Mental disorders in epilepsy

ness of epileptic process and the factors of biographical and personal order, undoubtedly, of the participating in the structuring mechanisms and clinical picture of disease.

A study showed that the long-term working prognosis is determined by predominance in the clinical picture of mental disorders of one of the basic psychopathological syndromes: affective, delusional or polymorphous with the catatonic disorders.

The extended prognosis of ability to work in the following three patients with the uniform affective disorders, for example, proves to be indisputably favorable.

Case 1

K., 39 years, engineer, the chief of construction-assembly section. Under the observation of the psychoneurological dispensary for 14 years.

From anamnesis: Heredity is not burdened. In the early childhood he developed normally. At the age of 4 years he had measles. In the school from 7 years, managed well. According to the character was stubborn. Occasionally used alcohol from age of 15. At the end of 10 classes he entered the Civil Engineering College, which finished in 4 years. He married after service in the army at the age of 23 years, soon he entered the Institute of Railway Transport. He had some troubles in his studies. He became irritable, sometimes anxious, there were bouts of headaches, talking in sleep. In one year several times per day began to appear attacs with the loss of consciousness, the tendency to run, absurd statements, the stereotype motions of the hands. Attacs continued several minutes, after which he fell asleep. During treatment with phenobarbital (0.1 per night) attacks soon ceased. At the age of 25 years was his first psychotic episode. During three days was the state of end irritability, the lowered mood, anxiety, the sharply pronounced headaches, nightmarish dreams, hyperemia of face, the hyperhydrosis of palms. He was quick tempered, whining, he even declared to wife, that he might commit suicide. The condition improved as suddenly as it began. In the subsequent three years were noted the short-term (with duration to 1-2 hours) periods of dull-malicious mood several times a year, one-two times per year the attacs with the loss of consciousness, during which he undressed, during several minutes sorted out the things located near to him, tore notebooks, hid the books under himself, etc. With increasing doses of phenobarbital to 0.15 and added to the treatment of chlorproma-

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zine (0.05) these paroxysms stopped, but there were short-term (a few minutes) “loss of consciousness” without falling and convulsive manifestations. The attacs with the loss of consciousness ceased during the addition of 0.2 benzonals; however, the attacs of the disorder of mood were renewed. By reducing daily doses of anticonvulsants or alcohol use occurred a series of seizures with involuntary motor acts. Upon graduation (at age 28) was released (by a doctor) from working in transport. He worked in a hot climate. He was treated on a regular basis. Once without any visible reason during 3-4 days was noted state with a feeling of melancholy, insomnia, depressed by mood, thoughts about death. He attempted to overcome these experiences by the use of the small doses of alcohol. He developed speech motor excitation attack lasting about 5 minutes, in connection with which he was hospitalized in a psychiatric hospital. The last seven years he is regularly treated by benzonal (0,6 in a 24 hour period) and diphenine (0,3 in a 24 hour period). Doesn’t drink alcohol. As a mas- ter-builder, by the chief of section, in the work he was pedantic, in the association and in the family irritable. The frequency of seizures with the psycho-motor manifestations was less than one per year. In last two years twice were noted the periods of headaches, the accompanied by reduction moods, by anxiety with the nuance of irascibility, the painful sensation of passiveness, sluggishness, apathy, loss of mental acuity. Irascibility flares are accompanied by statements of an unwillingness to live. The duration of these episodes is 3-4 days.

During the examination:

Somatic state: Stomach ulcer in the stage of remission. Neurologic state: Without the pathologic changes. Eye fundus: Arteries are narrowed.

Craniogram: Without pathologic changes.

The mental status: In the judgments is somewhat categorical. With the retention of known critical relation to his state and behavior nevertheless considers himself right when he is rough with the subordinates. He assumes that without this, he would not manage his responsibilities. He is accurate. Regularly attends dispensary. Thoughtful with respect to his wife and daughter. Ready for the continuation of treatment until the complete cessation of seizures.

Discussion: The clear dependence of frequency and nature of paroxysms on the conducted therapy with a sufficient activity of the latter, positive social activities, absence of gross changes in the personality allow K. for prolonged time to preserve a good qualifica-

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tion in the acquired profession, to fulfill duties of administrator, to be active in private life. The rare transient psychotic episodes in the form of alarming-depressive states with the vegetative-vascular manifestations cannot estimate as being located in connection with the demonstration of any personal shifts, which had a negative effect on the level of the social-working adaptation of patient. On the contrary, the gradually developing and moderately expressed changes in the personality in the form of a certain strengthening of features of accuracy, pedantry, hyper-social significance in a certain degree contribute to its professional growth.

Case 2

V., 48 years, commodity experts, head of the division of the store. Under the observation of the psychoneurological dispensary for 39 years.

From anamnesis: Heredity is not burdened. Early development is normal. At the age of 6 years had influenza. In school from 7 years, studied well. At the same age the first seizure, she ran forward with “wild cry”, was pale, eyes widely opened, did not react to questions, did not remember about her state subsequently. The attacs of another nature soon began to be repeated. “Thought” for several seconds, then turned pale. Sometimes “after agitation” began “tetanus” for 8-12 minutes. The frequency of such attacs reached up to 5 during the day. For the first time, according to the recommendation of doctor, began to assume phenobarbital – two years after the appearance of the first paroxysms (0,02 in a 24 hour period). Day seizures became considerably rarer: only sometimes with the sharp sound she stopped and looked into one point. At the same time, she began to note sleepiness in the daytime, the attacs of headache. At night “she jumped up, talked”. During the treatment with bromides, by liqueur valerians short-term attacs with pallor and loss of consciousness were increased in frequency up to 10 times a day, increased the frequency of sleepwalking and day paroxysms with the involuntary motions: she turned pale, the expression of face changed, winking was repeated, hands and feet “grew cold”, something spoke, swung by hands. In school she managed well; however, she was anxious in tests, in class 6 she was in connection this freed from exams. During the treatment by luminal (0,05 in a 24 hour period) the paroxysms became rare, they were repeated several times a year. At completion of secondary school she began to work as saleswoman in a book store,

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simultaneously entered the external department of pedagogical institute. She ceased to attend a doctor, ended treatment. Short-term attacs with the loss of consciousness again were increased in frequency to several time per day. In spite of this, successfully finished institute, she continued to work as the division head of the same store. At the age of 27 years the state with reduction in the mood with the periodically appearing feeling of irritation steadfast for a period of 4 months with respect to those surrounding, sensation of the loss of interest in the life for the first time arose. Connected this with the overstrain. Because of the apathy and passiveness she could not do any work at home and her work was carried out with the large stress. In the next year and a half condition was satisfactory. At age 29 began the second protracted period of one year when cited poor memory, fatigue, lethargy, difficulty coping with the usual work duties. She did not consult the doctor. The paroxysms in the form of nonpurposeful walking and incomprehensible speech began to be repeated several times per day. She was frequently irritable. Subsequently began the spontaneous improvement in the state, which was being continued in the course of two months. She was active, contented by her health, although the frequency and the nature of seizures did not change. At the age of 33 years the third psychotic paroxism with duration to four months. Together with the repetition of the disorders, noted in the structure of the previous paroxisms, occurred the continuances of headaches, the disorder of sleep. Paroxysms with the loss of consciousness, but without any motor or convulsive manifestations for a duration to 30-40 seconds were repeated up to 20 times a day. She was for the first time freed from work on the sheet of temporary disablement. Was assigned treatment with phenobarbital 0,1 in a 24 hour period, vitamin therapy. For with the advent of “medicine-induced rash” the dose of phenobarbital was reduced to 0,05. With the regular intake of medicine the frequency of paroxysms fluctuated from 3-5 during the day to 1 per month. She got married. Relationship with the husband was good. She took care of the child, sometimes turned to the doctor with the request about the hospital leaf in order to care of him. Following six protracted paroxisms of mental disorders differed little in the manifestations and the duration from previous. With the complete refusal from the treatment, the paroxysms of the short-term “blackouts” of consciousness were repeated up to 10-15 during the day. The latter, the tenth, according to the calculation, two week psychotic

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paroxism changed into the period, free from the mental disorders, whose duration to the time of inspection was 5 years. All the doctors appointments all these years were only after repeated invitations, she did not take any medication. Paroxysmal disorders with transient loss of consciousness are repeated several times a month , usually in the series to 3-5 day dysphoria – several times a year.

In the examination:

Somatical state: Chronic hyperacidic gastritis out of aggravation. Neurologic state: Light insufficiency of convergence. Light smoothness of right nasolabial fold. Higher patellar reflexes to the

right. Achilles are weakened.

Eye fundus: Arteries are somewhat narrowed. Craniogram: Without the pathologic changes.

The mental condition: Emphasized in her accuracy. Considers herself clinically healthy. She is dissatisfied by the invitations of dispensary. She answers questions monosyllabically. She rejects the proposed treatment, since she considers it ineffective. The circle of interests is limited to working and family responsibilities. She manages the work successfully, she loves it. To the subordinates is demanding. She is pedantic. In private life she is active. She is thoughtful with respect to the husband and the child. Volume, the switching capacity of attention, mnestic functions without the expressed disturbances. Thinking at the usual rate.

Discussion: Frequency and polymorphism of paroxysmal states, the presence of the affective psychotic paroxisms of average duration and the lengthened in the course diseases of the intermission of psychotic disorders made possible for patient for many years to carry out the administrative and operational work of a small volume, to make good adaptation in the working environment, to create family. Activity and endeavor of her behavior with a comparatively not wide circle of interests were outlined for entire elongation of disease, to the period of inspection a somewhat emphasized form were manifested only in, remaining the contributory factors, which facilitate the retention of the sufficiently high level of social-working adaptation. Low efficiency and the irregularity of the adapted therapy – only circumstance, which leaves doubts during the establishment of favorable prognosis.

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Case 3

B., 45 years, metal craftsman. Under the observation of the psychoneurological dispensary for 22 years.

From anamnesis: Both parents were characterized by accuracy, persistent character. At childhood he developed normally. Went to school at seven. At the end of 10 classes, in the age of 17, he began to work as turner, two years later, he was called into the army, where he served four years. On the demobilization, while working as a student of milling machine operator he periodically noted the fear of death, sometimes it seemed that comrades from work followed him, he heard some voices. He was soon hospitalized into the psychiatric hospital in the sharp state: he was inaccessible to contact, screamed out one and the same word (“Tonya”), slapped his hand on the table, grabbed the paper lying on it, made a face, not held in place. Through several days the disturbances indicated ceased, he became calmer, but loquacity was noted, and then began apathy, silence. After carried out insulin therapy he began to answer questions, he revealed partial amnesia for the period of the enumerated mental disorders. In the same sequence similar states were repeated several times in the course of five months. After the application of 7 insuline shocks and 34 sessions of insulin therapy with the development of hypoglycaemic states he was extracted from the hospital. At home he remained lost, pale, sluggish, he complained about the nightmarish dreams, he requested to direct him toward the health resort. He was acknowledged as the disabled of the second group and did not work for two years. During the visit to the dispensary he could not concentrate on the conversation with the doctor, he answered questions with large delay. At the same time he sufficiently actively attained an improvement in the housing conditions, sent many notifications in writing to different instances. In the letters attention was drawn to the tendency toward the detailing, the floridity of expressions. He composed statements strictly in one form, he wrote with clear beautiful handwriting, he always concluded by the phrase: “I do not have a possibility to eat in time which is most important for the health”. At the age of 26 years he was transferred into third group of disablement, he worked as a draftsman, technician. In a year he was acknowledged as completely capable of work, went to work for a senior technician. During this period, almost every night began to emerge sleepwalking , complained of attacks of headache , insomnia, marked periods of increase or decrease in sex

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drive. By months he was loquacious, active, laughed, by months – he was passive, sluggish, gloomy. In such periods he was occupied by self-treatment, especially thoroughly was observed a diet. With worsening in the health was manifested special tendency toward the conflicts in the domestic situation. At times “he came into the fury”, “he began to shake”, with the cry he ran out to the street, “rubbed off by snow”, etc. Independent of the fluctuations of mood with respect to the neighbors he was always arrogant. To the work management he turned with the statements, in which he indicated his “richest experience in work”, required creating for him conditions, with which he could “for this wages bring the greatest benefit in the solution of new problems”. At the age of 28 years he started evening technical school. During this period he noted a substantial improvement in health, was characterized as executive, industrious, initiative-taking worker. With the subsequent period of worsening of headaches, he left the studies; however, in two years later, he entered the same technical school. With the pride showed to the doctor multiplied by him, but not assured by administration production characteristics, in which he was recommended from most positive side. At the age of 36 years, after the use of alcohol developed the first generalized convulsive seizure, and in year – the second. At the same time the attacs of dizziness, which were being accompanied by the sensation of gravity in the head, were increased. Sleep again considerably deteriorated. Mood increased. He was loquacious, sugary, importunate, thorough, bindings. He took medicine on his own scheme. The generalized convulsive seizures began to be repeated several times a year. Usually they appeared in the period of awakening from the night sleep. At the age of 40 years during the regular treatment with benzonal (0.2 in a 24 hour period) the seizures ceased. For past years he worked as metal craftsman; however, invariably he applies to the post of designer, with the authorities he hold himself as “the equal”. He voiced the ideas of jealousy, frequently he quarreles with his wife. He wasn’t interested in the studies of children. In the conversation with the doctor the speech was of the type of monologue, abounded with calls, newspaper cliches. In the periods, continuous 1-3 of month, he was excited, irascible, he quarreled on the trifles, or he was taciturn, sullen, demonstratively left home for several days. Sometimes he completely ceases the treatment. The frequency of the generalized convulsive seizures in this case increases to 2-3 per month.

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On the examination:

Somatical state: Without pathologic changes. Neurologic state: Without pathologic changes. Eye fundus: Pathologies were not revealed.

Craniogram: Without pathologic changes.

The mental status: In the conversation of bindings, loquacious. Speech is florid. He is inclined to perseverations. Speaks about his health, about the methods of self-treatment, which he uses. He advises doctor to study treatment by hearbes, folk remedies. The behavior was demonstrative. With his numerous complaints he tries to show how much he suffers from his illness. He at the same time emphasizes that in spite of this lustrously he manages the responsibilities of technician-designer. Praises members of his family.

Discussion: After beginning from the subacute psychotic manifestations, the disease of more than two decades proceeds without the expressed tendency toward progressive course. In spite of constant sufficiently expressed affective disorders, which resemble cyclothymia, clearly expressed affective-delusional disorders with the aggravations of state, and also presence of paroxysmal disorders, decrease in the level of personality and disturbances of thinking, B. capability for professional work is preserve, as well as his family attachments.

Let us give three histories of disease, which testify the less favorable working prognosis in the cases of predominance in the clinical picture of the psychosis of delusional disorders.

Case 4

K., 53 years, the chief of the administrative and operational division for geological department. Under the observation of the psychoneurological dispensary of 4 years.

From anamnesis: Both parents were characterized as punctual, demanding towards the children. Early development was normal. At the age of 4 years he endured infectious parotitis and scarlet fever. In connection with the unfavorable family circumstances, he went to school only at the age of 10. He was persistent in his studies; however, the grades were “average”. At the end of 7 classes he started to do all housework. At twenty he entered the fire technical school. Two years later, he was drafted into the army. At the front , was wounded . Within two months, was treated in hospital. Then continued with the commander . A few months later (at age 25) suddenly emerged a series of non-deployed seizures. Was dis-

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charged due to illness, disability recognized by the second group. A year later transferred to the third group of disability. Worked as an inspector of fire protection. Married . Seizures with loss of consciousness and expressed mild to-nic-clonic seizures with a predominance of the tonic phase of no more than 1 minute, without further stun repeated 1-2 times a year, and at age 31 stopped without treatment. In the same age was noted the episode of querulant behavior. Within a few days he was anxious, tense, demanded that the authorities “ to take into account years of service, “ the recovery of disability. Despite the recent promotion, quarreled with the head and left work. Over the next several years he worked as an engineer for the supply, supply manager, head of administrative department. At the age of 49 years renewed seizures with a frequency of 4-5 per month. Treated regularly. In the same period there was an episode when during the week complained of numbness in hands and feet, was sluggish, slow, the mood was reduced, experienced difficulties in performing normal operations require a physician referral to the resort, the recovery of disability. Over the next two years such episodes were repeated three times. Every time he was convinced of the fact that he is heavily sick, he did not go to work. He attended the doctors of different specialties, he required the delivery of hospital leaf, he presented complaints of the headaches, shortness of breath, pains in the region of heart, pain in the feet with walking. Simultaneously he rejected the direction to the consultation with the psychiatrist, the continuation of antiepileptic therapy. A year later , after the cessation of seizures, the patient began to emerge daily paroxysms with brief loss of consciousness, pallor of face, preservation of poses. During the week, was anxious, slow. Believed that he had lung cancer. Stated that “ will not tolerate the injustice,” cried in the doctor’s office. Recent years, becoming more viscous and thorough in communicating with others. Emphasized his politeness with the strangers, he was frequently irritable in the conversation with the close ones and the colleagues. With the advent of the night generalized tonicclonic seizures (he yelled, he turned blue, the expanded tonicoclonic spasms, the subsequent sleep) at the age of 52 years started to regularly take phenobarbital (0,1) and benzonal (0,15). He no longer could cope with the same amount of work, for which he repeatedly reprimanded. Twice during the year there were two or three-day periods of elevated mood with the desire to “ get the truth “, written

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applications with complaints to various authorities to the alleged misconduct of doctors and chief of service.

At at examination:

Somatical state: Atherosclerotic cardiosclerosis without the signs of the insufficiency of blood circulation.

Neurologic state: Osteochondrosis of the cervical spine. LOR: Double-sided post-traumatic neuritis of auditory nerves. Eye fundus: veins are coiled, thickened.

Craniogram: Without pathological changes.

Mental Status: In the conversation he is thorough, bindings, is somewhat fussy, obsequious, he is inclined to the faint-hearted reactions. Memory for current events is reduced. In the contact with the close and surrounding patients in the department he is not restrained, inclined to the conflicts. To those occurred in the past for his suspicions relative to the presence in himself of malignant new formation he is sufficiently critical. Their appearance is explained by temporary worsenings in the health status. He sometimes complains to doctor about “incomprehensible agitation”, “close tears”. In general he is inclined to the overestimation of his possibilities. He assumes, for example, that he could completely manage any proposed to him amount of work.

Discussion: During the long period in spite of errors in the therapy, the epileptic process in K. was developed gradually. Was not noted the tendency toward the expressed transformation of paroxysmal states. The repeated psychotic episodes of affective-delusional structure were also little distinguished between themselves. Against the background sub-depressive disorders predominated hypochondriac ideas, ideas of relation, querulant tendencies. With the increase of the depth of dementia, which in recent years gives K. to a decrease in professional sense, to a certain degree the nature of psychotic states changes. To the foreground in their structure affective, predominantly hypomanic disorders come out.

Case 5

Sh., 45 years, in the past the machinist of the elevating crane, for the period of inspection – disabled of the third group, the female medical staff of a hospital. Under the observation of the psychoneurological dispensary during 14 years.

From anamnesis: Heredity is not burdened. Development is normal. In the childhood she healthy. Went to school from 8 years, ma-

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