Mental disorders in epilepsy

condition is in many respects caused by the activity of the position of patients with respect to their imaginary enemies or by the tension of hypochondriac reactions. The conviction of patients in its rightness is combined in them with the tendency to share with its experiences with those surrounding. By the concreteness of experiences is explained their tendency to hide from the persecutors or to be handled complaint on them into these or other establishments. They are able to work in the periods of remissions.

With the paroxismally elapsing predominantly delusional psychoses to the period of the appearance of signs of dementia the participation of “personal factor” in the nature of the working device of patients is observed more rarely than in patients with the transitory psychoses. The retention of residual delusional disorders in the structure of remission, depending on the plot of delusion, can be the reason for the appearance of a question about the change of the place of work.

In general one should say that in the cases of predominance in patients with the transient (transitory and schubweise) psychoses of delusional and catatonic disturbances the summary estimation of a working prognosis of the type “relatively unfavorable” and “unfavorable” frequently occurs insufficient as a result of the instability degree of the manifestation of these disturbances, appearance of the significant number “transitional” psychotic forms. In connection with this for refining the prognosis here more frequently it is necessary to use procedure of the prolongation of the periods of temporary disablement.

About explicit worsening in the working prognosis it is possible to speak in the cases of combination for the patients of high self-ap- praisal and inadequate level of the claims, which are observed with an increase in the structure of the affective-delusional psychosis of the portion of delusional disorders, and especial – with the appearance of catatonic inclusions. The patients in these cases are classified as frequent and prolonged suffering. With the retention of emotional contact with them and with the known safety in them of critical functions, depending on the special features of profession are already during this period expedient their transfer into the less qualified work or the recommendation of the significant decrease of volume the works within the framework of profession.

The participation of the paranoiac features of personality in the formation of the ratio of patients to its production responsibilities

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depends on the duration of psychotic schub. If the duration of psychosis up to 1 month, more flowing in patients with anxiety and depressive affect, the highest value for the occurrence of delusions are anxious and mistrustful line, but with increasing duration of psychosis of several months are dominated by hypochondriacal reactions and a tendency to querulant behavior, which largely relate to such personal manifestations as paranoid and mental rigidity. In the cases of further increase in the duration of psychotic paroxism the delusional ideas in patients acquire ever more “autochthonous nuance”. If in this case the persistent querulant behavior of patients is combined with their tendency toward the realization of its installations in accordance with the hypochondriac experiences or with their tendency to at any cost punish “the guilties”, and work acquires for them importance only of the arena “of fight”, appears the need for resolution of a question about the establishment of the group of disablement with the statement of the incapacity of patients to the professional activity.

Temporary disablement in such patients or need for their transfer into the work into the specially created conditions more frequently appear with the presence in structure of the personality in them of the features of hyper-social significance and the retention in them at least partial criticism to the predominant in the structure of psychosis hallucinatory experiences. In the cases of appearance in the patients of catatono-delusional, catatonic or polymorphous psychoses, which are accompanied by prolonged sub-stuporous states, personal reactions become less differentiated, and patients, as a rule, need job placement under the specially created conditions.

Chronic psychoses before the appearance of signs of dementia are characterized by the predominance of querulant delusion and submaniacal affect. Personal disorders are manifested here in a constant tendency of patients toward the conflicts and the uncompromising struggle against the imaginary encroachments of their rights. A sufficient safety of professional habits, super-valuable relation to their production responsibilities, prolongedly preservable ability to attain solution of the narrowly decreed problems make possible for them, however, to be retained under the conditions of usual production.

At the stages of the formation of epileptic dementia with the noted above significant reduction of individual personal (premorbid) features in patients, in general, as already indicated, it occurs reduction in the possibilities of social-working adaptation. This doesn’t

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exclude, however, existence of the specific differences in the nature of the actual working of patients.

The full social and labor disadaptation or adaptation of patients at a reduced level in the formative stages of epileptic dementia, as shown by our data, is a result of inadequate responses in the modified disease on the individual symptoms of the disease or the surrounding events. The nature of the response «of epileptic personality» depends on the specific conditions in which it is placed, whether the severity of psychotic disorders, the stage of the formation of epileptic dementia, social environment, etc. Predominance at the last stages of the development of the disease of specific for epilepsy changes in personality is manifested first of all in the fact that the patient becomes noncritical not only to the changes, which attack in the sphere of memory, thinking, intellect, but also in the complete absence of criticism to the sharper acute manifestations of disease

– paroxysmal or psychotic. Specifically, this anosognosia create the greatest dependence of patients on their illness, it requires the special attention of the doctors in the selection of the adequate measures for social-working rehabilitation.

In the process of the rehabilitation of patients with the late manifestations of epileptic disease is necessary to, first of all, rest on the special features “epileptic psyche” inherent in them, such, for example, as sthenia in the achievement of the objective, diligence, sequence in the process of fulfilling the work, tendency toward the prolonged retention of the specific stereotype in the fulfillment of working operations, accuracy, obligation, industriousness, etc., i.e., to such properties, which, being are to a considerable extent underlined in connection with the disease, nevertheless remains one of the most enduring links of «epileptoid» premorbid personality.

In this case obvious becomes the need for clear idea, as of this type the properties of personality can be realized at the last stages of the disease, when, according to the data of the conducted by us during the work epidemiological investigation, in the majority of the cases in patients during the prolonged period are established the second and first groups of disablement, i.e., when besides strictly the clinical factors, represented to the especially expressed degree, leads to the disablement a social factor.

During the first stage the formation of epileptic dementia the inherent in patients manifestation of affective (explosive) disorders considerably limits the possibilities of their working placement. With

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the condition for active treatment the part of them can work at the enterprises, which use labor of invalids, in the special shop or the therapeutic-production workshops.

To the big degree this is caused by complication in the structure of the transient (transitory or schubweise) psychosis of affective and affective-delusional disorders, by combination in the structure of the remissions of residual delusional experiences with explosive type reactions.

At the same stage of disease the patients with the paroxismal psychosis are completely disabled in the cases of predominance in them in clinical picture of hallucinatory-delusional and catatonic syndromes. The loss of ability to work is in many respects caused by the minimum participation of the premorbid properties of personality in the formation of psychosis, by appearance in the clinical picture of the disease of whimsical combination in the patients of obsequiousness and negativism, complacency and captiousness. A sufficient productivity of patients in the plan of self-service, in resolution of everyday questions contradicts their egocentric installations in the period of their stay in the family, group, the working association, to the installations, which cause their prolonged unemployment in the labor.

In the cases of chronic psychosis quickening of explosive reactions at this stage of the formation of epileptic dementia contribute to known development and systematization of delusional ideas. Actually, only because of the adequate, tolerable relation to the patients from the side of the work management and nearest colleagues such patients continue periodically to work in the usual production, already being acknowledged as disabled. As a rule, they reject the working placement in the specially created conditions.

The possibility of applying the more active measures in the plan of the social-working rehabilitation of patients appears at the subsequent two stages of the formation of epileptic dementia: the stage of the steadfast and expressed disturbances of thinking with the syndrome of so-called bradyphrenia and stage of the development of the expressed mnestico-intellectual defect.

The variability of the forms of the adaptation of patients to the greatest extent is manifested at these two last stages of epileptic disease.

This is first of all connected with the fact that further deepening of dementia due to those more expressed in the patients disorders of thinking occurs simultaneously with reduction in the sharpness

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of affective disturbances. In spite of tendency toward the increase of the polymorphism of psychotic episodes, especially with the presence of sharp catatonic and affective-delusional disorders, patients if they have the viscosity of thinking, tendencies toward the detailing, oligophasia sufficiently stably work in the specially created conditions. Here to the greatest extent positively are shown such premorbid qualities, as diligence, desire to carry out their work in the best way, installation to the quality of work.

At the same time the presence of the named disorders of thinking in patients with the chronic psychoses, especially with the tendency toward the systematization of delusional ideas with the formation of so-called paranoid epileptic dementia, contributes so that the patients frequently become completely disabled. With the decrease of tendency toward the aggressive behavior for them are typical the tendency toward the querulant activity, quarrelsome disposition not only with the neighbors, but also with the close ones, bigotry, ignoring the opinion of others, extreme egocentrism and the arbitrariness of judgments. Part of them, prolongedly working nowhere, rejects the proposed group of disablement.

Late remission in the psychotic symptoms begins with the completion of the formation of mnestico-intellectual defect in a number of patients. With an increase in the duration of remission, the rarer appearance of sharp catatonic states and the preservable installation to the qualitative fulfillment of the adequately selected simple working operations occur suitable to the working activity under the conditions of usual production. With the presence of the reduced affective and catatonic disorders and short-term remissions the part of them stably is adapted to the labor under the specially created conditions. With the preservable polymorphism of psychotic states with the predominance in their structure of catatonic disorders the patients can be occupied in the therapeutic-working workshops.

Without attempting to cover the full range of conditions considered in deciding whether to establish in each particular case of the disease of a group disability because among these conditions are often crucial factors of particular order: household, the presence of seniority, occupation, qualification, age of patients, duration of the period of stay in the first and second groups of disability, etc., in accordance with the theme of our research lets focus on the analysis of clinical factors that are likely to in the first place are considered in ascertaining the basis of disability.

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Taking into account entire variety of the noted versions of the social-working adaptation of patients at the stages of the development of psychopathological disorders, on the basis obtained data it is possible to arrive at the conclusion about existence of some clinicopsychosocial correlations.

The more sharply proceeded the disease (sharpness of psychotic symptomatology, the stage of the predominance of explosive disorders in the process of the formation of epileptic dementia, paranoid epileptic dementia), the more conditions appear for the reanimation of the individual, premorbid, “deep” features of personality and the more pronouncedly are manifested the installations of the latter to the realization of the already acquired work habits, which, however, with an inevitable in such cases decrease in the patient of critical abilities always cannot be considered as positive factor in the plan of socialworking rehabilitation.

Conversely, the lower the sharpness of psychopathology, the more “soldered” with psychotic features are acquired over a period of illness personality changes and, to a lesser extent manifest inadequacy of the claims of patients in terms of socio-labor unit that, with sufficient preservation of positive attitudes, can be used as residual disability allowance.

These two circumstances first of all must be considered with conducting of the medico-social examination of patients with epilepsy.

On the basis of the complex of given data, it is possible to propose the following criteria of evaluation of the ability to work of patients with the manifestations of epileptic psychosis and dementia.

During the first stage the development of psychopathological disorders, i.e., before the appearance of signs of dementia, in a number of cases the patients, in the period of transitory psychosis, do not need a release from the work with the certificate of temporary disablement. This relates to the short-term (for several hours) depressions, which take place with hypodynamia and sensitive delusion of relation, and also to the transitory depressions and the manias with the dysphoric manifestations. Sufficient productivity of labor remains in patients with sub-depressive protracted schubs different in the duration, with which is noted only certain reduction in the engine activity. In the cases of the chronic course of psychosis the ability to work of patients remains with the predominance in their structure of the affectivedelusional disorders of super-valuable delusion, and also with their critical relation to the frauds of perceptions.

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Temporary disablement for a period of several days more frequently begins in the cases of appearance in the patients transitory depressions, which take place with the vegetative disturbances, and also manias with the unproductive speech-motor excitation, sharp delusional and hallucinatory-delusional episodes, deliriums. With the paroxismal course of psychosis the patients are temporarily disabled in connection with the appearance in the structure of the psychotic disorders of the transient ideas of low value, hypochondriac prolonged reactions for the somatical and vegetative manifestations, in the cases of the appearance of senestopathias and psycho-senso- ry disorders with the alarming affect. With the affective-delusional chronic psychosis temporary disablement establishes with the aggravations of delusional experiences.

A question about the establishment of the third group of disablement at the stage of the development of psychopathological disorders before the appearance of signs of dementia is more frequently solved positively in the cases of the protracted course of affectivedelusional paroxism. In connection with the loading of the clinical picture of paroxismal psychosis due to the catatono-delusional, catatonic or polymorphous states, which include affective, hallucinatory and catatonic manifestations, as a rule, is established the second group of disablement.

At the second stage of the development of psychopathological disorders with the predominance in the structure of dementia of the manifestations of explosiveness in the cases of diagnostics in patients of schubweise and chronic psychotic disturbances, appears the need for their working device under the specially created conditions, including therapeutic-working workshops. With the paroxismal elapsing psychoses of delusional structure the ability to work of patients in the majority of the cases is stably reduced (third group of disablement) as a result of the detection in their periods of the remissions of reduction in the creative abilities and retention of tendency toward explosive type reactions. In the cases of the chronic course of psychosis with the domination in the clinical picture of catatono-delusional and hallucinatory-delusional syndromes the patients are unfit to the professional labor (second group of disablement).

At the third stage of the development of psychopathological disorders with steadfast and expressed disturbances of thinking, bradyphrenia, that attack more frequent in patients with the unfavorable type of the course of disease, are possible attempts at the wor-

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king device of patients under the specially created conditions with the establishment of the second or third group of disablement in the cases of the transformation of psychosis although into the polymorphous states, with the predominance of sharp catatonic and affective-delu- sional disorders. Patients are disabled (the second, and sometimes also the first group of disablement) with the development of epileptic paranoid dementia with querulant delusion and manifestations of secondary catatonia.

At the fourth stage of the development of psychopathological disorders with the formation of the expressed mnestico-intellectual defect the part of the patients as a result of the decrease of gravity of affective disturbances (late remission with the unfavorable course of process) occurs suitable to the production activity at the decreased level and after comparatively small periods of the previous stay in the first and second groups of disablement patients can be in certain cases acknowledged as the invalids of the third group. Another part of the patients stably is adapted to the work the specially created conditions (second and third group of disablement) because of the predominance in the structure of the psychosis “simple” or monomorphic affective and catatonic disorders. Patients are occupied with labor in the conditions of therapeutic-working workshops (second group of disablement) or nowhere work (second and first groups of disablement) when the polymorphism of the psychotic states is present, key place in structure of which belongs to catatonic disorders.

Thus, given in present chapter clinical data attest to the fact that the criteria of prognosis at the distant stages of epileptic disease with the insufficient effectiveness of the contemporary therapy of psychopathological disorders must be determined by the special features of structure and dynamics of the transitory, schubweise and chronic psychoses and, first of all, on those of them, which are connected with presence and degree of the manifestation of the personal changes, most which are distinctly observed at the stages of the formation of epileptic dementia. At the last stages the diseases under the conditions of the reduction of paroxysmal syndrome the criteria of the loading of prognosis together with the progression of personal disorders become the changeability of structure and “transitional nature” of the productive psychopathological symptoms, which indicate the continuous motion of epileptic process.

The evidence that variants of the course and the stage of disease are major determinants of both long-term and foreseeable at the time

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of the prognosis, is the dependence of the nature of disease outcomes not only on the inherent individual cases some form of psychosis flow: transitory, schubweise or chronic, but on how much from the register of the psychotic disorders: affective, delusional or the catatonic. Timely use of the enumerated criteria of diagnosis and prognosis of the varied versions of structure and dynamics of epileptic psychoses and dementia, in the totality the composing extensive, but up to now is still insufficiently studied region pathologies, can contribute to development and use for purposes of the rehabilitation of residual ability to work in one of the most extended contingents of mentally ill patients.

Pathogenetic therapy and social-working rehabilitation of patients predetermine by the results of the dynamically structured analysis of state itself. “Target” drug therapy is possible with the type of data flow and the preferential localization of epileptic process.

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Chapter 8

PREVENTION AND ORGANIZATION OF MEDICAL, PSYCHOLOGICAL AND SOCIAL SUPPORT

OF PATIENTS WITH EPILEPSY

By definition, the WHO experts, the primary prevention of mental disorders cover a wide range of measures relating to general health care, including maternity care, prevention of communicable diseases and injuries.

According to the data of the small number of studies, which analyze the tendencies of a change in the epidemiological characteristics in the course of time (to several decades), in the developed countries occurs reduction in the morbidity by epilepsy in the childhood and an increase of the morbidity in the elderly (W.A. Hauser, 2011).

The analysis of statistical data shows that the obstetrics in Russia in the last 10 years is enough qualified. The indices of the mortality of children at the age up to 1 year and the indices of the mortality of women from the complications of pregnancy, childbirths and postpartum period were reduced.

In the country was noted a decrease in the level of morbidity by infectious and parasitic diseases, also was outlined the stabilization of the indices of traumatism and poisonings both as a whole and especially in children and adolescents.

This finds reflection in reduction in the morbidity by mental disorders and morbidity by epilepsy. In connection with this the special interest present the statistical data, which relate to the object of our of experiment – mental disorders with epilepsy.

In general, in Russia, in comparison with 1994, by 2010 the incidence of epilepsy with primary non-psychotic mental disorders decreased in 2.3 times (8.8 and 3.8 per 100 thousand population, respectively).

The secondary preventive maintenance of mental disorders, as it is customary to assume, relates to the scope of the psychiatrists, who

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