Mental disorders in epilepsy

N. Landolt (1960), connecting positive mental disorders with the so-called normalization EEG, assumed that the negative disorders are accompanied by an increase of the pathologic changes in the bioelectric activity of the brain. Subsequently (1963) he noted, that “forced normalization” of EEG was characteristic of schizophrenialike syndromes and is absent with twilight states and dysphorias.

In connection to this was assumed that the study of KandinskiyClerambault syndrome in the structure of epileptic psychoses will help to overcome erroneous idea of the specifically schizophrenic nature of mental automatism (L.K Khokhlov, 1964).

The abortive version of this syndrome with epilepsy was described by M.G. Gulyamov (1963). It turned out that pseudohallucinations in epilepsy are more common for the steady paranoid syndromes (L.E. Muzychuk, 1964). They were combined with the special delusional treatment of different changes in the internal organs (N. Shumskiy, 1969), were reduced with the deepening of dementia (I.D. Muratova, 1967; D.S. Ozeretskovskiy, 1969).

Schizophrenia-like oligophrenia in epilepsy was also described (S.S. Mnukhin, 1963). There were indications on few reversible affective disorders, non systematic delusion and dependence of its theme on the biography of patient (W. Mayer-Gross et al., 1960; S.F. Semenov, 1965, and others).

Yet a major advance in the study of prognosis in epilepsy in the fifties-sixties, evidently, is a wider than before use of a clinico-dy- namic approach to the analysis of varied within it mental disorders. These included further attempts to study the correlation structure of psychosis productive and negative symptoms. Following the observed at the childhood age of eretic-hyperkinetic syndrome by enekhetic (M. Matthes, 1961) and apathetic (D.A. Pond, 1963) were revealed the progressive in adult patients tendency toward the systematization of delusional ideas with the disturbances of thinking in the form neologisms (D.A. Pond, 1963), the development of delusional ideas up to the paraphrenic syndrome (G.A. Safonov, 1963) or the development of schizophrenia-like symptoms with the statement of the general organic personal disorders in the late stage of disease (E. Glithero et al., 1963; R.G. Golodets and I.G. Ravkin, 1966). In proportion to reduction in the memory and intellect in the patients with epilepsy were observed affective tension, diverse protracted paranoid, catatonic and hebephrenic symptoms (N.M. Bergelson, 1964; G.S. Butrov, 1964; T. Negishi, 1965; K. Hosokawa,

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1966; R.G. Golodets and I.G. Ravkin, 1966, 1968, 1969; V.N. Favorina, 1969; N. Shumskiy, 1969).

One of the most fruitful areas of clinical epilepsy research in this period was the development of the issue of combined manifestations of epileptic psychosis and epileptic dementia.

According to the observations of M.F. Taltse (1951), the structure of epileptic dementia in a number of cases was caused by the periodically advancing acute psychotic states. In other cases occurred fragments of the paranoiac development of personality and absurd theories. Last suddenly arose, gradually intensified and as suddenly dimmed. Delusional statements bore the stamp of dementia.

E.B. Smyshlyaev (1960) and N.D. Statseiko (1961) described the clinical versions of the initial states of the epileptic disease, which contain in its structure dementia, as“attached” psychotic disorders. These versions were apathetic, paranoid and gravest conditions – type of the undulate stupor, with which the continuous twinkling of consciousness, according to the data, presented by I.S. Tets (1962), was the reason for insufficient tension of mental process.

E.Ya. Sternberg (1969) divided psychotic disturbances in epileptic dementia into the appearing with the clear consciousness short single hallucinations or the accretions of hallucinations with short term paranoid, hallucinoses with the duration of 1-2 months with the auditory and visual hallucinations and the secondary delusional interpretation, prolonged hallucinatory and hallucinatory-paranoid psychoses with the periodic exacerbations.

P.G. Metsov (1962) connected dynamics of intellectual disorders in patients with epilepsy with the duration of the course of disease. In accordance with the author a three groups of the patient were distinguishes: 1 – mainly outpatients with a significant reduction of intelligence and ability to work, 2 – patients, mostly located in the hospital, with a significant reduction of intelligence and ability to work, which are characterized by inertia, viscosity thinking, 3 – patients with profound changes for epileptic personality type with a pronounced dementia and almost complete incapacity. On the clinical manifestations patients of third groups were divided by the author on the mobile and the fussy and inhibited with clumsy movements and extremely slow pace of thinking.

D.P. Demonova (1968) described three types of deep epileptic dementia: with the predominance of the disorders of speech according to the type of schizophasia; with the expressed affective fluctuations

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in the form of distractedness, fussiness and vocal excitation; with the catatonic disorders in the form of a acute increase in the muscular tone, stereotype, impulsiveness. The author allowed the possibility of passing the paranoid version of epileptic dementia into the heavier

– apathetic or schizophasic.

Finally, according to the data of V.N. Favorina (1968, 1969), prior to the development of chronic lucid epileptic psychoses similar disorders entered into the structure of twilight states. Complex para- phrenic-schizophasic, the hallucinatorily schizophasic and catatonichallucinatory muttering states were evolved randomly, rudimentary, fastly and malignantly.

The complexity of the problem of the comparison of positive and negative disorders was due to, in the opinion of V.N. Favorina, by weakening perseneration, torpidity and stiffness of thinking, memory recovery or the appearance of autism, inactivity, apathy, not peculiar to patients earlier.

In a new light and with greater detail than before, were presented observational data showing a variety of versions of dynamics of protracted epileptic psychoses with paroxysmal manifestations, frequency and circularity.

It was reported, includingly, about the paranoid schubs by duration to 8-9 days, which take place without the deep shade of consciousness and without severe amnesia, which leaves residual delusion (S.S. Perskaya, 1950), about the patient with epilepsy, who underwent several bouts of psychosis lasting 2-3 months in the form of mutism, negativism, refusal of food, delusions of persecution and exposure (L.D.Argenio, 1959), about the repetitive epileptic psychoses with the twilight or delirious-oneiroid experiences, with duration to three weeks, different frequency, that either combined or not with dementia (E.K. Molchanova, 1960), about the remissions in the schizophrenia-like symptoms (E. Glithero et al., 1963; M. Sawa, 1963), about the gradual – from 5-6 months to 1,5-2 years – output of a psychotic state (R.G. Golodets and I.G. Ravkin, 1969), about the protracted shizoform states after the short episodes of stupefaction (A.W. Beard et al., 1962; V.S. Pozdniakov, 1967), about the intermittent schizophrenia-like symptoms (K. Hosokawa, 1966), about the need to differentiate epileptic psychoses primarily from schubweise schizophrenia (V.N. Dektyarev, 1967; N. Shumskiy, 1969).

The lesser degree of the manifestation of the organic brain damage during the periodic epileptic psychosis, in comparison with

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the continuous, was noted by P. Flor-Henry (1969). The intermittent course of hallucinatory-paranoid and catatonic states was established by E. Rohlfien (1961), V.M. Bleykher and R.I. Zolotnitskiy (1963), T. Negishi (1965). Frequency of flow in the presence of the epileptic psychosis of paranoid-catatonic symptomatology is present, was noted by R.G. Gismatulina (1968).

The distinctly circular and existence of phases in the course of affective episodic psychoses with epilepsy was observed by V.N. Favorina (1969).

Foundations of modern treatments for mental disorders inherent in the fifties and sixties, contributed significantly to the change of views on the prognosis of epileptic psychosis. In particular, along with the deepening research into the structure and dynamics of epileptic psychoses was actively develop an integrated approach to their therapy. Indeed, as it was pointed out by V.A. Gilyarovskiy et al. (1950), up to the middle of 20th century patients with the manifestations of epileptic psychosis were taken for the course of treatment into the psychiatric hospitals most frequently for the for acute indications and thus the possibility of a complete cure was minimized.

Specifically, in the fiftieth and especially in the sixtieth because of the application of new antiepileptic drugs and neuroleptics, for the first time were proposed the principles of therapy, which are used almost unchanged up to the present time. Simultaneously, since the beginning of the era of psychopharmacotherapy for the first time, for example, was reported about the favorable influence of treatment by classical antiepileptic drugs according to the method of E.I. Karmanova by dilantin, hexamidin, khlorakon, benzonal, epilarktin on the mental condition and the ability to work of the patients (E.I. Karmanova, 1950; S.S. Kaliner, 1950; V.P. Belov, 1956, 1960, 1962; E.S. Remezova et al., 1958; A.M. Korovin, 1962; I.M. Savic, 1962, and others).

The publications, dedicated to the account of the results of application with the epileptic psychoses of the new psychotropic drugs, appeared: elipten (K. Pearce], 1960, et al.), haloperidol (A. Madeddu and et al.., 1960), meprobamate (L. Rossi, 1960; E.S. Remezova, 1965, and others), the preparation of Ro-4-0443 (Demay-Laulam et al., 1960), phenuron (C Crause et al.., 1961), melleril (P.M. Pauig et al.., 1961), majeptil (J.P. Boucquey, 1963, and others), carbamazepine (H.A. Mueller, 1963; T.A. Nevzorova et al., 1968; and others), trioxazin, melipramin and [chloratsizin (V.P. Belyaev. 1964; L.I. Ru-

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binova, 1964), fluorezon and librium (J. Radermecker, 1964), reserpine (V.I. Zapadnyuk, 1965), propazin and nozinan (S.P. Vorobyev, 1965), perphenazine (T. Negishi, 1965), trifluoperazine (R.G. Golodets, I.G. Ravkin, 1966), pazaden (N.P. Hoheisel, 1966).

V.P. Belov (1962) and I.M. Savic (1962) indicated noticeable reduction in the intensity of affective reactions and the elimination of motor disinhibition syndrome, the recovery of thinking and the softening of dysphoria in patients during the treatment with benzonal. Patients felt themselves more cheerful, and their twilight states became less deep and less prolonged during the application of glutamic acid (A.L. Andreev et al., 1955, and others).

According to the data by G.A. Safonov (1963), during the treatment by aminazine the remission in patients began more rapidly and was more steady, if prolonged delusional psychosis was accompanied by the attacs with the loss of consciousness. V.P. Belyaev (1964) spoke about the pathogenetic action of aminazine, which decreases the malignancy of the course of epilepsy.

The combination of anticonvulsive and psychotropic effects was noted also in meprobamate (P.G. Ilem et al., 1960), carbamazepine (H.A. Mueller, 1963; R. Alnaes, 1965; R.G. Golodets, 1969, and others). The absence of narcotic properties and positive influence on the wide circle of psychotic and characterological disorders were attributed to the merits of the latter. According to the observations R. Alnaes (1965), during the treatment with carbamazepine patients became calmer and more sociable. Was noted, however, the low efficiency of this preparation with the chronic epileptic psychoses (V.M. Bantchikov et al., 1968).

Under the treatment by the preparation of Ro-4-0443 (DemayLaulam et al., 1960) and by Haloperidol (A. Madeddu et al., 1960) in patients noticeably decreased the manifestation of aggression, malice and cruelty.

With the accumulation of experience in drug therapy have been developed such general principles of treatment of mental disorders in epilepsy , as the need to customize treatment (E.S. Remezova, 1963; E.I. Sviridova, 1963, and others), prolonged and systematic treatment is similar to the treatment of patients with tuberculosis and diabetes (D.E. Melekhov, 1956). The complex application of the corresponding regime, diet, drugs, endocrine preparations, dehydration methods, physiotherapy, psychotherapy, working therapy, if necessary – surgical measures and climatic treatment became to be recognized as an

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effective (M.Sh. Wolf. 1958; L.I. Kruglova et al., 1963, and others). Control of treating the epileptic psychoses by EEG was required.

The modern (since the beginning of 1970s) development of the period of study of the prognosis of epilepsy, with the psychotic disorders, is characterized not only by the development of synthetic approach to the use of an experience of clinicians of the past, but also by the need to consider these disorders as the usual manifestation of epileptic disease. Occurred in the past and meeting still at present assertions about “the antagonism” between epilepsy and schizophrenia increasingly more frequently are considered as “incorrect” (P. Wolf et al., 1985; P. Sachdev, 1998).

Further development of the results, obtained in the course of structural psychopathological analysis, and knowledge of the course of epileptic process is accomplished predominantly from the clinical positions.

In 1970s-1980s were first published the literature reviews, especially dedicated to the clinical aspect of the problem of epileptic psychoses (M.G. Gulyamov, 1971; N. Wimmershoff, 1971; G. Huber, 1973; G.K. Koehler, 1973; N. Remschmidt, 1973; E. Vencovsky, 1979; G.B. Abramovich and R.A. Kharitonov, 1979; J. Parnas et al., 1982; M. Trimble, 1982; G. E. Berrios, 1984; J. Klosterkoetter, 1984). The thematics of the original works of the indicated period testify the reanimation of the interest of the representatives of clinical direction in psychiatry to the establishment of the connections between the forms of epileptic psychoses and the pattern of the course of epileptic disease.

Even in advanced cases of protracted epileptic psychoses the majority of the authors noted preservation in the patients of the basic radical of epileptic changes in the personality, which is actually the sole reliable diagnostic criterion of epileptic disease (R.G. Golodets, 1970;

S.S.Mnukhin and B.G. Frolov, 1970; B.G. Labun, 1970, and others). At the same time it was indicated the reflection of the premorbid

special features of personality in the structure of the epileptic psychosis. For example, it was noted that the hyper-social features precede paranoiac formations, ideas of relation and pursuit, hypochondriac production (R.G. Golodets, 1970), that the paranoic features are reflected in the protracted course of the delusional symptomatology, in which large place occupy the ideas of health, family, God, responsibility (V.E. Smirnov, 1971).

In terms of the study of the criteria of prognosis with the epileptic psychoses were undertaken attempts of the study not only

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of the role of personality, but also of structure itself, depth, gravity and duration the psychotic disorders (V.N. Favorina, 1971; I.S. Tets, 1977, and others).

The complexity of solving the problems of social and labor prediction in patients with chronic querulant-paranoiac disorders was indicated by R.G. Golodets (1970), M.M. Goreva (1970), R.G. Golodets et al. (1981). At the heart of “micro-social decompensation” was found the overestimation by the patients of their personality, the absence of positive social installations, proper level of self-control (V.I. Khizhnyakov, 1972). However, at the same time was recognized the possibility of retention effectiveness and social integration in patients with the chronic hallucinatory-paranoid epileptic psychoses (L. Gastaut, 1975, and others).

In this case the special importance was given to the data on the possibility of the prediction of various manifestations of psychosis depending on the special features of development, duration of disease and age of patients. As unfavorable, in particular, were recognized the detachment of psychoses from the seizures, the generalized forms of the latter, the inclination of «small seizures» to the status course (P. Wolf, 1973; А. Раhlа et al., 1979), and also the progressive course of schizophrenia-like psychoses 15 and more than years after beginning of epilepsy (E. West, 1972; P. Wolf, 1973; N. Helmchen, 1979; V.A. Derecha, 1979). There were noted short duration and uniformity of psychosis in the teenage period (N.N. Bodnyanskaya, 1970) and the more frequent appearance of psychotic symptomatology at the average age (K.F. Standage, 1973).

According to the data, given by L.V. Levitin (1971) and G.M. Kharchevnikov (1978), with the duration of epileptic disease for 10 and more years, the number of a more than half of the patients found on the clinic observation with the epileptic psychosis for the period of inspection did not work or worked in the lightened conditions.

It was indicated also that in “stunned type” of malignant epilepsy all paroxysms had psychotic imprint, and with “the dysphoric” – was revealed the significant variety of the pictures of psychosis (S.S. Mnukhin and B.G. Frolov, 1970). The development of psychoses with the malignant course of epilepsy was observed two or three times more frequently than with favorable prognosis (A.V. Utin, 1970; Z.D. Gavrilyuk, 1981).

When the versions of the favorable course of epilepsy were described, there was indicated their correlation with the periods of re-

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duction in the mood with the irritability and the impulsiveness in the patients, with psychotic episodes with the presence disorders of consciousness (L.Yu Pushchinskaya, 1971, and others). The unfavorable course of epilepsy more frequently was observed with the transitory verbal-hallucinatory psychoses, than with the analogous structure of protracted ones (V.N. Favorina, 1971, and others).

The type of the course of basic process explained the development of varied acute, prolonged and chronic psychoses (Ya.I. Chekhovich, 1975). The emphasized manifestation of paranoic bradiphrenic syndrome was connected with the unfavorable type of the course of disease (Yu.I. Afanasyev, 1975). The gradual development of epileptic disease before the appearance of protracted delusional psychoses was noted (N.P. Gudzenko, 1977; V.A. Derecha, 1980).

However, common to these groups work was undercount stage of the disease.

In this regard more successful were attempts to the study of prognosis with the epileptic psychoses with the simultaneous calculation of type and stage of the course of epileptic disease. After 4-10 years of relatively favorable course of epilepsy L.Ya. Visnevskaya (1974), for example, observed in patients the outlined depressive phases with duration from two months to the year. Depressive affect was characterized by lability, without reaching severity. All patients were intellectually safe. Changes in personality were manifested by sharpening of the positive pole of epileptic psyche. E.Radmayr (1979) has given cases of the favorable development of the disease, when depressions were its initial manifestations together with the rare convulsive seizures. G.M. Kharchevnikov (1978) described the unfavorable course of epileptic process in the cases of predominance in the clinical picture of twilight states and simultaneously isolated 4 stages of the development of the disease: the appearance of the first paroxysms, attachment to the monomorphic of other forms of paroxysms, the appearance of twilight states and signs of dementia, the growth of dementia.

A similar approach to the study of the prognosis of mental disorders with epilepsy did not contradict accepted for the indicated period ideas about the reasons for the variety of the forms of the course of psychoses generally.

As with every processual disease, epilepsy with the poor in presentation of positive disorders was possible to allocate flow patterns with a predominance of psychotic forms when the negative effects are

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expressed less intensively and found a clear trend toward remission. In this case in the circle of epileptic were included all psychopathological syndromes, except “coarse-organic psychoses”. It was emphasized, that in the nosologic refraction in the course of disease any form of psychotic disorder can begin, that the affective circularity, for example, can be not only manic-depressive, schizophrenic, paralytic, but also epileptic (A.V. Snezhnevskiy, 1974, 1975).

In this regard, special place belongs to the work, which is focused on refining the current forms of epileptic psychosis. In comparison with the distant periods of schizophrenia, with epilepsy was noted large productivity and polymorphism of late lucid hallucinatory psychoses (V.N. Favorina, 1971; J.H. Bruens, 1971). Qualitative differences in the syndrome of Kandinskyi were placed depending on the duration of epileptic psychosis, on presence and degree of the manifestation of epileptic changes in the personality (M.G. Gulyamov, 1971), the manifestation of hypomania – from the preservation of patients (S.G. Matthews et al., 1977). With the unfavorable course of epileptic disease was observed the formation of apathyc-abulic dementia (A.V. Utin, 1970). In the continuous development of the pseudo-paralytic version of epileptic dementia the similarity to the basic stages of progressive paralysis was found, although the states, states close to idiocy, unfolded in slow motion (V.M. Levyatov, 1972). In the late stage of the mixed (at first slow, then subacute) course of epilepsy were allotted the versions of epileptic dementia, different in the prognosis as a result of the different with them relationship of affective disorders, paranoiac formations, to degree and the nature of dementia (B.A. Kazakovtsev, 1976), as the frequent type of the progressive course of epileptic paranoid-hallucinatory psychosis was considered recurrent (B.M. Kutsenok, 1972).

According to the data of M.K. Tsaune and M.Ya. Upenietse (1972), expanded psychotic paoxisms in the patients with epilepsy were developed and concluded more gradually than transitory psychoses, and were divided into the affective, the affective-delusional, the catatonic-oneirod. In the periods of remissions occurred the residual productive symptomatology in the form of neurosis-like or paranoiac disorders and affective fluctuations. V.N. Favorina (1971, 1972, 1977) and L.F. Tuzovskaya (1977) also observed a common pattern with schubweise schizophrenia flow of so-called non-convulsive epilepsy. With this V.N. Favorina connected the increase and the depth of the defect with the frequency of epileptic psychoses and a progressive process, manifestations of which was the development of psy-

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chosis from paranoiac delusion of ordinary plot to the paraphreniachallucinatory syndrome with the delusional confabulations, and also secondary catatonia and formation of the specific negative disorders: bradypsychismus, oligophasia, epileptic optimism.

The same type of schizoaffective attacks with epilepsy, with duration from several weeks to several months with the remissions from several months to one-and-a-half years, were described by G.H. Christodoulou (1978) and G.W. Fenton (1978).

However, the issue of development of schubweise epileptic psychosis remained unfinished. In particular , there were no criteria for delimitation of the last periodic epileptic psychoses , which was repeatedly mentioned in the literature of previous years. It should be noted that M.D. Muratova (1970) considered the periods of the remitting and schubweise course of psychosis the stages of unstable compensation. According to the data of Ya.D. Chekhovich (1972), progressive course of underlaying disease in the periods of remissions could be manifested in strengthening or renewal of the symptoms of organic insufficiency.

It is possible, therefore, to say that in recent decades questions of clinical and labor prognosis with epilepsy, which takes place with the mental disorders, are studied mainly by domestic psychiatrists. The substantial part of the foreign works is not characterized by the novelty of ideas in this direction.

Thus, the given in this survey literatures information testifies the adequacy of structural and dynamic approach to the study of prognosis with epilepsy, which takes place with the mental disorders, and the positive value in this aspect of view on the combined nature of productive and negative disorders in the structure of these states. However, as little developed and largely “static” is the impression of the systematics of epileptic psychosis, which is limited by the traditional separation of psychotic states with epilepsy into transitory, prolonged and chronic. Up to now it is possible to consider it rare or insufficient of the attempt to represent the common picture of the development of mental disorders with epilepsy in their entire variety.

For example, “children’s benign partial epilepsy”, that is characterized by many contemporary authors as one of the rare and easily controlled seizures, by the absence of neurologic and cognitive defects, at the same time, does not exclude the presence in patients of so-called emotional problems. However, in the opinion of P. Vigliano et al. (1997), the data about the recent are sparse and contradic-

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