Mental disorders in epilepsy

rejected the food, assumed majestic poses. This state was changed by the stupor, when by months she was found in bed with crossed hands on the breast, being completely inaccessible to contact. The application of aminazine, triftazin, haloperidol, phenobarbital had little effective. In the structure of the short-term spaces between the schubs the undeveloped delusional ideas of sublimity were noted. In recent years during the regular treatment with the average doses of phenobarbital, benzonal, primidone the frequency of generalized convulsive seizures composes 1-2 times per month. During the curtailment of treatment the seizures were repeated to several time in the day. Frequency of dysphoria – one-two per month.

At the examination:

Somatical state: Internal of organs without the pathological changes.

Neurologic state: Light squint to the left. Smoothness of left nasolabial fold. Reanimation of abdominal and sole reflexes.

Eye fundus: Retinal veins are extended. Craniogram: Pathological changes are not discovered.

Mental state: She is inactive in the course of two months. Often leaves the house and is out for several days. She is hospitalized from the police department, where she stated that she cannot find her house, she called herself “saint Vasena”, she indicated that “she lives with the god”. In the department she is low-mobility, slovenly, laconic. Periodically in her is noted speech-motor excitation with foolishness, or irascibility, irritability, acts of aggression with respect to those surrounding with the refusal of the food, of the treatment, of the conversation with the doctor.

Discussion: For a period of many years the signs of epileptic dementia were combined in G. with the continuous course of the paroxysmal disorders, which did not undergo substantial changes with the appearance of psychotic symptoms. All three syndromes: paroxysmal, psychosis and dementia with the subacute in the entire course of disease reached their complete development. A comparatively small reversibility of productive psychopathological disorders under the action of the adapted therapy by neuroleptic preparations during comparatively the more effective treatment of seizures is of interest. Duration of the period of complete working deadaptation in G.

– main evidence of unfavorable prognosis.

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Case 9

K., 32 years, the district inspector of the police. He is not observed by psychiatrist.

From anamnesis: Heredity is not burdened. Early development is normal. In the childhood obedient, disciplined, executive, the matter initiated always led to the end. Attended school at 7 years. He was characterized by clear, beautiful handwriting, he contained notebooks in exemplary order. In the studies he was diligent. Because of good memory he easily learned lessons by heart. He began to manage more badly at 14 years, dubbed the seventh class. By eighteen years he fi- nished secondary school. From this time he began to observe the attacs of palpitation, which were repeated several times a year. He perceived that the blood overfilled blood vessels, rose “upward”. In this case he thought that the head increases in the sizes, appeared gravity in the region of forehead, grew dark in the eyes, in the field of sight dark yellow spots appeared, felt general weakness, changed the intonation of voice, but he did not lose consciousness. He went to the doctors; however, no treatment was assigned. Soon similar states began to be repeated to 5-6 times a week. To understand them, read the works of Pavlov, Sechenov. Despite his illness, he was drafted into the army. He was satisfied with service. Regulations strictly were carried out. He did not go in the release. In the free time he learned by heart school textbooks. He decided, that after demobilization from the army “will dedicate himself to fight with the disturbers of social order”. Immediately after demobilization he started working as a policeman. He continued to be interested “in the interrelation of nervous system and organism”. “Studied” psychology. Strictly observed the regime of day, diet. He refused drinking bouts with the comrades on the service, in connection with which served as the object of mockeries. At the age of 25 years was the first generalized convulsive seizure. Paroxysms without spasms were repeated with the previous frequency. He finished the one-year school of the police. Being district inspector, he tried to maximally rationally use his operating time. According to his own expression, he worked as clockwork. In the bearing of service he approached the ideal, which formulated as “the combination of most great modesty, simplicity and amazing fitness for work”. He by heart learned literature on criminal law. He reseated trees in the garden into one line. To the assumed different forms of disturbances from the side of the inhabitants of section on several years forward prepared the texts of reports to the imposition of penal-

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ty, thanks to which on the insignificant occasion he “in proper time” fined disturbers. In this case in the official characteristics he was represented as inspector, “weakly knowing the work of the organs of the police, incapable to be dismantled at the complaints of citizens”. At the age of 29 years unexpectedly for those surrounding he got married (wife to the wedding he saw only one time). Relations with the wife were considered good, from the marriage he had two children. He assumed that the conflict with the chief, whom, in his opinion, “harbored” to him “offence” in connection with the fact that he participated in the arrest of his friend, was the reason for direction to the working examination. In his opinion, for the substantiation of posing of the question about the fitness for further service chief used the case of the seizure, which arose in him during the work. According to the information, obtained from the wife, for the latter of one-and-a-half year she four times observed in him the states “of confusion”, when he did not answer questions and stood several minutes motionlessly.

Somatical state: Without the pathological changes. Neurologic state: Insufficiency of convergence. Light smooth-

ness of left nasolabial fold. The tone of muscles of extremities is reduced. Reflexes on the hands are evenly reduced. Knee reflexes are higher at the right. Achilles are reduced, the left higher. Dermographism is red, steadfast.

Eye fundus: Without the pathological changes.

Craniogram: The figure of finger depressions is somewhat intensified.

EEG: Gross diffuse disturbances of the electroactivity in the form of epileptic discharges, predominantly in the caudal divisions of brain trunk.

RheoEG: A certain lability of the blood flow of the brain in both hemispheres without the essential deviations from the standard is noted.

Mental state: He is always polite. He in detail presents anamnestic data, but in this case constantly he is distracted from the basic theme. Any question he answers immediately, without a moment’s hesitation. In the conversations with the doctor, with the manager of department, at the conference of doctors he behaves monotonous, without confuse with new situation, by the presence of the large number of unknown people. To the questions repeated in the different time he gives the absolutely stereotype answers, which occur the quotations learned by heart. He also by heart gives information from dif-

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ferent textbooks, periodicals, newspapers. Associations appear easily, but not in terms of the main semantic value, but according to the secondary signs. Without manifesting the signs of tiredness, he can speak for hours. With entire abundance of stamps he is only superficially informed in the basic events of public life. He is convinced that he could become great artist or scientist. For affirming this in any situation he attempts to sing, to recite verses, to give endurances from the philosophical compositions. In the department he is imperceptible, petty precise. Several psycho-motor seizures were noted by the duration of 20-30 minutes, when he was pale, “lost”, indistinctly he muttered, he walked along the corridor, he did not react to questions, disorderly he fussed, searched for something .

Discussion: The tendency toward the stereotype forms of behavior noted even at the childhood acquires since the beginning of the paroxysms the emphasized nature. The phenomena of eidetism, a good mechanical memory with the low development of intellect, comparatively rapidly developing dementia and further stereotypification of the acquired habits convert K. in the certain automaton, immediately, without any comprehension reproducing different little relating to the situation information. The inadequacy of behavior, which at first could estimate as the uniqueness of personality, with the deepening of dementia becomes the main reason for his working desadaptation. The absence of any attempts at the treatment of disease on entire its elongation, apparently, played big enough role in the latter.

These data provide evidence that the primary determinant of long-term employment prognosis for epilepsy flowing with mental disorders are biological factors that shape the stereotype of the disease in general. Under this condition, relevant in order to develop measures of secondary and tertiary prevention is the problem of modeling the type of flow of epilepsy in its entirety, including its later stages. In this regard, taking into account the results of the statistical verification of clinical patterns presented in the previous chapters, it was necessary to get some average quantitative data describing the dynamics of the epileptic process and the dynamics of social adaptation of patients.

It was established that in the majority of patients the first signs of psychosis appeared reliably within the later periods than the first paroxysms. On the average the beginning of the development of psy-

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chotic disorders was noted in 11,4+/-0,4 years after the appearance of the first seizures. Exception was only the cases of the unfavorable type of the course of disease with the chronic psychosis, when between the duration of life cycles in patients paroxysmal and psychotic disorders are not revealed statistically reliable differences.

The specific differences between the types of the course of disease occurred, also, in later development stages of psychopathological symptoms. If in patients with the set aside exacerbation of process with all forms of psychosis the first signs of dementia appeared reliably later, than psychotic disorders, on the average for 8,3+/-0,6 years, then psychosis and dementia were formed practically simultaneously with the unfavorable type of the course of disease.

At the same time, in spite of significant depending on the type of the course of the disease of the fluctuation of the age of patients in the period of the appearance of the first signs of psychosis, the average value of this index even in the most unfavorable cases was at least 19,0+/-1,3 years.

It was also established that the effectiveness of the conducted rehabilitative measures reliably distinguished with the different types of the course of disease.

Under the conditions of the regularly conducted combined therapy of epileptic psychoses this can be outlined on a number of indices. According to obtained by us statistical data, with the different forms of the course of the psychosis: transitory, schubweise or chronic, depending on the type of the course of disease are located the total duration of the period of the adaptation of patients in the conditions of usual production without the establishment of the group of disablement, the total duration of the period of disablement, the duration of the period of the complete working deadaptation of invalids, the duration of the period of the readaptation of invalids under the specially created conditions and under the conditions of usual production without the limitations.

The obtained by us data about a comparatively late appearance of psychopathological disorders, sufficient for the comparative measurement in the majority of the cases of the duration of the stages of disease and explicit dependence of the effectiveness of the measures for social-working rehabilitation on the type of the course of disease, finally convinced us of the need for the study of levels of social adaptation of patients to compare their existing structural and dynamic features of psychosis and dementia with characterological change.

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This need was caused by that circumstance that with the predominant number of cases of agreeing the clinical and working prognosis nevertheless occur the expert situations, when in spite of the progression of negative manifestations the advancing reduction of psychotic syndromes should be evaluated the favorable condition, which facilitates a certain increased level of the adaptation of patients. It was noted, that for practical job placement of patients in such cases fundamental importance acquire the criteria not of the general or longterm, but more visible on the time prognosis.

However, as far as extended prognosis is concerned, in the course of a study was revealed the possibility during its establishment to use some qualities of personality, typical for patients even before the demonstration of psychosis. It turned out that for the prediction of the type of the course of epileptic process in the period indicated the greatest value have such personal manifestations, which were noted in patients before the onset of the first paroxysms.

A study showed, in particular, that the complex of the personal characteristics, conditionally in reference to the premorbid, namely: the predominance of the steadiness of personal features in combination with the mildly expressed asthenic manifestations, the tendency toward the fantasies and the alarming-over-anxious features, reliably more frequently can be the base for the prediction of the favorable type of the course of epilepsy. The polymorphism of the premorbid special features of personality or the absence of tendency toward the predominance of any of these special features more frequently corresponded to the polymorphism of that forming many years of the later clinical picture of epilepsy with the set aside exacerbation of process. However, combination in the premorbid stage of such personal manifestations as introversion, excitability, reactive lability, retrospectively could be evaluated as the early of the forerunner of the unfavorable course of disease.

At the stage of the disease between the beginning of paroxysms and the appearance of the first signs of psychosis with exception of the group of patients, which were carried to the favorable type of the course of process, in patients were observed several different complexes premorbid personality manifestations. From the personal manifestations, which sufficiently definitely indicate the possibility of the set aside exacerbation of process, in this stage disease the greatest value had a strengthening in patients of paranoiac features and tendencies toward the fantasies with the general safety of ade-

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quate behavioral reactions. At the same time distinct personal signs of its unfavorable course became the difficulties of the adaptation of patients, the combination of introversion with the excitability and the reactive lability.

As has already been indicated above, the value of the personal special features of patients for the short-term or visible in the time prognosis in the cases of the offensive of the late manifestations of disease (psychosis and dementia) was expedient to trace via the analysis of the possibilities of the social-working adaptation of patients for each of the isolated by us stages of the development of psychopathological disorders.

During the first stage the developments of psychopathological disorders, that is concluded with the advent of the first signs of dementia, personal manifestations in patients acquire the features, which make it possible to speak no longer about the emphasis of the premorbid properties of personality, but about their specific qualitative changes. At the same time the differentiation of personal manifestations here could be noted only with the favorable course or the course of disease with the set aside exacerbation of process. To the favorable type of the course of disease corresponds combination in the patients manifestations of conformity and altruism with strengthening of hyper-sthenic features, hyper-social significance, tendency toward explosive type reactions, and also with the sufficiently expressed mental rigidity. Their hyper-social significance in combination with the tendency toward the conflicts, the high self-appraisal, the paranoiac reactions, the inadequate level of claims occurs the personal characteristics of patients with the type of the course of disease with the set aside exacerbation of process. In patients with the unfavorable type of the course of the disease at this point of the development of psychopathological disorders was not revealed the reliable predominance of any specific disturbances, and “the uniformity” of the distribution of personal disorders it rather testified in favor of their polymorphism.

Existence of above stereotype changes in the personality as the manifestations of progressive course of epilepsy in a certain degree is confirmed by indication of E.H. de Graaf et al. (1997) to the fact that it is possible to consider interrelations between epilepsy and personal disorders as those determining the general prevalence of psychopathology in the population of patients with the seizures. P. Moran et al. (1997) find personal disorders in 40% of patients with epilepsy, directed for the surgical treatment.

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At the subsequent stages of epileptic disease personal manifestations in our patients stepped back to the second plan, being found under the cover of psychotic and cognitive disorders.

Smaller in comparison with the previous stages of disease differentiation of characterological special features indicated here the so-called leveling of the features of individual reaction, characteristic of patients in the premorbid stage and in the early stages of disease. This circumstance confirms that expressed by us in the chapter, dedicated to the description of structure and dynamics of epileptic psychoses and dementia, position that the personal changes at the last stages of disease, to a considerable extent losing individual features, contribute to the consolidation of the classical features of the so-called epileptic psyche.

Approaching, therefore, the question of the relationship between the individual and in the later stages of psychosis of epilepsy, we, on the one hand, found that with the onset of symptoms of dementia manifestations of individual personality, to which one could “appeal” in the implementation of social and labor rehabilitation of patients are largely restrained disease. On the other hand, it appears that there is no reason to neglect this clinical reality, what are the facts of known variability in levels of social adaptation of patients considered at stages of the disease: from the device to work in home-based employment conditions to the device not only in specially created, but also in normal conditions of production. In any case, it is not sufficient to explain the diversity of social adaptation of patients only as a variety of manifestations of psychosis and dementia in epilepsy.

As the measure for the practical permission of a question it was intended to examine by stages of the diseases those special features of the personal reaction of patients, which would demonstrate their relation to work and others.

The corresponding analysis showed that the most productive in this respect is not so much the establishment of personal qualities that are important to model the type of disease in general (above personality shifts to the period of the onset of dementia), but the selection of “personal capacity”, which promotes the formation of attitudes and motivations of the patient, in some way adequate to the level of his actual adaptation. Terms of so-called natural experiment, to which is a long-standing practice of social and occupational rehabilitation of patients, in our opinion, are sufficient to detect this kind of setting and motivation.

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With the advent of the first paroxysms and further complication of paroxysmal symptoms the noted by us above strengthening or the emphasis of premorbid personal features, the manifested with the favorable course diseases and with its course with the set aside exacerbation in a sufficient ease of the adaptation of patients to the new conditions, and also in the emphasized obligation, the accuracy also of their kind of hyperthymism (“epileptic optimism”), not only contributes to an improvement in progress of patients in the school, but also, in the presence in them is critical relation to the disease, the satisfactory mastering of the habits of correct behavior of the association under the working conditions in the usual production. Patients are capable of acquiring not only average, but also secondary specialized and high education, they prolongedly preserve professional habits.

In contrast to this, the strengthening in patients at the same stage of the disease of paranoiac features, reactive lability, excitability, characteristic, as noted above, to the beginning of the unfavorable course of disease, leads to the fact that the majority of patients with difficulty are adapted in the environment beginning from the period of instruction in the general education school. They can acquire only initial or incomplete secondary education, and subsequently carry out predominantly physical work.

In the prognostic aspect special position belongs to the study of the problems of school desadaptation with epilepsy in the contemporary literature.

According to V. Sander et al. (1997), the delay of mental development in the children’s population of the patients with epilepsy is noted in 18,1% of cases.

With an increase in the risk of the delay of mental development with epilepsy connect the early beginning of seizures, some types of seizures, absence of the remissions of seizures, localization of damages lying at the basis of epilepto-genesis and “the modus operandi of seizure” (H. Holthausen, 1997; L.G. Neyens et al., 1997; R.M. Pressler et al., 1997; A. Quattrini et al., 1997).

E.H. de Graaf et al. (1997) report about the significant prevalence “of helplessness in the studies” among the patients with epilepsy.

Noting that the criteria of the selection of children with epilepsy for their direction to the special instruction are less distinct than in children without epilepsy, A.P. Aldenkamp et al. (1997) nevertheless emphasize that in children with epilepsy sluggishness more frequently prevails with the defect of cognitive functions. A. Alexander

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et al. (1997) reveal the statistically significant correlation between the formation and the results of neuropsychological testing. H. Mayer et al. (1997) in 30% of patients with epilepsy “with the favorable focal syndromes” note the disturbances of capability for instruction in writing, orthographies and to vocal functioning. According to the authors, these disturbances, with exception of vocal defects, are not connected with the localization of epileptic focus. M. Schuler et al. (1997) and A.- N.M. Shawki et al. (1997) report that the children with epilepsy have statistically significantly worse progress in the school, in comparison with the control group. Worse progress in child-schoolboys T. Wolanczyk (1997) connects with the larger duration of epilepsy.

H. Ring et al. (2007) established that “both the psychosis and depression” in children with epilepsy is differently connected with school progress: psychoses are more frequently noted with mild learning disability, and depressions – with the serious.

Relative to sexual differences in the capability for instruction in the patients with epilepsy the opinions of the authors are reduced to the fact that such are insignificant or absent (A. Georgi et al., 1997; S. Kochen et al., 1997).

According to our data, at the stage of disease, which is characterized by the development of psychosis before the onset of the manifestations of dementia, with resolution of questions of social-work- ing adaptation in patients from the very beginning it is necessary to consider the typical for them types of personal reactions, which are formed differently, including the correlation not only with the register of psychotic disorders, but also with the form of the course of psychosis.

To the period of the remissions of psychotic disorders, in the absence negative psychopathological symptoms the personal special features of epileptoid circle and reactive lability in the periods between the transitory psychoses, become more moderated. After the short temporary disablement, caused by the development of epileptic psychosis, the patients, for example, return to work without a decrease in the profession. In the majority of the cases at the stage of the development of psychopathological disorders without the signs of dementia the patients with the predominantly affective transitory psychoses reveal professional growth.

In the cases of transitory delusional psychoses personal manifestations in patients realize in their tendency toward the sharp affective reactions in the period of psychosis. The sharpness of mental

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