Neuropsychiatric aspects of epilepsy osmanali


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Neuropsychiatric aspects of epilepsy osmanali

  1. 1. • Neuropsychiatric aspects of epilepsy • • • • • • • • • • Presenter Dr Mohd Osman Ali Scheme of presentation Overview of epilepsy– epidemiology, terminology, mechanism, types, classification, diagnosis, investigations Introduction to psychiatric manifestations of epilepsy– epidemiology, different manifestations Ictal features Perictal features--Prodromal symptoms, Postictal confusion, Peri-ictal psychoses Interictal features-- Schizophreniform psychosis,Personality disorders, GastautGeschwind syndrome Behavioral Disturbances Variably Related to Ictus-- Mood disorders,Anxietydisorders, Aggression, Hyposexuality, Suicide, Other behaviors Management implications Over view of epilepsy • • • Epidemiology of epilepsy Epilepsy affects 20 to 40 million people worldwide and has a prevalence of at least 0.63 percent and an annual incidence of approximately 0.05 percent.
  2. 2. • • • • • • The overall incidence is high in the first year, drops to a minimum in the third and fourth decades of life, then increases again in later life. 12 to 20 percent have a familial incidence of seizures. Among adults, the most common seizures are complex partial and generalized tonic-clonic seizures. Etiology and pathology Most new-onset epilepsy is idiopathic, but other frequent causes include – – – • • trauma in the third and fourth decades of life, neoplasms in the fifth and sixth decades of life, and cerebrovascular disease in the elderly. Although some complex partial seizures originate from the frontal or temporal neocortex and other areas, at least two-thirds of complex partial seizures and generalized tonic-clonic seizures originate from the mediobasal temporal limbic structures (hippocampus, amygdala, and parahippocampal gyrus).
  3. 3. • • • • • • • Terminology related to epilepsy Epileptic seizures are sudden, involuntary behavioral events associated with excessive or hypersynchronous electrical discharges in the brain. Epilepsy is the recurrent tendency to seize, status epilepticus is prolonged or repetitive seizures without intervening recovery. The seizure itself is known as the ictus. The interictal period refers to the period between the postictal abnormalities and the next ictus, and the peri-ictal period refers to the period just before or after the ictus – • and is applied when there is insufficient information to know when the ictus ends or begins. Mechanism of Epilepsy
  4. 4. • In epilepsy, abnormal electrical discharges are due to hyperexcitable neurons with sustained postsynaptic depolarization.Proposed mechanisms – – – • • • • • • changes in ionic conductance, decreased γ-aminobutyric acid (GABA) inhibition of cortical excitability, and increased glutamate-mediated cortical excitation. Types of Epileptic Seizures primary secondary to a neurological condition, or reactive to a situational factor, such as sleep deprivation or drug withdrawal International Classification of Epileptic Seizures Partial (focal, local) seizures – Simple partial seizures • – Motor, somatosensory, autonomic, or psychic symptoms Complex partial seizures
  5. 5. • • • • • • • Begin with symptoms of simple partial seizure but progress to impairment of consciousness Begin with impairment of consciousness Partial seizures with secondary generalization Begin with simple partial seizure Begin with complex partial seizure (including those with symptoms of simple partial seizures at onset) International Classification of Epileptic Seizures (contd..) Generalized seizures (convulsive or nonconvulsive) – – – – – – Absence (typical and atypical) Myoclonus Clonic Tonic Tonic-clonic Atonic/akinetic • Unclassified • Partial seizures
  6. 6. • • are complex partial seizures (psychomotor or temporal lobe epilepsy) or simple partial seizures, depending on whether there is complex symptomatology, such as – – • • • • • an alteration of consciousness or psychic symptoms (table psychic auras). Simple partial seizures produce isolated motor, sensory, autonomic, psychic, or mixed symptoms in a clear sensorium. Simple partial seizures that evolve to complex partial seizures are considered auras Complex partial seizures are usually characterized – by motionless staring combined with simple automatisms, or – – automatic motor activity, and last approximately 1 minute.
  7. 7. • • • • Complex partial seizures that evolve to generalized tonic-clonic seizures are secondarily generalized. Generalised seizures In adults, most generalized seizures are tonicclonic seizures (grand mal seizures or convulsions) and are characterized by – – • • • • an abrupt loss of consciousness with tonic rigidity followed by a synchronous, clonic release absence (petit mal) seizures which occur less commonly in adults and are characterized by brief lapses of consciousness. Absence seizures differ from complex partial seizures in – being short (10 s in length) and
  8. 8. – – – • • • • • • repetitive; in lacking auras, postictal confusion, or complex automatisms; and in having characteristic 2 to 4 counts per second spike and wave discharges on EEG Pathological and laboratory examination--EEG is the most widely used confirmatory test for seizures; however, single EEGs are frequently normal and must be repeated, particularly with provocative maneuvers, such as sleep. Occasionally, CCTV-EEG telemetry for an extended period of time is necessary to capture seizure activity. Normal EEG Basic waves include – normal waking alpha waves (8 to 13 Hz), which are most prominent over the occipital region,
  9. 9. – high frequency beta waves (greater than 13 Hz), • • • • • – and theta waves (4.0 to 7.5 Hz) – and delta slowing (3.5 Hz or less). A spike is a sharp transient with a duration of 20 to 70 ms. Seizures are manifest as multiple spikes or spike and wave discharges on the EEG Interictally, single spikes and other markers of abnormal electrical activity may be seen, often emanating from a temporal lobe. Neuroimaging procedures such as CT scans and magnetic resonance imaging (MRI), – • can more precisely visualize a seizure focus or even mesial temporal sclerosis. PET scans may – show interictal hypometabolism around the temporal seizure focus
  10. 10. – • • • • • • • • • and are also useful in the presurgical assessment of medically intractable seizure patients. Neuropsychological examinations particularly during a Wada's test, – further help in localizing and lateralizing memory and language before surgery. Neuropathology The common pathological findings in epilepsy are mediobasal temporal lobe lesions. – Approximately two-thirds of epileptic adults have a temporal lobe focus, and twothirds of these have mesial temporal sclerosis with pyramidal cell loss in the hippocampus. Theories about the cause of mesial temporal sclerosis include – – – perinatal insults, dysgenesis, and kindling from reactive seizures. Another 20 to 25 percent of those with temporal lobe lesions have tumors, such as hamartomas and gangliogliomas. The rest have scars from trauma and other causes or lack a distinct histological lesion. Diagnostic considerations Clinicians must distinguish epileptic seizures from two other transient behavioral events,
  11. 11. – – • • • • • • • syncope and nonepileptic seizures (pseudoseizures). Syncope Syncope is a loss of consciousness, usually with premonitory lightheadedness, autonomic reactivity, a brief atonic ictus, and little or no postictal confusion. Syncope lacks the many characteristic features of seizures and a clear epileptiform EEG. Nonepileptic seizures are involuntary, psychogenically induced spells that, by definition, mimic many epileptic behaviors Differentiating epileptic seizures from nonepileptic seizures can be extremely difficult, and even epileptologists are incorrect 20 to 30 percent of the time. Patients with nonepileptic seizures are – most commonly women between the ages of 26 and 32 years of age
  12. 12. – – • with psychological stressors and poor coping skills. Approximately 10 to 15 percent of these patients have a true seizure disorder as well, and nonepileptic seizures may result from the elaborating or “highlighting” of their epileptic seizures. Nonepileptic seizures are most commonly characterized by – – unresponsiveness with motor activity that does not fit a typical complex partial or generalized tonic-clonic seizure In children, nonepileptic seizures are usually characterized by unresponsiveness, with violent and uncoordinated movements of the whole body. • • • • • However, every epileptic behavior can occasionally occur, including tongue biting and incontinence, and nonepileptic events are especially difficult to differentiate from the atypical motor behavior of frontal lobe epilepsy. The most helpful differentiation feature may be an ictal duration of 2 minutes or more. In addition, nonepileptic seizures – – – can often be induced with injections, hypnosis, or suggestions; and are poorly responsive to antiepileptic medications. Ultimately, the differentiation may require – – CCTV-EEG telemetry along with the assessment of the absence of a seizure-induced rise in serum prolactin levels. Nonepileptic seizures result from a variety of psychiatric conditions.The most common psychiatric disturbance among these patients is conversion disorder. – • usually occur in the presence of a witness; Patients with nonepileptic seizures who have conversion disorder have a high incidence of prior trauma or sexual or physical abuse. The remaining patients with nonepileptic seizures have – depression,
  13. 13. • • • • • • • – – – – dissociative disorders, anxiety disorders, PTSD, or borderline or other personality disorders. Additional diagnoses associated with nonepileptic seizures are – – – psychosis, impulse control problems, and mental retardation. Nonepileptic Seizures versus Epileptic Seizures-Preceding ictus Nonepileptic Seizures versus Epileptic Seizures--During ictus Nonepileptic Seizures versus Epileptic Seizures-after ictus malingering or feigning of epilepsy Nonepileptic seizures must be differentiated from those specifically due to the malingering or feigning of epilepsy for secondary gain Epileptic seizures lend themselves to malingering because of their behavioral and episodic nature and the lack of consistent physical or diagnostic findings.
  14. 14. • Malingered Seizures versus Nonmalingered Nonepileptic Seizures--Preceding ictus • Malingered Seizures versus Nonmalingered Nonepileptic Seizures--During ictus • Malingered Seizures versus Nonmalingered Nonepileptic Seizures--After ictus • Course and Prognosis • Most epileptic patients have a good prognosis. The majority of seizures can be controlled sufficiently with antiepileptic medications so that the patient can live a productive life. • Some seizures, such as absence seizures, tend to disappear by adulthood. • For epileptic patients who are medically intractable, epilepsy surgery offers a good alternative (e.g., temporal
  15. 15. lobectomy), provided that the focus can be localized. • In addition, most epileptic patients do not have psychiatric disorders, and others have psychiatric difficulties only if they endure many years of poorly controlled seizures. • For those with behavioral problems, antiepileptic drugs or epilepsy surgery may relieve some symptoms, such as hyposexuality and aggression, but may not affect the emergence of others, such as psychosis and suicidal behavior. Introduction to psychiatric manifestations of epilepsy • Epidemiology of Psychiatric manifestations of epilepsy
  16. 16. • • Epidemiological studies from communities, psychiatric hospitals, and epilepsy clinics report a 20 to 60 percent prevalence of psychiatric problems among epilepsy patients. Ictal – – • Prodromal symptoms: irritability, depression, headache, etc. Postictal confusion Peri-ictal psychoses • Concomitant with increased seizure frequency • Concomitant with decreased seizure frequency • Postictal psychoses Interictal psychosis and personality disturbances – – – • Nonconvulsive status: simple partial seizures, complex partial seizures, and periodic lateralizing epileptiform discharges Peri-ictal (includes prodromal, postictal, and mixed ictal) – – – • Ictal psychic symptoms Schizophreniform psychosis Personality disorders Gastaut-Geschwind syndrome Behavioral disturbances variably related to ictus – – Mood disorders (depression and mania) Anxiety disorders including panic and posttraumatic stress disorder
  17. 17. – – – – • • • • Aggression and violence Hyposexuality Suicide Other behaviors The most established association is between epilepsy and depression or dysthymia, These behaviors and others have different potential relationships to the ictus or seizure itself Pathological basis of psychiatric manifestations Although disputed by some investigators, several studies report more psychopathology among epileptic patients than among patients with chronic diseases that do not directly affect the brain. – it would suggest that the psychopathology is of biological origin rather than a less specific reaction to chronic disease.
  18. 18. • • • • • Furthermore, the pattern of behavioral changes in seizure patients appear specific to epilepsy. In summary, the psychiatric manifestations of epilepsy are heterogeneous disorders with potentially different causes. Nevertheless, 60 to 76 percent of adults with epilepsy, regardless of seizure type, have a temporal lobe focus, and many generalized tonic-clonic seizures are secondarily generalized from a temporal lobe focus without a preceding complex partial seizure. Moreover, psychic auras from the temporal lobe, particularly if associated with negative feelings (e.g., jamais vu and fear), predispose to psychosis or personality disorders. Psychiatric disturbances, primarily psychosis and personality disorders, are two to three times more common in patients with complex partial seizures, most of whom have a temporal focus,
  19. 19. compared to those with generalized tonic-clonic seizures; • Common neuropathology, genetics, or developmental disturbance • Ictal or subictal discharges potentiate abnormal behavior – Kindling or facilitation of a distributed neuronal matrix – Changes in spike frequency or inhibitory–excitatory balance – Altered receptor sensitivity, for example, dopamine receptors – Secondary epileptogenesis Absence of function at the seizure focus – Inhibition and hypometabolism surrounding the focus – Release or abnormal activity of remaining neurons – Dysfunction or downregulation of associated areas • • • • • • • Neurochemical – – Dopamine and other neurotransmitters Endorphins Gonadotrophins and other endocrine hormones Psychodynamic and psychosocial effects of living with epilepsy – – Dependence, learned helplessness, low self-esteem, weak defense mechanisms Disruption of reality testing Neurobiological and psychodynamic factors potentiate each other Sleep disturbance Antiepileptic drug related
  20. 20. • • • • • • • • • 1. Common neuropathology, genetics, or developmental disturbance Left hemisphere and temporal lobe lesions may be associated with a schizophreniform psychosis, and psychosis in epilepsy may be particularly frequent if there is specific underlying pathology or ventricular enlargement. Psychotic disorders may be more common with temporal dysplasia or neurodevelopmental abnormalities and depression with mesial temporal sclerosis. 2. Ictal or subictal discharges potentiate abnormal behavior by kindling or facilitating distributed neuronal connections, increasing limbic–sensory associations, or changing the overall balance between excitation and inhibition.
  21. 21. • Altered receptor sensitivity, for example, dopamine receptors • Secondary epileptogenesis • 3. Absence of function at the seizure focus • • • • • • such as the interictal hypometabolism observed on PET scans, may lead to depression or other interictal behavioral changes. Among epileptic patients with a schizophreniform psychosis, SPECT scans have shown reductions in cerebral blood flow in the left medial temporal region. Release or abnormal activity of remaining neurons. Dysfunction or downregulation of associated areas 4. Neurochemical changes endocrine or neurotransmitter changes, such as increased dopaminergic or inhibitory transmitters, decreased prolactin,
  22. 22. • • • • • • • • • • increased testosterone, or increased endogenous opioids, all of which can affect behavior. 5. psychodynamic factors neurobiological factors may be potentiated by, such as feelings of helplessness, learned helplessness, dependency, low self-esteem, and the disruption of reality testing. Gen reference articles Adachi N, Matsuura M, Okubo Y, Oana Y, Takei N: Predictive variables of interictal psychosis in epilepsy. Neurology. 2000;55:1310. Bear D, Fedio P: Quantitative analysis of interictal behavior in temporal lobe epilepsy. Arch Neurol. 1977;34:454. Dongier S: Statistical study of clinical and electroencephalographic manifestations of 536 psychotic episodes occurring in 516 epileptics between clinical seizures. Epilepsia. 1959;1:117. Hermann BP, Jones JE: Intractable epilepsy and patterns of psychiatric comorbidity. Adv Neurol. 2006:97:367.. Kanner AM, Stagno S, Kotagal P, Morris HH: Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies. Arch Neurol. 1996;53:258.
  23. 23. • • • • • • • Manchanda R, Freeland A, Schaefer B, McLachlan RS, Blume WT: Auras, seizure focus, and psychiatric disorders. Neuropsychiatry Neuropsychol Behav Neurol. 2000;13:13. [*Marsh L, Rao V: Psychiatric complications in patients with epilepsy: A review. Epilepsy Res. 2002;49:11. Oyebode F: The neurology of psychosis. Med Princ Pract. 2008;17:263. Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessendorf N: Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol. 2003;53:305. Riggio S: Psychiatric manifestations of nonconvulsive status epilepticus. Mt Sinai J Med. 2006;73:960. Swinkels WAM, Kuyk J, van Dyck R, Spinhoven Ph: Psychiatric comorbidity in epilepsy. Epilepsy Behav. 2005;7:37. Wong MT, Lumsden J, Fenton GW, Fenwick PB: Electroencephalography, computed tomography and violence ratings of male patients in a maximum-security mental hospital. Acta Psychiatr Scand. 1994;90:97. Reference articles related IJP • Neuro-Psychological Profile Of Epilepsy On LuriaNebraska Neuropsychological Battery B.P. Mishra, R. Mahajan, A. Dhanuka, R.L. Narang Indian Journal of Psychiatry, Year 2002, Volume 44, Issue 1
  24. 24. • • • • • • Psychiatric Aspects of Epilepsy N.G. Chakraborty Indian Journal of Psychiatry, Year 1966, Volume 8, Issue 3 IJP_psychiatric aspects of epilepsy_chakravarthy.pdf A Psycho-Social Study Of 180 Cases Of Epilepsy V. N Bagadia, D. V Jeste, A. S Charegaonkar, P. V Pradhan, L. P Shah Indian Journal of Psychiatry, Year 1973, Volume 15, Issue 4 Reference articles related to pediatric epilepsy Austin JK, Caplan R: Behavioral and psychiatric comorbidities in pediatric epilepsy: Toward an integrated model. Epilepsia. 2007:48:1639. Caplan R, Siddarth P, Stahl L, Lanphier E, Vona P: Childhood absence epilepsy: Behavioral, cognitive, and linguistic comorbidities. Epilepsia. 2008 [Epub ahead of print]. Ott D, Siddarth P, Gurbani S, Koh S, Tournay A: Behavioral disorders in pediatric epilepsy. Epilepsia. 2003;44:591. IJP article
  25. 25. • Psychiatric Disorders In Children With Temporal Lobe Epilepsy A Controlled Investigation G. D Shukla, S. C Katiyar Indian Journal of Psychiatry, Year 1981, Volume 23, Issue 1 Ictal Features Ictal psychic symptoms • Seizure discharges can produce – – semipurposeful automatisms and psychic auras, such • as mood changes, • derealization and • depersonalization, • and forced thinking. • • • The experience of epileptic derealization or depersonalization could impair realitytesting Some patients have pleasurable auras Another psychic aura is “forced thinking,” characterized by recurrent intrusive thoughts, ideas, or crowding of thoughts.
  26. 26. – Forced thinking must be distinguished from obsessional thoughts and compulsive urges. – Epileptic patients with forced thinking experience their thoughts as stereotypical, out-of-context, brief, and irrational, but not necessarily as ego dystonic. • Recurrent or prolonged simple partial seizures – – • do not result in alteration of consciousness or invariable abnormalities on EEG, and, if manifested by psychic auras, simple partial seizures may be difficult to distinguish from primary psychiatric disturbances. status epilepticus from complex partial seizures and absence seizures results in – prolonged alterations of responsiveness. – With the addition of various ictal auras, complex partial status epilepticus can appear psychotic.
  27. 27. • • • Ictal fear, which ranges from a vague apprehension to abject fright, has occurred without any other seizure manifestation, and ictal depression has extended days or longer after the seizure has passed. Cognitive disorders follow status epilepticus with simple partial seizures, complex partial seizures, or absence seizures. Peri-ictal features Prodomal features • Some patients experience prodromal symptoms – that begin at least 30 minutes before seizure onset, – last 10 minutes to 3 days, – and are continuous with irritability, depression, headache, confusion, and other symptoms. Peri ictal features Postictal confusion
  28. 28. • The postictal period is characterized by a confusional state – lasting minutes to hours or, occasionally, days. – Prolonged, postictal confusion may particularly follow right temporal complex partial seizures. • Some “twilight states” result from a protracted period of intermixed ictal and postictal changes. Peri-ictal features Perictal psychosis • • Concomitant with increased seizure frequency Concomitant with decreased seizure frequency • • postictal psychoses Peri-ictal psychotic symptoms often worsen with increasing seizure activity.
  29. 29. • Rarely, psychotic symptoms alternate with seizure activity. In this alternating psychosis, – – but when they are seizure free and their EEG has forced or paradoxical normalization, they manifest psychotic symptoms. – • when patients are having seizures, they are free of psychotic symptoms, This alternating pattern is much less common than the increased emergence of psychotic behavior with increasing seizure activity. An important peri-ictal psychiatric disorder consists of – • brief psychotic episodes that follow clusters of generalized tonic-clonic seizures (i.e., postictal psychosis). These psychotic episodes occur in patients who have – – complex partial seizures, – bilateral interictal discharges, frequent secondary generalization to tonic-clonic seizures,
  30. 30. – • • The postictal psychosis of epilepsy emerges after a lucid interval of 2 to 72 hours (with a mean of 1 day), during which the immediate postictal confusion resolves, and the patient appears to return to normal The postictal psychotic episodes last 16 to 432 hours (with a mean of 3.5 days) and often include – – – – • • and frequent discharges involving the left amygdala. grandiose or religious delusions, elevated moods or sudden mood swings, agitation, paranoia, and impulsive behaviors, but no perceptual delusions or voices are heard. The postictal psychoses remit spontaneously or with the use of low-dose psychotropic medication. Reference articles
  31. 31. • Kanemoto K, Kawasaki J, Kawai I: Postictal psychosis: A comparison with acute interictal and chronic psychoses. Epilepsia. 1996;37:551. Interictal feature schizophreniform psychosis Psychosis in general • • • • is the specific psychiatric disorder most clearly associated with epilepsy. The lifelong prevalence of all psychotic disorders among epileptic patients ranges from 7 to 12 percent patients whose epilepsy has a mediobasal temporal focus are especially at risk. Studies on the laterality of the seizure focus suggest an association of a left-sided focus with psychosis. • • Most epilepsy patients with a schizophreniform psychosis have
  32. 32. – a chronic interictal illness – without a known direct relationship to seizure events or ictal discharges. • Many of these patients, however, develop worsening psychotic symptoms that are concomitant with – – – • an increase in seizure frequency or with antiepileptic drug withdrawal, and a few others have worsening psychotic symptoms on control of the seizures (alternating psychosis). Epilepsy patients with this chronic interictal psychosis – – often have an early age of onset of seizures and a decade or more of poorly controlled partial complex seizures, usually with secondary generalized tonic-clonic seizures. • This interictal psychosis may evolve from prior recurrent postictal psychotic episodes. • Seizure control with antiepileptic drugs or removal of the seizure focus does not prevent the development of the interictal psychosis, which occasionally emerges for the first time after successful seizure treatment.
  33. 33. • • This disorder sometimes resembles a schizoaffective psychosis with intermixed affective symptoms. In addition, there are – – – – • • • • • • prominent paranoid delusions, relative preserved affect, normal premorbid personality, and no family history of schizophrenia Complex partial 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
  34. 34. • • • • • • • • • • • • Mediobasal temporal lesions, especially tumors 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 Reference articles related to psychosis
  35. 35. • • Slater E, Beard A: The schizophrenialike psychosis of epilepsy: Psychiatric aspects. Br J Psychiatry. 1963;109:95. Sachdev P. Schizophrenia-like psychosis and epilepsy: The status of the association. Am J Psychiatry. 1998;155:325. • Tarulli A, Devinsky O, Alper K: Progression of postictal to interictal psychosis. Epilepsia. 2001;42:1468. IJP article • Psychosis In Relation To Epilepsy - A Clinical Model Of Neuro – Psychiatry Indian Journal of Psychiatry, Year 1996, Volume 38, Issue 3 Interictal features Personality Disorders • Among epileptic patients, there is a high prevalence of personality disorders, including
  36. 36. – – – – • • and dependent disorders. dependent and avoidant personality traits. Not surprisingly, epileptic patients frequently lack a stable character structure and can be immature and impulsive This personality constellation partially explains the increased incidence of – – – • histrionic, The most common personality disorder in epilepsy is a borderline personality. – – • atypical or mixed, Patients with personality disorders tend to show – • borderline, irritability, suicide attempts, and intermittent explosive disorder. Those with epilepsy are – stigmatized,
  37. 37. – – – – • • and subject to difficulties in obtaining a job, driving an automobile, and maintaining a marriage. These psychosocial difficulties, along with any associated mental retardation, contribute to – – – • feared, the dependency, low self-esteem, and overall borderline personality traits present in many such patients. In addition, the experience of epileptic auras may contribute to the development of personality disorders. Studies with the Bear-Fedio Inventory, an MMPIlike instrument developed to assess these “epileptic traits,” found that epileptic patients with temporal lobe foci were – – sober and humorless, dependent, and
  38. 38. – – • had strong philosophical interests In addition, those with a left-sided focus had a more reflective ideational style and maximized their problems, – • circumstantial and whereas those with a right-sided focus had emotional tendencies and minimized their problems. Further investigations with the Bear-Fedio Inventory described these seizure patients as – having viscosity in interactions, – prominent religious interests, – a pronounced sense of personal destiny, – and deepened affect. • • Reference articles related to personality changes Swanson SJ, Rao SM, Grafman J, Salazar AM, Kraft J: The relationship between seizure subtype and interictal personality. Results from the Vietnam Head Injury Study. Brain. 1995;118:91
  39. 39. IJP article • Religious Conversion In Temporal Lobe Epilepsy G.D Shukla, B.C Katiyar, O.N Srivastava Indian Journal of Psychiatry, Year 1978, Volume 20, Issue 4 Interictal feature Gastaut-Geschwind Syndromes • • • Although there is no general epileptic personality, a group of traits termed the Gastaut-Geschwind syndrome occurs in a subset of patients with complex partial seizures. Some epilepsy patients with a temporal limbic focus develop a sense of the heightened significance of things. These patients are serious, humorless, and overinclusive and have an intense interest in philosophical, moral, or religious issues
  40. 40. • • Occasionally, epilepsy patients experience multiple religious conversions or experiences. In interpersonal encounters, they demonstrate viscosity, the tendency to talk repetitively and circumstantially about a restricted range of topics – • Viscosity may particularly occur in patients with left-sided or bilateral temporal foci. They can spend a long time getting to the point, give detailed background information with multiple quotations, or write copiously about their thoughts and feelings (hypergraphia). Behavioral Disturbances Variably Related to Ictus Mood Disorders • Depression
  41. 41. • • • • • • Depressive disorder is the most prevalent neuropsychiatric disorder in epilepsy, occurring in 7.5 to 25 percent of epileptic patients. Depression is also the main diagnosis among epileptic patients in mental hospitals. Depression is twice as common in epilepsy patients as in comparably disabled populations, suggesting that much of the depression in epilepsy patients is more than just a psychological reaction to a disability. Patients with interictal dysphoria tend to have frequent complex partial seizures, possibly with greater left-sided temporal foci, although this lateralization is not established. The experience of certain psychic auras, especially those with cognitive content, may predispose to interictal depression. These patients may have accompanying paranoia and hallucinations, emphasizing the continuum with psychotic disorders.
  42. 42. • • • • • • Several investigators also report 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 electroconvulsive therapy (ECT). The rare occurrence of ictal depression may not only outlast the actual ictus but also may lead to suicide. Depression also occurs peri-ictally. Postictal depression is common, and a prolonged depressive state occasionally follows complex partial seizures, even when ictal experiences do not include depression. Episodic mood disturbances, often with agitation, suicidal behavior, and psychotic symptoms, may occur with increasing seizure activity.
  43. 43. • • • • • • • • • • Mania Mood disorder due to epilepsy with manic features or with mixed features is much rarer than mood disorder due to epilepsy with depressive features or with major depressivelike features. Although a right temporal focus is a possible source of mania in epilepsy, this laterality is not established. Reference articles related to affective disorders Baker GA: Depression and suicide in adolescents with epilepsy. Neurology. 2006;66:S5. Blumer D, Montouris G, Davies K: The interictal dysphoric disorder: recognition, pathogenesis, and treatment of the major psychiatric disorder of epilepsy. Epilepsy Behav. 2004;5:826. Ekinci O, Titus JB, Rodopman AA, Berkem M, Trevathan E: Depression and anxiety in children and adolescents with epilepsy: Prevalence, risk factors, and treatment. Epilepsy Behav. 2008 [Epub ahead of print]. Fuller–Thomson E, Brennenstuhl S: The association between depression and epilepsy in a nationally representative sample. Epilepsia. 2008 [Epub ahead of print]. Jackson MJ, Turkington D: Depression and anxiety in epilepsy. J Neurol Neurosurg Psychiatry. 2005;76:i45.
  44. 44. • • • • Paradiso S, Hermann BP, Blumer D, Davies K, Robinson RG: Impact of depressed mood on neuropsychological status in temporal lobe epilepsy. J Neurol Neurosurg Psychiatry. 2001;70:180. Seethalakshmi R, Krishnamoorthy ES: Depression in epilepsy: Phenomenology, diagnosis and management. Epileptic Disord. 2007;9:1 Barry JJ, Ettinger AB, Friel P, Gilliam FG, Harden CL: Advisory Group of the Epilepsy Foundation as part of its Mood Disorder: Consensus statement: the evaluation and treatment of people with epilepsy and affective disorders. Epilepsy Behav. 2008;13 Suppl 1:S1. Williams D: The structure of emotions reflected in epileptic experiences. Brain. 1956;79:29. IJP articles
  45. 45. • • A Study To Assess Depression, Its Correlates And Suicidal Behaviour In Epilepsy; Rajesh Jacob, M. Suresh Kumar, R. Rajkumar, V. Palaniappun Indian Journal of Psychiatry, Year 2002, Volume 44, Issue 2ORIGINAL ARTICLE: High prevalence of depression among Iranian patients with first onset pseudoseizures Alireza Farnam, Mohammad Ali Goreishizadeh, Sara Farhang, Fatemeh Abdolaliyan Indian Journal of Psychiatry, Year 2008, Volume 50, Issue 4 Behavioral Disturbances Variably Related to Ictus Anxiety Disorders • • Anxiety and panic disorders occur among epileptic patients and must be distinguished from simple partial seizures manifesting as anxiety or panic. Anxiety may be present with depression or other psychopathology, as part of Cluster C
  46. 46. personality disorders, or independently as a generalized anxiety disorder. • • • Some patients with epilepsy clearly have posttraumatic stress disorder (PTSD) from the psychological trauma of their recurrent seizures. This may contribute to the prevalence of nonepileptic seizure epilepsy among patients with true epilepsy. Finally, among the impulse control disorders, intermittent explosive disorder is characterized by a prodromal of anxiety with increasing tension and irritability. Behavioral Disturbances Variably Related to Ictus Aggression • although the prevalence of epilepsy among prison inmates has been two to four times that among the general population, studies from the
  47. 47. United Kingdom and the United States have not found more violent crimes among prisoners with epilepsy than among prisoners without epilepsy. • • • • high violence rating scores are associated with abnormal temporal electrical discharges on EEG and temporal lobe abnormalities on CT. Moreover, patients with left temporal lobe seizure foci have higher scores on hostile feelings than other patients with epilepsy. Although aggression can occur in relation to an ictus, most aggression among epilepsy patients is not related to epileptiform activity. Aggression in epilepsy is usually associated with psychosis or with intermittent explosive disorder and correlates with – subnormal intelligence, – lower socioeconomic status (SES),
  48. 48. – childhood behavior problems, – prior head injuries, and – possible orbital frontal damage. • • • Simple violent automatisms, such as spitting or flailing the arms, can occur at the onset of complex partial seizures, and secondary violent automatisms can occur as a response to an unpleasant or emotional aura or peri-ictal sensation More commonly, nondirected violent movements, aimless destructive behavior, or angry verbal outbursts – – • occur during postictal delirium when patients misinterpret attempts to protect or restrain them or as a manifestation of postictal psychosis and subacute postictal aggression. The diagnosis of epilepsy is established by at least one specialist in epilepsy.
  49. 49. • The presence of epileptic automatisms are documented by history and by closed circuit television EEG telemetry. • The presence of violence during epileptic automatisms is verified in a videotape-recorded seizure in which ictal epileptiform patterns are also recorded on the EEG. • The aggressive act is characteristic of the patient's habitual seizures, as elicited by history. • A clinical judgment is made by the epilepsy specialist attesting to the possibility that the aggressive act was part of a seizure. • EEG, electroencephalogram. • Reference article related aggression IJP article • Crimes Of Persons With Epilepsy O Somasundaram Indian Journal of Psychiatry, Year 1972, Volume 14, Issue 4 Behavioral Disturbances Variably Related to Ictus sexuality • • Patients with epilepsy tend to be hyposexual Men have an increased risk of erectile dysfunction, suggesting a neurophysiological component, – • and studies of sex hormones suggest the possibility of a subclinical hypogonadotropic hypogonadism True ictal sexual manifestations are also unusual;
  50. 50. – – • • however, libidinous feelings, erotic sensations, sexual remembrances, and even orgasm rarely occur, primarily in women and probably from seizure discharges in the amygdala. In addition, ictal masturbation has occurred with absence status. Reference articles related to sexuality Morrell MJ, Guldner GT: Self-reported sexual function and sexual arousability in women with epilepsy. Epilepsia. 1996;37:1204. IJP article • Temporal Lobe Epilepsy : Phenomenology And Psycho-Sexul Manifestations G. D Shukla Indian Journal of Psychiatry, Year 1984, Volume 26, Issue 1 Behavioral Disturbances Variably Related to Ictus Suicide • The risk of completed suicide in epilepsy patients is four to five times greater than that among the nonepileptic population, • and those with complex partial seizures of temporal lobe origin have a particularly high risk, as much as 25 times greater.
  51. 51. • Death by suicide occurs in 3 to 7 percent of epilepsy patients • This increased risk of suicide continues even long after temporal lobectomy and successful control of seizures. • • • Most suicidal behavior among epileptic patients is not directly due to reactions to the psychosocial stressors of having a seizure disorder. Rather, these patients are likely to attempt suicide in conjunction with borderline personality behaviors and are likely to complete suicide during postictal psychosis. Contributors to successful suicides include – – – • paranoid hallucinations, agitated compunction to kill themselves, and occasional ictal command hallucinations to commit suicide. Reference articles related to suicide
  52. 52. • Jones JE, Hermann BP, Gilliam FG, Kanner AM, Meader KJ: Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy. Epilepsy Behav. 2003;4:S31 IJP article • CME: Self-injurious behavior: A clinical appraisal K Nagaraja Rao, CY Sudarshan, Shamshad Begum Indian Journal of Psychiatry, Year 2008, Volume 50, Issue 4 Behavioral Disturbances Variably Related to Ictus Other behavioral changes • A specific association of epilepsy with – – – – – dissociative identity disorder, depersonalization disorders, possession states, fugue states, and psychogenic amnesia • is intriguing but unresolved.
  53. 53. • • • In epilepsy, prolonged periods of compulsive wandering with amnesia have resulted from an admixture of ictal and postictal changes and have been termed poriomania. Among the somatoform disorders, some epileptic patients have a conversion disorder, often manifested as nonepileptic seizure events. Finally, patients with epilepsy are subject to other behavioral difficulties stemming from their epilepsy, such as – – – adjustment disorders, subtle cognitive effects of seizures, and the potential behavioral effects of antiepileptic medications. Management implications
  54. 54. • • In treating the neuropsychiatric disorders of epilepsy, a final consideration is altering the seizure management itself. In addition to the occasional behavior alleviated by strict seizure control, – allowing seizures under carefully controlled conditions, much like ECT, may relieve some cases of peri-ictal psychosis, depression, or other behaviors. • Psychiatrists and neurologists need to – – consider the seizure threshold lowering effects of some psychotropic medications, – • maximize the mood stabilizing and other psychotropic effects of antiepileptic drugs, and monitor the potential interaction of antiepileptic and psychotropic drugs. Antiepileptic Medications
  55. 55. • • In the treatment of psychiatrically disturbed epileptic patients, a first consideration is the behavioral effects of antiepileptic medications. Carbamazepine, valproate, lamotrigine, and gabapentink (Neurontin) have significant antimanic and modest antidepressant properties, probably through mood stabilization effects. – • • • • They have some efficacy in the long-term prophylaxis of manic and depressive episodes. Carbamazepine and valproate may also ameliorate some dyscontrolled, aggressive behavior in brain-injured patients. Clonazepam, in addition to its anxiolytic properties, can serve as a supplement to other antimanic therapies. Gabapentin also decreases anxiety and improves general well-being in some epilepsy patients. Carbamazepine and ethosuximide may have value for borderline personality disorder.
  56. 56. • • • • • • Encephalopathic changes occur at toxic levels of all antiepileptic drugs. Even at therapeutic levels, barbiturates may need discontinuation because of drug-induced depression, suicidal ideation, sedation, psychomotor slowing, and paradoxical hyperactivity in the very young and the very old. Gabapentin may induce aggressive behavior or hypomania, and vigabatrin (Sabril) may precipitate depression. In addition, clinicians need to be aware of the potential emergence of psychopathology on withdrawal of antiepileptic medications. Anxiety and depression are the most common emergent symptoms, but psychosis and other behaviors may also occur.
  57. 57. • • • • • • • • • • • • • • Seizure Threshold Lowering Effect of Psychotropic Medications-- high Antipsychotic Chlorpromazine (Thorazine Clozapine (Clozaril) Antidepressant Bupropion (Wellbutrin) Imipramine (Norfranil) Maprotiline (Ludiomil) Amitriptyline (Elavil) Amoxapine (Asendin) Nortriptyline (Aventyl) Seizure Threshold Lowering Effect of Psychotropic Medications– Moderate antipsychotics Most piperazines
  58. 58. • • • • • • • • • • • • • • • Thiothixene (Navane) antidepressants Protriptyline (Vivactil) Clomipramine (Anafranil) Other drugs Lithium (Eskalith) Seizure Threshold Lowering Effect of Psychotropic Medications– Low Antipsychotics Fluphenazine (Prolixin) Haloperidol (Haldol) Loxapine (Loxitane) Molindone (Moban) Pimozide (Orap) Thioridazine (Mellaril) Risperidone (Risperdal)
  59. 59. • • • • • • • • • • • • • • • Olanzapine (Zyprexa) Ziprasidone (Geodon) Aripiprazole (Abilify) Antidepressants Doxepin (Sinequan) Desipramine (Norpramin) Trazodone (Desyrel) Trimipramine (Surmontil) Selective serotonin reuptake inhibitors Other psychotropics Ethchlorvynol (Placidol) Glutethimide (Doriden) Hydroxyzine (Vistaril) Meprobamate (Equanil) Methaqualone (Quaalude)
  60. 60. • • • • Psychotropic medications A second consideration is the seizure threshold lowering effect of psychotropic medications. This is usually not a problem but can occasionally reach clinical significance in poorly controlled epilepsy. Psychotropic drugs are most convulsive with rapid introduction of the drug and in high doses. – • • • Clozapine (Clozaril), for example, has induced seizures in 1.0 to 4.4 percent of patients, particularly when the dose was rapidly increased. When initiating psychotropic therapy, it is best to start low and go slow while monitoring antiepileptic levels and EEGs. Drug Interactions A third treatment consideration is the potential for interaction of antiepileptic and psychotropic medications.
  61. 61. • • • • Most commonly, an antiepileptic drug increases the metabolism of a psychotropic drug with a consequent decrease in its therapeutic efficiency. Conversely, withdrawal of antiepileptic drugs can precipitate rebound elevations in psychotropic levels. Moreover, the initiation of a psychotropic drug may result in competitive inhibition of antiepileptic drug metabolism with elevations of antiepileptic drug levels to toxicity. In comparison to older drugs, the new antiepileptic medications have fewer potential interactions with psychotropic medications. – • Gabapentin, lamotrigine, vigabatrin, and tiagabine (Gabitril) are relatively free of enzyme-inducing or -inhibiting properties. Antiepileptic-Psychotropic Drug Effects on Blood Levels
  62. 62. • • Reference articles related to pharmacotherapy Ettinger AB: Psychotropic effects of antiepileptic drugs. Neurology. 2006;67:1916. • Schmitz B: Effects of antiepileptic drugs on mood and behavior. Epilepsia. 2006;47(Suppl 2):28. IJP article • • • • CASE REPORT: Valproic acid-induced abnormal behavior Nanjangud Chandrashekar Nagalakshmi, Madhan Ramesh, Gurumurthy Parthasarathi, Anand Harugeri, Mary Sam Christy, Belur Seshachala Keshava Indian Journal of Psychiatry, Year 2010, Volume 52, Issue 1 Neurosurgical aspects Epilepsy surgery is a fourth treatment consideration and is limited to patients with medically intractable seizures. The main operation involves resection of epileptogenic tissue by removal of 4 to 6 cm of the anterior temporal lobe. – – More than 80 percent of temporal lobectomy patients experience some reduction in their seizure frequency, and more than 50 percent of patients are entirely seizure free. Removal of the amygdala and most of the hippocampus may have postoperative behavioral effects .
  63. 63. – – and patients occasionally develop a transient postoperative affective disorder. – Others experience a reduction in postictal psychosis, depression, and hyposexuality, – but epileptic patients may continue to develop interictal psychosis, personality changes, and suicidal behavior even long after the temporal lobectomy. – • Some patients have an anomia or a verbal memory deficit after resection of the dominant hemisphere, Moreover, patients with preoperative psychotic symptoms are at higher risk for a poor surgical outcome and postoperative psychosis. Less common epilepsy surgeries include – – – • resection of extratemporal lesions, removal of the epileptogenic hemisphere, and ligation of the corpus callosum. Corpus callosotomy,
  64. 64. – which aims to prevent the interhemispheric spread of seizures, – results in a unique, transient disconnection syndrome of mutism, apathy, agnosia, apraxia of the nondominant limbs, difficulty naming, and writing with the nondominant hand. References CTP 9TH ED SOP 10TH • • • Further reading Ettinger AB, Kanner AM: Psychiatric Issues in Epilepsy: A Practical Guide to Diagnosis and Treatment. New York: Lippincott Williams & Wilkins; 2006. *Schachter SC, Holmes GL, Kasteleijn-Nolst Trenite DGA, eds. Behavioral Aspects of Epilepsy: Principles and Practice. New York: Demos Medical Publishing; 2008.