Mental disorders in epilepsy

the statement in the clinical picture of transitory psychoses was between 1 to 31 (9,2+/-0,5) years. The period of catamnesis was equal to the period of the observation of patients in the psychoneurological dispensary and was between 1 to 29 (9,6+/-0,5) years. At the moment inspections 16 out of 150 patients were the second group disabled, 21 – were third group disabled, 113 were able-bodied in their profession. In this case in the conditions in special workshop worked 7, in the therapeutic-labour workshops – 5, nowhere worked 11 people.

The criteria for the diagnosis of transient epileptic psychoses were their acute beginning and rapid end, the duration from a few hours to 6-7 days. The structure of psychopathological syndrome was considered, depending on the prevalence of affective disorders, delusional or catatonic. Traditionally marked with dysphoric or twilight disorders play the role of the structural components, which give specific epileptic psychotic flavor.

The transitory epileptic psychoses were divided into three basic groups, each of which was connected with the specific type of the disease. Psychoses with the predominantly affective disorders more frequently were developed in our patients with the favorable course of process (n=50), psychoses with the predominantly delusional disorders more frequently occurred in the processes with the set aside exacerbation (n=50), psychoses with the predominantly catatonic disorders more frequently appeared in the unfavorable course of epileptic process (n=50).

4.3.1.Transitory psychoses with the predominantly affective disorders

The description of short-term depressive and manic disorders with epilepsy was actually given already by Hippocrates (460-397 yr. B.C.), by Aretaeus (80 yr.), by Galenus (180 yr.), by Avicenna (9801037 yr.) (cited. O. Temkin, 1945). In spite of this, the structure of transitory affective epileptic psychoses still remains insufficiently investigated.

The results of our observations confirm the point of view, according to which nonparoxyismal dysphoric manifestations evaluated as the component part of more complex psychopathological syndromes.

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Transitory epileptic psychoses with the predominance of affective disorders composed the most numerous group of transitory psychoses (60,3%) investigated by us. To this group (286 psychotic episodes) were related 75 episodes of depressions with the vegetative manifestations, 36 episodes of depressions with hypodynamia, 49 episodes of depressions with dysphoria and anxiety, 60 episodes of manias, 66 episodes of affective psychoses with the disorders of drives.

The predominance of depressive forms of psychotic episodes in patients with epilepsy revealed by us, apparently, can serve as one of the confirmation of assumption of M. Bleuler (1946) about the fact that the depressive syndromes and epileptic manifestations have general biological basis.

Transitory depressions in our patients were characterized by sharp beginning and abortive course, high frequency “somatical” complaints, by hypodynamia, tendency of patients toward the reactions of anxiety.

To us is seemed valid the opinion of K.A. Novlyanskaya (1945) about the fact that for the transitory depressions with the vegetative disturbances (according to our data, components 15,8% of the total number of transitory psychoses with epilepsy) is typical the projection of affective disorders on the somato-vegetative field, when pathologic state is possible to define faster as poor health, than poor mood. In such cases in the inspected patients the expressed reduction in the mood was accompanied by intensive headaches and vertigoes with the subsequent general weakness, sleepiness, “pains in all body”, by insomnia, sometimes by nose hemorrhages.

With an increase in the duration of transitory psychosis reduction in the mood in patients accompanied a feeling of melancholy, tendency toward the faint-hearted reactions. At the same time occurred diffuse or according to the type of migraines the aching headaches, the algetic disorders of another localization, hyperpathia. Reduction in the appetite, unstable sleep, tachycardia, bolts, sweating, dryness in the mouth, salivation were combined in patients with the complaints of the general weakness, noise in the head, feeling of breakdown, reduction in the memory, nightmarish dreams. Patients looked sluggish, pale, sometimes somewhat deafened. Vocal activity and productivity in the work were reduced.

With reduced the intensity of headache with the greatest duration of transitory psychosis, predominated vertigo, nausea, feeling of suffocation, sensation of gravity or pressure in the head, fatigue.

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In the period of transitory depressions with hypodynamia (7,6% of the total number of transitory psychoses with epilepsy) the patients were characterized as passive, sluggish, apathic and silent. Were typical the complaints of patients of the difficulty of the concentration of attention, reduction in the mental acuity, capability for mastering of new, fatigue and sleepiness. With an increase in the duration of transitory psychosis with the same depth of affective disorders patients frequently complained about reduction in the memory. Psy- cho-motor retardation in them was combined with difficulty of movement and viscosity of thinking. Reduction in the interest in the usual occupations frequently occurred. Simultaneously appeared the feeling of guilt about the nonfulfillment of the outlined work, vexation to their unproductiveness, etc.

The cases of transitory depressions with dysphoria and anxiety (10,3%), were observed by us, when dull-malicious mood in patients was combined with the asthenic complaints, the complaints of headaches, feeling of endlessness. The patients of this groups in these periods were quick tempered, touchy, whining, they secluded, attempting to leave from the conflicts. With an increase in the duration of psychosis typical was the build-up of irritability and unmotivated anxiety in them. At the height of irratable flashes the suicidal statements of patients proved to be frequent which corresponds to data of L.W. Diehl (1986) about larger than in the general population of the probability of the accomplishment of suicides with epilepsy. However, the aggression, predominantly mental, and here more frequently was projected in patients on those surrounding. In them were frequently noted the convulsive phenomena in the form of the twitching of the separate groups of muscles – face, necks, shoulder girdles. With the greatest duration of psychosis the irritability is inferior place for fatigue, apathies, to reduction in the working activity. Retardation and affective viscosity predominated in patients above the emotional lability.

The structure of the transitory manias (12,5% of the total number of transitory psychoses with epilepsy) observed by us was close to described by V.N. Favorina (1969) euphoric or foolish manias; however, here were also noted dysphoric manifestations.

In general it was possible to note an increase in the activity of patients in work and studies. In a number of cases the enthusiasm in any occupations reached such degree, that the patients devoted almost entire their time to it. For a long time they could not fall asleep, they woke

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up with the new plans. A feeling of enthusiasm, pleasure, the tendency at any time to share with those surrounding their happiness on real or imaginary success, the accelerated motor activity in certain cases passed in them into the unproductive excitation, logorrhea, increased sociability, ease of judgments, inappropriate jokes, importunity. Selfglorification, impetuosity, tactlessness, neglect of the interests of those surrounding were supplemented with the fact that the patients completely lost criticism to their state and stopped treatment.

Unsuccessful, in our opinion, should be considered the designation of manic states in epilepsy as dysphorias with the positive affective coloring (A.A. Perelman, 1938, and others).

Transitory manias with the dysphoric disorders in our observations were characterized by combination in patients of the increased activity with the irritability. Approaching their goal with the bitterness and the emphasized intolerance to all interferences, patients were frequently inclined to the destructive effects. In the cases of failures they became loquacious, they quarrelled, they blamed in everything the surrounding, they threated, they required the immediate fulfilling of their requirements. In other cases they secluded and here, allowing oneself complete freedom, loudly they reckoned, they cursed failure, they brought on itself impacts, pulled thier hair, bit hands, etc

With an increase in the duration of psychosis the agitation although was less expressed, however, the directed on those surrounding aggression bore a kind sadistic nuance. In the less expressed cases internal uneasiness and irritation in patients were suppressed by their intensive activity, withdrawal in work.

The transitory affective psychoses with the drive disorders (14,1%) observed by us were cummulated in the patients from the episodes with the sub-maniacal, sub-depressive or mixed disorders, the episodes, which were being accompanied frequently by that mentioned not only in the classical, but also in the contemporary literature with the inclination to the use of alcohol, the sexual excesses, vagabondage, to arson, to stealing and other.

Dipsomania was always unexpected even for the close ones, since patients had a reputation of teetotallers, prudent and tight-fisted. Incomplete recollections remained for the period of hard drinking in patients. Its beginning was better memorized, when the need for the use of alcohol displaced other desires.

Patients temporarely left their work, their family, their friends, they drank singly or with the unknown. Contact for them was neces-

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sary in the cases of the predominance in them of the affective disorders of maniac pole. After several days the hard drinking concluded so suddenly as began. There were no signs of hangover syndrome. Asthenia occurred only in one degree or another. Frequently hard drinking broke itself in patients after prolonged deep sleep.

In a number of cases were noted the periods of strengthening of the libido, in such patients random sexual connections became more often. The tendency toward the vagabondage, the stealing, the arson appeared with the clear consciousness. Being caught, patients found it difficult to give an explanation for their behavior, they declared, that they acted as besides their will.

It should be noted that, according to the data of G. Bogliun et al. (1997), from a series of “psychiatric reactions” in epilepsy can be considered the prevailing depression.

4.3.2.Transitory psychoses with the predominantly delusional disorders

The vagueness of ideas about the nature of psychopathological disorders included in this group can be traced for centuries. First of all this relates to the sharp “delirious” manifestations, mentioned even in the ancient myths (murder by Herakles of its close ones and other). During the number of centuries by the different authors almost equally under the designation “epileptic delusion” were described sharp hallucinatory-delusional epileptic psychoses with the loss of consciousness up to 2-3 days.

In this case invariably were emphasized the brightness, the frightening nature of the experiences of patients, the predominantly mystical and sensual thematics of epileptic delusion. By the difference from a similar kind of psychoses with the schizophrenia K. Dewhurst et al. (1970), M. Martini et al. (1976) and M. Trimble et al. (1977) considered frequent detection in the patients with epilepsy of religious delusion, based on the visual hallucinations.

In the recent literature more frequently are mentioned the senestopathic disorders, entering the structure of lucid psychotic episodes with epilepsy. According to the data of I.R. Eglitis et al. (1974), senesthopathies in the patients with epilepsy are characterized by extraordinary brightness, intensity, emotional saturation and have the specific localization. The same was noted by M.Ya. Kissejnyi (1977)

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with respect to psycho-sensory disorders. Together with “the disorders of feeling and schematic of body”, the depersonalization and derealization phenomena were observed by A.A. Makhovskij (1967) and G. Huber (1973) in the patients with epilepsy delusional and hallucinatory experiences.

In contrast to given data, in the isolated by us group predominantly delusional transitory forms predominated affective-delusional psychoses. The cases of hallucinatory-delusional episodes were observed more rarely. The characteristic features of psychotic manifestations in patients were the correspondence of the plot of delusion to the predominant in the structure of psychosis sign of affective disturbances, experience of the elements of super-value, attachment to the situation. From the transitory psychoses with predominantly delusional disorders (20,4%) were noted affective-delusional episodes (81 of 97), hallucinatory-delusional episodes (6) and, according to the sign of the presence of sharp delusional manifestations, delirium (10).

In the cases of transitory affective-delusional psychoses with epilepsy (17%) studied by us, just as in patients, inspected by R. KrafftEbing (1883), M.G. Gulyamov (1971), G. Huber (1973), acute alar- ming-hypochondriac experiences were developed in combination with senesthopathies, psycho-sensory disorders. Pulsatory, tearing, pulling pains, itches, heat, sensations changes in the dimensions of body, noise in the ears were persistent in nature, they contributed to the development in patients of ideas about the presence in them of severe illness. As in the observations of L.E. Muzychuk (1975) and S. Rasmussen (1978), the state of patients approached sensitive delusion of relation. In the cases of an increase in the duration of psychoses the sub-depressions were combined in patients with the ideas of selfdisparagement.

In our observations, for transitory hallucinatory-delusional psychoses (1,2%), for the first time noted by J. Lachmund (1904), were typical affective-delusional symptoms, variety of hallucinatory and pseudo-hallucinatory experiences. Patients saw persecutors, perceived the action of rays and unpleasant smells. One patient heard, as his wife met her lover. Took place the phenomenon of dual orienting. Real events were interpreted in the delusional plan. About lucidness of the enumerated disorders testified the prolonged (detailed, lasting) recollections of patients.

Most acutely proceeded delirious states (2,7%). As in the cases, which were observed by S.F. Semenov (1967), obscuring conscious-

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ness with the disorientation in the place and time was accompanied in the patients with speech-motor uneasiness, by scene-like frightening hallucinations, by acute sensual delusion. The frightening pictures were seen all around: the destructive and falling walls, the scene of the murder of children, “terrible people with the iron tubes in the throat”, the attacking animals. Illusory disorders were expressed in the fact that the clothing on the relatives seemed foreign, the situation in general – unknown, changed. Patients actively participated in the survived events: they protected, they saved children, they walked on the quagmire, etc. Recollections about experience were fragmentary, several hours after the end of psychosis began complete amnesia. Were frequent indications of the alcoholization of patients preceding psychosis.

4.3.3.Transitory psychoses with the predominantly catatonic disorders

Represented in the classical psychiatric literature, these states for the duration of the number of decades up to the 60’s of the 20th century were mentioned as exquisite despite the fact that according to the descriptions they were almost required component of the socalled twilight disorders of consciousness in epilepsy.

Out of such required components of psychosis, first of all, it is possible to point out on the sharply pronounced psycho-motor excitation, even before the isolation of concept catatonia denoted as epileptic fury (A. Portal, 1827; P.P. Malinovskij, 1847; Delasiauve, 1854 (cited. P.O. Temkin, 1945); B.A. Morel, 1860, and others).

Already P. Samt (1875/76) emphasized the combination of catatonic disorders in the structure of sharp epileptic insanity with other psychopathological syndromes. By him, for example, were described postepileptical stupor, stupor with intercurrent similar to a dream delirium and excitation, stupor with the final illusory-hallucinato- ry confusion of consciousness, stupor with the verbigeration, state of epileptic fear with resounding delirium with the high excitation, postepileptical moria-like excitation. Subsequently the enumerated designations was reflected in the manuals of V. Griesinger (1881), R. Krafft-Ebing (1883), S.S. Korsakoff (1901), V.P. Serbsky (1906).

Separately should be noted the fact that transitory epileptic psychoses by many authors were divided into the states with rapidly

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transient consciousness obscuring and to the states of larger duration and larger gravity in the form of stupor or excitation.

A. Buchholz (1895) considered the literature about the mental disorders with epilepsy, which take place with the disorders of consciousness, “so great and so known”, that assumed that it is possible to forego the enumeration of separate works. In spite of this, still today the concept of the twilight disorder of consciousness with epilepsy still needs refinement. Most substantiated is, apparently, the position of the authors, according to which the twilight state of the consciousness is such state, when takes place unhealthy contraction on certain circle of perceptions with the subsequent development of partial or complete amnesia.

To us seems acceptable the point of view by M.F. Taltse (1951), R.G. Gismatulina (1959) and others on the lawfulness of association in the structure of the psychosis of affective, delusional, hallucinatory and catatonic disorders in spite of the tendency of a number of the authors to separate the numerous forms of twilight disorder of consciousness on the basis of the sign of the predominance of various clinical manifestations of psychosis. In our view, in these cases, probably, it is correct to speak about the complex psychopathological phenomena or about the polymorphous protracted psychotic episodes with the indication of the presence of various disorders.

As it is known, the structure of the epileptic psychoses, which take place with the disorders of consciousness, in many respects depends on the nature of the latter. Possibly therefore one should agree with the observations of those authors, who with the description of mental disorders with epilepsy propose to use the term change, not only the obscuring consciousness.

In our observations transitory psychoses with the predominantly catatonic disorders (19,2% of all transitory psychoses in epilepsy) more frequently (65 out of 91 cases) flowed with the disturbances of consciousness, rather than with luсid catatonic manifestations (26).

Luсid catatonic episodes (5,6%) were characterized by the manifestations of “soft” catatonia. The structure of the latter corresponded to the nature of affective disturbances. Аbsent-mindedness, reduction in the mobility, angularity of motor activity, passiveness were combined in patients with the sub-depressive disorders. Distractedness, loquacity, fussiness, affectation, familiarity and arrogance with respect to those surrounding, theatrical pose, carelessness, ease of judgments, on the contrary, testified to the presence of sub-maniac

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affect. As the catatonic inclusions were evaluated disorders of the type of forced weeping or laughter, impulsive irritability, roughness, spite, mildly expressed negativism, manifested in the patients of the, for example, in the form unexpected and unmotivated failure of the fulfillment of their usual responsibilities.

Development in the patients of twilight disorders with the total or partial loss of orienting, sharply pronounced by negativism, psychomotor excitation, wooden laughter, passion of spite, by aggressiveness was most frequent among the cases of transitory catatonic psychoses with the disorders of consciousness (13,7%) studied by us. Such psychoses continued several days. Patients were not retained on the spot, they silently resisted the attempts to look around them, they ran away from the house, they jumped out into the window, without bringing on themselves serious damages and creating the impression of special motor adroitness and reduction in the painful sensitivity.

In other cases the patients danced, laughed, recited verses, speech was torn, with the phenomena of echolalia. During the partial disorientation the patients were more calm, sometimes low-mobility. In these cases they could answer questions and with the known criticism evaluate their state. However, more frequent answers bore formal nature and patients did not master the content of conversation. To a certain degree it was possible to direct their behavior only with the aid of the simple goal-directed instructions.

The intermediate position occupied the cases of the simultaneous manifestation of the delusional disorders, when patients voiced the interrupted ideas of relation, jealousy, pursuit, action, value, damage, dramatization,. Occurred the false recognitions, tension, anxiety, suspiciousness, which were changed by panic, tendency to run. On the presence of delusion and hallucinations it was possible to assume on the threatening pose of patients, the mimicry of alertness, stressed attention, offence. Sometimes patients directly reported about the fact that they hear the voices of the concrete persons, they are surrounded by people, which play roles, they are located in the police department, etc. The degree of amnesia depended on the depth of changes in the consciousness.

Comparatively rarely described in the literature oneiroid and amential disorders with epilepsy in our observations were connected with the smaller duration of psychosis. In the cases of oneiroid with the expressed catatonic features, noted also by N.Ya. Belenkaya (1974), M.Ya. Upenietse (1974) and Ya.I. Chekhovich (1975), in pa-

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tients remained recollection about “nightmarish dreams”. However, frequently about the content of the experiences of patients is possible to judge from the conversation with them during the psychosis, when in the clinical picture there were no manifestations of mutism. Fixed pose, nonblinking fixed eyes, mimicry of ecstasy, enthusiasm, extreme interest, fear and stereotype short statements corresponded for patients to the experiences of flight into space, in stay in to paradise or in hell, among the angels or the devils, that threaten to carry off into the pit, the trips to zone with the poison gases and other.

Similarly, to what was noted by S.F. Semenov (1965), F.I. Ivanov (1968), M.G. Gulyamov (1971, 1981), Z.D. Gavrilyuk (1981), R.G. Golodets (1997), H. Motooka et al. (1997), in the part of the observed by us cases all enumerated disturbances of consciousness, psychomotor excitation, impulsive actions and another psychopathological symptomatology appeared in the complex, forming polymorphous picture. One ought to have, however, noted that special feature, that in this case in patients proceeded the change of the disorders of consciousness from the deeper to those less expressed.

To determine the degree of relationship between the structure of transient psychosis and its duration (with the use of associative coefficient of G. Yule) we have isolated three groups of the psychoses: shortterm (from several hours to days), average duration (from some to three days) and more prolonged (with duration of more than three days).

The duration of psychosis from several hours to days was typical of the cases with the delirious manifestations and the catatonic disorders, which are combined with the disturbances of consciousness. The duration of psychosis from one to three days was more typical for the cases with the presence in patients in the structure of the psychotic episode of hallucinatory-delusional disorders and depressions in combination with the expressed vegetative component. The duration of psychosis of more than three days more frequent was characteristic of manic episodes.

4.3.4. Structure and the duration of remissions

Despite claims about the legality of separation of “transitory type of the course of epileptic psychoses” (R.G. Golodets et al., 1966), in the literature is absent any systematized data about structure and dynamics of mental condition in patients in the periods between

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