This presentation provides details on management of interictal dysphoric disorder of epilepsy. For further details, contact nabeelasayed59@gmail.com

1. Challenges and Solutions in
Managing the transition of an
Epileptic patient with IDD
- By Nabeela Sayed

2. What is Intermittent Dysphoric disorder
(IDD)
 Epilepsy is one of the most prevalent neurological conditions and is the most
common chronic neurologic disorder in the general population.
 Literature indicates that up to 50% of patients with epilepsy (PWE) have
psychiatric disorders (PDs) such as mood swings, anxiety and psychotic
disorders. [1]
 Interictal dysphoric disorder (IDD) is a mood disorder sometimes found in
patients with epilepsy, at a prevalence rate of approximately 17%. [2]
 The most common symptom of IDD is intermittent dysphoric mood in between
seizures. [3]
1. Nascimento Pedro Paulo Gomes do, Oliva Carlos Henrique, Franco Clelia Maria Ribeiro, Mazetto Lennon, Yamashiro Alberto S., Araujo Filho Gerardo Maria de et al .
Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers. Arq. Neuro-Psiquiatr. [Internet].
2013 Nov [cited 2020 July 20] ; 71( 11 ): 852-855. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-
282X2013001200852&lng=en. https://doi.org/10.1590/0004-282X20130165.
2. Kōhō Miyoshi (9 August 2010). Neuropsychiatric Disorders. Springer. pp. 107. ISBN 978-4-431-53871-4.
3. Morita S, Taniguchi G, Tamune H, Kumakura Y, Kondo S, Kasai K. A case of interictal dysphoric disorder comorbid with interictal psychosis: Part of the same spectrum or
separate entities?. Epilepsy Behav Case Rep. 2018;10:102-105. Published 2018 Aug 3. doi:10.1016/j.ebcr.2018.07.007

3. History of Interictal Dysphoric Disorder
in Epilepsy
 Interictal dysphoric disorder (IDD) was first described by Kraepelin in 1923. He observed a clinical
state in PWE that he called “depressive state”, which comprised intermittent manifestations of
psychiatric symptoms that appeared and disappeared faster than in bipolar disorder.
 In 1984, Himmelhoch described a “dysthymic interictal subictal state” in patients with a moderate
chronic state of depression during seizure-free periods.
 Blumer preferred the term “dysphoric” because this term would be the best translation of
Kraepelin’s initial idea, especially concerning the frequency and periodicity of the mood swings,
irritability, and aggressive outbursts.
Nascimento Pedro Paulo Gomes do, Oliva Carlos Henrique, Franco Clelia Maria Ribeiro, Mazetto Lennon, Yamashiro Alberto S., Araujo Filho Gerardo Maria de et al .
Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers. Arq. Neuro-Psiquiatr.
[Internet]. 2013 Nov [cited 2020 July 20] ; 71( 11 ): 852-855. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-
282X2013001200852&lng=en. https://doi.org/10.1590/0004-282X20130165.

4. Nascimento Pedro Paulo Gomes do, Oliva Carlos Henrique, Franco Clelia Maria Ribeiro, Mazetto Lennon, Yamashiro Alberto S., Araujo Filho Gerardo Maria de et al . Interictal dysphoric disorder: a
frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers. Arq. Neuro-Psiquiatr. [Internet]. 2013 Nov [cited 2020 July 20] ; 71( 11 ): 852-855.
Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2013001200852&lng=en. https://doi.org/10.1590/0004-282X20130165.
 Sixty-five (63.1%) patients (41 females)
with mean age of 35.2±10.2 years were
included in this Brazilian study.
 All patients responded positively to at
least one IDD symptom and 33 (50.7%)
patients, 22 (66.7%) of whom were
females, fulfilled the diagnostic criteria
for IDD.
 More than 80% of all patients reported
labile depressive and affective
symptoms, but specific symptoms such
as euphoric mood were observed in only
60%, which has been observed in other
studies.

5. Classification of psychiatric disorders in
epilepsy
Psychiatric
disorders in
epilepsy
Peri-ictal (with
temporal
relationship with
seizures
Ictal (occur during
seizures)
Pre-ictal
(preceding
seizures)
Post-ictal (occur
following seizures)
Interictal (without
temporal
relationship with
seizures)

6. Case report of IDD
 64-year-old woman
 History of present illness: She complained of bizarre, antipsychotic-refractory cenesthetic
hallucinations in her interictal phase, and was hospitalized after a suicide attempt.
 Medical history: Right mesial temporal lobe epilepsy
 Family history: Negative for psychiatric disorders
 Examination: Detailed clinical observations revealed mood symptoms, which led to the
diagnosis of interictal dysphoric disorder comorbid with interictal psychosis.
 Investigation: EEG, MRI
 Treatment: Sertraline with low-dose aripiprazole markedly alleviated both depressive and
psychotic symptoms. This case suggested that the two diagnostic entities may overlap and
that depressive symptoms tend to be concurrent when concurring with psychosis, which
hampers the appropriate choice of a treatment option.
Susumu Morita, Go Taniguchi, Hidetaka Tamune, Yousuke Kumakura, Shinsuke Kondo, Kiyoto Kasai. A case of interictal dysphoric disorder
comorbid with interictal psychosis: Part of the same spectrum or separate entities? Epilepsy & Behavior Case Reports, 2018;10:102-105
https://doi.org/10.1016/j.ebcr.2018.07.007.

7. Diagnosis of IDD
 Mula et al. have developed and operationalized the concept of an IDD diagnosis by
forming the Interictal Dysphoric Disorder Inventory (IDDI), which is a 38-item, self-
report questionnaire specifically developed to diagnose IDD and to evaluate eight
IDD core symptoms in terms of symptom presence, symptom frequency, symptom
severity, and global impairment.
 The IDDI was constructed based on the main core symptoms of IDD, characterized
by eight key symptoms divided into three categories:
(1) labile depressive symptoms (e.g., depressed mood, anergia, pain, insomnia),
(2) labile affective symptoms (e.g., panic symptoms and anxiety), and
(3) “specific symptoms” (e.g., paroxysmal irritability and euphoria).
 Patients were considered to have IDD if they had at least three core symptoms
that were moderate or severe and caused moderate or severe distress for a period
of 12 months.
Nascimento Pedro Paulo Gomes do, Oliva Carlos Henrique, Franco Clelia Maria Ribeiro, Mazetto Lennon, Yamashiro Alberto S., Araujo Filho Gerardo Maria de et al .
Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers. Arq. Neuro-Psiquiatr. [Internet].
2013 Nov [cited 2020 July 20] ; 71( 11 ): 852-855. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2013001200852&lng=en.
https://doi.org/10.1590/0004-282X20130165.
Susumu Morita, Go Taniguchi, Hidetaka Tamune, Yousuke Kumakura, Shinsuke Kondo, Kiyoto Kasai. A case of interictal dysphoric disorder comorbid with interictal
psychosis: Part of the same spectrum or separate entities? Epilepsy & Behavior Case Reports, 2018;10:102-105
https://doi.org/10.1016/j.ebcr.2018.07.007.

8. Challenges associated with IDD
 1. No proper recognition and treatment of psychiatric disorders among patients
with epilepsy due to heterogeneous and atypical nature of psychiatric disorders.
 2. Reluctance to treat these comorbidities associated with epilepsy due to
traditional beliefs that some symptoms are attributed to antiepileptic medication
and that psychiatric drugs should be restricted in patients with epilepsy because
the drugs supposedly lower the seizure threshold. [1]
 3. An assessment using self-report inventory is recommended for screening of
depression in patients with epilepsy. However, patients' subjective experiences
of psychiatric symptoms often diverge from their objective severity, and self-
report inventory results are compromised in this sense.
 4. IDDI could not be used in this patient due to acute state of dysphoria, and even
after the remission of depression, the score was too low relative to other
objective observations and raised doubts on its reliability in this case. [2]
1. Nascimento Pedro Paulo Gomes do, Oliva Carlos Henrique, Franco Clelia Maria Ribeiro, Mazetto Lennon, Yamashiro Alberto S., Araujo Filho Gerardo Maria de et
al . Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers. Arq. Neuro-Psiquiatr.
[Internet]. 2013 Nov [cited 2020 July 20] ; 71( 11 ): 852-855. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-
282X2013001200852&lng=en. https://doi.org/10.1590/0004-282X20130165.
2. Susumu Morita, Go Taniguchi, Hidetaka Tamune, Yousuke Kumakura, Shinsuke Kondo, Kiyoto Kasai. A case of interictal dysphoric disorder comorbid with
interictal psychosis: Part of the same spectrum or separate entities? Epilepsy & Behavior Case Reports, 2018;10:102-105. https://doi.org/10.1016/j.ebcr.2018.07.007.

9. Solutions for management of epileptic patients
with IDD
 Psychiatric symptoms in PWE could be due to physiologic or drug-related exacerbation of inhibitory brain
activity against the appearance of an exacerbated excitatory epileptic activity.
 Blummer et al. have suggested that antidepressant drugs are highly effective at lower doses against all
IDD symptoms because the drugs antagonize excessive cerebral inhibition.
 In the same manner, if psychotic symptoms were present, the treatment would be enhanced through the
use of antipsychotic medication. However, more studies are necessary to clarify these clinical aspects
and to test a pharmacological treatment for IDD and its pathophysiological underpinnings. [1]
 SSRIs are recommended as the first-line pharmacological treatment for interictal depressive disorders
because of their favorable side effect profiles, and the proconvulsant effects reported to be associated
with some tricyclic antidepressants can be avoided.
 Sertraline, citalopram, reboxetine, mirtazapine, and fluoxetine were all shown to be effective in open
trials, although there is no randomized-controlled trial to date that shows the superiority of SSRIs over
other types of antidepressants or antiepileptic drugs with psychotropic effects. [2]
1. Nascimento Pedro Paulo Gomes do, Oliva Carlos Henrique, Franco Clelia Maria Ribeiro, Mazetto Lennon, Yamashiro Alberto S., Araujo Filho Gerardo Maria de et
al . Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers. Arq. Neuro-Psiquiatr.
[Internet]. 2013 Nov [cited 2020 July 20] ; 71( 11 ): 852-855. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-
282X2013001200852&lng=en. https://doi.org/10.1590/0004-282X20130165.
2. Susumu Morita, Go Taniguchi, Hidetaka Tamune, Yousuke Kumakura, Shinsuke Kondo, Kiyoto Kasai. A case of interictal dysphoric disorder comorbid
with interictal psychosis: Part of the same spectrum or separate entities? Epilepsy & Behavior Case Reports, 2018;10:102-105.
https://doi.org/10.1016/j.ebcr.2018.07.007.

10. Conclusion
 Considering that mood symptoms tend to be underrecognized, even if derived
from self-report inventories, an objective psychiatric assessment delivered by
qualified clinicians is essential for the accurate diagnosis of IDD.
 Pharmacological treatment with Sertraline may be useful in patients with IDD.