Mental disorders in epilepsy

but also laws governing the more general common order. First of all it was established the absence of the reliable differences between the frequency of aggravations in the compared groups of the diseases from time of year, and also the absence of reliable differences on the months in the frequency of the aggravations of schizophrenia and epilepsy with their favorable course. For the middle rate of progressive course of schizophrenic and epileptic processes in common was increasing of the amount of relapse in February, April, July, August and December. For the current unfavorable epileptic process was statistically significant positive correlation with the amount of flare-ups in January, March, April, July, September and October, the months, which most clearly reflect the features of all four seasons.

On the basis of already assumed preferential localization of pathologic process in various functional systems of brain, providing varying degrees of inclusion of mechanisms for compensation and adaptation, it was possible to interpret given data as follows.

“Particular”, “individual” or “autochthonous” rhythm of aggravations, characteristic of the favorable course of schizophrenia and epilepsy, that take place with the psychotic disorders, testifies about the known safety of compensating functions. With the middle rate of progressive course of processes it is observed the interference of “individual” rhythm of aggravations and general annual biorhythm, which can indicate the instability of compensating mechanisms. The decompensation of the processes of adaptation indicates the substitution “individual” rhythm by the general biological (annual) with unfavorably current epilepsy, which is hypothetically characterized by the total defeat of the functional systems of the brain.

In light of assumed special interest acquired the establishment of the diagnostic and prognostic importance of the phenomenon of the repeated aggravations of schizophrenia and epilepsy during one year, observed in general in 40% (n=1480) of the cases aggravations. It seemed appropriate to review constantly debatable question whether repeated within a year of hospitalization reflects a lack of efficacy and their premature extraction from the hospital, or each of the hospitalizations of this type is result relative to the short-term series episodes of disease.

The rubrication of the corresponding data about the hospitalizations of patients was conducted through the consecutive five-year development periods of disease. In each case disease was considered the total number of hospitalizations of patients during the given annum.

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The noted multiplicity of the facts of the repeated aggravations of disease during the year not let us consider them as therapeutic artifact, but rather point to the possibility of evaluating them as manifestations of increasing the activity of a process. In connection with this it was necessary to attempt to establish the prognostic significance of this phenomenon.

It turned out that in general population of the patients with schizophrenia, the tendency toward the repetitions of hospitalizations during the year can be saved for a period of 50 years of disease, with the greatest intensity in the first decade and gradually decreasing thereafter. With the same total duration of the appearance of repeated aggravations in the course of year with epilepsy, which takes place with the psychosis, the increase of the frequency of similar hospitalizations proceeds only after 15 years from the beginning of disease.

It was found that the prognosis has the following distribution of the value of the most active periods of the disease.

With the favorable course of the disease the frequency of repeated hospital admissions during the year both with the schizophrenia and with epilepsy evenly is distributed along entire their “length”.

With the middle rate of progressive course of schizophrenia the maximum values of the activity of the course of disease occur to its first decade, and so for the periods of disease from 16 to 25 years and from 31 to 35 years, while for the analogous type of the course of epilepsy is typical a lag exacerbation of process relating to the period of the disease between 21 and 40 years.

With the unfavorable course of schizophrenia the peaks of quickening of hospitalizations, repetitive in the course of year, coincide with the periods of disease from 6 to 15 years and from 21 year to 35 years, while with the unfavorable course of epilepsy – with the earlier period of disease, in the range between 6 to 20 years.

There is, therefore, some stretch and undulation of the total period of active pathological process in schizophrenia, and, on the contrary, its shornesst and “compactness” in epilepsy.

With regard to the prognostic value of the seasonality in the occurrence of repeated hospital admissions during the year, only with the middle rate of progressive course of schizophrenic and epileptic processes succeeds to reveal the data resembling seasonal flare-ups in their overall population, which was noted above with the unfavorable processes. The peaks of quickening of the number of hospitaliza-

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tions were felt here in January, June and December, i.e., they, actually, correlated with the polar values of annual cycle.

Received on the material of epidemiological study data suggests, therefore, that repeated during the year exacerbation of the disease to a greater extent may be useful for the differential diagnosis of schizophrenia and epilepsy, which flows with psychosis, than to determine the rate of progression of both diseases. The given indications of the presence of seasonal variations of the frequency of these aggravations testify to the confinement of the higher activity of process to the polar values of annual cycle.

According to the outlined diagram of a study it was logical to study another sufficiently extended type of the repeated aggravations of schizophrenia and epilepsy – aggravation of disease in the different years in the same months. In general on both inspected groups of the patients of this type of aggravation they occurred in 51,5% of cases (n=1907).

The corresponding analysis did not confirm the presence of general for the schizophrenia and epilepsy correlations between the seasonality of this phenomenon and the rate of progressive course of pathologic process. However, the nosological differences indicate a finding of such correlations in epilepsy flowing with psychosis. With the middle rate of progressive course of epilepsy the repetitions of the hospitalization of patients in the same months were reliably more frequently in the winter and summer, and in unfavorably current epilepsy – in autumn and in spring. On the basis of the fact that in general epilepsy is differed from schizophrenia in terms of heavier clinical prognosis, given data, apparently, can be estimated as the signs of the loading of prognosis. To verify this assumption, it is appropriate to investigate the character of correlation between the type of pathological process and the amount of cases of repetition and nonrepetition in the same months of exacerbations of the disease.

Obtained data indicates that, although in general the number of schizophrenia repeated in the same month of exacerbation of the disease is reliably more than the number of non-recurring, the first are more characteristic for the most common middle progressive type of the course of disease. However, with epilepsy also for equal representation of both types of exacerbations trend more typical adverse of current process.

In order to clarify the data and resolve the issue of whether the presence of cases of disease exacerbations in the same months, the re-

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sult of a longer duration of the disease, we carried out analysis of the data that differs from the above analysis not sum of hospitalizations, but the sums of the cases of disease.

To ensure the representativeness of the comparison groups of patients as a sign of their delineation was elected 15-year duration of the illness, recognized by a number of authors for the critical manifestation of epileptic psychoses. The study finally confirmed the assumption of membership phenomenon of repeated flare-ups in the same months to the criteria for worsening prediction.

Detected therefore, at least three rhythms during exacerbations of schizophrenia and epilepsy seem to be equally associated with the type of disease, but to varying degrees – the seasonality of hospitalizations. It is detected quite clearly seasonal exacerbations of both diseases in the general population of hospitalization of patients. At the same time the appearance of repeated aggravations during the year in the smaller measure is connected with the factor of seasonality. To the smallest degree the connection with the seasonality is revealed with the analysis of the cases of the aggravations of disease in the same months.

It seems appropriate to compare our data with the date of birth of patients. In particular, it was interesting to study the prognostic value of the latter.

First of all it was identified inconsistent with the literature (G. Parker et al., 1976), the absence of reliable differences in the dates of birth between general sets of schizophrenia and epilepsy of the seasons. However, such differences were found in the analysis of types of flow in both groups of diseases. The favorable course of schizophrenia and epilepsy more frequently occurred in patients, who were born in January, February, April, September, October and November (i.e. predominantly in winter and in autumn). The average degree of progressive course of these illnesses correlates with the date of the generation of patients in March, May, July, August and October (i.e. predominantly in the spring-summer period). With the unfavorable course of the process of difference in the date the generation in the inspected patients proved to be statistically uncertain.

Thus, in the analysis and evaluation of the role of biological rhythms in the course of a chronic mental illness in general, seems to be a simultaneous ownership of these factors as to the pathogenesis of this nosology, and, in particular, to the degree of its progressive

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course. The repetition of the aggravations of disease, which require stationary treatment, in one and the same month and during the annum is unfavorable prognosis sign. Development on the epidemiological material of nosologic and prognostic differences in the cyclic recurrence of the aggravations of disease can indicate the possible differences in the immunogenesis of schizophrenia and epilepsy. In the same plan it is possible to interpret correlations between the transient (transitory and schubweise) psychoses and the specific rhythm of the aggravations of disease. With the schizophrenia the rhythm of aggravations, apparently, more “is individualized”, i.e., is less connected with the biological rhythms, which, probably, is caused by the defeat of younger in phylogenetic sense of cerebral structures. With the progressive versions of epilepsy the rhythm of the aggravations of disease reveals the expressed features of seasonality. The nature of biological rhythm in the course of chronic psychic illnesses must be considered with the development of the general and individual measures of preventive maintenance.

As it is known, beginning with ICD-9, mental disorders with epilepsy gradually disappear from the class V “Mental disorders and the disorders of behavior”. One can only assume that the authors of the class V of ICD-10 set out to “start from scratch” to develop mental health problems in this disease, based on the category of the G40 class VI «Diseases of the nervous system”, or agreed that all existing in the population range mental and behavioral disorders can occur in epilepsy. More likely is that they felt that the syndrome of “epilepsy” accidentally combined with mental and behavioral disorders.

In favor of last assumption may indicate the following judgments, based on the current understanding of the so-called co-morbidity (SB Stefansson et al., 1998; A. Gaitatzis et al., 2004; W. Swinkels, et al., 2005; S. Farooq et al. , 2008; F. Sundram, 2010) of various clinical phenomena.

“Epilepsy – is a chronic state” (J. Beaussart-Defaye et al., 1997). “We attempt to connect the possible lying at the basis neurologic disorders with the epileptic syndrome” (D. Besana et al., 1997). “We are inclined to perceive the presence of interrelations between epilepsy and personal disorders” (E.H. de Graaf et al., 1997). “Youthful myoclonic epilepsy is the syndrome, classified as idiopathic generalized epilepsy with the beginning, dependent on the age” (S. Malagold et al., 1997). “One of the most frequent epileptic syndromes is favorable focal epilepsy” (H. Mayer et al., 1997). “Among the connected with the sleep

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paroxysmal disorders night frontal epilepsy is described as original syndrome” (G. Plazzi et al., 1997) and others.

However, our data shows that in epilepsy, which gets into the field of psychiatry, in 60-70% of cases is established disability, half of adult epilepsy patients diagnosed dementia and in more than 60% of cases at least once a life time arise psychosis.

At the same time the nomenclature of these states, represented in ICD-9 and ICD-10, including the versions adapted for the domestic psychiatric practice, is developed extremely insufficiently. The static estimation of epileptic dementia contradicts the dynamic approach to the classification of psychopathological disorders affirmed in the domestic practice. Definitions “acute transient psychotic state”, “subacute transient psychotic state”, “chronic psychotic state” and other need concrete definition. For example, in containing these terms division of adapted version ICD-9 “psychotic disorders due to organic brain damage” is not entirely observed the principle of glossary, wich is sufficiently widely used in other headings.

In addition to filling specific clinical content used in the ICD- 9 and ICD-10 types of epileptic psychosis and dementia, i.e, develop a glossary of psychopathological syndromes for unified structural and dynamic assessment of patients with manifestations of epileptic psychosis and dementia, in this chapter we wanted to provide suitable for use in medical practice and expert criteria for clinical diagnosis of the disease.

According to the fact that structural and dynamic approach to the analysis of clinica phenomena can be considered justified in the long-standing practice of medico-social and forensic-psychiatric examination, description of clinical forms in that proposed by us “the glossaries of mental disorders with epilepsy” is given simultaneously with the indication of the nature of outcomes with them, and in the division “the criteria of diagnosis” shows the place of the varied forms of epileptic psychoses and dementia in the structure of general laws governing the course of disease.

Coding of psychopathological syndromes is conducted in accordance with adapted for use in the Russian Federation class V «Mental and behavioral disorders” of ICD-9 and ICD-10.

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GLOSSARY

OF MENTAL DISORDERS

IN EPILEPSY

Sharp transient psychotic state ICD-9: 293. 05 ICD-10: F 06. 812

It develops as transient with a sudden onset and rapid completion of psychosis lasting from several hours to several days, with the predominance of the affective, delusional or catatonic disorders in the form of depressions, manias, hypochondriac states, anxiety states with the ideas of relation, poisoning, pursuit, hallucinatory-delusio- nal states, lucid catatonic disorders, catatonia with oneiroid or twilight disorders of consciousness, delirium.

Transitory psychoses with the predominance of affective disorders ICD-10: F06. 3

For the transitory depressions (ICD-10: F 06. 322 or F 06. 362), together with reduction in the mood, the most typical sign is hypodynamia. Patients tend to the subjective experience of passivity, sluggishness, lethargy. Complaints of the difficulty of the concentration of attention, reduction in mental acuity, capability for mastering of new, fatigue are frequent. With the presence of dysphoric disorders appear the anxiety, hot temper, touchiness, tearfulness. The statements about the unwillingness to live are frequent at the height of irascible flashes. However, the aggression, predominantly mental, is more frequently projected outside. Especially this is manifested in the cases of appearing sensitive delusion of relation. The patients fear, in such periods, that others suspect them of simulation, the swindle, the sponging, the alcoholism, etc. In connection with the fact that the cases “of the breakthrough of passion” further the threats of presenting a complaint of “the offender” do not go on, these states most frequently proceed without the interference of doctor and patients continue to work. With the curtailment of disorder in them appears critical relation to its experiences.

For the depressions with the predominance of vegetative manifestations are typical intensive headaches and vertigoes with the subsequent of general weakness, the sleepiness or insomnia, absence of apitite, sometimes by nose hemorrhages. Also noted the tendency toward the faint-hearted reactions, pains of different localization, hy-

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perpathia, the sensation of dryness in the mouth, a feeling of breakdown, the loss of memory. Sleep with the nightmarish dreams, the frequent awakenings. Patients appear sluggish, pale. The productivity in the work considerably is reduced in them, in connection with which for the period of psychosis they must be recognized as temporarily disabled.

In cases of transient delusions (ICD-10: F 06. 303 or F 06. 342) passion for any pursuits including industrial, reaches that the patients devote their entire time to them, for a long time they cannot fall asleep, they wake up with the new plans. A sense of delight, pleasure about real or imaginary success often accompanied of speech-motor excitation, impetuosity, neglect to the interests of others, tendency toward self-glorification. The feeling of “full health”, “evocation” combines with the loss of criticism to the disease in general. Patients stop the anti-epileptic medication, and this is often the reason for consulting a doctor about more frequent paroxysms. Actually same mental disorders typically do not reduce their disability status, and neuropsychiatric institution in consultation with the patient should contact the administration of the company with a request to not consider this as absence.

The plot of transitory delusional states with anxiety and ideas of relation, poisoning, pursuit includes the elements of the surrounding situation. Among the imaginary persecutors, who attempt to destroy patients, are called the concrete persons. Patients take active “counter-measure”: hide, attack “persecutors”, complain about them to law enforcement agencies. Due to increased public risk patients during these periods must be hospitalized in a psychiatric hospital for emergency indications.

With the transitory hallucinatory-delusional psychoses occur diverse hallucinatory and pseudo-hallucinatory experiences. Patients see persecutors, perceive “the action of rays” and unpleasant smells. The deceptions of perception are interwoven with the adequate perception of reality. Patients with bewilderment, confusion and fear ask whether their relatives are alive, what exactly is said about them on the radio or in the newspapers, etc. At the same time with the retention subsequently of detailed recollections about its experiences for the period of psychosis there are no enough evidence for constantius signs of consciousness obscuring. The enumerated disorders are, as a rule, the reason for the hospitalization of patients into the psychiatric hospital.

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Transitory psychoses with the predominance of delusional disorders ICD-9: 293. 05 ICD-10: F 06. 22

Transitory hypochondriac states are developed with the appearance of senestopathias and psycho-sensory disorders. Pulsatory, torn, pulling pains, itch, a feeling of heat, the sensation of a change in the dimensions of body, noise in the ears, etc. are clearly expressed. Patients believe they have a serious illness in his disability, the need for special treatment, often they refer to the doctors of different specialties, but in connection with the short duration of episode “they do not manage to reach” the psychiatrist and to obtain release from the work on the temporary disablement. In such cases must be justified the nonappearance of patients at work.

Transient psychosis with a predominance of catatonic disorders ICD-9: 293. 05 ICD-10: F 06.12

In the cases of transitory luсid psychoses with the catatonic disorders the manifestations of confusion, retardation, passiveness in patients are combined with the interrupted ideas of relation and pursuit. With the presence of distractedness, loquacity and affectation are typical the familiarity and arrogance with respect to those surrounding, carelessness, the ease of judgments. The polarities of passion correspond disorder of the type of forced weeping or laughter, impulsive irritability, rough manifestations of negativism, which are expressed, for example, in the form ofunmotivated failure of the fulfillment of usual responsibilities. When to see a doctor, such patients should be recognized temporarily disabled.

The structure of transitory catatonic psychoses with the disorders of consciousness is in many respects caused by the depth of the latter. Most frequently are developed the twilight disorders of consciousness with the total or partial loss of orienting, sharply pronounced by negativism, psycho-motor excitation, automated actions, “wooden” laughter, passion of spite, by aggressiveness. Patients are agitated, excited, they silently resist the attempts to hold them, they run away from the house. In other cases – they dance, they laugh, in the speech – there is abundance of verbigerations, manifestation of echolalia.

In a number of cases the patients express partial ideas of relation, jealousy, pursuit, damage, dramatization. There appear false recognitions. A feeling of tension, anxiety, suspiciousness is changed by panic, tendency to run. They hear familiar voices, “which play

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roles”. In the cases of mutism the presence of delusional and hallucinatory experiences can be judged from the threatening pose of patients, the mimicry of alertness, stressed attention, offence.

Sometimes in patients persists the partial orientation in the environment. They appear suspended, slow in movements, answer questions and with the known criticism their state is evaluated, although the answers frequently bear formal nature and patients do not master the content of conversation. In similar cases with the aid of the goal-directed instructions occurres the possibility to direct their behavior. The disturbance of consciousness for these patients can be characterized as obnubilation.

In the cases of the development of oneiroid remain the recollections about the nightmarish dreams, the flight into space, a stay in paradise or to hell, the trip to the zone with the poison gases, etc. About the contents of the experiences of patients is possible to judge, even with the presence of mutism, on the fixed pose, to the mimicry of ecstasy, enthusiasm, extreme interest, fear and to monosyllabic stereotype statements.

With the presence of acute catatonic disorders all patients are subject to pressing hospitalization into the psychiatric hospital.

Delirium ICD-9: 293. 05 ICD-10: F05. 92

With great acuity occur delirious disorder. As a rule, they are due to alcohol intoxication. Consciousness obscuring occurs for a period of several hours to two-three days. There are characteristic disorientation in place and time, speech-motor excitation, scene-like hallucinations, illusory disorders. All around are seen the destructive and falling walls, the scenes of murders attacking animals. The situation in general seems hostile, unknown. Patients experience fear, actively “participate” in the experienced events, defend themselfs or attack. Fragmentary recollections about the content remains on passing of psychosis for a short period, then there is complete amnesia. Patients are subject to immediate hospitalization.

Subacute transient psychotic state ICD-9: 293. 15 ICD-10: F 06. 812

Here are included psychoses with paroxismal course, differing from those described above not only by larger duration, but also by the more extended beginning and by gradual end. They continue from several weeks to several months and they are subdivided into the af-

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