neuropsychiatric aspect of epilepsy 1

1. Neuropsychiatric
Aspect of Epilepsy
Dr. Subodh Sharma
Resident
Department of Psychiatry, NMCTH, Birgunj

2. Definitions
Seizure /Ictus/ Fits
 From a Latin word that means ‘to take possession of ‘
 Paroxysmal event due to abnormal excessive, hypersynchronous
discharges from an aggregate of CNS neurons.
 Epilepsy
o Clinical phenomenon rather than a single identity.
o Recurrent seizures due to chronic underlying process.

3. Definitions
A convulsion is a medical condition where body muscles
contract and relax rapidly and repeatedly, resulting in an
uncontrolled shaking of the body.
Because a convulsion is often a symptom of epileptic
seizures, the term convulsion is sometimes used as a synonym
for seizure.
However, not all epileptic seizures lead to convulsions, and
not all convulsions are caused by epileptic seizures.

4. Epidemiology
 Epilepsy knows no geographical, racial, or social boundaries.
 About 50 million people in world have Epilepsy.
 It occurs in men and women and can begin at any age, but it is
most frequently diagnosed in infancy, childhood, adolescence, and
age.
 Prevalence:
o Developed countries- 0.5% (0.4% - 1%) Developing countries-
five times higher
o Incidence: After infancy annual incidence- is 20-70/100000 in
developed countries. Developing countries- Incidence is double.
(100/100000)
o The lifetime risk of having a single seizure: About 5%.

5. Classification
• Absence(petit mal)
• Tonic-Clonic
• Tonic
• Clonic
• Atonic
• Myoclonic
Primary
Generalized
Seizure
• Simple partial
• Complex partial
• Partial with secondary generalization
• Unclassified seizures
• Neonatal seizures
• Infantile spasms / West’s syndrome
Partial Seizures

6. Epilepsy Syndromes And Other Special Forms
Epilepsy syndromes are disorders in which epilepsy is a
predominant feature, and there is sufficient evidence
(e.g., through clinical, EEG, radiologic, or genetic
observations) to suggest a common underlying
mechanism.

7. Epilepsy Syndrome
Juvenile Myoclonic epilepsy
Lennox Gastaut syndrome
Mesial Temporal Lobe epilepsy
Infantile spasms / West’s syndrome
Landau-Kleffner syndrome (infantile acquired aphasia)
Other special forms
• Catamenial epilepsy
• Reflex epilepsy
• eg: eating epilepsy, hot water epilepsy
• Gelastic epilepsy
• Diencephalic or autonomic

8. Etiology
 In about 70% of people with
epilepsy, the cause is not known
 In 30%, most common causes are:
 Inherited
o genetic
 Acquired :
o Trauma
o Neurosurgery
o Inflammatory
o Metabolic
o Infections
o Tumor
o Toxic disorders
o Drugs
 Congenital:
o inborn error of metabolism.
 Withdrawal of drugs
o Alcohol
o Benzodiazepine
o Barbiturates
o Other Anti-Epileptics

9. Psychotropics and Seizure
o highest risk of seizures(0.5%)
 clomipramine 0.5%(tertiary amine TCA )
 bupropion (0.4%, up to 2.2% with doses higher than 450 mg per day)
 maprotiline (0.4%) (tetracyclic)
•
•
 Other TCAs:
 imipramine
 Intermediate in risk
 SSRI:- fluoxetine, sertraline, fluvoxamine, citalopram, and paroxetine
 NSRI :- venlafaxine
 Least risk – monoamine oxidase inhibitors (MAOIs) 
http://www.epilepsy.com/information/professionals/diagno sis-treatment/drugs-
their-contribution- seizures/antidepressants


10. Psychotropics and Seizure
 Antipsychotics
 Highest risk:
o clozapine
o loxapine
o chlorpromazine
 Intermediate ( less than 1.0–1.2%)
o fluphenazine
o thioridazine
o perphenazine
o Trifluoperazine
 Least seizure-induction
o haloperidol
o molindone
o pimozide
 The antipsychotics of choice on the basis both of epileptogenesis and the
side effect profiles are atypical agents:
o Risperidone, olanzapine, quetiapine

11. Triggers
 Missed medication (#1 reason)
 Stress, anxiety
 Hormonal changes, Menses
 Dehydration
 Lack of sleep, extreme fatigue
 Photosensitivity
 Illicit Drug, and alcohol use
 Certain Medications
 Fever in Some Children

12. Risks
 Groups at Increased Risk for Epilepsy
o About 1% of the general population develops epilepsy
o The risk is higher in people with certain medical conditions:
 Mental retardation
 Cerebral palsy
 Alzheimer’s disease
 Stroke
 Autism

13. Pathophysiology
 Glutamate and GABA (gamma-aminobutyric acid):
o the brain's major "workhorse" neurotransmitters that regulate action
potential traffic.
o GABA is an inhibitory neurotransmitter that stops action potentials.
o Glutamate, an excitatory neurotransmitter, starts action potentials or
keeps them going.
o Both work together to control many processes, including the brain's
overall level of excitation.

15. What is Seizure?
 An unpredictable, uncontrolled, abnormal, and
excessive paroxysmal synchronization imbalance of
the excitatory and inhibitory forces within the CNS
network of cortical neurons in the cerebral cortex.
 Repeated sub-threshold of a neuron generates action
potentials leading to seizures
 It has been suggested that chronic epileptic discharges
may lead to secondary epileptogenesis.

16. Clinical Presentation
 Partial Seizures
 Simple Partial Seizures:
o Consciousness is fully preserved
o Motor symptoms Involves motor strip, Manifested by
abnormal movement of an extremity,
o Jacksonian motor seizure: progression to adjacent muscle
groups
o Todds palsy: transient paralysis
o Adversive seizure: Forced deviation of the eyes and turning
head to the opposite side.

17. SPS
 Somatosensory symptoms Involves sensory strip, temporal(hearing and
smell) or occipital(visual) lobe
 Autonomic symptoms involve the temporal lobe (tachycardia, pallor,
flushing, sweating, and Piloerection.
 Psychic manifestation
o Dysphasic- when cortical speech area is affected (left perisylvian)
o Dysmnestic- disturbance of memory (mesobasal temporal right)
o Cognitive symptoms- dreamy state (mesobasal temporal and
temporal neocortex)
o Affective symptoms- fear, depression, anger, irritability, elation,
erotic thoughts (mesobasal temporal and temporal neocortex)
o Illusion of size, structured hallucination (mesobasal temporal and
temporal neocortex)

18. Complex Partial Seizure
 Complex partial seizures (= psychomotor seizures)
o Initial subjective feeling (aura)
o loss of consciousness
o abnormal behavior (perioral and hand automatisms)
o Majority originate in the Temporal lobe (60%)
o but also originate another lobe – particularly the Frontal(30%).
•
 Discriminating features
o Consciousness is altered
o Stereotyped
o Focal spikes in interictal EEG

19. CPS
 Consistent Features
o Approximately 60-180 seconds duration
o Paroxysmal
o Post-ictal confusion
 Variable Features
o Presence of aura Automatisms
o May secondarily generalize to a tonic-clonic seizure
o Associated with a focal structural lesion
o May elevate prolactin level
 May be confused with
o Drunkenness or drug use
o willful belligerence
o aggressiveness

20. Generalised Seizure
o Gtcs
o Absences
o Myoclonic seizures
o Clonic seizures
o Tonic seizures
o Atonic seizures
 Discriminating features
o Initial tonic phase followed by clonic activity involving all
extremities
 Consistent Features Loss of consciousness
o Typically 60-second duration
o Post-ictal period associated with confusion and drowsiness Variable
Features Tongue biting or injury Urinary incontinence Nonspecific
prodrome post-ictal paralysis

21. Absence Seizure
 Discriminating features
o Very brief duration (5-15 seconds)
and 100 – 200 time/day mat
o Family H/O of typical absence
seizures
o Response to ethosuximide and
valproate
 Consistent Features
o EEG-3 cycles/ sec of generalized
spike and wave(typical)
o No aura
o Impaired consciousness
o No post-ictal state
o Variable Features
o Automatisms
o Change in body tone
o Precipitation hyperventilation
 Atypical absence seizures
o Longer duration of loss of
consciousness
o Less abrupt onset and cessation
o More obvious focal signs
o Less responsive to drugs

23. Atypical Seizures
 Reflex epilepsy
o Hot water epilepsy: a person gets a seizure whenever
he/she pours hot water on the head.
o Initially it is reported more from South India, especially
from Bangalore.
 Eating epilepsy: Seizures are usually precipitated while a
person starts eating food. The masticatory and oro-
mandibular movements might trigger the seizure.
 Watching TV can precipitate seizures in a vulnerable
individual.
o This is akin to the photostimulation procedure seen in
EEG recording.
 Hyperventilation can also precipitate seizures

24. Differential Diagnosis
o Syncope
 Vasovagal syncope
 Cardiac arrhythmia
 Valvular heart disease
 Cardiac failure
 Orthostatic hypotension
o Psychological disorders
 Psychogenic seizure
 Hyperventilation
 Panic attack
o Metabolic disturbances
 Alcoholic blackouts
 Delirium tremens
 Hypoglycemia
 Hypoxia
o Psychoactive drugs (e.g., hallucinogens)
o Migraine
 Confusional migraine
 Basilar migraine
o Transient ischemic attack (TIA)
 Basilar artery TIA
o Sleep disorders
 Narcolepsy/cataplexy
 Benign sleep myoclonus
o Movement disorders
 Tics
 Nonepileptic myoclonus
 Paroxysmal choreoathetosis
 Special considerations in children
o Breath-holding spells
o Migraine with recurrent abdominal pain and
cyclic vomiting
o Benign paroxysmal vertigo – Apnea – Night
terrors – Sleepwalking

30. Investigations
The concern of the clinician is that epilepsy may be symptomatic of a treatable cerebral lesion.
Routine investigation:
• Hematology, biochemistry (electrolytes, urea, and calcium)
• chest X-ray
• electroencephalogram (EEG)
• Neuroimaging (CT/MRI) should be performed in all persons aged 25 or more presenting with
first seizure and in those pts. with focal epilepsy irrespective of age.
• Specialized neurophysiological investigations: Sleep-deprived EEG, video-EEG monitoring.
• Advanced investigations (in pts. with intractable focal epilepsy where surgery is considered):
Neuropsychology, Semi-invasive or invasive EEG recordings
• MR Spectroscopy
• Positron emission tomography (PET)
• ictal Single photon emission computed tomography (SPECT)

31. EEG in epilepsy
 A normal single EEG does not exclude the diagnosis of epilepsy.
 If a normal awake EEG is obtained in an individual with the
clinical suspicion of seizures, one should repeat the EEG
capturing sleep because many epileptic abnormalities appear
only in sleep
 Interictal findings in the EEG are invaluable aids for classifying
seizures and epilepsy syndromes

34. Management
Treatment Goals in Epilepsy
• Help person with epilepsy lead full and productive life
• Eliminate seizures without producing side effects
• Tailor treatment to needs of individuals/special populations : Women,
Children, Elderly, Hepatic or renal failure and other diseases
What if not treated?
• Seizures can be potentially life threatening with brain failure, heart and lung
failure, trauma, accidents
• Sudden Unexpected Death in Epilepsy (SUDEP)
• Even subtle seizures can cause small damage in brain
• Long Term problems: fall in IQ, depression, suicide, Social Problems,
Quality of Life

35. Types of Treatment
Medication
Surgery
Non-pharmacologic treatment
Ketogenic diet
Vagus nerve stimulation
Life style modifications

36. • Single Unprovoked Seizures
o Common affecting 4% of the population by age 80
o 30%-40% of patients with a first seizure will have a second
unprovoked seizure ( epilepsy)
o Risk factors for seizure recurrence include a history of
neurologic insult, focal lesions on MRI, epileptiform EEG, and
family history of epilepsy
o Adult patients with these risk factors have a 60%-70% of
recurrence

37. First Aid
o Stay calm and track time
o Protect head, remove glasses, loosen tight
neckwear
o Move anything hard or sharp out of the way
o Turn person on one side, position mouth to
ground
o Check for epilepsy or seizure disorder ID
o Understand that verbal instructions may not be
obeyed
o Stay until person is fully aware and help reorient
them
o Call ambulance if seizure lasts more than 5
minutes or if it is unknown whether the person
has had prior seizures

38. • Safety Issues for Patients with Epilepsy
o Cant Drive for about a year after the last seizure
o Climbing altitudes
o Swimming/ Bathing alone
o Operating heavy machinery or weapons that can be dangerous
o Cooking, hot water
o Taking care of babies
o Bone Health

39. Antiepileptic Drug Therapy
AED therapy is not necessary if a first seizure is
provoked by factors that resolve
AED therapy may be indicated if there is a permanent
injury to the brain (stroke , tumor)
In general AED therapy is started if there is a high risk of
recurrent seizures

40. Guidelines forAnticonvulsant Therapy
o Start with one of the first line drugs
o Start with low dose: Gradually increase to effective dose or until side effects.
o Check compliance If first drug fails due to side effects or continue seizures,
start second line drugs whilst gradually withdrawing first.
o Try Three AED singly before using combinations
o Beware about drug interactions
o Do not use more than two drugs in combination at any one time
o If above fails consider occult structural or metabolic lesion and whether
seizures are truly epileptic.

41. Second Generation AED’S
• Topiramate (Topomax – 1996)
• Oxcarbazepine (Trileptal – 2000)
• Lamotrigine (Lamictal – 1994)
• Gabapentin (Neurotin – 1993)
• Levetiracetam (Keppra – 1999)
• Tiagabine (Gabitril – 1997)
• Zonisamide (Zonegran – 2000)
• Pregabalin (Lyrica - 2005)
• Felbamate (Felbatol-1993)
• Vigabatrin (Sabril 2005-2006 Available in Canada and Europe)

42. Second Generation AEDs
o With the exception of Felbamate second generation AED’S have
advantages over first generation agents.
o Generally lower side effect rates
o Little or no need for serum monitoring
o Once or twice daily dosing
o Fewer drug interactions
o There is no significant difference in efficacy with the second
generation agents
o Higher cost associated with the new agents
o Monotherapy is well established for Lamotrigine and Oxcarbazepine
o The other agents are undergoing and many have completed
monotherapy trials

43. • AED In General
o The most important factor in determining the success of drug therapy
is the duration of the epilepsy
o The patient needs to know that AED treatment is a commitment and
non-compliance can be dangerous
• Pregnancy Considerations
o Consider withdrawing of AED’S if the patient is a good candidate
o Use monotherapy where appropriate
o Folate 1-4 mg per day in all women on AED
o The risk of fetal malformations is increased in pregnant women on
AED
o Seizures during pregnancy can induce miscarriage
o Seizures during pregnancy can be deleterious to the mother or fetus
o The possibility of prenatal diagnosis of malformations can be
considered with AFP levels and ultrasonography

46. • Withdrawal of AED
o After complete control of seizures for 3-5 years
o withdrawal of Anti Epileptic drugs may be considered
o But in the case of a special professional group (car driver, machine man, etc)
withdraw the AED after keen follow-up.
o 20% of pts will suffer a further sz within 2 yrs.
o AED should be tapered during the stopping of medications.
o Slow reduction by increments over at least 6 months.
o If the patient is taking two AEDs one drug should be slowly withdrawn before
the second is tapered.
o The risk of teratogenicity is well known (~5%), especially with valproates, but
withdrawing drug therapy in pregnancy is riskier than continuation.
o Epileptic females must be aware of this problem and thorough family planning
should be recommended.
o Over 90% of pregnant women with epilepsy will deliver a normal child.

47. • Epilepsy Surgery
o Factors influencing decision
o Likelihood seizures are due to epilepsy
o Likelihood surgery will help
o Ability to identify focus of seizures
o Other treatments attempted, and seizures
couldn’t be treated with 2-3 medications
o Benefits vs risks
o Surgical treatment:
o Removal of epileptic focus (eg:mesial
temporal sclerosis)
o Anterior Temporal Lobectomy
o Corpus callostomy
o Subpial transection
o

48. o Vagus Nerve Stimulation
o Device is implanted to control seizures
o by delivering electrical stimulation to
the vagus nerve in the neck, which
relays impulses to widespread areas of
the brain
o Used to treat partial seizures when
medication does not work 

49. o Ketogenic Diet
o Based on finding that starvation -- which burns
fat for energy -- has an antiepileptic effect
o Used primarily to treat severe childhood
epilepsy, has been effective in some adults &
adolescents
o High fat, low carbohydrate and protein intake
o Usually started in hospital
o Requires strong family commitment

50. • Other Treatment Approaches
o Behavioral therapy
o Biofeedback
o Relaxation
o Positive reinforcement
o Cognitive therapy
o Aromatherapy

51. References
o Harrison’s principles of internal medicine , 17th edition
o Organic psychiatry William Alwyn Lishman, 3rd edition.
o Ictal and postictalpsychiatric disturbances, Michael R. Trimble Institute of Neurology,
University College, London.
o CTP 10TH EDITION

52. Thank You!