Mental disorders in epilepsy
.pdfK.K. Blinova et al. (1971) proposed, for example, to concider the damages of neuron structures in the frontal and lower-sincipital regions of crust as referring to the development of mental disorders with epilepsy. On the background of a uniform internal hydrocephalus G.M. Kharchevnikov (1975) has discovered in a number of patients the involvment of the frontoparietal regions of lateral ventricles. Specificity of symptoms in the cases of development of psychosis in patients with epilepsy by F. Findji et al. (1979) was attributed to the immaturity of the brain structures and thus their lower resistance to pathogenic factors.
To slowing of «neurological maturation» and «immaturity EEG” as to the signs, which explain psychological underdevelopment in many areas of functioning of children, including hyperkinetic behavior, emotional immaturity and difficulty in the instruction, are indicated in recent years by O. Aleksic et al. (1997) and E. Biagioni et al. (1997). T. Deonna (1997) directly indicates that the epileptic activity in the young developing brain can “interfere with the cognitive functions and behavior”.
The connection between the activity flow of psychotic disorders in epilepsy and activity “ basal midline structures “ was established by J.H. Bruens (1971) and G.K. Koehler (1973, 1975). J.N. Bruens (1971), in particular, indicated such disorders of the mediobasal temporal lobe structures, which lead to the disturbances of the regulation of the emotional and instinctive base of personality. The author believes that due to these disorders in patients the control over aggressive and sexual pulses not only is reduced, but there is a noted tendency toward the false interpretations and the delusional ideas.
Manifestations of emotional stress in patients with epilepsy cases develop reactive psychosis O.N. Dokuchaeva (1972) posed in connection with the activation of the reticular formation. To the increased passive aggressiveness in these cases indicated also M. Popovic et al. (1997).
In accordance with the hypothesis of M. Sato et al. (1979), the appearance of psychotic states with epilepsy can result in paroxysmal activity in the mesolimbic structures, which are under the dopaminergic control.
In this regard, it should be said that in the seventies, eighties certain place in the origin of epileptic psychoses are increasingly allotted to biochemical (E.H. Reynolds, 1971; F. Lamprecht, 1973; L. Gram et al., 1981) and immunological (S.F. Semenov, 1972) factors.
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P.G. Metsov (1974), for example, connected the presence of anticerebral antibodies in the blood of the patients with epilepsy with the presence of the expressed progressive-destructive tendencies of epileptic process.
Beginning from the same period noticeable development receives the concept of influence on the epileptic process of the asymmetry of the brain functions. The disfunction of complex right hemispherelimbic system is considered, for example, out of the allergic conditions (A.P. Chuprikov, 1973). In patients, epilepsy with the predominance of the defeat of dominant hemisphere is more frequently connected hypochondricity, tension and super-valuable formations (I.I. Belaya et al., 1978) or shizophrenia-like psychoses (T. Sherwin et al., 1982; P. Flor-Henry, 1983; A. Stoudemire et al., 1983; A. Patroneva et al., 1997; W.M.A. Verhoeven et al.,2010), with the focus in the nondominant hemisphere – disorders, which resemble the manic-depressive psychosis (J. Alliez et al., 1978; P. Flor-Henry, 1983).
By the connections of the structures of temporal lobe with the hippocampus and the brainstem formations was explained diffuse pathologic bioelectric activity with the epileptic psychoses, assuming that against this background the dynamics of second foci causes the transformation of clinical picture in the later stages of the course of disease (P.M. Saradzhishvili, 1971; R.G. Golodets et al., 1972). The complexity of the neurodynamic relations between the region of cerebral defeat and the localization of primary epileptic focus was connected by I.S. Tets (1971) with the possibility of their noncoincidence. This was to a certain extent confirmed by data of E.S. Tolmasskaya et al. (1971), S.A. [Chkhenkeli et al. (1979) and M.R. Trimble (1984) about the relationship of local and general cerebral disturbances, and also by data of R.G. Golodets et al. (1972), V.E. Smirnov (1972), G.D. Shukla et al. (1980) about the manifestation of pathologic activity on EEG in chronic epileptic psychoses in the central-frontal-temporal region with the presence of bilateral paroxysmal discharges.
In conducting own research of prognostic significance of nature of brain activity in patients with epilepsy, proceeding with psychotic disorders, which takes place with the psychotic disorders, we relied on the data of the analysis of electroencephalograms of 157 patients with manifestations of one of three basic forms of the epileptic psychosis named above: with the predominance of affective, delusional or catatonic disorders. Together with the sufficiently extended study of the type of electroencephalogram was undertaken the spe-
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cial study of data of EEG, which could indicate the fact of presence or absence of epileptic focus.
In many instances, first of all, attention is drawn to the expressed character of changes in the bioelectric activity of the brain.
Only in 25 patients base EEG could be attributed to variations in norms. Afferent stimuli (rhythmical photostimulation and hyperventilation) revealed the concealed pathologic activity (discharges of sharp waves, epileptoid complexes). (First type of changes in the electroencephalogram).
A considerable part of patients EEG had a disorganized character without domination of any rhythm. Against the background of disorganized alpha, the beta, the theta-rhythms different amplitude were recorded the bilateralhypersynchronous discharges of the same rhythms, different localization sharp waves of epileptoid complexes. Response reactions to the rhythmical photostimulation had complex figure – this spikes, sharp waves, the complexes of the epileptic phenomena in the assigned rhythm, which sometimes independent of the frequency of the assigned rhythm acquired seemingly automatic nature. Hyperventilation strengthened pathologic nature EEG. (Second type of changes).
In the small percentage of the cases the figure EEG was distinguished by hypersynchronous activity in the range of alpha, beta, thetafrequencies (150-200 mcv) against the background of which the discharges of epileptoid activity were recorded. Response reactions to the stimuli were analogous to the above. (Third type of changes).
Out of 157 patients in 66 were noted the expressed diffuse changes in the biopotentials of the brain in the form of the general disorganization of rhythms, insufficient manifestation of alpha rhythm and presence of the pathologic discharges: sharp waves, spike-such fluctuations, the group of theta and delta-waves, pointed high-amplitude alphawaves, the generalized discharges of epileptoid complexes. In 34 patients were in this background registered the foci of epileptic activity in one of the hemispheres, predominantly frontotemporal localization, in 11- bilateral-synchronous foci in the same leads. (Fourth type of changes).
The specific correlations between the types of EEG and the basic registers of the psychotic disorders were revealed.
The presence in the structure of psychosis of catatonic disorders significantly more common was the fourth type of EEG changes. With the predominance of the structure of the EEG symptoms of psychotic
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delusions has polymorphic and undifferentiated nature. Mainly affective psychotic disorders significantly more often corresponds to the first type of EEG changes.
Given data of clinico-electroencephalographic study suggest that in patients with the epileptic psychoses, in structure of which predominate delusional and catatonic disorders, occurs essential reconstruction of the functional organization of the brain, another level of the activity of the brain appears with the foci of epileptic activity in its different divisions. Hence there is polymorphism and gravity of the revealed changes. In cases where the prevalence of catatonic disorders although is able to identify the leading center, but here recorded EEG changes are dynamic The presence of epileptic activity, its different manifestation, variety of manifestations show that with the epileptic psychoses the time-spatial relationships are subjected to fluctuations; however, general nature EEG remains pathologic. In the cases of the progressive course of disease with the epileptic psychoses in the brain constantly are located the foci of pathologic activity. Their distribution and preferred localization in the frontotemporal divisions of the brain can be considered as evidence of the generalization of process.
With regard to guidance on the localized nature of electroencephalographic changes, according to obtained by us data, in the cases of predominance in the structure of the epileptic psychosis of affective disorders on EEG most frequently there are no signs of the specific localization of epileptic focus, or is noted its localization in “deep”, “diencephalic”, “brainstem” divisions of the brain (difference from other two types of psychosis are statistically reliable).
At the same time in the cases of predominance in the structure of the psychosis of hallucinatory-delusional symptoms only on 11 of 73 electroencephalograms had indications on localization of focus in the temporal lobe divisions of the brain (difference from the number of cases of another localization are statistically insignificant).
With the presence in structure of the psychotic disorders of catatonic manifestations, more frequently is observed the localization of epileptic focus in the frontoparietal and frontotemporal divisions (difference from the psychoses with the predominance of affective disorders statistically reliably).
As it was already noted, many researchers were inclined to the conclusion about the absence of the connections between the type of seizure and the structure of psychosis. At the same time the data
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analysis of literature shows that also the judgments about the prognostic significance of the type of paroxysmal states with epilepsy were and remain sufficiently contradictory. And in recent years R. Nikolaishvili (1997) and J.A. Mauri (1997), for example, transferring diverse seizures with frontal epilepsy, inclined to attach prognostic importance faster to their frequency and polymorphism, than to their type.
In a study of the interrelation between the type of seizure and the structure of psychosis we, first of all, proceeded from that immutable fact that localization of epileptic focus to a considerable extent determines the clinical formulation of paroxysm (W. Penfield, T.G. Erickson, 1941). Taking this into account, the establishment of the above-indicated clinico-electroencephalographic correlations allowed us to consider as the their sufficient base in order to assume existence of this type of interrelation.
Our own research in that direction have been successful, however, upon required consideration of the factor dependent on age. In the course of the conducted investigation was established, for example, that at the age of up to 20 years in patients with the favorable course of disease it is noted the predominance of the vegetative paroxysms (paroxysmal headache, the disorders of sleep, enuresis, vegeto-visce- ral seizures and others) above dysphorias and generalized tonico-clonic seizures.
These data found confirmation in the results of study in 19901995 of the children with cerebral paralysis, in whom simultaneously was noted favorably current epilepsy. According to K.L. Kwong et al. (1997), in them, in spite of the early appearance of epileptic seizures, epileptic statuses were absent, also were revealed “normal intellect and normal EEG in the period between attacks”, and “control over seizures” was satisfactory.
We also established , that in epilepsy exacerbation of delayed process at all stages of ontogenesis remains the polymorphism of paroxysmal states. In this case it was not revealed the reliable differences in the number of cases of the appearance of seizures dependent on age new for this patient of various types: vegetative, dysphoria, temporal (psycho-motor and psycho-sensory), generalized tonic-clonic, etc.
In this cases, speaking about the new type of seizure, we, including the dynamics of the structure of the paroxysm dependent on age emergent in this patient. In the relation indicated they represent the interest of the observations, which testify, for example, about the fact that in children with temporal lobe epilepsy at the infantile
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age predominate the tonic and hemiclonic seizures, at the age from 5 to 7 years – simple partial motor or autonomous-visual seizures, while at the pubertal age – complex partial seizures or the seizures with the disorders of mental functions (L. Kalinina, 1997).
Finally, in the cases of the unfavorable course of disease we revealed reliable in the first decade of life predominance in patients generalized tonicoclonic seizures and dysphorias above vegetative, temporal and other paroxysms. At this point ontogenesis with the type of the course of disease indicated seizures were represented, furthermore, by the typical evolutionary forms: retro and propulsive, picnoleptic, myoclonic with the locomotor component, classical absences. Subsequently predominated the versions with the postural and psycho-motor components, the massive vaso-vegetative dissociations, and also the generalized convulsive with the expressed phenomena of postparoxysmal exhaustion. The number of cases of psycho-senso- ry and psycho-motor paroxysms with the age did not decrease in comparison with the number of generalized convulsive seizures.
With the unfavorable type of the course of process on the motion of disease in our patients appeared the continuances of the decompensation in the form of series of convulsive seizures, status-like states and statuses.
The study of the dynamics of paroxysmal syndrome carried out by us made it possible to establish that the frequency of the appearance of the types of seizures (2307 cases) new for this patient depends on the age of patient and the type of the course of disease. Furthermore, the analysis of the totality of the cases of registering the changes in the frequency of paroxysms (1867 cases) showed that the data about the age of patients in the period of this type of the manifestations of disease also can contain the specific information about the degree of progressive course of epileptic process in general.
It is possible to note the statistically reliable, for example, increase in the number of new for the patient types of paroxysms at the age after 40 years, which testifies as a whole about the retarded or favorable development of epileptic process. At the same time with epilepsy, which takes place with the set aside exacerbation, the rate of the appearance of new types of paroxysms in this period dependent on age returns to the initial. With the unfavorable type of the course of epilepsy the frequency of the appearance of the new types of paroxysms at the age after 40 years statistically reliably decreases in comparison with the first decade of life.
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Cumulatively, without the correlation with the type of the course of disease, “joint risk of the recovery” of the partial or generalized seizures was studied by the V. Bertol et al. (1997) with the use of a method of the tables of life in the cases, defined by the authors as “recurrent and provoked seizures”. In this case, as we expected, it was not noted the connection between the type of seizure and the age. To confirm these data, in cases of resistant epilepsy in children SL Moshe (1997) notes, “multifocal seizures and tendency toward the development of status of epilepticus”.
As for the general frequency of paroxysmal states in their entirety, then, according to our data, it is the smallest with a favorable course of the disease and the highest – at worst. In cases of epilepsy, which flows with a lag exacerbation of the process, along with the above-noted polymorphism structure seizures there are significant fluctuations in the frequency of the latter.
It should be noted that as the criterion of a good prognosis with epilepsy at childhood W.F. Arts et al. (1997) result in remission, characterized by the absence paroxysms for more than 12 months , and the bad – when the duration of remission under the same conditions does not exceed 6 months. To resistant with respect to the drug treatment A. Cerullo et al. (1997) carry patients, whose frequency of seizures during the treatment comprises more than one once a week. Poor prognosis is established by A. Berger et al. (1997) in the cases of the beginning of disease at the age between 2 and 20 months and the series course of seizures. In all children from the beginning of the disease at the age from 2 months to 7 years with the maximum frequency of seizures several times in the day O. Kanazawa et al. (1997) record to video EEG engine storm, unilateral tonic spasm, partial myoclonus, unilateral tonic and axial tonic seizures.
An increase in the so-called risk of the recovery of paroxysms in patients older than 20 years, which reveal deviations in neurologic status, was noted by V. Bertol et al. (1997) in the broad band dependent on age: from 20 to 60 years. In patients with “heavy mental retardation” at the age from 21 year to 52 years M. Derouaux et al. (1997) revealed the frequent and short-term typical and weakly expressed seizures with the symptoms of the disturbance of consciousness or the second generalization. According to the evidence of the authors, the little expressed manifistations are frequently received by ohers as the disorders of behavior.
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In patients with one type of seizures, inspected by P. Jallon (1992), generalized seizures were more frequent than partial. These observations agree with the data of J.H. Lee et al. (1997), who found rarer seizures in patients with “unotemporal” epilepsy. According to of D.M. Milevska et al. (1997), epileptic seizures are more frequent in patients from the beginning of the disease to the 15 years age, than with its beginning at the later age.
Established in our study age data on the dynamics of paroxysmal symptoms are comparable to those of M. Tepinoy (1987) on the manifestation of slow progression of the type of epilepsy patients mostly aged 15-18 years, a progressive subacute – aged 5-10 years and malignant – in infancy.
Particular interest in the study of age aspects of syndromokinesis with epilepsy presented the data we obtained about patients according to the age and type of the disease, nature of the relationship of major clinical syndromes, such as paroxysmal disorders, personality changes, productive psychopathological disorders and epileptic dementia.
In this respect the practical importance was the identification of criteria for the type of the disease, which could ensure prognostic information in the earliest possible stages of ontogenesis.
For purposes of the search for the indicated kind of criteria we assumed it necessary to compare the studies obtained in the course psychopathological signs of the type of the course of disease with the age of patients, including the period of the primary appearance of paroxysmal disorders, the period of the beginning of the statement of changes in the personality, the period of the appearance of the first signs of psychosis and the period of the appearance of signs of dementia.
The conducted by us clinico-epidemiological investigation made it possible to establish that only fact of the appearance of the phenomena at one or other age or another cannot be considered as the essential prognostic sign without taking into account the degree of the manifestation of changes in the personality.
In the course of a study was at the same time established a prognostic importance of the periods of the demonstration in the present work of such psychopathological phenomena as psychosis and dementia, the recognition of the beginning of the appearance of signs of which makes it possible to determine the rate of progressive course of epileptic process.
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Between selected types of the disease, we revealed statistically significant age differences in the frequency of the first signs of psychosis, epilepsy and epileptic dementia.
The obtained in the course studies data shows, for example, that the demonstration of psychotic disorders in the first three decades of life is typical for the unfavorable course of disease, and their first appearance in the fourth and fifth decades of life is more characteristic of the type of the course of disease with the set aside exacerbation of process. Age-qualification differences in the appearance of the first signs of psychosis with the favorable course of disease is not established.
It should be noted that in the literature there is practically no data, which establish the prognostic connection between the age of patients and the beginning of psychosis with epilepsy. There are only separate indications of the cases of the demonstration of catalepsy at the age of 4 years (I.M. Ravnik et al., 1997), hyper-religi- osity, obsessive-compulsive behavior, extremely intensive interpersonal connections and the undeveloped changes of the mood in the teenage period (V. Tretnjak et al., 1997), schizoaffective psychosis in patients at the age from 15 to 20 years (O. Panasenko, 1997), religious delusion and hallucinations in the fourth decade of life when, in the patient, the independent double-sided frontotemporal foci are present, on interparoxysmal EEG (A.J.S. Russel, 1997), which can only to a certain degree be used for maintaining the idea of conducting a study in the direction of the search for similar age-qualifica- tion correlations.
Several other correlations were noted in the analysis of appearance in the patients first signs of epileptic dementia. If for the unfavorable course of disease is typical the appearance of signs of dementia in the same periods dependent on age as the signs of psychosis, in the first 30 years of life, with a lag in disease exacerbation of epileptic process typically the signs of dementia in patients aged 20 to 50 years.
In recent years cognitive functions in the patients with epilepsy, especially in children, are investigated fairly active. A.R. Aldenkamp et al. (1997) note that up to 30% of children, patients with epilepsy, according to the data of the study of community, present risk “for the development of some forms of the disorders of instruction”. E. Biagioni et al. (1997) connect “early deviations on EEG” in children with the results of their linguistic and mathematical testing. M.G. Chez et al. (1997) separated the early (at the age to 18 months) and
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late regress of speech in children, sick with epilepsy, and, indicating the high percentage of the latter, they compare it with “epileptic aphasia”. In children with the generalized subclinical epileptoid discharges on EEG R.M. Pressler et al. (1997) observe noticeable reduction in the verbal and operating intellectual coefficient. According to J. Weglage et al. (1997), compared with the control group, children with so-called enabling children’s epilepsy under the conditions of experiment noticeably lagged on the intellectual coefficient, the visual perception, the short-term memory, the execution of thin motions. M. Lendt et al. (1997) voice the assumption that the soft versions “specific defect of frontal lobe” in children with frontal lobe epilepsy are compared with the defeats in adult basic functions without the defeat of the highest cortical representations.
C.D. Ferrie et al. (1997), studying the mechanisms of the disfunction of metabolism in adult with the syndrome of dementia, inclined to draw analogy with the same with the epileptic encephalopathy of the childhood. R. Khatami et al. (1997) assumed the presence “genetic syndrome of the combination of frontal lobe epilepsy with the mental retardation”.
Finally, we established correlations between the age of patients and the stages of the formation of epileptic dementia. It turned out that the signs of the second of these stages after a decade of life after the first signs is a typical exacerbation of epilepsy with a lag process. With this type of the course of disease the first stage of the formation of epileptic dementia was diagnosed predominantly at the age from 20 to 40 years, and the second – at the age from 40 to 60 years. But if the period of the appearance of signs of one or the other stage was extend to 4-5 decades of life and in this case the duration of the first stage it did not exceed 10 years, then the discussion could deal faster with the unfavorable type of the course of disease.
According to our data, the greatest activity of the development of paroxysmal syndrome takes place from the very beginning of the unfavorable course of disease. For this type of the course of disease is characteristic the earlier appearance of productive and negative psychopathological symptoms.
With the favorable type of the course of disease occurs the rate of the appearance of new for this patient paroxysms uniform for a period of the first 40 years of life, and also the later appearance of productive psychopathological disorders in the absence of the signs of epileptic dementia.
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