Mental disorders in epilepsy

naged well. At the end of 8 classes she entered in technical training college, which she finished at the age 17 years in the specialty of turner. In the subsequent 12 years of the machinist of the elevating crane of foundry shop, switchman. At the age of 20 in the periods of falling asleep for the first time had several episodes of visual frauds. Saw many people, heard their cries, anxiety and fear were experienced, sometimes experienced motor excitation. She got married at 23 years. At the age of 29 years, two months after the second childbirth, there was for the first time prolonged paroxism of psychotic disorders. In the course of three months she voiced the ideas of physical action, experienced imperative verbal hallucinations. Under the effect of “the voices” completed the murder of daughter. For two years she was found on the forced treatment in the psychiatric hospital. This entire period state was satisfactory. Actively she participated in the work on department. Soon after extraction developed the second paroxism, analogous to the first, but more prolonged. In the course of six months she was in the psychiatric hospital. The subsequent seven years she was hospitalized into it yearly. The ideas of relation, pursuit, phenomenon of mental automatism, confabulation, the inclusion in the sphere of the delusional experiences of those surrounding, the intermittent psycho-motor excitation, the short periods of stupor – all this completed by the gradual restoration of critical relation to her state, when she told doctor, that sometimes she accomplishes something against her will: “As if someone governs her organism”. True stereotypical verbal hallucinations were noted. “Voices” forced her to search for the killed daughter, “they forged” under the voices of familiar, scolded and offended. Paroxisms were ended by the intake of haloperidol and aminazine at the average daily doses. The duration of paroxisms were from 2 to 10 months, spaces between them – from 4 months to 1 year. Ideas of relation, pursuit and other did not appear in these periods. Immediately after discharge from the hospital she took up work. In one of these periods finished the trade school for the disabled in the specialty of repairman of household equipment; however, she continued to work as worker on the kitchen in the restaurant, female medical staff in the district hospital, etc. After the third paroxism of psychotic disorders in the spaces between the paroxisms was noted hypomanic affect, sometimes with the irregular verbal hallucinations. “The voices”, to which she preserved criticism, spoke about the loss of her son. In connection with this she left the family, she frequently changed apartments. Herself renewed treatment

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with haloperidol, actively she was turned for the council of the doctor regarding the treatment. In this case she was loquacious, insisted on her own qualification of her state. The eighth protracted psychotic schub developed at the age of 42 years. “The voices said” in the course of two months, that she must die, she was hospitalized into psychiatric hospital of connection with the suicidal statements. The lats, ninth, schub was at first in the form of sub-depression with the irregular verbal hallucinosis, and then with the continuous change of hypomanic and sub-depressive phases to the period of present inspection continue about three years. Hallucinatory disorders are more frequent in the form paroxysms – appear sudden noise, whistle, cry: “You will fall under the bus! You will be killed!” and the like. Sometimes in this case she saw the situation of street in the colored image, anxiety appeared. Greatest duration of such manifestations of two or three hours. Ended so suddenly, as they appeared. In the periods between the hospitalizations as before she was retained on the work with the third group of disablement, was characterized by administration from the last place of work as honest, executive, disciplined female worker. She participated in the public life of the environment. Room was obtained. At the age of 43 years the seizures with disconnection of consciousness, involuntary walking during several minutes for the first time appeared. Their frequency – several times a year.

At the examination:

Somatical state: Internal organs without the pathologic changes. Neurologic state: Pathologies were not revealed.

Eye fundus: Arteries are narrowed, veins are extended. Craniogram: Without pathologic changes.

Mental state: In the conversation she is active, inclined to complicated expressions. To the request “to describe” her state answered: “When I take the pen in the hand, everything becomes complicated”. She is thorough with the account of her complaints, details, binding, are somewhat sugary. To “the voices” she relates as to the manifestations of disease. She considers them as the consequence of overstrain. She acknowledges that she sometimes confuses them with the real. In this case are separated the states, which are accompanied by the auditory frauds, about which herself does not remember, but she knows about them from the words of surrounding, which told her about her behavior in the periods, when she accomplishes the involuntary actions (she considers that these actions are caused by the influence “of voices”). She is contented by her work. She answers positively

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on her colleagues. To the fact that lives separately from the family, she relates quietly. She assumes that it must be this way, because she “frequently is sick”. The work of the female medical staff of the receiving department of hospital she manages completely. She does not feel sorry about the decrease in the profession, which also is

Discussion: Attention is drawn to the demonstration of paroxysmal psycho-sensory disorders long before the beginning of the development of schubweise psychosis. Hallucinatory-paranoid and depressive-paranoid schubs in proportion to a decrease in the level of personality in Sh. lost their sharpness and became more prolonged. Paroxysmal disorders of the type of psycho-motor and psycho-sensory seizures became more distinct only in late development stages of psychopathological disorders. In spite of a decrease into the profession, the loss of family relations, prolongedly is retained under the usual work conditions. The delusional and catatonic disorders, noted in the structure of psychotic schubs and remissions, are tightly connected with the affective disorders, which to a considerable extent determine behavior of Sh.

Case 6

N., 44 years, engineer, disabled of the second group, does not work, single, lives with the parents. Is observed by psychoneurological dispensary for 31 years.

From anamnesis: Mother is inclined to the conflicts with others, she always tries to prove her rightness. Early development is normal. At seven years he went to the school, managed well. At the age of 11 years after the previous scarlet fever was the first frequent (to 15 per month) abortive convulsive seizure with the loss of consciousness. Frequently he entered the stationary treatment in the neurologic department; however, “course therapy” by anticonvulsive means proved to be little effective. Manifested perseverance in the studies in high school, with difficulty, but with good grades he finished secondary school. At 16 years he was acknowledged as the disabled of the second group. He finished the physics department of pedagogical institute in 9 years. The reduction of seizures to several time was noted per year from the 20-year age, which was accompanied by a change in their structure. Predominated attacs with the loss of consciousness, the involuntary actions in the form of the transfer of objects. At completion of institute he began to work as laboratory assistant. In two years he was transferred into third group of disablement and

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accepted to the work as the engineer in design bureau. From the first days he began to dispute with the colleagues and the administration. He considered that they underestimate him as engineer, they disregard him in connection with his illness. Besides the seizures indicated, were noted one-two-day dysphoric states with a feeling of depression, irritability, aggravation of the ideas of relation. He began to doubt the correctness of the treatment conducted by doctors. He rejected it. He declared, that it brings more harm, than benefit. In five years he was three times hospitalized into the psychiatric hospital in connection with the development of episodes with consciousness obscuring, that were being developed usually after a series of the convulsive seizures, when he moved furniture, ripped technical documentation, manifested aggression with respect to those, who were attempting to hold him. As an exception he was permitted to continue his work under the household conditions. Having, however, agreed to this, soon he began to require return of the previous place of work. He considered that the administration attempts thus to get rid of him. In the agreement with the administration charged doctors of dispensary and medical-working expert commission. At the age of 39 years with the dispensary inspection began to be noted noticeable sluggishness of patient, his viscosity in the conversation. He proposed his own treatment of his illness. In his opinion, he suffers not from epilepsy, but from the disease of vascular nature, or “the neurosis of right half of body”. As a proof he gave his observations, according to which before the seizure in him “thickened the soaking of right ear, and in the beginning of seizure were noted “shooting throughs from the head to the feet”. After the consultation on this occasion he was turned into the scientific research institute of traumatology and orthopedics. However, he understood on the behavior of the specialists of institute that any therapy was useless with respect to him. “I felt moral gravity because of it”. Consecutively diagnosed in himself “the neurosis of the liver”, “the neurosis of caudal nucleus”, “the neurosis of right thigh”. He proved, that “the center of disease in the liver and the gut”. He assumed that “he was poisoned by worms”: although the worms were brought out twenty years ago, poisoning remained and insufficient circulation in the brain developed. The liver and the caudal part of his brain are interconnected, and he constantly poisons. The frequent fluctuations of mood were noted. In the evenings appeared “stressed and grave condition”. Seizures were increased in frequency to 7-8 times per month. He was newly transferred into the second group of disablement; ho-

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wever, in spite of the recommendation of medical-working expert commission he didn’t leave work. He began to turn into different instances with the complaints of the scoffing relation to him from the side of administration, he frequently used hospital leaf, he “studied” medical literature. Found in himself the new symptoms, “which proved” the diagram of the development of hisillness proposed by him. At the age of 42 years left the work in enterprise. He attempted to work in the conditions of special shop; however, soon and here he began to note hostile attitude to himself from the side of workers and medical personnel. He began to declare, that in thirty years of treatment the doctors spoiled his health, and therefore he required the establishment of the first group of disablement. In the behavior he became extremely monotonous, even more sluggish. He became slovenly. In the expectation of the beginning of the meeting with doctor he could not change his pose for a long time. During the conversation with the doctor he did not turn head. With the smaller interest than it was earlier, he limply presented his view on the origin of his illness. One-two times per year took place the aggravation of the querulant activity, when he required recognizing him as an able-bodied and returning to the work in the specialty. In period of one of such aggravations he was directed toward the stationary inspection to the psychiatric department of the Central institute of the examination of ability to work and organization of the labor of invalids.

At the examnation:

Somatical state: Chronic colitis, dyskinesia of bowels. Doublesided moderately expressed contracture of Dupuytren in the region of hands.

Neurologic state: Moderately expressed vegetovascular disfunction.

Eye fundus: No pathological changes were discovered. Craniogram: No pathological changes were discovered.

EEG: Is revealed the presence of the paroxysms of the slow waves, which have tendency toward the generalization and greatest amplitude in the symmetrical temporal and frontal regions.

The mental condition: His accuracy is emphasized. He helds with a feeling of superiority. Mimicry is poor. Voice is a little modulated. Thinking is hardly mobile. In the speech there are many unique revolutions and neologisms. Judgments are inconsistent. Counts himself as a heavily patient, but at the same time he rejects both the group of disablement and job placement. In the proof of gravity of his

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illness, which was developed through the fault of doctors, he leads different sensations, which in him appear prior to the beginning of paroxysms. He does not notice the changes in the psyche occurred in him in the years of the disease. He considers his behavior correct. He assumes that he has two autonomous circulatory systems, and he feels, when one of them periodically is turned off. Presented his “study” on this question, which consists of the collection of different extractions from the periodicals, augmented by his own statements relative to nature of epilepsy. He is convinced that the greatest effect in the treatment gives the application of sheep feces and yogas. Release from the work estimates as “specially made”. He notes that he sometimes feels the influence of the induced current and gravity on the liver, bowels and head. Series of abortive convulsive seizures were noted within the period of observation in the department, in connection with which he was transferred into the chamber for the patients with the sharp states.

Discussion: Prolonged and active from the very beginning diseases the development of psychotic symptoms did not interfere for N. formally to be retained in the school, the institute, and then for a while to work in the conditions of usual production. The gradual complication of delusional system proceeded as if separately from the development of conflicting relations in enterprise. Only with the development of dementia and the appearance of absurd interpretative delusion, the complete on the delusional motives failure of the proposed treatment in N. social-working desadaptation begins. The phenomena of second catatonia they emphasize stereotypification, “thickening” of other psychopathological phenomena, which do not have tendency toward the reverse development, in spite of the increase of the depth of dementia.

Let us give three clinical observations, that testify the unfavorable working prognosis in the cases of predominance in patients of polymorphous catatonic manifestations.

Case 7

F., 40 years, in the past plasterer, the disabled of the second group, packer in the therapeutic-working workshops of psychoneurological house-boarding school for disabled. Under the observation in the psychiatrist for 19 years.

From anamnesis: Mother died in 37 years because of the sharply developed heart insufficiency. Early development is normal. Started

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school at 7 years. She was sluggish. Left school at the end of the second class. Willingly she worked on the housework, she loved to knit. The profession of plasterer mastered at age 17 of years, in work she was accurate. At age of 21 she got married. Husband soon left her after the first night convulsive seizure happened. Grieved at his departure, “ cried a few days.” Went to the doctor after the onset of daytime sleepiness and attacks of fever. Was hospitalized in a psychiatric hospital, where she had a tendency to detail, memory decline. Within two months of hospital stay was observed three generalized seizures with visual aura: she saw falling from somewhere above chicken eggs. Short-term dysphorias with reduction in the mood, feeling of offence, tearfulness were noted. In these periods she told the doctor about her fear that they will treat her incorrectly. She was acknowledged as the disabled of the second group. She did not work for 10 years, eighteen times she was hospitalized into the same hospital for the period from 1 to 3 months. The reasons for direction to the stationary treatment were at first quickenings of seizures to 3-5 in a 24 hour period, and then – appearance of uniform state with the disorder of consciousness, the disorientation and the subsequent during two-three days immobility, the passiveness, the difficulty of the concentration of attention, the untidiness, the short-term flashes of spite and the aggressiveness with respect to those surrounding. From the 24-years age before the appearance of the disorders indicated she began to complain on the pain of different localization, sobbed etc. The duration of the periods of the disease between the episodes indicated was different: from several months to two and one-half years. In these periods she was industrious, good-natured in private life, she followed her appearance. At the age of 27 years she began to enter the stationary treatment more frequently, since the increased in frequency of episodes with the mental disorders began to proceed with the speech-motor excitation, the sexual disinhibition, the tendency to bare, foolishness or mutism with the thickening mimicry or the expression of horror on face, loud screamings or sobbings, the broken off speech, by the repetition of words, styles. Sometimes appeared other states, when those surrounding within a week noted in her the mimicry of confusion and she repeated again and again one and the same question (where is she?), she saw before herself ten many-colored gallows, hear voice, propose her hang, fear, that she will be thrown in river or under streetcar. She once saw herself dead, she declared with the tears, that wanted to live more. These states every time rapidly were diluted by the ap-

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plication of anticonvulsive and neuroleptic means. The phenomena of mutism and negativism again began to predominate from the 30-year age in the picture of episodes. Generalized convulsive seizures periodically were repeated daily. In the periods of the disease between the episodes of mental disorders she was complacent, sugary, easily transferred to stay in the psychiatric hospital, willingly she participated in the working processes. From the 34-years age she lived in the psychoneurological home-boarding school for invalids, where during the regular antiepileptic treatment psychotic episodes are not repeated for 6 years, the frequency of the generalized convulsive seizures comprises not more than one time per month. Willingly she worked on the packing of cardboard articles in the therapeuticworking workshops of home-boarding school for invalids. She was proud of the quality of her work. The earned money she returned to the sister, who frequently visited her.

At the examination:

Somatical state: Without pathological changes.

Neurologic state: Small asymmetry of ocular slots and nasolabial folds.

Eye fundus: Without pathological changes. Craniogram: Without pathological changes. EEG: Standard version.

RheoEG: The increased resistance to blood flow of the brain in the system of internal sleepy and the vertebral basic of arteries is noted. A certain reduction in pulse hyperemia in the latter from the named systems occurs.

Mental status: In the conversation with the doctor she is complacent, affable. Speech “viscous”, with the expressed manifestations of oligophasia. She does not remember the name of her doctor, with whom associate many years. She does not know date. She does not remember the domestic address of her sister. She does not remember, how many years she lives in the boarding school, in what psychiatric hospital she was treated. In the course of the conversation several times begins to cry (“pitifully itself”). She simultaneously willingly fulfills the folk song, with which many years ago came out in the amateur artistic activity. Jams on the retelling of the unpleasant for her events, which happened many years ago. With the reproach she, for example, recalls the former husband, who left her because of the disease. She reported that she loves to watch“ridiculous” telecasts. She gives the example: “Yesterday it was ridiculous. I looked to the end.

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I already forgot, what love was between them. Some old tied, and she loved someone very young, and old tied…” and the like.

Discussion: The active epileptic process almost from the very beginning demonstrated the frequent polymorphous psychotic episodes, in structure of which catatonic symptoms predominated, occurred oneiroid states, hallucinatory-delusional and affective disorders. The enumerated disorders were, as a rule, developed simultaneously with the twilight disturbances of consciousness. Together with the psychotic disturbances in F. were noted frequent paroxysms, predominantly in the form generalized convulsive seizures. Soon after the subacute beginning of disease in her has been revealed the signs of epileptic dementia. The known stabilization of process at its late stages, in spite of the depth of dementia, contributes to sufficiently steady adaptation of F. to the conditions of working therapy in the psychoneurological home-boarding school for invalids.

Case 8

G., 30 years, in the past irregularly carried out the unqualified work, at present the disabled of the second group without the indication of the period of re-examination. To the period of inspection she does not work for 22 years. Under the observation of the psychoneurological dispensary for 33 years.

From anamnesis: Mother abused alcoholic beverages. Sister repeatedly was hospitalized into the psychiatric hospital. On the first year of life in G. were noted “infantile” seizures. From the childhood she lagged in the intellectual development. From the first class she was transferred into the auxiliary school. Without having finished the sixth class, she left school in connection with the appearances of daily series of convulsive seizures with the loss of consciousness. In spite of the frequency of seizures, to the doctor she for the first time turned only after five years. She was treated irregularly. At the age of 13 years with the inspection by psychiatrist were noted low intellect, weakening of memory to the current events. Was indicated that the patient is religious, obedient, industrious, active in private life. At the 14-years age the first schub of psychosis was noted. Has been lost, mood lowered, spoke about death, “fear of sin”, “fear of burn in that light”. Several times in the day were repeated the paroxysms, during which she moaned, she was braking her hands, she turned on the spot during the fifth-sixth of minutes, she did not answer questions. Afterward assigned in three months treatment with phenobar-

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bital seizures ceased, mood was improved, behavior was regulated, she studied needelwork. The ideas of relation were manifested only in the periods of dysphoria, when she declared, that everyone in her house hated her, wanted to get rid of her. Irregularly assumed phenobarbital 0,1-0,2 in a 24 hour period in the period of an improvement in the state for a period of 11 years, with the curtailment of treatment the paroxysms of the complex structure were repeated: loudly she hiccuped, appeared psycho-motor excitation, she repeated: “Bandits! Flea market! Base!”. During reduction in the mood she felt badly, she became sluggish, bolts were noted. From the 16-years age the disabled of the second group. Several months worked in the cooperative of the invalids on tailoring of blankets. She was discharged in the period of quickening of dysphoric states. She attempted to work at the soap factory, but she was also discharged in 10 days in connection with the frequent conflicts with those surrounding. At the age of 18-19 years depressive disorders were accompanied by suicidal statements, with an increase in the mood she became hyper-sexual, excited, importunate. In general she became more viscous, more sluggish. Coming to the method to the doctor, for a long time she was talking about the events of day as why she quarrelled with the relatives, and why it took her so much time to seat down into the streetcar, etc. The second and third schubs of mental disorders arose at the age of 28 years, they continued each approximately one month with the interval between them in five months. She became stressed, suspicious, she bared, went out, rejected the food, disorderly engine excitation was noted by periods. In spite of all this she was taciturn, she did not answer questions. In the hospital she for a long time remained passively, she was subordinated, almost constantly she was located in one pose, irregularly became excited, aggressive. The subsequent fourth, fifth and sixth schubs continued from four to six months at intervals in to 2-5 months, they proceeded of the same type: mood was elevated, she did not sleep in the course of several days, she heard and saw God, she talked with him, she bared. In the periods between the schubs much said on the religious themes. The latter the seventh, eighth and ninth schubs proceeded with the connection of the ideas of sublimity, they were more prolonged (from two to three years), they alternated by short-term (not more than one month) remissions. At the beginning of paroxisms she was loquacious, she scolded doctors, she called them antichrists. Then she became calm, called herself saint, Christ, she declared, that she will live eternally, did not attend herself, she

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