The psychiatrist usually faces four types of problems associated with: differential diagnosis (especially with atypical seizures, aggressive behavior and sleep disorders); treatment of mental and social complications; treatment of epilepsy itself in patients seeking medical attention; side effects from the psyche caused by anticonvulsants. For a review of these issues and other aspects of epilepsy, see Laidlaw et al. (1988), Reiynolds, Trimble (1981) and Pedley, Meldrum (1983, 1985, 1986).

TYPES OF EPILEPSY

To understand the psychiatric aspects of epilepsy, it is necessary to know its classification and the clinical features characteristic of its most common forms. It should be remembered that the term Seizure Refers to the seizure itself and that such a seizure is characterized by abnormal electrical activity. Aura- this is nothing more than a simple partial seizure and, therefore, it may be the only manifestation of a seizure or only its first stage, in which consciousness is maintained. Aura must be distinguished from Prodrome- symptoms, sometimes preceding an attack. The International Epilepsy League proposed the original classification of seizures (Gastaut 1969), which is now widely used in slightly modified form (Dreifuss et al. 1981). Traditional terms such as Petite Mal(small fit) and Grand Mal(grand convulsive seizure), are now not used due to their vagueness. The classification is rather complicated, and in Table. 11.6 shows its greatly simplified scheme. The main distinction made in this system is the distinction between generalized seizures, which are of this nature from the very beginning, and partial seizures, which begin locally. Since focal seizures often become generalized, the description of the initial stages of a seizure is of the utmost importance for the application of this diagnostic scheme.

Simple partial seizures

This group includes motor Jacksonian seizures and a variety of sensory seizures, during which the manifestations are relatively mild. Consciousness is not disturbed. Such a seizure can develop into a secondarily generalized one with impaired consciousness.

Table 11.6. Classification of seizures 1. Partial seizures or seizures that start locally (focally)

Simple motor or sensory (without loss of consciousness) Complex partial (with secondary generalization; with damage to consciousness)

2. Generalized seizures without local onset Tonic-clonic seizures Myoclonic, atonic seizures Absences

3. Unclassified seizures

Complex partial seizures

This category replaces the previously used categories "psychomotor seizures" and "". Such seizures are caused by the action of a focus localized most often (though not always) in the temporal lobe of the brain. Seizures that initially occur in the frontal lobe are particularly easy to mistake for a psychiatric disorder (Williamson and Spencer 1986). They are often preceded by an elementary partial seizure that lasts for several seconds and may take the form of olfactory, gustatory, visual, auditory, or somatic hallucinations. It is not uncommon for the patient to also have serious disorders of thinking, perception, or emotions. Consciousness is broken. The main clinical signs of complex partial seizures are presented in Table. 11.7 (detailed in Daly 1975). The important point is that in each individual patient, the dynamics of the seizure tends to remain unchanged each time. Especially typical is the "epigastric aura" - a feeling of "churning" in the stomach, extending to the back of the head.

In general, the seizure phase lasts 1-2 minutes. During this phase and in the post-seizure period, the patient seems disconnected from the environment; He may exhibit automatisms. When he regains consciousness, he is able to remember only the aura. Status epilepticus can be of two types: a prolonged single seizure or short-term seizures quickly following one after another. In such cases, a prolonged period of automatic behavior and amnesia may be mistaken for hysterical fugue or other forms of mental disturbance.

Table 11.7. Clinical manifestations of complex partial seizures

Consciousness Impaired Vegetative and visceral disorders "Epigastric aura", dizziness, redness of the skin, tachycardia and other somatic sensations

Perception Distorted perception, deja vu, visual, auditory, olfactory and somatic Cognitive impairments Speech, thinking and memory disorders Affective disorders Fear and anxiety Psychomotor disorders Automatisms, "grimacing" and other repetitive motor manifestations or more complex stereotyped behavior

Generalized tonic-clonic seizures

These are common with a sudden onset, tonic and clonic phases and a final period of clouded consciousness lasting several minutes. In most cases, tonic-clonic seizures are secondary to other types of seizures.

Myoclonic, atonic seizures

There are several types of generalized epilepsy with predominantly motor symptoms such as widespread myoclonic jerks or sudden falls. Such cases, as a rule, do not present a problem for the psychiatrist.

Absences

There are several clinical types of absence seizures, the main common feature of which is loss of consciousness. The seizure starts suddenly, without aura, lasts a few seconds and ends abruptly. There are no post-seizure disorders. Often there are motor symptoms or simple automatisms. Small convulsive seizure ("petit mal") is less common. For a number of reasons (this is particularly important for treatment), it is important to distinguish between small seizures and less pronounced forms of complex partial seizures. The latter often start with an aura, last longer, and then slowly return to normal. An EEG may be required for accurate delineation.

EPIDEMIOLOGY

In the United Kingdom, surveys of general medical practice show that the prevalence of epilepsy is at least 4-6 cases per 1,000 population. Most often, the disease begins in early childhood; in addition, an increase in the level of primary morbidity occurs in adolescence and in the age group over 65 years. In a small number of cases of epilepsy that began in childhood, it is combined with a mental defect. (For a review of the epidemiology of epilepsy, see Sander and Shorvon 1987.)

Causes of epilepsy

Many are famous; their frequency varies with age. In newborns, the most common causes are birth trauma, congenital malformations, metabolic disorders, and infections. In the elderly, the most common causes include cerebrovascular disease, traumatic brain injury, and degenerative brain disorders. In at least half of the patients, even after a comprehensive examination, it is not possible to detect the cause; in such cases, genetic factors seem to play a greater role than in cases with an established cause.

The Petit Point technique (French petite point "small point", colloquial petite point) is a miniature version of the tapestry seam, in which the seam is made not through two warp threads in height and width, but through one. Thus, it is 1/4 of a regular tapestry stitch. The Petit Point technique allows you to create a complete illusion of a tapestry fabric, while the underside of the embroidery is denser. Pros: no skewed embroidery, smooth color transition Cons: double thread consumption, laboriousness

petite-point- This is a small half-cross. It sews likeregular half cross:on the inside, the seams are vertical, or astapestry seam:on the inside, the seams are located diagonally

petite stitch- this is a small cross, the size of a quarter of the main cross.

That is, instead of 1 cross, 4 small ones are embroidered

stitches petite are used in embroidery so that the embroidered picture looks more detailed, more natural. Basically, faces are embroidered in this way in order to have a smoother and more realistic color transition. In addition, petit-point and/or petit-stitch are used when it is required to emphasize the roundness of some details in the embroidery.

I'll give you an example. This photo shows that the purple threads with which the berry is embroidered go beyond the border of the backstitch:

And here, thanks to the petit-stitch stitches, the raspberry and yellow threads do not climb out of the borders of the backing, this makes the picture look better, more natural:

You can embroider petite stitches in different ways, depending on the specific image, more precisely, a fragment of the image and its color scheme:

In the diagram, the stitches are indicated as follows:

In general, you can replace the petit-stitch stitch with a petit-point stitch if you wish, only at the same timeyou need to observe the direction of the top stitch in the main crosses.

Petites can be embroidered in different ways, there are two options for embroidering them: the first one is as described with the pictures above, and the second option (which I use) the square is divided into four parts and a semi-cross is embroidered (to the corner indicated in the diagram, from the center) basically then the backing falls on these petites (at least that's the only thing that happened to me) and everything becomes neat.

Thanks for the information to the girl Masha from the forum .

What is Status Epilepticus Petit mal (Status Epilepticus of Absences, SEA)

Most common in children. May occur in 5% of cases of generalized epilepsy.

What triggers Petit mal status epilepticus (Absence status epilepticus, SEA)

This form of status may be the first manifestation of epilepsy, in which older people suddenly develop confusion. The status of absences may follow or progress into a "major" seizure.

Symptoms of Status Epilepticus Petit mal (Status Epilepticus Absences, SEA)

SEA is a type of generalized non-seizure status. The condition is known by obsolete terms: "confusion status", "peak-wave stupor". The existing disorders of consciousness are expressed in varying degrees - from a slight violation of concentration to disorientation and stupor. In some cases, the change in consciousness is so insignificant that it can only be detected by psychological testing. Approximately 50% of patients have eyelid trembling, hand twitching, and other convulsive manifestations. SEA is the cause of epileptic fugue in some cases.

There are two varieties - the status of typical and the status of atypical absences - according to a number of features, the main of which are EEG manifestations.

The status of "typical" absences is clinically characterized by:

• - sudden start and end
• - duration - up to several days (usually - less),
• - a trance-like state with no response to external stimuli,
• - a history of idiopathic forms of generalized epilepsy.

The status of "atypical" absences is clinically characterized by:

• - gradual onset and end, the presence of a prodromal period,
• - duration - up to several weeks,
• - a combination of atypical absences with tonic, myoclonic seizures,
• - a history of symptomatic or cryptogenic generalized epilepsy (more often - Lennox-Gastaut syndrome).

Diagnosis of status epilepticus Petit mal (status epilepticus of absences, SEA)

Based on the clinic and mandatory EEG study. The EEG always shows spike-wave complexes, more or less continuous.

The frequency of discharges and the morphology of the complexes can often differ from their classical pattern - 3 in a second.

The status of "typical" absences is characterized on the EEG by the presence of generalized bilateral-synchronous "peak-wave" complexes, regularly repeating at a frequency of 3 per second.

For the status of "atypical" absences on the EEG - the presence of long slow complexes of "peak-waves", irregularly repeating at a frequency of 1.5-2 Hz.

Treatment of Status Epilepticus Petit mal (Status Epilepticus Absences, SEA)

Intravenous injections of drugs of the benzodiazepine group - Diazepam at a dose of 10-20 mg, for children - 0.02 - 0.04 mg / kg / b.w., or rectal administration of 20-30 mg of Diazepam. Infants - 5 mg, children weighing more than 15 kg - 10-20 mg.

Recently, the intravenous administration of Valproate has also been used. Therapy of the status of absences should be carried out, if possible, with ongoing EEG monitoring.

Which doctors should you see if you have Status Epilepticus Petit mal (Absence Status Epilepticus, SEA)

Psychiatrist

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Before talking about creativity in epilepsy, it is necessary to give at least superficial information about the essence of the disease itself.

Epilepsy It manifests itself in various painful forms, which can be briefly summarized as follows: grand mal, petit raal, status epilepticus, symptomatic epilepsy, Kozhevnikovskaya epilepsy and other forms.

Grand mal or grand mal seizures

Major epilepsy - grand mal- usually has a preliminary aura - a harbinger before the onset of a seizure. To characterize this condition, it is most convenient to refer to the author, who himself suffered from this disease; such an author is Dostoevsky. In his work "The Idiot" there are the following words characterizing this pre-seizure state: "He thought, among other things, that in his epileptic state there was one degree, almost before the seizure (if only the seizure came to reality), when suddenly, among sadness, spiritual gloom, pressure, for moments, his brain seemed to ignite, and with an extraordinary impulse all his vital forces were strained at once. all his doubts, all his worries seemed to be appeased at once, resolved into some kind of calm, full of clear harmonious joy and hope, full of reason and final reason.But these moments, these glimpses were still only a premonition of that final second (never more than a second). from which the seizure itself began. This second was, of course, unbearable. Thinking about this moment later, already in a healthy state, he often said to himself that all these lightning bolts and glimpses of higher self-awareness and self-knowledge, and therefore "higher being, is nothing but a disease, a violation of the normal state, and if so, then this is not the highest being at all, but, on the contrary, should be ranked among the lowest ... And, however, he finally reached to the extremely paradoxical conclusion: “What does it matter if this is an illness,” he finally decided, “what does it matter if this tension is abnormal, if the result itself, if a minute of sensation, remembered and considered already in a healthy state, turns out to be highest degree of harmony, beauty, gives an unheard of and hitherto unexplained feeling of fullness, measure, reconciliation and anxious, prayerful merging with the highest synthesis of life?

Here are the words that belong Dostoevsky, who suffered from epilepsy, who knows these moments and appreciates them much better than the author, who did not experience this suffering.

Then there comes a complete loss of consciousness, and the person falls, as it were, into mental chaos. But immediately after losing consciousness, he falls, and he begins at first with tonic, and then clonic convulsions; then he bites his tongue, saliva comes out of his mouth, pupils dilate, which lose their reaction to light. Usually in life it is thought that seizures can last a very long time, and often patients or relatives say that the seizure lasted an hour or more, but this situation never happens: the seizure lasts no more than a few minutes. If the attack had lasted longer, the patient would have died from lack of breath, since the muscles of respiration also come into a convulsive state, like other muscles of the body. The attack gradually subsides, and the patient falls into a subsequent sleep; after sleep, the patient feels overwhelmed, and his consciousness gradually clears up.

Dostoevsky characterizes the post-seizure state in this way: “The first impression was very strong,” the prince repeated, “when I was being taken from Russia through various German cities, I just watched in silence and, I remember, didn’t even ask about anything. This was after a series of strong and painful attacks of my illness, and I always, if the illness intensified and the attacks were repeated several times in a row, fell into complete stupefaction, completely lost my memory, and although my mind worked, the logical flow of thought seemed to break off. More than two or three ideas in succession I could not connect immediately. So it seems to me. When the attacks subsided, I again became healthy and strong, just like now. I remember: the sadness in me was unbearable; I even wanted to cry; I was not surprised and worried: it had a terrible effect on me that this is someone else's; I understood that. The stranger was killing me. I completely awoke from this darkness, I remember, in the evening in Basel, at the entrance to Switzerland, and I was awakened by the cry of a donkey in the city market. The donkey struck me terribly and for some reason I unusually liked , and at the same time, suddenly everything seemed to clear up in my head.

This is how the consciousness of an epileptic suffering from grand mal - large convulsive seizures gradually clears up.

Petit mal or petit mal seizures

petite mal it manifests itself with completely different symptoms than grand mal, since with petit mal the patient never falls, and if he loses consciousness, then for a second or a fraction of it; therefore, if the patient did any work, then after the petit mal fit, he continues this work in the same way as if he had no illness. How fleeting the state of petit mal can be judged from the words of the same Dostoevsky. Stavrogin says to Tikhon:
"You know, I love you very much.
- And I you, - Tikhon answered in an undertone.
Stavrogin fell silent and suddenly fell back into his old pensiveness. This happened as if by seizures, for the third time, and he said to Tikhon “I love you” - also almost in a fit, at least unexpectedly for himself. It's been over a minute."

But even in this state, the patient exhibits special signs when his inner perception becomes more acute and when his consciousness in some unknown way comprehends the truth or guesses the meaning that was not revealed outside. Dostoevsky spoke in the words of Stavrogin:
“Why did you find out that I was angry,” he said quickly. Tikhon wanted to say something, but he suddenly interrupted him in inexplicable anxiety. “Why exactly did you assume that I should certainly have been angry? Yes, I was angry , you are right, but you are a rude cynic, you think humiliatingly about human nature ... There could not have been malice, if only another person, and not me ... However, the point is not about a person, but about me. eccentric and foolish..."
Stavrogin goes on to say:
"- Did you probably know that I came with something?"
Tikhon replied:
"- I... guessed by the face."

With petit mal, there is only freezing, but there are never convulsions: but the state of loss of consciousness can continue for a longer time, and during this period of time the patient does not fall, but performs a series of coordinated actions that are no different from the actions of a healthy person. Therefore, epileptics are often travelers. So, for example, when going home from work, an epileptic may go in the opposite direction from the house and wake up in a place where he did not intend to go; after initial surprise, he returns home; and, usually, when these conditions are repeated several times, the patient seeks the advice of a doctor. Often, in the presence of such a condition, unconscious actions are observed, due to which the patient comes into conflict with existing legal norms. Often such patients steal, set fire to, or perform any other destructive anti-social acts.

Status epilepticus and Kozhevnikov epilepsy

Status epilepticus (epileptic status) characterized by rapidly alternating seizures. This condition, not interrupted in time, is extremely dangerous for the patient. In this state of creativity, the patient usually does not have.

Symptomatic epilepsy is manifested by the same signs as grand mal, differing from it only in the causes of this disease.

Kozhevnikov epilepsy has pre-seizure signs, because it begins with a separate organ, for example, from the hand, and convulsions can then pass to the whole body.

Typical absences (minor epileptic seizures)
Although the phrase "petit mal" is translated as "minor illness", it is not at all synonymous with the term "minor epilepsy", since there are all kinds of mild seizures that are by no means small seizures. True petit mal seizures, or typical absences, are by definition associated with characteristic EEG impulses. Short-term partial seizures, which are caused by abnormal nerve cells localized in the same temporal lobe of the brain (see website), may seem similar from a clinical point of view, but because of the completely different methods of treatment and consequences, it is worth distinguishing between them.
Absence epilepsy occurs exclusively in children. A typical seizure lasts only a few seconds. It starts and ends abruptly. The child suddenly stops his activities, he has an absent expression, he turns a little pale and tilts his head slightly forward, and twitching of the eyelids is possible. The position of the limbs and torso is usually not relaxed, so the patient does not fall. After the attack is over, the child resumes his activity. Since the loss of consciousness is very short, parents may not notice the attack, and the child may not tell about it. One of the authors observed such a typical seizure in a self-service store. A girl, about 9 years old, was helping her mother unload a wire basket at the checkout counter. Suddenly, she froze, holding a package of honey in her hand halfway between the basket and the counter, her eyelids twitching, after which she continued to shift the purchase without any delay.
While major seizures can happen once a day (and this is considered very common), there can be many more minor seizures - from 10 to 50 per day, while only a few of them can be noticed. Fortunately, most children have such seizures much less.
Minor seizures are in many cases accompanied by myoclonic twitches, which are especially common shortly after awakening. They are short jerky contractions of the muscles, so short that it is not always possible to establish whether a violation of consciousness has occurred or not. In one family, as far as we have heard, this phenomenon has been called "flying saucer syndrome" due to the development of utensils as a result of the occurrence of such convulsions in one of the family members during breakfast.