Mental disorders in epilepsy

pists, occupational therapist and psychologist (JE Chaplin et al., 1997), in others – epileptologist, nurses, social workers and neuropsychologists (K. Larsson et al., 1997), or psychologists, social workers and neurologists in cooperation with the municipality (A. Piazzini et al., 1997).

Conducting diagnostic interrogations in the population on different aspects of the clinic of epilepsy, quality of the life of patients and their families and other enters into the research programs of centers (M.S. Siffels et al., 1997; R. Thorbecke, 1997; D. Tourniaire et al., 1997, and others).

However, as can be seen from the data in this type of activity has no place for psychiatrists. In most cases, it brings together neurologists and neuropsychologists, at least – neurologists, neuropsychologists, and neurosurgeons.

At the same time one cannot fail to note the significant experience of the diagnostic work of a number of the foreign centers, which widely use for purposes of diagnostics psychological and neuropsychological testing of the patients with epilepsy.

In the opinion of E. Baeta et al. (1997), battery of neuropsychological tests for the investigation of patients with epilepsy should not be too long, which allows to differentiate patients with temporal and frontal focus and assists in the selection of patients for surgical treatment, including tests that have already been approved, determines patients with diffuse or multifocal cognitive defects.

The numerous contemporary methods of similar studies, which from the position of clinicians should be, apparently, carried to the discharge of the auxiliary during the study of the clinical picture of epilepsy, can be grouped as follows.

Studies of the personality: Internatonal Personality Disorder Examination (E.H. de Graaf et al., 1997), MMPI (J.L. Moore et al., 1997) and ММРI-2 (M. Inami et al., 1997), Personality Assessment Schedule (D. Fitzpatrick et al., 1997), The Test of Personal Regulation (M.O. Abdulghani et al., 1997), Three Dimensions Personality Inventory (M. Popovic et al., 1997).

Studies of the behavior: Aberrant Behaviour Checklist (G. Baker et al., 1997), Adaptive Behaviour Scale (S.D. Ferrie et al., 1997), The computerized system of neuro-behavior estimation (S.-L. Lai et al., 1997), Child Behaviour Cheklist (J.K. Austin et al., 1997), Conner’s Teachers and Parents Rating Scale (R.M. Pressler et al., 1997), The behavioral estimated scale (M.O. Abdulghani et al.,

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1997), Testing psycho-motor functions with the use of a labyrinth (M. Sato et al., 1997), Tsumori Infant Developmental Test (O. Sugiyama et al., 1997).

Studies of the cognitive sphere: A Global Assessment of Functions Scale (P. Moran et al., 1997), Continuous Performance Test (M. Levav et al., 1997), French Scale of Memory Efficiency (D. Torniaire et al., 1997), Group test to the general intellect (M.O. Abdulghani et al., 1997), Epilepsy Knowledge Profile Scale (S. Jarvie, 1997), Wechsler Adult Intelligence Scale (N. Adachi et al., 1997; P. Moran et al., 1997), Wechsler Intelligence Scale for Children (O. Aleksic et al., 1997; N. Krstic et al., 1997), Wechsler Memory Scale-Revised (the V. Lespinet, 1997; D. McMackin, 1997; E. Pauli et al., 1997; D. Tourniaire et al., 1997).

Vocal functions in the patients are investigated with epilepsy with the complex use: Porch Index of Communicative Ability, Boston Naming Test, Token Test, Reading Comprechension Battery for Aphasia, Wechsler Memory Scale and Slosson Intelligence Test-Re- vised (R. Abou-Khalil et al., 1997).

Reduction of progress of students is measured with the use of a standard test, which covers arithmetical calculation, writing dictation, a study of orthography, of speech and etc. (A.R. Aldenkamp et al., 1997).

Studies of emotional answer to the stress-factor events are conducted with the use of Picture Frustration Study, Apathy Evaluation Scale and Beck Depression Inventory (G. Bogliun et al., 1997).

For studying the depression in epilepsy are used Beck Depression Inventory and Hamilton Depression Rating Scale (E. Motta et al., 1997; V. Sofia et al., 1997), and also Inventory of Depressive Symptomatology Self Report Questionnaire (C. Sykes et al., 1997).

Special importance by contemporary researchers is given to the complex analysis of cognitive sphere in the patients with epilepsy with the application in each case of a battery of the tests, for example, Wechsler Adult Intelligece Scale, Hodkinson Abbreviated Mental Test, Visual Motor Gestalt Test, Visual Retention Test, Test for Verbal Fluency and Calculation (V. Sofia et al., 1997), Epilepsy Cognition Questionnaire (M.C. Siffels et al., 1997).

As the experience of domestic psychiatry, neuropsychological analysis can not replace clinical research in this complex area, which is a mental disorder in epilepsy. Need to integrate neurologists and psychiatrists in epilepsy centers, and in home practice – and in the mental hospital, confirmed by the following data.

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From the statistical indicators in Russia in general, that relate to epilepsy with absence or presence of mental disorders, i.e., to the contingents of the patients with epilepsy, that are observed by neurologists and psychiatrists, studied by us together with V.B. Golland and G.N. Khrunina, is visible a steady tendency toward the larger morbidity with epilepsy in the sphere of rendering to neurologic aid and larger sickliness by epilepsy in the sphere of psychiatric aid. This impelled us to the development on a scale of the country of the age-qualification differences between the groups of the patients with epilepsy, that were observed by neurologists and psychiatrists in 1997.

It was found that the incidence of epilepsy doesn’t significantly depend on the age of the patient nor the data neurologists, nor according to the data of psychiatrists. At the same time, among the patients observed by neurologists, fairly predominates age group of 0 to 18 years, whereas the psychiatric patients of similar age differences were observed. Obtained by us data emphasizes the need of conducting the special analysis of the age-qualification criteria of the neurologic and psychiatric diagnosis of epileptic disease for purposes of the guarantee of succession with the rendering to the specialized medical aid.

In the practical sense the collaboration of neurologists and psychiatrists would allow, in particular, the efficient use of paraclinic methods of the inspection of patients for diagnostics and treatment of epilepsy in all stages of disease, including those removed.

In this regard, the chapter on differential diagnosis seems appropriate to conclude with brief review of the material of recent years relating to the application simultaneously with neurological, neuropsychological and psychiatric assessment of patients with epilepsy as EEG and neuroradiologic (imaging) methods.

In patients with a favorable course of epilepsy with rare seizures, normal intelligence and normal behavior N. Tatishvili et al. (1997) observed normal basic activity on EEG with the short rare discharges of spike-waves and poly-spike-waves.

Out-patient EEG monitoring, according to C. Gifford et al. (1997), confirms the presence of the significant epileptiform deviations, which correlate with the psychotic episodes, in the form constant irregular spikes and the slow waves in the absence of EEG of deviations during the sleep.

To the importance of a neuropsychological study in the presence in patients of subclinical EEG discharges for purposes of the deter-

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mination of the negative influence of the latter on the cognitive functions in patients was indicated by G.L. Casara et al. (1997). According to them, these discharges in 58% of patients with epilepsy their would negatively reflect on the implementation of patient assignments on hold attention, especially during presenting of incentives. The discharges, which were being appeared before or after the presentation of stimulus, caused retarding temporary reactions to 1015%. As to the electroencephalographic expression of the progressive epileptic involvement of brain A. Cerullo (1997) indicates the second bilateral synchronism with partial epilepsy.

In patients of J. Weglage et al. (1997) the rolandic focus on EEG IQ scarcity distinctly correlated with the frequency of spikes on EEG, but not with the frequency of the clinically revealed seizures. Based on the results of 100 patients with 24-hour ambulatory EEG M.G. Chez et al. (1997) presented a classification of EEG abnormalities caused by the presence of multiple activated sleep focal manifestations.

For obtaining the image of the brain (mapping) are used magnetic, not electric (as with EEG) fields. Magnetoencephalography (MEG) determines the direction of the anomalous electrical activity of the brain, and not just strengthens signals. The epileptogenic section of cerebral cortex is characterized by the increased conducting of electric pulses. Pathologic electric pulses cause the disturbances of the magnetic field of the brain. MEG determines precise localization of epileptogenic center, recording these disturbances. It is considered that MEG supplements EEG, introducing new data in the process of preoperation inspection (H. Stefan, 2011).

According to the data of the MEG-study, carried out by K. Fukao et al. (2009), the disfunction of left temporal neocortex contributes to the manifestation of psychotic symptoms in patients with temporal epilepsy.

Increasing propagation acquires complex use by doctors in the diagnostic procedure of EEG methods and neuroradiologic methods (neuro-imaging).

The latter include nuclear magnetic resonance computer imaging (MRI, MRI), which is the method of choice in the evaluation of patients with epilepsy. Due to the high-contrast MRI decomposition into components and the ability to image small multisurface epileptogenic confirmation can be visualized using a fixed sequence of parameters (LC Meiners, 1997).

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CT (computer tomography) with the use of X-ray is an alternative procedure, if a study with the use of MRI is inaccessible or cannot be carried out for the technical reasons. Although images with CT, identify extensive structural abnormalities, possible errors in the hippocampal sclerosis, certain tumors, cavernous hemangioma, and other developmental disorders (ILAE Neroimaging Commission, 1997). PET (positron emission tomography) – a method of images of local blood flow, metabolism, and neurotransmitter systems in the brain in vivo using as markers of short-lived isotopes. In the inter-ictal period epileptic focus is visible as region with the lowered metabolism of glucose, usually with the marked 18-fluorodeoxyglucose (FDG). In 80% of cases PET with the use FDG visualizes hypo-metabolic region considerably more than the zone of seizure. The metabolism of glucose rises during the epileptic seizure.

SPECT (single photon emissive computer tomography) is characterized by the application of radioactive isotopes with gamma-radia- tion and the more prolonged period of half-life.

PET and SPECT are especially important for the patients with the double-sided foci in the temporal region and in children. SPECT during the epileptic seizure is very important with epilepsy of extratemporal localization (H.G. Wieser, 1997). The studies of SPECT and PET with different tagged compounds in patients with idiopathic generalized epilepsies revealed functional changes in the thalamus, the frontal cortex and to a lesser degree in parietooccipital cortex (P. Wolf, M. Koepp, 2011).

In the group of patients with the chronic epileptic psychosis and the lateralized paroxysmal of EEG by focus, observed by B.K. Toone et al. (1997), with structural MRI scanning was revealed the decrease of the volume of the brain, similar with the fact that is observed “with the primary schizophrenia”. To the presence of the indicated morphological changes in the left temporal lobe with the schizophrenia indicated B. Borgets et al. (1990), P.A. Barta et al. (1990), M.E Shenton et al. (1992), A. Rossi et al. (1992), R.W. McCarley et al. (1993), W.B. Barr et al. (1997), Y. Hirayasu et al. (2000).

With comparative MRI-study of different sections of the brain in patients with temporal epilepsy with the psychosis and without the psychosis in the latter is established the reduction of volumes by temporal, frontal and parietal lobes, superior temporal gyrus and the gray matter of left hippocampus, and also the bilateral amygdala

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enlargement (L. Marsh et al., 2001; L. Tebartz Van Elst et al., 2002; R.L. Marchetti et al., 2003). (Cited. on F. Sundram et al., 2010).

O. Dodu et al. (1997) established a correlation between reduction in the verbal memory and left-side arrangement EEG of focus and MRI-defect. Abnormal MRI-data at various sites in children with epilepsy with central-temporal spikes S. Lundberg et al. (1997) associated with the presence of memory, learning and speech dysfunction.

Furthermore, some data, obtained with the use of neuroradiologic methods (neuro-imaging), acquire independent value for diagnostics of mental disorders with epilepsy. Cerebral metabolism of glucose, for example, studied by D. Ferrie et al. (1997) with the application of PET, is different from the control of the content of the 18-fluorodeoxyglucose in patients with dementia in each share of the brain. Such metabolic disorders, according to the authors, suggests lack of cortical neurons or otherwise transneuronal separation. At the same point Bromfield EB et al. (1992), according to which bilateral reduction in glucose metabolism in the lower regions of the frontal lobe is noted in patients with depression and temporal lobe epilepsy. Prefrontal metabolic asymmetry, according to use this same method Jokeit N. et al. (1997), refers to “changes in episodic memory and the presence of psychiatric symptoms.” In a patient with psychotic episodes in the form of mania, according to N. Motooka et al. (1997), during SPECT in remission was observed hyperperfusion in the fronto-temporal region on the left, while in the period of mania hyperperfusion occurred in the parietal-temporal region on the right. And auditory hallucinations hyper-perfusion in the frontal region was revealed by the same authors in another patient with the psychotic episodes with delusion jealousy in the period of remission, and in the state of psychosis perfusion was “normal”. A third of the observed epileptic with mental retardation with psychotic episodes with auditory hallucinations out of the psychosis occurred the hyper-perfu- sion in of the frontal and lateral temporal regions, and during the psychosis – symmetrical perfusion.

As testified by M.M. Odinak et al. (2010), in the past 20 years in the patients with epilepsy were carried out the large number of PET-stu- dies. Interictal PET with 2-(18F)-fluoro-2-deoxy-glucose (FDG) occurs the reliable study, directed toward the development of the disfunction of the cortex in the form of its hypometabolism. In studies it is convincingly shown that the zone of epileptic focus in the period between attacks is characterized by hypometabolism of glucose.

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According to the data of the authors, with temporal lobe epilepsy PET reveals one-sided interparoxismal hypometabolism or asymmetric bitemporal (“specular focus”) hypometabolism in 90% of patients. Frequently in patients with medio-basal temporal lobe epilepsy in the presence of hippocampal sclerosis zone of cortex dysfunction affects the entire temporal lobe. With frontal lobe epilepsy hypometabolism between attacks is revealed approximately in 60% of patients. With approximately 90% of patients with diagnosed hypometabolism structural imaging reveals a significant anomaly. In contrast to temporal lobe epilepsy, the area hypometabolism is limited to basic defect.

It is also reported that by results of of the comparative PETstudy using [15O] H2O in epilepsy with psychosis and epilepsy without psychosis are established differences in the level of the extraction of oxygen in the frontal, temporal divisions and the basal nuclei and that with the use SPECT between the forms of epilepsy indicated are established the differences in the volume of blood flow in the left medial temporal region (P. Sachdev, 1998).

In light of given data should be supported the hope of M.A. Akimenko (2010) to the fact that the classification of epilepsy will be improved and supplemented taking into account the variety of the manifestations of this disease and different ideas, which relate to its etiology, to pathogenesis, to clinic and to outcomes. According to contemporary classification the diagnosis of epilepsy should be considered as the clinico-electro-anatomical, which is formed from: the description of paroxysms not only by patient, but also by those, who observed them; by the results of a EEG-study, including with the use of functional loads, prolonged video-EEG-monitoring, night EEGmonitoring; by the results of the study by the methods of [neuroimaging], since focal cortical dysplasias are verified with the use of CT in 5%, with the use of MRI – in 80%, PET – to 100% of cases. In this case basic criterion remains – clinical.

Relative to the future results of the search for the neuropsychiatric correlates of negative symptomatology with schizophrenia a similar hopes recently spoke out at the 15th World Congress of Psychiatry

– WPA (S. Galderisi, 2011).

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Chapter 6

POSSIBILITIES

OF THE COMBINED THERAPY

The bases of the contemporary drug therapy of mental disorders with epilepsy were formed in 1950-1960 years in connection with widespread putting into practice of new antiepileptic and psychotropic means. In the subsequent three decades the methods of the drug treatment of epilepsy were improved. One of the results of studies was the establishment of the influence of different antiepileptic means on the mental condition of patients and, in particular, the substantiation of the concept of alternative psychosis (H. Landolt, 1953, and others).

Among the side-effects of traditional and new antiepileptic treatments are noted sedative effect, sleepiness, irritability, headaches and others. For example, according to the data of P.A. Temin et al. (1997), up to 10% of patients, who assume vigabatrin, can have “sharp mood swings, and sometimes a depression”.

In the opinion of K. Wolf (1992), in connection with a sharp in recent years increase of the number of antiepileptic medications is required the development of contemporary approaches to the rational drug treatment of epilepsy, since it is highly improbable, that the application of other methods of therapy (surgical treatment of epilepsy, electrical stimulation and other) will change tendency in the near future.

Influence of the old and new used anti-epileptic drugs on the formation of cognitive-neuropsychological disfunctions in children H. Mayer et al. (1997) consider the factor not less significant risk, than seizures and the subclinical disturbances of the electrical activity of the brain.

C. Wolf (1997) to justify the strategy of the treatment of epilepsy recommends in the first place to consider the therapeutic effect of anticonvulsants. Although they all have an inhibitory effect on the ac-

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tivity of the brain: one – through the reduction of excitement in the cortex, the other – by strengthening the processes of inhibition in the brain – during the treatment it is necessary to strive only to the suppression of excessive excitation in the brain, without impacting on the normal balance between excitation and inhibition in the cortex. As the most frequent (11%) side effect of vigabatrin in children the author points out, for example, the presence in them of hyperkinesis.

A. Izmeth (1997) considers, in this regard necessary in any case of the treatment of epilepsy in patients assess “adequacy of behavior, attention, activity, restlessness, self-care, sleep and mood.”

R.G. Beran et al. (1997) report about the extremely specific syndrome of the aggressive behavior, provoked by lamotrigine – in patients with epilepsy and delay of development. T. Betts et al. (1997)

– about “depressive disorders” and “paranoid psychoses” the patients have in the period of treatment by topiramate. U.M.H. Klumpers et al. (1997) – about the recurrent postparoxysmal psychosis in the patient on the background of five-year treatment by vigabatrin. I.M. Ravnic et al. (1997) – about the manifestations of catalepsy and negativism in the patient with epilepsy, that was being treated by the same medication. According to F. Monaco (1997), vigabatrin is the reason for behavioral and psychotic symptoms in 3,4% adult and in of 6% children with epilepsy, who are treated with the large doses of preparation.

The number of researchers connect the appearance of mental disorders in patients with the resistance of the conducted antiepileptic therapy, including new treatments, which reach 20 -30% (A. Cerullo et al, 1997; P. Dodd et al, 1997; A. Horvath, 1997; S.S.M. Jawad et al, 1997; P. Veggiotti et al, 1997; D. Schmidt et al, 2002; S. Arroyo et al, 2002).

The conducted studies, at process of which the cognitive effects of traditional and new antiepileptic means are evaluated with the use of neuro-psychometric tests (L.C. Hartlage et al., 1980; K.J. Meador, 1997; A.R. Ogunrin, 1997, and others).

There are currently known (A. Maksutov, V. Fresher, 1998; M.J. Kissin, 2009; V.V. Jays, 2009; R.G. Beran et al., 1998; S.I. Johannessen, 2011; A. Khan etal. , 1999; E.H. Kossoff et al., 2001; J.W.A.S. Sander et al .., 1991, and others) the following negative effects of antiepileptic drugs on the psyche of people with epilepsy.

Barbiturates. – The degree of sedative influence is different and in some patients can be manifested with the completely low dosages.

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Short term memory suffers. The children might be hyperactive with the aggressiveness and the irritability, in the adult and elderly – the manifestation of depression, sleepiness, lethargy, depression, ataxia.

Carbamazepine (tegretol, finlepsin). – Ataxia, sleepiness, fatigue. Some patients have features of aggressiveness in behavior, psychosis.

Phenytoin (dipheninum). – Fatigue, cognitive and affective disorders, behavioral disorders, the disorder of drives, sleepiness, insomnia, nervousness, tremor, anorexia, psychosis.

Preparations of valproic acid. – At the doses, which exceed average therapeutic, renders distinct sedative action. Less common

– cause transient manifestations of aggression. With prolonged use of valproate may develop “valproic encephalopathy” with tremor, ataxia and disorders of consciousness.

Succinimides. – In certain cases with an increase in the dosages bradyphrenia, or the increased irritability, fears, aggression, anorexia. In the rare cases – development of psychosis.

Benzodiazepines. – Fatigue, the physical and mental weakness on the base of some retardation, in children – episodes of irritability and hyperactive behavior.

Vigabatrin. Most common are fatigue, mental and physical fatigue, irritability and aggressiveness in some patients, manifestations of depression. More often than during the treatment of other anticonvulsants, develop psychosis. In rare cases – “vigabatrin encephalopathy” with signs of altered consciousness.

Lamotrigine. – Rarely transient manifestations of aggression, agitation; sleepiness or insomnia, anorexia, fatigue, irritability, tremor, ataxia, impulsiveness, restlessness, the episodes of the tangled nature of consciousness, psychoses.

Felbamate. – Sedative action, irritability, fatigue, depression. Gabapentin. – Depressions, irritability, uneasiness, fatigue, the

disturbance of thinking, amnesia, change in the appetite, disorder of sleep, anxiety, tremor, ataxia, impotence.

Oxcarbazepine. – Aggressiveness, fatigue, obnubilation, the disturbance of the concentration of attention, disorder of sleep, fears, depression, mental lability, agitation, amnesia, asthenia, ataxia, tremor.

Tiagabine. – Weakness, fatigue, irritability, the disturbance of the concentration of attention, disturbance of memory, the lowered mood, emotional lability, psychoses.

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