Mental disorders in epilepsy

associations of psychotherapists. Not only in our country, but also in the entire world the specialty of psychotherapist, in spite of its prevalence, still remains as not completely acknowledged. In the best case psychotherapy plays the role of one of the additional methods of treatment.

Meanwhile the range of the possibilities of using psychotherapy in the medical practice and during the treatment of epilepsy does not yield to measurement, since, as it is known, all forms of mental action on the patient, if they are adapted by the doctor to the adequately clinical picture of disease, also, with the required calculation of the special features of the personality of patient, can successfully be used and can be called psychotherapy.

Should be noted that the prestige of domestic state psychiatry under the conditions for the development of market relations noticeably was reduced because of its chronic insufficient financing, and also, to the great degree, because of the criticism of its precisely that waning side, which was connected with the insufficient propagation in the psychiatric practice of psychotherapy and psychological correction. Indeed how much not proved the need for scientific studies in the customary for us style, medicine in general, and psychiatry in particular, in many respects remain practice and craft and the growing interest of the patients with epilepsy and their relatives in the alternative methods of treatment is the best substantiation of the expediency of more widespread introduction into the medical activity of psychotherapy.

It is impossible not to see that as being a cross-disciplinary view of medical care psychotherapy is addressed primarily to the emotional sphere of the individual and seeks to somehow to get rid of pharmacotherapy, the experience of which, seemingly, should contribute to the unification of the two methods in solving problems of big and small psychiatry. Psychotherapy attempts to occupy its place not only inside the stationary and extra-hospital psychiatric establishments, but also in the hospitals and the polyclinical establishments of general type. This is the consequence of the fact that in a certain sense the society shyly turns away from the fact of natural occurence of mental disorders. Indeed the not without purpose not only media call psychiatrist psychologist, neurologist, psychoneurologist, psychotherapist, but the representatives of control elements of public health use similar designations in their official communications. At the same time still a few clinical psychologists in psychiatric institutions primarily

251

execute the high role of diagnosticians, but not the professionals involved in the process of psychotherapy.

Under the conditions for the growth of the value of non-drug treatment of those, who suffer mental disorders, an increase of the number of psychotherapists and medical psychologists in practical psychiatry becomes necessary. Continuously, however, takes place a situation where developed enough methods of psychotherapy do not find in the domestic practice the wide application.

In the published monographs, managements and in the recently published in the country psychotherapeutic encyclopedia is summarized the enormous experience of foreign and domestic psychotherapy, differentiated guidelines for the use of its methods in the neuroses, alcoholism, drug addiction, mental and physical diseases; however, practical psychiatrists and all the more the doctors of other specialties extremely rarely use these methods.

The first steps in the organization of the system of the continuous education of psychotherapists and medical psychologists, made Russia’s first association of psychotherapists, let hope that it in contrast to earlier than the existed in the country scientific societies will be organizer and ideologist in its region, connecting link between the psychiatric and non-psychiatric establishments in the plan of the guarantee of need for psychotherapy, which exists in the sufficiently extended part of the citizens of the country.

From the total number of those observed by the psychoneurological dispensaries of the mentally sick patients of working age the patients with epilepsy consist about 40%. More than half of them are disabled, and, actually, their mental activity under the conditions of social crisis and unemployment is doomed to transformation into ruins. It is known that the so-called total professional rehabilitation of mentally sick disabled patients under the most favorable conditions comprises not more than 2-3%. The problem of the attraction of these patients to the labor under the specially created conditions cannot be solved without the participation of psychotherapist, medical psychologist and specialist in the social work.

To the greatest extent this relates to the group of the patients with epilepsy with the psychotic disorders and some degree of intellectual decline.

Among epilepsy patients with so-called non-psychotic mental disorders significantly dominate persons recognized as fully able. However, their working and living in the family is now often associated

252

with problems that could be removed with the help of psychotherapy, psycho-correction and sociotherapy.

Approximately in half of 267 inspected by S.A. Gromov (1993) patients with epilepsy are noted neurotic reactions with the fixation of patients on vital difficulties and questions, connected with their health. Psychotherapeutic and psycho-correction work with them was directed on the elimination of changes in the system of their relation to its illness, social position, working employment.

Besides the traditional methods, such as hypnosis and suggestion, the author uses a program of the psycho-correction measures, during the first stage realizations of which between the patient and the psychologist are established confidential relations, in the second stage are conducted basic psycho-diagnostic measures, and on the third are achieved strictly the psycho-correction actions, which are consisted of the following.

To patients with the intact cognitive functions are recommended the forms of employment and the working activities, connected with the fulfillment of calculating operations, writing, reading. “To emotionally labile” patients is recommended autotraining. In the individual and group interviews with the patients are discussed questions of their working activity, family relations. The models of the satisfactory permission of problems contribute to the removal in them of a feeling of uncertainty in the future.

Therapeutic recommendations with epilepsy, in the opinion of J. Beaussart-Defaue et al. (1997), must be addressed to the personality and the personal environment of each patient regardless of the fact, to what cases of disease (“resistent or yielding”) it relates.

With the obsessive-compulsory disorders in patients with epilepsy F.M.C. Besag et al. (1997) use antidepressants in combination with the use of behavioral technician. Behavioral, cognitive and consultative psychotherapies techniques, which are proven to be effective in some patients with the resistance seizures, are used by T. Betts (1997) and R. Thorbecke et al. (1997). Instruction of the patients with epilepsy “effective self-guidance” of M. Boyle (1997) and S. Ried et al. (1997) reduce to three main directions: caution every day, the adjusted style of life, the informed consciousness. As examples of the use of a behavioral therapy for the preventive maintenance of the sharp episodes “causing behavior” for the patients it is possible to conduct the following procedures, recommended by A. Medagoda et al. (1997): the study of the needs of patients, patterns of behavior

253

and starting gears, room games on soft area and in the swimming pool, and for stopping the sharp excitation the use of an aqueous ball or the use of a room of small profile.

Psychotherapeutic oriented art therapy of the patients with epilepsy with the expressed changes in the personality and reduction in the intellect is recommended by A. Germanavicius et al. (1997), who assume that for the persons with “mental disablement” their creation ensures their “self expression” and “realization of its own internal rod”, on which they can “base their life”. K. Geurts (1997) emphasizes that the photograph is capable of facilitating creative expression in the patients with epilepsy, transferring the ordinary language of doctor to “the intuitive, the deep, the self-realized and that healing”. Together with the use of figures in psychological diagnostics Z. Martinovic et al. (1997) systematically uses for psychotherapeutic purposes drawing in the groups of children with epilepsy.

Some studies of the last years are oriented to the aspect of psychological consultation with epilepsy dependent on age.

Investigating family therapy, A. Henley (1997) raises the question whether it must “be narrated” in order to be “accurately addressed” to the system of the relations of sick child toward epilepsy for the transfer of these relations into the discharge of optimum in the plan of self-perception.

With this Z. Martinovic et al. (1997), describing the training of sick sons in the age of 6-9 years conducted by parents, established parallels with the myth about Herakles. For example, each sick child of masculine sex is favorite in his father, who frequently stimulates his man identification via its athletic training. As the hero, who made his mythical exploits with its supernaturalness, child and his parents unite before the burden of epilepsy in their stimulation of physical abilities for scattering of fear before the uncontrollability of body, repeatedly caused by seizures.

S. Jarvie et al. (1997) note that, as in the adult population generally, the elderly patients with epilepsy, in contrast to the young, manifest different kind “psychological difficulties”, caused “somatical, psychiatric and social influences of epilepsy” and therefore in the larger measure they need “medical and psychological consultations”.

To this form of the consultations, conducted in the conditions, which ensure the use of elements of behavioral therapy, can be attributed the work of the so-called “workshops of the memory”, whose stages D. Sawyer (1997) described as follows. “Beginning from the

254

music and the routine relaxation with scene of action it appears establishment with the witty designation. The convicting anecdotes help to manufacture individual resources and strategy of the achievement of success. A call for patients to find harmony and balance, memory and using different techniques of overcoming negative thoughts, feelings and emotions in order to build capacity for long-term learning and memory. Two to three hour training courses in the workshops.”

Group therapy of preschool kids (between the age of 3 to 6 years) with epilepsy and delay of exploring behavior and acquisition of social experience, according to the communication of O. Sugiyama et al. (1997), distinctly increases the level of their social development after the weekly sessions of role games.

Group behavioral therapy of adult patients with resistant partial epilepsy, successfully pursued by C. Uhlmann et al. (1997), is based on the hypothesis of existence of “inverse biological connection”, which is manifested in two directions. Slow cortex potentials are considered as the index of cortex excitability, which changes with the development of seizure. However, the inverse connection of respiration more frequently is considered as unspecific relaxation effect. According to the data of the author, 20 patients obtained treatment “in the group of slow waves”, 10 “in the group of respiration”. Treatment consisted of 35 sessions of inverse biological connection and additional behavioral therapy in the course of 3 months. On the basis the results of therapy the authors come to the conclusion that many patients with epilepsy are capable of controlling the physiological parameters with the intensive training.

Traditionally surgical treatment with epilepsy is examined as the preventive – in the plan of the prevention of the development of steadfast mental disorders in the cases of the development of its forms, resistant to the treatment by anti-convulsants.

A. Ebner (1994) considers that the majority of patients with lateral temporal lobe epilepsy are candidates for the neurosurgical treatment. For the purpose of the development of clinical semiology, which makes it possible to distinguish the cases of mesial and neocortical temporal epilepsy, Y. Kim et al. (1997) analyzed the structure of 105 seizures in 22 operated patients. The sclerosis of hippocampus was diagnosed in 17 of them, in 5 – disembryoplastic neuroepithelial tumors and in 1

– neurocysticerkosis. Engine automatisms more frequent (p=0,02) were encountered with mesio-temporal epilepsy. The frequency of dizziness was greatest with neocortical epilepsy (p=0,006).

255

According to J. Engel (1993), complete control of seizures during the surgical treatment of epilepsy can be achieved in 50-70% of cases of true medicinal resistance. W.J. Kim et al. (1997) consider that 38-40% of patients with the mesial temporal sclerosis are resistant to the drug therapy and can be subjected to successful surgical intervention. According to Y. Mayanagi et al. (1997) mesio-temporal epilepsy is indisputable indication for the surgical treatment in the cases of resistance to the medicinal therapy, and surgical intervention with it has a good clinical prognosis.

The number of supporters of conducting surgical treatment during some psychopathological manifestations of epilepsy in recent years increases. For example, the scarcity of cognitive functions is not explicit contra-evidence for the surgical treatment of epilepsy. In patients with the syndrome Lennox-Gastaut effective can be front of callosotomy. According to J.V. Murphy et al. (1997), D. Blumer et al. (2001), the method of the stimulation of the vagus nerve successfully is used for treating the patients with resistance epilepsies and difficulties of the instruction of children with symptomatic generalized epilepsies.

O. Lapanogov et al. (1997) conducted the combined operations in 52 children with epilepsy, which included the cryo-destruction of amygdala and neurotransplantation of the nerve tissue of embryo in the cortex, nucleus of caudatus and medial part of amygdala. The purpose of transplantation depended “on the type of mental disorders and degree of intellectual development”. After the operation 50% patients were freed from the seizures, 41% had substantial improvement. Improvement in the intellectual functions and reduction of productive psychopathological syndromes occurres in 83% of patients, including – the reduction of affective disorders, anxiety, dysphoria. In 1/3 patients with the imbecility during the year after operation was noted an improvement in the vocal function and thinking.

Catamnetic studies of those, who had the neurosurgical operation in epilepsy, indicate the possibility of development in them after temporal lobectomy of the obsessive-compulsory disorders, which, however, yield to the medical therapy (F.M.C. Besag et al., 1997). E. Garcia-Flores (1997) gives the long-term (on the average 13,2 years) results of the surgical treatment of epilepsy in 100 adult patients, who transferred the operations with the resistant complex partial seizures, and comes to the conclusion about the need for considering chronic mental disorders as contraindications to the operation.

256

Chapter 7

CLINICAL AND PSYCHO-SOCIAL CRITERIA FOR PROGNOSIS

Long-standing antiepileptic therapy doesn’t exclude the possibility of appearance in patients of mental disorders. Determined in essence from the nature of the dynamics of paroxysmal syndrome reduction in progressive course of epileptic process can not be the basis for the approval of a significant improvement in their social prognosis until then, pending the development of the so-called causal treatment and while mental disorders in epilepsy will not be one of the reasons for the high level of disablement (60-70%). With the retention of the existing approaches to diagnostics of the dynamic characteristics of disease the contemporary nomenclature of the psychopathological disorders, revealed in epilepsy, does not contribute to the adequate evaluation of clinical and social prognosis.

The need for the dynamic and structured study of epileptic psychoses and dementia is first of all dictated by the fact that the ruling in the world literature tendency to examine rather neurologic, than psychiatric aspect of the clinical picture of epilepsy prevents the development of so-called “multi-axis classification” (H. Helmchen, 1980), which would satisfy the conditions contemporary diagnosis and prognosis.

If the existing narrowly-directed installation to diagnostics “epileptic syndromes” and the antiepileptic therapy corresponding to it is to a certain degree are justified by the purposes of preventive maintenance and treatment of the initial forms of disease, then the tendency of many doctors to consider psychotic manifestations with epilepsies as alien to it, caused by the combination of epileptic and schizophrenic processes serves so that the contemporary state of the study about the epileptic psychoses gives the possibility to reflect only in the one-sided order, separately from the common picture of disease in essence the statics of psychopathological disorders with epilepsy.

257

However, the dynamic classification of epileptic psychoses in the majority of the cases is limited to the statement of concepts known even in the 19th century, as transitory, protracted and chronic psychoses with the addition of determination “shizophrenia-like”, while the interrelation of the duration of psychosis with its structure actually remains not investigated.

Up to now, not only is not subject to verification the idea of conditionality nosology of psychosis in epilepsy and dementia, but in this respect is not being taught the basic patterns of clinical course of epilepsy. In this case the place, which the psychoses and dementia in the general clinical structure and the dynamics of disease occupy is not refined.

Apparently, only by scarcity of clinical knowledge about the epileptic psychoses and the dementia it is possible to explain the explicit contradiction between the data of the statistical reports of psychoneurological and psychiatric establishments, according to which the psychoses and dementia are observed in the practice during the year almost in each second adult patient with epilepsy, and by literature data, which attest to the fact that the frequency the prevalence of productive and negative psychopathological disorders with epilepsy varies in the limits from 3,8 to 60% (D.P. Scott, 1978; G.B. Abramovich et al., 1979; K.W. Bash et al., 1979; D. Blumer, 1982; V. Cosi, 1980; V. Milev et al., 1982;. Y. Fukushima et al., 1983).

The purpose of the undertaken clinico-catamnetic and epidemiological studies, based on the careful study of the data of the dispensary observation of 511 (244 men, 267 women) adult patients by epilepsy, that live in one district and obtaining regular antiepileptic therapy, was the isolation of some psychopathological criteria of the prognosis of ability to work.

In the course of our studies the data about the wide prevalence of psychoses (61,1%) and dementia (51,8%) with epilepsy, which takes place with the mental disorders, was confirmed.

In the group of patients with psychosis is found almost uniform distribution of the three main registers productive psychopathological disorders: affective (35.3%), delusional (34.9%), and catatonic (29.8%). In the structure of dementia in the majority of patients the inertia, stiffness, toughness and subject-specific nature of thinking (60.5%) is noted. Less common are initial manifestations of dementia with the prevalence of explosive disorders (22.2%) or total dementia expressed as a combination of mnemic-intellectual defect with aspon-

258

taneousness (17.3%). Taking into account the versions of the combination of psychosis and dementia, both groups of syndromes are noted in 383 (74%) patients.

Substantially important for refining the place of psychosis in a number of mental disorders with epilepsy proved to be the fact of the development of the reliable differences between the duration of disease in the groups of the patients with epilepsy with the psychosis and without it. It is established that in the group of patients, who reveal the signs of psychosis, the duration of disease of more than 15 years reliably predominates, and without the manifestation of psychosis occur inverse relationships. If one considers that these data is acquired in the course of a continuous study of all existing age classes of patients, then it is possible to consider that the epileptic psychoses are one of the basic stages of the development of epileptic disease, but not special and all the more not heterogeneous for it form. The basic stages of the progressive forms of epilepsy are: personal changes, paroxysmal and psychotic disorders, dementia. During disease these stages do not change, but seemingly are deposited to each other, the clinical manifestations of the previous stage with the offensive of that following not disappearing, but they are reduced.

Under the conditions of the medicinal pathomorphosis of epileptic disease are not seizures, but namely psychoses and dementia are the main reason of reduction in the ability to work of patients. If in a larger group of patients surveyed by us epilepsy disability was determined in 315 (61.6%) patients, then in patients with psychotic manifestations it is set in 237 (72%) and in group of patients with symptoms of dementia – in 243 (91, 7%).

Patients had insufficient information content for forecasting labor mere fact of establishing forms of flow psychosis: transitory, schubweise or chronic. It is established that the differences between the number of cases of complete ability to work and the establishment of the first and second groups of disablement occur only with the transitory and chronic psychotic disorders.

The forms of the course of psychosis supposedly can indicate the more general regularity, for example, to the genetically caused predisposition of brain to the specific duration of psychotic reactions to the harmfulness, which lie at the basis of epileptic process.

More differentiated data for the expert conclusion about retention or loss of ability to work can present studies of the structural

259

special features of productive psychopathological syndromes. In particular, fully able to work significantly more often than in other clinical forms are recognized with a predominance of patients in the structure of psychotic affective disorders. On the contrary, the second group disability often established where the prevalence of delusional disorders and polymorphic with catatonic inclusions. Disability of the first group more likely than in other forms of psychosis, is set in the presence of clinical manifestations of catatonic.

It was also established that the clinical differences in the nature of negative symptoms correspond only to the more frequent establishment of the first group of disablement with the development in the patients of the expressed mnestico-intellectual defect.

In connection with this specially we analyzed the dependence of the level of the working adaptation of patients on the established types of the course of the epileptic process: favorable, with the set aside exacerbation and unfavorable.

The best results of treatment, social-working rehabilitation and the less expressed manifestations of changes in the personality are noted in patients with the uniform affective and affective-delu- sional disorders. In the structure of transitory and more prolonged schubweise psychoses predominate unipolar affective disturbances, frequently with the dysphoric nuance. Affective-delusional syndromes with the predominance of super-valuable ideas are characteristic for the chronic psychoses.

To the favorable course of disease in these patients correspond to the predominance of the vegetative paroxysms over dysphorias and generalized convulsive seizures, the absence of the signs of epileptic dementia independent of the duration of disease. Characteristic of patients straightness, rigidity and unique egocentric understanding of their debt in combination with special hyperthymism, emphasized by industriousness, by assiduity cause the constancy of their social attitudes and prolonged ability to work.

The type of the course of disease with the set aside exacerbation is characterized by the hereditary presence of the characterological anomalies of epileptoid circle with the paranoiac component, distinct on the third decade of life by the characterological shift in the form of strengthening tendency toward the paranoiac reactions and the inadequate level of claims, by the polymorphism of paroxysmal manifestations and by the therapeutic resistance of the temporal forms of paroxysms, by the preferred appearance of hallucinatory-delusio-

260