Mental disorders in epilepsy

must plan all measures for preventing the exacerbation of mental disorders and their aggravation.

It should be noted that because of the active in the recent two decades reformation of the services of mental health, on the comparison since 1998, by 2010 primary morbidity by epilepsy with the psychosis and by dementia was reduced across Russia also in 2,3 (3,7 and 1,6 on 100 thousand population respectively).

In this case are noted some changes in the structure of mental disorders, which testify to the decreases of gravity of the clinical manifestations of disease. According to St. Petersburg urban epileptic center (M.Ya. Kissin, 2000) the number of patients with the transitory affective disorders within the period since 1990 to 2000 increased from 16 to 47%, and the number of patients with epilepsy with “classical changes in the personality” decreased by 12%.

Measures of tertiary prevention at the present stage of development of mental health services include: improving the quality of drug therapy, the development and introduction of new forms of psychosocial therapy and psychosocial rehabilitation. Psychiatrists are responsible for the social rehabilitation of the disease altered personality, preventing the onset and worsening of disability.

The data analysis, relating to the contingent patients with epilepsy with the mental disorders, shows that by 2010 across Russia, on the comparison with 2000, the level of primary disablement in this population was reduced in 2,5 (3,5 and 1,4 for 100 thousand populations respectively). On the comparison with 2000, the portion of epilepsy in the general structure of disablement as a result of the mental disorders by 2010 decreased in 1,4 (10,8 and 7,7% respectively). Reduction in the gravity of disablement in the total population of cases of epilepsy with the mental disorders are characterized by the fact that in 2000 in the total number of invalids as a result of epilepsy with the mental disorders the fraction of the invalids of the third group composed 9,5%, and in 2010 – 11,9%.

The professional debt of psychiatrist – regular planning of the development of service, basis of which must be a calculation of criteria of individual clinical and social prognosis constant in the course of conducting the patients. For the pediatric and teenage psychiatric practice in the implementation of the new legislation, priority of which is voluntary turning to the psychiatrist of minor patient and his family, are especially important mastery of the skill establishing partner relations, of convincing patient and members his families

321

in the expediency of dynamic psychiatric observation, on the basis of the fact that the criteria of prognosis in children and adolescents can be refined only with the sufficiently prolonged condition and continuous inspection and treatment.

As it was shown in the previous chapters, among the criteria of extended prognosis with the epileptic disease the type of the exogenous actions, postponed by patients by the different stages of ontogenesis, occupies the specific place. The presence and the nature of these actions, apparently, not only reflect the fluctuations of the general reactivity of organism, since they in different measure are connected with type and stage of the course of disease, but in a number of cases, probably, are the factors, which have a straight effect on prognosis. The possibilities of the preventive maintenance of this influence, therefore, can present additional reserves in the plan of the preventive maintenance of the loading of the course of epileptic process.

The data analysis of the electroencephalographic inspection of patients allowed us to reveal differences in the localization of epileptic center with three types of course of the epileptic disease described above: favorable, with the set aside exacerbation and unfavorable. With the favorable course of process, which is characterized by the predominance of convulsiveless paroxysms and affective psychoses, frequently there are no indications of the specific localization of epileptic focus, or were signs of its localization in the deep medial brain stem. In the cases of the set aside exacerbation of the course of process, for which is typical the predominance in the clinical picture of psycho-sensory and psycho-motor temporal paroxysms and hallucinatory-delusional symptoms in the structure of psychosis, the patients had indications of the lateralization of focus in the temporal lobe of the brain. With the unfavorable course of process with the predominance of the generalized convulsive seizures and the presence in structure of the psychotic disorders of catatonic symptoms more frequently detected localization of the epileptic focus in the frontoparietal and fronto-temporal lobe.

Traced in the present work interest in epilepsy of such functional systems of brain as limbic system, temporal and frontal lobes, can testify to the possible immune sensitization of structures in the course of the development of the disease, in formation of which the leading role plays the nature of exogenous actions at the different stages of ontogenesis.

322

Although the contemporary knowledge of etiology and pathogenesis of epilepsy does not make it possible to deny the influence of exogenous factors on the pattern of the course of disease, a question of the value of the latter for the prognosis in the literature remains insufficiently reviewed.

The obtained by us data about the presence of the prognostically significant connections between the occurring with epilepsy somatical and neurologic disorders and the steady clinical forms of this disease serve as the base to assume the unity of their pathogenesis.

In the course of the carried out clinico-catamnetic inspection of 450 patients by epilepsy to such steady clinical signs were related the transitory, schubweise and chronic forms of the epileptic psychosis, which is for the first time noted on the average of 10-15 years after the paroxysmal manifestation of disease. With the data analysis, being contained in the dispensary maps and stationary histories of disease, the presence and gravity of various exogenous factors in each inspected patient were traced not only in the period of the appearance of explicit symptoms of disease, but also prior to the beginning of disease.

In this case we established that the clinical and working prognosis in patients with the epileptic psychoses in many respects depends not only on the nature of pathogenic influences, but also on the age of patients, at which these influences occur, which, in turn, confirms the possibility of the timely application of adequate preventive measures.

With duration from several hours to several days with the favorable course of the disease of indication of exogenous actions with the transitory psychoses were rare. Only 5 of the 50 patients suffered birth defects. In this case pathogenic actions in general were placed in the category of light. They were identified as asphyxia, premature, rapid, prolonged labor, forceps delivery. Their consequences were manifested subsequently by unstable neurologic micro-symptoms and vegetative-vascular components in the structure of paroxysms. With the neurologic inspection in patients only in the first years of life in the maps of individual development were noted, for example, the weakness of convergence, the asymmetry, general invigoration or the apathy of tendinous reflexes. More steadfast (noted already in the period of the observation apropos of epilepsy) there were such symptoms, as the absence of abdominal reflexes, the asymmetry of ocular slots and nasolabial folds.

323

Among the first paroxysms dominated by short-term bouts of headaches, which are more or less marked in the structure arising in the future other paroxysms. As in general the patients with the favorable course of process, these patients did not have the signs of epileptic dementia. The moderate changes in the personality in the form of strengthening the characteristic of them from the childhood of such traits of nature as accuracy and industriousness, proved to be in a sense even useful for their adaptation in the period of instruction, acquisition of profession and fulfillment of professional responsibilities. The psychotic phenomena in the late stage of disease were relapsing not more frequent than one time per year affective and affective-delusional states. In the period of psychosis such patients remained able to work.

In the part of the cases (14 of 50) were not excluded the aggravation of prognosis at the more distant stages of disease in the cases of transitory psychoses with the favorable at first (for the elongation 14,5+/-0,6 years) course due to the tendency of patients toward the use of alcoholic beverages. The form of alcoholism in patients in such cases more frequently bore the nature of short hard drinkings, since the use of alcohol for a period of several days was, apparently, caused by changes in the mood. The aggravation of process was expressed by quickening in the periods of the alcoholism of psycho-sensory, psy- cho-motor and convulsive paroxysmal states, appearance and quickening to several time per year of psychotic episodes with the predominance of delusional disorders (including with the presence of delirious inclusions). The majorities of patients after the appearance of the symptomatology indicated more rarely came running to alcohol. To this period with the somatical inspection in them more frequently it was not revealed any pathologic deviations. Only chronic gastritis was revealed in 1 of 14 patients. Although the neurological examination did not found a single case of alcoholic polyneuritis, in all patients in the study period there were signs of alcohol degradation. If epileptic dementia did not reach their deepest level, the excitability and viscosity affect, particularly evident in the influence of alcohol, in some cases, led to a significant reduction of the professional.

Should be noted that greatest progressive course of epileptic disease with the transitory psychoses occurred, according to our data, in the cases of the combination by the latter with different infectious diseases of early age, which developed with the cerebral symptoms and those noted in the histories of disease in 19 of 50 patients. Among

324

the infections were noted measles, the scarlet fever, infectious parotitis, purulent otitis, pneumonia, are thinner frequent the chickenpox, typhus, malaria. In all patients in the period of repeated inspections subsequently was not revealed any somatical deviations. At the same time in 12 of 19 patients was noted the steadfast neurologic symptoms in the form of the weakness of convergence, general reanimation or light asymmetry of tendinous and periosteal reflexes, nystagmus with the view to the sides, anisocoria, deviation of language. In 5 of them at the same time with the x-ray examination were revealed the sections of calcification in the substance of the brain, pneumatization of basic cavity in the front divisions; with a study of eyeground in 4 patients was noted a certain contraction of arteries. In connection with the early beginning of epilepsy occurred the symptoms of the delay of intellectual development. The subacute course of disease was accompanied not only by the predominance of the generalized convulsive seizures and psychoses with the presence of catatonic disorders, but by the mainly expressed manifestations of epileptic dementia with the viscosity of thinking, oligophasia and other. The majorities of patients were able-bodied only under the special conditions of production.

With the current form of paroxismal epileptic psychoses, differ not only by larger duration than transitory, but also to by a certain stereotype of development of psychopathological disorders, other patterns also occurred.

Here was not revealed the connection between the favorable and unfavorable types of the course of disease with presence or absence of the associated diseases neither on the early nor on the late stages dependent on age.

With the favorable course of disease (50 patients) its late manifestations (in 13,8+/-1,3 years) were characterized by the protracted periods of the moderately expressed manic-depressive disorders, by the absence in the clinical picture of the signs of an intellectual decrease. In their profession the patients were able to work.

With the unfavorable course of epilepsy early (in 13,2+/-0,7 years) appearance in 50 patients of the signs of intellectual defect was revealed together with the presence in them of the protracted paroxisms of psychosis with the catatonic disorders. The level of working adaptation proved to be low. Many patients worked nowhere.

However, the impact of a special kind of exogenous hazards was quite closely associated with worsening of epilepsy on remote stages.

325

Its aggravation began after the prolonged (21,3+/-0,7 years) stage of the slow course of epileptic process. A number of otorhinolaringologic diseases and diseases of internal organs for a long time was noted in 16 of 50 patients at the age from 18 to 50 years. The first included chronic rhinitis, chronic pharyngitis, chronic double-sided mesotympanitis, the second – “miocardiodystrophia without the signs of the disrupted blood circulation”, chronic gastritis, ulcer of duodenum, chronic esophagitis, chronic cholecystitis, chronic hepatite.

Together with the psycho-motor seizures appeared the psychotic disorders of predominantly hallucinatory-delusional nature, which were alternated by remissions with duration up to the year. In the structure of the latter together with the residual productive psychopathological symptomatology with the years the signs of epileptic dementia became even more distinct. The ability to work of patients in the majority of the cases depended on the duration of psychosis and quality of the subsequent remission.

With the chronic epileptic psychoses were also revealed some significant for the prognosis of “somatopsychic correlations”.

The favorable course of disease with the complete during 29,8+/- 0,2 years safety of intellectual functions with the continuous change of the different duration of affective phases in 12 of 20 patients accompanied different cardiovascular diseases, and also chronic diseases, which could be carried to “precancerous states”. Hypertonic disease, insufficiency of mitral valve were noted in patients at the age from 21 year to 55 years. Chronic anacidic gastritis, chronic spastic colitis, the fibromyoma of womb, the struma of the II degree without the phenomena of thyrotoxicosis – at the age from 30 to 43 years. Patients for long preserved professional ability to work, since the undeveloped convulsive seizures in them were rare, and mental disorders were evinced by the fluctuations of the affect of circular nature.

With the relatively unfavorable prognosis in the cases of the mixed (at first slow, then subacute) course of disease in 77 patients was not established sufficiently close connections with the associated somatical disorders. The aggravation of the disease in 23,1+/- 0,2 years after its beginning was manifested by quickening of polymorphous of the predominantly temporal type of paroxysms and by development of the so-called “paranoid epileptic dementia” in the form of the combination of the symptoms of the paranoiac development of personality with the increasing epileptic defect in combina-

326

tion with the unique disorders of thinking, which simultaneously bear the signs of viscosity, floridity and difference in perspective. Patients’ ability to work for a long time depended on the plot of delusion. The known safety of professional habits was revealed in proportion to the deactualization of delusional ideas in patients.

On the contrary, it was possible to speak about the prognostic significance of early and repeated heavy infections in 15 of 53 patients with the unfavorable course of disease. At the age from 6 months to 4 years in them into average not less than 2 times the heavily flowed infectious diseases, which were accompanied by meningeal symptoms. In 2 patients was diagnosed meningitis, in 1-meningo- encephalitis. Most frequent were measles, pneumonia, scarlet fever, whooping cough, chickenpox, thinner frequent – influenza, dyspepsias, double-sided purulent mesotympanitis, infectious parotitis, diphtheria, recurrent typhus, typhoid fever. In the period of inspection in patients in the majority of the cases were not noted somatic disorders. Only in 1 patients was revealed chronic anacidic gastritis, in 1-symptomatic hypertonia. In neurologic status in 10 of 15 patients were noted the residual phenomena of the previous in the childhood organic disease of CNS. In particular, were indications of an uniform descent in the tendinous and periosteal reflexes, pathologic reflexes, weakness of pupil reactions to the light and the convergence, divergent squint. The appearance of signs of epileptic dementia frequently anticipated the appearance of the generalized convulsive seizures and the development of the chronic psychosis, basic manifestations of which were the catatonic disorders in the form of the protracted sub-stuporous states, which were being combined with the prolonged affective-delusional disturbances. Patients proved to be completely disabled for a prolonged time.

According to our data, in general in the patients with epilepsy, which takes place with the psychotic disorders, in the group of etiological factors in the first place are intracranial infections. In the second place through the etiological value is located the factor of heredity (presence of close relatives, who suffer epilepsy), while in the third place – ancestral injury. In comparison with the data, which characterize the general population of the patients with epilepsy and the group of the patients with epilepsy without the psychosis, in the group of the patients with epilepsy with the presence of psychosis larger place in the etiology of disease belongs to hereditary predisposition to epilepsy and ancestral injury.

327

The materials of our experiments testify also to the fact that in prognostic sense for the development of epilepsy with the psychotic manifestations the indications of the presence in the close relatives of the patients of the characterological anomalies of epileptoid circle, protracted psychotic disorders and alcoholism are not indifferent.

The value of the enumerated endogenous and exogenous etiological factors for the prognosis is unequal with the different forms of the course of epileptic psychosis. In the presence of clinical picture of transient (transitory and schubweise) epileptic psychoses unfavorable in terms of prognosis should be considered the hereditary burdensomeness in the form of the epileptoid traits of nature in the relatives of patients, alcoholism of parents and presence in patients at the early stages of the ontogenesis of intracranial infections. If we are talking about a chronic epileptic psychosis, the weighting of the prognosis etiological factors in addition to these should be considered if the patient has severe birth injury.

In the literature the last years in essence is confirmed the obtained by us data about the participation in the appearance of mental disorders with epilepsy of preand perinatal factors (W.A. Hauser, 1997; G.R. Khamitova et al., 1997; P.M. Leary et al., 1997, and others), and also heredity (M.C. Clarke et al., 2012). At the same time in the literature more than attention is given to the psycho-social actions, capable, in the opinion of researchers, to influence the pattern of the flow of epilepsy, including – to structure of family relations (D. Gigineishvili, 1997), to the conditions of stay and to psychological difficulties (S. Jarvie et al., 1997).

In recent years the attention of many researchers is paid to the quality of life of population in general – as the most general common and at the same time indisputable etiological factor, which facilitates demonstration and loading of the course of the epileptic disease (A. Jacoby et al., 1997; G.R. Khamitova et al., 1997, and others).

According to P.A. Temin (1997), medico-social preventive measures must be oriented to the solution of the following problems of children’s epileptology.

Antenatal diagnostics of epilepsy with the mapped out genes (high-quality family neonatal spasms, juvenile myoclonic epilepsy with the night paroxysms).

Determination of pregnant women at risk for birth of a child with seizures.

328

Isolation among the newborns and the children of the first year of the life of the risk groups on the development of epilepsy.

Production of strategy of observation of patients with the convulsive syndromes and epilepsies with the high-quality and unfavorable course.

An important task for the prevention of a possible disability of children with epilepsy the author considers the allocation among pregnant following groups:

●living in the ecologically unfavorable zones, including in the regions with the high intensity of radioactivity;

●transferred during the pregnancy of infection (toxoplasmosis, cytomegalia, rubella and other);

●assuming heroin, antidepressants, barbiturates, alcohol;

●suffering the diseases of hereditary nature (tuberose sclerosis, the disease of Recklinghausen);

●having the endocrine disturbances (diabetes mellitus, hyperand hypothyroidism);

●having hereditary burdensomeness on epilepsy or febrile convulsions.

The represented materials about the assumed etiology of epileptic disease and, in particular, about the correlation of various assumed etiological factors with the type of its course with the entire obviousness testify to the need of the goal-directed preventive work of the establishments of public health and state in general. The place of neurologists and psychiatrists, especially those, who specialize in the region of rendering aid to the patient with epilepsy, is logically predetermined in the system of preventive measures as leading in the realization of mental hygiene and psychoprophylaxis in the widest sense. The participation of the specialists in the primary preventive maintenance of indicated epileptic disease, mainly through the health and hygiene education of population and wide medical community, naturally must be combined with their work in the region of the second and tertiary preventive maintenance of mental disorders with epilepsy.

In the opinion of the experts of WHO (1983), for the realization of secondary preventive maintenance, i.e., during the already existing disturbances of function it is desirable, as far as possible, to prevent the onset of permanent disablement, is required an improvement in the work of doctors of the early development the connections of such disturbances with the defects in the organization of effective therapeutic work.

329

The special chapter of this book is dedicated to the study of the problems of the effectiveness of the combined drug treatment of epilepsy with different types and stages of its course. It is here expedient to emphasize the preventive aspect of antiepileptic therapy.

The given by us in the previous chapters criteria of diagnostics and prognosis of mental disorders with epilepsy, beginning from the neuropsychological studies of the earliest disturbances of cognitive functions revealed in the course and concluding by those established in the course of of dynamically structured clinical analysis the criteria of diagnosis and prognosis of psychopathological disorders varied with this disease, probably, during their adequate application, can grant to doctor considerably more than possibilities for the timely development of mental disorders with epilepsy, than only conventional calculation of frequency and nature of paroxysmal disorders.

On this, in turn, depends the timely (earlier) application of methods of the combined therapy of this disease with the use of data about the fact that many of the antiepileptic means both traditional, and new generation, render simultaneously antiepileptic and anti-psy- chotic effect.

Probably, precisely, this combination of therapeutic effects, which in the final analysis facilitates the normalization of the bioelectric activity of the brain, is the prerequisite of the fact that such most common in the practice of antiepileptic therapy preparations, as carbamazepine and lamotrigine, apparently, are most promising for the application during the treatment of the mental disorders, not compulsorily connected with epilepsy. As it is known, carbamazepine at present, together with the preparations of lithium, is customary to assume as preventive means with the schizophrenia, the affective psychoses, alcoholism and other.

Many contemporary authors agree about the fact that the organization of medicinal therapy must contribute to an improvement in the psycho-social functioning of the patients with epilepsy (G. Baker et al., 1997; M. Boyle, 1997; J. Fandino et al., 1997; A. Jacoby et al., 1997; E. Maxoutova et al., 1997). However, as before, there remain rare the publications, specially dedicated to the drug treatment of patients with epilepsy at the stage of the development in them of mental disorders. Meanwhile as show our data, not all patients at this point of disease are actually and legally disabled, who require the application of special measures for rehabilitation. The presence of mental disorders with epilepsy, in-

330