Mental disorders in epilepsy

CONCLUSION

Since held in 1997 in Dublin, 22th International Congress on Epilepsy International antiepileptic League (ILAE) as the main problem facing the modern professionals engaged prevention, treatment and rehabilitation of epilepsy in the community of persons affected by it, highlights the problem of stability for epilepsy traditional and new types of medical treatment. The most resistant not only in relation to drug therapy, but also for surgery are considered temporal and frontal partial epilepsy.

However, based on current and future materials of the Congresses ILAE (both international and regional level), you can judge how much more distant are from one another modern neurologists, psychiatrists and other specialists in solving complex problems that are combined under concepts such as primary, secondary and tertiary prevention of this disease. For the first time in the past decade at the 10th European Congress of epilepsy in London in 2012 was rised a question of need for a separate classification of mental disorders in epilepsy.

According to contemporary ideas, the psychoses with epilepsy are the important, but insufficiently studied model, which can contribute to understanding the pathophysiology of psychoses in general (A. Kanner, S.C. Schachter, 2008; T. Butler et al., 2011).

However, is seems that with the development of the study about epilepsy, this acknowledged “window into the brain”, indicated break between the specialists of different profile in the approaches to its knowledge increases in spite of the general tendency toward the formation in practical medicine of therapeutic brigades, therapeutic associations, etc.

For the existence of a similar kind of gap, there is, of course, the premise of a methodological nature, primarily resulting from the characteristics of the subject of the study. However, for overcoming this

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break there is much in common, which to the equal degree interests different specialists. For example, the predictors of prognosis.

Not without reason such researchers as E.K. Sepp and S.N. Davidenkov, H. Jasper, W.G. Penfild and T. Ericson, who worked in the not-too-distant past, did not divide epileptic disease into the forms, by which separately or predominantly must be occupied these or other specialists. And today, it is retrospective, according to the method of thinking the authors indicated it is difficult with the accuracy to determine, who of them was neurologist, neuropsychologist, psychiatrist or neurosurgeon.

The need to combine the efforts of different specialists at present consists not only in the plan of the succession and multidisciplinary nature in the organization of the medical, psychological and social aid to the patient with epilepsy. This need, first of all, is caused by the appearance of new methods of investigating of brain and new antiepileptic preparations, whose application not only changes idea of the fatalism of prognosis with many forms of epilepsy, but also changes idea of the size of its resistance to the treatment and, therefore, the criteria of prognosis.

Combining of the efforts of the specialists of different profile is necessary for creating the united classification of neurologic and mental disorders in epilepsy. After all, nothing else but the inconsistency of professional approaches, can not explaine the fact that the ICD-10 epilepsy has virtually disappeared from the class of mental disorders. Not confrontation, but the integration of efforts is necessary, first of all, from the side of neurologists and psychiatrists. And in this direction of joint activity for the beginning one should think about the formulation of such problems of a study as the establishment of correlation with the type of the course of the disease of the concepts of primary and second generalization, focality and diffusivity of epileptic process.

Indeed precisely the type of the course of disease or the type of its progressive course causes in the final analysis visible in the time and more extended prognosis.

On the possibility of organizing the joint operation of different specialists in Russia testifies the work experience of epileptologic centers in Moscow, Izhevsk, Petersburg, Saransk and a number of other cities.

The carried out by us complex case study of the long-standing course of epileptic disease with the application of clinico-catamnes- tic, epidemiological and statistical methods of study made it possible

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to refine and to reveal a number of the special features of epilepsy, which takes place with the mental disorders, and to formulate the positions, which relate both to laws governing its development for its entire elongation, and to the basic aspects of formation, course, ontogenesis and prognosis of mental disorders typical for epilepsy.

The results of the conducted studies, first of all, confirm the fact of the existence of the varied manifestations of epileptic psychoses. The special features of syndromokinesis with the epileptic disease show that the epileptic psychoses are one of the basic and frequently meeting symptoms of this disease, which reflect the specific stage of its development. On the average they appear in 10-15 years after it occurred the demonstration of disease and arose paroxysmal states.

Obtained data show that the manifestation of the so-called isomorphism of psychotic symptomatology with epilepsy and schizophrenia, which theoretically can be explained by the positions of the concept of united psychosis, according to which with epilepsy can be observed entire spectrum of the productive psychopathological syndromes, characteristic of the endogenous processes (A.V. Snezhnevskiy, 1974), under the contemporary conditions for a significant increase in the possibilities of an instrument study of biochemical, electroencephalographic and morphological changes in the brain can be explained, also, from the positions of the localization-generaliza- tion of pathologic process.

At the same time despite the fact that as with the schizophrenia, with epilepsy together with the relatively clearly outlined, “typical” affective, delusional and catatonic psychoses occur the most diverse integrated and complex on the clinical picture forms of psychoses, the polymorphism of psychopathological manifestations with it is caused and painted not only with such specific manifestations as dysphorias, the changed consciousness, but also by characteristic changes in the personality.

The uniqueness of the clinical picture of epileptic psychoses, probably reflecting the features of pathogenesis in epilepsy, the significant prevalence of psychotic disorders in the population of the patients with epilepsy (according to our data, more than in 60% of cases), a sufficient extent of the period of disease with the presence of epileptic psychoses (on the average, for the first time they appear in the age from 20 to 30 years), and also uniform distribution in the structure of the epileptic psychoses of three basic registers of productive psychopathological disorders (affective, delusional and catatonic) confirm the

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previously repeatedly expressed opinion of the independent existence together with the schizophrenia and the manic-depressive psychosis of the third endogenous psychosis – epilepsy.

In general pathokinesis of epileptic disease is characterized by the complication of clinical picture, by the deepening of the defeat of mental activity and can be represented in the form the sequential development of such basic forms of pathology as the personal special features of patients, in a number of cases beginning to be manifested even to the appearance of the first paroxysms, paroxysmal syndrome, psychotic disorders, epileptic dementia. Consistently arising, they do not replace each other, and the next as if superimposed on the preceding, and preceding the clinical features of the disease to some extent or are reduced or cease to occupy a leading position in the clinical picture.

The early forming special features of personality in majority are outlined for entire elongation of disease, including its latest stages, come out as pivotal syndrome and can be examined as the most pathognomonic nosologic sign. With the advent of paroxysmal and psychotic disorders they undergo qualitative shift. With the formation of epileptic dementia begins the erasure of individual differences, the consolidation of the so-called “epileptic personality”, basic special feature of which is combination in the patients of hyper-sthenic features and mental rigidity, reduction in the critical functions, bradyphrenia, egocentrism.

Paroxysmal disorders during their manifestation, and then throughout the entire disease is characterized by the appearance of new forms. With the advent of the signs of psychosis and especially dementia they have a tendency toward the reduction.

The varieties of the forms of the course of epileptic psychosis are reduced to three basic: transitory, schubweise and chronic. Their clinical picture is characterized by extreme variety and covers all registers of the productive psychopathological disorders: affective, delusional and catatonic.

Research has shown that every case of the disease is usually characterized by predominantly one of the following forms of the course of epileptic psychosis, which allows to think about the susceptibility of the brain to a certain duration of psychotic reactions to abnormal harm the underlying epileptic process.

For transient psychoses with sudden onset and rapid completion, lasting from a few hours to several days, relate psychotic episodes of the type of depression, mania, hypochondriac states, anxiety states

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with the ideas of relation, poisoning, pursuit, hallucinatory-delusio- nal states, delirium, lucid catatonic disorders, catatonia with oneiroid or dreamy disorders of consciousness.

The group of paroxismal psychoses with those less sharply outlined by beginning and output from the psychotic state, duration from several weeks to several months, is affective, depressive-delusional, maniacal-delusional and delusional schubs, psychoses with the cata- tono-delusional and catatonic manifestations.

The chronic psychoses include affective-delusional states with the predominance of super-valuable ideas, with the hallucinatory inclusions, states with predominantly querulant delusion, in combination with the manifestations of second catatonia, catatonic states with the affective-delusional iclusions.

A study showed that the structure of transitory, schubweise and chronic psychoses, and also syndromokinesis of psychopathological disorders with epilepsy are found in the definite dependence on the preferred localization of epileptic process and degree of progressive course of disease.

The studies of correlation between the dynamic and structured characteristics of psychosis and the stages of disease revealed in the course can be set in the connection with the preferred defeat of mesolimbic system, cortical divisions of the temporal or frontal lobes of the brain, consecutively implicated into the pathologic process. Depending on the extent of the disease progressive at different times after the phylogenetically ancient formations in the process included the overlying control the functional systems of the brain. The more stable the compensatory mechanisms , the less active in clinical manifestations flows epileptic process.

Depending on the rate of progressive course of epilepsy the development of psychosis can long time remain at that its stage, when cognitive functions clinically remain unaltered, or either with one or other speed pass all subsequent stages of the disease, when the picture of epileptic dementia is revealed: at first with gradual reduction in the creative abilities and working storage, appearance of the expressed affective (dysphoric) disorders, then – with the sluggishness, the viscosity, the objectively-concrete nature of thinking and fi- nally with the the oligophasia, by the expressed mnestico-intellectual decrease, by aspontaneity.

Psychotic symptoms to a certain degree are reduced at the stages of the formation of epileptic dementia in proportion to the dee-

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pening of intellectual defect. Affective reactions become less sharp, delusional manifestations acquire the thickening forms, is lost the urgency of delusional experiences, the catatonic disorders, entering the structure of polymorphous psychopathological formations, become more elementary, predominate the phenomena of second catatonia.

The clinico-prognostic aspect of the problem of the course of epilepsy with psychosis and dementia assumes the analysis of the factors of hereditary, biographical, personal, cerebral-organic, psychopathological and paroxysmal circle, which participate in the structuring of mechanisms and clinical picture of disease.

The results of observations made by us on two large groups of patients living in different distant regions of Russia, were very similar and showed that the type of epilepsy, to varying degrees, reflecting the destructive tendency of the epileptic process is a determinant of prognosis in all stages of the disease.

This circumstance is especially evident in the fact that with a combination of drug therapy for uncontested its significance to reduce mortality, reduce the severity of paroxysmal and psychotic symptoms and reduce the number of cases of the formation of the final states in epilepsy are not met radical shifts in the natural stereotype of the disease. The effectiveness of drug therapy seemingly is located in the specific dynamic equilibrium with the biologically caused rate of progressive course of epileptic process. Without being, apparently, in a sufficient measure of that of pathogenetically substantiated, therapy does not lead to the complete recovery or the stopping of process and in the dependence on the type of the course of the latter in the different measure ensures only the reduction of various paroxysmal and productive psychopathological manifestations. The latter, in turn, causes differences in the effectiveness of resolution of questions of the social rehabilitation of patients.

The best results of treatment and social rehabilitation, and the similarly and less expressed manifestations of a epileptic change in the personality are noted in the group of patients with uniform affective and affective-delusional disorders appearing at any age. In the structure of transitory and schubweise psychoses predominate unipole affective disturbances, frequently with the dysphoric nuance. The autonomous forms of the brutal dysphoria are exception. Chronic psychoses are characterized by affective-delusional syndromes with the predominance of super-valuable ideas.

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To the favorable course of disease in these patients correspond the hyper-social, compulsive structure of personality, predominance at the early stages of the ontogenesis (at the age of up to 20 years) of the vegetative paroxysms above dysphorias and generalized tonicoclonic seizures. Independent of the duration of disease here there are no expressed signs of epileptic dementia, and personal changes in essence are the exaggerated aggravation of premorbid special features. Straightness, rigidity and unique egocentric understanding of their debt are combined with the manifestations of conformity, their kind of altruism, manifested more frequent with respect to the relatives, and also with emphasized industriousness, assiduity, in many respects by the formal searches for the validity and irreproachable solutions, by tendency toward the categorical judgments. One of the typical sides of the personality of patients – special hyperthymism, which causes the constancy of their social installations and value orientation.

Special position occupies the group of patients with the moderately expressed signs of a intellectual-mnestic(mental) decrease, the distinct on the third decade of life characterological shift in the form of the combination of hyper-social significance with the tendency toward the conflicts, the high self-appraisal, the tendency toward the paranoiac reactions, the inadequate level of claims. Psychotic disorders more frequently are manifested in the fourth-fifth decade of life, whiches indicate the set aside exacerbation of epileptic process. Transitory psychoses with the predominantly delusional disorders are first of all affective-delusional and hallucinatory-delusional episodes. The schubweise include the psychoses with the protracted delusional disorders. Chronic psychoses are characterized by predominantly affective-delusional disorders with the hallucinatory inclusions. Delusional states with the plot of the hypochondriac content are noted here most frequently.

The versions of paroxysmal phenomena are from the very beginning characterized by polymorphism. Here in the equal measure are represented vegetative paroxysms, dysphorias, temporal (psycho-mo- tor and psycho-sensory), generalized tonicoclonic and other seizures. Under the conditions for systematic treatment convulsive forms disappear sufficiently rapidly, whereas temporal versions and some simple partial seizures are, as a rule, characterized by therapeutic resistance.

Epileptic process initially does not affect the nucleus of personality, but changes the formal course of the mental phenomena: ex-

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periences, the methods of expression, reactions, behavioral reports. However, a comparatively late exacerbation of process nevertheless leads to the fact that increasingly in larger measure changes the personal structure: emotional accessibility is inferior the place for egocentrism, empathy – irritability and aggressiveness, altruistic tendencies – love of power. Epileptic dementia is characterized by partiality. The stages of its formation are extended. The first stage of the formation of dementia with the predominance of affective disorders more frequently occurs at the age from 20 to 40 years, the second, basic signs of which are retarding of thinking and perseverations, diffusion and floridity of thinking at the age from 40 to 60 years.

In these cases the increase of changes in the personality is frequently caused, besides the most pathologic process, by the stereotype and monotonous reactions of patients for the manifestations of disease and first of all by those changing position in the family, in the working association, in the micro-social connections. In view of these circumstances in the majority of patients professional ability to work is considerably reduced or it is lost.

The pole of the unfavorable course of epilepsy is characterized by another collection of clinico-dynamic signs. This is mainly forms, which appear at the children and teenage period, caused, first of all, by the organic defeat of brain, which are characterized by the protracted transitory, schubweise and chronic psychopathological disorders.

Among the transitory psychotic states are most frequently noted the psychoses with the lucid catatonic disorders and catatonic episodes with oneirism or with dreamy changes in the consciousness. The paroxismal psychoses include the protracted disorders of catatono-delusio- nal and catatonic register. Chronic psychoses are characterized by the presence of predominantly querulant deusion or catatonic states with the affective-delusiona inclusions. Disease is developed in the presence of cerebral insufficiency. Seizures bear polymorphous nature. At the childhood they are the typical evolutionary forms: retro and propulsive, pyknoleptic with the elements of oral automatism, myoclonic with the locomotor component, classical absences. Already in the first decade of life is revealed the predominance generalized tonicoclonic of seizures above the vegetative. Subsequently temporal paroxysms are observed on the level with the generalized convulsive seizures.

In the course of the disease there are long periods of decompensation, the most dramatic manifestations of which should be con-

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sidered as part of a series of seizures, statuses, dreamy frustration of consciousness, constant obnubilation and finally the most negative component of the moved wreck of the patient as of personality – increase of the signs of epileptic dementia. Already in the first three decades of life to the foreground come out brutal explosiveness, insolvency in the estimation of the surrounding events, torpidity, viscosity of thinking and mnestic disturbances.

An increase in the daily doses of anti-convulsants to the maximally recommended level is frequent method for stopping the paroxysmal syndrome. This tactics is dictated by the high resistance of seizures, and in the essence it does not have alternative. Psychotic disorders seemingly continue the active motion of epileptic process, to a considerable extent growing from the personal pathology.

In many patients with predominantly querulant delusion in anamnesis it is possible to note the early tendency toward the supervaluable formations, subsequently which is changed by mono-subject delusional ideas or by the persecutory delusion. At the stages of the formation of epileptic dementia, separated from each other for not more than 10 years, are typical the extreme viscosity of thinking, the complete ignoring of strange opinion, edifying monologues and gross reduction in the critical abilities. In patients with the most rapid rate of the formation of dementia and oligophasia are developed prolonged sub-stuporous states, in connection with which is lost the capability for any working activity.

Special importance in the theoretical and practical sense have the revealed during the course studies versions of syndromokinesis of psychopathological disorders with epilepsy.

Syndromokinesis of paroxysmal and psychotic disorders, as show data of our study, apparently, is caused by those establishing reciprocal relations in the course of disease between pathological and functional systems of brain.

The epileptization of mesolimbic system with the favorable course of disease for long time is compensated because of the influence of the superincumbent (temporal and frontal) cortical divisions. The predominantly vegetative nature of the first paroxysms, the predominance of the hyper-thymic features of personality, the predominance of affective disorders in the structure of psychosis, the absence of the expressed signs of epileptic dementia correspond to electroencephalographic data, which indicate the preferred localization of epileptic center in the deep divisions of the brain.

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The preferred defeat of the lateral cortical divisions of the temporal lobes of brain with epilepsy with the set aside exacerbation of process is confirmed by the polymorphism of paroxysmal symptomatology, by the therapeutic resistance of temporal paroxysms, by predominance into structure of the psychosis of delusional and hallucinatory disorders, by the absence of a gross intellectual-mnestic decrease, by the multi-focus nature of the disturbances of the bioelectric activity of the brain.

Reciprocal relations with the the lower- (mesolimbic system) and the superincumbent (frontal lobes) functional systems are confirmed here by representation in the clinical picture together with the temporal paroxysms of the vegetative, affective and expanded convulsive seizures, by considerable proportion in the structure of the psychosis of affective and catatonic manifestations.

The complex nature of clinical picture in general and the average rate of progressive course of epileptic process can be explained by the result of interaction of the afferent activating influence of trunk and mesolimbic divisions and efferent controlling influence from the side of frontal structures.

In favor of a certain steadiness of these processes testifies the known limitedness of syndromokinesis of psychopathological disorders, which is manifested in the mutually-removability of affective and delusional disorders. Progressive course of process is manifested in the shortening and the complication due to the residual symptoms of the structure of the remissions, which follow after the repetitive transitory and schubweise psychoses, in the appearance of hallucinatory and catatonic symptomatology in the structure of chronic psychoses. The known stabilization of process advancing at the last stages of disease may indicate the shortening of the subsequent paroxisms of psychosis, the stability of the structure of polymorphous chronic psychotic states.

With the unfavorable course of epilepsy the distortion of the activity of all three functional systems advancing in the earliest stages of ontogenesis and the weakness of the processes of compensation appearing because of this cause not only the significant polymorphism of paroxysmal and psychotic symptoms, but also the rapid formation of epileptic dementia.

Personal reactions are here from the very beginning characterized by elementariness and smaller sharpness than in the cases of preferred localization of process in below lying functional systems.

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