neuropsychiatry

1. NEUROPSYCHIATRIC
ASPECTS OF EPILEPSY
 Presented by : Dr Swati ( junior resident)
 Coordinated by :Dr Sneha( senior resident)
 Faculty Incharge : Dr Dinesh Kataria( HOD)

2. CONTENTS:
 Definitions
 Earlier classification
 Latest classification of ILAE 2017
 Prevalence
 Etiology
 Investigations
 importance of neuropsychiatric aspect of epilepsy
 Different Neuropsychiatric aspects of epilepsy
 Management

3. Seizure is defined as:
 Intermittent, stereotyped disturbance of consciousness,
behaviour , emotion, motor function or sensation
 Mechanism-abnormal cortical discharge
 Diagnosis depends primarily on clinical judgement (1)
 Epileptic seizures are sudden, involuntary behavioral
events associated with excessive or hyper
synchronous electrical discharges in the brain (2)
1.LISHMAN’S 4th EDITION
2.CTP

4. EPILEPSY:
 disorder of the brain characterized by an predisposition to
generate epileptic seizures, and by neurobiologic, cognitive,
psychological, and social consequences of this condition (Wiley
Periodicals, Inc © 2014 International LeagueAgainst Epilepsy)
 recurrent epileptic seizures (unless they arise in the context of
a reversible toxic or metabolic state) (1)
 sign a result of abnormal electrical activity in the CNS
 It’s the recurrent tendency to seize, and status epilepticus is
prolonged or repetitive seizures without intervening recovery
(2)
1.LISHMAN’S 4th EDITION
2.CTP

5.  The task force proposed that epilepsy be considered to be a
disease of the brain defined by any of the following
conditions: (1)
 (1) At least two unprovoked (or reflex) seizures occurring >24 h
apart
 (2) one unprovoked (or reflex) seizure and a probability of
further seizures similar to the general recurrence risk (at least
60%) after two unprovoked seizures, occurring over the next
10 years
 (3) diagnosis of an epilepsy syndrome
One seizure does not signify epilepsy (up to 10% of people
worldwide have one seizure during their lifetime) (2)
(1) ILAE official report: a practical clinical definition of epilepsy. Fisher RS, et al. Epilepsia. 2014
(2) Megiddo I, Colson A, Chisholm D, DuaT, NandiA, and Laxminarayan R (2016). Health and economic
benefits of public financing of epilepsy treatment in India:An agent-based simulation model. Epilepsia
Official Journal of the International LeagueAgainst Epilepsy doi: 10.1111/epi.13294

6. CLASSIFICATION OF EPILEPSY
(Commission on Classification and Terminology of the
International League Against Epilepsy 1981, 1989)
Classifying seizures based on
1. Semiology
clinical signs and symptoms )
2. Epileptic syndromes
Its derived from the classification of seizures

7. INTERNATIONAL CLASSIFICATION OF EPILEPTIC SEIZURES
(I) PARTIAL SEIZURES (II)GENERALISED SEIZURES
 A Simple partial seizures
 B Complex partial seizures
 C Partial seizures evolving
to secondarily generalised
seizures
 (III) UNCLASSSIFIED
EPILEPTIC SEIZURES
 A1 Absence seizures
 A2 Atypical absence
seizures
 B Myoclonic seizures
 C Clonic seizures
 DTonic seizures
 ETonic–clonic seizures
 F Atonic seizures
(Adapted from Commission on Classification andTerminology of the
International LeagueAgainst Epilepsy 1981 with permission.)

8. INTERNATIONAL CLASSIFICATION OF EPILEPSIES AND
EPILEPTIC SYNDROMES
(1) Localisation-related (local, focal, partial) epilepsies
and syndromes
 1.1 IDIOPATHIC
 Benign childhood epilepsy with centrotemporal spikes
 Childhood epilepsy with occipital paroxysms
 Primary reading epilepsy
 1.2 SYMPTOMATIC
 Chronic epilepsia partialis continua of childhood (Kojewnikoff’s
 syndrome)
 Syndromes characterised by seizures with specific modes of
 precipitation
 Temporal lobe epilepsy
 Frontal lobe epilepsy
 Parietal lobe epilepsy
 Occipital lobe epilepsy
 1.3 CRYPTOGENIC

9. (2)Generalised epilepsies and syndromes
2.1 Idiopathic (with age-related onset)
• Benign neonatal familial convulsions*
• Benign neonatal convulsions*
• Benign myoclonic epilepsy in infancy*
• Juvenile absence epilepsy (pyknoepilepsy)
• Childhood absence epilepsy
• Juvenile myoclonic epilepsy (impulsive petit mal)
• Epilepsy with grand mal seizures on awakening
• Other generalised idiopathic epilepsies
• Epilepsies with seizures precipitated by specific modes of activation
2.2 Cryptogenic or symptomatic
West syndrome
Lennox–Gastaut syndrome
Epilepsy with myoclonic–astatic seizures
Epilepsy with myoclonic absences

10. 2.3 Symptomatic
• 2.3.1 Non-specific etiology
Early myoclonic encephalopathy*
Early infantile epileptic encephalopathy with suppression-burst*
Other symptomatic generalised epilepsies not defined above
• 2.3.2 Specific syndromes
Epileptic seizures complicating other disease states
3 Epilepsies and syndromes undetermined, whether
focal or generalised
4 Special syndromes
4.1 Situation-related seizures
• Febrile convulsions
• Isolated seizures or isolated status epilepticus
• Seizures occurring only when there is an acute metabolic or toxic event
due to factors such as alcohol, drugs, eclampsia, non-ketotic
hyperglycaemia

11. ILAE 2017 Classification of Seizure Types
(1) FOCAL ONSET (2) GENERALIZED ONSET
Aware /ImpairedAwareness
Motor Onset
1. automatisms
2. atonic
3. clonic
4. Epileptic spasms2
5. hyperkinetic
6. myoclonic
7. tonic
Non-Motor Onset
1. autonomic
2. behavior arrest
3. cognitive
4. Emotional
5. sensory
Motor
1. tonic-clonic
2. Clonic
3. tonic
4. myoclonic
5. myoclonic-tonic-
clonic
6. myoclonic-atonic
7. atonic
8. epileptic spasms2
Non-Motor (absence)
typical
atypical myoclonic
eyelid myoclonia
(3) UNKNOWN
ONSET
MOTOR
tonic-clonic
epileptic spasms
NON-MOTOR
behavior arrest
(4) UNCLASSIFIED3

12. PREVALENCE OF EPILEPSY
 70 million persons with epilepsy (PWE)worldwide
 nearly 12 million PWE are expected to reside in
India, contributes nearly 1/6 global burden
 overall prevalence (3.0-11.9 per 1,000 population)
 incidence (0.2-0.6 per 1,000 population per year)
 higher rates in male gender, rural population, and
low socioeconomic status
1.department of Epidemiology, Centre for Public Health, National Institute of Mental Health and
Neurosciences, Bangalore, Karnataka, India.
2.Director/Vice-chancellor and Professor of Neurology, National Institute of Mental Health and
Neurosciences, Bangalore, Karnataka, India.

13.  Approximately 50 million people worldwide-one
of the m/c neurological diseases globally
 estimated 2.4 million people diagnosed with
epilepsy each year
 In high-income countries annual new cases are
between 30 and 50 per 100 000 people in the
general population
 In low- and middle-income countries, this figure
can be up to two times higher
 http://www.who.int/mediacentre/factsheets/fs999/en/ updated on feb 21017

14. DALYs due to epilepsy in
Southeast Asia (GBD 2010).
SEARO = South-East Asia
Regional Office

15. AETIOLOGY
 Globally,TRAUMA- most frequently reported
 Central nervous system infections -including abscesses,
encephalitis with all aetiologies, and bacterial meningitis
 Antenatal(60.4%,) and perinatal(57.7% )risk factors and
cerebrovascular disorders(55%) -most frequently reported
by responding countries
 Idiopathic epilepsy (including the genetic causes) 54.4%

16.  tumours 40.9%
 congenital defects (27.5%)
 parasitic infestations (22.1%)
 exogenous chemicals including alcohol and drugs (13.4%)
 cryptogenic (9.4%)
 degenerative disorders (8.7%)
 febrile convulsions (7.4%)
 hippocampal sclerosis (7.4%)
 cerebral palsy (2.7%)
EPILEPSYATLASWHO 2005

17. Proposed Relationships of Psychiatric
Disturbances to Epilepsy
Common neuropathology, genetics, or developmental
disturbance
1. Ictal or subictal discharges potentiate abnormal behavior
2. Kindling or facilitation of a distributed neuronal matrix
3. Changes in spike frequency or inhibitory–excitatory balance
4. Altered receptor sensitivity, e.g., dopamine receptors
5. Secondary epileptogenesis
Absence of function at the seizure focus
1. Inhibition and hypometabolism surrounding the focus
2. Release or abnormal activity of remaining neurons
3. Dysfunction or downregulation of associated areas

18. Neurochemical
1. Dopamine and other neurotransmitters
2. Endorphins
 Gonadotropins and other endocrine hormones
 Psychodynamic and psychosocial effects of living with
epilepsy
1. Dependence, learned helplessness, low self-esteem, weak defense
mechanisms
2. Disruption of reality testing
 Neurobiological and psychodynamic factors potentiate
each other
 Sleep disturbance
 Antiepileptic drug related

19. INVESTIGATIONS:
1. Electroencephalography
 Obtained interictally when the patient is asymptomatic
 Interictal EEG abnormal-support for a diagnosis of epilepsy
 interictal EEG- never relied to exclude diagnosis of epilepsy
or indeed to prove it
 ictal EEG accompanied by video
 recording (video-EEG ) of clinical semiology-gold standard
for diagnosis
 Scalp EEG -most widely used confirmatory test, sensitivity
ranges from 29 to 55 percent

20. 2. Neuroimaging
 MRI is the structural imaging method of choice in epilepsy
 CT- lower sensitivity
 Used when MRI is contraindicated or in acute settings where
CT allows better access to a medically unstable patient during
scanning
 If patient planned for epilepsy surgery -other tests aid in
localizing the seizure focus include invasive EEG, SPECT
scans, and PET scans
3.CARDIOLOGICAL INVESTIGATIONS:
 routine ECG and a 24-hour ECG recording -first steps.

21. 3.Blood investigations
 Cbc
 Liver function test
 Kindey function test
 Blood sugar
4. SERUM PROLACTIN
 rises after tonic–clonic epileptic seizures
 peaking 10–20 mins after seizure,returning to
baseline after about 6 hours
 less reliable following complex partial seizures

22. Importance of NPA
 Bidirectional relationship between psychiatric
disorders and epilepsy (CTP)
 Psychiatric disorders are over-represented in
people with chronic intractable epilepsy
 Studies estimated that up to 50% of patients with
epilepsy develop psychiatric disorders, the most
common being depression, anxiety and psychotic
disturbances(1)
 Important implications in diagnosis and
management of psychiatric disorders
 MARSH L, RAOV. Psychiatric complications in patients with epilepsy: a review. Epilepsy Res 2002; 49: 11-33.
 LISHMAN’S 4th EDITION

23.  20 to 60 percent prevalence of psychiatric problems
among epilepsy patients (CTP)
 Among patients attending epilepsy clinics,
approximately 30% had a prior psychiatric
hospitalization, and 10 to 20% were on at least 1
psychotropic drug
 Need to adjust mood-stabilizing and other
psychotropic effects of antiepileptic drugs-seizure
threshold lowering effects
 Need to monitor the potential interaction of
antiepileptic and psychotropic drugs (CTP)

24. Disorders related in time to
seizure occurrence
 seizure itself is known as the ictus.
 interictal - period between the postictal
abnormalities and the next ictus
 peri-ictal - period just before or after the ictus
 applied when there is insufficient
information to know when the ictus ends or
begins.

25.  Subjective symptoms
 begin at least 30 minutes before seizure onset,
last 10 minutes to 3 days (CTP)
 Different from aura- with gradual onset and
prolonged duration
 Reported in 7–20% of patients
 Ill-defined feelings of malaise with headache,
tiredness, and dysphoria
 Prodromal mood changes-irritability, lability,
depression, anxiety or aggression and are
relieved by the seizure
PREICTAL DISORDERS:

26. ICTAL DISORDERS:
 Mood and behavioural changes - occur as direct
manifestation of the seizures, including anxiety,
depression, hallucinations
 episodes - brief (<1-3 minutes)
 stereotyped, begin and end abruptly
 associated with other ictal phenomena (oral,
motor automatisms)
 usually occur with partial seizures ,can also occur
in generalised seizures

27. Epileptic Aura
 brief, paroxysmal and highly stereotyped
 They are not psychiatric disorders –importance
occasionally be mistaken for the paroxysmal
symptoms of functional psychiatric illness
 Hallucinations and odd abberrations of thought, such
as forced thinking or crowding of thoughts, may raise
the possibility of psychosis
Epileptic automatisms
 Behavioural concomitants of ictal or postictal delirium
 Brief, lasting few sec to several mins
 EG: Oro-alimentary lip-smacking, lip-pursing,
chewing, licking, tooth grinding or swallowing
 Mimetic -facial expression suggesting an emotional
state, often fear

28. ICTAL ANXIETY:
 Very Common
 up to 1/3 patients with partial seizures reports
fear as part of their aura
 Confused with panic attacks
 Eg. Right temporal foci
ICTAL DEPRESSION:
 less frequently than ictal anxiety
 symptoms are guilt,hopelessness, worthlessness,
and suicidal ideation

29. ICTAL PSYCHOTIC SYMPTOMS:
 manifest as visual, gustatory or auditory
hallucinations
 usually not well defined
 mainly associated with partial seizures
ICTAL AGGRESSION:
 very rare
 mostly involves undirected or unintentional
violence

30. TREATMENT:
 aimed at adequate seizure control
 maintaining the patient’s safety is the
primary concern
 Educating their families about the psychiatric
manifestations is also important

31. POSTICTAL DISORDERS:
 more likely to occur following clusters of
seizures ,generalised seizures or status
epilepticus
DELIRIUM
 epileptic seizures begin abruptly, recovery of
normal function is usually gradual
 In a complex partial seizure-transition occer
over minutes.

32.  Prolonged recovery - in temporal lobe
seizures
 abrupt recovery - frontal lobe seizures
 Consciousness-profoundly impaired in GTCS
and recovery more protracted
 in the elderly and/or patients with learning
difficulties- prolonged recovery
 Aggressive behavior-usually undirected or
resistive
 patient is likely to be amnesic for the event
 diffuse EEG slowing without ictal discharges

33. POST ICTAL PSYCHOSIS:
 Brief self-limiting episodes of psychosis that
are of abrupt onset and follow seizures
 M/c psychotic disorder seen in epilepsy
 Prevelance-6-10% (common inTLE)
 Epilepsy present for over 10yrs before 1ST
episode
 Precipitating event - exacerbation of seizures
(cluster of complex partial seizures or a
secondarily generalised seizure)
 followed by a lucid interval (12-72 hours)

34.  Sudden onset of psychotic symptoms
 marked agitation and behavioural
disturbance
 pleomorphic - mixed picture
 paranoid, grandiose and religious delusions
 auditory, visual and somatic hallucinations
 prominent variable affective changes
 Duration:16 hours to 18 days (mean 3.5 days)

35. PSYCHOSIS CHARACTERISTICS
 Atypical paranoid psychosis–paranoia with sudden
onset
 Psychosis alternating with seizures
 Preserved affective warmth
 Failure of personality deterioration
 Less social withdrawal than schizophrenia
 Less systematized delusions than schizophrenia
 More hallucinations and affective symptoms than
schizophrenia
 More religiosity than schizophrenia
 More positive, as opposed to negative, symptoms
 Few schneiderian first-rank symptoms

36. Logsdail andToone’s Diagnostic Criteria for
Postictal Psychosis
1. Episode of psychosis (often with confusion and
delirium),developing within 1 week of a seizure or
cluster of seizures
2. Psychosis lasting at least 15 hours and less than 2
months
3. Mental state characterized by delirium or delusions
(e.g.paranoid, non paranoid, delusional,
misidentifications) or hallucinations (e.g., auditory,
visual, somatosensory, olfactory) in clear
consciousness

37. 4. No evidence of:
a) a history of treatment with antipsychotic
medications
or psychosis within the past 3 months,
b) antiepileptic drug toxicity,
c) an EEG demonstrating non convulsive status,
d) a recent history of head trauma or
alcohol/drug intoxication or withdrawal (other
than benzodiazepines used for epilepsy)

38.  Treatment of acute post-ictal psychosis
 self-limiting
 treatment with antipsychotic-not indicated
 short courses of benzodiazepines
 main focus of treatment -improved seizure
control.
 14% and 20% of patients develop chronic
interictal psychoses, after several years and
recurrent episodes

39. POST-ICTAL MOOD DISTURBANCES:
 include depression, anxiety or mania
 Post-ictal depression - last longer (up to two
weeks) than other post-ictal states
 Symptoms range-mild to severe
 may involve suicidal behaviour (Common in
right sided temporal or frontal foci)
 Post-ictal anxiety symptoms are less common
 post-ictal mania - overactivity, irritability, and
disorganised or disinhibited behaviour ,brief in
duration.

40. INTERICTAL DISORDERS
 Depressive disorder is the most prevalent
neuropsychiatric disorder in epilepsy
1.DEPRESSION
 The prevalence of major depression in such settings
has been estimated as 17–21%
 majority - having medically refractoryTLE
 clinical picture-of chronic dysthymia,interrupted at
frequent intervals with brief periods of normal mood
 Affective symptoms -pleomorphic, with prominent
irritability and endogenous somatic symptoms.

41. Can manifest as:
 MDD, dysthymic disorder,adjustment disorder,
and depressive episode of bipolar disorder
 Most patients have dysthymia- chronic interictal
depression (interictal dysphoric disorder of
epilepsy)
 increased seizure control or a decrease in seizures
before the onset of interictal depressive
symptoms
 Patients with this “alternating depression”
experience relief with a seizure or ECT

42. clinical features of major depression
persistent low mood, anhedonia,loss of interest
and biological symptoms of sleep or appetite
disturbance
 can present with atypical depressive
symptoms-inter-ictal dysphoric disorder.
 characterised by chronic intermittent
dysthymia, irritability and anxiety symptoms
 good therapeutic response to antidepressant
medications
 Suicide-risk higher than general population.

43. INTER-ICTAL ANXIETY DISORDERS:
 incidence greater than in the general
population
 Panic disorder, generalised anxiety,
agoraphobia, social phobia and obsessive
compulsive disorder (rare) can occur
 common in patients with temporal lobe
epilepsy, especially left-sided foci

44. INTER-ICTAL BIPOLAR DISORDER
 prevalence low (<5%)
 characterised by periods of depressed mood
and episodes of mania.
 preponderance of patients with complex
partial epilepsy, particularly with right-sided
foci.

45. INTER-ICTAL PSYCHOSIS
 Prevalence- 4-10% in patients with epilepsy
 Mainly in temporal lobe epilepsy
 chronic disorder and clinically resembles chronic
schizophrenia
 symptoms of delusions, hallucinations, thought
disorder
 personality is preserved
 risk factors-epilepsy (more than ten years),early
age of onset of epilepsy, bilateral temporal foci
 spontaneous resolution - not common

46.  Psychotic episodes are of relatively long duration-
vary greatly from days to years
 Usually last longer than 1 month
 No known direct relationship to seizure events or
ictal discharge
 Worsening psychotic symptoms-with increase in
seizure frequency or with antiepileptic drug
withdrawal
 Few others have worsening psychotic symptoms
on control of the seizures (alternating psychosis)

47. Proposed Predisposing Factors for the
Interictal Psychosis of Epilepsy:
EPILEPSY CHARACTERISTICS
 Focal dyscognitive seizures with secondary generalized
tonic-clonic seizures
 More auras and automatisms than nonpsychotic epilepsy
patients
 Epilepsy present for 11 to 15 years before psychosis
 Long interval of poorly controlled seizures
 Recently diminished seizure frequency, especially
generalized tonic–clonic seizures
 Left temporal focus
 Mediobasal temporal lesions, especially tumors

48. PSYCHOSIS CHARACTERISTICS
 Atypical paranoid psychosis–paranoia with sudden
onset
 Psychosis alternating with seizures
 Preserved affective warmth
 Failure of personality deterioration
 Less social withdrawal than schizophrenia
 Less systematized delusions than schizophrenia
 More hallucinations and affective symptoms than
schizophrenia
 More religiosity than schizophrenia
 More positive, as opposed to negative, symptoms
 Few schneiderian first-rank symptoms

49. Risk factors-
 early age of onset of seizures
 A decade or more of poorly controlled partial
complex seizures with secondary generalized
tonic–clonic seizures
 history of status
 A family history of psychosis
 Seizure control with drugs or removal of
seizure focus does not prevent its development

50. Treatment:
 require treatment with neuroleptic drugs
 Drugs with low risk of seizure exacerbation
include sulpiride, haloperidol,risperidone and
trifluoperazine.
 Amisulpiride, olanzapine and quetiapine - a
higher risk
 Depot neuroleptics –avoided
 A ‘start low, go slow’ approach is again sensible
 treatment of refractory psychosis poses a difficult
 problem – clozapine can be started

51. PERSONALITY DISORDERS
 High prevalence
 Including borderline, atypical or mixed, histrionic, and
dependent disorders.
 Patients tend to show dependent and avoidant
personality traits.
 Most common-borderline personality
 Pt’s frequently lack stable character,can be immature
and impulsive
 Psychosocial difficulties,with associated mental
retardation, leads to dependency, low self-esteem,
overall borderline personality traits

52. SEXUALITY:
 Men and women experience disturbances of
sexual arousal and a lower sexual drive
 loss of erotic fantasies or dreams experience
impotence or frigidity
 comorbid depression and anxiety may affect
sexual behavior
 2-3 fold increased risk of erectile dysfunction

53.  possibility of a subclinical hypongonadotropic
hypongonadism
 antiepileptic medication- may cause erectile
dysfunction, decreased sexual desire, retrograde
ejaculation, and altered semen quality
 Hormone replacement therapy may normalize
sexual drive and sexual performance

54. DISSOCIATIVE SEIZURES
 In ICD-10, the term ‘dissociative convulsions’ refer to-
paroxysmal episodes of behaviour that resemble
epileptic seizures
 due to unconscious psychological processes
 functional neurological symptoms disorder in DSM-5
 may imitate any form of epilepsy
 convulsions are often not present
 wilful, conscious attempt to simulate illness for
reasons that are understandable in terms of the
individual’s psychological state

55.  Factitious disorder is in turn differentiated from
malingering-simulated to achieve some practical
gain
 Video EEG monitoring is the gold standard
 diagnosis of nonepileptic seizures does not rule
out epileptic seizures
 Approximately 10 to 15% of nonepileptic seizure
patients have trueseizure disorder

56. Cognitive function in epilepsy
 most people function within normal range of
cognitive ability
 comparisons with appropriate control groups
demonstrate deficits
 Potential causes are: possible cumulative effects
of neuronal damage due to repeated seizures,
 brain injury-secondary to trauma
 status epilepticus
 effects of drug treatment-Adverse cognitive
effects are likely in patients taking two or more
antiepileptic drugs

57. Psychotropic medication in epilepsy
 Most psychotropic drugs have the potential to
exacerbate seizures
 the incidence of seizures with antidepressants and
antipsychotics is very low, well below 1%
 Clozapine associated with a significant risk of seizures
 seizures may be expected in 2–3% of patients with
doses 300–600 mg daily
 Two studies have described improvement in seizure
control, one with fluoxetine and one with citalopram
 Lithium -proconvulsant in overdose
 probably not associated with any change in seizure
control at therapeutic doses.

58.  Overdose & intoxication of TCA and tetracyclic anti
depressants ,SSRI, and SNRI- potential causes of seizure
High potential:
Antipsychotic Antidepressant
 Chlorpromazine Bupropion
 Clozapine Imipramine
 Thioridazine Maprotiline
 Perphenazine Amitriptyline
 Olanzapine Amoxapine
 Quetiapine Nortriptyline
 SSRI and SNRI can be given as first-line antidepressants- due to
better tolerability profile
 TCA andTeCA require higher dose for achieving their
antidepressant property-considered when patients failed to
respond with the first-line agents

59. TREATMENT-RELATED PSYCHIATRIC PROBLEMS
 Antiepileptic drugs - can cause psychiatric problems,
 most commonly-depression, anxiety, behavioural or cognitive
problems and psychosis(rare)
 Improved seizure control - associated with the emergence of
psychiatric symptoms
 forced normalisation- dramatic reduction in epileptiform
activity on EEG being associated with the emergence of
psychosis or sometimes behavioural /mood disturbances
 Its common with most AEDs and therefore any new drug should
be started at low doses and increased slowly
.

60. Behavioral Effects of Antiepileptic Drugs
1. Barbiturates Depression, irritability, aggression, impaired cognition and
attention, hyperactivity
2. Carbamazepine,Oxcarbazepine - Irritability, impaired attention
3. Ethosuximide -Behavioral abnormalities, psychosis
4. Felbamate- Depression, anxiety, irritability
5. Gabapentin- Behavioral problems in children
6. Lamotrigine- Insomnia, agitation, emotional lability
7. Levetiracetam -Irritability, emotional lability
8. Phenytoin -Encephalopathy, depression, impaired attention
9. Tiagabine -Depression (non convulsive status epilepticus), irritability
10. Topiramate -Depression, psychomotor slowing, psychosis, impaired
cognition (word findingand memory)
11. Valproate - Encephalopathy, depression
12. Vigabatrin - Depression, aggression, psychosis
13. Zonisamide – Agitation, depression, psychosis

61.  Carbamazepine and valproate- antimanic and antidepressant
properties
 Carbamazepine and valproate -dyscontrolled, aggressive
behavior in brain-injured patients
 Lamotrigine -only antiepileptic well-established efficacy
preventing recurrence of depressive episode in bipolar
disorder
 Clonazepam- anxiolytic properties, antimanic therapies
 Gabapentin and pregabalin decrease anxiety,improve
general well-being in some epilepsy patients

62. EPILEPSY SURGERY:
 Transient mood disturbances
(emotional lability, depression and anxiety)
reported following temporal lobe surgery
 about 25% in the first 6-12 weeks
 some patients (10%)-depression may persist
 inter-ictal psychosis arising after surgery
Psychiatric disorders in epilepsy JACQUELINE FOONG
(Department of Neuropsychiatry, National Hospital for Neurology and Neurosurgery, QueenSquare, London)

63. PSYCHOLOGICAL TREATMENT OF EPILEPSY
 Psychological approaches to seizure control are
helpful
 stress is an aggravating factor
 helping people deal with stress-reduction in
seizures
 Cognitive–behaviour therapy target -anxiety and
coping skills
 specific interventions -variety of cognitive and
relaxation techniques
 patients can engage when they experience an aura
or prodromal symptoms