Mental disorders in epilepsy

with chronic temporal epilepsy in the comparison with the control group of 53 people without epilepsy, patients with epilepsy had more structural deviations in the brain, than the healthy persons, and with the age these deviations became more expressed. According to R. Kälviäinen et al. (1998), with MRI investigation in patients with temporal lobe epilepsy with the frequent paroxysms there is found more expressed reduction of hippocampus, than in patients with well controlled epilepsy.

In a comparatively minor literature it is not excluded the role of exogenous factors in the appearance of mental disorders with epilepsy. Increased transient epileptic psychoses, for example, was noted in patients during the development of their infections (E. Siemerling, 1909). Among provoking exogenous hazards in patients with chronic epileptic psychoses were indicated acute infectious diseases, rheumatism, tumors , metabolic disturbances of folic acid, “ prefrontal metabolic asymmetry” , etc. (A. Gastaut, 1975; R.G. Golodets, 1970; V.A. Derecha, 1980; E. Slater, A.W. Beard, E. Glithero, 1963; R. FlorHenry, 1969; N. Jokeit et al., 1997; M. Macovei et al., 1997). Unfavorable prognostic importance of the disorders of the function of memory in patients with epilepsy D. Tourniaire et al. (1997) connected with the beginning of “etiological diseases” at an earlier age.

In the opinion of C.D. Ferrie et al. (1997), mental disorders frequently appear with the epileptic encephalopathy of the childhood.

It is not excluded, that the enumerated factors can be important for the delayed development of mental disorders in epilepsy.

According to the communication Y. Manelis et al. (1997), children, born by the mothers, who suffer from epilepsy, have considerably larger risk of mental retardation, in comparison with the control. Also it is noted (P. Vigliano et al., 1997), that 25% of children with epilepsy and psychosomatic disorders simultaneously, had mothers, suffered the depression.

Our results of the retrospective analysis of the assumed etiological factors demonstrate that the light birth injuries, which take place without the phenomena of asphyxia (“premature”, “swift”, “tightened” kinds, the imposition of tongs and other ), reliably more frequently accompany the favorable course of disease. In recent years by some studies (F. Nakamura et al., 1997) it is also confirmed the possibility of the connection of perinatal factors with the development of the simple partial seizures, which have favorable prognosis.

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Polyethiological, in our opinion, can be named epilepsy, which takes place with a lag exacerbation of process, since it is not noted the predominance of any factor or group of the factors with it, which could be related to exogenous or endogenous. To a certain degree “multifactorial” origin of personal and cognitive disorders with epilepsy is confirmed by data of Z. Martinovic et al. (1997).

The more complex relationships between the assumed etiological factors, according to our data, occur with the unfavorable type of the course of disease. To such factors here in the first place can be referred the presence of the epileptoid traits in the close relatives of patients and alcoholism of the parents. From the exogenous etiological factors here, first of all, should be noted the intracranial infections of early age. Carrying the presence of alcoholism in the parents of patients to the assumed endogenous etiological factors, we imply mainly the tendency of the representatives of the previous generation toward the abuse of alcohol as tendency as a tendency to deviations in drives.

According to E.A. Balina (2011), the symptomatic forms of epilepsy in children, caused by the organic defeat of brain, make a debut substantially earlier, in their etiology the perinatal hypoxic-ischemic and infectious defeats of brain predominate, in the clinic more frequently are noted multifocal and resistant to the therapy forms.

The emergence of neocortical temporal lobe epilepsy resistant to medication, Y. Kim et al. (1997) associated with neuroepithelial tumors. In frequency with a history in 73 patients with frontal epilepsy etiological factors J.A. Mauri et al. (1997) distributed as follows : etiology “unknown “ in 49 % of cases, in 12% of cases there are indications of the resi-dual defect (anoxic encephalopathy, in other cases, 12% – to neoplasia or vascular abnormalities, 10% of patients suffer from “post-traumatic epilepsy” the same – “vascular epilepsy”, and 6 % of patients have cerebral malformations (1997). In 69 % of cases of frontal epilepsy causes M.E. Weis et al. find tumors, vascular abnormalities or deficit medulla.

Regarding the etiology of epilepsy in general (without the indication of its localization and prognosis), some authors consider that the leading role in its appearance or provocation is given to infectious diseases, “cerebral rheumatism”, chronic tonsillary infection, to the diseases of cardiovascular system.

Concordant rates for the etiology of epilepsy, according to of M.J. Kjeldsen et al. (1997), compose 0,31 in monozygotic twins and

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0,06 in dizygotic. M. Levav et al. (1997) find hereditary nature of the epileptic absences of the childhood well documented. Together with the wide collection of perinatal complications of the factors, which refer to the etiology of epilepsy, M. Nikanorova et al. (1997), P.M. Leary et al. (1997), the V. Sander et aL. (1997) and F. Vigevano et al. (1997) consider meningitis, tuberculosis, neurocysticercosis, injury. P. Satischandra et al. (1997) consider natal injuries and intracranial infections leading among the reasons for epilepsy.

An increase in the morbidity of epilepsy is placed in the relation to the more frequent “survival of the children weakened in the heavy childbirths”, and also to the more frequent “after suffering cerebral strokes” (W.A. Hauser, 1997). According to P. Jallon (1997), cerebrovascular disorders generally and the use of alcohol to a considerable extent can be a risk factor.

Carried out by A.I. Boldyrev (1984) investigation of 600 patients with the duration of the course of epilepsy of up to 3 years, showed that before the beginning, the somatic pathology took place more than in half of the cases.

Considering the data presented, one of the tasks of our study was the determination of the frequency of somatical and infectious diseases in patients with epilepsy with the presence in them of psychotic manifestations of epilepsy. Among the latter were included remote stages of the disease such as transitory, schubweise and chronic psychosis, on the average which were being noted in patients 10-15 years after the demonstration of paroxysms.

In this context, we specially examined 450 patients (men – 234, women – 216). Over the entire period of epilepsy (mean 29.9 + / -0.8 years), was noted 707 cases of somatic disease, the emergence or aggravation of which somehow affected the nature of its course. This effect was reflected in provocation or quickening in patients of paroxysmal disorders, signs of fatigue or persistent development of psychotic disorders. Infectious diseases of childhood were observed in 380 (53.7 %) cases, diseases of the ear, nose and throat – in 112 (15.8%), chronic diseases of the digestive system – in 80 (11.3%), respiratory diseases – in 71 (10,1 %), chronic diseases of the cardiovascular system – 64 (9.1 %) cases.

The presence and gravity of the somatic diseases, which was revealed in the course of inspection in 287 of 450 patients (63,8%), are traced in the cases of epilepsy with the psychotic disorders taking into account its type in general.

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Statistic study with use of an associative coefficient of G. Yule (CYu) showed that each of the groups of somatic diseases in general only to a slight degree (value CYu from -0,14 to +0,2) was connected not only with the above indicated form of the course of psychosis, but also with the basic determinant of prognosis – type of the course of epileptic process. This testified in favor of the low probability of involvement of only one factor-emptive destruction of one or another system of the body in the origin, formation or worsening of epilepsy.

However, an explicit general predominance of infectious diseases suggests the possibility of the influence of individual infectious or non-infectious forms of pathology on the nature of epilepsy.

With the transitory form of the course of epileptic psychosis and the favorable outcome of disease in the sufficiently close connection were located the chickenpox (CYu +0,5) and whooping cough (CYu +0,5) endured by patients in the childhood, frequent were the cases of chronic sinusitis (maxillary sinusitus, frontal sinusitis) (CYu +0,63). The psychotic disorders in the late stage of epilepsy in these patients were characterized by the relapsing (not more frequent than one time per year) affective and affective-delusional states with duration from several hours to several days.

The course of disease with the exacerbation after period relative to its favorable (for a period of 14,5+/-0,6 years) development revealed the average degree of relation with the presence in the patients in the past of pharyngitis (CYu +0,4) and chronic cholecystitis (CYu +0,34). The aggravation of the epileptic process in the form of quickening of paroxysmal states and psychotic episodes with the predominance of deliusional disorders in its distant development stages accompanied appearance in the patients initial signs of epileptic dementia.

Early appeared progressive course of epileptic process was closer connected with those occurred in patients already in the childhood with chronic purulent mesotympanitis (CYu +0,6) and chronic laryngitis (CYu +0,44). The early beginning of epilepsy in patients distinctly was combined with the symptoms of the delay of somatoneurological and intellectual development expressed in them. The subacute from the very beginning course of disease was accompanied not only by the presence of the generalized seizures and transitory psychoses, in structure of which predominated catatonic disorders was, but with the manifestations of epileptic dementia with the viscosity of thought mainly expressed in the patients and oligophasia.

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With the schubweise course of the epileptic psychoses, which was characterized by larger than transitory psychoses, duration and slow rate of the development of the psychopathological disorders within the framework of psychotic schub, were revealed other regularities.

The favorable development of disease in these cases had the average degree of connection (CYu +0,4) with the rheumatism, with the formation of the moderately expressed insufficiency of mitral valve. Characteristic were protracted and mildly expressed manic-depres- sive disorders.

Relatively unfavorable course of epileptic process (with the set aside exacerbation) closer (CYu +0,8) was connected with chronic rhinitis and chronic pharyngitis. With the aggravation of the course of epilepsy frequent (CYu +0,44) were the cases of development in the patients of stomach ulcer and duodenum. In such patients on the average only in 21,3+/-0,7 years from the beginning of epilepsy appeared the signs of intellectual disorders, also were developed the protracted paroxisms of psychosis with the predominance of halluci- natory-delusional manifestations.

At the same time only morbidity with chronic laryngitis closely enough (CYu +0,55) was assosiated with the unfavorable course of epileptic disease in patients with schubweise forms of psychoses. On the average after only 13,2 + 0,7 years from the beginning of epilepsy the psychotic disorders of predominantly catatonic nature alternated in them by short-term (with duration from several months to 1 year) remissions. In the structure of the latter together with the residual productive psychopathological symptoms the signs of epileptic dementia were sharply pronounced.

The uniqueness somatic disorders have been identified in patients and in chronic epileptic psychosis. Favorable course of the disease was closely associated (CYu +0,5) with a tendency of patients to acute respiratory diseases, as well as with the development of chronic sinusitis and chronic gastritis.. With the complete intact intellectual in patients, there was a continuous change of the different duration of sub-affective phases.

In cases of relatively poor – slowly at first , and then subacute – manifestations of the disease with chronic psychosis showed no correlation between epilepsy and somatic disorders. Exacerbation by 23.1 + / -0.2 years after its beginning combined with the development of so-called paranoid epileptic dementia, ie, symptoms of paranoiac personality development in conjunction with the progressive intellec-

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tual defect, distinctive features of which were in the form of viscosity, ornateness and multiplicity of thought.

At the same time if the patients in childhood had typhoid fever and presence in them of chronic hepatite to a certain degree (CYu +0,4 and +0,47 respectively) were connected with the unfavorable course of disease. The appearance of signs of epileptic dementia frequently anticipated the development of the chronic psychosis, special features of which were protracted sub-stuporous states in combination with the prolonged affective-delusional disorders.

In patients we inspected were not discovered prognostically significant connections between epilepsy and dysentery, dyspepsia, diphtheria, infectious parotitis, crust, scarlet fever, recurrent typhus or typhus that they suffered. The cases of chronic tonsillitis, frequently mentioned in the literature as the etiological factor assumed in epilepsy, also proved to be evenly distributed according to the forms of the course of epileptic psychosis and the types of the course of disease. Found no prognostic significance of hypertension, hypotension, ischemic heart disease. Indifferent in terms of prognosis were pneumonia and chronic bronchitis .

The results of an epidemiological study given in the previous chapter convinced us of the fact that the formation of syndrome, syndromokinesis and pathokinesis in general as the expression of the nosologic essence of epilepsy must be examined from the positions of the ontogenesis.

To resolve this issue, we first needed to establish a statistically significant predominance of a particular type of the disease of one of the three identified empirically productive structures of psychopathological disorders.

Our data indicate that, in general with a favorable course of the disease in the structure of transient and schubweise psychosis affective disorders prevail in cases of delayed disease progression with transient exacerbation in the structure, schubweise and chronic psychoses – hallucinatory-delusional symptoms, and in cases of unfavorable course all forms of the disease characterized by psychosis catatonic manifestations.

These data allowed us to assume that the register of productive psychopathological disorders, being the sufficiently steady characteristic of epileptic disease for its considerable length, should carry information about the influence on the development of the disease of primary involvement in the pathological process of certain parts of the brain.

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As it was already noted in the chapter, dedicated to the analysis of the literature, none of the existing approaches to the study of clin- ico-electroencephalographic relationships proved to be productive for purposes of the determination of prognosis of epilepsy, which takes place with the mental disorders, precisely, because the pathology of the bioelectric activity of the brain with it frequently is examined out of the connection with the type of the course of disease.

In this connection great interest for us represents the fact that many authors, establishing the variety of the mental disorders in the cases of the detection of epileptic focuses in the temporal lobe (H. Landolt, 1960, and others), did not examine the value of this variety differentially.

In particular, it is a fairly common of idea of the combination “over a wide range” of productive and negative symptoms in temporal epilepsy (W.G. Lennox, 1951; L.P. Lobova and T.A. Dobrokhotova, 1964, and others).

It is important , however, to note that the issue of the so -called lateralization of foci of epileptic activity on EEG was given some attention . For example, on a sufficiently large clinical material was detected left-sided localization of the epileptic focus in combination with behavioral disorders in patients with epilepsy (M. Masson, 1960 S. Marsan and E. Laskovski, 1962). The right temporal lobe lesions were found during the visual illusions, olfactory and gustatory hallucinations, impulsivity patients (M. Masson, 1960). In patients with left temporal lobe epilepsy often was noted the “verbal deficit”, while in patients with right temporal lobe epilepsy prevailed “visual deficit» (V. Lespinet et al. , 1992). R. Manchanda et al. (1997) relate vistsero symmetric aura to right temporal focus, and cephalic aura – to a left.

It was noted that the main condition for the occurrence of depression in temporal lobe epilepsy is the localization of focus (especially in the left hemisphere) in combination with the decreased functional state of the frontal divisions of the brain (B. Schmitz, 1997, 2002; C. Helmstaedter et al., 2004). There have been allegations that the depression in the medial temporal lobe epilepsy can occur regardless of the side of the focus, and depression with the mezial temporal sclerosis reaches the greatest manifestation in the right-hemispheric focus, and the development of anxiety – in the the left-hemispheric (A. Quiske et al., 2000). On the material of 319 patients with the partial forms of epilepsy S.J. Adams et al. (2008) established that the psychopathological symptomatology more often (in 69,2% of cases) ap-

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pears in the partial cryptogenic forms of epilepsy (temporal and nontemporal). In this case the statistically significant differences in the prevalence of depressions for the patients with the temporal and nontemporal epilepsy by the authors was not established (respectively, 31,2% and 37,9%; χ2= 1,06, [r]=0,3). Differences in the frequency of depression between left-hemispheric (33,1%), right-hemispheric (32,6%) and bilateral foci (31,8%) also was not established (χ2= 0.2, p=1,0). (Cited. on V.V. Kalinin, 2010).

However, now preserved opinion regarding the distribution of functional disorders in epilepsy between the two temporal lobes.

According to P. Flor-Henry (1969), schizophrenia-like psychoses with epilepsy more frequently appear with the left-side or bilateral liesions of temporal lobes. To the considerably smaller degree local component occurs with the twilight disorders of consciousness (S.N. Davidenkov et al., 1952; J.R. Rughes et al., 1961).

Evaluating the defeats of vocal functions with left and right-side temporal lobe in epilepsy, R. Abou-Khalil et al. (1997) not with all applicable tests revealed significant statistically significant differences. Approximately about the same results in a study of verbal memory reports O. Dogu et al. (1997). Both groups of the patients: with the left and right-side temporal lobe epileptic focuses, in the opinion of L.H. Goldstein (1997), to the equal terms are more slow than patients from the inspection team in terms of execution time of computerized tests. M. Hendricks et al. (1997) do not find the differences between the analogous groups of patients through the indices of general intellect, irregular and semantic memory, although they note some correlations between left-side temporal lobe epilepsy and insolvency of patients in the instruction in irregular verbal knowledge and in the knowledge of categorial information. Obtained by N. Pender and L.H. Goldstein (1997) data did not allow them to demonstrate the presence of the material specific character of the scarcity of memory as the predictor of the basis of the lateralization of temporal lobe foci in patients.

Hypoand hypersexuality in the men suffering epilepsy was explained by defect in both temporal lobes (G. Anastasopulos et al., 1964). At the same time without the indications of the predominance of the interest of any of the latter were cited the data about the most varied kind illusory disorders (S. Mullan and W. Penfield, 1959) and about worsening in the mental condition generally (A. Cerullo et al., 1997).

Some researchers, without singling out in this regard any one of the temporal lobes, pointed to the localization of the pathological

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process in their specific areas: the cortex (V. Ioneshesku, 1960), in the piriform lobe, amygdala and hippocampus nuclei (T. Ott et al ., 1962; Ch. Cristinzio et al., 2007), in the cortex of upper and side surface (W.G. Penfild and L. Roberts, 1964). In this case beginning of psychoses was explained “by the disconnection” of any region of temporal lobes (H.S. Saksena, 1969).

A number of the authors spoke out in favor possible establishment the relations of organic and typical epileptic changes with the general slowdown in the background rhythm on the EEG (E. Slater et al., 1963; G.H. Glaser, 1967; E.S Tolmasskaya et al., 1968 and others).

At the same time there is no unified opinion about the existence of the specific clinico-electrophysiological correlations. Results of the studies of H. Penin and W. Zeh (1964) testified more in favor of the possibility of establishing the latter between active bilateral basal pathologic process and EEG data. The cause of mental retardation in epilepsy J.E. Festen et al. (1997) considered a bilateral damage in the Sylvian fissure.

Many contradictions consist also in the given by researchers data about the relationships between the clinical manifestations of epileptic psychosis and the type of paroxysmal states. Interesting in this aspect is the observation by E.J.A. Nuffield (1961) of the fact that it is more easy to establish the connection between the special features EEG and the disturbances of behavior in patients, than between the latter and the predominant type of seizure. On the absence of any connection between the clinical characteristics of psychosis and seizure spoke out also M. Sawa (1963) and J. Stevens (1966). In spite of this E. Niedermeyer (1959), S. S. Mnukhin et al. (1965), K. Savelli et al. (1966) gave a significant role in the formation of sharp psychoses to the so-called percept seizures. P. Flor-Henry (1969) more frequently observed shizophrenia-like psychoses with the psycho-motor and psycho-sensory seizures, manic-depressive – with generalized, and shizoaffective – with both.

It is at the same time necessary to note that in contrast to the represented above general tendency, the concept of localization evaluated by a number of authors as completely questionable and not determined.

G.B. Abramovich (1959), for example, objected to the establishment of the relationship between the anxiety, fears and other phenomena in the region of affect and disturbances of the activity of temporal lobe, and later (1964) he defined by the localization of focus

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only the modality of hallucinations, the type of depersonalization. E.N. Kameneva (1969) and others considered possible to indicate the presence of the connection of psychopathological disorders with the specific localization of the defect of the brain only in adult patients with epilepsy. In connection with the subjectivity of experiences in patients R. Baeri (1959) declared groundless the searches of cortical localization of aura, and A S. Dongier (1959) came to the conclusion about the ambiguity of the data about the nature EEG during the psychotic episode.

Original approach to the study of the pathogenesis of epileptic psychoses was proposed by H. Landolt (1953, 1955, 1962). Experimental data allowed him and his followers to objectify the phenomenon of the forced normalization of EEG and to propose the concept of alternative psychosis. In this case they, first of all, mean cases of dreamy, delirious, paranoid or catatonic disorders with the extinction on EEG of convulsive focus. Patient, thus, according to the ideas of the authors, either was in the state of seizure, or was mentally sick A similar concept represent particular interest for the topic of our research, as a favorable therapeutic effect on a number of clinicians paroxysmal conditions observed in some patients deteriorating mental state (O.V. Kerbikov, 1953, cited. on A.A. Khachaturyan et al., 1954; E.A. Weinstein, 1959; G. Schorsch, 1962; N.F. Bezugolnikova et al., 1964; H. Penin, 1965; I.S. Tets, 1969, and others); however, it hardly can cover entire totality of varied psychopathological disorders with epilepsy. According to the data of M.V. Lambert et al. (2000), alternative psychoses comprise not more than 1% all cases of psychoses with this disease.

Some authors undertook the attempts to interpret in epilepsy the role of the manifestations of agnosia and apraxia in the pathogenesis of psychomotor restlessness and hallucinations (S.F. Semenov, 1965), and also the place of hallucinatory-paranoid syndrome in the development of twilight states (R. de Smedt, 1963). There have been searches for a connection between the stimulation of some part of the body and the formation of the “reflected epilepsy” (C. Mattioli-Foggia, 1959) and the role of the illusions of comparison in the appearance of the incorrect evaluation of situation (S. Mullan et al., 1959). In contrast to such a great extent speculations, in general in the literature of the subsequent seventietheightieth years began to be foreshadowed more progressive tendency toward the development of morphological, biochemical and immunological substrate in the pathogenesis of mental epilepsy.

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