretentiousness, unique construction of phrases, use of neologisms, tendency toward logic-chopping.

Formal intellectual functions and prerequisites of intellect proved to be here comparatively more decreased, than in patients of two higher described groups. Memory, attention, simple comprehension, formation of simple abstract notions nevertheless did not achieve a heavy decrease and disintegration. In these patients the disturbances of thinner highest intellectual functions were revealed in essence. The criticism was sharply affected in them, the possibility of correct understanding and evaluating the life situation, daily activity was reduced, weakened motives even to the solution of various previously so “necessary” for them, in view of delusional treatment, tasks. The situational activity of patients therefore became of ever of more sluggish and monotonous and ceased in many instances.

In connection with the gravity of the state of these patients the level of family adaptation in them was low. Among the patients predominated lonely, not having thier family.

In the patients of this group, regularly recieved small doses different antiepileptic drugs (on the average in the conversion to phenobarbital to 0,15 g in a 24 hour period), together with further decrease of the frequency of paroxysms was noted also the decrease of their polymorphism: not more than 2 forms of paroxysmal states with their general frequency several times a year.

In the described period the patients needed active aid in the plan of their employment. Success proved to be possible because

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of the joint efforts of dispensary, division of social welfare, and also relatives of patients.

Thus, three versions of paranoid epileptic dementia simultaneously occur to be as three stages of its formation: the first – with the presence in the patients of the expressed affective disorders and the fixed super-valuable formations, the second – with expressed disturbances of thinking and paranoiac delusion, the third – with the expressed reduction in intellect and the deactualization of delusional experiences.

On the first of the stages indicated the patients are retained, although unstable, under the working conditions. In the second stage the complete social-working desadaptation of patients begins. By basic factor, the making patients resistance to all conducted rehabilitative measures, is their incapacity to the working activity. Raising of the level of social-working adaptation, possibility of the adaptation of patients to the work under the conditions of special workshop and usual works are observed in the following, later stage of the formation of dementia

The course of disease before the development in the patients of dementia bore the predominantly mixed nature both on the rate of progressive course and on the clinical picture. It was possible to isolate two periods, that are distinguished according to the degree of progressive course of process. The first, with the duration of 1020 years, was the period of the slow course of disease, the second, with duration of up to 5-10 years, with period of subacute course. The mixed type of the course of epileptic process was characterized by the polymorphism of psychopathological symptoms (due to the tendency toward the super-valuable formations and paranoiac type reactions early manifested in patients), and also by the predominance of nonconvulsive paroxysms. Patients, in their majority, obtained secondary and high education and reached sometimes high professional level, in view characterological of the special features indicated, as a rule, sharply survived the appeared in the period exacerbations of the process of difficulties, connected with the need of changing the working stereotype, decrease in the professional level.

Early revealed in patients affective disturbances and the epileptoid traits of nature, tendency toward the super-valuable formations deepened in proportion to the development of disease.

The results of the investigation conducted by us show that in this group of the patients with epilepsy the psychopathological symptoms

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in late development stages of disease to the larger degree than paroxysmal, is the index of the acuteness of epileptic process.

Continuous prolonged active medication is the necessary condition of conducting the rehabilitative measures with respect to the indicated heavy contingent of patient-chronic.

The calculation of the noted clinical regularities is expedient during the determination of clinical and social prognosis, the selection of ways and methods of social-working rehabilitation, and also the production of adequate to the state of the patient of individual rehabilitative programs.

The traditional view, according to which with epileptic dementia the patients do not preserve ability to work, is in contradiction with the existing practice. This view is caused by the opinion of many clinicians about totality and irreversibility of epileptic dementia. The opposite point of view, based on the dynamically structured understanding of the syndrome of epileptic dementia, is more adequate for evaluating the functional possibilities of patients, development of their rehabilitative potential.

To a certain degree our data about the structure of paranoid epileptic dementia correspond to the data of S. Field et al. (1997) about the fact that the patients with temporal epilepsy are incapable of the regulation of the balance between the factors, which cause the need for speech with the large-scale nature of requirements, and by the factors, which restrain the lingual production (social “adhesion”, thoroughness). According to the data of R.G. Golodets (1997), upon decay delusional syndrome with the chronic course of epileptic psychosis in patients “with the special clarity come out the manifestation of oligoand bradyphasia”.

The given positions in general found their confirmation, also, in the results of our clinical analysis of structure and dynamics of the so-called simple epileptic dementia, often developing, according to our observations, in the cases of the disease, which from the very beginning take place subacute-progressive.

We have inspected 92 invalids of the second group – the patients with epilepsy with subacute-progressive type and the duration of the disease for 18,7+/-1,4 years.

Subacute-progressive epilepsy frequently began in the patients of this group at the pre-school age, in consequence of which in the clinical picture in them were noted the signs of the delay of intellectual development and phenomenon of mental infantilism.

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This circumstance is being actively discussed in recent years in the literature concerning the problems of identification of symptoms of delayed mental (psychological) and overall development of epilepsy.

Mental retardation, microorchism in men, hypo-gonadism in men and women (n=282) with chronic epilepsy was noted by M. Veendrick et al. (1997). Just as in children without epilepsy incapable of the learning, A.P. Aldenkamp et al. (1997) in children with epilepsy established the disturbances of calculation and especially spelling and of speech technique, together with the slow fulfillment of all tests on the reaction rate. In children with epilepsy, who regularly attend school, A. Papavasiliou et al. (1997) frequently revealed lingual problems. Degree “the immaturity of background EEG” E. Biagioni et al. (1997) connected with the linguistic and mathematical results of the psychological inspection of children with epilepsy, caused by prematurity birth. Positive correlation between the low level of IQ, social regulation and school progress are established by A.-H.M. Shawki et al. (1997) in children with epilepsy and indications of anomalous perinatal period. In the opinion of M.G. Chez et al. (1997), “the cognitive regress of behavior and speech at the childhood frequently indicates the delay of development”. “Incapacity to the development” in children with epilepsy, who were born in Finland in 1987, U. Seppala (1997) reveals in 28% of cases.

In the patients with the subacute process observed by us paroxysmal syndrome was from the very beginning characterized by large polymorphism, frequent primarily-generaliztd tonicoclonic seizures, bright affective (fire excitability) disturbances. The expressed changes in the personality occurred in them only in 5-10 years after the beginning of disease. During this period the majority of patients proved to be disabled.

The significant difficulties of social-working adaptation in patients appeared during the first stage of the formation of dementia, that began following the stage of the most active course of disease. In this stage the significant intellectual decrease in patients, to which corresponded the reduction of seizures (to 1-2 times per month – several time per year), was combined with the presence of heavy affective disturbances, revealed the expressed polymorphism of psychopathological disorders. With constant affective stress in patients easily appeared the protracted disorders of mood, explosive reactions, frequent conflicts. The rough noncriticality of patients prevented social compensation. With external liveliness they lacked capability for the

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goal-directed activity. Even under the working conditions in the the- rapeutic-labour workshops they were unproductive. It was difficult to fix their attention in the fulfillment of simple target. In the process of work they easily were distracted for the consideration of outside questions and events.

The acceleration of the rate of associations, superficiality and inconsistency of judgments occurred in patients together with the thoroughness and detailed thinking, and also with the difficulty of the comprehension of task in general, the incapacity to separate the main and secondary. Frequently in them was noted tendency toward empty logic-chopping.

In a group patients frequently interfered in the work of those surrounding, were importunate, annoying with different requests, complaints and proposals, frequently clashed. The expressed affective disturbances, which appeared to the foreground in the structure of dementia, the pathology of behavior considerably hampered attempts at their transfer into the work from the therapeutic-produc- tion workshops to the conventional labor. Here important place has the prolonged and active antiepileptic therapy, conducted in combination with the working therapy.

In the second stage of the formation of epileptic dementia the sharpness of affective disturbances gradually decreased. In this case, in spite of the progression of dementia, rose the rehabilitative potential of patients, were revealed the possibilities of more steadfast working adaptation. Patients became more assiduous, the capability for simple activity with the installation to the qualitative fulfillment of work was revealed in them. Retarding of motor rate, inherent in these patients, was compensated by the absence in them of exhaustion. Epileptic defect with the viscosity, the sluggishness, the deceleration of thinking, expressed by the contraction of the volume of attention, by the significant weakening of mnestico-intellectual functions did not prevent the including of patients even in production labor under the normal conditions.

The expressed reduction in the memory both to the past and present was noted in the overwhelming majority of patients. Even more than during the first stage the formation of dementia in them became narrow the circle of interests, was impoverished the reserve of knowledge, and capability for generalization and critical estimation of situation also was reduced. Noticeably manifested oligophasia.

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Mood in patients was characterized as predominantly flat. The episodes of irascibility, spite, aggressiveness in the majority of the cases appeared in them only in the form reaction to the unfavorable external factors. In general the patients were characterized by egocentrism, closure, small sociability.

In the patients of this group was revealed a certain dissociation of the rate of mental and motor processes. Slowing down of mental processes in the larger number of cases proved to be more expressed than retarding motor activity.

To raising of the level of the social-working adaptation of patients contributed the absence in them of the expressed affective disturbances, the ordering of behavior, directivity to the labor. For the more successful advance of patients in the stages of social-working rehabilitation here was necessary such organization of measures, during which was provided adequate to the possibilities of patients professional preparation in combination with the adequate medication.

The level of social-working adaptation in patients, however, again was reduced on the following, the third stage of the formation of dementia, when in them set a sharp intellectual decrease, was manifested expressed oligophasia, emotional impoverishment.

The previous reserve of knowledge was almost lost completely. Lexical reserve became extremely poor. Together with the difficulties of switching and the contraction of the volume of attention in patients was revealed its exhaustion. The latter, however, more greatly was manifested in patients with the solution of intellectual (elementary) problems and did not influence the fulfillment by them of simple, especially customary, motor acts.

Here proved to be extremely important the ability of patients to perform the uniform working operations, which do not require complex manipulations. Simple working processes were accessible to these patients only under the conditions of therapeutic-working workshops.

Interesting is the circumstance that in the latest foreign literature, as more than one hundred years ago, more frequently is encountered the description of precisely simple epileptic dementia and less frequently – paranoid. In this case is discussed the presence of “cognitive scarcity” (O. Dogu et al., 1997), “disconnection trans-neuron- whethernoy of function” (C.D. Ferrie et al., 1997; E. Heminghyt et al., 1997), “progressive psycho-motor decrease” (F. Vigevano et al., 1997) and others.

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

The frequency of transitory or episodic mental disorders in the patients is evaluated in epilepsy differently. The short-term twilight states of consciousness were revealed in 7,7% of patients with epilepsy, who are under the observation of psychiatrist (G.M. Kharchevnikov, 1978). The portion of the so-called shizophrenia-like episodes with epilepsy with the psychotic disorders is between 4,5% (K.W. Bash et al., 1979) to 10% (M. Vitrovic, 1961).

According to the data of the epidemiological investigation conducted by us, the transitory psychoses of different structure occur in 22,3% of adult patients with epilepsy, who are observed in psychoneurological dispensary.

Episodic psychoses with the disorders of consciousness and by psycho-motor excitation since olden times related to the universally recognized manifestations of epileptic disease, which was, apparently, caused by the frequent observations of the direct chronological connection between the psychosis and the epileptic seizure, which either preceded psychosis or followed it. It was noted from the earliest times that the sharpness, saturation, tension and colorfulness of the experiences of patients were combined in them with the stormy beginning of psychosis, its rapid development and sharp end.

The authors of the majority of the works, which relate to the 20th century and dedicated to the study of transitory epileptic psychoses, were also limited to indications of the so-called twilight disorders of consciousness, and this designation frequently applied to the epileptic psychoses, which didn’t have in their structure any sign of the disorder of consciousness. Beginning from the twentieth years, affective, hallucinatory and delusional episodes with epilepsy are examined in a number of works out of the connection with the disorders of consciousness.

The tasks of present chapter are not only the refinement of classification scheme in transitory epileptic psychoses depending on the predominance in their structure of one or other psychopathological syndrome, but also the study of the nature of the interrelation of structure and duration of transitory epileptic psychoses.

Only in 150 patients (97 men, 53 women) we have revealed 474 cases of transitory psychoses. The age of patients was between 18 to 61 (38,8+/-0,7) year. The duration of the period of disease with

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