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PSYCHIATRIC ASPECTS OF EPILEPSY

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PSYCHIATRIC ASPECTS OF EPILEPSY Dr John Mellers Department of Neuropsychiatry Maudsley Hospital This system of classification was first proposed by Fenton (1981) NB ... – PowerPoint PPT presentation

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Title: PSYCHIATRIC ASPECTS OF EPILEPSY


1
PSYCHIATRIC ASPECTS OF EPILEPSY
  • Dr John Mellers
  • Department of Neuropsychiatry
  • Maudsley Hospital

2
PSYCHIATRIC DISORDER IN EPILEPSY
  • Background
  • Prevalence, aetiology
  • Psychiatric presentations in epilepsy -
  • Related to underlying cause of the epilepsy
  • Related to seizures
  • Pre-ictal
  • Ictal
  • Post-ictal
  • Interictal disorders
  • Non-epileptic (dissociative) seizures
  • Management

3
Epilepsy and Psychiatric Disorder overall
perspective
  • Most patients with epilepsy do not suffer from
    psychiatric problems
  • Patients with severe epilepsy are at increased
    risk of psychiatric problems

Relevance ?
  • Epilepsy and comorbid psychiatric disorder
  • Differential diagnosis epilepsy or psychiatric
    disorder ?
  • Research understanding psychiatric disorder

4
  • Overall Prevalence of Psychiatric Morbidity
  • Population survey
  • Children gt 3-fold increased psychiatric
    morbidity in epilepsy (GrahamRutter, 1968)
  • GP- surveys-
  • 30 - 50 significant psychiatric morbidity
  • Lower prevalence in seizure-free patients
    (Jacoby, 1996 ODonoghue, 1999)
  • Prevalence in specialist settings-
  • 30 current, plus 30 past, DSM diagnoses in
    Lobectomy series (Manchanda, 1996)
  • Compared to other patient groups-
  • Disability Claimants- 35 epilepsy / 30
    non-neurological disability (Steffansson, 1998)
  • Asthma- no difference with epilepsy, both
    patient groups gt controls (Ettinger, 2004)

5
Overall risk factors for psychiatric disorder in
epilepsy
  • Intractable epilepsy
  • associated brain damage
  • temporal lobe epilepsy
  • early onset epilepsy
  • perceived seizure severity
  • social handicap
  • adverse family background

6
Models of Aetiology
  • 1. Same underlying pathology responsible for
    epilepsy and psychiatric disorder.
  • 2. Seizures produce pathogenic electrical /
    biochemical changes.
  • 3. Effects of treatment.
  • 4. Psychosocial correlates of epilepsy
    (disability/ stigma / family background).

7
Classification of Psychiatric Disorders
Associated with Epilepsy
  • 1. Disorders clearly attributable to the brain
    disorder causing the epilepsy
  • Learning disability
  • Symptomatic epileptic syndromes (eg Wests,
    Landau-Kleffner )
  • Chronic organic brain syndromes
  • Focal brain disease
  • 2. Disorders strictly related in time to seizure
    occurrence
  • Preictal - prodrome
  • Ictal - psychiatric manifestations of seizure
    activity (aura, automatisms, nc status, FLE)
  • Postictal - psychiatric abnormalities occurring
    in the immediate postictal period
  • 3. Interictal psychiatric disorders
  • Childhood disorders
  • Neuroses
  • Psychoses
  • Personality disorder
  • Dementia

8
Classification of Psychiatric Disorders
Associated with Epilepsy
  • 1. Disorders clearly attributable to the brain
    disorder causing the epilepsy
  • Learning disability
  • Symptomatic epileptic syndromes (eg Wests,
    Landau-Kleffner )
  • Chronic organic brain syndromes
  • Focal brain disease
  • 2. Disorders strictly related in time to seizure
    occurrence
  • Preictal prodromata
  • Ictal - psychiatric manifestations of seizure
    activity (aura, automatisms, nc status)
  • Postictal - psychiatric abnormalities occurring
    in the immediate postictal period
  • 3. Interictal psychiatric disorders
  • Childhood disorders
  • Neuroses
  • Psychoses
  • Personality disorder
  • Dementia

9
Disorders clearly attributable to the brain
disorder causing the epilepsy
  • Learning disability
  • Symptomatic epileptic syndromes
  • Wests syndrome
  • Lennox Gastaut
  • Acquired Epileptic Aphasia (Landau-Kleffner)
  • Progressive Myoclonic Epilepsies
  • Chronic organic brain syndromes (eg dementia)
  • Focal brain disease (eg sol causing epilepsy)

10
Classification of Psychiatric Disorders
Associated with Epilepsy
  • 1. Disorders clearly attributable to the brain
    disorder causing the epilepsy
  • Learning disability
  • Symptomatic epileptic syndromes (eg Wests,
    Landau-Kleffner )
  • Chronic organic brain syndromes
  • Focal brain disease
  • 2. Disorders strictly related in time to seizure
    occurrence
  • Preictal prodromata
  • Ictal - psychiatric manifestations of seizure
    activity (aura, automatisms, nc status, FLE)
  • Postictal - psychiatric abnormalities occurring
    in the immediate postictal period
  • 3. Interictal psychiatric disorders
  • Neuroses
  • Psychoses
  • Personality disorder
  • Dementia

11
Disorders related in time to seizure
occurrenceA. Pre-ictal
  • Prodrome
  • Non-specific, unwell, dysphoria
  • Hours - days
  • 30
  • Focal gt Generalised epilepsy
  • Unknown pathophysiology

12
Classification of Psychiatric Disorders
Associated with Epilepsy
  • 1. Disorders clearly attributable to the brain
    disorder causing the epilepsy
  • Learning disability
  • Symptomatic (generalised ) epileptic syndromes
    (eg Wests, Landau-Kleffner )
  • Chronic organic brain syndromes
  • Focal brain disease
  • 2. Disorders strictly related in time to seizure
    occurrence
  • Preictal prodromata
  • Ictal - psychiatric manifestations of seizure
    activity (aura, automatisms, nc status, FLE)
  • Postictal - psychiatric abnormalities occurring
    in the immediate postictal period
  • 3. Interictal psychiatric disorders
  • Childhood disorders
  • Personality disorder / behaviour disorder
  • Neuroses
  • Psychoses
  • Dementia

13
Features that distinguish epileptic seizures from
symptoms in functional psychiatric disorder
  • Psychic / experiential symptoms in epilepsy are
    usually-
  • Highly stereotyped
  • Brief in duration
  • Accompanied by other epileptic semiology
  • Impaired consciousness
  • Motor automatisms

14
Disorders related in time to seizure
occurrenceB. Ictal
  • Experiential aura
  • Affect (eg ictal fear)
  • Dymnesic (eg deja vu, jamais vu, panoramic
    memory)
  • Perceptual (illusions / hallucinations /
    elementary complex)
  • Aberrations of subjective thinking (eg forced
    thinking)
  • Frontal seizures
  • Bizarre posturing, hypermotor seizures
  • Automatisms
  • Semi-purposeful activity with impaired
    consciousness
  • May be prolonged (20 minutes) in TLE
  • Non-convulsive status
  • Absence status eyelid myoclonus in 50, 3Hz EEG
  • Complex Partial status fluctuations, motor
    features
  • Simple Partial Status Aura continua rare

15
Features that distinguish epileptic seizures from
symptoms in functional psychiatric disorder
  • Psychic / experiential symptoms in epilepsy are
    usually-
  • Highly stereotyped
  • Brief in duration
  • Accompanied by other epileptic semiology
  • Impaired consciousness
  • Motor automatisms

16
Classification of Psychiatric Disorders
Associated with Epilepsy
  • 1. Disorders clearly attributable to the brain
    disorder causing the epilepsy
  • Learning disability
  • Symptomatic (generalised ) epileptic syndromes
    (eg Wests, Landau-Kleffner )
  • Chronic organic brain syndromes
  • Focal brain disease
  • 2. Disorders strictly related in time to seizure
    occurrence
  • Preictal prodromata
  • Ictal - psychiatric manifestations of seizure
    activity (aura, automatisms, nc status, FLE)
  • Postictal - psychiatric abnormalities occurring
    in the immediate postictal period
  • 3. Interictal psychiatric disorders
  • Childhood disorders
  • Personality disorder / behaviour disorder
  • Neuroses
  • Psychoses
  • Dementia

17
Disorders related in time to seizure
occurrenceC. Post - ictal
  • Post-ictal delirium
  • May be prolonged (elderly, underlying brain
    disease)
  • Post-ictal Psychosis
  • Psychiatric features
  • Brief, dramatic, self-limiting psychosis (lt 1 day
    18 days)
  • Follows seizure exacerbation
  • lucid interval (mean 1 day)
  • pleomorphic phenomenology
  • Marked Agitation
  • Rapidly changing affect / psychotic symptoms
  • May have degree of intermittent delirium
  • Prevalence / neurological features
  • 6-7 telemetry series
  • Focal epilepsy gt Generalised epilepsy
  • Associated with bilateral pathology
  • Up to 20 develop inter-ictal psychosis

18
Classification of Psychiatric Disorders
Associated with Epilepsy
  • 1. Disorders clearly attributable to the brain
    disorder causing the epilepsy
  • Learning disability
  • Symptomatic (generalised ) epileptic syndromes
    (eg Wests, Landau-Kleffner )
  • Chronic organic brain syndromes
  • Focal brain disease
  • 2. Disorders strictly related in time to seizure
    occurrence
  • Preictal prodromata
  • Ictal - psychiatric manifestations of seizure
    activity (aura, automatisms, nc status, FLE)
  • Postictal - psychiatric abnormalities occurring
    in the immediate postictal period
  • 3. Interictal psychiatric disorders
  • Neuroses
  • Psychoses
  • Personality disorder
  • Dementia

19
Interictal psychiatric disorders
  • Depression
  • Common
  • Up to 50 atypical (Mendez, 1986)
  • Interictal Dysphoric Disorder (Blumer, 1995
    Kanner, 2002)
  • Up to 70 of depressed patients with epilepsy
  • Chronic, recurrent episodes of-
  • Irritability, dysphoria, anxiety, brief episodes
    normality and hypomania
  • Somatic symptoms anergia, atypical pain,
    insomnia.
  • Risk Factors
  • Severity of epilepsy (seizure frequency) (Jacoby,
    1996)
  • Family history of affective disorder
  • Controversial relationship to laterality and type
    of epilepsy
  • Low folate
  • AEDs eg levetiracetam, tiagabine, topiramate
  • 3 - 5 x suicide rate
  • Major risk factor is psychiatric history.
  • also early onset (lt18), and infrequent neurology
    follow-up) (Nilsson, 2002)

20
Interictal psychiatric disorders
  • Anxiety disorder
  • Similar prevalence to depression
  • Similar risk factors
  • seizure Phobia
  • fear of having attack in public
  • Agoraphobic avoidance
  • May be more disabling than seizures

21
Interictal psychiatric disorders
  • Non-Affective Psychosis
  • 2-3-fold increased risk
  • characteristics of the psychosis-
  • onset 10 - 15 years after onset of epilepsy
  • PSE profiles very similar to that found in
    schizophrenia
  • -ve family history of schizophrenia
  • lack of premorbid personality disturbance
  • ?possible excess of women and left handedness
  • characteristics of the epilepsy-
  • Severe epilepsy
  • Bilateral cerebral pathology
  • ?TLE / ?? left sided focus
  • gangliogliomas (of development origin) more
    common
  • variable relationship between seizures and
    psychosis
  • AEDs eg. ethosuxamide, vigabatrin, levetiracetam

22
Interictal psychiatric disorders
  • Personality in Epilepsy
  • controversial / discredited temporal lobe
    Geschwind syndrome-
  • hyposexuality
  • hypergraphia
  • Religiosity
  • Bear Fedio (1977)
  • hyperemotionality (R)
  • Ruminative, humourless, philosophically inclined,
    (L)
  • Non-specific marker of psychiatric morbidity
  • Some support for hypergraphia in TLE (Sachdev,
    81 Hermann, 83)
  • ? Overlap with autistic spectrum disorder
  • Intractable TLE 18-22 DSM Personality
    Disorder (dependent / avoidant)
  • Juvenile Myoclonic Epilepsy association with
    Emotional instability traits ?

23
Interictal psychiatric disorders
  • Epilepsy and Cognitive impairment
  • Most people with epilepsy have IQ in normal range
  • TLE memory impairments
  • Dominant hemisphere verbal memory
  • Non-dominant non-verbal memory
  • small number of patients have slowly progressive
    dementia
  • status epilepticus
  • repeated head injury
  • cumulative effect of seizures
  • underlying degenerative brain disorder
  • Anti-epileptic medication

24
Epilepsy and Violence
  • Prevalence of epilepsy in prisons is 4 times that
    in the general population
  • but, crimes committed by epileptics are not more
    violent
  • social factors may predispose towards epilepsy
    and crime
  • brain disorder causing epilepsy may predispose to
    criminality
  • psychosocial impact of epilepsy may predispose
    towards criminality
  • criminal lifestyle may predispose towards
    epilepsy
  • Ictal aggression is very rare
  • Usually resistive - provoked by attempts to
    contain patient during automatism

25
DISSOCIATIVE SEIZURES
  • OTHER TERMS
  • (Psychogenic) non-epileptic seizures,
    pseudoseizures, NEAD, hysterical seizures,
    functional seizures
  • PREVALENCE
  • 20 of patients with medically intractable
    seizures
  • 15 also have epilepsy
  • DEMOGRAPHIC CHARACTERISTICS
  • 75 female
  • age onset
  • mean early 20s range 4 - 71 (one third
    between 10 and 20)
  • duration at diagnosis
  • mean 3 years range 1 - 20 years

26
DISTINGUISHING CLINICAL FEATURES
  • MOST HELPFUL
  • atypical sequence
  • long duration (50 gt 2 mins)
  • Specific Features-
  • Conscious but unresponsive...
  • Eyes closed
  • Violent movements
  • Prolonged, motionless unresponsive
  • NB confusing features( 10)
  • injuries incontinence
  • pseudostatus
  • arise in sleep
  • past / family neurological Hx
  • ON EXAMINATION
  • out-of-phase clonic movement
  • eyes closed
  • avoidance / resistance
  • Henry Woodruff sign
  • Prof Binnie mirror sign

27
DIAGNOSIS - EXCLUDING EPILEPSY
  • 1. Clinical suspicion
  • 2. Inter-ictal EEG
  • 3. Telemetry
  • 4. Serum prolactin

28
  • Principles of psychiatric management
  • Consider neurological, psychological and social
    factors
  • Optimise epilepsy treatment
  • Antidepressants and neuroleptics may worsen
    seizures
  • Usually NOT clinically relevant apart from
    clozapine
  • Drugs of choice in epilepsy are said to be-
  • neuroleptics risperidone, sulpiride, olanzapine
  • antidepressants SSRIs, Venlafaxine, MAOIs
  • Look up interactions before prescribing

29
PSYCHIATRIC DISORDER IN EPILEPSY
  • Background
  • Prevalence, aetiology
  • Psychiatric presentations in epilepsy -
  • Related to underlying cause of the epilepsy
  • Related to seizures
  • Pre-ictal
  • Ictal
  • Post-ictal
  • Interictal disorders
  • Non-epileptic (dissociative) seizures
  • Management
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