Mental disorders in epilepsy

fective, depressive-delusional, maniacal-delusional states, paroxisms with the circular, paranoiac, delusional and catatonic disorders.

Affective paroxisms (ICD-10: F 06. 327 and F 06. 302) proceed in the form of sub-depressions or hypomanias with the duration of several months. In hypomanic status the patients are productive in their activity. The optimistic estimation of that surrounding, loquacity are combined with the inclination to the inappropriate jokes.

Depressive-delusional paroxisms (ICD-10: F 06. 332) with the paranoiac disorders substantially are not reflected in the behavior and the working activity of patients. They are characterized by a combination of depressive affect with low systematic ideas of everyday content, hypochondriacal ideas and not developed querulant delusion, isolated from the concrete situation of ideas of truth seeking. Maniacal-delusional version is characterized by a good health, high self-appraisal, tendency toward the egotism, the underlining of its volitional qualities, “ability to attain of all”. Ability to work is, as a rule, preserved.

The paroxisms with the two-phase circular affective and paranoiac disorders (ICD-10: F 06. 332) do not lead to the disturbance of the working adaptation of patients. Depressions with hypodynamia or passion of anxiety are soon changed by sub-maniacal states. Hypochondriac experiences – by good health. Delusional ideas bear unstable nature.

From the number of delusional paroxisms (ICD-10: F 06. 22) by smaller duration (to two-three months) and relatively larger sharpness are characterized paranoid. All pathologic experiences are concrete, the irregular deceptions of perception have the specific projection in the space. Hallucinatory experiences are urgent for the patients and after their curtailment they are frequently the reason for querulant behavior. With the repeated paroxisms to the deceptions of perception the patients relate as to the special life, which goes in parallel with real and not interfering in their normal occupation. Some patients evaluate it positively, others – as “the spoiling”, which they request to treat by hypnosis or “black magic”.

The paroxisms of confabulatory paraphrenia last to 4-6 months. The ideas of high origin, sublimity, beauty, might are expressed in “terrestrial” forms. In spite of the tendency to work in the administrative establishments, patients in the cases of corresponding job placement are satisfied by modest post. The special theatricality of their behavior is colored with the plot of delusion. The lat-

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ter agrees with the content of read or seen earlier. In the stories of patients real events are combined with those imagined. The ideas of sublimity remain with the change of maniacal disorders by subdepressive.

Catatono-delusional (ICD-10: F 06. 332) and catatonic paroxisms (ICD-10: F 06. 12) are the basic reason of the repeated hospitalizations of patients into the psychiatric hospital with epileptic psychosis, and in these states patients frequently accomplish illegal actions.

By polymorphism of subacute symptoms differ catatonia-delu- sional attacks, for weeks running with a pronounced excitation, inexpressive tense facial expressions, inappropriate gestures, echolalia, impulsive actions. In the cases of sub-stupor the patients are untidy. Sometimes they are inclined to the vagabondage. The delusional conditionality of the behavior of patients more frequently is revealed on passing of psychosis.

The two-phase nature of course, which is expressed in the alternation of the states of excitation and stupor, is characteristic for the subacute psychotic paroxisms with the catatonic disorders. The tendency to run, to bare, by continuous speech, by unrecognizing of close ones follow passive submission, monotony of poses. In the period of excitation are frequent the verbigerations, echolalias, negative answers, foolishness with the features of infantilism. The disorders of inclinations are expressed in the gluttony or in the failure of the food. Recollections for the period of psychosis remain; however patients can’t explain their behavior.

Other transient psychotic states ICD-9: 293. 85 ICD-10: F 06. 812

Psychoses with the protracted (more than six months, sometimes for a period of several years) paroxismal course are characterized by further reduction in the sharpness of clinical manifestations, and in a number of cases – by specific stereotype of development. On the clinical picture they are divided into the depressive-delusional, paranoiac and catatono-delusional psychoses.

With the protracted depressive-delusional states (from six months to one year) (ICD-10: F 06. 332) delusional ideas are formed against the background sub-depression, the sensations of indisposition, apathy, illness, the disorders of sleep. With increasing duration of psychosis last give way to senestopathias: the brain aches, is paralyzed the tip of the language, void in the head, pulsation in the ear

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membranes, weightlessness, etc. In general delusional experiences are characterized by monotony, absence of alarming agitation. Patients are directed to medical and social expertise to decide on the extension of the temporary disability for “aftercare” and clarify the employment prognosis.

Protracted schubs of psychosis with the paranoiac disorders (ICD10: F 06. 22) (by duration several years) are characterized by the outwardly calm and goal-directed actions of patients on the realization of their ideas. Steady proves to be the querulant activity of patients. Many organizations assign on the examination of their statements of patients. Their letters are characterized by the stereotype quality of expressions, the monotony of descriptions and estimations of the actions “of enemies”. In the expectation of the assumed failure on officials, to whom the letters are addressed, is prepared the project of complaint into the higher authorities. Depending on the plot of delusion, wether, it is connected with the work situation or not, question of ability to work is solved.

For the protracted catatono-delusional paroxisms (ICD-10: F 06. 332) with duration from by 7-8 of months to one year is typical the passage of catatono-delusional symptoms into the prolonged states with the predominantly delusional experiences. Ideas about the presence of special disease, irregular verbal hallucinations are combined, however, in spite of the loss of professional ability to work, with the outwardly correct behavior, and sometimes with the partial understanding of their fears.

Dementia ICD-9: 294. 14 ICD-10: F 02. 8x2

The signs of “simple” epileptic dementia (without the phenomena of psychosis) appear at specific development stage of disease after the curtailment of the transient psychoses with the predominance of hallucinatory-delusional, catatono-delusional and catatonic disorders, and also in the cases of the course of disease without the psychotic disorders.

In the structure of dementia in the majority of patients are noted the sluggishness, difficulty of movement and objectively-concrete nature of thinking; more rarely are observed the cases with the initial manifestations of dementia with the predominance of explosive disorders, and also the cases with the total dementia in the form of the combination of the expressed mnestiko-intellectual defect and aspontaneity.

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The higher level of socio-working adaptation preserve patients with the demonsrations of bradyphrenia, when “affective fire” or “fire excitability” fade, but mnestiko-intellectual disorders do not reach deep degrees. In such cases for rational job placement and determining the degree of the loss of ability to work special importance has the correct estimation of preservable in patients installations to the fulfillment of the monotonous repetitive working operations, to the carefulness of finishing components, installations to the quality of the performance of work, its total fulfillment, not by separate fragments.

With the small manifestation of the viscosity of passion it is possible the job placement in the specially created conditions of the patients with the explosive version of dementia. Patients with the expressed intellectual-mnestic defect most stably are adapted to the labor under the conditions of therapeutic-working workshops.

Other chronic psychotic states ICD-9: 294. 84 ICD-10: F 06. 812

Chronic psychoses with epilepsy according to the nature of the leading syndrome are subdivided into the affective-delusional with the predominance of super-valuable ideas, affective-delusional with the hallucinatory episodes, psychoses with the predominance of querulant delusion, the catatonic psychoses with the affective-delusional inclusions.

Due to the smaller, compared with transient psychosis, acute clinical symptoms, positive symptoms turns out to be “soldered” with the negative. Therefore chronic epileptic psychoses, especially with the predominance of affective and paranoiac disorders, in a number of cases are difficult to distinguish from the pathologic development of personality. The abundance of senestopathias, the complication of delusional disorders, the appearance against the background of af- fective-delusional disorders of hallucinatory and catatonic manifestations, testify, however, in favor “autochthonous” nature of psychosis, to the mechanisms of its formation due to the progression of cerebral pathology. The less impressed personal sphere, the less pronounced dementia, and the later is formed, than to a greater extent remain the most important features of premorbid personality. In the cases of the growth of epileptic dementia and prolonged long-standing course of psychosis in patients increasingly in larger measure is reduced the level of social adaptation.

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The patients of this groups are rarely hospitalized with the aggravation of psychosis and rarely accomplish illegal actions.

Disabled patients in cases of chronic current-affective psychotic delusional structure with a predominance of overvalued ideas is maintained by the weak expression of continuously changing affective phases. The lawfulness of the reference of similar states to the chronic psychosis is based by the stability of the plot of delusional disorders. It is noted the close connection of hypochondriac ideas with senestopathias of different localization. The super-valuable ideas of infidelity appear frequently. The aggravations of depressive-delu- sional experiences are accompanied by insomnia. With the fluctuations of the depth of depression or the change by its short-term phases of maniacal pole the sharpness of delusional disorders decreases. In patients with any duration of psychosis the signs of epileptic dementia are not noted.

The disability of patients with chronic affective-delusional hallucinatory psychosis with inclusions (ICD-10: F 06. 332) depends on the stage of formation of epileptic dementia.

Before the appearance of signs of dementia hypochondriac ideas were located in the close connection with the monotonic sub-depres- sive passion. Therefore in spite of the presence of true visual and auditory hallucinations remains a certain criticism to the frauds of perception, patients are retained under production conditions. To a certain degree to this contribute the ideas of low value and sinfulness with the tendency frequently appearing in them to search for sympathies and support in others. Typical are the senestopathias and tactile hallucinations.

With the onset of steadfast explosive disorders, i.e., with the advent of the initial signs of epileptic dementia, and also by strengthening then the manifestations of bradyphrenia patients completely lose ability to work.

With the appearance of expressed explosive disorders delusional experiences became worse. Hypochondriac ideas are transformed into querulant delusion. Visual deceptions lose their urgency. Patients describe them as the incomprehensible visions. At the same time appears a feeling of artificiality. As if separately appear the ideas of jealousy, different kind the unstable ideas of relation.

With the growth of bradyphrenia the occurring unhealthy sensations completely seize the consciousness of patients, prevent shaping in them of the arbitrary goal-directed efforts, decrease the need for

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the working activity. It is noted the quickening of the phenomena of mental automatism, which serve as material for developing absurd interpretative delusion. Hypochondriac ideas whimsical are united with the ideas of relation and pursuit. The methods of self-treatment are based on “thickening” content of delusion.

In the development of chronic querulant delusion (ICD-10: F 06. 22) is also outlined the specific phasic nature.

Before the appearance of signs of dementia the conflicts with the administration, the members of family, the medical workers rides by fight against the imaginary encroachments of her own rights, prestige, merit. Their detailed systematization is absent with the difference in perspective of the ideas of relation. Super-valuable conviction in their infallibility and superiority over environment, “monotonic rigidity”, sufficient safety of professional habits make it possible for patients to carry out narrowly stated production problems. A decrease in adaptation level sets in in the following stage, when hypomanic passion is complicated due to the tension, the irascibility, the tendency toward the protracted reactions, which facilitate sticking patients on the conflicts, to expansion and the systematization of delusional ideas. querulant delusion is interwoven with the hypochondriac, ideas of relation and pursuit.

The loss of ability to work starts in patients in following development stage of the psychopathological disorders, when delusional constructions acquire ever more monotonous, more absurd and more contradictory nature. With further deepening of the disorders of thinking, querulant behavior in them loses now and then any endeavor. Patients without any regret leave the achievement in the persistent fight and they pass to the litigiousness on another not less absurd occasion. Monologue is usual. Completely there is no interest in the opinion of collocutor. Any objection is received as hostile or not substantiated. The majorities of the patients for years work nowhere end also reject the establishment of the group of disablement. They frequently reject the antiepileptic treatment, and stationary treatment (by way of urgent hospitalization) brings only temporary success.

Uniqueness of the dynamics of chronic catatonic psychosis with the affective-delusional inclusions (ICD-10: F 06. 332) reveal itself in the gradual reduction of the latter and the growth of the expression of the syndrome of monotonic rigidity. The developments of the psychosis of the possibility of working adaptation in patients are evaluated differently in accordance with the stages.

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Appearing before the onset of dementia neurosis-like disturbances are expressed in the form of obtrusive calculation, phobias, irritability. Soon set in the sub-stuporous states, when the low mobility of patients is combined with the phenomena of mutism. There appears the need for the stimulation of patients to the self-service. Stereotypes are noted in the nature of mimic disorders, for example, in the appearance every time with the failure of anything mask of fastidiousness, in the stormy (on the negligible occasion) reactions of protest, in the difficulties in the establishment of contacts with those surrounding. Affective-delusional inclusions are represented by the periods of sub-depression, sensitivity, experiences of a feeling of their own inferiority.

With the first signs of dementia, ideas of reference increasingly cause opposition to others. There appears tendency toward the hostile and petty criticism of entire of proceeding. Malicious grumble on any occasion, a constant distrustfulness, dissatisfaction by all is characteristic. Patients are incapable of the prolonged querulant, and then of any other activity. The frequently expressed negativism repulses from them the close ones.

With the decrease of the acuteness of the affective disorders, the manifestation of negativism will move away to the second plan. Appearance in the patients of tendency toward the stereotype, mechanically figurative forms of behavior corresponds to strengthening the signs of bradyphrenia. Monotonic rigidity is expressed here in the tendency to carry out anything in the best way. Emphasized accurate, imperturbable polite, pedantic, untiring in the work, patients sometimes after prolonged interruption stably adapt to the simple labor.

CRITERIA OF THE DIAGNOSIS

There is no structural differences between the psychoses with epilepsy and schizophrenia. This finds explanation in light of the positions of the concept of united psychosis in its contemporary understanding, which does not reject the generality of basic sectional pathogenesis of processual disorders. The basic differential-diagnos- tic criterias, with the aid of which is verified the diagnosis of epileptic psychosis, are: the presence of epileptic changes in the personality and paroxysms, the appearance of psychotic disorders after is many years (on the average through 10-15) after the appearance of the first

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seizures. The dynamics of epileptic defect is essential diagnostic sign. With the growth of deficiental disorders at first are accented characteristic of patients prior to the beginning of the paroxysms of the feature of the so-called epileptoid personality, and then begins their “consolidation”, because of which “are erased” the specific features of reaction.

These typical epilepsy personality features are: the polarity of affect, propensity to detail, directness and categorical judgments, rigidity, self-centered kind of understanding of his duty, emphasized diligence, punctuality, diligence. These manifestations considerably differ from the changes in the personality, characteristic of the patients with the schizophrenia: closure from those surrounding, paradoxicalness of judgments, ambivalence and other. Changes in the personality in the patients with epilepsy superimpose their imprint, also, on the manifestations of the psychosis: the presence of dysphoric disorders in the structure of affective psychoses, predominantly “terrestrial nature” and detailing the plot of delusion, the heaviness of negativism and the brutal nature of catatonic excitation.

The general diagnostic sign of the progressive course of epileptic disease is the appearance of psychotic disorders on the average after 10-15 years from the onset of the first paroxysms. There occur, however, the predictors of development of one or other type of progressive course of epileptic process. The predominance of vegetative paroxysms in combination with the affective psychoses, for example, should be estimated as the sign of the favorable course of disease. Strengthening the paranoiac features of personality in the third decade of life – as the factor of the risk of the set aside exacerbation of process with the advent of in the subsequent two decades of hallu- cinatory-delusional disorders. Appearance of the generalized convulsive seizures and the polymorphism of psychoses with the catatonic inclusions at the young age – as the factor of the risk of the unfavorable course of disease.

For the diagnosis has a value the dependence of the structure of psychosis on the preferred localization of epileptic focus.

The data of electroencephalogram about the localization of epileptic centers in the deep divisions of the brain more frequently correspond to the predominance of affective disorders in the structure of psychosis. The predominance of hallucinatory-delusional disorders more frequently is noted with the defeat of the temporal shares of the brain, the correlate of which is “the multi-focality” of the disturbanc-

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es of its bioelectric activity. Frontotemporal and frontal localization of epileptic focus corresponds to the presence of catatonic manifestations in the structure of polymorphous epileptic psychosis.

The structure of psychotic disorders changes (complicated, impoverished) or stabilizes in proportion to the development of epileptic process. With all types of the course of epileptic process undoubted value has a regularity and a continuity of the long-standing therapy by antiepileptic means. The doses of the antiepileptic and psychotropic means, effective during the combined treatment of paroxysmal and psychotic disorders, depend on the degree of progressive course of epileptic process. It is established the seemingly dynamic equilibrium between the effectiveness of drug therapy and the rate of progressive course of disease.

The favorable course of epileptic disease does not lead to the formation of epileptic dementia. To it correspond the hyper-social compulsive structure of premorbid personality, the predominance of the vegetative forms of the paroxysms, which successfully are diluted by the corresponding drugs. The therapeutic action of antiepileptic means is manifested immediately after their designation either into the first half-two week of treatment and almost never it leads to the appearance of the new or modified paroxysms. Personal changes in essence are the exaggerated aggravation of premorbid specific features. Straightness, rigidity are combined with emphasized industriousness, assiduity, in many respects by the formal searches for the validity and irreproachable solutions. Special hyperthymism, which causes the constancy of social-working installations and value orientations, is one of the characteristic aspects of the psyche of such patients.

In the structure of the transient or chronic psychoses is noted the predominance of affective and affective-delusional disorders. The transitory psychoses include the depressions, manias, sharp hypochondriac states, anxiety states with the ideas of relation, poisoning, pursuit. The group of paroxismal psychoses is represented by affective, depressive-delusional and maniacal-delusional bouts. Chronic psychoses are characterized by affective-delusional syndromes with the predominance of super-valuable ideas.

To the course of disease with the set aside exacerbation of epileptic process correspond the moderately expressed signs of a intellectu- al-mnestic decrease, distinct personal shift and aggravation of productive psychopathological symptomatology in the distant stages of disease.

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In contrast to the favorable version of the course of disease, paroxysmal phenomena in patients from the very beginning are represented by diverse forms: the psycho-sensory and psycho-motor versions of temporal seizures, absences, the adversive and generalized convulsive seizures.

Under the conditions of systematic treatment the reverse development of paroxysmal syndrome passes several stages; however, convulsive forms disappear very rapidly, whereas the varieties of temporal epilepsy and some focal seizures are, as a rule, characterized by therapeutic resistance.

Epileptic process does not affect the original core of personality, but changes the formal course of the mental phenomena: experiences, methods of expression, reactions, behavioral reports. This is expressed in their moderation and perseveration. However, a comparatively late exacerbation of process nevertheless leads to the fact that increasingly in larger measure changes the personal structure: emotional accessibility gives way for egocentrism, empathy – irritability and aggressiveness, altruistic tendencies – love of power. In these cases epileptic changes in the personality and ability to work are caused, besides the most pathologic process, by the stereotype and monotonous reactions of patient for the manifestations of disease and first of all to the changed position in the family, in the working association, in the micro-social connections. Psychotic manifestations are expressed mainly in the delusional disorders with the hallucinatory inclusions. Here to the greatest extent represented delusional states with the plot of the hypochondriac content. From the transitory psychoses with the predominantly delusional disorders are noted sharp hallucinatory-delusional states, deliria. The schubweise psychoses include the psychoses with the protracted affective-delusional, delusional and catatonic disorders. Chronic psychoses are characterized by predominantly affective-delusional disorders with the hallucinatory and catatonic episodes.

The unfavorable course of epilepsy begins predominantly at the children’s and teenage period and it is caused, first of all, by the organic liasion of brain.

The disease is developed against on the base of cerebral insufficiency and somatoneurological disturbances. Seizures bear polymorphous nature. At childhood they are represented by the typical evolutionary forms: retro and propulsive (“salaams” bows, astatic), pyknoleptic with the elements of oral automatism, myoclonic with

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