This interesting ppt deals with the Pharmacology of Antiepileptic drugs and the treatment of different types of seizures with beautiful illustrations....
This interesting ppt deals with the Pharmacology of Antiepileptic drugs and the treatment of different types of seizures with beautiful illustrations....
Lametec (Lamotrigine Tablets) is an antiepileptic drug (AED) used for adjunctive therapy for Epilepsy in patients 2 years of age and above, Epilepsy monotherapy in patients 16 years of age and above and Bipolar Disorder in patients 18 years of age and above.
-Management of various of forms of epilepsies including treatment of status epilepticus
-Status of newer anti-epileptic drugs in treatment of epilepsies
Anticonvulsants are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Charles Locock commented in the Lancet on his use of potassium bromide in 15 cases of "hysterical" epilepsy in young women. The next development was the serendipitous discovery of the anticonvulsant properties of phenobarbital by Alfred Hauptmann in 1912. This predated by more than 20 years the screening of potential therapeutic agents against "electrical seizures" in cats by Houston Merritt and Tracy Putnam. The result was the launching of phenytoin in 1938. Next came primidone, ethosuximide, carbamazepine and valproic acid, all of which can be regarded as first generation antiepileptic drugs (AEDs). Shortly after their synthesis, the benzodiazepines were rapidly recognised as having anticonvulsant activity. The modern era focused on the systematic screening of many thousands of compounds against rodent seizure models under the Anticonvulsant Drug Development Program in the US. This resulted in the global licensing, in chronological order, of vigabatrin, zonisamide, oxcarbazepine, lamotrigine, felbamate, gabapentin, topiramate, tiagabine, levetiracetam, pregabalin and lacosamide.
anti epileptics drugs is a part of pharmacology. the topic contain information regarding epilepsy and their drug. ppt is short and simple and have correct information
Adcapone Tablets (Generic Entacapone Tablets) are used as an adjunct to Levodopa and Carbidopa to treat end-of-dose “wearing-off” in patients with Parkinson’s disease.
Entacapone tablets effectiveness has not been systematically evaluated in patients with Parkinson’s disease who do not experience end-of-dose “wearing-off”.
Lametec (Lamotrigine Tablets) is an antiepileptic drug (AED) used for adjunctive therapy for Epilepsy in patients 2 years of age and above, Epilepsy monotherapy in patients 16 years of age and above and Bipolar Disorder in patients 18 years of age and above.
-Management of various of forms of epilepsies including treatment of status epilepticus
-Status of newer anti-epileptic drugs in treatment of epilepsies
Anticonvulsants are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Charles Locock commented in the Lancet on his use of potassium bromide in 15 cases of "hysterical" epilepsy in young women. The next development was the serendipitous discovery of the anticonvulsant properties of phenobarbital by Alfred Hauptmann in 1912. This predated by more than 20 years the screening of potential therapeutic agents against "electrical seizures" in cats by Houston Merritt and Tracy Putnam. The result was the launching of phenytoin in 1938. Next came primidone, ethosuximide, carbamazepine and valproic acid, all of which can be regarded as first generation antiepileptic drugs (AEDs). Shortly after their synthesis, the benzodiazepines were rapidly recognised as having anticonvulsant activity. The modern era focused on the systematic screening of many thousands of compounds against rodent seizure models under the Anticonvulsant Drug Development Program in the US. This resulted in the global licensing, in chronological order, of vigabatrin, zonisamide, oxcarbazepine, lamotrigine, felbamate, gabapentin, topiramate, tiagabine, levetiracetam, pregabalin and lacosamide.
anti epileptics drugs is a part of pharmacology. the topic contain information regarding epilepsy and their drug. ppt is short and simple and have correct information
Adcapone Tablets (Generic Entacapone Tablets) are used as an adjunct to Levodopa and Carbidopa to treat end-of-dose “wearing-off” in patients with Parkinson’s disease.
Entacapone tablets effectiveness has not been systematically evaluated in patients with Parkinson’s disease who do not experience end-of-dose “wearing-off”.
Overview of intravenous anti-epileptic drugs, including benzodiazepine(BZD), phenytoin, valproate, levetiracetam, phenobarbital, lacosamide and general anesthetics.
LGS Foundation 2016 Conference - Friday MorningLGS Foundation
Topics Include: Therapies for LGS (Part One) - Pharmacological, presented by Angus A WIlfong, MD and Therapies for LGS (Part 2) - Non-Pharmacological presented by Scott Demarest, MD
40 slides that focus on the drugs used to treat epilepsy (anti-epileptic drugs) and their their primary molecular mechanisms of action. Produced by Stephen Kelley (University of Dundee, UK).
Epilepsy Management: Key issues and challengesPramod Krishnan
This brief presentation summarises the key issues and challenges in Epilepsy management, including diagnosis, treatment, compliance, special populations, adverse effects, psychiatric comorbidities and ASM withdrawal.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
APA Workshop Slides 05.20.15 What Every Psychiatrist Needs to Know About Epilepsy
1. 5/20/15
1
New Anti-Seizure
Medications
Elia M Pestana Knight, MD
Cleveland Clinic
Epilepsy Center
Nothing to disclose
2. 5/20/15
2
Topics for this lecture
Antiepileptic Drugs
What are antiepileptic drugs?
Historical development of the drugs
How doctors select the drugs to treat the
seizures?
Common side effect
Drug interactions
A case for the need of Epilepsy and
Psychiatry team interaction
Antiepileptic Drugs
3. 5/20/15
3
What are antiepileptic drugs?
Antiepileptic drugs (AEDs)
Anticonvulsant medications
Antiseizure medications
4. 5/20/15
4
Antiseizure medications
Drugs that decrease the frequency and/or
severity of seizures in people with epilepsy
Treat the symptom of seizures, not the
underlying epileptic condition
They don’t change the course of the disease
Antiepileptic drugs
Drugs that prevent the development of recurrent
seizures in people at risk
Drugs that reduce seizure frequency and severity
outlasting the treatment period
Example: after head trauma, stroke, brain tumors, etc.
Animal studies suggest that Levetiracetam and
Ethosuximide are potential antiepileptic drugs BUT
there are no studies in humans to support this
5. 5/20/15
5
Use of antiseizure medications
Epilepsy
Pain treatment
Neuralgias, neuropathic pain, etc.
Migraine prophylaxis
Treatment of bipolar disorder, mood disorder
and anxiety
Historical development of the
drugs
6. 5/20/15
6
History of AEDs in the U.S.
1857 – Bromides
1882 – Paraldehyde (not longer in use in USA)
1912 – Phenobarbital (PB)
1937 – Phenytoin (PHT)
1944 – Trimethodione
1953 – Acetazolamide
1954 - Primidone
1960 – Ethosuximide
1963 - Diazepam
1974 – Carbamazepine (CBZ)
1972 – Clorazepate and Lorazepam
1975 – Clonazepam (CZP)
1978 – Valproate (VPA)
New AEDs in the U.S.
1993 – Felbamate (FBM), gabapentin (GBP)
1995 – Lamotrigine (LTG)
1996 – Fosphenytoin
1997 – Topiramate (TPM), tiagabine (TGB)
1999 – Levetiracetam (LEV)
2000 – Oxcarbazepine (OXCBZ), zonisamide (ZNS)
2005 - Pregabalin (PGB)
8. 5/20/15
8
Other treatments, diet and
devices
Sex hormones: Progesterone
Diets: Ketogenic diet, Low glycemic diet,
modified Atkins diet
Devices: Vagus Nerve Stimulator (VNS) and
Neuropace
Epilepsy Surgery
How doctors select the drugs to
treat the seizures?
9. 5/20/15
9
Selecting the AEDs
Seizure types or syndrome
Rational polytherapy
Age of the patient (oral suspension, chewable,
sprinkles for children)
Dosing schedule
Comorbidities and other medical conditions
Potential side effects and toxicity
Interaction with other drugs
Cost-effectiveness
Goals of treatment
Reduced number of seizures
Minimal adverse events or side effects
Best quality of life possible
10. 5/20/15
10
Common side effects
Adverse Effects
Acute dose-related: reversible
Idiosyncratic
Uncommon - rare
Potentially serious or life threatening
Chronic: reversibility and seriousness vary
11. 5/20/15
11
Acute - Dose-Related Adverse
Effects of AEDs
Neurologic/psychiatric: most common
• Sedation, fatigue
- All AEDs, except unusual with LTG and FBM
- More pronounced with traditional AED
• Unsteadiness, poor coordination, dizziness
- Mainly traditional AEDs
- May be sign of toxicity with many AEDs
• Tremor – valproate
• Depression ????
Acute, Dose-Related Adverse
Effects of AEDs (cont.)
• Parenthesis (topiramate, zonisamide)
• Diplopia, blurred vision, visual distortion
(carbamazepine, lamotrigine)
• Mental/motor slowing or impairment (topiramate at
higher doses)
• Mood or behavioral changes (levetiracetam)
• Changes in libido or sexual function
(carbamazepine, phenytoin, phenobarbital)
12. 5/20/15
12
Acute, Dose-Related Adverse
Effects of AEDs (cont.)
Gastrointestinal (nausea, heartburn)
Mild to moderate laboratory changes
• Hyponatremia: carbamazepine, oxcarbazepine
• Increases in ALT or AST: valproate
• Leukopenia:
• Thrombocytopenia: valproate
P-Slide 23
Acute, Dose-Related Adverse
Effects of AEDs (cont.)
Weight gain/appetite changes
Valproic acid
Gabapentin
Pregabalin
Weight loss
Topiramate
Zonisamide
Felbamate
P-Slide 24
13. 5/20/15
13
Idiosyncratic Adverse
Effects of AEDs
Toxic Epidermal necrolysis
Stevens-Johnson syndrome
More common in lamotrigine, patients receiving valproate and/
or aggressively titrated.
Signs of potential Stevens-Johnson syndrome
Hepatic damage
Early symptoms: abdominal pain, vomiting, jaundice
Laboratory monitoring probably not helpful in early detection
Patient education
Fever and mucus membrane involvement
HLA-B 1502 and AED induced
rash
Racial groups: Han Chinese and other South
East Asian groups
Drugs: Carbamazepine, Oxcarbazepine,
Phenytoin, Fosphenytoin
US FDA recommendations:
Genotypic all Asian descend patients before
therapy
(Ferrell and McLeod. Pharmacogenomics 2008)
14. 5/20/15
14
AED Hypersensitivity
Syndrome
Characterized by rash, systemic involvement
hydrolase
Cross-reactivity
Phenytoin
Carbamazepine
Phenobarbital
Oxcarbazepine
Relative cross reactivity - lamotrigine
Idiosyncratic Adverse
Effects of AEDs
Hematologic damage
Marrow aplasia, agranulocytosis, aplastic anemia
Early symptoms: abnormal bleeding, acute onset of fever,
symptoms of anemia
Laboratory monitoring probably not helpful in early
detection
Felbamate aplastic anemia approx. 1:5,000 treated
patients
Patient education
16. 5/20/15
16
Drug interactions
Pharmacokinetic Interactions
Be aware that drug interactions may occur when
there is the:
Addition of a new medication when an inducer/
inhibitor is present.
Addition of inducer/inhibitor to an existing
medication regimen.
Removal of an inducer/inhibitor from chronic
medication regimen.
17. 5/20/15
17
Hepatic Drug Metabolizing Enzymes
and Specific AED Interactions
Phenytoin: CYP2C9/CYP2C19
Inhibitors: valproate, ticlopidine, fluoxetine, topiramate,
fluconazole
Carbamazepine: CYP3A4/CYP2C8/CYP1A2
Inhibitors: ketoconazole, fluconazole, erythromycin,
diltiazem
Lamotrigine: UGT 1A4
Inhibitor: valproate
Important note about oral contraceptives (OCPs):
OCP efficacy is decreased by inducers,
including: phenytoin, phenobarbital, primidone, carbamazepine;
and higher doses of topiramate and oxcarbazepine
OCPs and pregnancy significantly decrease serum levels of
lamotrigine.
Potent inducers
Carbamazepine, Phenobarbital, Phenytoin
Effect of induction is seen within the first 3 weeks of treatment
Caution when prescribing Bupropion, Quetiapine, etc
Definitively have a significant effect over the metabolism of
Sex hormones
Vitamin D
Thyroid hormones
Lipid metabolism
Folic acid
18. 5/20/15
18
Mild inducers
Clobazam, eslicarbazepine, felbamate,
lamotrigine, oxcarbazepine, rufinamide,
topiramate, vigabatrin, and vaproic acid
Can be inducers at higher doses
Sometime have combined inhibitor effects
It can take months before the maximum effect
is seen
Effect on systemic metabolism is present at a
lesser degree
AEDs and Drug Interactions
Although many AEDs can cause pharmacokinetic
interactions, several agents appear to be less
problematic.
AEDs that do not appear to be either inducers or
inhibitors of the CYP system include:
Gabapentin
Lamotrigine (low dose)
Pregabalin
Tiagabine
Levetiracetam
Zonisamide
P-Slide 36
19. 5/20/15
19
AEDs and Foods
Grapefruit juice
A case for the need of Epilepsy
and Psychiatry team interaction
20. 5/20/15
20
Case 1. Marcella
15 years old
left handed female
refractory right parieto-occipital epilepsy status post
partial right occipital cortical resection at age 13
years
seizure-free for a month
Seizures recurred
Past Antiepileptic Medications
Carbamazepine, Lamotrigine, Zonisamide
Current Antiepileptic Medications
• Keppra 2,000 mg bid
• Trileptal 1,200 mg bid
• Other Meds: Prozac, Folic acid,
multivitamin, Vitamin D
22. 5/20/15
22
Pre-op PET
Pre-op Neuropsychological
Evaluation
Report :
Full scale IQ=77(6th%-borderline)
Verbal scale=78(7th%-borderline)
Performance scale=81(10th%-borderline)
Visual immediate memory=109(73rd%-high average)
Visual delayed memory=103(58th%average to high
average)
Verbal immediate memory=69(2nd%-low average to poor)
Verbal delayed memory=72(3rd%-low average to poor)
23. 5/20/15
23
Her Medical Comorbidities
Morbid Obesity
Weight = 145 kg = 319 lbs
Mild to Moderate Asthma
Obstructive Sleep Apnea
Her Neuropsychiatric Comorbidities
Depression
treated with Prozac
10mg
suicidal ideation
Anxiety
not treated
Migraine without aura
chronic daily
headaches
Learning disability
in need of IEP
home schooled
Epilepsy stigma
bullying at school
poor peer
acceptance
24. 5/20/15
24
Anesthesiologist
Sleep Medicine
Pulmonologist
Endocrinologist
Neurosurgeon
Epileptologist
Psychiatrist
Pediatrician
Child and Family
The Knowledge Program
Developed at the Cleveland Clinic
Screening tool for neuropsychiatry
comorbidities
Katzan I et al. 2011
25. 5/20/15
25
Take home points
Antiseizure medications are prescribed taking
into account a number of factors
Keep in mind drug drug interaction when
prescribing antiseizure medications
A multidisciplinary team, that includes a
Psychiatrist, is a very important part of the
care for patients with epilepsy
QUESTIONS
26. 5/20/15
26
Jana E. Jones, PhD
Associate Professor
Department of Neurology
University of Wisconsin
School of Medicine & Public Health
May 20, 2015
Anxiety Disorders
in Epilepsy
Outline
1. Anxiety & Adults with Epilepsy
2. Anxiety & Children with Epilepsy
3. Anxiety & Quality of Life
3. Treatment Options
4. Conclusions
27. 5/20/15
27
• 15%
to
25%
Community
prevalence.
• 16%
to
25%
Hospital
prevalence.
• 11%
to
32%
prevalence
among
surgery
candidates.
Vazquez & Devinsky, 2003
DSM/ICD
Based
Diagnoses
Victoroff
(1994)
32%
Manachanda
et
al.
(1996)
11%
Perini
et
al.
(1996)
16%
Altschuler
et
al.
(1999)
5%
Glosser
et
al.
(2000)
22%
Swinkles
et
al.
(2001)
25%
Jones
et
al.
(2007)
35%
Tellez-‐Zenteno
et
al.
(2007)
22%
Brandt
et
al.
(2010)
20%
Kanner
et
al.
(2010)
15%
Mean = 20%
Median = 21%
29. 5/20/15
29
• A large number of participants have more than one diagnosis (n=59).
(Jones et al., 2005)
30. 5/20/15
30
Anxiety
in
Pediatric
Epilepsy
Observational Studies
Authors Measure Outcome in epilepsy
__________________________________________________________
Ettinger et al. (1998) RCMAS 16% elevated anxiety
Williams et al. (2003) RCMAS 23% elevated anxiety
Baki et al. (2004) STAI 49% mild to mod. Anxiety
Vega et al. (2011) BASC 30% elevated anxiety
__________________________________________________________
31. 5/20/15
31
Controlled Studies
Authors Measure Outcome
_____________________________________________________
Oguz et al. (2002) STAI High state & trait anxiety
Baker et al. (2005) SADS/LOI High social anxiety
& obsessive
symptoms
Loney et al. (2008) RCMAS Elevated anxiety
_____________________________________________________
DSM
based
studies
Anxiety
Disorders
Alwash
et
al.
(2000)
48.5%
OM
et
al.
(2001)
13.0%
Adewuya
&
Ola
(2005)
31.4%
Caplan
et
al.
(2005)
36.0%
Jones
et
al.
(2007)
35.8%
32. 5/20/15
32
New Onset Sample
• Children
with
new-‐onset
epilepsy
(n
=
180)
and
healthy
first-‐degree
cousin
controls
(n
=
107).
• Study
parVcipants
were
recruited
from
pediatric
neurology
clinics
at
two
large
Midwestern
medical
centers.
• Children
with
epilepsy
were
included:
(1)
diagnosis
of
epilepsy
within
the
past
12
months
(2)
chronological
age
between
8–18
years
(3)
no
other
developmental
disabiliVes
(e.g.
auVsm,
intellectual
disability)
(4)
no
other
neurological
disorder
and
normal
clinical
MRI.
• Children
and
parents
parVcipated
in
a
structured
psychiatric
interview
(K-‐SADS)
at
baseline.
Prevalence
of
Current
Anxiety
Disorders
at
Baseline
Epilepsy
(n=180)
Control
(n=107)
Any
Axis
I
Disorder 113
(62.8%) 28
(26.2%)
Any
Anxiety
Disorder
70
(38.9%) 19
(17.8%)
Specific
Phobia
36
(20.0%) 11
(10.3%)
Social
Phobia
16
(8.9%) 1
(1.0%)
SeparaTon
Anxiety
13
(7.2%) 0
Generalized
Anxiety
Disorder
15
(8.3%) 5
(4.7%)
Anxiety
NOS
15
(8.3%) 6
(5.6%)
Number
of
Anxiety
Disorders
Single
Anxiety
Disorder 48
(68.6%) 15
(78.9%)
Two
or
More
Anxiety
Disorders 22
(31.4%)
4
(21.1%)
1
No
cases
of
Agoraphobia
and
Panic
Disorders
33. 5/20/15
33
0
2
4
6
8
10
12
14
16
18
20
22
24
Specific
Phobia
Social
Phobia
SeparaVon
Anxiety
Prevalence
(percent)
Median
Age
of
Onset
(years)
Common anxiety disorders in childhood: Prevalence and age of onset
(Kessler et al., 2012)
New
Onset
Epilepsy
with
&
without
Anxiety
36. 5/20/15
36
MRI Findings
• Anxiety is a common psychiatric
comorbidity in children with recent-onset
epilepsy.
• Potential neuroanatomical substrate
consisting of volumetric enlargement of
the amygdala. Daley et al. (2008) reported
a similar finding.
• Thinner cortex in orbital and other regions
of prefrontal cortex.
MRI findings
• There are abnormalities in brain structures
that are involved in the networks found in
individuals with anxiety disorders in the
general population.
• These anatomic findings:
– are evident early in the course of epilepsy.
– are not related to chronicity of seizures.
– are linked to a family history of anxiety and
depressive disorders.
37. 5/20/15
37
2 Year Follow-up
• Children with epilepsy returned for follow-
up 2 years after their baseline evaluation.
• Healthy controls also returned.
• The KSADS was repeated with child and
parent separately.
Jones et al.
(2015)
Jones et al., in progress
38. 5/20/15
38
In
epilepsy,
suicide
aMempters
had
elevated
anxiety
compared
to
those
with
no
history
of
suicide
aMempts.
Batzell
&
Dodrill
(1986)
• At
Baseline:
– 42%
children
with
epilepsy
and
anxiety
had
suicidal
thoughts.
– 45%
children
with
epilepsy
and
no
anxiety.
• At
Follow-‐up:
– 21%
children
with
epilepsy
and
anxiety
had
suicidal
thoughts.
– 34%
children
with
epilepsy
and
no
anxiety.
• Suicidal
thoughts
are
common
in
children
with
epilepsy
and
anxiety.
• Suicidal
thoughts
are
also
quite
common
in
children
with
epilepsy
without
anxiety.
39. 5/20/15
39
Poorer HRQOL is significantly associated with
increased symptoms of anxiety.
Proportion of variance in HRQOL accounted for by
demographic, clinical epilepsy and anxiety variables.
40. 5/20/15
40
Treatment Recommendations
• No
randomized
controlled
trials
for
the
treatment
of
anxiety
disorders
in
children
or
adults
with
epilepsy,
including
pharmacological
and
nonpharmacological
intervenVons.
• Very
lidle
evidence
regarding
specific
pracVce
parameters
for
the
treatment
anxiety
disorders
in
adults
or
children.
Baseline:
KSADS interview
Questionnaires
3-month follow up:
Booster session
Parent Meeting
Questionnaires
Level 7:
Begin Exposure Tasks
Parent Meeting
Questionnaires
Level 2:
Physical signs of anxiety
Level 1:
CBT & anxiety
Parent Meeting
Level 12:
Exposure Tasks
Parent Meeting
Questionnaires
Levels 8-11:
Exposure Tasks
Level 3:
Relaxation
Parent Meeting
Levels 4-6:
Anxious thoughts, coping
thoughts, problem solving, &
self-reward
Skill Building Phase
Skill Practice Phase
Camp Cope-A-Lot Intervention Outline
(Khanna & Kendall, 2008)
41. 5/20/15
41
(Blocher et al., 2013)r
(Jones et al., 2014)
al
Piers-Harris-2 at
baseline, week 7,
12 and 3 months
42. 5/20/15
42
Pharmacological Treatment
• There are no randomized controlled trials
of the use of SSRIs in the treatment of
anxiety disorders in adults or children with
epilepsy.
• There is evidence to suggest that seizure
frequency is not adversely impacted by the
introduction of SSRIs.
• Anxiety
is
common
in
adults
and
children
with
epilepsy.
• There
are
potenTal
neuroanatomical
substrates
idenTfied
in
children
with
epilepsy
similar
to
those
reported
in
the
general
populaTon.
• Anxiety
has
a
negaTve
impact
on
overall
QOL.
• Anxiety
is
frequently
under
recognized
and
under
treated.
43. 5/20/15
43
• Only
1/3
of
children
with
epilepsy
and
mental
health
problems
receive
treatment
(OM
et
al.,
2001).
• Parents
report
that
emoTonal
and
behavioral
problems
are
very
concerning
to
them
(Wu
et
al.,
2008).
• Neurologists
&
pediatricians
who
treat
children
with
epilepsy
feel
there
is
a
resistance
on
the
part
of
mental
health
providers
to
treat
children
with
epilepsy
(Smith
et
al.,
2007).
Acknowledgements
University
of
Wisconsin
UCLA
Bruce
P.
Hermann,
PhD
Rochelle
Caplan,
MD
Carl
Stafstrom,
MD,
PhD
David
Hsu,
MD,
PhD
Mayo/Nemours
Children’s
Hospital
Fred
Edelman,
MD
Raj
Sheth,
MD
Lucy
Zawadzki,
MD
Chris
Ikonomidou,
MD
Rosalind
Franklin
University
Daren
Jackson,
PhD
Michael
Seidenberg,
PhD
Kevin
Dabbs,
MS
Jacque
Blocher
Funding:
Connie
Sung,
MPh
RO1
NINDS
4435-‐06-‐07
Mayu
Fujikawa,
MS
People
Against
Childhood
Epilepsy
Michelle
Szomi
(PACE)
Dace
Almane,
MS
1KL2RR025012-‐01
Kelly
Darby,
MS
Kate
Young,
MS
44. 5/20/15
44
Gaston
Baslet,
M.D.
Division
of
Neuropsychiatry
Department
of
Psychiatry
Brigham
and
Women’s
Hospital
Harvard
Medical
School
I
have
no
conflicts
of
interest
to
disclose
I
will
be
discussing
off
label
use
of
medications
45. 5/20/15
45
Psychogenic Non Epileptic Seizures are
paroxysmal episodes of altered consciousness,
movement, sensation or experience resembling
epileptic seizures, but not associated with ictal
electrical discharges in the brain or other
recognized physiological paroxysms
Most
common
condition
misdiagnosed
as
epilepsy.
Average
of
7
years
until
correct
diagnosis
is
made.
25-‐33%
of
EMU
admissions
diagnosed
as
PNES.1
12%
in
outpatient
Neurology
Clinics.2
Annual
incidence
in
Scotland
is
3-‐5
per
100,000
but
this
is
an
underestimate.3
1. Reuber et al, Neurology, 2002; 2. Reuber, Epilepsy and Behavior, 2008;
3. Duncan et al, Epilepsy and Behavior, 2011.
47. 5/20/15
47
A.
One
or
more
symptoms
of
altered
voluntary
motor
or
sensory
function.
B.
Clinical
findings
provide
evidence
of
incompatibility
between
the
symptom
and
recognized
neurological
or
medical
conditions.
C.
The
symptom
or
deficit
is
not
explained
by
another
medical
or
mental
disorder.
D.
The
symptom
or
deficit
causes
clinically
significant
distress
or
impairment
in
social,
occupational,
or
other
important
areas
of
functioning
or
warrants
medical
evaluation
Specifier:
with
weakness
or
paralysis,
with
abnormal
movement
(PMD),
with
swallowing
symptoms,
with
speech
symptom,
with
attacks
or
seizures
(PNES),
with
anesthesia
or
sensory
loss,
with
special
sensory
symptom,
with
mixed
symptom.
Specifier:
acute
episode
(<
6
months),
persistent
(>
6
months).
Specifier:
with
psychological
stressor,
without
psychological
stressor.
American Psychiatric Association, 2013
PNES: Psychogenic Non-Epileptic Seizures; PMD: Psychogenic Movement Disorder.
Levels
of
Diagnostic
Certainty
History
Witnessed
event
EEG
Possible
+
By
witness
or
self-‐report/
description
No
epileptiform
activity
in
routine
or
sleep
deprived
interictal
EEG
Probable
+
By
clinician
who
reviewed
video
recording
in
person,
showing
semiology
typical
of
PNES
No
epileptiform
activity
in
routine
or
sleep
deprived
interictal
EEG
Clinically
established
+
By
clinician
experienced
in
diagnosis
of
sz
disorders
(on
video
or
in
person)
showing
semiology
typical
of
PNES
No
epileptiform
activity
in
routine
or
ambulatory
EEG
during
a
typical
ictus/
event
in
which
the
semiology
would
make
ictal
epileptiform
EEG
expectable
during
equivalent
epileptic
sz
Documented
+
By
clinician
experienced
in
diagnosis
of
sz
disorders,
showing
semiology
typical
of
PNES,
on
video
EEG
No
epileptiform
activity
immediately
before,
during
or
after
ictus
captured
on
ictal
video
EEG
with
typical
PNES
semiology
La
France
et
al,
Epilepsia,
2013
48. 5/20/15
48
Signs
that
favor
PNES
Evidence
from
primary
studies
Sensitivity
(%)
for
PNES
Specificity
(%)
for
ES
Long
duration
Fluctuating
course
Asynchronous
movements
Pelvic
thrusting
Side-‐to-‐side
head
or
body
movements
Closed
eyes
Ictal
crying
Memory
recall
Good
Good
Good
(FLS
excluded)
Good
(FLS
excluded)
Good
(convulsive
events
only)
Good
Good
Good
69
(events)
47-‐88
(patients)
44-‐96
(events)
9-‐56
(patients)
1-‐31
(events)
7.4-‐44
(patients)
25-‐63
(events)
15-‐36
(patients)
34-‐88
(events)
52-‐96
(patients)
13-‐14
(events)
3.7-‐37
(patients)
63
(events)
77-‐88
(patients)
96
96-‐100
93-‐96
93-‐100
96-‐100
92-‐100
96-‐100
92-‐100
74-‐100
97
100
100
96
90
Signs
that
favor
ES
Evidence
from
primary
studies
Sensitivity
for
ES
Specificity
for
ES
Occurrence
from
EEG-‐confirmed
sleep
Post-‐ictal
confusion
Stertorous
breathing
Good
Good
Good
(convulsive
events
only)
31-‐59
(events)
-‐
61-‐100
(events)
67
(patients)
61-‐91
(events)
100
-‐
88
84
100
Other
signs
Evidence
from
primary
studies
Gradual
onset
Non-‐stereotyped
events
Flailing
or
thrashing
movements
Opisthotonus
Tongue
biting
Urinary
incontinence
Insufficient
Insufficient
Insufficient
Insufficient
Insufficient
Insufficient
La
France
et
al,
Epilepsia,
2013
PNES:
psychogenic
non-‐epileptic
seizures
ES:
epileptic
seizures
Psychosocial
Factors
Child/Adult
Trauma
Family
Dysfunction
Interpersonal
communication
Adverse
life
events
Psychiatric
Conditions
Depression,
Anxiety,
PTSD
Somatoform
Disorders
Dissociative
Disorders
Personality
Disorders
Substance
Abuse
Eating
Disorders
Neurological
Conditions
Epilepsy
Migraine
Chronic
pain
Head
Trauma
Neuropsychological
Deficits/
Vulnerability
Traits
Avoidance
Impulsivity
Somatic
preoccupation
Alexithymia
Emotion
regulation
styles
Limited
effort
Suggestibility
?
PNES
49. 5/20/15
49
As
a
psychiatrist,
you
can
establish
the
diagnosis
of
PNES
after
carefully
reviewing
the
exam
and
tests
that
confirm
incompatibility
between
the
symptom
and
the
preserved
physiological
functioning.
Always
confer
with
a
neurologist.
Early
screening
for
risk
factors
can
help
you
formulate
an
explanatory
model
for
the
patient.
There
is
growing
evidence
of
effective
treatments
for
PNES,
mostly
based
on
psychotherapeutic
interventions.
50. 5/20/15
50
Symptom
Presentation
Engagement
Acute
treatment
Phase
Long-‐term
Follow-‐up
Baslet
et
al,
Clin
EEG
Neurosci,
2014
MDD:
Major
Depressive
Disorder;
Kanner
et
al,
Neurology,
1999
Class I, n = 13 Class II, n = 12 Class III, n = 20
Psychiatric variable n (%) n (%) n (%)
Recurrent MDD 1 (8) 2 (17) 14 (70)
Personality disorder 1 (8) 3 (25) 16 (80)
Chronic abuse 3 (23) 1 (8) 16 (80)
Denial of
psychosocial
problems
0 8 (75) 1 (5)
What
happens
after
an
acute
intervention
in
PNES?
51. 5/20/15
51
Patient
filled
postal
questionnaire
(n=164)
4.1
years
post-‐PNES
diagnosis
71%
of
patients
continue
to
be
symptomatic.1
Complaint
at
doctor’s
visit
over
6
months
(n=167)
5-‐10
years
post-‐PNES
diagnosis
26%
of
patients
continue
to
complain
of
seizures.
Significant
reduction
in
ED
visits
and
AED
prescription,
but
not
in
employment
rates.2
1. Reuber
et
al,
Annals
of
Neurology,
2003
2. Duncan
et
al,
JNNP,
2014
There
is
a
variety
of
outcome
patterns
in
PNES
patients.
Identifying
subgroups
of
patients
with
different
outcomes
may
help
customize
treatment
protocols
for
subpopulations
and
improve
overall
functional
outcomes.
55. 5/20/15
55
Falcone et al Psychiatric comorbidities in patients undergoing epilepsy
surgery- AES 2009
56. 5/20/15
56
EXAMPLE OF SEIZURE DRAWING THAT DEPICTS THE THEME OF
HELPLESSNESS OR DEPRESSION
10-year-old boy with complex partial seizures depicts himself inside a coffin, screaming,
‘‘Let me out!’’
57. 5/20/15
57
16-year-old boy with left temporal lobe epilepsy and generalized tonic–clonic seizures.
58. 5/20/15
58
Make sure that you listen,
make sure that you care,
make sure
you are watching —
something’s always there.
Adwoa Boakye
Release
Emily Good