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Psychiatric Comorbidity in Pediatric and Adult Epilepsy


Psychiatric Comorbidity in Pediatric and Adult Epilepsy John M. Pellock, MD Professor and Chairman, Division of Child Neurology Children s Hospital of Richmond at VCU – PowerPoint PPT presentation

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Title: Psychiatric Comorbidity in Pediatric and Adult Epilepsy

Psychiatric Comorbidity in Pediatric and Adult
  • John M. Pellock, MD
  • Professor and Chairman, Division of Child
  • Childrens Hospital of Richmond at VCU
  • Virginia Commonwealth University/Medical College
    of Virginia Hospitals
  • Richmond, Virginia

1) Appreciate the occurrence of neuropsychiatric
comorbidities associated with epilepsy 2) Underst
and how psychiatric comorbidities influence the
quality of life in persons with
epilepsy 3) Discuss appropriate treatment needs
of persons with epilepsy and depression
John M. Pellock, MD Professor and Chairman,
Division of Child Neurology Virginia Commonwealth
University/ Medical College of Virginia Childrens
Hospital of Richmond Richmond, Virginia Dr
Pellock has received grants/research support in
excess of 10,000 and is a paid consultant as
listed below. All grants, research support,
consultant fees and honoraria are paid to
Virginia Commonwealth University or the physician
practice plan (MCV Physicians). Dr Pellock has NO
equity, stock or any other ownership interest in
any of these companies.
Company Advisory Board Consultant Research
Catalyst YES YES  
GlaxoSmithKline   YES  
King Pharmaceuticals   YES  
KV Pharmaceuticals   YES  
Marinus Pharmaceuticals   YES YES
Neuropace   YES  
Lundbeck YES YES YES
Questcor YES YES YES
Sepracor YES YES  
Sunovion   YES  
UCB Pharmaceuticals YES YES YES
Upshur Smith YES YES YES
Valeant   YES  
Epilepsy - Definition
  • Seizure disturbances in the electrical activity
    of the brain
  • Epilepsy two or more unprovoked seizures
    separated by at least 24 hours
  • Epilepsy is a spectrum of disorders
  • Many different types of seizures
  • Many causes
  • Many syndromes and types of epilepsy

Institute of Medicine of the National Academies,
(No Transcript)
Seizure Type versus Epileptic Syndrome
  • A seizure is determined by the patients behavior
    and EEG pattern during the ictal event
  • An epileptic syndrome is defined by
  • seizure type(s)
  • natural history
  • EEG (ictal and interictal)
  • Response to treatment
  • Etiology

Juvenile absence epilepsy
Primary reading epilepsy
10 year-old
Benign childhood epilepsy with centrotemporal
Juvenile myoclonic epilepsy
Childhood absence epilepsy
Epilepsy with grand-mal seizures on awaking
Idiopathic or Cryptogenic
1 year-old
Childhood epilepsy with occipital paroxysms
1 month-old
Epilepsy with specific modes of activation
West syndrome
Temporal, frontal, parietal, or occipital lobe
epilepsies -symptomatic
Lennox Gastaut syndrome
Neonatal Seizures
Epilepsy with myoclono-astatic seizures
Chronic progressive epilepsia
partialis continua of childhood
Severe myoclonic epilepsy in infancy
Epilepsy with myoclonic absences
Symptomatic or Cryptogenic
Epilepsy with continuous spike- waves during
slow-wave sleep
Acquired epileptic aphasia
EME Early Myoclonic Encephalopathy EIEE Early
Infantile Epileptic Encephalopathy BNFC Benign
Neonatal Familial Convulsions BNC Benign
Neonatal Convulsions BMEI Benign Myoclonic
Epilepsy in Infancy
Epilepsia 199940531.
  • 2.2 million people in the United States and more
    than 65 million people worldwide have epilepsy
  • 150,000 new cases of epilepsy are diagnosed in
    the United States annually
  • 1 in 26 people in the United States will develop
    epilepsy at some point in their lifetime
  • Children and older adults are the fastest-growing
    segments of the population with new cases of
  • Epilepsy is the fourth most common neurological
    disorder in the United States after migraine,
    stroke, and Alzheimers disease

Institute of Medicine of the National Academies,
Psychogenic Nonepileptic Seizures
  • Terminology
  • Hysteria, pseudoseizures (pejorative)
  • PNES or non-epileptic seizures (preferred)
  • Psychological profile
  • Significant depression (gt 50)
  • Anxiety disorder (gt 50)
  • Posttraumatic stress disorder (22-100)
  • Includes sexual abuse
  • Rapid diagnosis associated with better outcome

Dickinson,Looper Epilepsia, 2012
Paroxysmal Nonepileptic Events in Children and
  • PNEs in 15.2 of those monitored
  • 2 months to 5 years 26 patients
  • Stereotypical movements, hypnic jerks,
    parasomnias, Sandifer (GER)
  • 5-12 years 61 patients
  • Conversion disorder (psychogenic seizures),
    inattention/daydreaming, stereotyped movements,
    hypnic jerks, paroxysmal movements (15 with
    concomitant epilepsy)
  • 12-18 years 48 patients
  • Conversion disorder (40/83 9 concomitant

Kotegal, Pediatics, 2002
Not All Seizures Are Epilepsy Also Applies to the
Military Rochelle Caplan, MD Psychogenic
Nonepileptic Seizures in US Veterans. Salinsky M,
Spencer D, Boudreau E, Ferguson F. Neurology
201177(10) 945950 OBJECTIVES Psychogenic
nonepileptic seizures (PNES) are frequently
encountered in epilepsy monitoring units (EMU)
and can result in significant long-term
disability. We reviewed our experience with
veterans undergoing seizure evaluation in the EMU
to determine the time delay to diagnosis of PNES,
the frequency of PNES, and cumulative
antiepileptic drug (AED) treatment. We compared
veterans with PNES to civilians with PNES studied
in the same EMU. METHODS We reviewed records of
all patients admitted to one Veterans Affairs
Medical Center (VAMC) EMU over a 10-year
interval. These patients included 203 veterans
and 726 civilians from the university affiliate.
The percentage of patients with PNES was
calculated for the veteran and civilian groups.
Fifty veterans with only PNES were identified.
Each veteran with PNES was matched to the next
civilian patient with PNES. The 2 groups were
compared for interval from onset of the habitual
spells to EMU diagnosis, cumulative AED
treatment, and other measures. RESULTS PNES were
identified in 25 of veterans and 26 of
civilians admitted to the EMU. The delay from
onset of spells to EMU diagnosis averaged 60.5
months for veterans and 12.5 months for civilians
(p lt 0.001). Cumulative AED treatment was 4 times
greater for veterans with PNES as compared to
civilians (p lt 0.01). Fifty-eight percent of
veterans with PNES were thought to have seizures
related to traumatic brain injury. CONCLUSIONS
The results indicate a substantial delay in the
diagnosis of PNES in veterans as compared to
civilians. The delay is associated with greater
cumulative AED treatment.
Epilepsy Currents, 2012
Epilepsy and Neurological Comorbidity
  • Approximately 30 of patients with epilepsy have
    significant neurological comorbidity
  • MR, CP, autism, prior stroke, major head trauma,
  • Conversely, epilepsy is more common in those with
    these neurological impairments or prior
    neurological insults
  • MR, CP, autism, prior stroke, major head trauma
  • The more severe the neurological comorbidity, the
    higher the frequency of epilepsy

National Profile of Childhood Epilepsy
  • 2007 survey 977 of 91,605 reported
  • Epilepsy/seizure prevalence higher in lower
    income families
  • Children with epilepsy/seizures
  • Depression (8 vs 2)
  • Anxiety (17 vs 3)
  • ADHD (23 vs 6)
  • Conduct problems (16 vs 3)
  • DD (51 vs 3)
  • ASD (16 VS 1)
  • Headache (14 vs 5)
  • Epilepsy/seizure group poorer education, social

Russ, Larson, Halfon Pediatrics, 2012
Psychiatric Comorbidities with Epilepsy
  • Frequent finding lifetime prevalence of
    depression and anxiety disorders 30-35
  • Associated with worse response to AEDs and
    surgery and worse medication tolerance
  • Affective disorders increase the completed
    suicide risk by 32-fold

Bateman, et al, Ep Currents, 2012
Prevalence of Psychiatric Disorders
In epilepsy (range) In the general population (range)
Depression 11-60 2.0-4.0
Anxiety 19-45 2.5-6.5
Psychosis 2-8 0.5-0.7
ADHD 25-30 2.0-10.0
Kanner, Epilepsia 200344(5)3-8.
Prevalence of Psychiatric and Behavioral
  • Population-based, retrospective study
  • Incident cases of epilepsy (1980-1995)
  • Rochester, MN
  • Prevalence
  • DSM-IV diagnosis 51 (69/104)
  • Without mental retardation and/or pervasive
    developmental disorder 40.4 (44/109)
  • Children with newly diagnosed epilepsy frequently
    exhibit comorbid psychiatric or behavioral

Prevalence ()
ADHD Mood Adjustment
Disorder Disorder
Hedderick E, et al. Ann Neurol. 200354(suppl
7)S115. Abstract E12.
ADHD and Childhood Epilepsy
  • ADHD in children
  • Up to 87 have gt1 additional psychiatric disorder
  • ADHD and epilepsy
  • Predominately inattention type
  • Differential diagnosis
  • Medical effect
  • Nocturnal seizures
  • Absence or complex partial seizures
  • Comparison with ADHD seen in psychiatric clinics
  • Children with epilepsy more inattentive
  • Equal malefemale ratio

Dunn D, et al. Dev Med Child Neurol.
20034550-54. Semrud-Clikeman M, Wical B.
Epilepsia. 199940211-215.
Epilepsy and Attention Deficit Hyperactivity
Disorder (ADHD)
  • Prevalence
  • ADHD 5
  • Epilepsy 1
  • ADHD in epilepsy 20
  • ADHD in patients with epilepsy treated with
    AED 30

Impulsive-Aggressive Spectrum
Bipolar Spectrum
Tourette /OCD
Cluster B Personality Disorders
Developmental Disorders
Borderline Personality Disorders
Autism Spectrum Disorders
Sexual Compulsions
Impulse Control Disorders
SubstanceUse Disorder
Salpekar, 2005
Social Outcome - Results
CAE patients () JRA patients () Odds ratio (CI)
No high school grad 36 14 3.7 (1.3-10.4)
Special classes 16 3 5.7 (1.1-40.5)
Repeated a grade before diagnosis 20 3 7.6 (1.4-52.8)
Ever considered a behavior problem 41 10 6.4 (2.2-19.9)
Unplanned pregnancy 34 3 19.3 (2.3-426.1)
Psychiatric or emotional problems 54 31 2.6 (1.1-5.9)
Unskilled laborer 53 16 5.9 (1.6-24.0)
Manager or professional 0 29 undefined
Not employed in area of training 50 14 5.7 (1.2-33.9)
Wirrell et al, 1997.
Juvenile Myoclonic Epilepsy
  • 1st described in 1867
  • Triad
  • Myoclonic, absence, tonic clonic seizures
  • Normal development
  • 3.5 - 6 Hz multispike and wave
  • Onset pre- to post-puberty (12-18 years)
  • F M
  • 2 - 5 of all patients with epilepsy

Ethosuximide, Valproic Acid, and Lamotrigine in
Childhood Absence Epilepsy
Glauser TA, et al. NEJM 3629, March 4, 2010
  • Psychiatric Comorbidities and Epilepsy
  • Is It the Old Story of the Chicken and the Egg?

Kanner, Ann Neurol, 2012
Epilepsy Curr. 2012 Sep-Oct 12(5) 201202.
Hospitalization for Psychiatric Disorders
Before and After Onset of Unprovoked
Seizures/Epilepsy. Adelöw C, Andersson T, Ahlbom
A, Tomson T. Neurology 201278396401
PubMed OBJECTIVE To study hospitalization for
psychiatric disorders before and after onset of
unprovoked epileptic seizures/epilepsy. METHOD
In this population-based case-control study, the
cases were 1,885 persons from Stockholm with new
onset of unprovoked seizures from September 1,
2000, through August 31, 2008, identified in the
Stockholm Epilepsy Register. Controls, in total
15,080, were randomly selected from the register
of the Stockholm County population. Odds ratios
(ORs) were calculated to assess the risk of
developing unprovoked epileptic seizures before
and after hospitalization for a psychiatric
diagnosis defined as a psychiatric hospital
discharge diagnosis using International
Classification of Disease codes from the Swedish
Hospital Discharge Registry. RESULTS The
age-adjusted OR (95 confidence interval) for
unprovoked seizures was 2.5 (1.73.7) after a
hospital discharge diagnosis for depression, 2.7
(1.45.3) for bipolar disorder, 2.3 (1.53.5) for
psychosis, 2.7 (1.64.8) for anxiety disorders,
and 2.6 (1.74.1) for suicide attempts. The risk
of developing unprovoked epileptic seizures was
highest less than 2 years before and up to 2
years after a first psychiatric diagnosis.
CONCLUSION The increased rate of psychiatric
comorbidity predating and succeeding seizure
onset indicates a bidirectional relationship and
common underlying mechanisms for psychiatric
disorders and epilepsy.
Epilepsy, Suicidality, and Psychiatric Disorders
A Bidirectional Association Dale C. Hesdorffer,
PhD,1 Lianna Ishihara, PhD,2 Lakshmi Mynepalli,
MSc,3, David J. Webb, MSc,4 John Weil, MD,5 and
W. Allen Hauser, MD1,6 Objective A study was
undertaken to determine whether psychiatric
disorders associated with suicide are more common
in incident epilepsy than in matched controls
without epilepsy, before and after epilepsy
diagnosis. Methods A matched, longitudinal
cohort study was conducted in the UK General
Practice Research Database. A total of 3,773
cases diagnosed with epilepsy between the ages of
10 and 60 years were compared to 14,025 controls
matched by year of birth, sex, general practice,
and years of medical records before the index
date. We examined first diagnosis of psychosis,
depression, anxiety, and suicidality in each of
the 3 years before and after the index date and
annual prevalence of suicide. Referent diagnoses
were eczema and acute surgery. The incidence rate
ratio (IRR) was calculated for each year in the
study period the prevalence ratio (PR) was
calculated for suicidality. Results The IRR of
psychosis, depression, and anxiety was
significantly increased for all years before
epilepsy diagnosis (IRR, 1.515.7) and after
diagnosis (IRR, 2.210.9) and for suicidality
before epilepsy diagnosis (IRR, 3.14.5) and 1
year after diagnosis (IRR, 5.3). The PR was
increased for suicide attempt before epilepsy
onset (PR, 2.65.2) and after onset (PR,
2.45.6). Eczema and acute surgery were both
associated with epilepsy in the first and third
year after diagnosis. Interpretation Epilepsy
is associated with an increased onset of
psychiatric disorders and suicide before and
after epilepsy diagnosis. These relations suggest
common underlying pathophysiological mechanisms
that both lower seizure threshold and increase
risk for psychiatric disorders and suicide. ANN
NEUROL 201272184191
Epilepsy and Psychiatric DisordersA
Bidirectional Relation
  • With epilepsy, significantly higher risk for
  • Psychosis
  • Depression
  • Anxiety disorders
  • Suicidality
  • With psychiatric disorders, significantly higher
    risk for developing epilepsy
  • Psychiatric disorders not simply a reaction to
    psychosocial obstacles!

Hesdorffer, Ann Neurol, 2012
Psychiatric Disorders and EpilepsyBidirectional
Relation Neurobiological/Pathogenesis
  • Neurotransmitters serotonin, norephinephrine,
    dopamine, glutamate, GABA
  • Endocrine hyperactive hypothalamic-pituitary-adre
    nal axis producing high cortisol
  • Inflammatory mechanisms

Kanner, Annals of Neurology, 2012
(No Transcript)
Psychiatric Comorbidities with Epilepsy
  • Persons with epilepsy need screening throughout
    lifetime, particularly with
  • Medication changes
  • Life changes
  • Pregnancy/postpartum
  • A barrier to successful epilepsy management
  • A public health challenge

Bateman, et al, Ep Currents, 2012
Epilepsy, AEDs and Suicidality(FDA Alert
January 2008)
  • AEDS Suicidal thoughts/behavior risk 0.43 vs.
    0.22 (pbo)
  • - Estimated 2.1/1000 more patients on AEDs vs.
  • - Not specific to single drug or class
  • Recommendations Class warning.
  • - Balance risk for suicidality with clinical
    need for AED
  • - Be aware of possibility of emergence or
    worsening of depression, suicidality, or unusual
    changes in behavior
  • - Inform patients, their families, and
    caregivers of the potential. Symptoms such as
    anxiety, agitation, hostility, mania and
    hypomania may be precursors to emerging
  • Suicide rate increased in epilepsy
  • Suicide rate increased in adolescents

Antidepressants Suicidality in Adolescents
  • Depression . the common cold of psychiatry
  • Prevalence in children 2.4 adolescents 8.3
  • Adolescent suicide increased 4x since 1950
  • Therapy medication and behavioral/cognitive/psyc
  • FDA 10/15/2004 Black Box Warning
    Antidepressants increase suicidal thinking and
    behavior (suicidality) in children
  • Must balance risk/benefit and closely monitor
  • Subsequent decrease in adolescent SSRI Rx by
    22 suicide increased 14

Gibbons et al (2007) AJ Psych
Twenty Leading Causes of Death Highlighting
Suicide Among Persons Ages 10 Years and Older,
United States, 2006
  • Among 15- to 24-year olds, suicide accounts for
    12 of all deaths annually
  • Second leading cause of death among 25-34 year
    olds third leading cause among 15- to

In 2006, suicide was ranked as the 11th leading
cause of death among persons ages 10 years and
older, accounting for 33,289 deaths.
Epilepsy and Suicidality
  • Encompasses
  • Completed suicide
  • Suicide attempt
  • Suicidal ideation
  • More frequent in epilepsy vs general population
  • Mean 11.5 deaths in chronic epilepsy patients
  • 3x suicide causing death
  • Bidirectional relationship (suicidality 5x risk
  • Kanner, 2009

AEDs and SuicidalityFDA Alert
  • Questions Remain
  • Assessment based on spontaneous reports
  • Risk associated with all AEDs, but significant
  • with only TPM and LTG
  • -Adding 3 additional LTG studies lost
  • -VPA and CBZ demonstrated small protective
  • Most epilepsy trials adjunctive therapy
  • Geographic differences
  • Consider results with caution

Epilepsy and Suicidality
  • History of attempt strongest predictor
  • 34.8 attempts, later successful
  • 46.2 successful with prior attempts
  • Comorbid psychiatric disorders increased risk 14x
  • Mood 32x
  • Anxiety 12x
  • Risk greatest 1st 6 months following diagnosis of
  • Kanner, 2009

Epilepsy and SuicidalityRecommendations
  • Identify psychiatric disorders
  • Neurologists not expected to manage
  • Most frequent associated risks
  • Current or past history of mood/anxiety disorder
  • Family psyche history of mood disorder
  • suicidal behavior
  • Past suicide attempts
  • Document Assessment
  • ?Format
  • Referral

Kanner, 2009 Willmore, Pellock, 2009
Medication Effects on Seizures
  • Increase in seizures with antidepressants
    amoxapine, maprotiline, clomipramine, bupropion
  • Protective effect for unprovoked seizure SSRIs
    (unless toxic)
  • Fluoxetine, citalopram protective effect
    (animal models)
  • High risk de novo seizures 2nd generation
    anti-psychotics clozapine, olanzapine,
  • Stimulants no seizure increase, unless toxic

Kanner, Annals of Neurology, 2012
Long-Term Mortality in Childhood-Onset
Epilepsy Matti Sillanpää, M.D., Ph.D., and Shlomo
Shinnar, M.D., Ph.D. From the Departments of
Pediatric Neurology and Public Health, University
of Turku and Turku University Hospital both in
Turku, Finland (M.S.) and the Departments of
Neurology, Pediatrics, and Epidemiology and
Population Health and the Comprehensive Epilepsy
Management Center, Montefiore Medical Center,
Albert Einstein College of Medicine, Bronx, NY
(S.S.). ABSTR ACT Background There are few
studies on long-term mortality in prospectively
followed, well-characterized cohorts of children
with epilepsy. We report on long-term mortality
in a Finnish cohort of subjects with a diagnosis
of epilepsy in childhood. Methods We assessed
seizure outcomes and mortality in a
population-based cohort of 245 children with a
diagnosis of epilepsy in 1964 this cohort was
prospectively followed for 40 years. Rates of
sudden, unexplained death were estimated. The
very high autopsy rate in the cohort allowed for
a specific diagnosis in almost all
subjects. Results Sixty subjects died (24) this
rate is three times as high as the expected age-
and sex-adjusted mortality in the general
population. The subjects who died included 51 of
107 subjects (48) who were not in 5-year
terminal remission (i.e., 5 years seizure-free
at the time of death or last follow-up). A remote
symptomatic cause of epilepsy (i.e., a major
neurologic impairment or insult) was also
associated with an increased risk of death as
compared with an idiopathic or cryptogenic cause
(37 vs.12, Plt0.001). Of the 60 deaths, 33 (55)
were related to epilepsy, including sudden,
unexplained death in 18 subjects (30), definite
or probable seizure in 9 (15), and accidental
drowning in 6 (10). The deaths that were not
related to epilepsy occurred primarily in
subjects with remote symptomatic epilepsy. The
cumulative risk of sudden, unexplained death was
7 at 40 years overall and 12 in an analysis
that was limited to subjects who were not in
long-term remission and not receiving medication.
Among subjects with idiopathic or cryptogenic
epilepsy, there were no sudden, unexplained
deaths in subjects younger than 14 years of age.
Conclusions Childhood-onset epilepsy was
associated with a substantial risk of
epilepsy-related death, including sudden,
unexplained death. The risk was especially high
among children who were not in remission. (Funded
by the Finnish Epilepsy Research Foundation.)
N Engl J Med, 2010 Dec 23363(26) 2522-9
Long-Term Mortality in Childhood-Onset Epilepsy
  • Sillampaa M and Shinnar S. N Engl J Med

Long-Term Mortality in Childhood-Onset Epilepsy
Sillampaa M and Shinnar S. N Engl J Med
Epilepsy Quality of Life
  • Patient's concerns
  • Memory
  • Fear of seizures
  • Im depressed
  • Just dont feel right
  • Mortality
  • Parents concerns
  • Behavior
  • Cognition

Epilepsy Quality of Life
  • Array of challenges to daily living
  • Vary with severity of epilepsy
  • Change with age
  • Negative effects can be severe and involve family
  • Social relationships
  • Academic achievement
  • Employment
  • Housing
  • Independent functioning
  • Family support community services critical

IOM, 2012
Epilepsy Cross-Cutting Themes
  • A common and complex neurological disorder
  • Often affects quality of life
  • Whole-patient perspective needed
  • Effective treatments available but access falls
  • Data needed to improve epilepsy knowledge and
    care and to inform policy
  • Strengthen health professionals education
  • Bolster education efforts for people with
    epilepsy and their families
  • Eliminate stigma

Institute of Medicine of the National Academies,
Improve Quality of Life
  • Living with epilepsy is about much more than
    seizures. For people with epilepsy, the disorder
    is often defined in practical terms, such as
    challenges in school, uncertainties about social
    and employment situations, limitations on driving
    a car, and questions about independent living.
    At the same time, they are faced with health care
    and community services that are often fragmented,
    uncoordinated, and difficult to obtain.

IOM, 2012
Epilepsy and Comorbid Behavioral Disorders
  • Comorbid behavioral disorders are common in both
    children and adults with epilepsy
  • Comprehensive management of epilepsy is more than
    just controlling seizures
  • Clinicians caring for patients with epilepsy must
    be sensitive to these common and often treatable
    comorbid conditions

Pellock, JCN, 2002
(No Transcript)