Mental disorders in epilepsy

al registers, according to our data, are encountered much more frequently (into 4/5 cases), than syndromes with the presence of catatonic manifestations.

The minimal duration (from several days to 1 months) are characterized by the schubs of psychosis with the predominance of paranoid, catatono-delusional and catatonic disorders. Average duration (from 1 months to 1 year) more typical for the schubs of psychosis with the maniac-delusional and paranoiac disorders. The long-stan- ding course of psychosis is more typical for the affective-delusional bouts with the circular manifestations.

To these characteristics of psychotic schubs and remissions corresponds to smaller, than with the transitory form of the course of epileptic psychosis, preservation of “positive” personality traits that contribute to social adaptation of patients. The level of the adaptive abilities of the group of patients with the schubweise psychoses as a whole proves to be lower than in patients with the transitory psychoses.

The variety of psychopathological structure and the different duration of the periods of disease out of the schubs of psychosis correspond to predominance in patients with this form of the course of the epileptic psychosis of tendency toward the sub-compensation of pathologic process. This is expressed in a relatively small frequency of the cases of temporary compensation (intermissions), the predominance of “mixed” type remissions, which combine in their structure productive and negative psychopathological disorders, and remission in their clinical remissions approaching hypersthenic type.

In general, given the structural and dynamic features of pro-

in a group of patients of more general regularities noted in the ICD- 9 in the allocation of category “subacute transient psychotic state.” Obtained data showed also existence of the clinical differences between the named transient epileptic psychoses not only according to the sign of their duration (less or more than 6 months), but also on the presence much more important in the practical sense sign of the decrease of the sharpness of psychotic state in patients with an increase of its duration.

In contrast to transitory psychoses, where the catathymic mechanisms participate in the genesis mainly of affective manifestations, with the schubweise psychoses, these mechanisms participate more frequently in the formulation of protracted delusional psychotic states.

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The structure of the schubs of affective psychosis with its recurrence almost does not change. Polymorphism and complication of clinical picture in proportion to the development of disease are more typical for the psychoses of affective-delusional, delusional and catatonic registers.

4.5. Structure and dynamics of mental disorders in patients with chronic flow of epileptic psychosis

According to a number of authors, the autistic-paralogistic type of thinking frequently is encountered in patients with epilepsy (Ya.V. Berenshteyn, 1936; V.A. Gilyarovskiy, 1949; S.S. Mnukhin, 1963). E. Kraepelin (1919) in 16% of cases of dementia praecox as its forerunner. A. Yde et al. (1941) in 715 patients with schizophrenia noted epileptic seizures doubly more frequently than in the general population. According to A. Gaitatzis et al. (2004), chronic schizophrenialike psychoses in epilepsy after more than 10 years from the beginning of disease occur in 10-30% of cases.

To the above data confronts the evidence of other authors about the fact that the chronic shizophrenia-like psychoses are noted in the patients with epilepsy only in 0,5-7% of cases (J.E.A. Bartlet, 1957; G. Schorsch, 1962; R. de Smedt, 1963; R. Niemann, 1980; P.J. McKenna et al., 1985).

Among the hospitalized patients with epilepsy these psychoses in recent years are diagnosed in 1-3% of cases (V.S. Pozdniakov, A.I. Boldyrev, 1981). “Comparatively more frequent” they are observed in temporal epilepsy (E. Slater et al., 1963; G. Kury et al., 1964; P. Flor-Henry, 1969; S. Currie et al., 1971; G. Huber, 1973; A. Gastaut, 1975; M. Sigal, 1976; A. Pahla et al., 1979).

According to our data, chronic psychoses occur in 16,6% of patients with epilepsy, that are found under the observation of psychoneurological dispensary.

Although existence of chronic epileptic psychoses is acknowledged by many psychiatrists, any attempts at the dynamically structured analysis of these states was not undertaken. The descriptions of chronic epileptic psychoses are more frequently limited to the tendency to show their difference from the schizophrenia or similarity to it. Personal special features in patients are usually considered as the diagnostic signs. Strictly psychotic symptomatology is examined frequently

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as “shizophrenia-like”, alien to epileptic disease, caused by the development of pathologic process on the heterogeneous soil and manifesting as the consequence of the combination of two processes, considered as “shizoepilepsy” or “epishizophrenia”. (Mendez M.F. et al., 1993; Sachdev P., 1998; Qin P. et al., 2005; and oters).

The purpose of present chapter is to present the dynamically structured special features of chronic epileptic psychoses for the subsequent study of the problem about the possibility of their use as the criteria of a clinical and working prognosis.

We studied structure and dynamics of chronic psychoses in 150 patients with epilepsy (76 men, 74 women) aged between 20 to 66 (41,1+/-0,8) years, with the duration of disease from 9 to 53 (29,9+/-0,8) years and the duration of the development period of psychosis from 2 to 53 (18,8+/-0,9) years. The period of catamnetic observation (since the beginning of the observation in the psychoneurological dispensary) was from 2 to 42 (16,6+/-0,7) years. For the period the inspections 3 patients were the invalids of the first group, 60 patients

– the invalids of the second group, 40 patients – the invalids of the second third group, 47 patients did not have a group of disablement and they were completely able-bodied in their profession. In this case in the conditions of usual production 77 people worked, in the conditions of the special workshop of 11 people, in therapeutic-working workshop -12, 50 people worked nowhere.

Taking into account the clinical variety of psychopathological symptoms in the inspected patients the dynamically structured analysis of the versions of chronic epileptic psychosis was carried out by us on the basis of diagnostics of one or other type or another of the course of disease, leading psychopathological syndrome, relationship of productive and negative psychopathological symptomatology for each of the chosen stages. In this case special attention was paid to the study of the problem about the presence of the interrelation between the structural special features of chronic psychosis and the dynamics of epileptic defect.

Obtained data confirmed indications of V.A. Muratov (1900) and V.P. Osipov (1926) hat the development of continuous current or chronic epileptic psychosis may experience exacerbation and relief. Furthermore, in the course of the present investigation it proved possible to reveal that expressed in this type of mental disorders tendency toward their forming dependending on the degree of progressive course of epileptic process. The analysis of the course of disease

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on entire its elongation made it possible to establish that, in contrast to the transitory and schubweise forms of the course of psychosis, typical is the presence in the patients of chronic psychosis, complex according to its structure syndrome united for all clinical versions, which we preferred to designate as affective-delusional. It turned out that with the favorable development of process in patients most frequently occurs affective-delusional psychosis with the predominance of circular disorders (50 patients), in the cases of epileptic process with the set aside exacerbation – affective-delusional psychosis with the predominance of delusional disorders (50 patients), and with the unfavorable course of process – affective-delusional psychosis with the catatonic disorders (50 patients).

In the course of the study, besides the establishment of stages in the development of indicated psychopathological disorders, was undertaken an attempt at the development of correlation between the structure of psychosis in patients and the duration of the stage of disease.

The following stages of the development of psychopathological symptoms were isolated. The first – with the presence of psychotic disorders before the appearance of the first signs of dementia. The second – with the presence of psychotic disorders in the stage of the formation of dementia, whose characteristic features are the expression of explosive disorder. The third – with the presence of psychotic disorders in the stage of the formation of dementia with the expressed disturbances of thinking. The fourth – with the presence of the psychotic disorders, which are combined in patients with the expressed mnestiсo-intellectual defect.

In the course of a study was also established an increase in the duration of the stages of the formation of psychopathological syndromes gradual in proportion to the motion of epileptic process, either with the predominance in patients delusional disorders or with the presence together with the delusional of catatonic manifestations. These special features of the dynamics of productive psychopathological symptoms were examined by us as the signs of the known stabilization of process, advancing with the deepening of negative violations.

For dynamic and structural analysis of the clinical manifestations of chronic epileptic psychosis, we isolated a number of the psychopathological syndromes, the sum total of the cases of appearance of which at the different stages of disease composed 338. Among

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them – the syndromes: affective-delusional with super-valuable delusion (36,6%), affective-delusional with the tendency toward the systematization of delusional ideas (16,5%), affective-delusional with catatonic disorders (5%), catatonic with affective-delusional inclusions (36,3%).

Should be noted that for the period of inspection in patients more completely were considered earlier stages, whereas any of the subsequent stages of disease in a number of cases fell out from the number of those taken into account as not completed. Total number of stages in the analytical tables, which contain the values of associative of coefficient of Yule, occurred therefore not to the multiple of undertaken for the development cases of disease. Furthermore, in accordance with the intermediate tasks of a study, the sum of the stages of disease in the tables fluctuated depending on whether only final or all stages of disease were considered, including the inspections established at the moment.

4.5.1.Affective-delusional syndromes with over-valuable delusion

For entire duration of the period of the formation of chronic psychopathological disorders in patients with the predominance in the clinical picture of the affective disturbances, which are combined with the super-valuable formations, which, taking into account their durability, frequently is difficult to distinguish from paranoiac delusion, remained tendency toward the continuous change of affective phases.

Before signs of dementia persistent overvalued disorders were noted in patients in 47 cases. In this case was revealed the close connection of the super-valuable ideas of the hypochondriac content in patients with senestopathias of different localization, especially with the presence in them of anxiety-phobic and sub-depressive disorders. Patients feared, for example, the development in them of severe illness, seizure aggravation. In part of them occurred the prolonged, accompanied by a feeling anxiety doubts about the infidelity of spouse. With the aggravation of these experiences, usually against the background the deepenings of depression, typical for the patients were complaint of insomnia, feeling of melancholy, offence. They, however, as a rule, hushed up about their experiences. The ideas of jealousy

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were hidden by them not only out of the fear to bring on mocked, but also from a feeling of uncertainty of their fears. At the same time all attempts to convince patients of the groundlessness of their suspicions were received by them as the manifestations of hostility from the side of those surrounding or as the tendency to insult them, to humble, to laugh at them.

With a change in the nature of the affective disorders, caused by the fluctuations of the depth of depression or continuous, sometimes several times per day, change of short-term sub-depressive and sub-maniac phases (“gloomy” or “too enthusiastic” a mood, regarding one of the patients), the degree of the manifestation of the enumerated disorders in patients also changed. However, despite this in patients prolongedly remained readiness for the hypochondriac reactions and the appearance of the ideas of relation. To this contributed such typical for them personal special features, as hyper-social significance, super-valuable relation to their responsibilities, industriousness, assiduity, straightness, unique (egocentric) understanding of validity, order, debt. This includes patients with a tendency to categorical judgments, self-reassessment, pedantry and demands in relation to others.

Attention was drawn to the special, in many instances, hyperthymic nature of affective background. It is possible to assume that hyperthymia of patients caused not only by their increased activity, but also constancy in them of super-valuable installations. However, the repetition of depressive phases contributed to aggravation in patients of delusional experiences and thus, had an effect on formation in them of more or less constant plot of experiences.

In the next stage of development of psychopathology , marked in 54 patients and characterize the appearance of their first signs of dementia as a persistent decrease in the critical functions and the formation of the classic syndrome of “ fire excitability “ delusional disorder became more pronounced. The tendency in patients toward the realization of their super-valuable ideas came out to the foreground. Protracted conflicts with those surrounding appeared in them. The special features of thinking in patients were during this period noted by their tendency toward the detailing. This contributed to the fact that the ratio of patients overly responsible to responsibilities and their petty fault-finding in others became especially noticeable. On the insignificant occasion they had brutal reactions. This gave the color of inadequacy to entire behavior of patients. Irritability, loqua-

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city, importunity, “mental aggressiveness” of patients in the course of time considerably hampered contact with them. At the same time, named disorders were to a considerable extent preservation in patients of positive social attitudes. For patients were characteristic conscientious attitude to the work, careful attitude to the close ones. This is to a certain extent contributed to the fact that the affective fluctuations in general decreased the tension of explosive reactions. However, from other side, depressive phases were characterized in them by the deepening of hypochondriac disorders, by the ease of the appearance of the ideas of jealousy or ideas of relation, and in a number of cases – by formation of the ideas of low value.

With further progression of dementia, which could be revealed in 20 patients, increased the manifestation of another classical sign of “epileptic” psyche – bradyphrenia. The manifestations of explosiveness in this case in patients became less expressed. The circularity of the course of mental disorders remained with the rigidity of delusional experiences. Affective manifestations did not have an effect on the clinical picture and did not cause the appearance of supervaluable disorders and the mental productivity of patients in general. Sub-depressive disorders were manifested mainly in a decrease, and hypomanic – in an increase in the activity of patients in the plan of the realization of their installations. Tendency toward the querulant behavior was more frequently limited in them to verbal level. Reduction in the querulant activity in patients was explained even and by the fact that they no longer could estimate situation in general and bring fight to the specific logical result. At this stage of disease super-valu- able formations yet did not cover entire personality of patients by pillar. Their positive working orientation because of the predominance in them of extroverth features typical for them, accuracy, love for the order and the absence in them of satiety in the activity customary for them occurred the factor, capable to the known degree to compensate the sufficiently expressed defect of psyche available to them.

On the completing stage of the formation of the syndrome of epileptic dementia with further deepening of intellectual defect and significant reduction in the mnestic functions (in 3 patients) super-valu- able and delusional symptoms was reduced in patients to a simple and unstable ideas of relation. Simultaneously working activity was reduced, their emotional sphere was impoverished. The continuances of hypodynamic depression with the complaints of the poor health alternated in the patients with the episodes of unproductive excitation.

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4.5.2.Affective-delusional syndromes with a tendency for systematization of delusions

In the course of the study was established that the structure and the dynamics of chronic, with the tendency toward the systematization of delusion disorders, which were observed in 2 our patients before the appearance of signs of dementia, have their special features. In proportion to gradual accumulation in patients of special features of thinking, which were being first of all expressed in categorical and egocentric judgments, from the circle of affective disorders here predominated hypomanic.

In this stage disease, constant conflicts with the administration, the members of family, medical workers and others were caused by their fight for the enclosure itself from the imaginary encroachments of its rights, the prestige, the merit. The ease of appearance in the patients of relation ideas did not contradict the absence of a tendency toward the sticking on any conflict. The conviction of patients on thir own infallibility and superiority over those surrounding with a sufficient safety in them of professional habits and ability to attain the fulfillment of narrowly stated problem did not prevent patient from prolongedly being retained on the work under the conditions of usual production.

In the initial stage of the formation of dementia, which it was possible to diagnose in 15 patients, quickening of explosive reactions contributed to the loading of their conflicts with others. The typical for patients in this stage thoroughness of thinking became favorable for the development and the systematization of delusional ideas. Querulant delusion was combined and was interwoven in patients with the hypochondriac ideas, the ideas of relation and pursuit. Unfair, in the opinion of patients, offence was connected with their ideas about their own feebleness, incapacity to stand for themselfs. One of the patients, for example, required changing the working schedule, since she considered that the work prevents her from conducting treatment according to her developed scheme.

Delusions in 38 patients became increasingly monotonous , absurd and contradictory nature in the following stage of the formation of epileptic dementia. Querulant behavior in them with the retention of its activity lost endeavor. After attaining what desired, patients did not, as a rule, find satisfaction in the victory. Without the regret leaving the achievement in the persistent, frequently long-standing

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fight, they passed to the new period of querulant behavior already on another occasion. Received, for example, required referrals for treatment at the clinic shortly after entering it, they began to insist on discharge. Restored, with their own enormous effort, contrindicated work, several days after restoration presented the administration a requirement about a change in the working conditions or about their release. At the same time, in spite of manifested perseverance in the fight, patients rarely were hospitalized into the psychiatric hospital. Over the years of querulant activities they developed a particular style of behavior and speech. Even the talk of the patients abounded with office terms, newspaper cliches, appeals. The requirements of the immediate punishment of the guilties predominated in their letters at the cost of consistent presentation of the content of the conflict. Often it was difficult to trace the patients’ schemes of their delusional constructions because of the extreme detailing of their thinking. By patients equally important were all biographical details and episodes of their fight. For the proof of their own rightness, they gave, for example, many unknown to the collocutor names, establishments, places, dates and other. Demagogic and categorical judgments, infinite monologue, bulky revolutions, neologisms composed the uniqueness of their written production. For the majority of the patients of this group with a constant characteristic feature there was bigotededifying tone in the contact with those surrounding and practically complete absence of interest in the opinion of collocutor.

At the completing stage of the formation of dementia, revealed by us in one patient, was noted a decrease in the former level of claims and the decrease of querulant activity. Egocentrism, sluggishness, inactivity corresponded to the small scale of querulant constructions. Predominated senestopathic-hypochondriac disorders.

4.5.3.Affective-delusional syndromes with the hallucinatory disorders

The presence and the nature of hallucinatory-delusional manifestations in observed by us patients in many respects depended on the stage of the formation of epileptic dementia.

Prior to the onset of dementia symptoms these manifestations were detected in 6 of our patients. Hypochondriac ideas were in close

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connection with the monotonic sub-depressive affect. Therefore, despite having had a true visual and auditory hallucinations, usually differing brightness and intimidating character, patients retain some criticism of the deceptions of perception. Frequently in them appeared the ideas of low value and sinfulness with the tendency to search for sympathies and supports from others. Typical were tactile hallucinations and senestopathias, expressed in patients, for example, in a feeling of numbness or immobility of the individual parts of the body, the agonizing sensation of the lump of hair in the mouth, a feeling of weightlessness with the closed eyes, the sensation “of squeak in back of the head” and other. In one of the patients were noted pseudo-hallucinatory disorders, which himself characterized as: “Some phenomenon, appears suddenly, takes your hand and takes you away. Moreover all this in the bright, fiery tones”. With all enumerated experiences in patients remain a feeling of attachment to the close ones, the active concern about them. Patients tend to hold onto their jobs.

In the period of appearance in the clinical picture of the initial signs of dementia for 9 patients it was possible to note the loading of delusional disorders. Hypochondriac ideas were transformed in them into querulant delusion. Patients required doctors to use a specific treatment, direction to the treatment into the leading clinics, abroad and other. The scheme of treatment was changed at their own discretion. Visual deceptions lost previous urgency. Patients described them as some incomprehensible visions. At the same time with the experience of visual deceptions in some of them sometimes appeared the sensation of artificial creation: “grandson appears as a horse”, “the cat has eyes of man”, “the similarity of the appearance of old women and beasts is noted” and other. As if separately, out of the connection with the hallucinatory means appeared the ideas of jealousy, different kind the unstable ideas of relation. With the presence of passion hypomanic with the nuance of irritability the patients retain activity at home and at work.

With an increase of the signs of epileptic dementia, with the growth of the viscosity of thinking (in 4 patients) more frequently were noted the phenomena of the associative automatism: “Thoughts do not finish, they will encounter and will be radiated, or another appears instead of one, thoughts as the birds of God’s fly, they flutter, they do not sit at one place”. The content of the latter frequently served in the patients as the material for the delusional construc-

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