Mental disorders in epilepsy

cluding of chronic, in the course of time will not be, probable, to be examined by neurologists, neurosurgeons and psychiatrists, with their correct interaction as the required sign of unfavorable clinical and social prognosis.

The committee of experts of WHO considers expedient to pay greater attention to scientific studies in the region of the preventive maintenance of the basic reasons of disablement. The expansion of the concept of medico-social rehabilitation indicates, in it’s opinion, “the scope by it not only the persons with the motor or sensory forms of disablement, but also the persons with the mental retardation and patients, who suffer mental disorders”.

The study of the problems of the organization of rehabilitative process in application to patients with epilepsy seems necessary for us to begin from bringing of the following sufficiently extensive quotation from the report of the committee of experts of WHO of 1983 on the prevention of disablement and rehabilitation.

“The conference of the appraisal group of United Nations on the social and economic effect of the investments of financial means into the rehabilitative services for the invalids expressed the opinion that regardless of the fact, is ensured the rehabilitative maintenance or not, society is forced to take the expenditures, connected with the economic and social consequences of disablement, to itself, and that these expenditures can be reduced due to the realization of the effective programs of rehabilitation and aid to invalids. The social policy, based on the respect of the rights of each person and on the tendency to guarantee the social equality of all citizens, will ensure official support to measures of rendering aid to disabled and their families. In some developed countries too narrow interpretation of the economic aspects of problem led to the fact that the unjustified accent was made on the guarantee of participation of invalids in the productive work and as a result attention was concentrated during the profes- sional-oriented rehabilitation due to other forms of rehabilitation. A similar selectivity should be avoided, since the true value of disablement for the society and all benefits, which it is possible to obtain as a result of the rehabilitations of invalids, probably, depend on the position of all persons with the disablement, and on the development of all rehabilitative services”.

It is known that the rehabilitation in the field of psychiatry is examined at present as process and simultaneously as the system of the medical, psychological, pedagogical, social and economic measures,

331

directed toward the elimination or the most complete compensation of the limitations of the life activity of patient.

Most adequate for evaluating the rehabilitative potential in the patients with epilepsy with these or other mental disorders to us seems age-qualification approach to the estimation of the possibility of use for purposes of the rehabilitation of the personal special features of patients.

According to G.K. Ushakov (1973), the level of the development of the components of mental human activity in the ontogenesis is caused by differences at the rate of molding of the generalized functional systems (motor, sensorimotor, affective, ideational), the levels of consciousness (keeping awake, object and of consciousness “I”, the consciousness of his own personality, reflexive) and levels of the personality (temperament, nature and strictly personality as the unique type of the attitudes of individual with the public reality).

Against the background of individual mental development correspondingly is manifested the preferability of the demonstration of various psychopathological disorders dependent on age, including psycho-motor, sensorimotor, affective and ideational disorders.

In this context it was necessary to analyze some data, which relate to the age of patient and the course of epileptic process as basic clinical determinant of social prognosis. First of all this related to the transitory, schubweise and chronic forms of the course of epileptic psychosis, which have, as this was shown in the previous chapters, different relation to the structure of the personality of patient.

As was already mentioned, with the transitory and schubweise psychoses do not exist differences according to the types of the course of disease and with respect to the age of patients for the period of the appearance of the first signs of disease. At the same time if with the transitory psychoses the prognostic importance of the age of patients does not succeed in establishing in the period of the appearance of the first signs of psychosis, then with the schubweise psychoses such differences are manifested in the fact that the signs of psychosis with the unfavorable course of disease appear in patients at the earlier stages.

In regard to chronic psychoses, closer connected with structure and dynamics of personal changes in patients, are concerned, the differences between three types of the course of epileptic process dependent on age prove to be statistically reliable.

332

Interesting is the circumstance that if with the transitory and schubweise psychoses the age-qualification differences in patients in the period of acknowledgement by their invalids have prognostic importance, then the age-qualification differences between the types of the course of disease for this period is absent with the chronic psychoses.

More “sensitive” markers of the types of the course of disease, almost in the equal measure meant for all three forms of the course of psychosis (transitory, schubweise and chronic), appeared such indices, as the duration of the period of the adaptation of patients under the conditions of usual production without the establishment of the group of disablement, and also number of interruptions in the work in the period of disease from the beginning of the development of psychosis, the duration in the patients of the period of the disablement, including the first and second groups, the duration in the invalids of the period of complete working deadaptation and the duration of the period of their readaptation under the specially created working conditions.

Finally, such indices as the duration of the period of the readaptation of invalids under the conditions of usual production with the limitations and the duration of the period of the total working rehabilitation (former invalids – under the conditions of usual production), which have prognostic importance with the transient (transitory and schubweise) psychoses, with the chronic psychoses are not important for a prognosis. Apparently, this can indicate the absence of determining for the social prognosis of value personal potential in the cases of development in chronic mental disorders patients with epilepsy.

A.R. Aldenkamp et al. (1997), A. Papavasiliou et al. (1997), A.- N.M. Shawki et al. (1997) and others considered epilepsy in general as the risk factor of capability for education at the childhood, but in this case they note that there does not exist objective criteria for answering a question about the direction of children with epilepsy to the special educational facilities. According to the authors , in some cases it can go only on the provision of specific types of support to those who are due to violations of specific performance show slow reaction rate, as well as a special quality of thought and speech function. Not to the seizures, namely to “behavioral problems” in children, which appear almost in fourth of them even before the demonstration of paroxysmal states, pay attention J.K. Austin et al. (1997), defending thesis about

333

the fact that these problems prolongedly are the base for the social development with epilepsy. According to S. Ehlers et al. (1997), this special feature, leading to the delay of vocal and motor development in preschool children, at the age after 8 years can contribute to their social isolation. In the opinion of A. Henley (1997), P. Hoare (1997) and J.L. Schofield-King et al. (1997), to a considerable extent to this corresponds how schoolboys, who suffer epilepsy, «see themselves”. The frequently appearing ideas of their own incompetence and incapacity, the insufficiency of self-esteem and confidence in themselfs undermine the process of their socialization, which in turn negatively influences their emotional development and independence.

A. Alexander et al. (1997) in patients at the age of 26,6+/-7,2 years revealed the significant correlation between the level of their formation and the quality of life. J. Beaussart-Defaye et al. (1997) note the high, in comparison with the younger and more elder patients, frequency of the cases of the therapeutic resistance in the persons of average age, which reduces their social status. To a certain extent these data find confirmation in works of J. Cloyd et al. (1997) where in the group of patients older than 65 years the value of antiepileptic therapy for the quality of life is reduced. In first place in the average age group of patients with epilepsy in terms of impact on the possibility of achieving them a certain level of employment, according to N. Mayer et al. (1997), is a cognitive and emotional deficits.

For such patients the important significance acquire the recommendations of doctor to carry out feasible work, for example, not requiring the specialized education (S.A. Gromov, V.S. Lobzin, 1993).

G. Baker, A. Jacoby and D. Chadwick (1997), noting the insufficient mastery of a question about the influence of epilepsy and its treatment on the quality of the life of elderly people, conducted the special study of their physical and psychological functioning. The authors carried out the questionaire of 186 persons with epilepsy at the age 60 and more, as a result of which it was established the presence of seizures, anxiety and depression as the significant factor for the quality of life almost in half of patients. The tendency of a growing population in elderly patients with epilepsy in the development of «psychological difficulties» indicate S. Jarvie et al. (1997).

Should be, however, noted the indisputable fact that negative in general relation in the society to those, who suffer neurologic and mental disorders, at present changes by the wider understanding of the need for their public support. For the duration of the number

334

of decades the doctors, medical psychologists and specialists in the social work actively discuss questions about the rights of the young patients with epilepsy to the integration in the society, participation in the education and the work, and also about the possibility of assistance to employers in the placement of patient in work (S.M. Al Deeb, 1997; O. Baum et al., 1997; A. Jacoby et al., 2005). In 1989 the Manpower Services Commission of International League of Epilepsy formulated the following principles of the social-working adaptation of the patients with epilepsy.

Neither diagnosis of epilepsy nor possibility of the appearance of assaults are obstacle for obtaining the paid work.

In the insignificant percentage of the cases, when there are limitations for the selection of the specific forms of working activity, the solution starts individually taking into account the desire of patient and requirements, presented to this form of activity.

All patients with epilepsy must have the equal capabilities under the protection of health, rehabilitation and the conditions, and also social support for an increase in the employment opportunities and improvement in the social adaptation.

The patients with epilepsy have equal right to the search for work with the remaining society members, selection of profession and job placement.

As an example of the real realization of similar approaches to the observance of the rights of patients by epilepsy are the following recommendations regarding the driving them automobile, developed in 1994 by American academy neurologies, by the Society of epileptologists of the USA and by the American fund for epilepsy.

“The favorable factors: the seizures, which appear as a result of changes in the therapy according to the designation of doctor; simple partial seizures without the disturbance of consciousness and/or engine control; the seizures of in the form isolated auras; the seizures, which appear only in the night time; the seizures, caused by sharp metabolic disorders or intoxications without the probability of repetition; the seizures, caused by the deprivation of sleep; the seizures, caused by the reversible acute diseases”.

“The unfavorable factors: the inadequacy of the reception of preparations and visits of doctor; alcoholic and/or medicinal dependence in the course of the recent 3 months; an increase in the frequency of seizures during last year; the structural damage of the brain; the incurable functional or metabolic state of the brain; fre-

335

quent seizures after the long period of lack of seizures; transport incidents for 5 last years”.

In this case, however, in the society increasingly more frequently appears the need for the more differentiated estimation of possibilities of their patients with epilepsy in realization rights and an increase in their responsibility. In its publication R.G. Beran (1997), in particular, gives the materials of Australian College of Legal Medicine, that controls professional privileges and accomplishing a study of public opinion relative to patients – the drivers of automobile in spite of the medical recommendation. From 23 interrogated persons 22 consider that the doctor is right to require of the patient of the information about the disease in the cases of claims to the activity, connected with the risk for the society. Relative to fatal outcomes as a result of the road-transport incidents through the fault of driver-patients, who do not have medical recommendation, 9 of 23 respondents support charge in the murder, and 8 -only charge in the carelessness.

Principles of the dynamic and structured analysis of mental disorders utilized in our country for purposes of the social adaptation of patients, including psychotic and nonpsychotic, formulated in 19201930th years, as the prognostic categories, which reflect pathogenesis and pathokinesis of mental disorders, assume the calculation of type and stage of the course of disease. In this connection the joint use of principles of ICD-9, which releases as the diagnostic criteria the lifetime of psychopathological syndrome, and principles of ICD-10, by placing its task the study of the prevalence not only the nosologic, but also the syndromal diagnostic categories, could become the condition, which facilitates the development of the concept of dynamic and structured observation and conducting of patients.

In the situation of the social and economic crisis to domestic psychiatrists to the equal degree it is necessary to consider both the positive and negative experience of the developing and economically developed countries. In the developing countries in sharpest acute form remain all problems noted above of primary preventive maintenance of mental disorders (N.E. Bharucha et al., 1997; P.M. Leary et al., 1997 and others). In the economically developed countries, where acknowledges the right of patient to the selection of its means of the life, including vagabondage, the quality of the life of society in general is such that it makes possible for itself to have and to develop establishments, actively using different funds for purposes of the re-

336

alization of the medical, psychological and social rehabilitation of the voluntarily rotating patients.

According to S.M. Al Deeb (1997), in the developing countries the ideas of community about epilepsy “are primitive”. In majority their “stigmatized” patients with epilepsy “are squeezed, insulted and limited” in their relations with those surrounding. The author, however, considers the characteristic for these countries “strong family connections” with an improvement in the service of health can be prerequisite for an improvement in the public position of patients with the achievement in them of the proper therapeutic effect. This point of view share L. Andermann (1997) and A. Bener et al. (1997), who assume that the adequate conducting of the patients with epilepsy in the developing countries entails conducting the studies, which use both the cultural knowledge about this illness and practical experience of western medicine.

Sociopsychological study, carried out in the St. Petersburg psychoneurological institute of V.M. Bekhterev, showed the importance of conducting psycho-formation in the different population groups for purposes of shaping in them of tolerant relation to the patients with epilepsy. Majority from 694 not suffer epilepsy respondent, living in different regions of Russia, report, that receive epilepsy as incurable disease (78,6%), whose diagnosis which in themselves or close person they prefer hide (71,1%), 64,2% respondent consider, that majority employer don’t take on work man with given disease, 46,5% assume that majority person fear patients with epilepsy, 20,1% don’t allow possibility of education of patients with epilepsy in regular school. (V.A. Mikhaylov et al., 2010).

To “the influence of crosscountry race-cultural diseases to our multiethical society” in application to epilepsy focus attention E. Cerino et al. (1997). The analyzed by them experiences of patients, connected with the use of methods of treating epilepsy in their own country, were compared with those that the same patients experience after emigration. He concluded that epilepsy treatment-wise up to now remains disease, located between the traditional and scientific culture. According to S. Guerreiro et al. (1997), an effective opposition prejudice against epilepsy requires specific training, rather than just general and superficial information about her.

“Reconciling” position is shared by E. Beggi and M.L. Montichelli (1997). They consider that during the study the social consequences of epilepsy should be considered the national and sociocultural spe-

337

cial features of the concrete country or region. In the opinion of the authors, is necessary the comparison of different sociocultural conditions for explaining different points of view to the social aspects of epilepsy.

The propagation of the ideas of the rehabilitation of mentally ill patients in the postwar (since 1946) period was not for our country something fundamentally new, since the basis of rehabilitative process as a maximally possible restoration of personality and as the systems of organizational measures for any social and political formation comprised and comprises the natural requirement of individual and society to optimum interaction.

Precisely this natural need spurred domestic psychiatrists of the previous two centuries to be occupied by the device of agricultural colonies, workshop and secondary economies for the patients, who are prolongedly found on the stationary treatment.

In the 1930th years was emphasized the need of developing the criteria of effectiveness of working therapy. As the basic organizational principle was defended the succession in the organization of working therapy and working device of invalids (M.Ya. Grebliovskiy, 1966). The use of special privileges was provided for their working placement.

In the postwar years were satisfactorily solved questions of the working placement of invalids at home, also, in the cooperatives of disabled. Subsequently the enterprise management in the legislative order was forced to assume upon the work of invalids in accordance with the medical recommendations, creating by them the necessary conditions, including partial workday or partial work week.

At the beginning of 1950th it was possible to speak about existence in the country of psychiatric service as the specific rehabilitative system. Although the barbiturates remained the singularly efficient means of the drug treatment of epilepsy and there was an institute of patients with the protracted and chronic forms of the psychic illnesses, directed in the psychiatric colonies, among which approximately the tenth part composed the patients with epilepsy, the already most important condition of conducting the patients in the stationary establishments it became “systematic treatment by working regime” in the complex with the physiotherapy and the culturaleducational measures.

To this period were outlined some provisions of neuropsychiatric clinic, which now continues to be a key institution which pro-

338

vides control of the process of rehabilitation of persons suffering from mental disorders.

Since 1954 to the therapeutic-working workshops was extended general for the enterprises, which use work of disabled, the order of the guarantee with raw material and the necessary equipment. From the same time the patients, located on extra-hospital home nursing, began to be introduced to agricultural labor and in industrial enterprise. Labour standards here as in the therapeutic-working workshops and the secondary economy with the psychiatric establishment were determined by doctor.

Psycho-pharmacotherapy becomes most important component of the process of the social-working rehabilitation of patients with the mental disorders from the beginning of 1960th. Increasing interest in psychiatry from the side of doctors because of its successes in the treatment of patients is noted by the doubling of the number of psychiatrists in Russia within the period from 1959 through 1967. Specifically, in these years was developed the system of measures for the guarantee of population of the country with drug means, which made it possible to satisfy the annual need of establishments for the medicines for conducting psycho-pharmacotherapy under the control of regional pharmaceutical administrations.

Success of drug therapy formed the basis of the greater involvement of patients in occupational therapy. By the beginning of the 1970s, employment in health shops across Russia counted 17 thousand seats, of which 10% were occupied by patients with epilepsy.

From the beginning of 1980th attempts at the organization of department-hostels for the patients, who lost the related connections and a constant place of residence were undertaken by psychiatric establishments. In a number of the regions of the country these patients with the minimum medical observation proved to be capable of the self-service and the work at the usual or specialized enterprises. Because of the introduction in 1980 of position about the special shop for the invalids as a result of the mental disorders was activated the activity of the specialized subdivisions of industrial enterprises. In some regions of the country, they provide professional career or employment of patients for whom work in the mainstream has been difficult or contraindicated. Special shops and sites designed for the working device disabled the second and third groups, and also for patients who refuse pensioning on its proposed disability group.

339

Accumulation in the last decade in the community of nondisabled due to epilepsy, promotes poor logistics and staffing state of neurological and psychiatric services.

Should be considered that in general in the country the neurologic contingent of the patients with epilepsy more than twice exceeds psychiatric (in 2010 238 and 114 on 100 thousand population respectively). Social rehabilitation of persons with disabilities as a result of epilepsy in treatment neurologists and psychiatrists, may be conducted in rehabilitation facilities, organized in accordance with the Federal Law on social protection of disabled people.

By the Decision-order of the Ministry of labor and social development, Ministry of public health and Ministry of general and vocational education of the Russian Federation from 23.12.1996 № 21/417/515 provided the creation of rehabilitative establishments for the professional instruction, the professional-production and socialwelfare adaptation for disabled.

Rehabilitative establishment operates in interaction with the organs of civil service of the rehabilitation of disabled, the establishments of civil service of medico-social examination, and also the public unions of disabled.

The structure of institutions is included an educational complex with units that provide a process of general and vocational education, and vocational and industrial structure adjustment and facilitate the employment of people with disabilities. Relevant departments are created for rehabilitation.

Structure, staffing and operation mode developed by institutions according to their type, and view tasks assigned to them, taking into account contingent features disabled and the service area.

The period of a stay in the establishment is determined by the individual program of the rehabilitation of invalid, developed by the organs of civil service of medico-social examination.

Contraindications for admission to the institution are mental disorders with a penchant for frequent exacerbations or relapses of the disease and frequent decompensation requiring treatment in hospital.

To the disabled, who pass rehabilitation in the establishment, monthly is given the payment of pensions, grants and allowances.

To the disabled, who received the vocational education and the pass total certification, isgiven an official document about the obtained formation and the qualification.

340