Mental disorders in epilepsy

nal disorders and by the moderately expressed signs of a intellectualmnemic decrease in the fourth-fifth decades of life.

In these cases the increase of changes in the personality is frequently caused, besides the most epileptic process, by the stereotypical and monotonous reactions of patient for the manifestations of disease, first of all to the changed position in the working association, in the micro-social connections. In view of these circumstances in the majority of patients professional ability to work is considerably reduced or lost.

Of the unfavorable type of the course of disease are typical elementary and sharpness of personal reactions before the appearance of seizures, paroxysmal manifestations in childhood and adolescence, predominance of the generalized convulsive and temporal paroxysms over the vegetative, series of seizures. Stopping paroxysmal syndrome is possible only with the designation of the maximum daily doses of antiepileptic means.

Personal and intellectual disorders begin simultaneously with the psychotic manifestations in the first three decades of life. Brutal explosiveness, insolvency in the estimation of the surrounding events, torpidity, viscosity of thinking and mnestic disorders are combined with the transitory lucid or with changes in the consciousness by catatonic disorders, protracted catatono-delusional and catatonic psychoses or chronic psychoses with predominantly querulant delusion, polymorphous catatonic states. At the stage of the formation of epileptic dementia by patient characteristically gross reduction in the critical abilities, in connection with which loses capability for any working activity.

In the course of a study we have established, thus, the correspondence of three basic registers of productive psychopathological disorders and three basic types of the course of disease, i.e., existence of the specific continuum of clinico-prognostic regularities in epilepsy.

The revealed almost uniform distribution in the population of patients with epilepsy of the three types of the course of disease must, apparently, have the specific biological basis, which most probably can be studied via the development of the preferred defeat of the functional systems of brain.

As it was already noted in the previous chapters, statistically reliable differences in structure and syndromokinesis of productive and negative psychopathological disorders with epilepsy allow to assume that the favorable type of the course of disease is caused

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by the preferred defeat of the mediobasal divisions of the temporal lobes of the brain, the type of the course of disease with the set aside exacerbation – more extended, including cortical divisions, by the defeat of the temporal lobes of the brain and the unfavorable type of the course of disease – in essence by the diffuse defeat of the frontal lobes of the brain.

In this connection the assumption of F. Oyebode (2008) about the fact that the mental disorders with epilepsy are connected with the organic damages, which affect limbic structures and which implicate frontal lobes are of interest.

The uniform tripolar distribution of the versions of the preferred defeat of the functional systems of brain, apparently, can be considered as the biological prerequisite of the possibility in principle of an improvement in the prognosis, since it is possible that it can be used with the therapeutic and prophylactic purpose the mechanisms of compensation, placed in the nature of the reciprocal relations between these systems (G.N. Kryzhanovskiy, 1981; B.M. Rachkov et al., 1984; A.N. Chibisova, 1984).

The preventive maintenance of epilepsy can be achieved, following the same assumptions, by warning the influence of the exogenous factors, which refer to the preferred defeat of various divisions of the brain. For example, ancestral injuries, according to our data, more closely are connected with the favorable course of disease, while alcoholism of parents and the intracranial infections of early age mainly with the development of the unfavorable type of the course of disease.

At least in the future the substantiation of the pathogenetic therapy of epilepsy must be carried out, in our opinion, not only by the way of the establishment of the possibilities of conducting “target” drug therapy by antiepileptic and psychotropic means according to clinical data, but also via the development of the immune conditionality of preferred localization of epileptic process. On the basis of the aforesaid, and the contemporary data about the effectiveness of the treatment of epilepsy confirm this, the most adequate methods of the combined drug therapy of epileptic disease should be considered in proper time initiated individually adequate mono-therapy, directed toward stopping of the primary or prevailing epileptic focus, and if necessary – also poly-therapy as an attempt at the effect on the interested functional system in general.

Structural and dynamic approach to the analysis of clinical data allowed us already in the previous chapters not only to show a signifi-

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cant variability of psychotic forms of epilepsy, but also to come to the assumption that the current type of epileptic process, as a rule, corresponds to a certain type of psychosis, clinical structure which depends on the affective relationships, delusions and catatonic disorders.

To verify the existence of psychopathology correlates of the type and stage of course of epilepsy was possible, however, only on the basis of the positive results to detect statistically significant associations between these determinants of prognosis. In the course of the search for the proofs of existence of a similar kind of connections we considered expedient to isolate the appropriate risk factors.

Without stepping back from the general principle, that has been adopted in the presenting of the preceding chapters: to consider psychopathological syndrome as the main referance during the study of all manifestations of disease, we, however, considering the latter, simultaneously taking into account the type and stage of the disease, had in mind not only the register of the leading psychopathological disorders, but also the duration of the syndrome and the dynamics of its structure in a period of acute illness, stability or turnover structure syndrome throughout the disease, variants of combinations with other syndromes.

As it is shown by the data of our study, with passing – transient and paroxismal – a reflection of psychosis in some degree progressive epileptic process is the structure of psychosis, duration of psychosis and remission, and their variability in the growth of negative symptoms, stability, or the tendency to transform into the next episode.

Transient psychosis

Due to the fact that the greatest manifestation of activity in the process with the transient psychosis have noted at the stage of development of psychopathology before signs of dementia, and in the initial stage of dementia (percentage of psychotic episodes in relation to the total number of the first of these steps is 49,2, the second – 41.1), interesting for us versions of syndromokinesis were first of all analyzed in these periods of disease.

It was, in particular, found that the clinical pattern of previous and subsequent transient psychosis with a favorable course of the disease is almost constant. The variability of the structure of the subsequent transient psychosis was noted in cases of delayed exacerbation

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of the disease with the process, which is characterized by alternating episodes of psychotic affective disorders with predominantly psychotic episodes and with the predominance of delusional disorders. With the unfavorable course of the disease has been a steady complication of the structure of subsequent psychotic episodes due to catatonic and delusional disorders.

The duration of remissions or spaces of the disease between the transitory psychotic episodes also to a certain degree is connected with the type of the course of the disease: in the cases of process from the remission set aside by exacerbation are more prolonged than with its unfavorable course.

Cases of delayed exacerbation of the disease with epileptic process are often characterized by a change of more prolonged (more than 3 days), psychotic episodes of longer duration (more than 1 year) of remissions, and cases with adverse flowing process – a change of transient psychoses of different duration less time (up to 1 year) remission.

Schubweise psychosis

Greater, than in transient psychosis, polymorphism of productive and negative psychiatric symptoms occurs in cases of schubweise flow of psychosis, in which a considerable variability in frequency and duration of episodes of psychosis and remission rates makes difficult in many cases the timely recognition of a particular stage of the disease. In this regard, for determining the criteria of dynamics of the development of psychopathological disorders in general we elected the sequence number of attack and remission.

For simplification in the statistical processing of clinical material, first paroxisms and remissions in patients were considered by us as initial development stage of psychopathological disorders, the latter – as late, and all paroxisms and remission between them – as the manifestations of the stage of the active development of psychopathological disorders. Since absence or the presence of the signs of defect could be established only with the analysis of the structure of remissions, this approach to the study of the dynamics of disease did not contradict our general installation to the study of the nature of the interrelation between the productive and negative psychopathological symptoms of disease.

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The structure of the previous and subsequent affective paroxisms and intermissions remained practically constant for entire elongation of the favorable course of disease. Delusional paroxisms with the processes with the set aside exacerbation more frequently were observed in the stage of the active development of psychopathological disorders. Affective-delusional paroxisms with the catatonic inclusions and remissions with the productive disorders with the unfavorable course of process more frequently were observed in initial development stage of psychopathological disorders, while the catatono-delusional and catatonic bouts also as remissions with the negative manifestations – in late development stage of psychopathological disorders.

Prolonged (more than 1 year) remissions in late development stage of psychopathological disorders in the paroxismal psychoses were more frequently the sign of the favorable course of process, and short-term (from several days to 1 months) remissions in the same stage of disease were more typical for the process with the set aside exacerbation. The prolonged (more than 1 year) paroxisms in initial and late development stages of psychopathological disorders more frequently were observed in the unfavorable course of epileptic process.

At the same time in the cases of the favorable course of disease the change of the affective and affective-delusional paroxisms by intermissions and by remissions with the residual psychotic manifestations was observed by us for entire elongation of the development of psychopathological disorders.

The change of delusional paroxisms by intermissions in initial development stage of psychopathological disorders and by remissions with the residual psychotic manifestations in the stage of the active development of psychopathological disorders is typical for the course of disease with the set aside exacerbation of process. The change of the paroxisms of any structure by remissions with the negative manifestations more frequently is observed in the stage of the active development of psychopathological disorders, and also in the late stage with the unfavorably current processes.

The results of our analysis of the versions of the change of remissions by the paroxisms made it possible to establish that with the unfavorably elapsing epileptic processes occurs the connection between the previous “poor quality” remissions and the subsequent heavier productive psychopathological disorders. This could be the sign, which indicates the possibility of the combination of negative and productive psychopathological disorders in the structure of psy-

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chotic paroxisms, combination, substantially important for the prognosis for the period of psychosis.

The comparison of the duration of the previous paroxisms and subsequent remissions, and also previous remissions and subsequent paroxisms also proved to be sufficiently productive for the development of the versions of syndromokinesis, which depend on the type of the course of disease.

It turned out that with the favorable type of the course of epilepsy in late development stage of psychopathological disorders more closely is connected the change of short-term (from several days to 1 months) and average duration (from 1 months to 1 year) of paroxisms with prolonged remissions. In the cases of disease with the set aside exacerbation of process in initial development stage of psychopathological disorders more frequently take place the change of the protracted paroxisms by prolonged remissions, and on the stage of the active development of psychopathological disorders – change of short-term remissions and average duration of short-term bouts of psychosis. With the unfavorable course of disease in the stage of the active development of psychopathological disorders most frequent are the changes of short-term paroxisms by the remissions of average duration.

Chronic psychosis

With the chronic epileptic psychoses the analysis of the special features of syndromokinesis of productive and negative psychopathological disorders are presented less than in schubweise form of psychosis difficulties due to the lower variability of the clinical picture within the main stages of the disease.

As showed obtained by us data, the favorable type of the course of disease here also is limited to the initial stage of development of psychopathological disorders. The clinical expression of this are the presence of circular manifestations in the structure of affectivedelusional syndrome, safety in the patients of mnestico-intellectual functions.

For syndromokinesis in the cases of disease with the set aside exacerbation of process and the unfavorable type of course is typical the specific phasic nature, which is manifested in the change of structure and duration of psychotic states.

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At the initial stage of development of psychopathological disorders (before the appearance of signs of dementia) the presence in patients of hallucinatory manifestations in the structure of af- fective-delusional syndromes corresponds to processes with the set aside exacerbation. Adversely for the processes taking place at this stage is peculiar occurrence of symptoms of catatonia in the structure of non-deployed affective and delusional disorders, as well as the transformation of the latter in the polymorphic psychotic states with the presence of affective, hallucinatory and catatonic disorders.

At the stage of the formation of the first signs of dementia with the processes with the set aside exacerbation in the structure of the undeveloped affective-delusional syndromes predominate delusional and appear catatonic disorders. Delusional manifestations predominate with the unfavorably current processes in the structure of complex syndromes with the presence of affective, delusional and hallucinatory disorders, there is noted the transformation of affective-delusional syndromes into the catatonic with the affective-delusional inclusions.

At the stage of epileptic dementia prevalence in patients with disorders of thinking processes of delayed exacerbation corresponds to the weighting of the clinical picture due to the presence of polymorphic affective syndromes, hallucinatory and catatonic disorders. Unfavorable trend characterized by ongoing processes of systematization of delusions, forming the so-called epileptic paranoid dementia.

At the completing or last stage of the development of psychopathological disorders the characteristic feature of the unfavorable course of process is the predominance in the clinical picture of catatonic disturbances.

As far as changes in the duration of the enumerated stages of disease are concerned, tendency toward their shortening in the cases of processes with the set aside exacerbation is manifested later, than in the cases of the unfavorable course of process.

The results of the carried out dynamic and structured analysis of productive and negative psychopathological syndromes in epilepsy, their comparison with the special features of the dynamics of paroxysmal syndrome dependent on age, and also with the assumed ethiological factors and the data of electroencephalographic of study made it possible to approach some assumptions relative to syndromogenesis in epilepsy.

Obtained data allow, in particular, to present the pathogenesis of the development of the form of epileptic disease in question and

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opposing by it the processes of compensation by the mechanism of the liberation phylogenetically of the earlier forms of neuropsychic reactivity from under the controlling influence is later than the formed functional systems of brain. In the ontogenesis this regularity is manifested in the fact that the combination of the factors of hereditary predisposition with the heaviest exogenous harmfulness, which occur in patients at the earliest age, first of all strikes young in phylogenetic sense and, apparently, the more vulnerable functional systems, as a result of which control over the underlying divisions of the brain is disrupted and epileptic process early acquires the greatest degree of progressive course.

Probably due to this syndromokinesis of productive and negative psychopathological disorders with epilepsy, in addition to typical differences (communication options progressive disease with predominant localization of the pathological process), has some differences depending on the depth and extent of cerebral lesion. Clinically, it can be shown that the stage of development of the productive psychopathological disorders in general is in a certain relation to the stage of formation of epileptic dementia.

Many of the contemporary researchers by the general clinical signs “of the loading of prognosis” with epilepsy consider its presence in early childhood, early beginning and frequency of the generalized tonicoclonic and complex partial seizures.

However, in this case the majority of them are oriented to the study of the so-called short-term therapeutic prognosis, first of all keeping in mind the resistance to the therapy cases of disease or the side effects of the medicines used, which one way or another cause the cognitive disfunctions (G. Baker et al., 1997; V. Bourgeois, 1997; N. Collinge, 1997; V. Tretnjak et al., 1997, and others), and only the small part of the authors speaks out about the general favorable or unfavorable outcomes of epilepsy as a whole either of those or others sufficiently prolonged periods.

J. Beaussart-Defaye et al. (1997), for example, speak about “the type and the hardness of epilepsy”. R. Вeran et al. (1997) – about “persistent generalized epilepsy”, P. Vigliano et al. (1997) – about “children’s benign partial epilepsy, which is characterized by the absence of cognitive defect, but with the emotional problems”. G. Braathen et al. (1997) is described “favorable partial epilepsy with the rolandic solderings, with which individual outcome can be sufficiently well prognosis”. E.H. de Graaf et al. (1997) – indicate “high risk of de-

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velopment in patients with epilepsy of different kind of psychopathological symptoms or syndromes”, H. Holthausen (1997) – to the risk of the appearance of psychiatric problems with children’s temporal lobe epilepsy.

The works, which one way or another relate to the prognosis with epilepsy, which already takes place with the mental disorders, prove to be even rarer. E.J. Clarke et al. (1997) compare in this sense the group of patients with the psychosis and without it.

J.E. Festen et al. (1997) voice assumption about the fact that “the form of epileptic syndrome, and also type and gravity of seizure, probably, influence cognitive development”. S. Gifford et al. (1997) present “clinical data about the gravity of the resistance psychotic symptoms of irregular nature”. As about the significant problem answer B. Barraclough (1987) and E. Motta et al. (1997) about the depression with epilepsy taking into account the fact that the suicides with it are observed five, and with its temporal form – 25 times more frequently than in the general population.

According to M.M. Robertson (1997), from 5 to 14% of patients with epilepsy undertake suicidal attempts or commit suicide (cited. on M. Pompili et al. (2007).

In contrast to clinical the given, in the literature last years data of neuropsychological of studies in the region of epilepsy are more static and therefore poorly informative for the prognosis. To judge their prognostic value, probably, it is possible only in their relationship with the clinical manifestations of disease. Nearest of all to our data about the prognosis are located the following clinico-neuropsy- chological correlations.

To the variety and the partial nature, and also “excessive presence of cognitive-neuropsychological disfunctions in children and adolescents with epilepsy” indicate H. Mayer et al. (1997). According to the summary and separate scales G. Baker et al. (1998) find differences in the indices of memory, concentration of attention and motor skill in patients with recently diagnosed epilepsy with different gravity and frequency of paroxysms.

In patients since the beginning of the seizures in the childhood V. Lespinet et al. (1997) established the verbal and visual scarcity of memory, and A.M. Weber et al. (1997) – “the mildly expressed disorders in the cognitive sphere”.

In patients with “good control of the seizures” S.-L. Lai et al. (1997) establish “the disturbances of neuro-behavioural functions, in-

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cluding the speed of motions, visual-engine performance, attention, memory, instruction and mood”, traditionally not excepting in this case as one of the reasons the influence of antiepileptic means. E. Mojs et al. (1997), however, conduct the data, which make it possible to doubt into the inevitability of the detection of the unfavorable effect of antiepileptic drug treatment to the cognitive abilities in patients, including to the verbal memory, the oculomotor integration, the attention and the psycho-motor speed.

D. Tourniaire et al. (1997) indicate to the insignificant influence of antiepileptic drug treatment to the verbal and visual memory.

At the same time, in comparison with the control group, which consists of the healthy persons, in patients with primarily generalized epilepsy even with “well controllable seizures” E. Sarac et al. (1997) reveal the statistically significant reduction in the estimations with the presentation with it verbal and nonverbal tests to short term and permanent memory, and also tests on the fluency of speech. In comparison with the control group, patients of J. Weglage et al. (1997) with favorable epilepsy with the center-temporal spikes noticeably lagged on IQ, visual perception, short-term memory, execution of thin motions. V Sofia et al. (1997) indicate to the presence of the causal connection between juvenile myoclonic epilepsy and disturbances of short term memory and calculation.

Table. 4 shows a set of literature data on the currently allocated to children’s forms of epilepsy, and the likelihood of mental disorders along with them. It is seen how a careful psychiatric verification of preliminary judgments about the prognosis for most of the “new forms” of epilepsy is needed.

Our results, evidencing on the dependence of the nature of the combination of productive and negative syndrome on the degree of progressive course of epileptic process, point to the validity of separation of stages in the development of psychopathological disorders. Along with the increase in the severity of the personal and intellectual disorders leading criteria for clinical worsening symptoms at all stages of the disease is the variability of the structure and the “transitional” nature of the productive psychopathological disorders.

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