Mental disorders in epilepsy

To determine the development strategy of institutions, improving efficiency and strengthening control over its activities, at the establishment can be created the board of trustees, in which can be included the representatives of the organs of civil service of the rehabilitation of invalids, of civil service of medico-social examination, interested organs of executive power, organs of local self-guidance, public associations of invalids and invalids, undergoing rehabilitation in an institution.

Beginning from the second-half of the 1990th in many regions of the country were undertaken attempts of the reorganization of all sectional psychiatric services, including psychiatric hospitals, psychoneurological dispensaries, clinic departments and offices, rehabilitative establishments and the subdivisions, by general task of which together with conducting of psycho-social work, working therapy and instruction in new professions is applying to a constant work of the persons with the mental disorders, including invalids.

Rehabilitative subdivisions use in their work new technologies of rendering to the psychiatric aid, directed toward the preventive maintenance of hospitalization and rehospitalization to the psychiatric hospital.

Pressing psychiatric aid occurs the departments of intensive rendering to psychiatric aid at home; including pharmacotherapy and psycho-social therapy in the customary for the patients environment.

In the medico-rehabilitative departments after the discharge of patients from the hospital is conducted pharmacotherapy, group psycho-social therapy and psycho-social rehabilitation of patients and members of their families in interaction with the divisions of the social protection of population, the charitable foundations, the societies of disabled and other organizations.

In the stationary medico-rehabilitative departments drug, psychological and social aid takes place in order to motivate them and members of their families in further (out of the hospital) participation in the medico-rehabilitative process.

For the realization of the individual rehabilitative program of invalid as a result of epilepsy it is necessary to the psychoneurological dispensary and the clinic department of psychiatric hospital to be responsible for eventual result of the reducing treatment of patient and his job placement. The hospitalization of patient, discharge from the hospital, direction into the day hospital, to the the- rapeutic-working workshops, to the specialized or usual enterprise

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are possible only with the consent and participation of the district psychiatrist, working in conjunction with the clinical psychologist and specialist in social work.

In accordance with the active use in the country over the past two decades of biopsychosocial concept of mental health care, individual rehabilitation program for persons with mental illness is a set of activities, which include shapes, volumes, timing and order of the medical, psychological and social assistance aimed at restoring or compensation for damaged or lost functions, restoration or compensation of a patient’s ability to perform certain activities.

The individual program of rehabilitation is compiled during the examination of the invalid of bureau of medico-social examination. It must also include the measures, directed toward improvement in the quality of life of patient, professional instruction and retraining, active employment, family rehabilitation. The realization of the necessary measures for social protection and aid is important (including the guarantee with free medicines). (V.G. Pomnikov et al., 2010).

For the patients with epilepsy job search is the main problem of rehabilitation (R. Raessler et al., 1990). British Epilepsy Association (1990) carried out the interrogation of 2000 patients with epilepsy, as a result of which, it was established that 72% of them were unemployed. However, level of unemployment in the patients with epilepsy, that have the combined neuropsychic disturbances, according to E. Beggi and M.L. Montichelli (1997), composes 77-79%. The greatest percentage of unemployment occurs among the patients, observed in the so-called “tertiary” medical centers and having together with the resistant seizures mental disorders (P.J. Thompson et al., 1993).

The rehabilitation of the patients with epilepsy with the mental disorders, in the opinion of many specialists, must not be carried out in the specialized centers. Organization of the so-called therapeutic society (M. Jones, 1950 is adequate not only for patients who are forced to be together for a long time, for example, in a hospital, but also in day and night hospitals, therapeutic-working workshops and conventional manufacturing enterprises. In this case, it is not necessary, or even desirable, to make this community consisted only of patients with epilepsy.

Employment, achieved on the voluntary selection, V.A. Tarpis (1973) divides into the occupations according to the abilities (music, depictive skill, literature), the occupations of applied nature (circles

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of economics, cutting out and sewing and other), the general measures of entertaining-cognitive nature (conversation, the evening of leisure, excursion and other). Employment includes also working therapy.

However, in the post-war years, a number of countries made decisions about the construction of specialized facilities for the treatment of patients with epilepsy. One of them – Sain-Paul in Marseille was built according to the project of A. Gastaut in 1960. Establishment consisted the center of diagnostics and center of hospital or ambalant treatment. All patients after primary inspection was bound for the biological, the neurologic, psychological and, if necessary, psychiatric studies, the selection of drug dosages, EEG. For the prolonged treatment the patients were placed into the so-called family houses, which were located in the park of center, and patients were located under the medical control in the conditions, approximating relatives. Experience showed the effectiveness of similar centers as one of the links of rehabilitation. (M.A. Akimenko, 2010).

In 2003 for the dynamic observation of the patients with epilepsy in Moscow were organized 5 epileptologic offices, in which during the year were recorded not less than 400-500 new cases of disease. By 2011 the total number of patients in the offices composed 12,5 thousand. All offices were equipped for the registration EEG. In the cases resistance to pharmacotherapy the patients are directed during the consultation into the neurosurgical subdivisions. In 2008 were organized 3 interdistrict neurologic departments of paroxysmal states with the day hospitals (A.N. Boyko et al., 2011).

As to an example of satisfactory resolution of questions of the rehabilitation of the patients with epilepsy with the mental disorders under the extra-hospital conditions it is possible to name the activity of the specialized epileptologic office with the republic (Republic Udmurtia) psychoneurological dispensary in Izhevsk, the effectiveness of work of which is the fact that up to 84% of more than 900 epilepsy patients obtain timely diagnostics, adequate individual therapy, psychological diagnostics and correction, the professional orientation and the prognostication of stage and the like of the course of disease (V.T. Lekomtsev et al., 1997).

In 1960th in four regions of Leningrad were created the specialized epileptologic offices, the joint activity of neurologists and psychiatrists in which made it possible in 7 years to double the number of patients with epilepsy for the clinic observation. In 1967 on the base of psychoneurological dispensary, and then psychiatric hospital in the city

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was organized epileptologic center with the posts of neurosurgeons, anesthesiologist, psychiatrist, neurologist, electro-physiologist, neuroophthalmologist. With the advent of new antiepileptic preparations was reduced the neurosurgical activity of center, and conducting consultations for the patients of the ambulant-polyclinical establishments of city on questions of diagnostics, examination and optimum drug antiepileptic therapy became its main task. (M.Ya. Kissin. 2009).

In the period of stationary treatment under the conditions of the specialized clinic of St. Petersburg Bekhterev Psychoneurological Institute the patients with epilepsy are included in the system of the rehabilitative measures, which encompass a wide complex of psychosocial actions. Several stages of the psychotherapeutic work are separated: the establishment of contact with the patient, conducting complex psycho-diagnostic inspection, the realization strictly of psychotherapeutic actions. The psychological correction of personal manifestations in patient adapts when patient recognizes its undesirability for himself or when it is the reason for the disorganization of the activity of those surrounding and tension of interpersonal relations. (S.A. Gromov, M.Ya. Kissin et al., 2006; N. Ismailov et al., 2011).

It should also be noted that the rehabilitative function of the specialized centers epilepsies, as shows experience, are directed toward the instruction of children and adolescents along the all-school program, the therapy by employment and the social work with the patients and their families (J. Fandino et al., 1997; D. Sawyer, 1997; J.L. Schofield-King et al., 1997; M. Skov-Hausen, 1998; and others).

The provided by Law on the psychiatric aid assistance of state in the working device to the persons with the mental disorders assumes establishment for them by the organs of power of the state and by the organs of the local self-guidance of the quotas of work sites.

This measure is in sufficient detail developed by Federal law on the social protection of the invalids of 1995 with respect to persons with disabilities.

With regard to the labor unit of mentally ill who do not have the disability, they exercise their right to work in the usual manner in accordance with Article 5 of the Law on Psychiatric Care. In the implementation of the rights of patients are actively involved social workers.

The individual program of social-working rehabilitation, which includes the drug forms of treatment, working therapy and the working device of those, who suffer mental disorders, provides for the

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differentiated step by step restoration of patient, the application of personally oriented individual, family and group psychotherapy, sociotherapy, milieu therapy.

Analysis of the work of general practicioners, carried out by K. Smith et al. (1997) in the United Kingdom and M. Sande Lemos (l998) – in France, Germany and Portugal, showed that they are occupied by the treatment of patients with epilepsy frequently ignoring the problems of differential diagnosis, sedative effect of antiepileptic means, pregnancy in the patients with epilepsy and other. Aid to patient without the consultation with the specialists in the region of epilepsy is rendered from 8 to 60% of them, and the percentage of correct answers in them to the knowledge of clinic and therapy of epilepsy varies in the limits from 43 to 56.

The need of using the team method of treatment and social support of patients with epilepsy is dictated by the complex nature of the clinical, psychological and social problems, which appear with this disease in patients and their close environment, presence of which is indicated by many well-known therapeutists-epileptologists, since 1950th.

Nowadays none of the doctors and organizers of public health doubts about need for the drawing up a protocol of diagnostics, treatment and social rehabilitation of patients with epilepsy with the simultaneous participation not only neurologist, but also psychiatrist (T. Betts et al., 1997; S.E. Selai et al., 1997), surgeon (S. Dykgraaf, 1997; L.A. Lathrop, 1997; D. Ruta et al., 1997), nurse, who specializes in epilepsy (J.E. Chaplin et al., 1997; K. Larsson et al., 1997; R. Lossius et al., 1997; A. Medagoda et al., 1997), physiotherapist and specialist in the massage (M. Boyle, 1997; J.E. Chaplin et al., 1997), specialist in the therapy by employment (J.E. Chaplin et al., 1997; M. Skov-Hansen, 1998), psychologist or neuropsychologist (J.E. Chaplin et al., 1997; S. Jarvie et al., 1997; K. Larsson et al., 1997; Z. Martinovic et al., 1997; A. Piazzini et al., 1997; and others), social worker, who specializes in epilepsy (J.E. Chaplin et al., 1997; S. Dykgraaf, 1997; A. Izmeth, 1997; K. Larsson et al., 1997; P. M. Leary et al., 1997; A. Piazzini, 1997).

By necessary condition of the work of therapeutic multidisciplinary brigade R. Thorbecke et al. (1997) counted the high scope of its terms in questions of interaction.

At the same time, as correctly note J.E. Chaplin et al. (1997), this type of work is still insufficiently studied. The authors themselves,

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in our view, too much importance attached to the work in group, containing only patients with epilepsy. We consider that participation in the group therapy of any patients with the mental disorders, not compulsorily entirely connected with epilepsy, is not only possible, but even is necessary. As an example, the work of dynamic psychiatry centers in Germany (Berlin, Munich), which combines the principles of long-term group psychotherapy patients with different nosology from everyday informal communication between members of the group itself and the therapist, joint participation in occupational therapy, occupational therapy, music therapy, dance therapy, etc. and finishing the regular pharmacotherapy. In the group of patients suffering from a wide range of mental disorders, including personality disorders, delusional disorders and catatonic, also includes enough «changed» patiens with epilepsy (G. Ammon and M. Ammon, 1999).

Similarly is organized the work of support groups led by the Center for Epilepsy I.M. Ravnik et al. (1997), conducted by a team of professionals with differentiated by leading clinical and therapeutic issues groups for parents of children with epilepsy, as well as with former patients, adolescents and young adults after surgery for epilepsy. Typical scenario assumes gang work (epileptologist, clinical psychologist, neuropsychologist, neurosurgeon, the former patient) and includes: 2 hours “topical” special support, nonformal contacts, 1 hour of the studies with video, planned by individual arrangement, invitation to the activity in inter and the self-help. According to the estimation of the authors, group work is capable of substantially improving the quality of aid and contributing to the best regulation of vital problems in patients and their families.

M. Skov-Hansen (1998) reports about the positive results of the brigade conducting of 40 adult patients with epilepsy “with the heavy psycho-social problems”. By the members of multidisciplinary brigade are doctors, nurses, psychologist, social worker, specialist in the therapy employment, teacher. Patient interview with the entering for the stationary treatment, on the eve of the discharge and through 3 and 6 months after discharge from the hospital.

Taking into account the special attachment of the majority of the patients with epilepsy to the family, school and working relations, many contemporary specialists fundamental importance in the rehabilitative process give to work with the family of patient, his teachers and administration. This first of all relates to the children, who suffer epilepsy, for majority of whom the concepts “family” and “school” are

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inseparably interconnected, almost just as for many adult patients of concept “family” and “work”.

The research related to the study of knowledge of school teachers about epilepsy. According to P. De Marco et al. (1997), of 1032 interrogated school teachers 36% train children with epilepsy in their class. More than 51% teachers express a feeling of solidarity with respect to the schoolboys, who suffer this ailment, 16% experience the feeling of discomfort, 11% – feeling of pity, 5% – fear. Only 0,4% of teachers connect word “epilepsy” with the word “madness”, and 0,8% – with “holiness”. About 10% of teachers believe that for children with epilepsy is necessary a constant support in the form lightened school program with the condition of visit by them special school. The latter, however, in their opinion, is not compulsorily and can be substituted with the instruction of staff of schools “to manage epilepsy”.

These data to the certain degree coincide with the data of the interrogation of the parents of children, who suffer epilepsy, obtained by D. Gigineishvili (1997), according to which the majority of parents are disposed against any limitations in the guarantee of sick children with “controlled seizures” “harmonious atmosphere in the society”. A. Henley (1997) considers the propagation of ideas about incompetence and incapacity “of children with epilepsy”, “undermines school process” and “socialization” of patients. D. Settle (1997) proposes one-day educational course on epilepsy for the instructors of schools.

Many authors suggest that children with epilepsy helps the holistic, multidisciplinary approach to the satisfaction of their needs. With this march, according to J.L. Schoffield-King et al. (1997), parents and students are considered as equal partners, and individual educational plan, reflecting this approach, contains division “students and the parents/of the prospect for career” and is considered the potential of this child. According to F. Besag (1987) and P.J. Thompson (1987), in Great Britain the majority of children with epilepsy attends usual schools, and only 1/3 – special, because of the available to them mental disorders and the problems of instruction and behavior.

E.A.R. Souza et al. (1997) conducted the study of effectiveness in the work of the group of the support of the parents of children with epilepsy. In the relations between the parents and the children were noted the following emotions: vexation (94,4%), fear (72,2%), horror (27,8%), melancholy (33,3%), anxiety (27,8%) and failure (38,9%). Parents realized the connection between their behavior and reactions of children (77,8%). After the sessions of support 94,4% of parents

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noted in themself reduction in the anxiety and hope for an improvement in the interrelations with the children.

In the opinion of P.A. Temin (1992), the parents of children with benign epilepsies must not accentuate the attention of child at the disease and relate to it as to “crystal vessel”. By factors of the risk of the development of psychopathological disorders in children with epilepsy, according to V.P. Hermann et al. (1991), appear not only the absence of the control of paroxysms, the prolonged course of disease and the low budget of family, but also divorces and the separate stay of parents.

According to the data of a study of the public opinion, carried out by M.D. Hills et al. (1997) using a random sampling method with 450 rural and urban subscribers in New Zealand, the attempts to decrease the prejudices in the society against the adult patients with epilepsy relative to their family and professional status have in recent years certain success, but some negative stigmas remain, which requires the continuation “of the opposition with respect to prejudices”. To the same conclusion come A. Jacoby et al. (1997), conducted crosscountry race-cultural study positions of patients in the society, including questions of their working device and remuneration for labor, with the attraction of 5 thousand respondents in several countries of Europe. The need to raise awareness on issues of epilepsy related thereto social groups indicate S. Kochen et al. (1997).

Nevertheless it is necessary to keep in mind, that in the young adult patients with epilepsy the social activity is lower than in their contemporaries with other chronic diseases (A. Apter et al., 1991; J.K. Austin et a., 1994). E. Beggi and M.L. Montichelli (1997) consider that the young adult patients with epilepsy more frequently encounter the problems of the search for work or retention of their work, since in a number of cases they need additional aid and instruction in order to manage the requirements presented on the work. Unemployment and problems of job placement of the patients with epilepsy are caused, in particular, by the attitude of employers because of the fear of accidents, truancies, inability to perform the work in full (W.A. Hauser et a., 1990). S. Bugler (1996) proposed recommendations on education in the field of epilepsy for the patients, their parents, populations, doctors, medical personnel, teachers, civil agents.

Since 1995 medical psychologist in Russia as a part of multiprofile therapeutic brigade, which achieves rendering to psychiatric and psychotherapeutic aid, conducts work, directed toward the

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restoration of mental health and the correction of deviations in the development of the personality of patient. Revealing the conditions, which impede the harmonic development of the personality of patient or which hamper him, are achieved measures for psychoprophylaxis, psycho-correction, to psychological consultation, by means of what is rendered aid to patient, to his relatives and to medical personnel in the solution of personal, professional and everyday psychological problems. Conducting psycho-diagnostic studies and lasting diagnostic observations of the patients and paying in this case special attention to those, who have the factors of the risk of the development of the mental disorders, which are based on pathopsychological pathogenic mechanisms and behavioral patterns, medical psychologist together with the doctor carries out work on the professional orientation of patient taking into account his value installations, abilities, situation possibilities and urgent plans.

In the country is actively conducted social work with the psychiatric patients and their environment. In the composition of the multiprofile brigade of specialists in the establishments, which render psychiatric and psychotherapeutic aid, the specialist in the social work on the direction of doctor organizes the individual and group work with the patients, directed toward an improvement in their social adaptation, the training of communicative habits, taking measures for the social-lawful protection of patient, the cooperation of establishment with the organizations, which render social aid. Together with the doctor and medical psychologist are created therapeutic medium, therapeutic associations of patients, group on the interests, accomplish club work, deals with continuing of the level of social adaptation of patients, building their responsibility for their social behavior, develop and organize activities for their social protection and support their employment and living conditions. Specialist in the social work determines the forms of the work of social workers on an improvement in the social functioning of patients in the family, the school, nonformal groups, the production associations and other.

In light of the data presented, which relate to the organization of rehabilitative process, for the domestic psychiatrists are of undoubted interest some theses of the trade union of German psychologists, formulated and accepted by it at the beginning of 1997.

“It should not be the first a question to the patient: “How can I help you?” It should read: “What living conditions do you need to be healthy?”.

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“Practical aid to patient – is in his orientation for the daily independent formulation of life, in the individual psychological tracking, in the complex of medico-pharmacological support and the aid in the reaching of “useful medium”.

““It is necessary to psychologists, in accordance with his professional competence, have their place in the clinical hierarchy, more covering the tasks of the development of concepts, the supervision and management. Their participation in the education of psychiatric personnel appears already sufficiently to commonly used and indisputable”.

In the conclusion of chapter let’s turn to some data of literature, which illustrate and which develop the represented above general judgments in application to the theme of preventive maintenance and rehabilitation of epilepsy.

The identification “of benefit” for the individual-patient is complex, but necessary condition of creating the individual programs of the rehabilitation of those, who suffer the mental disorders, which are caused by this widespread and varied on its manifestations illness, such as is epilepsy. By the leading line in this case, as it is considered by O. Baum et al. (1997), must be “the development of young person with epilepsy”, his “integration into the working peace and the society” with the use of adequate instruction for the acquisition of qualification and work. In this case the recommendations of specialists must relate both directly to this personality and to its personal environment (J. Beaussart-Defaye et al., 1997).

Next to the traditional medically oriented system of rendering aid to the patient with epilepsy increasing influence acquires the system of aid, which can be considered not less competent, but more integral holistic for those, who suffer epilepsy, the system, whose basic purpose is to lead patient to the effective self-guidance (M. Boyle, 1997), to the skill “to manage epilepsy” (P. De Marco et al., 1997; S.E. Selai and M.R. Trimble, 1997).

For the adaptation of the patients with epilepsy in the surrounding world it is especially important to use their creative personal potential and absence in their majority of the cases of this extended with other forms of mental pathology syndrome as a decreese in the energy potential. As note A. Germanavicius et al. (1997), J. T. Moroney et al. (1997) and others, great significance for the man with the mental disablement as a result of epilepsy has his creative activity, which ensures its self expression.

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