Mental disorders in epilepsy

sion about their nosological entity (end of the 19th and the first two decades of the 20th century).

Third – the beginning of a comprehensive study of the role of biological, personal and social factors in the genesis and development of psychiatric disorders in epilepsy (1920-1940).

Fourth – a period of intense search for morphological substrate in the pathogenesis of psychiatric disorders in epilepsy, accumulation of clinical data for the prediction of the significance of relationship of productive and negative symptoms and the development of active therapies for these conditions (1950-1960s).

Finally, the modern – fifth – the period of synthetic approach to the biological, psychological and social factors in shaping the structure and dynamics of mental disorders in epilepsy, attempts to justify the criteria of clinical and social prognosis of patients with this pathology.

There are many examples given by doctors and authors, distant from medicine, of structural special features of short-term acute psychotic disorders with the loss of consciousness and the psychomotor excitation in patients, who suffer the black, sacred or holly disease, which for the millennia was epilepsy. It suffices in this respect the number of judgments and evidence of the contemporary authors.

The ancient people of Mesopotamia, for example, the fate of the patient with epilepsy predetermined for his sins by the God Moon. Aztecs were turned to Chihuapipiltin for treating the convulsions by the evaporations of incense, which remove, according to their ideas, “heavy respiration along the curved lines”. Indicated “prescientific symbolism”, in the opinion S. Iannacoune et al. (1997), is the source of existing in some peoples such therapeutic practices, as custom to spit on the patients with epilepsy from the fear of contact with their respiration or treatment by placing on their head a hot egg and etc.

In symbolic images in the paintings of the Middle Ages was noted a cosmic analogy between a seizure and a thunderstorm. Those who prayed for help, portrayed in a cruciform pose of generalized tonicclonic seizures, while those who empathized with the patient – in poses that express “the love of Christ» (D. Janz, 1997).

R. Sans et al. (1997) focus attention on the circumstance that later, for example, on engravings and pictures of Goya the patients with epilepsy are represented as dangerously mad, and also to the fact that subsequently, already in the middle of the 19th century, in the works of painting, based on the biblical subjects, the patients

11

were depicted in the form of saints in the state of ecstasy or in the form of obsessed. P. Dodd et al. (1997) show that many authors in entire course of history of medicine established the connection between epilepsy and forced behavior, arguing only about the fact whether, the latter is caused directly by epileptic seizure in the patient or by other circumstances.

Long before the creation of E. Esquirol (1838) of the first clinical classification of psychosis in patients with epilepsy, some doctors have described mental disorders related to epileptic seizures. Tyson (1650-1708) (cited on O. Temkin, 1945), in particular, connected “ordinary madness” with the epileptic symptoms. J.E. Greding (1790/91) (cited on O. Temkin, 1945) allocated madmen prone to the seizures. Boushet and Caravieich (1825) emphasized the establishment of the connections between epilepsy and insanity. J.S. Prichard (1822) (cited on M. Trimble, 1982) spoke about delirium, which began from the phenomena of excitation and continued in patients with epilepsy for two or three days. A. Portal (1827) described in the patient with epilepsy the state of fury, extremely dangerous for those surrounding.

Novelty of classification by E. Esquirol (1838) consisted in the use of statistical method during the study of the psychotic disturbances of different structure and duration. Out of 385 patients with epilepsy, 12 of them he considered suffering from monomania, 30 of them with the diagnosis of mania, 34 – fury. 50 from the total number of patients, in author’s opinion “had whimsical ideas”, and some – “transient delusion”.

In spite of the domination of the concept of united psychosis in psychiatry in the subsequent two-three decades, epilepsy, as earlier, has occupied special position in the general classification of mental disorders. As a result of profound study of the symptoms of psychotic disorders during this period there were in detail outlined some of their special structural features. Here, for example, were involved the periods of depression and excitation (J.G.F. Baillarger, 1854), distrust and resentment against violent urge to hit and destroy (L. Delasiauve, 1854) (cited on O. Temkin, 1945), he combination of religiosity and unbridled eroticism (A. Morel, 1860). By explicit signs of fury in patient with epilepsy I.M. Babinski (1859) (cited on V.E. Smirnov, 1971) counted unhealthy multiactivity, irritability, tendency to violence and rampant libido, which was assessed by the patients themselves as “ sublime power of their

12

abilities and will.” Patients with epilepsy, obsessed by melancholy, on the contrary, he noted “constantly sad arrangement of spirit” and corresponding to this “the elevated receptivity to surface impression, the assaults of desperation or the fears, which are finished by suicide”.

If the attitude of the majority of these authors to the possibility of detecting typical psychotic and nonpsychotic psychiatric symptoms in epilepsy was uncertain or rather negative, then B.A. Morel (1860) was the first representative of clinical psychiatry, who held the view of the existence of mental disorders peculiar to epilepsy itself. His concept of mental epilepsy was actively developed in the future. To a large extent this was due to the onset of the so-called nosological stage in psychiatry. B.A. Morel, in particular, described the suddenly appearing transitory disorders of consciousness, which are combined in patients with the agitation, delusions, frightening hallucinations, sometimes aggressiveness.

Almost simultaneously J. Falret (1860) proposed the concept of concealed epilepsy, which emphasized the possibility of absence of convulsive paroxysms in patients. Only the suspiciousness, tendency toward conflicts on the least occasion, extreme change of mood was noted in such cases.

As originated by these two concepts, terms, such as phrenepilepsia (K. Kahlbaum, 1863), epileptic insanity (Adisson, 1868) (cited on Y.V. Kannabikh, 1929), the epileptic states (W. Griesinger, 1868/69), together with the first communications of K. Kahlbaum (1874) about the combination of epileptic seizures with the catatonic disorders proved to be by the forerunners of the subsequent systematization of mental disorders of epilepsy, which was realized by P. Samt (1875/76).

Isolation by P. Samt of the numerous versions of epileptic insanity (primary or after the simple and relapsing equivalents protracted epileptic insanity, doubtful epileptic or epileptoid insanity) reflected the specific tendency to detail the symptoms for the purpose of the isolation of the larger possible number of forms of transitory psychoses to the detriment of the description of the forms, which lasted for months. (As it is known, this tendency was preserved and even was strengthened recently, for example, in ICD-10). Nevertheless, P. Samt proved to be the first researcher of epilepsy, who undertook the study needed to prognosis attempts to study the dynamics of epileptic psychoses.

13

Soon after him V.Ch. Kandinsky (1876) observed a separate, fully equal periodic bouts of mental illness, in which, after a short stage of stuporous melancholia with delirium and transient nature of fearfulness, an epileptic patient falls into mania with hallucinations. R. Krafft-Ebing (1881) reported about the repetitive cases of expansive delusion in the patient with epilepsy. Even greater interest in the formation of ideas about long-term prognosis of mental disorders in epilepsy was a judgment of W.R. Gowers (1881), who believed that a childhood malignancy in patients with epilepsy, restlessness and irritability might develop with age in their vices and criminal tendencies.

R. Gnauck (1882) gave a separate description of episodic and permanent manifestations of epileptic insanity. R. Pohl (1888) distinguished between patients with epilepsy acute short-term illness, which occurs with hallucinations and delusions, and chronic systematized delusional ideas. Chronic epilepsy delusion was described by J. Respaut (1883), A.Y. Kozhevnikov (1894), A. Buchholz (1895), F. Meens (1908), E. Siemerling (1909), A. Tamburini (1909), etc.

Essential, in order to establish the prognosis of epilepsy by corrections and additions to the classification of P. Samt, was the description by R. Krafft-Ebing (1885) of transient episodes of psychosis: stupor, impaired consciousness with the affect of melancholy, delirium, impaired consciousness with proudly-religious delusion, sleep like obscuring of consciousness, disturbance of consciousness with the moria like excitation and prolonged repeated or recurrent “equivalents of epilepsy” and chronic epileptic psychoses.

Should be noted an interesting in prognostic sense indication of P.A. Ostankov (1905) on the polymorphism of prolonged epileptic insanity, which in the series of its observations was evinced by the change of melancholy, catatonic, stupor-like and delusional states.

Summarizing the data on the dynamics of epileptic psychosis, some writers even in the early 19th century expressed original ideas about their pathogenesis. V.A. Muratov (1900), for example, considered completely identical the transitory psychoses, connected or not connected with the seizures. He also explained the differences in the structure of protracted psychoses differences in the depth of consciousness disorders. P.A. Ostankov (1905) as an unfavorable prognostic sign in cases of protracted epileptic psychosis assessed “spilled expansion of glia in the upper layers of the entire cortex of the brain”.

Followers of E. Kraepelin considered forms of epileptic insanity in terms of changing stages of pathological process. From this posi-

14

tion, many authors in a new way interpreted the stages of outcome in epilepsy. R. Sommer (1904), for example, connected severe dementia in the patients with lethargy, apathy and indifference observed in them. J.B. Gelineau (1901) spoke about moral insanity, which contrasts in the patients with epilepsy with their emphasized religiosity. S.A. Sukhanov (1912) compared sluggishness in the judgments of patients with the curved logic of moralizers.

However, often preserved in the first decades of the twentieth century understanding of psychopathological syndromes and multiple forms of pathologic response as stereotypical unchangeable states in epileptic patients served as a return to chaos of symptomatological prenosological period in psychiatry.

Dynamics of individual personality traits of patients in this period was not linked to the stage of epilepsy as a disease by all psychiatrists. So-called basic properties of psyche in those suffering from it were understood differently. E. Siemerling (1909) preferred to attribute to them unceremoniousness, brutality and selfishness. E. Kraepelin (1919), on the other side, emphasized geniality and tenderness of many patients with epilepsy. N. Dehlbruck (1926) noted excitability and viscosity, H. Goldbladt (1928) – religiosity. W. Jahrreis (1928) carried the unhealthy contraction of consciousness in patients on certain circle of perceptions to the differential-diagnostic signs, M.Ya. Sereyskiy (1929) – defensiveness and aggressiveness, the I. Atkin (1929) – amorality, H. Heinze (1932) – fire excitability, J. Gens (1934) – thoroughness. N.I. Ozeretskiy (1934) considered most frequent for the patients with epilepsy the features of psyche fluctuations from hypocrisy, servility, sweetness, stickiness, and molestation to a sharp bitterness, cruelty, and revenge. Ya.V. Berenshteyn (1935) singled out as a qualitative change in the psyche of these patients a dysfunction of concentration.

The isolation of the versions of the structure of personality, which was important for studying the dynamics of mental epilepsy, proved to be more productive in the plan of the development of the criteria of prognosis with the epileptic disease. Remarkable, in particular, were in this respect assumptions about the fact that the constitution must be understood as the problem of development of the possibilities of organism as the biological dynamics of personality.

In this context, a substantial interest in the differential diagnosis and prognosis provided comments of I.M. Slivko (1935) on the presence in structure of the epileptic psychosis of the characterologi-

15

cal elements of premorbid personality. S.M. Korsunskiy (1938) spoke, for example, about the terrestrial nature of religious-mystical experiences in the patients with epilepsy. E.K. Krasnushkin (1936) recognized sluggishness and heaviness as the qualities, which are formed depending on the process, whereas viscosity and irascibility, in view of their durability, explained by constitutional features.

In the 1930s a frequent statements by psychiatrists was about the possibility to meet in epilepsy any psychopathological syndrome, which is encountered with other psychic illnesses (H.W. Gruhle, 1930, 1936). It was indicated, in particular, an existence of the circular form of epileptic insanity (I.M. Slivko, 1935), to the cyclothymic phases in the epileptoid personalities (A.N. Aleksandrova, 1934), to the psycho-sensory (M.O. Gurevich, 1936; E.N. Kameneva, 1938), hallucinatory-paranoid (S.M. Korsunskiy, 1938) and catatonic (V.A. Nicolskaya, 1938) syndromes. For the first time esspecially about the structure, duration, dynamics and outcome of prolonged seizure of epileptic psychosis reported L.N. Vishnevskaya (1935).

The special interest during this period was the new data on the combination of the signs of psychosis and signs of “epileptoid personality” or epileptic defect. In particular, as the biological prerequisite of paranoic reaction was considered the presence of epileptoid constitution, which facilitates the formation of super-valuable ideas, pathologic self assertion and viscosity thinking (V.A. Gilyarovskiy, 1935; A.N. Molochov, 1940). Ya.V. Berenshteyn (1936) noted that for a long period remains the possibility of processing residual delusional ideas with that type of epileptic dementia, which he designated as autisticparalogistic. Ya.P. Frumkin (1936) and A.A. Perelman (1938) saw in the content of the transitory epileptic psychoses the manifestation of epileptic nature and epileptic dementia.

Completely essential for understanding the relationship of productive and negative psychopathological symptomatology with epilepsy were represented by A.M. Dubinin (1935), data showing that mandatory in determining the depth of the defect is to conduct structural and dynamic analysis of epileptic syndrome dementia. According to the author , epileptic dementia syndrome , which manifests itself mainly in slowing of mental processes and , in particular , difficulties in associative activities closely linked to relevant characterological changes. The viscosity affect and selfish poverty of interests in patients form, according to the ideas of A.M. Dubinin, a corresponding disorder of mindset as thoroughness and

16

depletion. Intensity of these phenomena posed by the author in the dependence of the intensity of the process.

Consideration in the thirties of the structure and dynamics of mental disorders in epilepsy in terms of their formation during the development of the epileptic process represents a significant contribution to the development of the doctrine of the prognosis of mental illness in general. It was established that the epileptic process at first sharpens the premorbid features of personality and only after that subsequently erases them (S.I. Polinkovskiy, 1935), that the statics of outcome is only the reflection of the practical requirement of the estimation of the stage of the clinical course of disease, but its not clinical essence (Ya.V. Berenshteyn, 1936), and that changes in the nature can be considered as the mild case of dementia (A.S. Kronfeld, 1938).

Of particular interest were indications of domestic authors on mismatch pathogenesis and type of flow process. G.I. Bershteyn (1937), for example, described a benign form of epilepsy, in which accentuated the constitutional personality traits and psychogenic formations. In the opinion of E.K. Krasnushkin (1936), small intensity process can lead to endogenous psychosis, in consequence of which appears the duality of the pathogenesis of the entire picture of the latter. Ya.P. Frumkin (1938) isolated three types of progressive epileptic mental changes: characterological, intellectual and mixed. The author considered that with the transitory epileptic psychoses more frequently is observed the characterological type. During the study the rate of the destructive changes by T.A. Geyer (1939), M.N. Polybina and S.A. Shubina (1939) was established connection of the slow clinical course of the process with the so-called simple form of epilepsy. According to the data of N.G. Kholzakova (1939), with it is subacute progressive and malignant processes predominated the defective states with an intellectual decrease, which were being combined sometimes with the development of querulant-paranoiac installations.

In the forties, clinical descriptions of epileptic psychoses abroad were mostly finished, which was probably due to the increasing influence of antinosological schools. Undoubted value of the fact of wartime and postwar distraction of medical attention at a relatively more frequently encountered in the practice of non-psychotic manifestations of traumatic epilepsy. In our country, the development of productive relations issues and negative symptoms in cases of epileptic psychoses continued both in clinical and, particularly,

17

in clinical and pathogenetic aspects. The originality of these approaches can be seen from the following comparisons.

If the foreign authors traditionally “separately” and standardly described the special features of epileptic psychoses, changes in nature and dementia, then many domestic psychiatrists urged to abandon the artificial division of the totality of symptoms of the disease on procedural and defective symptoms. On the feasibility of establishing correlations types of transient epileptic psychosis patients with persistent status said, in particular, O.V. Kerbikov (1940).

In contrast to the reports in the foreign publications about the clinical versions of epileptic psychoses with their stereotype description in the hospitalized patients, G.E. Sukhareva (1945) for purposes of the study of various forms of epileptic disease has not only traced the heterogeneity of the clinical picture of disease in the patients of different age, but also has analyzed the individual development of symptomatology in patients for several years. M.Y. Sereyskiy (1945) and P.F. Malkin (1945) indicated the need of the follow-up study of mental disorders with epilepsy and especially – types and the structures of therapeutic and spontaneous remissions.

Most domestic psychiatrists in war and postwar years for differentiated examination of clinical material used criterion of intensity and rate of current process, and the study took into account the type of defect structure of personality changes and mindset of the patient.

The development of the psychosis in the form of schubs was connected in these years with the more progressive course of the disease (R.S. Povitskaya, 1945). Likewise regarded cases of prolonged disorders of consciousness type of stupor (M.S. Pevzner, 1945) and the presence of residual delusion (K.A. Novlyanskaya, 1945). For continuous psychosis as a prerequisite was considered “psychopathic epileptic turn”, the beginning of the dynamics of psychopathological disorders from the overvalued formations or hardening paradoxical thoughts and false ideas (D.A. Amenitskiy, 1942).

There were also common with some foreign psychiatrists points of view common, which were manifested during this period in the explanation of the versions of paranoiac development with epilepsy by the pathologic reactivity, caused by the organic inferiority of central nervous system (S.G. Zhislin, 1945).

The fifties and sixties – a phase of active search for the necessary judgments about the relations between the prognosis changes in brain bioelectrical activity and psychopathology of epilepsy.

18

However, relevant data inconsistency was due to a significant loss of clinical approach to the analysis of psychopathological disorders. As never before the concept of epilepsy was reduced to the rank of paroxysmal syndrome or reaction, and the concept of epileptic psychosis to the individual symptoms or behavior of patients, i.e not clinical, but rather psychological and behavioral phenomena, as if by accident, combined with epilepsy seizure.

Perhaps it is because of this electrophysiological findings of this period did not find its complete interpretation on “psycho-morpholo- gical” basis, similar to what was done in the case of paroxysmal states.

The attempts to use a concept of reaction for explaining the fact of existence of mental epilepsy (M. Lennox, J. Mohr, 1950; W. Brautigam, 1951; W.G. Lennox, 1954; S.M. Ferguson et al., 1965; H.D. Pache, 1965, and others) turned to be unproductive.

W.G. Lennox (1954), in particular, considered as obstacle for treating epilepsy the factors of reticence, shame and fear, experienced by patient and his family, and also incorrect ideas about the disease and the ostracism from the side of community. S.M. Ferguson et al. (1965) and H.D. Pache (1965) recommended the withdrawal of patients from the family and introduction to “analogous medium” to avoid “difficult competition”.

Position, relatively more moderate and approaching modern, was expressed in consideration of psychopathic and psychotic disorders in epilepsy as signs of behavioral disorders due to “not exclusively organic factors, but also always simultaneously psycho-reactive and environmental” (H. Hoff, 1953; D.A. Pond, 1955; E.A. Weinstein, 1959, and others).

In contrast to the one-sided searches for the electrophysiological and social correlates of mental disorders with epilepsy, in the same years was outlined the specific recovery to the study of the characteristics of epileptic psychosis. In defense the concepts of epilepsy as po- ly-etiological disease with the united pathogenesis were given the data about the clinical similarity of the temporal forms of epilepsy (W. Scholz, 1951), about existence of the intellectual and emotional storage of the patient with epilepsy (E.T. Zimmermann et al., 1951), about the possibility of the treatment of epilepsy as “third psychosis” (K. Schneider, 1959), about the presence of the psycho-syndrome, which correspond to epilepsy of sleep and wakefulness (D. Janz, 1955), about the dependence of residual delusion on quickening of irregular psychotic states (L.E. Muzychuk, 1964) and other.

19

The foreign authors K. Simma (1953), F.A. Gibbs (1954), H.G. Perustich (1957) for the first time after many years expressed doubts about the possibility of exceptional explanation by psychogenesis of changes in the personality with epilepsy. Great significance in the origin of these disorders G. Goellnitz (1954) was, for example, given to damages of brain in the early childhood, V. Harvard (1954) and R. de Smedt (1963) – heredity.

Removing the leading part to clinical diagnostics, T. Ott et al. (1962) emphasized that the data do not automate EEG diagnostics and are not the basis for therapeutic recommendations. Acknowledged the need of studying “the longitudinal section” of disease for diagnostics and treatment (H. Doose, 1967). The prematurity of the physiological interpretation of symptoms in patient indicated was by N.A. Popov (1954), G.E. Sukhareva (1955), E.N. Kameneva (1956, 1959).

With the application of the indicated methodological approaches the study program of prognosis with “mental epilepsy” acquired the necessary purposefulness. The connections between the intensity of epileptic process and the sharpness and the polymorphism of the dreamy states (R.G. Gismatulina, 1959), with the rate of restoration after the seizure of neuropsychic activity (S.S.Mnukhin, 1958), by the predominance of acute psychoses or dementia was established (Ya.P. Frumkin and N.Ya. Zavilyanskiy, 1959).

The variety of mental disorders in epilepsy was attributed to the phasic nature of the course of disease (M.F. Taltse, 1951) and to the depth of the disturbance in the activity of the brain (A.B. Smulevich, 1965). It was emphasized that the epileptic seizure is only the element of epileptic process, but not the source of the formation of all other symptoms of epilepsy (S.F. Semenov, 1967, and others).

It was established that in the majority of the cases the development of psychosis begins several years after appearance of the first signs of epileptic disease (D.A. Pond, 1957; T. Negishi, 1965; S. Ohuchida, 1966, and others). The numbers were given: 3-15 years (A. Beard et al., 1962; B.M. Kutsenok, 1967, and others), 18 years (W. Mayer-Gross et al., 1960; R.G. Gismatulina, 1968), 10-20 years (L.E. Muzychuk, 1964), 6-32 years (N.M. Bergelson, 1964), 11-40 years V.N. Favorina, 1968).

A.V. Snezhevskiy (1960) placed the range of mental disorders in epilepsy between the clinical polymorphism in the organic psychoses and the narrowness of the circle of syndromes in schizophrenia.

20