Neuropsychiatry of Medical Disorders

1. P R E S E N T E R : D R . M E L A K U . Y ( Y E A R I M E D I C A L
R E S I D E N T )
M O D E R A T O R : D R . M E S A L I
J E M A L ( P S Y C H I A T R I S T , A S S I S T A N T
P R O F E S S O R O F P S Y C H I A T R Y )
Adama Hospital Medical College
Department of Psychiatry
Seminar On
Neuropsychiatry of HIV and
Epilepsy

2. Outline
 Introduction
 HIV associated neurocognitive disorder
 Depression
 Mania
 Anxiety disorder
 Substance use disorder
 Pain
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3. Introduction
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 Neuropsychiatry is the assessment and treatment of
patients with psychiatric illnesses or symptoms
associated with brain abnormalities

4. Intro…
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 The essence of neuropsychiatric intervention is
• prevention
• Early detection of the underlying neuropsychiatric disorders
• Highly focused assessment and specific neurolocalization
• Early and specific treatment when possible
• Utilization of multiple therapeutic and psychosocial modalities

5. Evaluation of Mental Status in Patients with
HIV/AIDS
Physical neurological exam:
 Focal deficits may indicate space-occupying lesion;
e.g., CNS lymphoma, toxoplasmosis
 Ataxia or changes in gait may indicate myelopathy
associated with HAD
 Sensory changes indicative of peripheral neuropathy
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6. Evaluation of Mental Status…
Labs
 Complete blood count with differential
 Serum chemistries
 Arterial blood gas in patients with pneumonia
 Venereal Disease Research Laboratory (VDRL), Flourescent Treponemal
Antibody (FTA)
 B12, folate
Neuroradiology
 MRI to rule out space-occupying lesion, Progressive Multifocal
Leukoencephalopathy PML
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7. Evaluation of Mental Status…
Lumbar Puncture
 To rule out acute infection; e.g., herpes, cryptococcal
meningitis, syphilis, toxoplasmosis
Review of Medications
 Neuropsychiatric side effects of AIDS meds; drug
interactions, especially with protease inhibitors
Neuropsychological Testing
 AIDS Dementia Rating Scale
EEG
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8. HIV-Associated Neurocognitive Disorders
Introduction and Epidemiology:
 Neurocognitive disorders and subtle cognitive impairment are
seen throughout the spectrum of HIV infection.
 Some of the earliest reports about HIV/AIDS indicated that
the virus entered the central nervous system during initial
infection and that this was a neurocognitive disease as much
as it was an immunological disease.
 In 1991, the American Academy of Neurology published
criteria to be used in the diagnosis of HIV-associated
dementia (HAD) and the minor cognitive motor disorder
(MCMD).
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9. HIV-Associated Neurocognitive…
EPI &…
These criteria indicated that HAD
 acquired abnormality in at least two cognitive areas,
 causing impairment in work or acitivities of daily
living (ADLs),
 and that there was abnormality in motor function or
abnormality in neuropsychiatric or psychosocial
functioning leading to behavioral change.
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10. HIV-Associated Neurocognitive…
EPI &…
 These criteria have been updated to cover a slightly
broader range of HIV-associated neurocognitive
disorders (HAND)
 Suggestions are given for age- and education-
appropriate neuropsychological testing of eight
cognitive domains as well as psychosocial evaluation
that must be performed in order to make a HAND
diagnosis
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11. HIV-Associated Neurocognitive…
EPI &…
Three categories of HAND are defined:
1. Asymptomatic neurocognitive impairment (ANI), in which the
patient scores one standard deviation below the mean in two
cognitive areas, with no subjective or objective signs of
impairment in functioning;
2. Mild neurocognitive disorder (MND), again scoring one standard
deviation below the mean in two or more areas, but with some mild
impairment and
3. HIV-associated dementia (HAD), in which the patient scores two
standard deviations below the mean on normative neuropsychiatric
tests and has moderate to severe impairment in functioning
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12. HIV-Associated Neurocognitive…
EPI &…
 HAD is most commonly seen in more advanced stages of HIV
disease
 In the pre-HAART era, some degree of cognitive impairment
was reported to be found in up to 60–90% of individuals with
advanced-stage disease, and HAD was diagnosed in 15–20%
patients
 The annual incidence of HAD was reported to be 7%
 Since the introduction of HAART, several studies have shown
the yearly incidence of HAD to have dropped to approximately
1%
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13. HIV-Associated Neurocognitive…
EPI &…
 However, as patients live longer with HIV, and with the
inclusion of asymptomatic states, the overall prevalence
of HAND has increased.
 For patients stabilized on a HAART regimen with no
detectable viral load, the current prevalence estimates of
ANI ranges from 32–50%; for MND, 12–17%; and for
HAD, approximately 2–3%
 The prevalence rates of HAND rise in patients with poor
immunological control, as seen particularly in resource-
poor countries
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14. HIV-Associated Neurocognitive…
Proposed Pathophysiology:
 The precise pathophysiology of HAND remains unclear,
but it appears to be related to neurotoxins secreted by
mononuclear phagocytes
 The immune cascade hypothesis supposes that
inflammation at the blood–brain barrier (BBB) allows
more HIV to enter the CNS
 This hypothesis also emphasizes the importance of
maintaining good immunological control peripherally to
minimize CNS malfunction
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15. HIV-Associated Neurocognitive…
Clinical features:
 The early symptoms of HAD are subtle, typically with
subcortical brain dysfunction and overlapping with the
cognitive impairment associated with depression.
 Common early features include apathy, memory loss,
cognitive slowing, impaired concentration, psychomotor
slowing and slowed information processing, social
withdrawal, and dyscoordination
 Later features include psychosis, severe memory loss
with attention-deficit disorder, gross ataxia, seizures, and
mutism
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16. HIV-Associated Neurocognitive…
Diagnosis:
 The diagnosis of HAD is basically one of exclusion, and the
evaluation will involve ruling out other primary causes of cognitive
dysfunction, such as opportunistic CNS infections or neoplasms.
 Since the introduction of HAART, confounding factors such as
increased age, co-infection with hepatitis C, substance use
disorders, endocrinological disorders, and mental illness play a
greater role in causing cognitive impairment in long-term survivors
of HIV/AIDS.
 Computed tomography (CT) and magnetic resonance imaging
(MRI), although not diagnostic, usually show some degree of
cortical atrophy, and subcortical or periventricular white matter
changes.
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17. HIV-Associated Neurocognitive…
DX…
 Lumbar puncture
 The HIV Dementia Rating Scale
 Formal neuropsychological testing
 Corroborative history from family and friends is
extremely important in accurately characterizing
functional impairment.
 Risk factors for HAD
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18. HIV-Associated Neurocognitive…
Treatment:
 The primary choice of treatment for HAD, and possibly all HAND, is
a regimen of HAART
 Psychostimulant medications such as methylphenidate and more
recently modafinil have been studied extensively in HIV-positive
patients
 Other agents, such as memantine, selegiline, nimodipine, and
peptide T, thought to have neuroprotective effects
 With current treatment regimens, the course of HAND has become
more variable over time, with fluctuations and at times nearly
complete remission of symptoms.
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19. Delirium
Introduction:
 Delirium occurs frequently among hospitalized HIV-
infected patients, with reported prevalence rates ranging
from 29% to 57%
 AIDS patients may be especially susceptible to the
development of delirium in the context of underlying
HIV brain infection, the common use of multiple drugs,
and the frequency of multiple medical complications.
 Evaluation and correction of the underlying medical
cause of delirium is of primary importance
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20. Delirium…
Causes:
Intracranial
 Infections
 Cryptococcal meningitis
 Encephalitis due to (HIV, herpes, Cytomegalovirus (CMV)
Progressive multifocal leukoencephalopathy (PML) )
 Mass lesions (Lymphoma, Toxoplasmosis)
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21. Delirium…
Causes:
Extracranial
 Medications :
 Amphotericin B:
 Sedative/hypnotics
 Acyclovir:
 Cycloserine
 Ganciclovir:
 Opiate analgesics
 Ethambutol:
 Isoniazid
 Trimethoprim/ sulfamethoxazole:
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22. Delirium…
Causes:
 Rifampin
 Pentamidine
 Zidovudine
 Didanosine
 Foscarnet
 Vincristine
 Ketoconazole
 Dapsone
 Drug or alcohol withdrawal
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23. Delirium…
Causes:
 Infections/sepsis
 Endocrine dysfunction/metabolic abnormality
 Hypoglycemia due to pentamidine, protease inhibitors
 Liver failure due to comorbid hepatitis, medication
toxicities
 Nutritional deficiencies
 Wasting syndrome
 Failure to replace trace elements or vitamins in total
parenteral nutrition
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24. Delirium…
Treatment:
 Prompt management of agitation due to delirium is
extremely important
 Neuroleptics are the mainstay of treatment of the
agitated delirious patient, and low-dose haloperidol is
often effective in the AIDS population
 Cardiac arrhythmias and lengthening of the Q-T interval
on electrocardiogram (EKG) have also been reported
with the use of high-dose intravenous haloperidol
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25. Delirium…
Treatment:
 Atypical neuroleptics such as aripiprazole,
quetiapine, risperidone, and olanzapine have been
shown to be useful in the management of delirium
 Clinical experience indicates that patients with
HIV/AIDS may tolerate these medications with
fewer side effects and less EPS than they have with
high-potency neuroleptics.
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26. Mood Disorders
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27. Depression
Epidemiology:
 Depressive disorders are the most frequently
diagnosed mental disorder among patients with
HIV/AIDS, with prevalence rates ranging from 35–
85%
 One of the largest surveys of mental disorders
among HIV patients found a rate of 36% for major
depressive disorder and 26.5% for dysthymia
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28. Depression…
Clinical features and Diagnosis:
 Frontal lobe and subcortical dementias, may be
misdiagnosed as major depression
 As HIV disease progresses, depressive symptoms are
more likely to arise
 Many investigators have found an association
between the severity of HIV-related physical
symptoms and the severity of depressive symptoms
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29. Depression…
Clinical features and Diagnosis:
 A thorough evaluation for suicide risk should be part of
the assessment of all depressed individuals with HIV
infection.
 Although HIV/AIDS may be more commonly viewed as a
treatable disease in the age of HAART, some studies have
shown suicidal ideation to still be highly prevalent, in the
range of 17–38%
 Completed suicides appear to occur at a significantly
increased rate among persons with HIV infection
compared to age-matched controls
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30. Depression…
Treatment:
 Initial treatment should be aimed at correcting the
underlying problem
 Otherwise, treatment regimens include typical
pharmacological and psychological strategies for the
treatment of major depression in medical illness.
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31. Depression…
Treatment:
 Research utilizing randomized, placebo-controlled designs reveals
that SSRIs such as fluoxetine, paroxetine, citalopram, and
escitalopram may be particularly useful in treating HIV-related
major depression
 Psychostimulants have been shown to have a beneficial effect on
depressive symptoms, especially when depression is accompanied
by cognitive impairment
 Although not specifically studied in this population, there is no
specific contraindication to using electro-convulsive therapy (ECT)
or repetitive transcranial magnetic stimulation (rTMS) and may be
considered in patients with treatment-resistant depression
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32. Depression…
Treatment:
 Most psychotherapeutic interventions reported in HIV-
positive individuals have aimed at reducing risk
behaviors or lowering distress.
 Nonetheless, research data and clinical experience
suggest that various modes of psychotherapy are
beneficial in the management of HIV-related depression.
 Investigators have reported the successful use of
interpersonal therapy ,cognitive behavioral therapy,
supportive therapy , and antidepressant
pharmacotherapy
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33. Mania
Epidemiology:
 Prevalence rates of manic syndromes in HIV patients
have respectively been reported as 2.4 to 30%
 Mania in the HIV patient may be due to preexisting
psychiatric illness, the CNS effects of HIV-related
opportunistic infections or tumors, HAD, or side effects
of medications
 Some authors have noted differences between patients
presenting with mania early or late in the course of HIV
disease
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34. Mania…
Clinical features and Diagnosis:
 Early-onset mania was more likely in patients with a personal or
family history of mood disorders, and these patients more often
presented with increased talking as a symptom
 Late-onset mania was more often associated with a diagnosis of
HAD, and irritability was a more frequent symptom
 Evaluation of HIV patients with mania should first rule out a
secondary mania.
 In patients with evidence of late-onset mania, examination of the
CSF and neuropsychological evaluation for HAD are also indicated
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35. Mania…
Treatment:
 The clinician must aggressively treat the acutely manic patient
with HIV/AIDS
 Those with asymptomatic HIV infection and a premorbid
history of bipolar disorder may be managed with standard
lithium
 Due to the greater risk of myelosuppression by
carbamazepine, sodium valproate is preferred,
 Anticonvulsants such as lamotrigine may also prove to be
effective and well tolerated in this population
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36. Mania…
Treatment:
 High-potency neuroleptics, such as haloperidol in low
doses, may be useful in the acute management of manic
HIV patients
 Some have reported the safe and effective use of
risperidone in the management of mania in AIDS
patients
 Lorazepam or clonazepam have also been shown to be
effective in the treatment of the acutely manic HIV but
act therapeutically primarily as sedatives.
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37. Anxiety Disorders
 Treatment of anxiety disorders in persons with HIV/
AIDS follows the general guidelines for other
medical patients.
 For chronic generalized anxiety, buspirone has been
shown to be effective in this population
 benzodiazepine may be the drug of choice for acute
anxiety
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38. Anxiety Disorders…
Treatment…
 The antidepressant venlafaxine is approved by the US
Food and Drug Administration (FDA) for Generalized
Anxiety disorder (GAD) and should be considered as a
first-line drug as well.
 Psychotherapies play an important treatment option for
many patients with anxiety
 In most settings, the preferred treatment combines
pharmacotherapy and methods of anxiety self-regulation.
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39. Substance Use Disorder(SUD)
Introduction:
 A high lifetime prevalence of psychiatric disorders
among those with SUD, in the range of 50–80%, has
been reported,
 Several studies have demonstrated high rates of
psychiatric disorders among HIV patients with SUD
 studies have demonstrated increased risk behaviors
associated with HIV transmission among these
populations
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40. What is the urge to
manage pts with
Substance use disorder?
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41. SUD…
Three major reasons:
1.Continued substance use may lead to an increase in
unsafe behaviors such as needle-sharing or
unprotected sex
2. Adherence to medical treatment may be impaired
3. The mental and physical changes resulting from
SUD can negatively affect the patients’ quality
of life.
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42. SUD…
Treatment:
 The most helpful treatment approach is to determine whether SUD
is a primary diagnosis
 This can be difficult, either because of a patient’s poor reliability or
because of a mixed picture, such as a sleep disorder and alcohol
abuse presenting simultaneously
 If SUD is the primary diagnosis, then specific drug abuse treatment
and abstinence should be required before further psychiatric
treatment can continue
 Treatment options include brief inpatient detoxification for
patients with physiological dependence on substances such as
heroin or alcohol, followed by inpatient rehabilitation
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43. SUD…
Tx…
 outpatient rehabilitation or therapeutic communities
or group therapy for longer term intensive treatment
 Various types of therapies have been recommended
for treating HIV patients with SUD, including
cognitive, interpersonal as well as motivational
interviewing
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44. SUD…
Tx…
 Harm-reduction strategies that acknowledge that not all patients
will achieve or maintain abstinence are especially applicable to HIV
patients with SUD
 Studies have shown that counseling and education regarding risk
behaviors and corresponding precautions should be incorporated
into the treatment and can have beneficial effects
 The clinician must be prepared to be flexible, and to incorporate
whichever form of treatment (or combination of treatments) is most
useful for a particular patient at a particular time.
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45. Pain
Introduction:
 Studies have shown that pain may be undertreated in AIDS
patients, as it is in most medical and surgical patients
 The prevalence of pain in this population has been estimated
to range from 30–80%
 Pain in the AIDS patient can be managed according to the
same guidelines for cancer pain management
 Complete physical, neurological, and psychiatric evaluation
for correctable causes of pain.
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46. What causes pain in HIV
patients?
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47. Pain…
Pain Related to HIV/AIDS
 HIV neuropathy
 HIV myelopathy
 Kaposi’s sarcoma
 Opportunistic infections (intestines, skin)
 Organomegaly
 Arthritis/vasculitis
 Myopathy/myositis
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48. Pain…
Pain Related to HIV/AIDS Therapy
 Antiretrovirals
 antivirals
 Antimycobacterials,
 PCP prophylaxis
 Chemotherapy (vincristine)
 Radiation
 Surgery
 Procedures (bronchoscopy, biopsies)
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49. Pain…
Pain Unrelated to AIDS
 Spinal disc disease
 Diabetic neuropathy
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50. Pain…
Treatment:
 Analgesic medications can then be prescribed
according to the level of pain
 Psychotropic medications play an important role in
the management of pain in AIDS patients
 Duloxetine, gabapentin, and pregabalin are all
approved for patients with post herpetic and diabetic
neuropathies
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51. Pain…
Tx…
 The management of pain in AIDS patients with a history
of substance abuse can be problematic
 As there is no objective way to measure pain, one must
rely on the patient’s report of pain and its severity
 Although a certain number of patients with a substance
use disorder may malinger in order to obtain drugs,
complaints of pain should be taken seriously and fully
evaluated
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52. References:
 Psychiatric Care of the medical patient,3rd
edition(2016)
 Uptodate,2018
 Kaplan and Sadock’s Synopsis of Pyschiatry,11th
edition
 WWW.researchgate.net
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53. Neuropsychiatry of
Epilepsy
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54. Outline
• Introduction
• Depression
• Anxiety
• Psychosis
• Stigma
• Non-Epileptic Seizure
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55. Introduction
 When evaluating a patient with seizures, the first step is
to establish whether the paroxysmal episodes are in fact
epileptic seizures or physiological or psychogenic non-
epileptic events
 If the patient has epilepsy, it is essential to establish the
type of epileptic syndrome and the type of seizures
 As with any other neurological or psychiatric disorder, a
detailed history of the paroxysmal events is of the
essence
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56. intro…
 The initial workup of the patient with seizures includes
an electroencephalogram (EEG), structural
neuroimaging, and also an evaluation of the psychiatric
comorbidities in epilepsy
 Patients with epilepsy (PWE) have been found to be at
higher risk of suffering from mood, anxiety, psychotic,
and attention-deficit disorders and non-epileptic seizures
 The relationship between psychiatric disorders and
epilepsy is complex and is not only the consequence of
the epileptic disorder
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57. Intro…
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58. Depression
 Depression is the most frequent psychiatric disorder in
patients with epilepsy
 Prevalence rate is 21% to 33% compared to 4% to 6% in
those who are seizure free
 It’s more common in patients with partial seizure
disorders of temporal or frontal lobe origin and among
patients with poorly controlled seizures)
 It’s also a predictor of worse seizure control
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59. Depression…
 Presents as dysphoric mood 1 to 3 days before the
occurrence of seizure
 Fear and anxiety are common presentations in the
ictal episode
 Atypical clinical presentation during the inter-ictal
period.
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60. Depression…
 Treatment includes:
 Antidepressants
 ECT
 Psychotherapy
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61. Anxiety
 Anxiety is the second most common psychiatric
comorbid diagnosis in PWE, with an estimated
prevalence between 15% and 25%
 The various forms of anxiety can present inter-ictally
with the same clinical manifestations as anxiety
disorders in the general population
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62. Anxiety…
 Antidepressants belonging to the SSRI class can
prevent the occurrence of inter-ictal panic attacks as
well as treat generalized anxiety disorders
 Antidepressant drugs of the SNRI family have been
also been used with success, but no controlled
studies exist in patients with epilepsy
 Benzodiazepines have been used for years in the
management of anxiety disorders.
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63. Psychosis
 Psychotic disorders are more frequent in PWE than in
the general population, with some studies suggesting
prevalence rates of up to 10%.
 Psychotic disorders can present as a schizophreniform
disorder, indistinguishable from those of patients
without epilepsy
 However, the term “psychosis of epilepsy” implies the
presence of certain characteristics that distinguish these
disorders from those of patients without epilepsy
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64. Psychosis
 Antipsychotic drugs (APD) are necessary in the
management of psychotic disorders in epilepsy
patients, despite their proconvulsant properties
 While the risk of seizure occurrence must always be
carefully considered when starting antipsychotic
drugs in these patients, it should never be a reason
not to treat a patient in need of antipsychotic
medication.
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65. Psychosis
 The seizure rate associated with the use of antipsychotic drugs
has ranged from 0.5% to 1.2% among non-epileptic patients
 The risk is higher with certain drugs, and higher in the
presence of the following factors:
(1) a history of epilepsy;
(2) abnormal EEG recordings;
(3) history of central nervous system disorder
(4) rapid titration of the APD dose;
(5) high doses of antipsychotic drugs; and
(6) the presence of other drugs that lower the seizure
threshold
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66. Psychosis
 The risk of seizure occurrence or worsening of seizures
with atypical antipsychotic drugs in PWE has not been
well studied
 Clozapine followed by chlorpromazine and loxapine are
the three antipsychotic drugs with the highest risk of
seizure occurrence
 Those with a lower seizure risk include haloperidol,
fluphenazine, perphenazine, trifluoperazine, and the
atypical, risperidone
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67. Psycho…
 AEDs at adequate levels protects patients with epilepsy from
breakthrough seizures upon the introduction of antipsychotic
drugs with proconvulsant properties is yet to be established.
 AEDs are sometimes started when clozapine is used at greater
than 600 mg/d
 In addition to the proconvulsant properties of antipsychotic
drugs, clinicians must also consider the pharmacokinetic and
pharmacodynamic interactions between these and AEDs
 Induction of hepatic enzymes upon the introduction of
enzyme-inducing AEDs may result in an increase of the
clearance of most antipsychotics.
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68. Stigma
The statement that “treating the seizure is not the sum
of treating the patient with epilepsy”
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69. Stigma…
 The authors found that 55% of 82 women with epilepsy
concealed their history of epilepsy before marriage, and 38%
of those who concealed it were separated or divorced
 Concealment was described as a coping strategy for
anticipated negative consequences of disclosure of the
stigmatized disease. Unfortunately, this attitude is not solely a
reflection of a developing country’s practice
 Other researchers found that family, marriage, financial, and
moral consequences of the social experience of epilepsy as a
chronic disease demonstrated the importance of the social
impact of epilepsy
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70. Stigma…
 Along with the stigma of epilepsy itself, the comorbidities
of epilepsy, including depression, anxiety, and non-
epileptic seizures, impose a psychosocial burden
themselves
 Because of stigmatizing attitudes, patients may avoid or
delay medical care and treatment for their mental health
problems
 High stigmatization concerning psychiatry, even in
patients with epilepsy with psychiatric comorbidity, and
concluded that perceived stigma is a barrier to recovery.
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71. Non-Epileptic Seizure(NES)
 Non-epileptic events are either physiological or
psychological in origin
 Psychogenic non-epileptic seizures (NES) resemble
epileptic seizures presenting as a sudden, involuntary,
time-limited alteration in behavior, motor activity,
autonomic function, consciousness, or sensation
 However, unlike epilepsy, NES do not result from
epileptogenic pathology and are not accompanied by an
epileptiform electrographic ictal pattern
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72. NES…
 Of the U.S. population diagnosed with epilepsy, 5–20% have NES
 They are usually women (~80%) and most are between 15 and
35 years old (~80%)
 Patients with NES take double the number of medications
compared to patients with epilepsy and while NES are not
responsive to AEDs
 In some cases, potentially dangerous invasive diagnostic studies,
toxic parenteral medications, or emergency intubation are
administered
 Diagnostic and therapeutic challenges are complicated by the 10–
30% rate of comorbid NES and epileptic seizures (ES)
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73. NES…
 While there is not a specific focal “lesion” that produces
NES, we do have an understanding of the comorbid
psychopathology in patients with NES
 The phenomenology of NES, formerly referred to as
“pseudoseizures,” is well defined, with systematic
assessments of diagnostic comorbidities and
psychological testing
 Negative prognostic factors include longer duration of
NES, comorbid neurological and/or psychiatric disease,
and pending litigation, among others.
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74. NES…
 There are two main “causes” of NES: post-traumatic and
developmental)
 NES are clinically classified under different DSM-5 diagnoses,
including Conversion, and Dissociation disorders
 A much smaller percentage (<5%), present as Factitious disorder
and malingering
 A psychosocial stressor (e.g., sexual or physical abuse, loss of a
relationship, work stress, parental divorce) is usually present
 Many patients with NES also suffer from mood, anxiety, personality
and non-seizure conversion/somatic disorders
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75. NES…
 Obtaining an accurate diagnosis of NES is the essential
first step for instituting proper therapy and avoiding
unnecessary and potentially dangerous therapies.
 Clinical features of ES and NES overlap, however, and
there is no one clinical feature that reliably distinguishes
ES from NES
 Subjective visceral, sensory, or psychic phenomena,
alterations in responsiveness, and convulsive motor
activity can be present in both disorders
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76. NES vs ES
NES:
 Pre-ictal pseudosleep
 Geotropic eye
movements
 Eye closure and post-
ictal whispering
 May be stopped or
provoked with suggesion
ES:
 Post-ictal headache
 Post-ictal nose rubbing
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77. NES…
 An article reviewing the diagnostic tests, including EEG, neuroimaging, &prolactin
levels provides the sensitivities and specificities for each of these tests
 It was once thought that absence of physical injury sustained during a seizure was a
diagnostic indicator differentiating NES from ES; however, more than half of all
patients with NES actually do have physical injuries associated with their NES
 Other injuries occur as a result of iatrogenic issues, which are also prevalent in NES,
and death has resulted from medically aggressive treatment of NES
 27.8% of patients with NES are admitted to intensive care units inappropriately for
treatment
 NES are not associated with epileptiform discharges on vEEG recordings, the gold
standard for NES diagnosis
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78. NES…
 A 2004 paper described three criteria in NES
patients admitted for vEEG, yielding a positive
predictive value of 85%
The criteria were
1.at least two NES per week,
2.refractory to at least two AEDs,
3. at least two EEGs without epileptiform activity
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79. NES…
 Although psychotherapy is the mainstay of treatment
recommendations, its efficacy had been unproven with
controlled data
 Furthermore, no medications had proven effective in the
treatment of NES
 Clinicians do, however, use psychotropic medications to
treat comorbid mood, anxiety, and elements of
personality disorders, which often occur in patients
with NES.
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80. References:
 Psychiatric Care of the medical patient,3rd
edition(2016)
 Uptodate,2018
 Kaplan and Sadock’s Synopsis of Pyschiatry,11th
edition
 WWW.researchgate.net
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81. Thank you…!!!
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