Mental disorders in epilepsy

During the observation 109 patients did not work, 33 were occupied with labor in the therapeutic-production workshops, 29 worked in the conditions of special shop, 279 in the conditions of usual production.

Distribution in the population of those evaluated during the first stage of a study of the determinants of prognosis was studied in the second stage of a study.

In the appropriate cohort of 511 of patients, who composed entire totality of the patients with epilepsy, that were being observed by the district psychiatrists of one psychoneurological dispensary, psychotic disorders in the period of inspection or retrospectively were noted in 329. Disablement 1 was established for the period of inspection in 53 of them, in 121 – 2, in 63 – 3 groups, 88 patients were able to work and 4 were retired.

It should be noted that in different countries epidemiological studies on the large non-chosen populations of the patients with epilepsy were carried out. Although not all of them refer straight to the theme of our study, it is nevertheless of interest to trace the methods of the analysis of laws governing the development of epileptic disease as a whole.

The analysis of the cases of epilepsy of 1011 children, who entered in 1995 into the dispensary of children’s neurology in Capetown, showed the presence in 35% of them the mental disorders of “significant degree” (P.M. Leary et al., 1997). Among 945 children with epilepsy, selected from the general population of children in Tallinn, 18,1% revealed the delay of mental development (the V. Sander et al., 1997). According to the data of the retrospective study, carried out in Germany and based on “well documented histories of disease” 469 dispensary patientchildren and adolescents, free from the seizures for a period of 3 years, “cognitive scarcity” is noted in 50% of cases of disease (H. Mayer et al., 1997). In the population of 2152 adult ambulant patients with epilepsy in Italy the resistance to the therapy positively correlated with the delay of mental development (A. Quattrini et al., 1997). Of 7865 adult patients who entered in one of the cities to England the in-patient treatment from the sharp indications with the diagnosis epilepsy during the period since February 1991 until May 1994 10,7% composed those hospitalized into the psychiatric hospital (C.J. Currie et al., 1997).

According to the data of the investigation conducted in Japan (M Masato et al., 2000), among 128 patients with the epileptic psy-

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choses predominated paranoid type of schizophrenia-like disorders, delusional disorders and sharp transitory psychotic disorders. Hallucinoses and catatonic disorders were noted relatively rare. A single episodes, recurrent episodes or chronic course observed with almost equal frequency.

The given facts convince us in the large-scale nature of the problem of mental disorders of epilepsy. However, as far as development according to the data of the population of the studies of the criteria of prognosis with the epileptic disease is concerned, the complexity of the realization of this work noted in the literature, first of all, is caused, in our opinion, by discrepancy and carelessness in the prognostic sense of International League Aqainst Epilepsy Classification chosen in of 1989 of the versions of the development of the epileptic syndromes, which rather characterize the forms of the course of disease, than the types of its progressive course.

Partial seizures as the conditional criterion of the favorable course of disease in the adult population of the patients with epilepsy, according to the data of V. Conde et al. (1997), compose 58,9%, and according to the data of the V. Sander et al. (1997) -55,1% of the total set of the types of seizures. In the children’s population of the patients with epilepsy 50% are the syndromes “with the specific localization” (M Endziniene et al., 1997). It is noted, however, that also with so-called favorable partial epilepsy of the childhood “cognitive defeciency” occurs in 30% of cases (H. Mayer et al., 1997).

The partial seizures with the secondary generalization, which, probably, should be carried to the criteria of the average rate of progressive course of epileptic process, that is according to the terminology accepted by us – the type of the course of epilepsy with the set aside exacerbation, are noted by A. Quattrini et al. (1997) in 64,6% of cases from the ambulant population of the adult patients with epilepsy.

The factors, which can be implied as the cause of “inflexibility” of disease, encountered in 37% of cases in the population of 2861 patients, inspected in the specialized clinical picture of epilepsy, J. Beaussart-Defaye et al. (1997) consider obscure. The primarily generalized seizures in the general population of the ambulant patients with epilepsy according to one data compose 34,1% (E. Centurion et al., 1997), and to others – more than 50% (M. Donaldo et al., 1997).

On the one hand, it is noted, that the number of cases of refractory epilepsy, which comprised in 60-70 years is more than 40%, in the 1990s as if was reduced to 25-30% (L. Mouzitchouk et al., 1997). Ho-

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wever, at the same time in the adult population of patients with refractory epilepsy, according to M.C. Picot et al. (1997), patients with a frequency of seizures of more than one per day compose 15%, more than one per month – 36%, and 18% have the status epilepticus. Furthermore, according to the data of the V. Sander et al. (1997), the generalized seizures occur in 34,9% of children with epilepsy, but resistant to antiepileptic therapy are observed in a much smaller number of cases (5,3%), than in adults.

The variety of approaches to the evaluation of prognosis with epilepsy in the course of epidemiological studies can be seen also from the following comparisons.

In India, where the prevalence of epilepsy in the population is high, during the epidemiological study conducted in 1993-1995 revealed the significant in the general population of the patients with epilepsy content of the cases primarily generalized tonicoclonic epilepsy – 55,5% (P. Satischandra et al., 1997). However, under the treatment of patients since 1990 over a number of years in the university clinic in France (prospective study) this percentage proved to be considerably lower – 21 (F. Semah et al., 1997). Finally, the retrospective cohort study, carried out in 1995 and included all children with epilepsy, who were being born and lived from 1985 until 1994 in the western part of the Slovakia (n=78), revealed the presence of the generalized seizures in 44,9% of them, which can testify about significant progressive course of disease in children at the age of up to 10 years.

In 7,9% of cases it was revealed the delay of mental development out of 494 children with the newly established diagnosis of epilepsy (W. T. Arts et al., 1997). It is noted also, that “cognitive damage” in half of the ambulant cases (n=469) remains in children and adolescents after the successful treatment of paroxysmal disorders (H. Mayer et al., 1997).

For the search of the general measures of the preventive maintenance of appearance and development of epilepsy the intransient value have data about its etiologies, obtained on the continuous populations.

According to the data of M. Endziniene et al. (1997), “innate reasons” occur in 18,8% of children with epilepsy at the age from 0 to 15 years, “perinatal” – in 15,3%, “injuries” – in 2,6%, neuroinfection – in 2,4% of children. V. Sander et al. (1997) assume that the perinatal damages of the brain as the reason for epilepsy in children occur

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in 48,4% of patients. “Family history of epilepsy with the first and second degree of the relationship” of P. Satischandra et al. (1997) revealed in 13,7, and A.-H.M. Shawki et al. (1997) – in 21,5% of cases in the general population of patients. G.R. Khamitova et al. (1997) note that the progressive course of epilepsy in children, who live in the regions with “the environmental pollution”, occurs 1,9 times more frequently than in the control group. M. Endziniene et al. (1997) and H. Velickov et al. (1997), studied populations of children at the age of up to 15 years and up to 10 years respectively, consider that more than in half of the cases the etiology of epilepsy cannot be established.

Quality of the life of patients by epilepsy rrefers to the establishment of the criteria of social prognosis. According to the data of G. Baker et al. (1997), it is more than 30% of 186 patients with the data by disease at the age of 60 years and they older reported that epilepsy influences their “social functioning, self-esteem and the general health”. In the investigated group, which covers all Finnish children, who were born in 1987, U. Seppala (1997) considers epilepsy as the disease, which has a significant effect on the quality of the life of children and their families.

To the therapeutic prognosis in epilepsy in the last decade is paid significant attention. This can be seen, for example, by the volume of the material on the problem of refractory epilepsy, represented at the 22nd international congress for epilepsy of 1997. J. BeaussartDefaye et al. (1997) the basic reason for the insufficient «compliance» of epilepsy is considered the refusal from drug therapy, the use of traditional medicine and the irregularity of treatment.

In the frequency of the utilized in the population antiepileptic drugs E. Centurion et al. (1997) distribute as follows: carbamazepine, diphenine, phenobarbital, valproate of sodium. According to G. Baker et al. (1997), more than half of the elderly patients with epilepsy use phenytoin and carbamazepine. According to the results of the study, carried out by J. Cloyd et al. (1997), 10,8% of 30929 residents older than 65 years use one or more antiepileptic drug. In this case the patients aged from 65 to 74 years use them more frequently than the person of older age. In the general population patients with epilepsy M. Donaldo et al. (1997) find 74% of patients, who are treated predominantly with the use of monotherapy. In the adult population M.C. Picot et al. (1997) observe other relationships: the one third of the patients obtains bitherapy, while the other third part – 3 or more antiepileptic drugs. According to the data of A.-H.M. Shawki et al. (1997),

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from the total number of children of school age (from 6 to 14 years) with epilepsy only 28,2% use antiepileptic drugs.

Should be noted that the special studies, dedicated strictly to the study of the prevalence of epileptic psychoses and assosiated dementia, are rare. Actually, it is possible to name only two of them, published comparatively recently. This work by V. Milev and R. Kirova (1982), in which in Bulgaria was investigated the population of the patients with epilepsy, simultaneously found on the clinic psychiatric observation, and the work of the Swiss authors K.W. Bash and P. Mahnig (1979, 1984), based on the results of the continuous study of patients with epilepsy (n=203), that entered university psychiatric clinic in Bern for a period of ten years.

Both studies, first of which was based on the out-patient material, and second one – on the material of the in-patient psychiatric observation of patients, differ significantly from many works, not sufficient in the plan of the results of an epidemiological study. The latter is caused, in our opinion, by the narrowness of the purpose of the study, when the propagation of any phenomenon, for example, of separate form or sign of psychopathological disorders, is studied in one or other limited by the specific framework population or another. It is investigated, for example, only one or another of the psychoses, predominantly affective or delusional, “epileptic” or “schizophrenia-like”, transitory or chronic and other, and on the basis the data about the small prevalence of these groups of mental disorders is formulated conclusion about the small prevalence of mental (psychopathological) disorders with epilepsy generally.

Another example. For a study agroup of patients with the small duration of epileptic disease is selected. As a result of this the signs of psychosis and dementia can be absent or be rare in the clinical picture of disease. In the final analysis the incorrect conclusion about the presence of the therapeutic pathomorphosis of disease as a whole, about improvement in the extended prognosis with it and other is formed.

In contrast to a similar kind of studies, the adequacy of the epidemiological study of patients with the epileptic psychosis and the epileptic dementia by above cited authors is manifested in the fact that in the first place, they used the method of continuous research and, secondly, simultaneously present all the existing surveys for the period of psychopathological disorders.

At the same time in spite of the similarity of methodological approach two the works indicated are distinguished between them-

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selves by the value of the obtained indices of the prevalence of epileptic psychoses and dementia. The prevalence of psychoses among the out-patients with epilepsy, comprises, according to the data of V. Milev and R. Kirova, 8,2%, and in the population of the stationary patients with epilepsy, according to the data of K.W. Bash and P. Mahnig, composes 60%. If one considers that in the whole totality of those studied by the authors of the cases of disease its duration and age of patients do not have essential differences, possible to assume that the noted differences in the statistical indices are caused not only by the fact that the concentration of the patients with epilepsy for the intelligible reasons is higher in the hospital, than among the ambulant patients, but also by divergences in the diagnostic criteria.

Although the clinical classifications utilized in both works cannot be the object of criticism, since it is known that any classification is caused by the purposes of a study, one should recognize that the differences in the clinical content of the groups of epileptic psychoses examined by the authors prove to be significant. If in K.W. Bash and P. Mahnig the fraction of affective psychoses composes 41,8% of the total number of psychoses examined by them, then in V. Milev and R. Kirova it is equal to only 8,7%. Is distinguished the portion of psychoses with the signs of the catatonic disorders: 18,9 and 8,8% respectively.

Taking into account the similarity of our own data with the data by Robins et al. (1984) about the fact that affective psychoses in the population compose at least 25% of the total number of all mental disorders, at least one time of those being encountering in the investigated patients in the course of the entire life, and also given G. Baker et al. (1997), that are been based on the study of the substantial part of the adult population of patients by epilepsy in the United Kingdom, about the fact that “psychologically” 33% of them are anxious and 25% – are depressive, we assumed it necessary to conduct the verification of the indices of the prevalence of psychopathological disorders with epilepsy and, in particular, epileptic psychoses and epileptic dementia.

Another our goal is to study the possibility of using our data on the structure and dynamics of productive and negative psychopathology in epilepsy for more in-depth study of social prognosis for her.

Even before the description of the methods of study we assumed it appropriate, based on the results of the data analysis of literature, represented in the previous chapter, and also on the results of own

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studies, to give some definitions, which make it possible attribute the mental disorders to the psychosis or the dementia.

We assume that on the basis of the existing at present descriptive definition of psychosis as the disturbances of mental activity, which are manifested by obscuring of consciousness, expressed in a sufficient degree by affective disorders, the delusional, hallucinatory, catatonic disorders, which considerably decrease the understanding proceeding, own personality and the ability to support adequate contact with the reality, described in the present work productive psychopathological syndromes with the predominance of affective, delusional or polymorphous with the catatonic inclusions disorders can be related to the criteria of psychosis.

Psychoses with the predominance of affective disorders we call the states, which include different depth of depression, anxiety or mania, as a rule, in the sharp cases accompanying by delusion, confusion, and rough disorders of behavior. In the cases of the prolonged or chronic course of affective disorders they can be accompanied by the disturbances of self-appraisal, by the inadequacy of the estimation of the surrounding events, by the fluctuations in activity and productivity in daily occupations.

In the group of psychoses with the predominance of sharp, protracted and chronic delusional disorders were included sharp hal- lucinatory-delusional disorders, cases of prolonged existence in the patients of small scale delusion of persecution or of state with the sufficiently developed and systematized delusional ideas, and also chronic affective-delusional states with the hallucinatory inclusions.

To polymorphic epileptic psychoses , the structure of which at the same time or in sequence occur affective , delusional disorder , or catatonic , we include acute affective delirium with catatonic inclusions with or without disturbances of consciousness disorders , prolonged sustainable development stereotype hallucinatory-delusional state with inclusions and chronic catatonic state polymorphic, which are based on the affective-delusional disorders that accompany subacute catatonic and hallucinatory inclusion or secondary manifestations of catatonia.

On the basis of duration and the stereotype of mental disorders included in the listed group of epileptic psychosis, separated by us on transient, schubweise and chronic. Transient psychosis, in addition to its short duration (no more than a week), characterized by the almost simultaneous appearance and disappearance of all

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its structural features. For schubweise psychosis – transient states of varying lengths – characterized by a gradual increase and gradual return development within the boundaries of attack severity of psychopathology. Chronic or continuous current psychosis characterized by long-term change in the axial stages of formation of the affectivedelusional syndrom, the rate of which depends on the rate of increase of epileptic symptoms of dementia.

On the basis of obtained data, we assumed that syndromokinesis at the stage of the formation of epileptic dementia must be considered as steady, although at different rate, reduction in the mental functions, with which the manifestations of partiality and totality of dementia occur interconnected over a long period.

It is this relationship stretched in time, apparently, is a source of compensatory mechanisms that contribute to the preservation of residual disability patients.

In order to reveal the prevalence in the population of the basic clinical regularities we were interesting in, it was necessary to examine the latter in the course of studying the group of patients epilepsy, that were being observed in one psychoneurological dispensary and lived in one district. The accepted use of the criteria of psychosis and dementia corresponded to the task to represented the epidemiological analysis of the most common special features of structure and dynamics of mental disorders in epilepsy.

Besides the information on age, education and profession of the investigated patients, into the patient card of epidemiological experiment was provided the data, that reflect the duration of disease and the duration of clinic observation, the number of hospitalizations, type and the stage of epileptic process, the nature of the leading psychopathological syndromes. With the application of previously approved (N.M. Zharikov, 1977) procedure was studied the level of the labor adaptation in patients.

In the course of a study, first of all, attention was paid to the fact that in the population of the patients with epilepsy, consisting under medical supervision by a psychiatrist, with the duration of disease of more than 15 years (period, according to literature data, critical for the demonstration of epileptic psychosis) composed the overwhelming majority – 82,1%. This circumstance confirmed the urgency of the theme of the study undertaken by us.

In this respect data of M. Pfafflin et al. (1997) seems interesting. In 87% of the 1206, surveyed by authors adult patients with epilepsy,

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the duration of disease was not less than 5 years, and with this 22% of patients were related to those suffering from “severe epilepsy”, and 63% of patients reported about the limitations in the daily life connected with the disease.

In our study of the population observed in the mental hospital patients, the diagnosis of epilepsy was verified over a long period of observation. Regarding this disease only 122 (23.9%) patients were followed for 1 to 10 years, whereas the observation period 247 (48.3%) of patients ranged from 11 to 20 years, 114 (22.3%) patients – from 21 to 30 years, 28 (5.5%) patients – over 30 years.

In most cases, the diagnosis of epilepsy was confirmed by the data of the stationary survey. Never been hospitalized only 146 (28.6%) patients. Were treated in a psychiatric hospital from 1 to 3 times 258 (50.5%) patients, 4 to 6 times – 56 (11%) patients, 7 to 9 times-17 (3.3%) patients, and 10 more times – 34 (6.6%) patients.

Information about the nature of mental disorders in the studied group of patients demonstrate a high prevalence of psychosis and dementia among patients with epilepsy. Symptoms of psychosis in general were observed in 64.1% of cases (329 patients) (1.5 per 1000), signs of dementia – in 51.8% of cases (265 patients) (1.2 per 1,000 population). (Hereinafter, the data presented is based on the population mean administrative area).

However, taking into account the versions with the combination of psychosis and dementia both syndromes in total were noted in 74% of inspected cases of disease (383 patients) (1,8 for 1000 populations).

For purposes of the general characteristic of the observed group of the patients with epilepsy, which consist under the observation of district psychiatrist, it is also of interest to cite following data.

Lack of any mental disorder patients on the study period was observed by us only in 4.5% of cases (23 patients) (0.1 per 1,000 population). Nonpsychotic mental disorders or “personality change” with no signs of psychosis and dementia observed in 20.7% of cases (106 patients) (0.5 per 1,000 population), psychosis without dementia

– in 23.1% of cases (118 patients) (0, 6 per 1,000 population), psychosis in conjunction with dementia – in 41.1% of cases (210 patients) (1.0 per 1,000 population), dementia without psychosis-in 10.6% of cases (54 patients) (0.25 per 1000 population ).

These data indicate that a simple statement of mental disorders in epilepsy reported neuropsychiatric dispensaries not enough for prognosis but also for planning mental health services.

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Proof of this can also serve the data by S.M. Al Deeb (1997) on the direction in psychiatric hospitals only of some “neglected” patients, mostly concealed by their families for fear of the negative impact on the marriage of other family members. Notable is the data by E.H. de Graaf et al. (1997) who estimates the prevalence of psychopathological disorders in epilepsy depending on the use of various diagnostic tools.

Taking into account the data we assumed that in the case of a confirmation in the epidemiological study of the presence of a sufficiently large share in the structure of mental disorders in epilepsy psychopathological forms of affective and catatonic manifestations may be necessary to develop a more differentiated approach to assessing the mental state of the observed in neuropsychiatric clinic patients with epilepsy in general.

The obtained by us data about the presence in the group of patients with the manifestations of the psychosis 35,3% cases with the predominantly affective, 34,9% of percent of the cases with the predominantly delusional disorders and 29,8% of cases with the polymorphous psychotic disorders with the catatonic inclusions made it possible not only to establish the fact of almost uniform distribution in the population of the patients with epilepsy three basic registers of productive psychopathological symptomatology, but also to assume, wether this fact is not only reflection of the possible connection between the processes, which lies at the basis of existence of one or other rate of progressive course of disease, from one side, and by age-qualification factor – from another.

The corresponding chapters are dedicated to the detailed study of this problem. Here, in the plan of the examination of most general laws governing the course of epileptic disease, we assumed it appropriate to only compare the age of patients with basic clinical syndromes revealed in them for the period of observation.

Before representing the results of our own studies in this direction, it is reasonable, apparently, to give a brief survey of literature data of the last years, which relates to general age-qualification dynamics of epilepsy and confirming our position about the fact that summary data, without the differentiation of the entire totality of the cases of disease according to the types of course, practically does not have prognostic importance.

On the material, obtained by J. Beaussart-Defaye et al. (1997) with the inspection of the significant number of patients (n=2861)

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