The document discusses neuropsychiatric aspects of epilepsy. It begins with definitions of key terms like seizure, epilepsy, and convulsion. It then provides epidemiological data on epilepsy prevalence and incidence globally. It describes different types of seizures including primary generalized seizures, partial seizures, and epilepsy syndromes. Causes of epilepsy including genetic, acquired, congenital, and withdrawal factors are outlined. Risk factors for developing epilepsy and common seizure triggers are mentioned. The pathophysiology involving glutamate and GABA neurotransmitters is explained. Finally, clinical presentations of different seizure types and differential diagnosis considerations are covered.
The association of neuropsychiatric disorders with cerebrovascular disease has been recognized by clinicians for over 100 years. Disease of the vascular system contribute greatly to the sum total of psychiatric disability, chiefly in the elderly population, mainly as a result of stroke, cerebrovascular accidents & subarachnoid haemorrhage.
This presentation looks at generalised periodic epileptiform discharges and the various disorders like Creutzfeldt Jacob disease (CJD), SSPE and metabolic encephalopathies in which it is seen. SIRPID is also discussed. Triphasic waves are described. Radermacker complexes in SSPE are described.
Neurocognitive disorders includes : Delirium and Dementia.
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Aging is associated with cognitive decline, and older subjects can have demonstrable cognitive impairment without crossing the threshold for dementia.
This condition has been termed “mild cognitive impairment” (MCI), and these patients have an increased risk of developing dementia, especially Alzheimer disease (AD).
Studies conducted in referral clinics have shown that patients with MCI progress to AD at a rate of 10% to 15% per year, and 80% of these patients have converted to AD after approximately 6 years of follow-up.
The identification and classification of MCI can be a major challenge.
This is a presentation done on 4/6/11 for the Grand Rounds at Wayne State university by Pallav Pareek M.D.
This presentation talks about the concept of prdrome as it is(if?) applicable to schizophrenia, and if schizophrenia is becoming more of a preventable illness as science progresses. If so what are the various ways and means in which we can accomplish this prevention.
Amidst so much controversy on the issue , whether there is a prodrome for this illness or not, here I have tried to present the recent advances in this field and the recent scientific literature in this regard.
La certificación BULATS están orientada a la preparación del examen homologado por Cambridge ESOL.
El exámen comprende las 4 DESTREZAS (Comprensión Auditiva y de Lectura, Expresión Oral, Expresión Escrita)
Valreklam 2 och Löfte 2 idag den 2.10 2015 ... och Valreklam 3 och Löfte 3 EritoCap Ltd
I promise my voters only promises I perform in majority or opposition in the Åland Parliament. These are promises nr 2 and 3. The precondition is that I get enough votes on Sunday 18.10 2015 election.
The association of neuropsychiatric disorders with cerebrovascular disease has been recognized by clinicians for over 100 years. Disease of the vascular system contribute greatly to the sum total of psychiatric disability, chiefly in the elderly population, mainly as a result of stroke, cerebrovascular accidents & subarachnoid haemorrhage.
This presentation looks at generalised periodic epileptiform discharges and the various disorders like Creutzfeldt Jacob disease (CJD), SSPE and metabolic encephalopathies in which it is seen. SIRPID is also discussed. Triphasic waves are described. Radermacker complexes in SSPE are described.
Neurocognitive disorders includes : Delirium and Dementia.
This presentation focuses on causes, risk factors, management and how to prevent its complication
Aging is associated with cognitive decline, and older subjects can have demonstrable cognitive impairment without crossing the threshold for dementia.
This condition has been termed “mild cognitive impairment” (MCI), and these patients have an increased risk of developing dementia, especially Alzheimer disease (AD).
Studies conducted in referral clinics have shown that patients with MCI progress to AD at a rate of 10% to 15% per year, and 80% of these patients have converted to AD after approximately 6 years of follow-up.
The identification and classification of MCI can be a major challenge.
This is a presentation done on 4/6/11 for the Grand Rounds at Wayne State university by Pallav Pareek M.D.
This presentation talks about the concept of prdrome as it is(if?) applicable to schizophrenia, and if schizophrenia is becoming more of a preventable illness as science progresses. If so what are the various ways and means in which we can accomplish this prevention.
Amidst so much controversy on the issue , whether there is a prodrome for this illness or not, here I have tried to present the recent advances in this field and the recent scientific literature in this regard.
La certificación BULATS están orientada a la preparación del examen homologado por Cambridge ESOL.
El exámen comprende las 4 DESTREZAS (Comprensión Auditiva y de Lectura, Expresión Oral, Expresión Escrita)
Valreklam 2 och Löfte 2 idag den 2.10 2015 ... och Valreklam 3 och Löfte 3 EritoCap Ltd
I promise my voters only promises I perform in majority or opposition in the Åland Parliament. These are promises nr 2 and 3. The precondition is that I get enough votes on Sunday 18.10 2015 election.
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Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
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He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
2. DEFINITIONS
Seizure /ictus/ fits
From a Latin word which means ‘to take possession of’
Paroxysmal event due to abnormal excessive, hyper
synchronous discharges from an aggregate of CNS neurons.
Epilepsy
Clinical phenomenon rather than a single identity.
Recurrent seizures due to chronic underlying process.
3. A convulsion is a medical condition where
body muscles contract and relax rapidly and repeatedly,
resulting in an uncontrolled shaking of the body.
Because a convulsion is often a symptom of
an epileptic seizures, the term convulsion is sometimes
used as a synonym for seizure. However, not all epileptic
seizures lead to convulsions, and not all convulsions are
caused by epileptic seizures.
4. Epidemiology of Epilepsy
Epilepsy knows no geographical, racial or social boundaries.
About 50 million people in World have Epilepsy.
It occurs in men and women and can begin at any age, but is
most frequently diagnosed in infancy, childhood, adolescence
and old age.
Prevalence:
Developed countries- 0.5% (0.4% - 1%)
Developing countries- five times higher
Incidence:
After infancy annual incidence- 20-70/100000 in developed
countries.
Developing countries- Incidence is double. (100/100000)
The life time risk of having a single seizure:
About 5%.
6. EPILEPSY SYNDROMES AND OTHER SPECIAL FORMS
Epilepsy syndromes are disorders in which epilepsy is a predominant
feature, and there is sufficient evidence (e.g., through clinical, EEG,
radiologic, or genetic observations) to suggest a common underlying
mechanism.
Epilepsy syndromes
Juvenile Myoclonic epilepsy
Lennox Gastaut syndrome
Mesial Temporal Lobe epilepsy
Infantile spasms / West’s syndrome
Landau-Kleffner syndrome (infantile acquired aphasia)
Other special forms
catamenial epilepsy
Reflex epilepsy eg : eating epilepsy , hot water epilepsy
Gelastic epilepsy
Diencephalic or autonomic
8. What Causes Epilepsy?
In about 70% of people with epilepsy, the cause is not known
In 30%, most common causes are:
Inherited genetic
Acquired : Trauma, Neuro surgery,
Inflammatory, Metabolic,
Infections, Tumor, Toxic disorders, drugs,
Congenital: inborn error of metabolism.
Withdrawal of drugs
Alcohol, Benzodiazepine,
Barbiturates, Other Anti-Epileptics
9. Psychiatric drugs
ANTI DEPRESSANTS
highest risk of seizures(0.5%)
– clomipramine 0.5%(tertiary amine
TCA )
– bupropion (0.4%, up to 2.2% with
doses higher than 450 mg per day)
– maprotiline (0.4%) (tetracyclic)
– Other TCAs: imipramine
Intermediate in risk
– SSRI :- fluoxetine, sertraline,
fluvoxamine, citalopram, and
paroxetine
– NSRI :- venlafaxine,.
Least risk
– monoamine oxidase inhibitors
(MAOIs)
http://www.epilepsy.com/information/professionals/diagno
sis-treatment/drugs-their-contribution-
seizures/antidepressants
Anti psychotics
– Highest risk:-
clozapine
loxapine
chlorpromazine
– Intermediate ( less than 1.0–1.2%)
fluphenazine
thioridazine
perphenazine
Trifluoperazine
– Least seizure-induction
haloperidol
molindone
pimozide
The antipsychotics of choice on the basis
both of epileptogenesis and of the side effect
profiles are atypical agents:
Risperidone, olanzapine, quetiapine
http://www.epilepsy.com/information/professionals/diagnosis-treatment/psychotropic-
drugs-developmental-disabilities/comorb-3
10. Seizure Triggers
Missed medication (#1 reason)
Stress, anxiety
Hormonal changes, Menses
Dehydration
Lack of sleep, extreme fatigue
Photosensitivity
Illicit Drug, alcohol use
Certain Medications
Fever in Some Children
11. Groups at Increased Risk for Epilepsy
About 1% of the general population develops epilepsy
The risk is higher in people with certain medical conditions:
Mental retardation
Cerebral palsy
Alzheimer’s disease
Stroke
Autism
13. Glutamate and GABA (gamma-aminobutyric acid): the brain's
major "workhorse" neurotransmitters that regulate action potential
traffic.
GABA is an inhibitory neurotransmitter
which stops action potentials.
Glutamate, an excitatory neurotransmitter,
starts action potentials or keeps them going.
Both work together to control many processes,
including the brain's overall level of excitation.
What is going on inside the skull?
14. GABA
Glutamate
So then, what is a SEIZURE?
An unpredictable, uncontrolled,
abnormal and excessive
paroxysmal synchronization
imbalance of the excitatory
and inhibitory forces within
the CNS network of cortical
neurons in the cerebral
cortex.
15. Pathophysiology of Epilepsy contd
Repeated sub-threshhold of a neuron
generates an action potentials
seizures
It has been suggested that chronic
epileptic discharges may lead to
secondary epileptogenesis.
17. Partial Seizures
Simple Partial Seizures:
Consciousness is fully preserved
Motor symptoms Involves motor strip, Manifested by
abnormal movement of an extremity,
– Jacksonian motor seizure: progression to adjacent muscle groups
– Todds palsy: transient paralysis
– Adversive seizure: Forced deviation of the eyes and turning head
to the opposite side.
Somatosensory symptoms Involves sensory strip,
temporal(hearing and smell) or occipital(visual) lobe
Autonomic symptoms involves temporal lobe
(tachycardia, pallor, flushing, sweating, Piloerection.
18.
19. Simple Partial Seizures (continued)
Psychic manifestation:
– Dysphasic- when cortical speech area affected (left preisylvian),
– Dysmnestic- disturbance of memory (mesobasal temporal right),
– Cognitive symptoms- dreamy state (mesobasal temporal and
temporal neocortex),
– Affective symptoms- fear, depression, anger, irritability, elation,
erotic thoughts (mesobasal temporal and temporal neocortex),
– Illusion of size, structured hallucination (mesobasal temporal and
temporal neocortex).
20. Copmplex Partial seizures
Complex partial seizures (= psychomotor seizures)
Initial subjective feeling (aura), loss of consciousness, abnormal behavior
(perioral and hand automatisms)
Majority originate in Temporal lobe (60%); but also originate another lobe –
particularly Frontal(30%).
21. Complex Partial Seizures
Discriminating features
Consciousness is altered
Stereotyped
Focal spikes in interictal EEG
Consistent Features
Approximately 60-180 second duration
Paroxysmal
Post-ictal confusion
Variable Features
Presence of aura
Automatisms
May secondarily generalize to a tonic-clonic seizure
Associated with focal structural lesion
May elevate prolactin level
May be confused with:
Drunkenness or drug use,
willful belligerence, aggressiveness
22. Partial seizures and 20 GTCS
Partial seizures evolving to tonic/clonic convulsions –
secondary generalised tonic/clonic seizures (sGTCS)
24. Generalized tonic-clonic seizures
Discriminating features
Initial tonic phase followed by clonic activity involving all
extremities
Consistent Features
Loss of consciousness
Typically 60 second duration
Post-ictal period associated with confusion and drowsiness
Variable Features
Tongue biting or injury
Urinary incontinence
Nonspecific prodrome
post-ictal paralysis
25. Absense seizures
Discriminating features
Very brief duration (5-15 seconds) and 100 – 200 time/day mat
Family H/O of typical absence seizures
Response to ethosuximide and valproate
Consistent Features
EEG-3 cycles/ sec of generalized spike and wave(typical)
No aura
Impaired consciousness
No post-ictal state
Variable Features
Automatisms
Change in body tone
Precipitation by hyper ventilation
Atypical absenceseizures
Longer duration of loss of consciousness,
Less abrupt onset and cessation
More obvious focal signs
Less responsive to drugs
26. Reflex epilepsy
Hot water epilepsy : person gets a seizure whenever he/she pours hot
water on the head. Initially it is reported more from South India
especially from Bangalore.
Eating epilepsy: Seizures are usually precipitated while a person starts
eating food. The masticatory and oro- mandibular movements might
trigger the seizure.
Watching TV can precipitate seizures in a vulnerable individual. This is
akin to photo stimulation procedure seen in EEG recording.
Hyperventilation can also precipitate seizures
29. Non Epileptic Seizures Epileptic Seizures
Preceding ictus
1 Absence of explanatory disease or
signs
Frequent evidence of neurological
disease
2 Anxiety auras: palpitations, choking
etc.
Wide range of epileptic auras
3 Seizures may be induced or provoked Rarely induced except for reactive
seizures
DURING ICTERUS
1 Inconsistencies in clinical
presentation
Fit specific seizures types
2 Seizure may differ from attack to
attack
Stereotypical seizure pattern
3 Only occurs when others are present Often occurs without witnesses or at
night
4 Gradual onset, pronged
duration(>2min)
Abrupt onset, short duration(<2min)
5 Asymmetrical, out of phase
movements, pelvic thrusts, and
hyperarching
Decrescendo, symmetrical clonic activity
in GTC seizure
30. Non Epileptic Seizures Epileptic Seizures
DURING ICTERUS(continued)
6 Rare whole body rigidity Tonic rigidity at onset of GTC seizure
7 Rare incontinence, tongue biting, self
injury.
incontinence, tongue biting if generalised
8 Normal autonomic reactivity, corneal
reflexes, and pupillary response
Distrubed autonomic reactivity, corneal
reflexes, and pupillary response
9 Avoids noxious stimuli or eye opening Cannot avoid noxious stimuli
10 Vocalization may occur throughout
ictus
Single Vocalization, if present at onset
11 Normal ictal EEG Abnormal ictal EEG
AFTER ICTUS
1 No post ictal delirium Typical post ictal delirium
2 No increase prolactin Prolactin >1000IU/L,10 to 20 min post
ictally
3 Normal post ictal EEG Post ictal slowing on EEG
4 Subsequent recall of events during
ictus
No or fragmentary recall of ictal events
5. No relationship of ictal frequency to
anti epileptic medication
Diminished seizure frequency with anti
epileptic medication
31. Differential Diagnosis
Malingered Seizure Non Malingered NonEpileptic Seizure
PRECEDING ICTUS
1 More common in men Female
2 Abuse history less likely Physical or sexual abuse
3 Prior psychiatry history: less likely
to obtain
present
4 Evident secondary gain No clear 20 gain
5 Emotional precipitants: not clear Frequent
6 Seizures are not suggestible suggestible
DURING ICTUS
1 Seizures under volitional control not
2 Conscious awareness of seizures Subconscious awareness of seizures only
3 Cannot maintain deficits overtime Able to maintain
4 Errors in seizures behaviour are
likely to be major distortions
Errors in seizures behaviour are likely
to be omissions, perseverations, near
misses
Malingered Seizure Vs Non Malingered NonEpileptic Seizure
32. Malingered Seizure Non Malingered NonEpileptic Seizure
AFTER ICTUS
Angry anxious on confrontation, with
lack of evidence for epileptic seizures
Indifferent , detched
Uncooperative, including circumstantial
and evasive answers, may leave against
medical advice
Cooperative with the workup, but
answers may be devoid of content
Malingered Seizure Vs Non Malingered NonEpileptic Seizure
33. Features that Distinguish Generalized Tonic-
Clonic Seizure from Syncope
Features Seizure Syncope
Immediate precipitating factors Usually none Emotional stress, Valsalva,
orthostatic hypotension, cardiac
etiologies
Premonitory symptoms None or aura (e.g., odd
odor)
Tiredness, nausea, diaphoresis,
tunneling of vision
Posture at onset Variable Usually erect
Transition to unconsciousness Often immediate Gradual over secondsa
Duration of unconsciousness Minutes Seconds
Duration of tonic or clonic
movements
30–60 s Never more than 15 s
Facial appearance during event Cyanosis, frothing at
mouth
Pallor
Disorientation and sleepiness
after event
Many minutes to hours <5 min
Aching of muscles after event Often Sometimes
Biting of tongue Sometimes Rarely
Incontinence Sometimes Sometimes
Headache Sometimes Rarely
35. Epilepsy – Investigation
The concern of the clinician is that epilepsy may be symptomatic of a
treatable cerebral lesion.
Routine investigation: Haematology, biochemistry (electrolytes, urea
and calcium), chest X-ray, electroencephalogram (EEG).
Neuroimaging (CT/MRI) should be performed in all persons aged 25 or
more presenting with first seizure and in those pts. with focal epilepsy
irrespective of age.
Specialised neurophysiological investigations: Sleep deprived
EEG, video-EEG monitoring.
Advanced investigations (in pts. with intractable focal epilepsy
where surgery is considered): Neuropsychology, Semiinvasive or
invasive EEG recordings, MR Spectroscopy, Positron emission
tomography (PET) and ictal Single photon emission computed
tomography (SPECT)
36. Tools to Confirm the Diagnosis of Epilepsy
EEG Imaging Scans
(Abnormal electricity) (Lesions)
37. EEG in epilepsy
A normal single EEG does not exclude the diagnosis of epilepsy.
If a normal awake EEG is obtained in an individual with the clinical
suspicion of seizures, one should repeat the EEG capturing sleep
because many epileptic abnormalities appear only in sleep
Interictal findings in the EEG are invaluable aids for classifying
seizures and epilepsy syndromes
39. Treatment Goals in Epilepsy
Help person with epilepsy lead full and productive life
Eliminate seizures without producing side effects
Tailor treatment to needs of individuals/special populations :
Women, Children, Elderly, Hepatic or renal failure and other
diseases
40. What if not treated?
Seizures can be potentially life threatening with brain failure,
heart and lung failure, trauma, accidents
Sudden Unexpected Death in Epilepsy (SUDEP)
Even subtle seizures can cause small damage in brain
Long Term problems: fall in IQ, depression, suicide, Social
Problems, Quality of Life
41. Types of Treatment
Medication
Surgery
Non-pharmacologic treatment
Ketogenic diet
Vagus nerve stimulation
Life style modifications
42. Single Unprovoked Seizures
Common affecting 4% of the population by age 80
30%-40% of patients with a first seizure will have a second
unprovoked seizure ( epilepsy)
43. Single Unprovoked Seizures
Risk factors for seizure recurrence include a history of
neurologic insult, focal lesions on MRI, epileptiform EEG,
and family history of epilepsy
Adult patients with these risk factors have a 60%-70% of
recurrence
44. Stay calm and track time
Protect head, remove glasses, loosen
tight neckwear
Move anything hard or sharp out of
the way
Turn person on one side, position
mouth to ground
Check for epilepsy or seizure disorder
ID
Understand that verbal instructions
may not be obeyed
Stay until person is fully aware and
help reorient them
Call ambulance if seizure lasts more
than 5 minutes or if it is unknown
whether the person has had prior
seizures
45. Potentially Dangerous Responses to
Seizure
Don’t restrain person
Don’t put anything in the person’s mouth
Don’t try to hold down or restrain the person
Don’t attempt to give oral anti-seizure medication
Don’t keep the person on their back face up
46. Safety Issues for Patients with
Epilepsy
Cant Drive for about a year after the last seizure
Climbing altitudes
Swimming/ Bathing alone
Operating heavy machinery or weapons that can be dangerous
Cooking, hot water
Taking care of babies
Bone Health
47. Antiepileptic Drug Therapy
AED therapy is not necessary if a first seizure provoked by
factors that resolve
AED therapy may be indicated if there is a permanent
injury to the brain (stroke , tumor)
In general AED therapy is started if there is a high risk of
recurrent seizures
48. Guidelines for Anticonvulsant Therapy
Start with one of the first line drugs
Start with low dose: Gradually increase to effective dose or
until side effects.
Check compliance
If first drug fails due to side effects or continue seizures,
start second line drugs whilst gradually withdrawing first.
49. Guidelines for Anticonvulsant Therapy
Try Three AED singly before using combinations
Beware about drug interactions
Do not use more than two drugs in combination at any one time
If above fails consider occult structural or metabolic lesion and
whether seizures are truly epileptic.
52. Second Generation AED’S
With the exception of Felbamate second generation AED’S
have advantages over first generation agents.
Generally lower side effect rates
Little or no need for serum monitoring
Once or twice daily dosing
Fewer drug interactions
There is no significant difference in efficacy with the second
generation agents
Higher cost associated with the new agents
Monotherapy is well established for Lamotrigine and
Oxcarbazepine
The other agents are undergoing and many have completed
monotherapy trials
53. AED’S In General
The most important factor in determining success of drug
therapy is the duration of the epilepsy
The patient needs to know that AED treatment is a
commitment and non-compliance can be dangerous
54. Pregnancy Considerations
Consider withdraw of AED’S if patient is a good candidate
Use monotherapy where appropriate
Folate 1-4 mg per day in all women on AED’S
The risk of fetal malformations are increased in pregnant
women on AED’S
Seizures during pregnancy can induce miscarriage
Seizures during pregnancy can be deleterious to the mother
or fetus
The possibility of prenatal diagnosis of malformations can
be considered with AFP levels and ultrasonography
56. Withdrawal of AED
After complete control of seizures for 3-5 years, withdrawal of Anti
Epileptic drugs may be considered. But in case of special professional
group (car driver, machine man etc) withdraw the AED after keen
follow-up.
20% of pts will suffer a further sz within 2 yrs.
AED should be tapered during the stopping of medications.
Slow reduction by increments over at least 6 months.
If the patient is taking two AEDs one drug should be slowly withdrawn
before the second is tapered.
The risk of teratogenicity is well known (~5%), especially with
valproates, but withdrawing drug therapy in pregnancy is more risky
than continuation.
Epileptic females must be aware of this problem and thorough family
planning should be recommended.
Over 90% of pregnant women with epilepsy will deliver a normal child.
57. Epilepsy Surgery
Factors influencing decision
Likelihood seizures are due to epilepsy
Likelihood surgery will help
Ability to identify focus of seizures
Other treatments attempted, and seizures couldn’t be treated with 2-3
medications
Benefits vs risks
Surgical treatment:
Removal of epileptic focus (eg:mesial temporal sclerosis)
Anterior Temporal Lobectomy
Corpus callostomy
Subpial transection
58. Vagus Nerve Stimulation
Device is implanted to control seizures
by delivering electrical stimulation to the
vagus nerve in the neck, which relays
impulses to widespread areas of the brain
Used to treat partial seizures when
medication does not work
59. Ketogenic Diet
Based on finding that starvation -- which burns fat for energy -- has
an antiepileptic effect
Used primarily to treat severe childhood epilepsy, has been effective
in some adults & adolescents
High fat, low carbohydrate
and protein intake
Usually started in hospital
Requires strong family commitment
62. PSYCHIATRY AND EPILEPSY
Epilepsy associated with a range of psychiatric disorders.
Increased prevalence of psychiatric problems among
epileptic patients.
May have auras with psychic content
One-fourth or more have schizophreniform psychoses,
depression, personality changes, or hyposexuality.
63. Why it is important to know Neuropsychiatry of Epilepsy
Approximately 30 to 50% of patients with epilepsy suffer at
some time from a psychiatric disorder
Important implications in diagnosis
Important implications for the management
Good opportunity to study organic basis of psychiatric
disorders.
65. Classification of psychiatric presentations
and disorders in Epilepsy
•Mood disorders (depression
and mania)
•Anxiety disorders
including panic and
posttraumatic stress
disorder
•Aggression and violence
•Hyposexuality
•Suicide
•Dementia
Behavioral
disrubances
variobly related
to ICTUS
66. Phases Of Epilepsy
Ictal period refers to events that take place during seizure
Post ictal events shortly after seizures
Inter ictal period is time between seizures in epilepsy
Peri ictal disturbances include pre ictal dysphorias , ictal
and post ictal syndromes.
Psychiatric phenomena can be associated with the seizure
itself, as well as the peri ictal and interictal phases of
epilepsy.
67. Phases of Epilepsy (continued)
Different phases are not always readily distinguished,
Affective auras, ictal automatisms, post ictal confusion,
and mood lability can confound psychiatric assessment
Model for understanding basic mechanism underlying
various psychiatric disorder.
Once identified , are best treated by optimizing treatment
accordingly.
69. Psychopathology
The relationship of seizures, psychiatric syndromes, and
the mediobasal temporal lobes implies that many
behavioral changes are more than psychological reactions
to the psychosocial stressors of epilepsy
70. Proposed Relationships of Psychiatric
Disturbances to Epilepsy
1. Common neuropathology, genetics, or
developmental disturbance
a) The pathology itself could be the source of seizures and
behavioral changes. Ex: Left hemisphere and temporal lobe
lesions may be associated with a schizophreniform
psychosis, and depression with mesial temporal sclerosis
2. Ictal or subictal discharges potentiate abnormal
behaviour
a) Kindling or facilitation of a distributed neuronal matrix
b) Changes in spike frequency or inhibitory–excitatory
balance
c) Altered receptor sensitivity, for example, dopamine
receptors
d) Secondary epileptogenesis.
e) This may occur in temporal lobe seizures and the frontal
lobe seizures.
71. Proposed Relationships of
Psychiatric Disturbances to Epilepsy
3. Absence of function at the seizure focus
a) Inhibition and hypometabolism surrounding the focus
b) Release or abnormal activity of remaining neurons
c) Dysfunction or downregulation of associated areas
d) Ex:the interictal hypometabolism observed on PET scans may
lead to depression or other interictal behavioral changes
e) In schizophreniform psychosis SPECT scans have shown
reductions in cerebral blood flow in the left medial temporal
region.
4. Neurochemical
a) Dopamine and other neurotransmitters
b) Endorphins
c) Gonadotrophins and other endocrine hormones
(Increased dopaminergic or inhibitory transmitters, decreased prolactin, increased
testosterone, or increased endogenous opioids, all of which can affect behavior)
72. Proposed Relationships of
Psychiatric Disturbances to Epilepsy
5.Psychodynamic and psychosocial effects of living with
epilepsy
a) Dependence, learned helplessness, low self-esteem, weak
defense mechanisms
b) Disruption of reality testing
6.Neurobiological and psychodynamic factors potentiate
each other
7. Sleep disturbance
8. Antiepileptic drug relate
74. Prodrome:-
The term ‘prodrome’ refers to a variety of subjective symptoms
occurring in the hours or even days leading up to a seizure.
Prodromal symptoms are distinguished from the aura of partial seizures by
their gradual onset and prolonged duration.
Non-specific, ill-defined feelings of malaise with headache, tiredness,
irritability and dysphoria are typical but there may be more pronounced
affective symptoms, in particular depression.
Prodromal symptoms are reported by 7–20% of patients and are more common
among patients with localisation-related epilepsy.
Also Described by patients with generalised epilepsy syndromes and they
should not be interpreted as evidence of focal brain disorder.
The pathophysiological basis for these symptoms is not understood
PSYCHIATRIC PHENOMENA IN EPILEPSY
75. PSYCHIATRIC PHENOMENA IN EPILEPSY
Auras of epilepsy
Portion of the seizure which occurs before consciousness is lost.
Range from simple discrete sensation to complex abnormalities
of emotion and ideation
Appear abruptly, rarely occupy more than a few seconds.
Must be distinguished from a prodromata which by their
gradual onset and prolonged duration.
Specially important in TLE
76. Psychic Auras
Type Symptoms Probable Source
Dysphasic Nonfluent
Impaired comprehension
Left perisylvian language
areas
Dysmnesic Déjà vu, déjà vécu, déjà pensé, déjà
entendu, jamais vu, etc.,
prescience, illusion of memory
Mesobasal temporal,
especially on right
Cognitive Dreamy state, altered time sense,
derealization, depersonalization
Mesobasal temporal and
temporal neocortex
Forced thinking, forced actions, and
altered or obscure thoughts
Frontal association cortex
Affective Fear, anxiety, apprehension,
depression, pleasure, displeasure
Mesobasal temporal and
temporal neocortex
Illusions Macropsia, micropsia, teleopsia,
metamorphopsia, increased color
intensity, increased stereopsis
intensity
Lateral superior temporal
neocortex, especially on
right for visual illusions
Hallucination
s
Structured, hallucinatory
remembrances, autoscopy
Mesobasal temporal and
temporal neocortex
77. Epileptic Automatism
Defined as state of clouding of consciousness
Occurs during or immediately after seizure
Individual retains control of posture
Performs simple or complex movements
Commonly preceded by aura
Frequently terminates with a Grand Mal convulsions
Lasts for a few seconds to hours
78. Epileptic Automatism (continued)
Chiefly in the form of:
epigastric sensation
confusion , difficulty with memory, diziness
feeling of strangeness
masticatory movements,
dazed expressions,
pulling at clothes and passing hand over face
walking around , searching or moving objects, removing
clothes etc.
79. Automatisms
Term Description
Oro-
alimentary
Lip-smacking, lip-pursing, chewing, licking, tooth grinding or
swallowing
Mimetic Facial expression suggesting an emotional state, often fear
Manual or
pedal
Indicates principally distal components, bilateral or unilateral
Fumbling, tapping, manipulating movements
Gestural
(often
unilateral)
Fumbling or exploratory movements with the hand directed
toward self or environment
Movements resembling those intended to lend emotional tone to
speech
Hyperkinetic Involves predominantly proximal limb and axial muscles
producing irregular sequential ballistic movements such
as pedalling, pelvic thrusting, thrashing, rocking movements
Increase in rate of ongoing movements or inappropriately rapid
performance of a movement
Hypokinetic Decrease in amplitude and/or rate or arrest of ongoing motor
activity
80. Automatisms
Term Description
Dysphasic Impairment of language without dysfunction of relevant primary
motor or sensory pathways, manifested as impaired
comprehension, anomia, paraphasic errors
Gelastic Bursts of laughter or giggling, usually without an appropriate
affective tone
Dyscrastic Bursts of crying
Vocal Single or repetitive utterances consisting of sounds such as grunts
or shrieks
Verbal Single or repetitive utterances consisting of words, phrases or brief
sentencses
spontaneo
us
Stereotyped, involve only self, virtually independent of
environmental influences
interactive Not stereotyped, involve more than self, environmentally
influenced
81. Epileptic Fugues
Consists of longer lasting disturbances of behavior with
tendency to wander away.
Actions are usually erratic, may appear to be drowsy or
intoxicated.
Consciousness is said to be less severely impaired
Abnormal behavior more complex, extended and
integrated.
Lasts for many hours to days.
Upon recovery amnesia is typically complete.
82. Twilight States
“Twilight states” result from a protracted period of
intermixed ictal and postictal changes
Range from automatisms and fugues to schizophrenia like
disorders.
It lasts from one to several hours.
May show as:
dream like absent minded behavior
muddling of comprehension
complete unawareness of environment
Psychomotor retardation is common
Marked perseveration in speech and action
83. Twilight States(continued)
Abnormal affective states prominently panic , terror , anger
, ecstasy
Hallucinations may form a large part
Usually ends spontaneously
May also terminate in Grand Mal Convulsions
Memory for the content is usually incomplete
85. DEPRESSION AND EPILEPSY
Depressive disorder is the most prevalent neuropsychiatric
disorder in epilepsy, occurring in 7.5 to 25 % of epileptic patients
A family history of depression has been reported in some
studies.
Some studies found association between depression and early
onset and late onset epilepsy.
More common in patients with CPS,TLE
Tebartz van Elst et al found a positive correlation between left
amygdala volumes and depression
They suggested that increased processing of negative emotional
information might increase blood flow.
86. DEPRESSION AND EPILEPSY
(CONTINUED)
LOCATION OF THE SEIZURE FOCUS
Studies report a higher prevalence of mood disorders in TLE
Supporting a specific role for temporal–limbic disorder.
Left-sided foci and with an increased risk of depression
Right-sided foci and with an increased risk of mania
87. DEPRESSION AND EPILEPSY
Divided in to
Interictal depression or dysthymia aka Interictal
dysphoric disorder of epilepsy.
Postictal depression
Ictal depression
Peri ictal depression
Ictal depression
Rare and may lead to suicide
Peri ictal depression
Episodic mood disturbances, with agitation, suicidal behavior,
and psychotic symptoms,
Associated with increasing seizure activity.
Postictal depression
Associated CPS
88. Interictal dysphoric disorder of epilepsy.
Also known as inter ictal depression/dysthymia
Associated with paroxysmal irritability or agitation,
accompanying paranoia and hallucinations.
Patients with interictal dysphoria tend to have frequent
complex partial seizures, with greater left-sided temporal foci
Experience of certain psychic auras, especially those with
cognitive content, may predispose to interictal depression.
89. DEPRESSION AND EPILEPSY
(CONTINUED)
SEIZURE FREQUENCY/SEVERITY AND CONTROL;
THE ROLE OF FORCED NORMALIZATION
Refers to an EEG phenomenon
In which better seizure control and a reduction in interictal
epileptiform abnormalities are associated with emergence of
depressive symptoms, called as alternating depression.
90. DEPRESSION AND EPILEPSY
(CONTINUED)
IATROGENIC
Poly pharmacy in epilepsy has been shown to be associated with
depression
The anticonvulsants most associated with depression are
barbiturates(phenobarbital, primidone, phenytoin and
vigabatrin)
Anticonvulsants least associated are Valproate, Gabapentin,
Lamotrigine.
Decrease in folate levels associated with mainly depression
91. SUICIDE AND EPILEPSY
Rates higher among epileptics
20% deaths were due to suicides in mentally abnormal epileptics
Complete Suicide risks is 4-5 fold among epileptics and those with CPS
of temporal lobe origin, as much as 25 times greater
Suicidal behaviour is not directly related to reaction to the psychosocial
stressors of having seizure disorder
Epileptic patients are likely to attempt suicide in conjunction with
borderline personality behaviour and contributors to successful suicides
include paranoid hallucination, agitated compunction and ictal command
hallucination
92. CHOICE OF ANTI DEPRESSANTS(AD) IN EPILEPSY
DEPENDS ON VARIOUS FACTORS
Efficacy
No significant difference in newer ADs and TCAs
Interactions
Fluoxetine or Fluvoxamine can cause toxic anticonvulsants
levels
Sertraline, Paroxetine, and Citalopram have little effect
Safety
Incidence of seizures with therapeutic doses of ADs varies
from 0.1 to 4%
Not higher than incidence in general population
94. Drug Related
High dose/high plasma level
Overdose
Rapid dose escalation
Concurrent use of drugs that lower seizure threshold
Concurrent use of drugs that inhibit metabolism
95. BPAD AND EPILEPSY
No sufficient data regarding incidence
Maniacal episodes described in range of 1.5 to 4.8%
Reported in patients with orbitofrontal and basotemporal
cortical lesions of the right side.
Mania mostly related to peri-ictal state, improved seizure
control
Hypomania has been described as occurring denovo after
temporal lobe surgery with right sided emphasis.
96. BPAD Treatment in Epilepsy
Several studies have noted seizures in treatment with
Lithium at therapeutic levels.
The use of anticonvulsants as Carbamazepine and Valproic
acid are known to be effective in t/t of BPAD in epilepsy
98. ANXIETY DISORDERS AND EPILEPSY
Generalized anxiety , phobic and panic disorders are most
common.
Studies implicates disease processes involving limbic
system.
Anxiety and panic disorders occur among epileptic patients
and must be distinguished from simple partial seizures
manifesting as anxiety or panic.
Conversely, anxiety symptoms during seizures need to be
distinguished from interictal anxiety.
Ictal anxiety or fear is usually stereotyped, with rapid
onset and shorter duration than panic attacks.
99. ANXIETY DISORDERS AND EPILEPSY(CONTINUED)
Anxiety can be reaction to acquiring the diagnosis of epilepsy.
Some patients with epilepsy clearly have posttraumatic stress
disorder (PTSD) from the psychological trauma of their
recurrent seizures.
Treatment of anxiety in epilepsy consists of relaxation
techniques, counseling, behavior therapy mainly.
100. OCD AND EPILEPSY
Abnormal EEG in some patients of OCD
Consisting of temporal sharp waves activity
One case report described inverse relationship b/w seizures
and OCD
Higher obsessionality scores a/w hyperperfusion in
ipsilateral temporal, thalamic and basal ganglia
Treatment- Serotonergics may be given.
Carbamazepine may be an effective and safer alternative
Behavioral therapy and psychosurgery are effective
102. PSYCHOSES AND EPILEPSY
Range from transient self limiting episodes to chronic illnesses
Various population based studies found a prevalence of 2 to 7 %
Divided into:
1) Psychoses in which confusion and impairment of consciousness
are outstanding features while affective or schizophreniform
elements are absent.
2) Psychoses with admixture of ‘organic’ and ‘functional’
manifestations.
3) Psychoses which occur in setting of clear consciousness and
take a form characteristic of schizophrenia or affective disorder
103. Clinical characteristics of psychosis in relation to
seizure activity
Ictal
psychosis
Post ictal
psychosis
Peri ictal
psychosis
Inter ictal
psychosis
Consciousnes
s
impaired Impaired or
normal
Impaired normal
Duration Hours to
days
Days to
weeks
Days to
weeks
months
EEG Status
epilepticus
Increased
epileptic and
Slow activity
Increased
epileptic and
Slow activity
unchanged
Treatment Anticonvulsa
nts (i/v)
Spontaneous
recovery in
many cases
Improved
seizure
control
Neuroleptic
drugs
104. POST ICTAL PSYCHOSIS(PIP)
Risk factors
Bilateral cerebral dysfunction
Ictal fear
Clusters of seizures
Absence of H/O febrile convulsions or mesial temporal sclerosis
Less hippocampal sclerosis, anterior preservation of hippocampus
Family H/O psychotic disorder
105. Clinical features and phenomenology of
post ictal psychosis.
PIP develops in patients with CPS mostly
Duration of PIP ranges from 1 to 90 days
There can be
Delirium
Delusions, (paranoid, grandiose and religious delusions )
Hallucinations (auditory, visual and somatic)
Mood disorders
Aggressive behavior
Sexual disorders
106. The operational criteria for post ictal psychosis
1. characteristically followed by a lucid interval lasting up to 24 hours,
during which the patient appears to recover fully from the after-
effects of seizures.
2. The onset of psychotic symptoms is then often sudden and dramatic,
accompanied by marked agitation and behavioural disturbance.
3. Duration between one day and three months.
4. A mental state characterized by
a) clouding of consciousness, disorientation or delirium
b) delusions, hallucinations in clear consciousness
c) a mixture of a and b.
5. No evidence of factors which may have contributed to the abnormal
mental state
a) anticonvulsant toxicity
b) previous history of interictal psychosis
c) EEG evidence of status epilepticus
d) recent head injury or alcohol or drugs
107. PERI ICTAL PSYCHOSIS
A wide range of phenomena including affective, behavioral ,
and perceptual experiences may occur
Often accompanied by automatisms
Consciousness is usually impaired
Tends to be maintained
Amnesia will often follow
Diagnosis is made by EEG
108. INTER ICTAL PSYCHOSIS
It tends to last days to weeks.
Many patients, develop worsening psychotic symptoms
when an increase in seizure frequency or with antiepileptic
drug withdrawal,Few others have worsening psychotic
symptoms on control of the seizures (alternating psychosis).
The terms alternating psychosis and forced or paradoxical
normalization refer to this demonstrable antagonism
between the psychosis and the seizures or EEG discharges
109. SCHIZOPHRENIA LIKE PSYCHOSIS OF EPILEPSY(SLPE)
Develops in 7 -9 % cases of epilepsy
TLE is the most common form of epilepsy
Most patients have delusions without any changes in level of
consciousness
Delusions are mainly paranoid
Vivid hallucinations of all kinds may occur
110. Risk factors for SLPE
Age of onset before or around puberty
H/O intractable status epilepticus
Epilepsy syndrome, TLE
Seizure frequency is diminished
Gender F>M
No family history
EEG- mesio basal focus L> R , or B/L
SPECT- left temporal hyper perfusion
Pathology- Ganglioglioma/ Hamartoma
111. Clinical features of SLPE
Paranoid psychosis
Religious delusions
Preservation of affect and lack of negative symptoms
Rarely catatonic symptoms
Patients with frontal lobe epilepsy show marked emotional
withdrawal and blunted affect
Psychosis Characteristics:
- paranoia with sudden onset
- psychosis alternating with seizure
- preserved affective warmth
- failure of personality deterioration
- less social withdrawal
- less systematized delusions
- more hallucinations and affective symptoms
- more religiosity
- few schneidreian first-rank symptoms
- no family history of schizophrenia
112. Flor-Henry felt that there is a relationship between the
lateralization of the epileptic focus in patients with
temporal lobe epilepsy and psychosis. He postulated that
left- and right-sided seizure foci are more likely to be
associated with a schizophrenia-like and manic-depressive
presentation, respectively. Empirical support has been
mixed.
113. Treatment
First line management of patients who only have episodes of
psychosis after seizures should be attaining seizure control
All neuroleptics reduce seizure threshold, Rates of seizure range
from 0.5 to 1.2
Avoid Clozapine (seizure induction 1%-4.4%) , Loxapine,
Chlorpromazine
Of conventional Haloperidol is relatively safe
Sulpiride , Quetiapine, Olanzipine and Risperidine are safe in
long term treatment
When possible give only one drug
Monitor seizure frequency
114. Forced Normalization
Brief episodes of abnormal behavior recorded after dramatic
reduction in seizures using AEDs
This phenomenon Is called alternative psychosis or forced
normalization when supportive EEG e% is available
Landolt was the first to report improvement in EEG activity during
periods of abnormal behavior
115. Forced normalization: mechanism
Not fully understood
Possible mechanisms proposed are:
The kindling phenomenon of long-term potentiation
Channel disorder potentiation
Epileptiform discharges may mimic ECT in a focal area and
this seizure suppression may lead to psychopathology
116. Forced Normalization: krishnamoorthy & Trimble criteria
Primary (essential)criteria:
1.Esatblished diagnosis of epilepsy based on H%, EEG, &
imaging
2.Presence of behavioral disturbance of acute/ sub acute onset
characterized by one of the following
– Psychosis with thought disorder , delusion ,
hallucination
– Significant mood change, mania/hypomania or
depression
– Anxiety with depersonalization/ derealization
– Hysteria : motor, sensory , abasia
3A .Reduction in total no of spikes counted in a 60 mt awake EEG
recording by over 50% compared with a similar recording
performed during a normal state of behavior
Or
3B.Report of complete cessation of seizures for at least one wk ,
corroborated by a relative or a care giver
117. Krishnamoorthy&Trimble criteria
Supplementary criteria
1.Recent change(with in 30 days) of pharmacotherapeutic regimen
2.Report of similar episodes of seizure cessation and behavioral
disturbance in the past
The diagnosis is made in the presence of
Primary criteria 1,2,and 3A
One primary criteria 1,2& 3B & one supportive criteri0n
120. PERSONALITY DISORDER AND EPILEPSY
Twenty-one percent of patients met threshold criteria for
an Axis II disorder.
Borderline, atypical or mixed, histrionic, and dependent
disorders
The most common personality disorder in epilepsy is a
borderline personality
Epileptic aura was positively correlated
It has been associated with poorer response to treatment,
lower compliance, and increased risk of suicide attempts
Most commonly associated with TLE
122. PD in association with type of epilepsy
TLE > Grand mal > Petit mal
In Petit mal patients are generally passive and ‘nice
mannered’
They are referred for neurotic symptoms mainly
In TLE children are more aggressive and less neurotic
Brain injured epileptic patients are often aggressive,
explosive and unpredictable.
123. Etiology of PD in Epilepsy
MULTIFACTORIAL
Psychosocial Effects
Behavioral disturbances closely related to adverse factors in
family
Patient is liable to be object of anxious concern and
overprotection
Attitude of dependency, egocentricity or hypochondriasis in
personality.
Psychosocial difficulties stigmatized, feared, and subject to
difficulties in obtaining a job, driving an automobile, and
maintaining a marriage
along with any associated mental retardation, contribute to the
dependency, low self-esteem, and overall borderline personality
traits present in many such patients
124. Etiology of PD in Epilepsy(continued)
Effects of brain damage
Many problems seen are similar to those in brain damage
Association claimed b/w TLE and PD is likely d/t brain
damage in limbic system
Nothing specific to epilepsy about mental slowing,
perseveration, stickiness or viscosity of thoughts and
emotions.
125. Etiology of PD in Epilepsy(continued)
Effect of seizures and abnormal electrical activity
Disorganization of cerebral functioning by epileptic
discharge also contribute
Shown by :
Increased disturbance in some prior to fit
Traits may improve when fit frequency is low
Effect of temporal lobectomy postoperatively
126. Gastaut-Geschwind Syndrome
A group of personality traits termed the Gastaut-Geschwind
syndrome.
Mostly seen complex partial seizures, at temporal limbic focus.
These patients are serious, humorless, and overinclusive and have
an intense interest in philosophical, moral, or religious issues.
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.
left-sided focus had a more reflective ideational style and
maximized their problems, whereas those with a right-sided focus
had emotional tendencies and minimized their problems.
128. Sexual Function in Epilepsy
Decrease of sexual interest, a decrease in activity and impaired
performance are common
Decreased libido and ED are reported in men receiving AEDs
Decreased Testosterone, sperm count and morphological
abnormalities and reduced sperm mobility were reported
Menstrual irregularities are increased in women with increased
seizure frequency, pts using Sod.Valproate, polytherapy.
Infertility , PCOD occur more frequently.
Hypo sexuality may be more pronounced in partial seizures
More vaginismus in women, more ED in men with physiologic
origin
129. SEXUAL DISORDERS
Especially reported with TLE, resolves with cessation of attacks
Prevalence varies from 22-67%
Most common sexual dysfunction is inter ictal disorder of
hyposexuality
Self mutilation, homosexuality,transvestism , masochism,
exhibitionism and fetishism have been reported
A woman with nymphomania proved to have incidental sexuality
from sensory simple partial seizures caused by a tumor in the
sensory cortex representing her genital region.
Endocrine changes have been reported on t/t with liver enzyme
inducing antiepileptics
131. EPILEPTIC DEMENTIA
Many undergo a decline in intellectual ability
Progressive impairment of memory, concentration and
judgment
Usually coupled with severe personality deterioration and
behavioral disorders
Neuro imaging may demonstrate cerebral atrophy
Common when epilepsy is secondary to a known brain
lesion.
132. EPILEPTIC DEMENTIA(continued)
In children a/w
prolonged febrile status
west syndrome
Lennox – Gastaut syndrome
In adults
Etiology differs from case to case
Epileptic with brain damage dement earlier
It may represent chronic end state of SLPE
133. Aggression,Violence and Crime
Lay people have accredited to epilepsy aggressive and violent acts
and have even used this epilepsy defense in criminal proceedings.
This belief peaked in the 19th century.
High violence rating scores are associated with abnormal temporal
electrical discharges on EEG and temporal lobe abnormalities on CT
Male epileptics are 3 times more likely to receive a criminal
conviction.
Aggression in epilepsy is usually associated with psychosis or with
intermittent explosive disorder and correlates with subnormal
intelligence, lower socioeconomic status (SES), childhood behaviour
problems, prior head injuries, and possible orbital frontal damage.
Prevalence of epilepsy among prison inmates has been two to four
times that among the general population, studies from the United
Kingdom and the United States have not found more violent crimes
among prisoners with epilepsy than among prisoners without
epilepsy.
134. Can violence itself be a seizure?
After the 1976 case of a New York City policeman who had never had
seizures and successfully claimed the epilepsy defense, criteria for ictal
violence were proposed that included video-EEG telemetry.
Since then, epilepsy has rarely, if ever, been proved to directly result in
premeditated violence.
More commonly, nondirected violent movements, aimless destructive
behavior, or angry verbal outbursts occur during postictal delirium,
postictal psychosis and subacute postictal aggression.
135. Criteria for the Assessment of Ictal
Violence in Epilepsy
The diagnosis of epilepsy is established by at least one
specialist in epilepsy.
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.
136. Mechanisms of Aggression among Epilepsy Patients
Period Cause
Interictal Impulse-control disorder
Mental retardation or cognitive impairments
Personality disorders
Schizophrenia like psychosis of epilepsy
Medication related
Prodromal Mounting tension, irritability
Ictal Direct manifestation of the seizure
Violent automatism
Reaction to a negative aura
Subtle seizure equivalents
Post Ictal Resistive
Postictal psychosis
Subacute postictal aggression
Poriomania and somnambulism
In epilepsy, prolonged periods of compulsive wandering with amnesia have resulted from an admixture of ictal and
postictal changes and have been termed poriomania.
137. SUMMARY
Psychiatric syndromes often occur in patients with epilepsy
at rates that seem to exceed the normal population.
A lack of good prevalence studies makes it difficult to know
whether or not prevalence rates of these syndromes exceeds
that of other patient groups experiencing CNS dysfunction.
Symptoms sometimes occur in association with seizures
episodes (either ictally or peri-ictally), and such
symptomatology tends to be brief and context-free.
Classic psychiatric syndromes tend to occur inter-ictally.
Depression appears to be the most common psychiatric
feature in patients with epilepsy.
Multiple factors likely contribute to depression in epilepsy
(including psychosocial, neurologic, and treatment related
variables)
138. REFERENCES
Harrison’s principles of internal medicine , 17th edition
Organic psychiatry William Alwyn Lishman, 3rd edition.
Ictal and postictalpsychiatric disturbances, Michael R.
Trimble Institute of Neurology, University College, London.
CTP 9TH EDITION