Mental health psychiatric

1. EPILEPSY AND
PSYCHIATRIC ASPECTS
OF EPILEPSY
DR. D.ZIMBA (MD)

2. OBJECTIVES
 At the end of the lesson, students should be
able to:
1. Define (a)epilepsy (b) seizure (c) status
epilepticus
2. Know the different types of epilepsy
3. Know psychiatry aspects of epilepsy
4. Manage psychiatry patients with epilepsy
5. Give first aid in pre-ictal, ictal and post ictal
phases of epilepsy

3. Introduction
 SEIZURE - An abnormal, sudden
excessive, uncontrolled electrical
discharge of neurons within the
brain that may result in alteration
in consciousness, motor, or sensory
ability and or behaviour.
 When these electrical impulses
become excessive or uncontrolled,
a seizure results

4. Introduction Contn’d…
 Seizures is when the neurons of the brain are
synchronously active or firing. This happens due to
the opening of channels called excitatory or close up
of the channels called inhibitory neurotransmission
 The main excitatory neurotransmitter of the brain is
glutamate which interacts with the NMDA receptors
allowing calcium into the cell.
 The main inhibitory neurotransmitter is GABA
(gama-aminobutyric acid)that binds to GABA
receptors to open chloride channels inhibiting neuron
response.
 When they will be too much excitation and too
inhibition a person will experience signs such as
jerking.

5. Introduction Contn’d…
 Epilepsy or a seizure disorder is a chronic
condition that is characterized by recurrent
seizures.
 Epilepsy is the tendency to recurrent seizures,
where the seizure consists of paroxysmal
electrical discharge in the brain and its clinical
sequelae.
 Many clients with epilepsy have more than one
seizure type and may have other symptoms as
well, including psychiatric symptoms.

6. Introduction continuation
The tendency to recurrent seizures which
defines epilepsy must be distinguished from
isolated seizures that may be provoked by
many factors including drugs, hypoglycemia
and recurrent illness. However, epilepsy
also ha several important psychiatric
aspects, reflecting its description as the
bridge between psychiatry and neurology:
 The differential diagnosis of episodic
disturbances of behaviour (particularly
atypical attacks, aggressive behaviour,
sleep problems and pseudoseizures)

7. Introduction Contn’d…
Incidence
 About 1 in 30 people in USA have a
seizure at some stage.
 It is a common neuronal problem
affecting individuals irrespective of
their age, sex, location or geographical
positions.
Causes
 Most cases, are idiopathic (of unknown
cause), however there are certain
factors associated with the disease.

8. AETIOLOGY OF EPILEPSY
 Age at onset is an important clue to aetiology.
For example, in the newborn, birth injury,
congenital brain malformations and metabolic
disorders are common causes.
 History in adulthood of; head injury,
autoimmune disorders and neurodegenerative
disorders.
 seizure threshold may be lowered by drug
therapy including antipsychotics, tricyclic
antidepressants and bupropion. Sudden
withdrawal of substantial doses of any drug with
anticonvulsant properties , most commonly
diazepam or alcohol can precipitate seizures.

9. Etiological factors
 Genetic predisposition- 30% of
patients with epilepsy have first
degree relatives with seizure, mode of
inheritance are uncertain just thought
to be due to low seizure threshold.
 Trauma- diffused cerebral damage
result from either systemic infections
or a direct trauma to the brain in cases
of accidents, birth injury or trauma.

10. Etiological factors
 Poisoning- commonly caused by
chemicals or drugs which may include
lead, mercury, alcohol and
phenothiazides (antidepressants).
 Brain Tumours and abscesses- masses
or lesions in the cerebral cortex can
cause epilepsy.
 Encephalitis and other inflammatory
conditions.

11. Types of seizures
 There are over 30 types of seizures. We shall
look at 2 types of seizures.
 These are partial seizures and generalized
seizures.
 Partial seizures are of focal onset, which
means that they originate in a specific area of
the brain.
 They are further subdivided into simple
partial, and complex partial seizures.

12. Simple partial seizures
 People with Simple Partial seizures experience
the following:
 Uncontrollable jerky movements of body part
 The twitching may start in the thumb and then
spread to affect the hand and arm and possibly
include the affected side of the body
(Jacksonian seizure)

13. Simple partial seizures
 Sight and hearing impairment
 Sudden sweating and flushing
 Nausea
 Feelings of fear
 The patient may or may not lose
consciousness.
 The affected part may become paralyzed
for some time called Todd’s paralysis.

14. Complex partial seizure
 Also called temporal lobe epilepsy because
they arise from lesions in one or both
temporal lobes of the brain.
 May also arise from the frontal lobe.
 In addition, they have also been termed
psychomotor seizures because they cause
strange behaviours as well as movements.
 Seizure may be preceeded by an aura which is
a warning sensation characterized by feelings
of fear, abdominal discomfort, dizziness, or
strange odors and sensations.

15. Complex partial seizure
cont’d…
 Then the affected individual may appear to be in a
trance (staring at nothing)
 Followed by an episode of altered behaviour in which
the patient performs a series of repeated
movements in which a patient may continually rub
his hands or smack his lips continually (automatisms)
with no control over body movements.
 Occasionally, a prolonged period of confusion lasting
for hours to days with differing levels of awareness
and strange behaviours may develop

16. Generalized seizures or
grand mal epilepsy
 In these seizures, you have epileptic activity in
both hemispheres (halves) of the brain.
 The affected person usually loses consciousness
during these types of seizure, but sometimes it
can be so brief that no one notices.
 The muscles in the body may stiffen and/or jerk
and the person may fall down.
 The following is about the different types of
generalized seizures.

17. Generalized seizures or
grand mal epilepsy
Clonic- Tonic Seizure
 Tonic seizures
 Atonic seizures
 Myoclonic seizures
 Absence seizures

18. Generalized seizures or
grand mal epilepsy
 Clonic- Tonic Seizure
 It is one of the commonest types and almost
always occurs in stages.
 Prodromal phase: is the phase before the
actual seizure.
 It may last for hours to days, and is
characterized by a change in the patient’s
mood.
 In most cases, patient may become aware of
this and adjust his or her treatment.

19. Generalized seizures or
grandmal epilepsy
 Aura- Premonition: This stage may last for seconds or
minutes.
 Patient experiences sensation of either smell or feeling
of crawling insects on their body, ringing in their ears and
flashes of light.
 At this stage if there is any one near the patient they
should assist the patient as follows:
 Make patient lie down especially in lateral position in a
safe place.
 Roll a small handkerchief and place it in between the
upper teeth to avoid patient biting the tongue.
 Be near them and observe.

20. Generalized seizures or grand mal
epilepsy
Tonic stage: There is stiffening of the body, jaw closes tight
and the patient may utter a sound mistaken for a cry as there
is partial closure of the epiglottis.
 Increased forceful discharge of motor impulses causes
muscle contraction and if the patient was standing, he falls
down due to loss of consciousness.
 A patient may bite his tongue since his teeth are clenched.
 The process may last for a few minutes and if pad is not
placed in aura stage, you may not be able to do so due to
muscle rigidity.

21. Generalized seizures or
grand mal epilepsy
 Loosen all tight clothing i.e. tie, belt, and cuff.
 Roll patient to a semi prone position or lateral,
remove any dangerous items near the patient.
Put soft material under the patient’s head to
prevent damage to head.
 Advice onlookers to move away so that when the
patient wakes up he or she is not embarrassed.
 While twitching observe closely to see which part
of the body started twitching first.

22. Generalized seizures or grand mal
epilepsy
 Clonic stage: This is the stage of violent convulsions,
frothing from the mouth due to increased salivation and
patient can chew his tongue.
 If lying in supine position can aspirate his saliva and choke.
 Phase can last for seconds in some patients and several
minutes in other patients.
 There is throwing of arms and legs and can bang his head
against anything that is nearby.
 Patient has tachycardia and is sweating.
 Do not restrict the patient’s movements but remove any
dangerous objects nearby. Restrictions can lead to
fractures.
 Try to put a cushion under the patient’s head for
protection.

23. Generalized seizures or grand mal
epilepsy
 Comatose stage or stage of relaxation: This is
when movements cease and patient become
flaccid and may go into a comatose stage which
may lead to a deep sleep.
 May last for several minutes after which the
patient gains normal consciousness, some patients
may become confused, others may complain of
weakness and headache or generalized body
pains. Some patients may become violent.

24. Generalized seizures or
grand mal epilepsy
 When the muscles relax, clear airway by putting them
in a safer position, lateral or semi prone position to aid
drainage of secretions.
 Wipe out secretions, if messed, clean him up.
 In a hospital situation, tongue biting can be prevented
by use of a padded spatula.
 The head may be protected by a small pillow, or towel
and if possible put mattress on the floor.
 Suction machine must be available for sucking.
 Oxygen apparatus should be available.

25. Generalized seizures or
grand mal epilepsy
Tonic seizures
 The symptoms of a tonic seizure are like the first part of a tonic
clonic seizure.
 But, in a tonic seizure, one does not go on to have the jerking
stage (clonic). The affected person may just cry out.
Atonic seizures
 Atonic seizures are also called drop attacks. If you have atonic
seizures, you will lose all muscle tone and drop heavily to the
floor.
 These seizures are very brief and you will usually be able to get up
again straight away.
 However, you might hurt your face, nose or head when you fall.

26. Generalized seizures or grand mal
epilepsy
Myoclonic seizures
 These are usually isolated or short-lasting jerks
that can affect some or all of your body.
 They are usually too short to affect your
consciousness.
 The jerking can be very mild, like a twitch, or it
can be very forceful.
 Myoclonic seizures often only last for a fraction
of a second and you might have a single jerk or
clusters of several jerks

27. Generalized seizures or grand mal
epilepsy
Absence seizure or petit mal
 A brief and sudden loss of consciousness which
onlookers often do not notice.
 Typically occurs in childhood and is often only noticed
as the child falls further behind with school work
 Symptoms that are noticeable or observable may be
slight such as upward staring of the eyes.
 Staggering gait
 Twitching of the facial muscles

28. Generalized seizures or
grand mal epilepsy
 Absence seizure or petit mal Cont’d…
 No aura
 The person will often resume activity previously
involved before seizure in without realizing that the
seizure has occurred.
 In complex absences, automatism, as previously
described accompanies the brief alteration in
consciousness.
 Absences seizures are often precipitated by
hyperventilation and flashing lights

29. PRECIPITATING
FACTORS FOR
SEIZURES

30. CONDITIONS FACTORS
Physical • Overexertion
• Sleep deprivation
•Alteration in bowel
elimination
• Fever
• Recent head trauma
• Concurrent illness/infections
• Over-hydration

31. CONDITIONS FACTORS
Metabolic and electrolyte
imbalance
Low blood glucose
Low sodium
Low calcium
Low magnesium
Dehydration
hyperventilation

32. CONDITIONS FACTORS
Medication or chemical Withdrawal of alcohol or other
sedative agents
Administration of drugs with pro-
convulsant e.g. CNS stimulants a
anticholinergics including over th
counter antihistamines
Most dopamine blocking agents

33. DIAGNOSIS OF EPILEPSY
 Background history
 Examination
 Investigation ( you do an EEG to
confirm the diagnosis but not to
exclude the diagnosis).
 Blood tests

34. First Aid pre-ictal
1. Safety measures should be taken if there is an
indication that the person is experiencing an aura
before the onset of a seizure, (e.g., have the individual
lie down).
2. Determine if changes can be made in activities or
situations that may trigger seizures.
3. Keep the bed in a low position with side rails up, and
use padded side rails as needed.
4. (These precautions help prevent injury from fall or
trauma.)
5. Individuals with mental retardation or other
developmental disabilities may have altered bowel
habits, slowed activity, and /or decreased motor skills
before a seizure.

35. First Aid during a seizure: (Ictal stage)
1. When a seizure occurs, observe and document the
following:
i. Date, time of onset, duration
ii. Activity at time of onset
iii. Level of consciousness (confused, dazed, excited,
unconscious)
iv. Presence of aura (if known)
v. Movements:
vi. Body part involved
 - Progression and sequencing of activity (site of onset of
first movement is very important as well as pattern, order
of progression, or spreading involvement)

36. First Aid during a seizure
cont.'s…
2. Observe for type of motor activity
i. Clonic type(jerking)
ii. myoclonic (single jerk of muscle or limb)
iii. tonic (stiffening)
iv. abnormal posturing movements,
 - dystonia,
 - eyes: eye deviation, open, rolling or closed, eyelids
flickering
 - head turning,
 - twitching

37. First Aid during a seizure
cont.'s…
3. Ensure adequate ventilation.
i. Loosen clothing, postural support devices and/or restraints.
ii. DO NOT try to force an airway or tongue blade through clenched
teeth. (Forced airway insertion can cause injury.)
iii. Turn the person into a side-lying position as soon as convulsing has
stopped. (This will help the tongue return to its normal front-
forward position and will also allow accumulated saliva to drain
from the mouth.)
4. Protect the person from injury (e.g., help break fall, clear the
area of furniture).

38. First Aid during a seizure cont.'s…
5. DO NOT restrain movement. (Trying to hold down the
person's arms or legs will not stop the seizure.
Restraining movement may result in musculoskeletal
injury.)
6. Remain with the person and give verbal reassurance.
(The person may not be able to hear you during
unconsciousness but verbal assurances help as a person is
regaining consciousness.)
7. Provide as much privacy as possible for the individual
during and after seizure activity.
8. Provide other supportive therapy as ordered by
primary care prescriber or according to facility protocol.

39. First Aid after the Seizure:
(Post ictal Stage)
 1. After the seizure activity has ceased, record the
presence of the following conditions
i. gag reflex, decreased
ii. headache (character, duration, location, severity)
iii. incontinence (bladder and bowel)
iv. injury (bruises, burns, fractures, lacerations, mouth
trauma)

40. First Aid after the Seizure:
(Post ictal Stage)
Observe for residual deficit such as:
 - behavior change
 - confusion
 - language disturbance
 - poor coordination
 - weakness/paralysis of body part(s)
 - sleep pattern disturbance

41. First Aid after the Seizure:
(Post ictal Stage)
2. Allow the individual to sleep;
 reorient upon awakening.(The individual may experience
amnesia; reorientation can help regain a sense of control
and help reduce anxiety).
3. Conduct a post seizure evaluation
 What was the person doing prior to the seizure?
 Was this the first seizure?
 Review current medications including recent changes in
medicine and/or dose.
 Other illnesses?
 Possible precipitating factors

42. Diagnosis of epilepsy
 History
 Examination
 Brain imaging ( MRI, CT-scan)
 Electroencephalogram(EEG). To
detect the electrical activity of
the brain

43. Treatment of epilepsy
 Anticonvulsants
 Benzodiazepines for short periods and during
status epilepticus
 Carbamazepine (Tegretol) 100-200mg b.d
 Sodium valproate: 300mg b.d
 Phenytoin (Epanutin (PHT)) 150‐300mgs daily
 Phenobarbitone (PHB) 30 mgs daily
 Epilepsy surgery (to remove brain tumors etc)
 Nerve stimulation
 Ketogenic diet (high fat, low carbohydrates and
proteins)

44. Information Education and Communication
(IEC) to Family and Friends
1. Avoid constipation, excessive fatigue, hyperventilation and
stress because they may trigger seizures.
2. Seizures may increase around the time of menses.
3. Fever may trigger seizures, therefore, the fever and
underlying cause must be treated. If antibiotics are ordered,
interactions with anti-epileptic drugs (AEDs) should be
evaluated.
4. Environmental and recreational risk factors that should be
avoided or minimized:
a. Electric shocks
b. Noisy environments
c. Bright, flashing lights
d. Poorly adjusted televisions or computer screens

45. Information Education and
Communication (IEC) to Family and
Friends
5. Showers, rather than tub baths, should be taken, when possible.
6. Good oral hygiene and regular visits to the dentist are important to
minimize effects of gingival hyperplasia that can occur from some
AEDs.
Diet
 A well balanced diet should be eaten at regular times.
 Coffee and other caffeinated beverages should be limited to a
moderate amount.
 Fluid intake should be adequate (i.e. between 1,000 to 1,500 ml
per day (depending on the weather).
 Alcoholic beverages should be avoided.

46. Information Education and
Communication (IEC) to Family and
Friends
 Many different types of psychiatric disorders are
associated with epilepsy.
 They include cognitive, affective, emotional, and
behavioural disturbances.
 Ictal means seizure.
 Behavioural disturbances occur in relation to seizures.
 These can occur before (pre-ictal), during (ictal), after
(post-ictal), or between (inter-ictal) seizures.

47. Psychiatric aspects of epilepsy
 Psychiatric commodity is common in people with
epilepsy.
 Many different types of psychiatric disorder are
associated with epilepsy including ; cognitive,
affective, emotional and behavioural disturbances.
 The relationship between epilepsy and psychiatric
disorder may reflect any of the following factors;
• A shared aetiology or pathopathphysiology. For
example, temporal lobe pathology appears to
predispose epilepsy and to psychosis.
• The stigma and psychosocial impairments associated
with epilepsy.

48. Psychiatric aspects of
epilepsy……
 Depression and anxiety are common in
people with epilepsy for both
biological and psychological reasons.
 Suicide and deliberate self-harm are
more common among people with
epilepsy than the general population.
 Sexual dysfunction with reduced libido
and impaired performance is common
in patients with epilepsy. This is
thought due to epileptic medication.

49. Pre-ictal psychiatric disturbances
 Vague symptoms known as prodromal symptoms may be
experienced hours to days before a seizure.
 They include increasing tension, irritability, anxiety and
depression generally increasing as the seizure
approaches.
 An aura may occur just before the seizure and may
consist of derealization and depersonalization
experiences, perceptual experiences (auditory, visual,
sensory, and olfactory hallucinations or illusions).

50. Ictal psychiatric disturbances
 Ictal psychiatric disturbances (those directly related to
seizure activity) are common and diverse.
 During a seizure the following can occur:
 Transient confusional states
 Affective disturbances
 Anxiety
 Automatisms - are stereotyped movements that tend to
be disorganized and purposeless (although complex
actions may be carried out).

51. Ictal psychiatric
disturbances
 Abnormal behaviours (especially in partial
seizures)
 Abnormal mental state may be the only
sign of non convulsive (complex partial or
absence) status epilepticus and this
diagnosis can be easily overlooked.
 Psychoses may occur as an ictal
phenomena (perceptual disorders).
 Ictal violence is extremely rare.

52. Post-ictal disturbances
 Psychiatric disturbances may occur in the hours following a seizure.
 Psychotic symptoms are seen in about 10%.
 They may be due to long duration of epilepsy and structural brain
lesions.
 They may occur as part of a delirium (confusional state with
disorientation, inattention, variable levels of consciousness, and
sometimes paranoia) or in clear consciousness.
 Post ictal violence is rare but may be secondary to psychotic
experiences.
 If violence does occur, it is extreme, recurrent, stereotyped, and
more likely to occur in men, after a cluster of seizures.
 There is usually amnesia of the event.

53. Inter-ictal psychiatric disturbances
 Brief psychosis may occur unrelated to a seizure, even when
there is good control of epilepsy.
 Chronic ‘schizophrenia-like’ psychosis: A chronic
schizophrenia like psychotic illness is 6-12 times more
common in people with epilepsy than in the general
population.
 It is particularly associated with left temporal lobe
epilepsy, early severe epilepsy and in women with epilepsy.
 The onset of this illness is often 10-15 years after the
diagnosis of epilepsy has been made.
 Other disorders include cognitive impairments, personality
difficulties in a few people, depression and suicide.

54. Other presentations of psychiatric
disorders in people with epilepsy
 Cognitive deterioration is a common outcome of
chronic epilepsy and is caused by a number of factors
including repeated seizures with cerebral hypoxia as
well as the effects of chronic anti-convulsant therapy.
 Neurosis – There is an increased prevalence of
conversion disorder in epileptics, including an
increased risk of ‘pseudo seizures’.
 Mania in right Temporal Lobe Epilepsy (TLE).
 Epileptic personality syndrome – This is controversial
and is associated with Temporal Lobe Epilepsy.

55. Other presentations of psychiatric
disorders in people with epilepsy
 Traits include religiosity, hyposexuality, ‘viscosity of
personality’, ie, a personality that is not easy to get
along with.
 Violence – also a controversial issue.
 There is an increased risk of violence and aggression in
people with TLE (a lesion can lead to psychotic and
manic symptoms) or Frontal Lobe epilepsy (personality
and judgment affected, which leads to aggression).
 Anti-convulsants are often effective in reducing
aggressive outbursts.

56. STATUS EPILEPTICUS
 Status epilepticus is when the seizure lasts
more that 5 minutes or having multiple
seizures without coming to normal in
between.
 A status epilepticus occurs whenever a
seizure persist for at least 30minutes, or is
repeated so frequently that recovery
between attacks doesn’t occur.
 It is usually have tonic clonic seizures
 A status epilepticus is a medical emergency
and the patient should be treated with Iv
injection, to stop the seizures as quickly as
possible

57. STATUS EPILEPTICUS…..
 Status epilepticus is referred to as a
medical emergency. And patient are
usually treated with benzodiazepines.
 It is a dangerous condition which may
result in brain damage [cerebral
necrosis], a status may be the
patient’s first epileptic event or
maybe precipitated by sudden
discontinuing of anti-convulsants
therapy
 An initial status epilepticus in an adult
may be due to a brain tumor.

58. MGT OF EPILEPTICUS
STATUS
 Cease the seizures using diazepam 10 to 20mg IV
start or dilute phenobarbitone injection 1 in 10
with water for injection, 10mgkg give in less a
minute,
 Intravenous 5 to 10 percent of dextrose 1 litre,
 Give O2 therapy PRN

59. THE END