Download NEUROPSYCHIATRY OF SEIZURES - EPILEPSY Association Of Sri

NEUROPSYCHIATRIC ASPECTS
OF EPILEPSY
Presenter: Dr. Shravan Kumar
Moderator: Prof. R. K. Gaur
INTRODUCTION
• Clinicians have recognized the association of epilepsy with psychiatric
disorders since antiquity.
• At the turn of the 19th century, Emil Kraepelin emphasized that
epileptic patients possessed personality changes and a predisposition
to psychosis.
• The development of new antiepileptic and psychiatric therapies and
novel neuroimaging techniques makes understanding the association
of epileptic seizures and psychopathology increasingly important.
• Epidemiological data support an increased risk for psychiatric
comorbidity among epileptics as compared to nonepileptic patients..
• The most established association is between epilepsy and depression or
dysthymia, but a range of psychopathology occurs in one-fourth or
more epileptics.
• Psychiatric comorbidity has also a serious impact on the quality of
life and social well-being of patients with epilepsy.
DEFINITIONS
Seizure
• This term came from a Latin word which means ‘to take possession
of’
• This is a paroxysmal event due to abnormal, excessive, hyper
synchronous discharges from an aggregate of CNS neurons.
• The seizure itself is known as the ictus.
Epilepsy
• Epilepsy is the recurrent tendency to seize i.e to have seizures.
• This is a clinical phenomenon rather than a single identity.
• In epilepsy, abnormal electrical discharges occurs due to
hyperexcitable neurons with sustained postsynaptic depolarization.
Convulsion
• This is a condition where body muscles contract and relax rapidly
and repeatedly, resulting in an uncontrolled shaking of the body.
• Convulsion is often a symptom of an epileptic seizure.
• Not all epileptic seizures lead to convulsions, and not all
convulsions are due to epileptic seizures, examples being non
convulsive epileptic seizures and eclampsia respectively.
Fits
• This is the general term often used for sudden violent attack of
convulsion and also for presyncope/syncope by non medical
persons.
EPIDEMIOLOGY OF EPILEPSY
• Seizure disorders are common and usually have an early onset.
• Epilepsy affects 20 to 40 million people worldwide and has a
prevalence of at least 0.63 percent and an annual incidence of
approximately 0.05 percent.
• The overall incidence is high in the first year, drops to a minimum in
the third and fourth decades of life, then increases again in later life
(bimodal distribution).
• More than 75 percent of patients have their first seizure before 18
years of age, and 12 to 20 percent have a familial incidence of
seizures.
• Among adults, the most common seizures are complex partial and
generalized tonic-clonic seizures.
• Epidemiological studies from communities, psychiatric hospitals, and
epilepsy clinics report a 20 to 60 percent prevalence of
neuropsychiatric problems among epilepsy patients.
• Epilepsy patients are prone to psychosis, depression, personality
disorders, hyposexuality, and other behavioral disorders.
• The percentage of epilepsy patients in psychiatric hospitals was also
higher than the general prevalence of epilepsy.
• Among patients attending epilepsy clinics, approximately 30 percent
had a prior psychiatric hospitalization, and 18 percent were on at least
one psychotropic drug.
• Furthermore, epidemiological studies indicate an increased interictal
psychopathology among head-injured patients with epilepsy
compared to head-injured patients without epilepsy.
• Studies on the laterality of the seizure focus suggest an association of
a left-sided focus with psychosis.
CLASSIFICATION OF EPILEPTIC
SEIZURES
Primary generalized seizure
•
•
•
•
•
Absence (petit mal)
Tonic Clonic (grand mal)
Tonic
Atonic
Myoclonic
Partial seizures
• Simple partial
• Complex partial
• Partial with secondary generalization
Unclassified seizures
• Neonatal seizures
• Infantile spasms
EPILEPSY SYNDROMES AND
OTHER SPECIAL FORMS
Epilepsy syndromes
• Juvenile Myoclonic epilepsy
(absence, myoclonic and GTC seizures)
• Lennox Gastaut syndrome
(seizure of multiple types, intellectual impairment and abnormal EEG)
• Mesial Temporal Lobe epilepsy
(seizure with sensory changes)
continued
• Landau-Kleffner syndrome
(infantile acquired aphasia with convulsion)
• West syndrome
(infantile spasm, mental retardation, hypsarrhythmia on EEG)
• Ramsay Hunt syndrome
(myoclonic seizure, progressive ataxia, tremor, dementia)
Other special forms
• Reflex epilepsy
(trigger present eg photosensitivity)
• Gelastic epilepsy
(sudden uncontrollable burst of laughing/crying)
• Diencephalic or autonomic
(episodes of sudden autonomic dysfunction)
PSYCHIATRY AND EPILEPSY
• Epilepsy is associated with a range of psychiatric disorders.
• There is increased prevalence of psychiatric problems among
epileptic patients.
• There may have auras with psychic content.
• One-fourth or more have schizophreniform psychoses, depression,
personality changes, or hyposexuality.
• Psychiatric phenomena can be associated with the seizure itself, as
well as the peri ictal and interictal phases of epilepsy.
• Peri ictal disturbances include pre ictal dysphorias , ictal and post
ictal syndromes.
PSYCHOPATHOLOGY
ASSOCIATED WITH EPILEPSY
• The psychiatric manifestations of epilepsy are heterogeneous
disorders with potentially different causes.
• The neuro-pathology itself could be the source of seizures and
behavioral changes.
• Left hemisphere and temporal lobe lesions may be associated with a
schizophreniform psychosis, and psychosis in epilepsy may be
particularly frequent if there is specific underlying pathology or
ventricular enlargement.
• Ictal or subictal epileptiform activity may promote behavioral
changes by facilitating distributed neuronal connections, increasing
limbic–sensory associations, or changing the overall balance
between excitation and inhibition.
• The absence of function, such as the interictal hypometabolism
observed on PET scans may lead to depression or other interictal
behavioral changes.
• Seizures may result in neuroendocrine or neurotransmitter changes,
such as increased dopaminergic or decreased inhibitory transmitters,
decreased prolactin, increased testosterone, or increased endogenous
opioids, all of which can affect behavior.
• Neurobiological factors may be potentiated by psychodynamic
factors, such as feelings of helplessness, learned helplessness,
dependency, low self esteem, and the disruption of reality testing.
PSYCHIATRIC FEATURES IN
EPILEPSY
• Different psychiatric phenomena are associated with epilepsy
and they are particularly associated with any phase.
Ictal Features
• Psychic auras
• Ictal fear
Peri-ictal Features
• irritability,
• depression,
• headache,
• confusion,
• twilight states
Interictal Features
• Schizophreniform Psychosis.
• Gastaut-Geschwind Syndrome


temporal lobe epilepsy
hypergraphia, hyperreligiosity, reduced sexuality, circustantiality,
intensified mental life
• Personality Disorders
AURAS OF EPILEPSY
• Occurs in the portion of the seizure just 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.
• Specially important in Temporal Lobe Epilepsy
EPILEPTIC AUTOMATISM
• Defined as state of clouding of consciousness
• Occurs during or immediately after seizure
• Individual retains control of posture and performs simple or
complex movements
• Commonly preceded by aura
• Frequently terminates with a Grand Mal convulsions
• Lasts for a few seconds to hours.
(continued)
Chiefly in the form of:
•
•
•
•
•
•
•
epigastric sensation
confusion , difficulty with memory, diziness
feeling of strangeness
masticatory movements,
dazed expressions,
pulling out clothes and passing hand over face
walking around , searching or moving objects, removing clothes etc.
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.
TWILIGHT STATES
• Range from automatisms and fugues to schizophrenia like disorders.
• It lasts from one to several hours.
• May appear as:
dream like absent minded behavior
muddling of comprehension
complete unawareness of environment
• Psychomotor retardation is common
(continued)
• Marked perseveration in speech and action can be present.
• 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
ABSENCE STATUS
(PETIT MAL STATUS)
• Longer lasting form of automatism.
• Periods of abnormality are too brief for resumption of awareness.
• Episodes starts and stops abruptly.
• There is marked disorientation, impaired grasp and automatic
behavior.
• Patient may be virtually stupurous , motionless and apathetic.
• There may be paranoid delusional ideation , thought blocking and
hallucinations.
TEMPORAL LOBE STATUS
(PSYCHOMOTOR STATUS)
• Episodes can lasts for hours or days
• Patient is confused , withdrawn and retarded
• Sometimes continuous movements of hands , lip smacking and
picking up of clothes
• Presence of confusion and disorientation
• Hallucinations and paranoid delusions may be present
POST-ICTAL DISORDERS
• Post ictal confusion may last hours to days
• Manifestations are very complex.
• Very confused and movements are clumsy and in coordinated .
• Usually followed by a period of sleep , malaise , headache and
nausea
• Agitation and irritability are sometimes prominent
(CONTINUED)
• May be dangerously aggressive epileptic furore
• Post ictal twilight states last longer,and characterize by psychomotor
retardation, vivid hallucinations affective abnormalities.
NEUROPSYCHIATRIC
DISORDERS IN
PATIENTS WITH
EPILEPSY
DEPRESSION AND EPILEPSY
• The prevalence of depression in different studies varies and may
range from 7.5 to 34 percent of patients with epilepsy.
• Those with complex partial seizures and poor seizure control are
more likely to have mood disorders.
• Psychological studies also suggest a greater incidence of ideational
orientation, self-criticism, and depression among epilepsy patients
with a left hemisphere focus.
(CONTINUED)
• More common in patients with CPS,TLE
• Tebartz van 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 to left amygdala.
CAUSES OF DEPRESSION IN
EPILEPTICS
[1] 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.
[2] SEIZURE FREQUENCY
• Better seizure control and a reduction in interictal epileptiform
abnormalities are associated with emergence of depressive
symptoms or other psychiatric complaints (psychosis, mania or
anxiety).
[3] 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
Lamotrigine.
associated
are Valproate,
Gabapentin,
• Decrease in folate levels associated with mainly depression.
CHOICE OF ANTI DEPRESSANTS
IN EPILEPSY
It 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%
• This is not higher than incidence in general population.
SUICIDE AND EPILEPSY
• Rates higher among epileptics
• 20% deaths were due to suicides in mentally abnormal epileptics
• Suicide risks is 5 fold among epileptics
• Suicides attempts also appear to be especially common
BMD AND EPILEPSY
• Manic episodes described in range of 1.5 to 4.8%.
• Reported in patients with orbitofrontal and basotemporal cortical
lesions of the right side.
• Mania is mostly related to peri-ictal state, and improves with seizure
control.
• Hypomania has been described as occuring de novo after temporal
lobe surgery with right sided emphasis.
TREATMENT OF BMD
• Most of the antipsychotics possess proconvulsant effect.Hence they
should be used very cautiously.
• Lithium at therapeutic levels has very low proconvulsant effect.
• At toxic levels Lithium causes neuronal hyperexcitability and thus
acts as proconvulsant.
• The use of anticonvulsants as Carbamazepine and Valproic acid are
known to be effective in treatment of BMD in epilepsy.
ANXIETY DISORDERS AND
EPILEPSY
• Generalized anxiety , phobic and panic disorders are common.
• The lifetime prevalence is 21% in epileptics, much higher than 1%
prevalence rate in the general population.
• Interictal panic disorder represents a paroxysmal condition that can
be misdiagnosed as an epileptic seizure. Conversely, anxiety
symptoms during seizures need to be distinguished from interictal
anxiety.
(CONTINUED)
• Ictal anxiety or fear is usually stereotyped, with rapid onset and
shorter duration than panic attacks.
• Anxiety can be reaction to acquiring the diagnosis of epilepsy.
• Treatment of anxiety in epilepsy consists of relaxation techniques,
counselling, and behavior therapy mainly.
OCD AND EPILEPSY
• Abnormal EEG is recorded in some patients of OCD consisting of
temporal sharp waves activity.
• One case report described inverse relationship between seiures and
OCD.
• Higher obsessionality scores is associated with 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.
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.
(continued)
[2]
Psychoses with
manifestations.
admixture
of
‘organic’ and
‘functional’
[3] Psychoses which occur in setting of clear consciousness and take a
form characteristic of schizophrenia or affective disorder.
CLINICAL CHARACTERISTICS OF
PSYCHOSIS IN RELATION TO
SEIZURE ACTIVITY
Ictal psychosis
Post ictal
psychosis
Peri ictal
psychosis
Inter ictal
psychosis
Consciousness
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
Anticonvulsants
(i/v)
Spontaneous
recovery in
many cases
Improved
seizure control
Neuroleptic
drugs
POST ICTAL PSYCHOSIS
(PIP)
Risk factors
•
•
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Bilateral cerebral dysfunction
Ictal fear
Clusters of seizures
H/O febrile convulsions or mesial temporal sclerosis
Less hippocampal sclerosis, anterior preservation of hippocampus
Preexisting psychiatric disorder
Family H/O psychotic disorder
CLINICAL FEATURES AND
PHENOMENOLOGY OF POST ICTAL
PSYCHOSIS
• PIP develops in patients with Complex Partial Seizure mostly.
• Duration of PIP ranges from 1 to 90 days
• There can be
Delirium
Delusions, Hallucinations
Mood disorders
Aggressive behavior
Sexual disorders (hypersexuality)
OPERATIONAL CRITERIA FOR
POST ICTAL PSYCHOSIS
1. Onset of confusional psychosis within a week of the return of
apparently normal mental function
2. Duration of between one day to three months
3. 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
4.
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
PERI ICTAL PSYCHOSIS
• A wide range of phenomena including affective, behavioral , and
perceptual experiences may occur
•
Often accompanied by automatisms
•
Consciousness is usually impaired
• Amnesia will often follow
• Diagnosis is made by EEG
INTER ICTAL PSYCHOSIS
• It tends to last days to weeks.
• More common when seizures are infrequent or fully controlled.
• Premonitory symptoms as anxiety and insomnia may be present.
• EEG normalizes during such episodes generating the terms ‘ forced
normalization’.
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.
RISK FACTORS FOR SLPE
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Age of onset before or around puberty.
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
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
PRINCIPLES OF
TREATMENT OF PSYCHOSIS
• First line management of patients who only have episodes of
psychosis after seizures should be attaining seizure control.
• All neuroleptics reduce seizure threshold so they should be uesd
very cautiously.
• Rates of seizure range from 0.5 to 1.2 with neuroleptic use in cases
of previously controlled epilepsy.
• Avoid Clozapine , Loxapine, Chlorpromazine
• Of conventional neuroleptics Haloperidol is relatively safe
• Sulpiride , Quetiapine, Olanzapine and Risperidone are safe in long
term treatment
• When possible, give only one drug
•
Monitor seizure frequency strictly.
PERSONALITY DISORDER AND
EPILEPSY
• Most commonly associated with TLE
• Dependent and avoidant personality disorders were the most
common diagnoses
• Epileptic aura was positively correlated
• It has been associated with poorer response to treatment, lower
compliance, and increased risk of suicide attempts.
PERSONALITY TRAITS A/W
EPILEPSY
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Aggression , Anger
Circumstantiality
Dependence
Passivity
Depression, sadness, elation
Emotionality
Increased
philosophical
interest
• hyposexuality
•
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•
•
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•
•
Guilt
Humourlessness
Hyper graphia
Hyper moralism
Hyper religiosity
Obsessionalism
Paranoia
viscosity
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.
(continued)
• Other characteristics seen in TLE are:
impulsiveness,
antisocial conduct,
paranoid attitude
moodiness
hysterical symptoms,
perseveration and viscosity of thoughts
• ‘Ixophrenic Syndrome’ of slowness, perseveration and viscosity is
common in TLE.
ETIOLOGY OF PD IN EPILEPSY
[1] 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.
(continued)
[2] Effects of brain damage
• Many problems seen are similar to those in brain damage
• Nothing specific to epilepsy about mental slowing, perseveration,
stickiness or viscosity of thoughts and emotions.
• Association claimed b/w TLE and PD is likely d/t brain damage in
limbic system
(continued)
[3] Effect of seizures and abnormal electrical activity
• Disorganization of cerebral functioning by epileptic discharge also
contribute
• Shown by :
Increase disturbance in some prior to fit
Traits may improve when fit frequency is low
Effect of temporal lobectomy postoperatively
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, transvestism , masochism, exhibitionism and
fetishism have been reported
• More vaginismus in women, more ED in men with physiologic
origin
• Endocrine changes have been reported on t/t with liver enzyme
inducing antiepileptics
EPILEPTIC DEMENTIA
• Many epileptics undergo a decline in intellectual ability.
• Progressive impairment of memory, concentration and judgment.
• Usually coupled with severe personality
behavioral disorders.
deterioration and
• Neuro imaging may demonstrate cerebral atrophy.
• Common when epilepsy is secondary to a known brain lesion.
(continued)
In children a/w
• prolonged febrile status
• West syndrome
• Lennox – Gastaut syndrome
In adults
• Etiology differs from case to case
• Epileptic with brain lesion dement earlier
• It may represent chronic end state of SLPE
PSYCHOSOCIAL
ISSUES
ASSOCIATED
WITH EPILEPSY
Common problems reported in epileptics:
•
•
•
•
•
•
•
•
Anxiety
Poor self-esteem
Social isolation
Depression
Stigma
Marriage issues
Employment
Poor quality of life
WAYS TO COPE WITH EPILEPSY
Counselling
– to educate regarding epilepsy, assist in adaption of life with epilepsy
and treat any comorbid psychiatric conditions
Recreation therapy
– to approach social isolation problem and relationship with peers
Social skills and cognitive rehabilitation
– to assist patient with brain dysfunction complicated by epilepsy
Self-help and support group
Vocational rehabilitation
EPILEPSY IN
THE INDIAN
LAW
Marriage
• The Hindu Marriage Act of 1955 and the Special Marriage Act of
1954 stated that a marriage under these acts can be solemnized “if at
the time of marriage neither party suffers from recurrent attacks of
insanity or epilepsy”.
•
After 12 years of struggle by the Indian Epilepsy Association the
word ‘epilepsy’ deleted from this law in December 1999.
• The religion Hindu includes followers of Sikh, Jain and Buddhism
also.
• Marriages in muslims and christians are governed by personal laws
based on their religious books.
Employment
paradoxical laws
• Barring employment to any person on the grounds he/she has
epilepsy would amount to violation of the Indian constitution.
• However the law also says that a State can prohibit employment of
persons who are medically unfit if the nature of the job requires a
“fit” person!
• And the paradox is still present in law.
Insurance
• The Life Insurance Company of India issue life insurance policies
to epilepsy patient at a slightly increased premium rate of 10-15%.
• However personal, accident, health and travel insurances are
available with a provision that the insurance does not cover illness/
accident related to epilepsy.
• Motor insurance and home insurance are issued without any
restrictions.
• There are also private companies who provide life insurance with or
without extra premium depending on recommendations of a medical
board.
Driving
• All driving license applicants have to fill in a form which
specifically asks ‘Do you have epilepsy?’.
• If a person answers in the affirmative, he or she is denied a license.
Disability status
• In India, epilepsy does not fall under the ‘disability’ category.
• We also do not have a disability discrimination act applying for
epilepsy.
REFERENCES
•
•
•
•
•
Harrison’s principles of Internal medicine , 19th ed.
Kaplan and Sadock’s CTP 9th ed.
CMDT 2016.
Organic psychiatry William Alwyn Lishman, 3rd ed.
The Psychiatric Perspectives of Epilepsy Joseph M.
Schwartz, and Laura Marsh, Psychosomatics 41:31-38,
February 2000
• Neuropsychiatry BY Randolph B. Schiffer, Stephen M.
Rao, Barry S. Fogel
REFERENCES
(continued)
• www.indianlaw.gov.in
• Personality Disorders Among Medically Refractory
Epileptic Patients ,Faustino Lopez-Rodriguez, Lori
Altshuler Joanne Kay, Mario Mendez, and Jerome Engel, J
Neuropsychiatry
Clin
Neuroscience
11:464-469,
November 1999.
• Ictal and postictal psychiatric disturbances, Michael R.
Trimble Institute of Neurology, University College,
London.
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