Mental disorders in epilepsy

the transitory psychotic episodes. Only the general idea itself about the duration of interpsychotic periods can give rare reports about the unequal frequency of the appearance of transitory psychoses (R.G. Gismatulina, 1959; E.K. Molchanova, 1960; V.S. Pozdniakov, 1967; Z.D. Gavrilyuk, 1981).

The insufficiency of the information about structure and dynamics of the psychopathological symptoms, free from the irregular psychotic disorders, prevented the study of the special features of the dynamics of personal changes in patients in the course of the development of disease and, therefore, to the creation of prerequisites for studying the possibilities of their social-working adaptation.

In the structure of the studied by us 399 cases of remissions, that is the periods of the disease between the relapses of transitory epileptic psychoses, the nature of personal manifestations in the patients with pillar depended on structure and dynamics of negative disturbances as a whole. The stages of epileptic disease designating in the previous chapters could be traced, thus, with the transitory form of the course of psychosis is sufficiently distinct. In the cases of the absence of the signs of dementia it was possible to speak about the stage of the development of psychopathological disorders before the appearance of dementia. In the presence in the period of the remission of the signs of epileptic dementia were outlined all three stages of the formation of the lattest.

We called the periods of disease free from the negative psychopathological symptomatology as intermissions, and by remissions with the defect – periods of the disease between the psychotic episodes in the stages of the formation of epileptic dementia.

Study of duration of selected by us for the analysis of those completed” (that is changed into the relapse of psychosis) remissions showed the validity of that expressed even at the beginning of the 20th century (E. Siemerling, 1909) opinion about the sufficiently large duration of the periods of the disease between the transitory epileptic psychoses. Based on this, for the dynamically structured analysis we isolated two groups of the remissions: with duration up to one year inclusively and longer ones.

It was established that in the stage of the formation of epileptic dementia with the expressed affective disturbances in patient were typical remissions with duration up to one year. More prolonged remissions are observed in the following stage of the formation of dementia – with the expressed disturbances of thinking in the form

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viscosity and bradyphychism. Similar correlations (established with the use associative coefficient of G. Yule) were evaluated not only as the reflection of different degree of the activity of epileptic process in the stages of the formation of epileptic dementia, but also as the sign of its stabilization at the distant stages of disease.

It was difficult, however, to judge stability in the patients of tendency toward the further increase in the duration of remissions in the completing stage of the formation of dementia, since here more frequently it was necessary to observe the inspections of remission yet not ended for the period.

Special position with the analysis of the structure of remissions by us was assigned to the refinement of those occurred in patients personal manifestations.

One should emphasize that a question about the participation of the premorbid properties of personality in the development and the structuring of transitory epileptic psychosis is still distant from its complete coverage. From the literature can be given only some observations about the correlation of those appearing in the patients twilight disorders of consciousness with such personal special features as “cyclophrenia-like” (T.M. Vilenskiy. 1929), sthenia, overanxiousness and touchiness (V.E. Smirnov, 1972).

According to our of study, in the periods of intermissions (42,8% from the total number of remissions) personal manifestations in patients more frequently are determined by their premorbid special features of personality, formed in them to the appearance of the first signs of psychosis. In each cases this was expressed in the predominance in the structure of personality in the patients of so-called epileptoid and extroversion features, the manifestations of sthenia with the relative ease of adaptation.

In the course of a study very interesting was a question about what forms of personal manifestations more frequently are encountered in patients with the transitory epileptic psychoses. It was also necessary to refine the validity of expressed by M.Ya. Upenietse (1974) thesis about the predominance in the patients in such cases of “mental degradation above the characterological disorders”.

The carried out study of the structure of remissions with negative disorders (57,2%) made it possible to arrive at the conclusion about the relative safety in patients at the different, including distant stages of the disease of the nucleus, of premorbid personality with the transitory epileptic psychoses. Were established, for example, that more than

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90% patients from of this type by pathology on the period of inspection revealed hypersthenic features and manifestations of mental rigidity. In 86,7% of cases in them is noted reduction in the critical functions, in 78,7% of cases – bradyphrenia, in 63,3% of cases – egocentrism.

At the same time only in 35-45% of cases in patients we have revealed the low level of self-control, explosiveness, reactive lability, hy- po-sthenic features. With the same frequency, however, were observed “positive” special features of the behavior of patients, which it was possible to define as the manifestations of conformity and altruism.

Less than in third of cases in patients were noted tendency toward the conflicts, high self-appraisal, tendency toward the paranoiac reactions, inadequate level of claims.

And, finally, in spite of all this, the expressed disturbances of adaptation we have noted only in 8% of cases.

Thus, our study showed variety and sufficiently wide (in each fifth of the observing in the psychiatrist apropos of epilepsy patients) prevalence of transitory epileptic psychoses. As the criteria of diagnostics of transitory psychosis for us served its sharp beginning, short (not more than 6-7 days) course, polymorphism of the observing psychopathological symptomatology and rapid end. The dysphoric and twilight disorders frequently mentioned in the old and new literature in patients comparatively rarely proved to be in our observations prevailing in the clinical picture of transitory epileptic psychoses. On the contrary, with large base it was possible to speak about the predominance in the structure of last depressive and maniac disorders, and also about sufficient presence of delusional or catatonic manifestations.

The lowest duration (hours to days) differ transient epileptic psychosis occurring with hallucinatory and delusional disorders and catatonic manifestations of consciousness. Average duration (up to three days) is more typical transient psychosis with lucid hallucinatory, senestopathies and pronounced autonomic manifestations. Highest (over three days), was provided the duration of psychosis in patients with transient, occurring in the form of manic episodes.

With any structure of transitory psychosis was noted the decrease of the acuteness of the state with an increase of the duration of psychosis in indicated temporary boundaries.

The tendency toward more frequent recurrence of transient psychosis took place, according to our observations, in the stage of forming an epileptic dementia, characterized by severe affective (explosive) disorders.

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With the transitory form of the course of epileptic psychosis we revealed the connection between the type of psychotic disorders and the type of personal manifestations both typical for the patients in the premorbid stage and acquired by them in the course of disease, which indicates the relative safety in them of “the nucleus of personality”.

This circumstance, and also given dynamically structured special features of productive and negative psychopathological disorders with the transitory form of the course of epileptic psychosis attest to the fact that in the formulation of the clinical picture of transitory epileptic psychoses the large role belongs to catathymic mechanisms. Typical for the patients with the transitory depressions of manifestation passiveness, sluggishness, reduction in the mental acuity, capability for mastering of new, undoubtedly, contributes to their existing weighting of subjective experiences. The participation of external events in the formulation of sharp delusional psychotic states especially frequently occurs in the cases of relation appearing in the part of the patients of sensitive delusion. Finally, the plot of transient delusional experiences with the anxiety, the ideas of poisoning and pursuit to a considerable extent includes the elements of the surrounding situation. Patients take active “counter” measures against the concrete persons, they hide or attack “the persecutors”. More “autochthonous” nature bear transitory psychoses with the predominance of hallucinatory and catatonic disorders.

4.4. Structure and dynamics of mental disorders in patients with schubweise form

of the epileptic psychosis

The index of the prevalence of “organic psychoses” with the schubweise course, which are combined with the polymorphous paroxysmal states, comprises, according to the data of T.A. Balandina (1980), 0,28 for 1000 of people. According to our data, in the population of the patients with epilepsy, that are observed by psychiatrist, schubweise psychoses occur in 25,2% of cases.

Repeated assumptions of different authors about the possibility of schubweise course of the so-called protracted epileptic psychoses (L.N. Vishnevskaya, 1935; S.S. Perskaya, 1950; L. D’Argenio, 1959; E.K. Molchanova, 1960; V.N. Dektyarev, 1967; N. Shumskiy, 1969;

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V.N. Favorina, 1972) were only comparatively recently confirmed by the descriptions of the corresponding form (M.K. Tsaune and M.Ya. Upenietse, 1974; T.A. Balandina, 1980; B.A. Kazakovtsev, 1982).

In the previous chapters there was given literature data with the indications of similarity and differences between “protracted” or schubweise epileptic psychoses and the similarity of the latter to the schubweise schizophrenia. In particular it was noted that the significant fluctuations of the duration of the schubweise epileptic psychoses: from several days to several months or years, and also the significant range of the clinical formulation of the psychopathological disorders, entering the structure of these states.

However, the insufficiency of existing in the literature knowledge both about the criteria isolations and especially about structure and dynamics of the leading psychopathological syndromes with the schubweise form of the course of epileptic psychosis were for us the base for special evaluation of the appropriate aspects of a problem.

For this purpose all paroxisms of psychosis were studied (n=701), noted in 150 patients (61 men, 89 women). Age of patients for the period of inspection was between 17 to 68 (40,2+/-0,9) years. Duration of disease from 8 to 63 (26,6+/-0,9) years. Duration of the period of disease from the moment of the appearance of the first schub of psychosis from 1 year to 47 (13,9+/-0,6) years. The period of catamnesis corresponded to the duration of the period of the psychiatric clinic observation of patients and was from 5 years to 41 (13,7+/-0,7) years. With inspection by 2 of 150 patients were the disabled of the first group, 70 – by disabled of the second group, 22 – by disabled of the third group, 56 patients were completely able-bodied. In this case under the conditions of usual production they were occupied with labor 75, in the conditions of special workshop – 11, in therapeutic-working workshop 16, nowhere worked 48 people.

In contrast to the given in the literature classifications, which consider only the structure of psychosis and the presence of residual psychotic symptoms in the period between the schubs of psychosis, in present chapter we undertook the attempt to examine structure and dynamics of schubweise epileptic psychosis in the interrelation with its duration.

It was assumed that such characteristics of psychosis as structure, dynamics of psychopathological disorders and the duration of psychotic schub only in the totality can reflect the degree of the

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sharpness of the course of disease and that only integral approach to their study can be basis for developing the clinical material, suitable for using as the criteria the prognosis.

Corresponding analysis of 701 patients who made their development of psychotic schubs completely and 631 “final” remissions patients showed that base for the isolation of the schubweise form of the course of epileptic psychosis must be considered not only its gradual beginning and end and duration from several weeks to several months or years, but also the revealed in many instances in patients tendency toward the specific stereotype of the development of psychopathological disorders.

By the criteria of the predominance of the simple or polymorphous psychopathological syndromes, whose presence can be set in the connection with type and stage of the course of epileptic process, for the dynamically structured analysis of schubweise psychoses were isolated their following forms: affective (31,8%), affective-delu- sional (38,8%), delusional (11%), affective-delusional with catatonic inclusions (9%), catatono-delusional (4,8%) and catatonic (4,6%).

Affective schubs proceeded in the form of depressions and manias. The first were characterized in the patients with alarming mood, by the fluctuations of the depth of depression, by reduction in the engine activity, by the transient ideas of low value, by the mildly expressed psycho-sensory disorders, by hypochondriac reactions. In the structure of the affective schubs of antipole in patients predominated maniacal passion variable in the intensity, which was reflected in reduction or increase in their working activity. The optimistic estimation of that surrounding, loquacity frequently were combined in patients with the tendency toward the inappropriate and rough jokes.

Into the group of affective-delusional schubs entered the states with the disorders of paranoiac and paranoid circle in combination with the depressive or maniacal passion and delusional schubs with the affective disorders, which bear circular nature.

The schubs of psychosis with the paranoiac, paranoid and paraphrenic disorders composed the group of delusional schubs. Paranoiac schubs were characterized by the monotonic and rigid (“balanced”) emotional background, to which corresponded outwardly the calm actions of patients, directed toward the realization of them of the sufficiently systematized ideas. In the cases of paranoid schubs were typical tension, the anxiety, fear in patients before the imaginary

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danger. Paraphrenic disorders more frequently proceeded over the type of confabulatory paraphrenia.

The catatono-delusional and catatonic schubs of psychosis proceeded predominantly with the engine excitation, the inadequate gesticulation, the incomprehensible monosyllabic statements, the false recognitions, the impulsiveness, the manifestations of untidiness. Only on passing of schub or with the appearance of the possibility in the period of psychosis to establish contact with the patient it was possible to open or to reject delusional nature of his behavior.

The enumerated psychoses were distributed to three basic groups: short-term, average duration and protracted for purposes of the study of the dynamics of productive psychopathological disorders.

The short-term included the schubs of psychosis by duration up to one month, to the averages on the duration – with a duration from one month to one year, to the protracted – by duration for more than one year. In the course of a study it was established that shorter-term more frequently prove to be the paranoid, catatono-delusional and catatonic schubs of epileptic psychosis, average duration – maniacaldelusional and paranoiac, protracted – affective-delusional schubs with the catatonic inclusions and affective-delusional schubs with the circular disorders.

The connection of structures and dynamics of psychosis in their indissoluble unity and interdependence have traced we with the comparison of the structural special features of basic psychopathological syndromes with duration enumerated above of psychosis.

4.4.1. Affective psychoses

According to our observations, the structure of depressive (n=217) and maniac (n=6) schubs although is characterized by in general relative simplicity of affective manifestations and small manifestation of dysphoric components, in many respects it depends on the duration of psychosis. Appearance in our patients of depersonalization disorders and sensitivity corresponded to an increase in the duration of these states.

Short-term depressive schubs were accompanied by reduction in the patients of mood with the fluctuations of the depth of passion in the course of twenty-four hours and by reduction in the engine activity of different degree. To the transient ideas of low value,

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to hypochondriac reactions for the so-called somatical and vegetative manifestations of depression, and also to senestopathias and psychosensory disorders frequently accompanied anxiety.

Average duration and protracted duration of depressive schubs usually proceeded in patients in the form of sub-depressions with reduction in the mental and motor activity. However, here frequently took place the fluctuation of passion to the side of its decreases, not developed hypochondriac reactions to the appearance of the mildly expressed vegetative disorders. In patients were noted the phenomena of depersonalization, sensitivity, tendency toward the vital experiences.

In the structure of the maniac schubs, whose duration was measured by months and years, in patients predominated hypomanic passion with the tendency toward the fluctuations. A feeling of gaiety frequently was combined in patients with the irritability. The optimistic estimation of that surrounding, lightheartedness, careless attitude to the disorder, increased libido frequently was observed in them together with the loquacity, verboseness, tendency toward the jokes of the doubtful content, nonobservance of distance. As a rule, in patients in the periods indicated rose working activity. They sometimes without taking into account situation sang and danced at the height of mood.

4.4.2. Affective-delusional psychoses

Data of the presen tstudy showed that the structure of affectivedelusional schubs (n=272) with the relatively greater than with the affective psychoses, presence of dysphoric components is in many respects connected with their duration. The smaller depth of affective of fluctuations and tendency toward the known systematization of delusional ideas corresponded to an increase in the duration of psychosis.

For the short-term depressive-delusional schubss with the presence in patients of paranoiac disorders together with different depth by depressive affect and the little systematized delusional ideas, it is more frequent than the ordinary content, were typical hypochondriac ideas, undeveloped querulant-paranoiac delusion, ideas of truth seeking, outwardly difficultly distinguishable from the short in patients of subacute paranoiac reactions.

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In the cases of the schubs of average duration the delusional ideas more frequently were formed in patients against the background of sub-depression. Dysphoric manifestations contributed so that the sensations of indisposition, gravity, “internal trembling”, apathies, headaches, disorders of sleep were combined in them with a feeling of offence, tension. All sensations were interpreted in an individual manner. Delusional interpretation underwent behavior of those surrounding. The statement of the ideas of self-disparage- ment bore rather demonstrative nature, since it contradicted the tendency of patients toward the active self-defence. “Physical and nervous exhaustion” was connected, for example, with the imaginary humiliations and the provocations, the slander, the mockeries, the vengeance from the side of relatives, colleagues, neighbors. To the worsening of depression corresponded tearfulness, anxiety, demonstrative suicidal intentions. Simultaneously were aggravated excitability, irascibility, tendency toward the aggressive behavior, installation appeared to punish offender, tendency to attain an improvement in its position.

To the most prolonged bouts of psychosis also was typical similar structural component, as sub-depression. In this case in the clinical picture in patients the portion of vegetative manifestations decreased. The latter let the place for the uncommon sensations: “aches the brain”, “is paralyzed tip of the tongue”, “appears a feeling of pink void in the head”, “spasms inside the organs”, “the constraint in the forehead”, “pulsation in the ear membranes”, “its own weightlessness”. Appearance in the patients of ideas of relation impelled them to the acts with aggression or the tendency to avoid society. Appearance of hypochondriac ideas – to visit different specialists in search of the treatment, to reading medical literature, to the recognition in itself all new diseases. With the deepening of depression the patients attempted to hide their imaginary defects; however, they were inclined to autoaggression. To the development of querulant delusion in them corresponded readiness for a constant criticism of actions of administration, doctors. Attention is drawn to combination in the patients of requirements of the attention with ignoring of obtained advises and proposals. With an increase duration of psychotic schubs delusional experiences ever more were characterized by monotony, rigidity, absence of alarming agitation. Small efficiency of patients in the normal occupation was limited more frequently to mental sphere. Unskilled physical labor proved

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to be more accessible. In the period of learning were typical the complaints of patients of reduction in the mental acuity, difficulty in the selection of necessary words, especially in the oral account.

Basic manifestations of the schubs of paranoiac structure with the circular disorders – polymorphism and the instability of the plot of delusional ideas, caused by the changeability of affect. The expressed depressions with the adynamia or the suicidal tendencies frequently converted in patients to the expressed maniac states. The hypochondriac ideas, formed in the period of predominance in patients vegetative disorders, at first caused their searches for the corresponding treatment and continuances “of leisure”, they were and then changed by the periods of unproductive activity, good health, by normalization or increase libido, by tendency toward the querulant behavior, by the tendency to show themselves “excellent person”, by altruist. With the visible egotism the patients emphasized their volitional qualities, ability “to attain in all”. With the mixed affect, when hypochondricity was combined in patients with the active tendency toward self-treatment, typical for them became vocal excitation, resuscitation of motor activity, fight for obtaining of privileges became more active.

By average duration or more protracted delayed flow were characterized maniacal-delusional schubs with the paranoiac manifestations. In accordance with the uniqueness of affective disorders (hypomanic states) in patients occurred an increase in drives, increased sociability, the predominantly positive estimation of surroundings. However, the expressed tendency of patients “to strengthen their health” was one of the evidence of their hypochondriac ideas. In the list of “health-improvement measures” entered the gymnastics of yogi, autotraining, pedantic exception of external stimuli, capable, in the opinion of patients, to provoke the aggravation of disease, yearly sanatorium treatment, dietetic nourishment and other. In many patients there is the tendency to see the world, to visit other cities acquired super-valuable nature. They were found as ticketless passengers, charged with the vagabondage. Some patients manifested tendency toward the arson, the stealing, gathering of unnecessary items. Common for the patients with this pathology appeared the overestimation of their personality. This caused their tendency to interference in the affairs of others, tendency to teach, impose their opinion.

The short duration was typical for the depressive-delusional schubs with the paranoid syndrom. An anxious-fearfull affect and

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