Mental disorders in epilepsy

in the specialized clinic, it is shown that better to treat “the younger or older patients”. Of 2251 patients with epilepsy in the general population K. Smith et al. (1997) in 51,9% of cases note the beginning of disease before the age of 20 years. E. Centurion et al. (1997) note that, according to the data of the protocols of diagnostics and treatment, from the general population of ambulant patients (n=2115) in 70,3% of cases the first seizure can be registered in patients under the age of 19 years. According to the observations D. Milevska et al. (1997), in 73,4% of patients (n=249) with the simple partial seizures disease begins before the age of 15 years, and seizures and epileptiform changes on EEG in them are more frequent than in patients with the later beginning of epilepsy. M. Donaldo et al. (1997) in the analogous population of patients establish that in 59% of patients the first seizure appears at the before the age of 10 years.

According to the data of M. S. Picot et al. (1997) and A. Quattrini et al. (1997), patients’ average age at the beginning of disease was reliably younger with resistance epilepsy.

Some interest if not for clinical prognosis, in terms of confirmation of the increasing incidence of epilepsy patients as they approach puberty to age data are statistically significant (r < 0,05) differences in the prevalence of epilepsy in children, given H. Velickov et al. (1997): 9,0 to 1000 at the age from 7 to 10 years, 7,4 to 1000 at the age from 4 to 6 years and 3,7 to 1000 at the age from 1 to 3 years.

In our studies, in particular , it was found that at a certain stage of ontogeny, after an average of the first 30 years of life of patients with epilepsy in a qualitative change in the severity of symptoms of psychiatric disorders. If in patients with a pronounced tendency to progression of the disease in the first three decades of life significantly dominated nonpsychotic form (so-called personality changes without signs of dementia ), then at a later age periods established a statistically significant prevalence of symptoms of psychosis and dementia combinations . At the same time, there was no significant age-related differences in the clinical picture of the disease in a group of patients who did not show any mental disorders , as well as in patients with no signs of psychosis and dementia in patients with dementia without psychotic manifestations.

We assumed it possible to interpreting these data as “changes in the personality” and complex “psychosis-dementia” relate to the signs of the motion of epileptic process. At the same time prolonged absence “of changes in the personality”, prolonged existence of psy-

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chosis (predominantly affective register) without the signs of dementia, and also prolonged existence of dementia without the signs of psychosis (“simple type of dementia”) are faster can be attributed to the signs of the known stabilization of epileptic process.

When analyzing the data we have obtained in the course of an epidemiological study also confirmed the assumption that patients with epilepsy in each case of the disease, regardless of its duration, is most likely to be one of the stable forms of the course of psychosis. The study showed that the prevalence of transient flow pattern epileptic psychosis occurs in patients in 34.7 % of cases ( 115 patients) (0.53 per 1000) , episodic – in 39.3 % of cases ( 129 patients) (0.59 to 1000 population), chronic – in 26 % of cases (85 patients) (0.39 per 1000) epilepsy flowing with psychotic disorders.

The special interest in the confirmation of the assumption about existence of the change of syndromes in the structure of negative psychopathological disorders in epileptic disease represent the indices of the prevalence of the stages of the formation of epileptic dementia in the inspected population of patients.

For the period of the observation of 265 cases of epilepsy with the presence of the signs of dementia, the stage of the formation of epileptic dementia with the predominance of affective disorders united 22,2% of cases (59 patients) (0,27 for 1000 populations), the stage of the formation of epileptic dementia with the predominance of the disorders of thinking – 60,5% of cases (160 patients) (0,74 for 1000 populations), the stage of the formation of epileptic dementia with the presence of the signs of total dementia – 17,3% of cases (46 patients) (0,21 for 1000 populations), which on the whole corresponds to the existing among the psychiatrists opinion about the predominance “viscous type” of the patients with epilepsy, in comparison with the patients, who are characterized “firing excitability”.

Essential to clarify the place of psychosis among mental disorders in epilepsy, we also present the facts to detect statistically significant differences between the duration of disease in groups of patients with psychosis and without psychosis.

In particular, we established that in the group of patients, for the period of the examination of those revealing the signs of psychosis, predominates the duration of disease of more than 15 years. Taking into account the fact that these data were obtained in the course of an epidemiological study, it is possible to consider that the epileptic psychoses are frequent manifestation (stage) of epileptic

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disease, and by no means exquisite and all the more not foreign for this clinical form.

Comparing all circumstances with those dated from the beginning of century by indication V.P. Serbsky (1906) to the possibility of “favorable outcome in 30-40% those all newly fallen sick with the sincere disorders”, data of contemporary bureaus of medico-social expertise, which establish disablement with epilepsy in 60-70% of cases, and also with data of the psychoneurological dispensaries, which diagnose psychoses and dementia at least in each second adult patient with epilepsy, we assumed it necessary to give some general information about the actual distribution of the population of patients on the levels of social-working adaptation.

Of 511 examined patients living in the same administrative region, in 132 (25.8%) the age at study period ranged from 16 to 29 years, 91 (17.8%) – from 30 to 44 years, 288 (56, 4%) – over 44 years.

In this case 50 (9,6%) patients did not have education, 18 (3,5%) finished auxiliary school, 68 (13,3%) patients had elementary education. The greatest number of patients had incomplete secondary education – 207 (40,5%). Complete secondary education only 62 (12,1%) obtained, 50 (9,6%) finished trade school, 45 (8,8%) patients graduated secondary special educational institutions. 3 (0,8%) patients had incomplete higher education, higher education

– 8 (1,6%) patients.

Thus, according to given epidemiological data, people with secondary, specialized and highest education in the general population of the observing in psychiatrists adult patients with epilepsy compose 33,1%. If we add to this 40,5% of persons with incomplete secondary education, then assertion by E.H. de Graaf et al. (1997) about the helplessness of the patients with epilepsy in the studies, apparently, should be recognized too categorical.

Before the onset of disablement from the population of patients whom we observed, with intellectual kinds of labor were occupied only 89 (17,4%) whereas, majority of them were occupied by skilled physical labor – 259 (50,8%) patients. Unskilled labor was carried out 82 (16%), nowhere worked 81 (15,8%) patients.

Disability in the population of patients with epilepsy, long being on psychiatric medical supervision, at the time the survey was established in 61.6% of cases (315 patients) (1.45 per 1,000). Still a higher prevalence had the disability in patients with manifestations of psychosis – in 72% of cases (237 patients) (1,09 for 1000 populations)

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and even large – in the group of patients with the signs of dementia: in 91,7% of cases (243 patients) (1,12 for 1000 populations).

Consequently, the total number of simultaneously observed psychiatrist epilepsy patients and fully able can be considered only 38.4% of them.

If we consider that working employment in the general population of the patients with epilepsy (including and observing by neurologist) comprises, according to the data of M. Pfafflin et al. (1997), 44%, than our data and data of these authors, probably, can not possibly considered comparable.

Correlations of productive and negative psychopathological disorders noted above have been estimated as indication of the need for the search for the criteria of working prognosis in general dynamic structured characteristics of psychopathological disorders with epilepsy.

If the absence of mental disorders (in 23 patients) and the presence of changes in the personality without the signs of psychosis and dementia (in 106 patients) were explained by the favorable course of process, then the data about the almost uniform distribution of the signs of dementia without the psychosis among the patients with the type of the course of disease, for which was characteristic the set aside exacerbation of process (in 23), and patients with the unfavorable course of disease from its beginning itself (in 32) they confirm the possibility of existence of the so-called simple form of epileptic dementia.

During the epidemiological analysis of mental disorders with epilepsy we were convinced of the insufficiency of information, which in the plan of working prognosis present the indications only in existence of the forms of the course of epileptic psychosis again. In particular, it was established, for instance, that statistically reliable differences in the number of cases of complete ability to work and the number of cases of establishment I and II disability occur only between transient and chronic psychotic disorders.

We established also, that more differentiated data, suitable for using as the markers the type of the flow of epileptic process in making including expert opinion on maintaining or disability , can be identified in the analysis of structural features of productive psychopathological syndromes: the prevalence of affective disorders , the presence of catatonic disorders and others. Specifically, fully employable significantly more frequently than in other clinical forms are recognized in cases of patients in the structure of psychosis preva-

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lence of affective disorders. In particular, as completely able-bodied with other clinical forms, are reliably more frequent than recognized patients in the cases of predominance in the structure of the psychosis of affective disorders. In contrast, group II disability often established where the prevalence of delusional patients and polymorphic psychotic disorders with catatonic inclusions. Group I disability more often than in other forms of psychosis , set at a higher representation in its clinical manifestations catatonic.

We identified clinical differences in the nature of negative psychopathology correspond only to establish more frequent in group I disability in the development of patients expressed mnestiko-intel- lectual defect. In connection with this, we have been specifically considered the actual level of labor adaptation of working patients and disabled.

It turned out that the presence or the absence of psychotic disorders on the stages of the formation of epileptic dementia does not have vital importance for the nature of the working ability of patients. In each case the level of working adaptation as a whole proves to be reliably lower, than in patients with the epileptic psychosis without the signs of dementia.

However, it was found that between the groups of patients with and without epileptic dementia there were statistically significant differences not only in the number of cases of employment of patients in conventional and specially created conditions of production, but also on the number of cases of unemployed patients.

A similar smoothing of differences in the nature of job placement between the patients with the psychosis and without the psychosis at the stages of the formation of epileptic dementia can, in our opinion, occur due to the fading severity of psychotic symptoms. From other side, the significant number (more than half) of the unemployed patients at these stages of epileptic disease indicates the need of refining the criteria of evaluation of residual ability to work in these patients and, correspondingly, the developments of the more differentiated working recommendations for patients during the expert examination for the group of disablement.

Thus, data given in present chapter, confirms that expressed by a number of authors point of view, according to which with the use of epidemiological methods of study it is possible to most fully study entire spectrum of the manifestations of disease, nature of its outcome, to estimate the actual risk of the development of various

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manifestations of disease, and to also verify the correctness of scientific hypotheses (P.G. Metsov et al., 1984; M. Shepherd, 1984).

The results of the epidemiological investigation conducted by us not only show the significant prevalence of epileptic psychoses and epileptic dementia, but they also represent enough evidence in order to consider productive psychopathological disorders with epilepsy almost required development stage of this illness. Is confirmed, therefore, also view by N.M. Zharikov (1977) about the fact that “study of the dynamics of disease on the population” gives “greatest possibilities for the development of pathogenetic factors”.

Detected during epidemiological analysis of decisive importance for the prediction of disability and negative productive psychopathological disorders in a population of epileptic patients with long-term course of the disease demonstrate the relevance of research tasks set before us, and especially emphasizes the necessity of search criteria differentiated assessment of disability in patients with this pathology.

Established in the course of our studies, with the use of an epidemiological method, fact of almost uniform distributions among the patients with epilepsy psychoses with the predominance of affective disorders, psychoses with the predominance of delusional disorders and psychoses with the polymorphous clinical picture, which includes catatonic disorders, and also revealed by us correlations between the rate of progressive course of epileptic process and by duration of disease and between the age of patients and the degree of the manifestation in them of negative psychopathological manifestations can be examined as the base for the passage to the more intensified study of pathokinesis of epileptic disease, since, as it seemed, not only the register of psychotic disorders, but also special feature of the formation of epileptic dementia are actually markers of the type the course of epileptic process, rate of its progressive course.

Almost uniform distribution in the population of the patients with epilepsy of three indicated registers of psychotic manifestations: affective, delusional and catatonic, corresponds to the distribution in it of three basic types of the course of disease and indicates both existence of the continuum of productive and negative psychopathological disorders with epilepsy and the specific stability in the population of the signs indicated.

Data of the epidemiological analysis, which we carried out, show that the observing in the adult patients with epilepsy productive and negative disorders, qualified as epileptic psychoses and demen-

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tia, have fundamental importance for resolution of questions of the working adaptation of patients, since precisely their quality reflects the rate of progressive course of epileptic process, which determines the degree of the safety of personal potential in patients and their rehabilitative potential. The basic factors, which cause the variety of structure and dynamics of epileptic psychoses and dementia, occur type and stage of the course of epileptic process.

In light of the data seems reasonable to follow some noted in the literature overall direction, objectives and tasks of clinical and epidemiological studies and to the subject matter of our research to try to establish a parallel between them in the field of psychiatry and epileptology.

B.D. Petrakov and B.D. Tsygankov (1996) the most common purpose of application of clinical epidemiological methods in psychiatric research believe to be such improvement: the identification and diagnosis of mental disorders; levels of studying the incidence and prevalence of mental illness; treatment and rehabilitation of the mentally ill; multifactorial prevention of mental disorders; organization of psychiatric care.

According to the opinion of contemporary authors, who carry out clinical-epidemiological studies of epilepsy, the purpose of the latter must be the verification of the existing classifications of epilepsy (W.F. Arts et al., 1997), the generalization of the work experience of the centers of epilepsy (E. Centurion et al., 1997), the study of the prevalence of the clinical special features of eplepsy in different population groups (V. Conde et al., 1997; M. Donaldo et al., 1997; L. Forsgren, 1997; W.A. Hauser, 1997, and others), the refinement of the criteria of gravity of the course of disease (M.S. Picot et al., 1997; F. Semah, 1997, and others), the establishment “of the value of problem” (K. Puvanendran, 1997), and also the study of the cost of the social welfare of invalids as a result of epilepsy (H. Silfenius, 1997).

To the required tasks of the psychiatric clinical-epidemiological studies B.D. Petrakov and B.D. Tsygankov carry: the development of tendencies and laws governing of morbidity and prevalence of mental disorders; development and the analysis of the factors of risk; the development of new and the improvement of the existing forms and methods of psychiatric aid to population.

In the tasks of epidemiological studies contemporary epileptologists include the improvement of the protocol of diagnostics and treatment of patients (E. Centurion, 1997), establishment of the in-

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fluence of age, sex of patients and employmet to the effectiveness of the long-term treatment of epilepsy (J. Cloyd, 1997; R.S. McLachlan et al., 1997; M. Pfafflin et al., 1997 and others), creation, development and the use of a data bank of other as the working tool for the different kind studies (B. Dalla Bernardina, 1997; R.S. McLachlan et al., 1997).

In the classical version, as are considered B.D. Petrakov and B.D. Tsygankov (1996), a clinical-epidemiological study is accomplished according to the scheme: the development of program and methods of study, the collection of material, the development “of the program of summary” or the tabular summary of material, the analysis of the obtained material into the dependence on the tasks of a study, the determination of scientific clinico-epidemiological value and practical significance of the carried out work.

To the most common methods of constructing the contemporary epidemiological case study in patients with epilepsy and their environment can be attributed the prospective screening of the cohort of patients (W.F. Arts et al., 1997; V. Dalla Of bernardina, 1997; L. Forsgren, 1997; P.M. Leary et al., 1997, and others), the analysis of the data base (E. Centurion et al., 1997; J. Cloyd et al., 1997; R.S. McLachlan et al., 1997. and others), including the use of questionnaires (M. Donaldo et al., 1997; M. Pfafflin et al., 1997) or interview (M. Yerby et al., 1997) with the inclusion of different information sources – general doctors, the documents from general and psychiatric hospitals, houses for the elderly, the associations of patients (M.S. Picot et al., 1997), and also the clinics of training establishments, establishments of military statistics (K. Puvanendran, 1997), ambulant patients (V. Sander et al., 1997), the parents of patients (M. Schuler et al., 1997) with the elimination in the course of investigating the methodological flaws (D. Ruta et al., 1997) and by the application of check studies (P. Satischandra et al., 1997; V. Seppala, 1997; A.- H.M. Shawki, 1997, and others).

With the illumination of questions of the methodology of clinicalepidemiological studies in psychiatry and special features of clinicalepidemiological studies of biogenesis B.D. Petrakov and B.D. Tsygankov (1996) correctly indicate the need for passage from the group prognosis of the course of disease to the individual. However, the analysis of literature given by the authors indicates that as before during the study prognosis with the application of clinical-catamnes- tic methods of study the discussion deals not about the type and the

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stage, but about the forms of the course of disease, which, as obtained by us data testify, far from always gives reliable prognostic signs.

Connecting to this our general considerations relative to the construction of the stages of an epidemiological study of prognosis with the mental disorders, which reveal one or other degree of progressive course, are reduced to the following.

The main criterion for the selection of the material must be sufficiently verified nosological diagnosis, based on the characteristic of this nosological form constellation of personal, productive and negative symptoms.

Differentiation of the types and stages of the pathological process of clinical material, identified using a solid research, fully covering the population of patients with this form of nosology in the territory or part of one or more supervised institutions providing outpatient psychiatric care.

The revealed clinical-statistical groups of patients must be distributed on the basic forms of the course of disease for the subsequent structural and dynamic analysis of mental disorders.

The comparison of the results of the dynamically structured analysis of mental disorders must be carried out with the sex, the age, the formation of patients, their profession, marital status, actual working device, disablement and other social and demographic factors.

During this comparison the basic criteria of clinical and social prognosis are allocated. Correlations between the chosen criteria of prognosis, the special features of the individually oriented complex therapy and the individual rehabilitative programs are established. With the use of all data, obtained in the previous stages of an epidemiological study, are established clinical-pathogenetic correlations.

In present chapter only the most generalized results of an epidemiological study of the prognosis of mental disorders with epilepsy are represented. In more detail study of the data of the dynamically structured analysis of psychopathological disorders with it as the data about those assumed of etiology and pathogenesis of the basic types of the course of disease, about the possibilities of drug therapy and social-working rehabilitation of patients is represented in the following chapters.

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Chapter 3

ETIOLOGY AND THE PATHOGENESIS

According to D.E Dyskin (2003), out of 134 patients with the epileptic seizures, who entered clinic of nervous diseases of the military medical academy named S.M. Kirov, only in 42,9% of the patients’ computer tomograms did not revealed organic changes in the brain. The atrophy of different cortical and subcortical regions of the brain was revealed in 23,2%, intra-cerebral cysts – in 4,4%, the tumor of the brain – in 14,3%, the foci of softening – in 7,1%, intra-cerebral calcifications – in 3,6%, the cyst of transparent partition – in 2,7% and adhesive processes – in 1,8% of cases. In this case only in 12 patients with a neurologic study were noted the scattered and weakly expressed organic signs. (Cited. on S.A. Gromov, 2010).

According to V.A. Mikhaylov et al. (2010), these or other structu- ral-morphological changes were registered in 279 of 296 patients with epilepsy (94,3%), who passed MRI inspection in the St. Petersburg scientific institute of research of psychoneurologic of V.M. Bekhterev. There were predominated diffuse atrophic processes in the cortex (55,7% of patients). The insignificant manifestation of atrophies was noted in 27,4%, moderate – in 55,4%, expressed – in 6,1% of patients. Internal hydrocephalus is revealed in 39,5% of patients. Anomalies of the development in the form of heterotopia of gray substance – in 0,3%, the cyst of transparent partition – in 1%, the agenesia of septum of pellucidum – in 0,3%, the combination of the cyst of transparent partition and anomaly of Arnold-Chiari – in 0,3%, the combination of the cyst of transparent partition and cavum of Verge – in 0,3%, the anomaly of Arnold-Chiari – in 0,3%, the cyst of cone-shaped gland

– in 0,3% of patients. Intra-cerebral cysts are discovered in 4,4%, gliosis or the atrophy of hippocampus in 3,8% of patients.

According to B. Hermann (2012) from the university of Wiscon- sin-Madison, who carried out an MRI study of brain in 55 patients

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