Treatment of Psychiatric Patients with Seizures
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Overview of the relationship between seizures, epilepsy and most common psychiatric problems and possible treatments
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Treatment of Psychiatric Patients with Seizures
- 1. Treatment of Psychiatric patients with Seizures Shokry Alemam, MD. Shokry Alemam Sutherland Hospital April 2020
- 2. Learning objectives • Overview of seizures. • Relation between seizures and psychiatric disorders. • Treatment recommendations. Shokry Alemam Sutherland Hospital April 2020
- 3. Overview of seizures Definition: An abnormal paroxysmal discharge of cerebral neurons sufficient to cause clinically detectable events that are apparent to the patient or an observer Shokry Alemam Sutherland Hospital April 2020
- 4. Types of seizures 1- Focal (partial) seizures: • Simple focal seizures • Complex partial seizures • Temporal lobe epilepsy and psychomotor seizures Shokry Alemam Sutherland Hospital April 2020
- 5. Types of seizures (cont.) 2- Generalized seizures • Generalized tonic clonic (GTCs) seizures • Absence seizures • Myoclonic seizures • Atonic seizures 3- Non-Epileptic seizures Shokry Alemam Sutherland Hospital April 2020
- 6. Epileptic seizures Non-Epileptic seizures Onset Sudden onset and offset Often gradual Duration Often < 3 minutes Variable Perception +/- olfactory, gustatory, visual, dega vu, depersonalization +/- auditory hallucination, paranoia Incontinence May be present Rare Tongue bite Lateeral tongue None or tip of tongue Eyes during event Open Closed Awareness Often impaired except some focal seizures Variable and may be responsive Recall of events None or limited (aura) Usually intact Ictal EEG Abnormal Unchanged from baseline Inter-ictal EEG Normal or abnormal Often normal injury May be present Rarely present Post-ictal state Confusion or drowsiness Rare prolactin Elevated or normal Normal, rarely elevated
- 7. Relation with psychiatric disorder Focal Seizures Sensory and Perceptual Affective Behavioral Cognitive Shokry Alemam Sutherland Hospital April 2020
- 8. Comorbid conditions with epilepsy Epilepsy Affective Disorders PsychosisDestructive behaviors Shokry Alemam Sutherland Hospital April 2020
- 9. Affactive Disorders 1- Depression • Prevalence is 7.5 – 55% • The most common psychiatric comorbidity • Risk factors • Anti-epileptic drugs (AEDs) • Complicated relationship Shokry Alemam Sutherland Hospital April 2020
- 10. Affactive Disorders 2- Anxiety • 20-60% • It can be generalized anxiety disorder or panic disorder • Can happen at any stage, pre-ictal, ictal, post ictal or interictal 3- Bipolar Affective disorder Relatively uncommon; however, epilepsy patients post- operative from temporal lobectomy, particularly right- sided procedures, and those with preoperative bilateral EEG abnormalities may develop mania Shokry Alemam Sutherland Hospital April 2020
- 11. Psychosis In (DSM-5), it is called Psychotic Disorder due to Another Medical Condition (epilepsy). A.Postictal psychosis: • It lasts from hours to 2 weeks • After lucid interval • Treatment depends on severity • Risk factors Shokry Alemam Sutherland Hospital April 2020
- 12. Psychosis B. Interictal psychosis • Chronic condition • 30s or 40s • Persistent • Normal affect • Risk factors Shokry Alemam Sutherland Hospital April 2020
- 13. Destructive behaviors • Ictal anger and aggression rarely reported (less than 0.5%) • Suicide occurs four to five times more frequently in all epilepsy patients and 25 times more frequently in those with focal seizures with altered consciousness than in the general population Shokry Alemam Sutherland Hospital April 2020
- 14. Treatment • Initial therapy of comorbid conditions should not be necessary towards the condition but control seizures which will improve the comorbid condition. • Most psychotropic medicines in epileptic patients are generally safe; however, precautions are required. Shokry Alemam Sutherland Hospital April 2020
- 15. Treatment Low risk/ good choice • SSRIs • mirtazapine • Citalopram, escitalopram and sertraline • Recommended Probably low risk/ use with caution Agomelatine, Duloxetine, MAOIs, Moclobemide, Reboxetine, Vortioxetine Limited evidence Moderate risk/ care required Lithium, trazodone, venlafaxine, vilazodone Limited data suggest low risk of seizures High risk/avoid Amoxapine, bupropion, maprotiline, TCAs Several reports of dose related seizure risk Antidepressants Shokry Alemam Sutherland Hospital April 2020
- 16. Treatment Antipsychotics Low risk / Good choice Sulpride, amisulpride, aripiprazole, ziprasidone, FGAs, risperidone Rare to low risk of lowering seizure threshold Probably low risk/ use with caution Asenapine, brexpiprazole, cariprazine, lurasidone Similar to placebo seizure rate,. Limited clinical use in PWE Moderate risk/ care required Olanzapine and quetiapine Olanzapine causes more EEG changes. Both associated with seizures in RCTs of Low risk High risk/care required or avoid • Clozapine • Chlorpromazine, Loxapine, LAIs • Dose related • Avoid in PWE Shokry Alemam Sutherland Hospital April 2020
- 17. Treatment Drugs for ADHD Low risk Methylphenidate Safe in children within therapeutic doses (0.3 – 1mg/kg/day). No effect on seizure with adult PWE Probably low risk/ use with caution Amphetamines Atomoxetine Limited data with no evidence to increase frequency of seizures Shokry Alemam Sutherland Hospital April 2020
- 18. References • Bacon, D., Fisher, R. S., Morris, J. C., et al. (2007). American Academy of Neurology position statement on physician reporting of medical condi- tions that may affect driving competence. Neurology, 68, 1174–1177. • Bear, D. M., & Fedio, P. (1977). Quantitative analysis of interictal behav- ior in temporal lobe epilepsy. Archives of Neurology, 34, 454–467. • Devinsky, O. (2008). Postictal psychosis: Common, dangerous, and treatable. Epilepsy Currents, 8, 31–34. • Ettinger, A. B., & Kanner, A. M. (Eds.), (2007). Psychiatric Issues in Epilepsy (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. • Fiest, K. M., Dykeman, J., Patten, S. B., et al. (2013). Depression in epi- lepsy: A systematic review and meta-analysis. Neurology, 80, 590–599. • Gross, A., Devinsky, O., Westbrook, L. E., et al. (2000). Psychotropic medication use in patients with epilepsy: Effect on seizure frequency. The Journal of Neuropsychiatry and Clinical Neurosciences, 12, 4. • Hermann, B. P., Seidenberg, M., Dow, C., et al. (2006). Cognitive prognosis in chronic temporal lobe epilepsy. Annals of Neurology, 60, 80–87. Shokry Alemam Sutherland Hospital April 2020
- 19. References • Irwin, L. G., & Fortune, D. G. (2014). Risk factors for psychosis sec- ondary to temporal lobe epilepsy: A systematic review. The Journal of Neuropsychiatry and Clinical Neurosciences, 26, 5–23. • Lee, K. C., Finley, P. R., & Alldredge, B. K. (2003). Risk of seizures associated with psychotropic medications: Emphasis on new drugs and new findings. Expert Opinion on Drug Safety, 2, 233–247. • Schachter, S. C. (Ed.), (2003). Visions: Artists Living With Epilepsy. Elsevier. • Pillmann, F., Rohde, A., Ullrich, A., et al. (1999). Violence, criminal behavior, and the EEG. The Journal of Neuropsychiatry and Clinical Neurosciences, 11, 454–457. • Tellez-Zenteno, J. F., Patten, S. B., Jette, N., et al. (2007). Psychiatric comorbidity in epilepsy: A population-based analysis. Epilepsia, 48, 2336–2344. • Tracy, J. I., Dechant, V., Sperling, M. R., et al. (2007). The association of mood with quality of life ratings in epilepsy. Neurology, 68, 1101–1107. • Tremont, G., Smith, M. M., Bauer, L., et al. (2012). Comparison of personality characteristics on the Bear-Fedio Inventory between patients with epilepsy and those with non-epileptic seizures. The Journal of Neuropsychiatry and Clinical Neurosciences, 24, 47–52. • Whitman, S., Coleman, T. E., Patmon, C., et al. (1984). Epilepsy in prison: Elevated prevalence and no relationship to violence. Neurol- ogy, 34, 775–782. • Delgado-Escueta AV, Mattson RH, King L, et al. Special report. The nature of aggression during epileptic seizures. N Engl J Med. 1981;305(12):711–716. • Standage KF, Fenton GW. Psychiatric symptom profiles of patients with epilepsy: a controlled investigation. Psychol Med. 1975;5(2):152–160. • Barraclough BM. The suicide rate of epilepsy. Acta Psychiatr Scand. 1987;76(4):339–345. Shokry Alemam Sutherland Hospital April 2020
- 20. References • Schwartz JM, Marsh L. The psychiatric perspectives of epilepsy. Psychosomatics. 2000;41(1):31– 38. • Geschwind N. Behavioural changes in temporal lobe epilepsy. Psychol Med. 1979;9(2):217–219. • Kanner AM. Most antidepressant drugs are safe for patients with epilepsy at therapeutic doses: a review of the evidence. Epilepsy Behav 2016; 61:282–286. • Steinert T et al. [Epileptic seizures during treatment with antidepressants and neuroleptics]. Fortschr Neurol Psychiatr 2011; 79:138–143. • Mula M. Epilepsy and psychiatric comorbidities: drug selection. Curr Treat Options Neurol 2017; 19:44. • Steinert T, Fröscher W. Chapter 9 – Seizures. In: Manu P, Flanagan RJ, Ronaldson KJ, eds. Life‐threatening Effects of Antipsychotic Drugs. San Diego: Academic Press; 2016. • Truven Health Analytics. Micromedex. 2018. http://truvenhealth.com/products/micromedex. • Elnazer H et al. Managing aggression in epilepsy. BJPsych Advances 2017; 23:253. • Adams J et al. Methylphenidate, cognition, and epilepsy: a 1‐month open‐label trial. Epilepsia 2017; 58:2124–2132. Shokry Alemam Sutherland Hospital April 2020
- 21. Thank you Shokry Alemam Sutherland Hospital April 2020
Editor's Notes
- Focal seizures can be with or without secondary generalization Complex partial seizures…. Impairment of consciousness… the most common type of seizures in adults and commonly associated with neuropsychiatric symptoms. TLE…… high prevalence of neuropsychiatric symptoms
- NES… due to another neurologic or medical problem or as a consequence of psychological factors (psychogenic non-epileptic seizures, PNESs)
- Sensory (olfactory, visual, auditory, gustatory or tactile) Affective (depression and anxiety) Behavior ( oral or buccal movements, picking, or prolonged staring) Cognitive (déjà vu , jamais vu, macropsia, micropsia, and dissociative experiences.
- RF (seizures with cognitive impairment, onset of epilepsy in late-adult years, and, in most studies, frequent seizures , levetiracetam, tiagabine, topiramate, and vigabatrin) failure of focal seizures to undergo secondary generalization comorbid depression worsens epilepsy patients’ quality of life
- RF (preceding flurry of seizures in patients with chronic epilepsy, low intelligence, bilateral seizure foci, and a family history of psychiatric illness)
- RF(childhood onset of epilepsy, physical neurological abnormalities, low intelligence, frequent seizures, multiple seizure types, seizures that require multiple AEDs, and episodes of postictal psychosis) Forced normalization….. Develop either psychosis or depression)
- Usually safe in therapeutic doses and may provoke seizures in overdoses. Psychotropic-induced seizures, in general, most often occur during the first week of treatment, following sudden large increases in dose, or with regimens involving multiple medicines. Bupropion more than 400 mg immediate release TCA especially clomipramine over 300 mg
- 2nd generation usually safe Chlorpromazine in therapeutic and overdoses is not recommended. Clozapine more than 600 mg daily.
- Maudsley guidelines 2018 Massachusstes general hospital psychiatry 2018 Kaufman’s clinical neurology for psychiatrists 2017