Mental disorders in epilepsy

a feeling of depression in patients corresponded with the subacute nature of clinical manifestations. Their appetite deteriorated, sleep sharply was disrupted. A feeling of suspiciousness was rapidly changed by the systematized ideas of poisoning, pursuit. The latter were usually caused by the content of the verbal hallucinations of the commenting on or imperative nature, less frequently – of concrete nature by visual and tactile hallucinations. Along with the hallucinatory experiences took place different kinds of senestopathias. Patients feared not only for their life, but also for the life of their close ones. Delusion of dramatization was characterized in them by concreteness and completeness: “relatives charge with fictitious behavior”, “neighbors look for a disease”, “hospital separates with wife” and other. Delusion of action was also expressed specifically: “to the head are connect galvanometers”. About the presence of the manifestations of mental automatism testified the communications of patients about the presence in them of the vibration of body, their subordination to voices, as a result of which suffer the close ones, about desire to go somewhere and other. The manifestations of active protest from the side of patients against the action imaginary hostile were frequent. This was expressed by swearing, declarations of hunger strikes, sometimes – in the form straight aggression.

With an increasing duration of the schubs of psychosis indicated the sharpness of experiences in patients, tension and affect of anxiety were less expressed. With different depth of depressive disorders the unstable ideas of relation and hypochondriac ideas in patients corresponded to the frauds of perception in them in the form of hails, or to senestopathias with the preferred localization in the region of head. Complaints on “movement and bells in the head”, “shooting throughs in the back of the head”, “turning off of the brain”, “tearing headaches” coexisted, for example, with the statements of patients about “the voices in the head”, the manifestations of mentism, the sensations of already experience with a feeling of the alienation of their own thoughts. However, in contrast to the short-term schubs of psychosis, in patients was not lost completely critical relation to their experiences. The exception were the periods of the aggravations of state in the patients with the advent of elements of nihilistic delusion. In such cases depression was accompanied in them by the ideas of low value, sinfulness, by suicidal attempts. In other cases in patients predominated the ideas of openness, hallucination of a general feeling, olfactory hallucinations.

151

Paranoid schubs with the circular disorders differed by the protracted course. With the same delusional experiences and senestopathias the inconsistency of affective background in patients, in contrast to the depressive-delusional schubs with the paranoid syndrome, caused the inconstancy of their interests. The periods of irritability in them were changed, as a rule, by the periods of apathy, the periods of the excessive concern about their health – with periods of neglection. The presence of mixed affect explained patient’s ambivalence to their own experiences. For a period of many years, for example, one of the patients could not decided wether to divorce her husband, in connection with the periodically appearing doubts, about the facts of infidelity from his side, which before seemed obvious. Fear of the hails and visions was combined in patients with the desire to their new appearance.

Average duration or protracted nature were more typical for the schubs of maniac-delusional structure with the paranoid syndrome. The constant components of the structure of the latter were the maniac affect of the different degree of manifestation, combination in the behavior in the patients of obsequiousness and complacency with the irritability and the captiousness. There were no senestopathies. The verbal true hallucinations or the pseudo-hallucinations (“voice proceed from the body”) were often indifferent or commenting nature, less frequently – erotic. “The impact from the outside” usually was evaluated by patients as positive (“influence by government apparatus”, “science investigates consciousness”, “they are directed thought about training of new person” and other). The common manifestations of psychosis were the states of euphoria in patients with verboseness, tendency toward rhyming, prolonged trips without the specific purpose. During exacerbation of the state they felt their own power, the ability to positively affect others, in less severe cases – re-evaluation of thier personality and the neglect of others.

4.4.3. Delusional psychoses

This group of schubweise psychoses (n=77) in our patients composed bouts with the paranoiac, paranoid and paraphrenic disorders. A study showed the possibility of establishment in patients correlations between the structure of psychosis, whose basis compose the enumerated syndromes, and the duration of psychotic schub.

152

The average duration and prolonged paranoiac schubs were characterized in the patients with the monotonic and rigid (“by that balanced”) emotional background, which corresponded to their outwardly calm and goal-directed actions, directed toward the realization of their systematized delusional ideas. Transcribing medical recommendations from the different kind of sources, prolonged excursions for the purpose of the search for medicinal herbs and roots for subsequent self-treatment and their active propagation among the familiar and unknown people were achieved persistently, also, without the agitation. Thorough and “mandatory” was the querulant activity of patients. To review their applications they attracted various organizations. Their letters, statements and complaints were characterized by the stereotype quality of expressions. Image and estimation of the actions of imaginary enemies and ill-wishers were achieved in the calm narrative tone. For averting the assumed encroachments of neighbors of the belonging to patients things “in advance” were made special attachments or were undertaken other “guardian” measures. One of the patients, for example, allotted by paint “her territory” on the kitchen. Some patients, assuming obtaining unfavorable answers from the side of officials unfavorable for them, previously prepared complaints on them into the higher authorities. Delusional ideas were openly spoke out by patients in the periods of aggravations. In another time about the presence in them of delusional experiences a constant captiousness of patients to those surrounding it was possible to only surmise, for example.

The manifestations of the affect of tension and anxiety in patients could be related to the distinguishing features of short-term and the average duration of paranoid schubs. Their active and uncompromising struggle with the imaginary danger alternated in them by the periods of inaction with the advent of confusion and fear. The following statements, which indicate concreteness and urgency of their experiences, testified on the acutness of the state in patients. Neighbors, for example, influenced them by “brown ray from the shed through the wall”, destryed organism during several days. “Thoughts leave from the words and flow by themselves”. “Heard witchcraft under the floor”. “My father crossed the border” and involves the patient “in espionage activities.”. “Radio hides war”. “Doctor influences by impulses”. “To the right and to the left man and female voices forbid to eat and to talk” and other.

153

In contrast to the short-term, to the schubs of the psychosis of average duration was typical the smaller sharpness of the experiences of patients, thanks to which patients seemingly had time for “the adaptation” to the imaginarily dangerous situation. Their content of hallucinatory-delusional experiences frequently were connected with querulant activity, less frequently – with acts of aggression. In some of them to the existing frauds of perception was added the relation to the special, second, life, which goes as in parallel to real. This second life of patients was frequently evaluated positively. Of hallucinations some of them called “voices”, others “spoiling”, which, in their opinion, more right it was to treat “by hypnosis” or “black magic”.

The paraphrenic schubs of average duration proceeded in our patients as of confabulatory paraphrenia. Fantastic experiences of patients were characteristic of a particular everyday shade, although their behavior was generally due to the ideas of high birth, grandeur, beauty, and power. Proud pose and expressed arrogance frequently were manifested in patients in the emphasized tendency to only show their superiority over the nearest environment. At the same time, for example, statement of one of the patients about the desire to work as porter in the administrative establishment or his requirement about the immediate assignment to him apartments were forwarded by them for the highest instances. There was created an impression theatrical behavior of the patients, apparently, colored by the content of that read or seen by them. One of the patients, for example, came to the doctor and, without removing gloves, declared, that he is going to hunting the hares. He, being in the recreation center, bathed in the ice hole, conducted choral circle and as in musical-comedy “he courted girls”.

In the stories of patients actually proceeding was combined with that imagined. Suddenly the same patient reported about obtaining a pass on world festival. Another declared about the discovery of vibration nature of the universe, whose units are the perceptible material. The predominant maniac affect was changed sometimes by depressive phases; however, in this case the ideas of sublimity remained. Patient grandiloquently declared, for example, that he lives in the expectation of punishment for the error done in the past.

154

4.4.4. Affective-delusional psychoses with catatonic inclusions

In our observations among the psychotic schubs of this type (n=63) distinctly stood out acute short-term, subacute of average duration and protracted bouts. The specific stereotype of the development of the schubweise psychoses of this group correlates with their duration.

For the short-term affective-delusional schubs of psychosis with the catatonic inclusions were typical speech-motor excitation in patients, verbigeration, recitation of the fragments of verses, chaotic motions, verbal hallucinations of the threatening nature. The enumerated disorders were very soon changed by oneiroid with the predominance of a feeling of fear or enthusiasm or by stupor with the religiously colored hallucinatory-delusional experiences. Patients “were present” at the international meetings, where their life or the forthcoming loss of planet with the migration of humanity into space was discussed, took places conversations with God. In the cases of the undeveloped schubs the clinical picture of psychosis was limited erratic motor excitation, laughter or tears, impulsive, sometimes violent aggressive acts against present, ridiculous artsy poses, negativism, unexpected suicide attempts.

The paroxisms of average duration had the steadier stereotype of development. Increase activities, sometimes with foolishness and unceremonious relation to those surrounding, were changed in the patients with anxiety with the loquacious account of fears for their life, and then by tension, by the ideas of relation or by hypochondriac ideas, by delusion of openness, damage, spoiling, obsession with the verbal (more frequent imperative), olfactory and tactile hallucinations, senestopathias. Hallucinatory and delusional experiences in patients were accompanied by sadistic shade or suicide attempts. The next stage of development is the emergence of psychotic episode in patients with silent stupor, aspontaniousness, passivity, negativism manifestations.

The formation of the protracted bouts of psychosis, represented in the most final version, also made somewhat sufficiently outlined stages. Stage of the affective-delusional disorders in the form of undeveloped ideas of relation, jealousy, depressive-hypochondriacal experiences with the fluctuations of passion or the explicit circularity. Stage of paranoid manifestations with the ideas of action, different by the degree of the systematization of delusion and by the

155

rapidly changing passion. Most prolonged stage – development against the general affective-delusional background of the episodes of the catatonic disorders: after the catatonic excitation in patients followed the period of maniacal passion with the acceleration of associative process, rhyming, grandiloquent and florid speech, symbolism, ideas of invention, ideas of reforming. The disturbances indicated alternated in patients with a number of the depressive phases. Proved possible the versions of the abortive course of paroxisms. In these cases fragmentary psychopathological picture was the separate enumerated stages of schub, or, in the cases of the accelerated development of the latter, acquired seemingly greased and differentiated nature.

4.4.5. Catatono-delusional psychoses

For the patients with this type the psychotic schubs (n=34) was not typical the development of psychosis in any specific sequence. Some differences in the clinical formulation of psychosis at the same time were outlined depending on its duration.

Short-term schubs proceeded in patients with the predominantly motor excitation, the monotonous poorly expressed mimicry, the incomprehensible monosyllabic statements, the impulsive acts of aggression, mutism, negativism, tendency toward the vagabondage. Even on passing of psychotic schub during the establishment of contact with the patients it was possible to a certain extent to open delusional nature of their behavior on their recollections. Patient, who jumped on the eve of the hospitalization from the high bridge, reported, for example, that he was doing this with the test purpose, “calculating” everything in order to survive. Another patient with the aggressive behavior in the period of psychosis explained his aggression by the fact that surrounding, in his opinion, was behaving suspiciously. The third patient did not answer in the period of psychosis questions only because, as he subsequently explained, that into head “entered the counter thoughts” and it was desirable “to grasp them”. One of the patients completed arson, since she was “forced” to do this. Another patient was in the state “of confusion”, because she couldn’t understand the purposes of her of preparation for the flight.

In cases of schubs of the average length and of a protracted ones, in series of observations could be observed shift catatono-

156

delusional syndromes with excitement or stupor more prolonged in patients with delusional states. Outwardly correct behavior in patients in this case was combined with the presence in them of the undeveloped manifestations of mental automatism, the verbal hallucinations with the content irrelevant for the patients (“voice they are talking between themselves”). Patients, for example, calmly reported, that they had “specular disease” or that they “were cursed”. Sometimes in them was observed an ambivalence toward their experiences with partial understanding of their painful character.

4.4.6. Catatonic psychoses

According to obtained data both short-term and average duration catatonic schubs (n=32) proceeded outwardly and on self-de- scriptions of patients without the noticeable affective and delusional experiences.

For the short-term schubs of psychosis was typical two-phase proceeding. Catatonic excitation was changed by stupor or vice versa. After the psycho-motor excitation with the tendency to run, to bare, by continuous and broken speech, unrecognizing of close ones followed passive submission of patients, monotonous poses, fixed view, failure of the food. The phenomena of stupor alternated in them by the prolonged periods of excitation, foolishness, irascibility, irritability. Typical for the patients for the period of the sharp manifestations of psychosis was amnesia.

With the average schubs of psychosis with the presence of the disorders, noted in the short-term schubs for patients were more typical the vocal disorders in the form of verbigerations, echolalia, negativistic answers. Foolishness was combined in them with the features of infantilism, untidiness – with the hypomania. In comparison with the short-term schubs, in patients more frequently remained the recollections about the events, which occurred around them in the period of their stay in the state of psychosis. However, patients made it difficult to give any explanations relative to the motivation of their behavior.

157

4.4.7. Structure and duration of remissions

As has already been indicated above, the number of analysed periods of the disease between the schubs of epileptic psychosis was equal to 631. With the schubweise psychoses we revealed greater than with the transitory psychoses variety of psychopathological pictures in the structure of remissions, which was caused by different relationship of residual productive psychopathological disorders and negative symptoms. Were observed intermissions (17% of all remissions), remissions with residual productive disorders (36%), remissions with the mixed disorders – by residual psychotic and with the signs of defect (31,4%), remission with predominantly negative disorders (15,6%).

According to our data, the short duration (from several days to 1 months) was more typical for remissions with the residual delusional and catatono-delusional disorders whith the signs of dementia. Average duration (from 1 months to 1 year) more frequently was typical for remissions with the predominantly negative disorders. Most prolonged (more than 1 year) were remissions with the presence of residual catatonic manifestations.

Obtained data confirms noted in the literature facts, which testify about the significant fluctuations (from several months to several years) of the duration of intermissions in the cases of schubweise course of epileptic psychosis. Mental condition in patients in these periods was characterized by the absence in them of rough personal and intellectual disorders. In each case was consistent with characteristic of the premorbid special features of the personality of patients, or to the special features of personality, which were being manifested already in the period of disease, but before the appearance of the first signs of psychosis. As a whole in the structure of personality in patients predominated epileptoid and extrovert features, sthenia, sufficiently high adaptive abilities.

The named complex of personal manifestations did not undergo significant qualitative changes also at the subsequent stages of disease. Since with the paroxismal course of psychosis in general progressive course of epileptic process occurs greater than with its transitory course, this fact in the more emphasized form than with the transitory psychoses, it testified about the tendency toward the consolidation of epileptoid features in patients in proportion to the development of disease. Taking into account the fact that in 83,3% of patients for the period of inspection was not noted the expressed

158

disturbances of adaptive abilities, it was interesting to note in them predominance in the remissions “negative” personality traits. More than in 80% of patients occurred reduction in the critical functions, mental rigidity, hypersthenic features, bradyphrenia, egocentrism. From 40 to 70% of patients revealed tendency toward paranoiac type reactions, reactive lability, hypo-sthenic features, tendency toward the conflicts with the high self-appraisal, the low level of self-control and the inadequate level of claims. At the same time hypersocial significance was revealed in patients in 50% of cases, conformity – in 30,7%, altruism – in 26,7% of cases.

In the structure of prolonged (more than one year) remissions with the presence of residual productive symptomatology the greatest specific weight belonged to the mildly expressed and transient affective and delusional disorders in patients, unstable super-valuable formations. Considerably less frequent in our observations occurred remissions with the residual catatono-delusional and catatonic inclusions. Residual positive symptoms in patients was presented here by blurred affective-delusional disorder and sometimes mild manifestations of catatonia in the form of stereotyped behavior of patients, uniqueness of their motility.

In the structure of diverse in the duration remissions, which combine the residual psychotic disorders and the signs of defect, also more frequently were observed affective and delusional disorders, than catatonic. In general the majority of remissions of this type could be described, in spite of the presence of the signs of dementia as hypersthenic.

In clinical picture 94 out of 99 remissions with the negative disorders, with the duration from 1 months to 1 year, with the leading syndrome of dementia and only in 5 cases – changes in personality without the signs of dementia. The presence of remissions with the mental disorders in the form of changes in the personality in patients indicated the possibility of diagnostics of initial development stage of epileptic defect. Attention was drawn to the rarity of this type of states. Their “atypic” characteristics were, apparently, caused by the fact that changes in the personality in patients with the schubweise course of epileptic psychosis in the larger part of the cases were combined with the residual psychotic symptoms and masked it. In any case, it definitely could be noted that personality traits in patients appear here in their so-called rigid monotonous activity, unsociable, overvalued with respect to their duties.

159

Dementia patients, as identified in the prevailing number of remissions with signs of defect, could be characterized as simple since it is not combined with productive psychopathology. A similar defect was observed in patients in three versions in accordance with the stage of the formation of epileptic dementia.

On that stage of the formation of epileptic dementia, when in the clinical picture of patients predominated affective disorders, were noted the increased excitability, irascibility, inadequacy of claims, egocentrism, tendency toward self-glorification. This was supplemented by the signs of the instability of attention, floridity of speech, by the manifestations of obsequiousness and flattery in the relations with those surrounding.

Next stage of the formation of epileptic dementia was characterized by viscosity and thoroughness thinking in patients, as well as the depletion of their speech, reduced mnemonic functions with simultaneous tendency of patients to commit to unpleasant experiences. Complex clinical picture of mental disorders in patients in such cases complement mental and motor slowness and inertia, pedantry, excessive attachment to certain stereotype activities, complacency and a further increase in egocentric installations.

Significant mnestico-intellectual disturbances, oligophasia and low mobility corresponded to completing development stage of epileptic dementia in patients.

Thus, the investigation which was conducted, confirms the lawfulness of the isolation of the schubweise form of the course of epileptic psychosis, which is encountered in each fourth patient with epilepsy, who is found under the observation in psychiatrist.

Diagnostics of this form of pathology must be based not only on the establishment in patients greater, than in the presence transitory psychoses, duration of psychotic states, smaller expression of their boundaries and in the periods between the schubs of the psychosis of residual productive psychopathological symptoms, but also on the determination of tendency toward the change of psychopathological syndromes in the course of the development of separate psychotic schub.

We established identical prevalence in patients with epilepsy comparatively simple or “monomorphic” (affective, delusional and catatonic) and polymorphous (affective-delusional, affective-delu- sional with the catatonic inclusaions and catatono-delusional syndromes in the structure of psychotic disorders. At the same time productive psychopathological syndromes of affective and delusion-

160