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PSYCHIATRIC ASPECTS OF EPILEPSY

PSYCHIATRIC ASPECTS OF EPILEPSY. Dr John Mellers Department of Neuropsychiatry Maudsley Hospital. PSYCHIATRIC DISORDER IN EPILEPSY. Background Prevalence, aetiology Psychiatric presentations in epilepsy :- Related to underlying cause of the epilepsy Related to seizures Pre-ictal

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PSYCHIATRIC ASPECTS OF EPILEPSY

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  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 • Inter–ictal 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 : > 3-fold increased psychiatric morbidity in epilepsy (Graham&Rutter, 1968) • GP- surveys:- • 30 - 50% significant psychiatric morbidity • Lower prevalence in seizure-free patients (Jacoby, 1996; O’Donoghue, 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 > 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 • West’s 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 > 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 • Preictalprodromata • 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 • Preictalprodromata • 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 (< 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 > 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 (<18), 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 20’s ; range : 4 - 71 (one third between 10 and 20) • duration at diagnosis • mean : 3 years ; range : 1 - 20 years

  26. MOST HELPFUL atypical sequence long duration (50 % > 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” DISTINGUISHING CLINICAL FEATURES

  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, MAOI’s … • 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 • Inter–ictal disorders Non-epileptic (dissociative) seizures Management

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