Mental disorders in epilepsy

tions. Hypochondriac ideas in them whimsical were united with querulant t delusion, ideas of relation and pursuit. The methods of selftreatment in one of them were based, for example, on his idea about the presence in his organism of “two autonomous circulatory systems, one of which is turned off during the seizure”, or during the sensation “hypnotic action or gravity on the liver, the bowels and the head”. The interpretation of this type of sensations frequently completely seized the consciousness of patients, which in turn prevented the formation in them of the goal-directed efforts, decreased the need for the useful activity. In the absence adequate emotional relation to the situation and the complete absence of criticism to its state for the patients was tyical the insurmountable hardness of installations as one of the conditions of their narrowly-directed and at the same time contradictory querulant behavior. Patients simultaneously attained, for example, the establishment of highest group of disablement and restoration at the previous place of work in their profession.

It should be noted that the cases of the development of the psychopathological syndromes of a similar structure at the completing stage of the formation of dementia were not observed by us.

To the given observations corresponds observation of R.G. Golodets (1997) about the possibility of development with epilepsy of the syndrome of mental automatism and participation of senestopathia in the formation in the patients of hypochondriac delusion.

4.5.4.Affective-delusional syndromes with the catatonic disorders

In our observations the nature of complex in the structural ratio psychopathological formations, described in this division, changed in the patients depending on the presence and the dynamics in them of the syndrome of epileptic dementia. Significant place in the clinical picture here belonged to the undeveloped hallucinatory-delusional symptoms, senestopathias and catatonic manifestations.

In the period of the diseases prior to the beginning of the development of epileptic dementia such kind of disorder were revealed in 3 patients. Against the general background of steadfast hypomanic passion in them appeared the frequent and prolonged aggravations in the form of the mildly expressed excitation, which is accompanied by fanciful motions, inadequate laughter, loquacity, phenomena

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of mentism, by interrupted ideas of relation, pursuit. Occurred undeveloped erotic delusion, verbal hallucinosis, hails, frightening dreams. The periods of chaotic engine excitation alternated in the patients with the phenomena of stupor. Patients were inclined to the presentation of stereotype questions or complaints. One of them, for example, every time meeting the doctor asked, is it possible for her “in this state to get married and to have children”. Another constantly presented complaints “of the itch in the feet and tension in the eyes”. In this case the patients were retained under the extra-hospital conditions, they continued to work.

With the beginning of formation of dementia in 3 patients enumerated disturbances were manifested in combination with the expressed explosive reactions. With steadfast reduction in the critical functions special dysphoric background caused in them more frequent manifestations of aggressiveness. In the clinical picture of disease in this stage large place in patients occured senestopathias, gustatory and olfactory hallucinations. Complaints of the unpleasant smells, a sensation of sweet in the mouth, a feeling of the bursting open of head and other were frequent. With the appearance of symptoms of mental automatism in them were noted the ambivalence of emotional experiences. Action from without simultaneously was received by them as unpleasant and as beneficial. More often they were painful for the patients, and was accompanied by depressive reactions. Patients noted, for example, that they do everything “mechanically”, “not as before”. The urgency of a similar kind of experiences caused the need of conducting the active dispensary or stationary treatment of patients with their temporary release from the work.

The described symptoms came out especially vividly at the stage of the formation of dementia with the manifestations of the so-called viscosity of thinking (in 9 patients). The patients for hours told about their sensations, willingly wrote in a diary. Attention was drawn to their tendency toward use of neologisms, inadequate agitation of speech. Expressing dissatisfaction at their experiences and feelings, patients seemingly alienated and animated them. The uniqueness of the appearance of patients was emphasized by their thickening smile, affectation, fanciful gesticulation. One of the patients called herself “the fool of the delayed action”. In order to be distracted from the sensation “of cobweb in the head”, “the tickling in the fingers” and “bursting of the soap bubbles in the ears”, she sang. She said,

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that with reduction in the mood in her appears a sense of “veiling of the environment”. With entire variety of a similar kinds of sensations the patients lacked tendency toward the systematization of hypochondriac ideas. At the same time, while maintaining the adequacy of emotional reactions to events happening around them the patients because of their permanent employment experiences proved incapable of organized labor.

At the completing stage of the formation of dementia, diagnosed in 2 patients, the polymorphism of pathologic sensations described above decreased. Patients became more monotonous in the behavior and not so more loquacious as before. Noticeably was reduced the memory. The impression of odd eccentricity remained. They as before used neologisms. Statement of one of the patients can be illustration: “Behind a brain and in hole in the region of neck, and also behind a hump something as crab grabbed and pulled”. Patients ceased any working activity, they were passive in private life.

4.5.5.Catatonic syndromes with the affective-delusional inclusions

In the cases of chronic epileptic psychosis studied by us for the inspected patients it was possible to isolate the sufficiently large number of versions of the combination of catatonic and affective-de- lusional disorders. In spite of variety in the clinical expression, these disorders were subjected to the specific stereotype of development. The gradual reduction of affective-delusional disorders was outlined in proportion to the growth of the manifestation of the syndrome of monotonic rigidity in patients.

At the stage of disease before the appearance of signs of dementia such states were observed in 7 patients. Frequently appeared neurosis-like disturbances, which were manifested in the form of obtrusive calculation, phobias, irritability. Set in sub-stuporous states, with which the low mobility in patients was combined with the phenomena of mutism. In this case frequently appeared the need for the stimulation of patients to their self-service or fulfillment of actions customary for them. Stereotypes were manifested in patients in the nature of their mimic disorders. For example, in their appearance of the mask of fastidiousness, in the stormy on the negligible occasion reactions of protest. Were noted difficulties in attempts from the

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side of those surrounding to establish contact with the patient. Affec- tive-delusional inclusions more frequent were the short-term periods of sub-depression, sensitivity, the ideas of low value.

With the advent of the initial signs of dementia (in 26 patients) affective disorders became unexpected. The ideas of relation in patients increasingly caused in them the contrast themselves to those surrounding. In patients appeared the tendency toward the hostile criticism of entire of proceeding. Typical of them was malicious grumble in to any occasion, constant manifestations of distrustfulness, dissatisfaction with everything. At the same time, “grumbling aspontaneity” did not allow for patients how to before, actively overcome vital circumstances unpleasant for them. They occurred incapable of the prolonged querulant, and then any activity. However, more frequent the expressed negativism repelled from them the close ones.

At the following stage of the formation of dementia, noted in 47 patients, decreased the sharpness of affective disorders. In patients was strengthened the tendency toward the stereotype, “mechanically” forms of behavior. Monotonic rigidity with the presence of the euphoric background of mood, was expressed in patients in their tendency to perfection. Overly accurate, imperturbable polite, pedantic, untiring in the work, they sometimes after prolonged interruption, adapted to the simple labor. In third of cases, in connection with the early beginning of epileptic process in patients were noted the signs of the so-called oligophrenic type of defect. They had such special features of intellectual development that with age they were “better did something, than actually knew”. The latter contributed so that the level of claims in patients was relatively more adequate.

In proportion to further deepening of intellectual defect (in 42 patients) in the connection with predominance in the clinical picture of the monotony of affective reactions and sluggishness was redused the productivity of patients in the work. At the same time their positive working installations and activity in private life remained for long. Sociability, complacency, ease of judgments occurred the exact opposite to the heavy negativism of patients in the past. At this stage of disease the remained work habits more frequently found use in the period of their work in esspecially created conditions.

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4.5.6. Structure of the personal changes

The materials, represented in present chapter, not only confirmed the expressed by us in the previous general statement that the depth and severity of epileptic defect and gravity of productive psychopathological symptomatology were interdependent (defect less it was expressed with the predominance in the clinical picture of affective and delusional symptomatology and more distinctly it comes out in the presence in patients of catatonic disorders), but also they made it possible to a certain extent in a new way to approach the study of the problem about the connection in them of personal disorders with the structure of chronic psychosis.

On the basis of the results of the conducted above dynamic and structured investigation of chronic psychotic disorders with epilepsy, we considered it possible to assume that each of the revealed special features of personality in patients with this form of pathology must, apparently, be treated as the special feature of the reflection of their premorbid stage, and as manifestation in the course of the disease of personal shift and, furthermore as composite, and in a number of cases and as major portion of the complex of productive and negative psychopathological disorders.

It was interesting therefore an attempt to establish correlations between the special features of the personality of patients and the dynamic and structured characteristics of chronic epileptic psychosis. For this purpose were taken into consideration only those qualities of personality in the patients, who were most tightly connected with type and stage of the course of disease.

From the premorbid special features of the personality of patients, in which in the structure of chronic psychosis predominated affective disorders, most frequently were noted asthenic and anxioushypochondriac features, tendency toward the fantasies. At the same time in the cases, for which there was more characteristic the presence in the clinical picture of the psychosis of catatonic manifestations, retrospectively in patients even prior to the beginning of disease more frequent was the difficulty of adaptation, hysterical features, reactive lability. In contrast to that, were not established typical premorbid personal features in the patients, in the clinical picture of psychosis in whom were noted predominantly delusional disorders.

The carried out study of the personal special features of patients at the stages of disease showed that the difficulties of ada-

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ptation especially frequently were noted with the predominance in the structure of the psychosis of catatonic disorders in patients in the period of disease preceding the beginning of psychosis. As for the period of the disease with psychosis manifestations, there were not revealed any correlation between the individual personality manifestations and stages of the disease. For the established here personal special feature each time it was necessary therefore to assess total.

Were established, for example, that more than 90% patients with the chronic epileptic psychoses reveal hypersthenic features, phenomena of bradyphrenia, reduction in the critical functions, egocentrism, mental rigidity. More than 80% of inspected patients manifest the tendency toward the conflicts, they reveal the high level of selfappraisal, the inadequate level of claims. From 60 to 75% of patients, are hypersocial, reactively labil, explosive, with low level of self-con- trol. At the same time, the expressed disturbances of adaptation were noted only in 50% of cases, hyposthenic features – in 43,3% of cases. The small group consisted of patients with “positive” personality traits. Altruism was, for example, revealed only in 18%, conformity – in 5,3% of patients.

In light of the above interesting are the observations of A. Magaudda et al. (1997), according to whom “dependent and oppositional personal features considerably more frequent” are encountered in the group of the dispensary patients with epilepsy with “dysthymic depression”. T. Wolanczyk (1997) reports that adolescents with epilepsy with the depressive symptoms, in comparison with the control group of contemporaries, not only appear less optimistic, but they also little value their independence and therefore are perceived by others as “mentally inferior”.

Thus, obtained data confirmed the need of applying the dynamic and structured approach to the analysis of the elaborate complex of the psychopathological manifestations, which are observed in the clinical picture of the chronic epileptic psychoses, which, as data of the epidemiological investigation showed, occur in each sixth patient with epilepsy, under the observation of psychiatrist. The obtained results make possible for us with larger confidence to speak, that besides the delusional forms of chronic epileptic psychosis, there are such independently forms, as affective-delusional psychoses with the predominance of affective disorders and affective-delusional psychoses with the presence of catatonic disorders.

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The conducted investigation showed that as “through” syndrome and, correspondingly, as one of the basic (together with the fact of long-standing continuous course) criteria of diagnostics of chronic epileptic psychosis can be acknowledged the affective-de- lusional syndrome. Structure and dynamics of the latter, and also the nature of the hallucinatory and catatonic disorders being contained in the clinical picture depend on type and stage of the course of epileptic process. The clinical expression of one or other degree of progressive course of process are such syndromes, as affectivedelusional with the hallucinatory disorders, affective-delusional with the catatonic disorders, catatonic syndrome with the affectivedelusional inclusions.

In connection with smaller, in comparison with the transient psychoses (transitory and schubweise), sharpness of clinical manifestations productive psychopathological symptoms in patients with the chronic psychosis occur as if “soldered” with the negative. Therefore, probably, chronic epileptic psychoses, especially with the predominance in their structure of affective and paranoiac disorders, in a number of cases are difficult to distinguish with the pathologic development of personality. The abundance of senestopathias, the complication of delusional disorders, the appearance against the background of affective-delusional disorders of hallucinatory and catatonic manifestations testify, however, more in favor of “autochthonous” nature of psychosis, also, about the mechanisms of its formation, due to the progression of cerebral pathology.

In spite of the considerable proportion of catatonic manifestations (2/5 cases), the level of social adaptation in the studied group of patients with the chronic course of epileptic psychosis in general differs little from the level of social adaptation in the group of patients with the paroxismal course of psychosis, which, probably, can be explained by the fact that with the similarity of the structure of personal changes the patients to the chronic course of psychosis have the capability for the duration of a longer period “to adapted” to the psychopathological manifestations of their illness.

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Chapter 5

DIFFERENTIAL DIAGNOSIS

Understanding of schizophrenia and epilepsy as specific disorders of mental activity, or, actually as psychopathological syndromes, can, in our opinion, lead to the fact that these two concepts will be used as the terms, usually included in the division of general psychopathology.

And although the tendency toward the approximation precisely to this understanding of terms schizophrenia and epilepsy is reflected in ICD-10, even with the attempt “to penetrate” in the content of a similar point of view and the assumption of the fact that a motive can serve the tendency to isolate “basic disorder”, which distinguishes one or other nosologic form from another, nevertheless, it is difficult to imagine, for example, as in one patient can be combined schizophrenia and epilepsy, even if they are only syndromes, as it is difficult to understand that the fact that in one patient can simultaneously exist measles and scarlet fever, two forms of anemia and etc.

Meanwhile for sometime are outlined the sufficiently extended tendencies to prove compatability or incompatibility of these two forms of pathology. With the use of speculative constructions it is allowed, for example, the possibility “of the absorption” of schizophrenia by epilepsy or vice versa the possibility of the combination of schizophrenic and epileptic processes.

Psychiatrist, who studies the pathology based on the clinical approach, judgments about the antagonism of two diseases seem absurd. Since the beginning of the century the majority of clinicians accepted position, that basic thing that distinguishes the patient with schizophrenia from the patient with epilepsy – is the difference in the structure of personality in patients along the disease, or the fact that they at present in a broader sense call pathos.

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Probably, psychiatrists in this sense can be divided into two categories. The first assume that everything in the world is preformed, given once and for all, if not all is stable and invariabl, than at least constant are such components: mental functions, functional systems and other, which determine one or other “type of reaction”. The second, recognizing the existence of the exogenous and endogenous types of reactions, do not exclude that that the etiology and pathogenesis can determine or cause the type of the course of pathologic process and the type of reaction, and also that there is a general arena, in which are developed qualitatively diverse diseases and reactions, including brain and organism as a whole, and only by generality and by the complexity of the reactions of the brain and organism in total, it is possible to make an attempt to explain known similarity and differences in the clinical manifestations of pathologic processes and psychogeneses. Indeed if we return ourselves to an example of infectious diseases – measles and scarlet fever, it should be noted that they on their clinical formulation have much in common between themselves; however, in the same time they are distinguished by the course and the outcome.

Similar points of view were expressed by M.O. Gurevich (1913), H. Gruhle (1936), A.S. Kronfeld (1940). They considered that the acknowledgement of the possibility of connecting two endogenous processes in one individual undermines the basis of nosologic concept in psychiatry.

Antagonism between the representatives of the first and second types of psychiatric thinking appeared, as known, already at the turn of the century and began from the expressions of surprise from the side of a number of the authors about the fact that not all fit the rigid nosologic system.

R. Gaupp (1901) (cited. on G. Koehler, 1973), for example, was struck by the fact that in the patients with epilepsy can appear insurmountable drives and, in particular, dipsomania. P. Naecke (1905) indicated the possibility of the appearance of the first seizures after the beginning of chronic psychosis. E. Siemerling (1909) raised the question about the lawfulness of the isolation of the fluctuations of mood, specific for epilepsy. Chotzen (1905), R. Nouet and L. Trepsat (1909), E. Siemerling (1909), O. Hinrichsen (1911), W. Bausch (1922), E. Grunthal (1923) described the separate forms of catatonic disorders in this illness. M.L. Bianchini (1904, 1906) separated paranoid and catatonic epilepsy. J. Voisin (1907) – the catatonic form of dementia

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praecox with epilepsy. J. Lachmund (1904) and W.V. Holst (1919) – epileptic hallucinosis. N. Giese (1914) considered epilepsy as an early symptom of schizophrenia.

To a certain degree precisely this type of mechanical approach to the examination of the reasons for the appearance of complex psychopathological formations with epilepsy contributed subsequently to the more frequent appearance of works, which defend the concept of the combination of two processes. In favor of the lattest spoke not only R. Gaupp (1925), but also E. Krapf (1928), S.N. Rodenberg (1929), A. Glaus (1931), V.A. Nicolskaya (1938). In this case about the presence of antagonism between psychosis and epilepsy spoke W. Held (1919), L. Meduna (1937) (cited. on A.A Perelman, 1944), E.N. Kameneva (1938) and M.A. Goldenberg (1938). All given constructions could not solve the problem of the pathogenesis of epileptic psychoses, since, in the essence, were reduced to the known scholastic dispute about, how much devils it is possible to seat to the point of needle. For example, the appearance of epileptic psychosis was examined completely speculatively: as the reaction of schizoid personality to the epileptic process or, on the contrary, as the reaction of epileptoid personality to the schizophrenic process (R. Gaupp, 1925, and others).

For the first three-four decades of the 20th century was typical the treatment of chronic mental disorders with epilepsy as a version of pathologic development of personality. Profoundly in this sense, for example, were analyzed heavy progressive anancast development with genuine epilepsy (A. Fuchs, 1927), atypical epileptoid psychosis (K. Kleist, 1928), the chronic systematized delusional formations (H.W. Gruhle, 1936; K. Leonhard, 1938, and others). Similar cases were pointed out by T.A. Geyer (1939) as the paranoic developments of personality on the defective epileptic soil.

Along with this there was obvious during this period the priority of domestic psychiatrists in further attempts at the study of questions of the origin of the separate forms of epileptic psychoses.

According to different degree of the preservation of memory and affective saturation of the experiences of patients P.A. Yudelevich (1941), for example, objectified differences in the intensity of the disorders of consciousness with the transitory of epileptic psychoses. Protracted epileptic psychosis A.L. Epstein (1945) considered as continuous in the course of several days, weeks or months as a chain of the small epileptic seizures, connected with the periods of the disorders of consciousness. Not rough disturbances of consciousness

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