EPILEPSY AND PSYCHIATRY ATHULfgyjgftt.pptx

Epilepsy

1. Neuropsychiatric aspects of epilepsy Presenter Dr Athul Raj Chaired by Dr Lekshmi

2. Definitions Classification Epidemiology Relation with Psychiatry Behavioural disorders in epilepsy Treatment considerations Overview

3. Seizure- Sudden involuntary behavioural events associated with excessive or hypersynchronous electrical discharges in brain Epilepsy – Two unprovoked seizure occurring more than 24 hr apart (Lancet) Recurrent tendancy for seizure Status epilepticus – prolonged or repetitive seizure without intervening recovery Definitions

4. One of the most common serious brain condition Epilepsy should be viewed as a symptom rather than a disease. 0.63 % Prevalence 2/3 cases no discernable cause(idiopathic) It has Multiple risk factors and strong genetic predisposition Incidence high in first year ( more than 75 % ) , Minimum in 30 – 40 years Approximately 75 % of those with active epilepsy are untreated ( Lancet ) Epilepsy

5. Focal seizure Occur without impairment in consciousness isolated motor/ sensory / autonomic / psychic / mixed Focal dyscognitive Seizure Focal onset seizure with impairment of consciousness Motionless stay with simple automatism Most common seizure in adult Tonic Clonic Grand mal / convulsion Abrupt loss of consciousness with tonic rigidity , followed by synchronous clonus release

6. Absence seizure ( Petit mal ) Less common in adults Brief lapse in consciousness Generalised in mode of onset Short lasting – 10 seconds Repetitive lacking auras / post ictal confusion or complex automatism

7. Up to 30 – 50 % people with newly diagnosed epilepsy 50 – 70 % of people with pharmacoresistant epilepsu experience psychiatric behavioural and cognitive problems Comorbid psychiatric conditions add to existing burden Psychiatric comorbidity in epilepsy

8. Common neuropathology, genetics, or developmental disturbance Ictal or sub ictal discharges potentiate abnormal behavior Kindling or facilitation of a distributed neuronal matrix Changes in spike frequency or inhibitory–excitatory balance Altered receptor sensitivity, for example, dopamine receptors Secondary epileptogenesis Proposed relationships of psychiatric disturbances to epilepsy

9. Absence of function at the seizure focus Inhibition and hypometabolism surrounding the focus Release or abnormal activity of remaining neurons Dysfunction or down regulation of associated areas Neurochemical Dopamine and other neurotransmitters Endorphins

10. Gonadotrophins and other endocrine hormones Psychodynamic and psychosocial effects of living with epilepsy Dependence, learned helplessness, low self-esteem, weak defense mechanisms Disruption of reality testing Neurobiological and psychodynamic factors potentiate each other Sleep disturbance Antiepileptic drug related

11. Epilepsy mimicking psychiatric illness Psychiatric illness arising out of epilepsy Psychosis- Post ictal and inter ictal Personality disorder Cognitive dysfunctions Dementia like picture 3. Comorbid psychiatric illness with epilepsy 4. Epileptic drug induced behavioural problems 5. Secondary epilepsy – Infective / auto immune Neuropsychiatric aspects

12. 1.Epilepsy mimicking Psychiatric symptoms Prodrome Aura Seizure Post ictal confusion

13. Prodromes are charectarized by a broad spectrum of pre ictal symptoms that may be experienced for a duration of 10 min to several days , which usually persist until onset of seizure Funny feeling 10.4% Confusion 9 % Anxiety 8.6 % Irritability 7.7 % Prodrome

14. Epilepsy mimicking Psychiatric symptoms Prodrome Aura Seizure Post ictal confusion

15. Aura , means breeze in Latin Focal seizure that involve subjective sensory or psychic phenomenon without observed motor / autonomic changes Auditory hallucinations – Elementary Visual Hallucinations – Flashes of light Olfactory hallucinations – pleasant / unpleasant Gustatory hallucinations – pleasant / unpleasant Fear / Anxiety / Panic attack Dejavu / Jamais vu Aura

16. Epilepsy mimicking Psychiatric symptoms Prodrome Aura Seizure Post ictal confusion

17. Temporal lobe epilepsy Frontal lobe epilepsy Complex partial seizure / Non convulsive status epilepticus Macropsia Micropsia Automatism Repetitive hand movements Hallucinations – taste and smell Delusion I llusion Agitation Head and eye movement to one side Unresponsiveness Difficulty in speaking Explosive screams Abnormal body posturing Repetetive movements

18. Epileptic furor Cursive epilepsy Sudden outburst of rage or excitement during which an irrational act of violence may be committed Involves running in paroxyms Rare phenomenons Orgasmolepsy Gelastic epilepsy Quiritarian epilepsy

19. Epilepsy mimicking Psychiatric symptoms Prodrome Aura Seizure Post ictal confusion

20. Time – 15 mins to hours ( rarely last for days when associated with substance use or metabolic encephalopathy ) Disorientation / confusion Agitation / Irritability Violence Altered sleep Post ictal confusion

21. Psychosis- Post ictal and inter ictal Personality disorder Cognitive dysfunctions 2. Psychiatric illness arising out of epilepsy

22. Overall Inter ictal psychosis – 5.2 % Post ictal psychosis – 2.0 % 6 % of persons with epilepsy had a comorbid psychotic illness meta analysis of 58 studies

23. Focal dyscognitve seizure with secondary generalised tonic clonic seizure More auras and automatisms Long standing epilepsy Cluster of attacks Left temporal focus involvement Intellectual disabiltity Substance use Family history of psychosis Risk factors for psychosis

24. Post ical psychosis Prodrome Aura Seizure Post ictal confusion Post ictal psychosis Lucid interval

25. About 6 % patients Acute onset & Spontaneous remission Characteristic lucid interval prior to the event 14-20% go on to develop c/c interictal psychosis Prominent features- Persecutory, religious or grandiose delusions Should be differentiated from Non convulsive status  periods of impaired consiousness with focal neurological signs Lucid interval Post ictal psychosis

26. Psychosis devoloping within one week of a seizure or cluster of seizure Psychosis lasting for at least 15 hours to 2 months Phenomenology in clear consciousness Delusions Hallucinations No evidence of Seizure on EEG Antiepileptic drug toxixity Head trauma Alcohol or drug intoxication / withdrawal Logsdail & Toons criteria for post ictal psychosis

27. Psychosis in unrelated to seizure Inter Ictal Psycosis Seizure Seizure PSYCHOSIS

28. Resemble Schizophrenia But less social withdrawal and negative symptoms Preserved affective warmth Less systematized delusions More religious delusions Few first rank symptoms Can last from days to years – approximately 1 month Often early age of onset May evolve from Post ictal No preventive measures as such But it is found to worsen with increased seizure frequency and antiepileptic withdrawal Interictal psychosis

29. An antagonistic relationship between psychosis and seizure Inverse relation between EEG and Psychosis Forced Normalization Seizure Seizure PSYCHOSIS

30. Heinrich Landolt Electrophysiological phenomenon Emergance of psychiatric symptoms on electrical stabilization of EEG Parodoxical Normalisation Coined by Wolf in 1991 Eplilepsy that is still active but it remains subcortical (sphenoidal EEG ) Forced Normalization

31. Also known as Reciprocal Psychosis Was coined by Tellenbach Clinical phenomenon of a reciprocal relationship between abnormal mental states and seizures that do not rely on EEG Findings Alternative Psychosis

32. ii. personality changes High prevalence reported. Borderline –most common Others- Histrionic PD, Dependent PD, Atypical or mixed PD Psychosocial factors + Associated intellectual disability Dependency traits Low self esteem , Epileptic personality- outdated idea Temporal lobe epilepsy – There is difficulty in understanding the perspective of others ( Theroy of mind )

33. Gastaut-Geschwind Syndrome(F07.0) Cluster of personality traits Subset of patients with CPS with temporal limbic focus temporal lobe dysfunction Heightened significance of things Hypergraphia Serious , humorless Increased interest in philosophical ideas and religion Viscocity in interpersonal interaction – Tendancy to talks repetitively and and circumstantially about a restricted range of topics

34. In children manifest as Loss of mile stones Decreased attention and concentration Aphasisa Memory loss Language impairment In adults Depends on epileptoenic focus of Brain Temporal lobe – Memory disturbance Frontal – Behavioural abnormality /personality changes / Impuslivity Prologed seizure – Dementia like picture Mild Cognitive Disorder is not uncommon Cognitive deficits in epilepsy

35. Childhood onset and age of the patient High seizure frequency Seizure intractability Duration of epilepsy Type of epilepsu Choice and drug compliance Comorbid condition Landau kleffner syndrome Dravet syndrome Benign Rolandic epilepsy Lennox Gastaut syndrome Risk factors

36. Anxiety disorders Mood disorder Dissociative symptoms - Psychogenic non epileptic seizures Sexual dysfunction Substance use / dependence Aggression /Intermittent explosive disorder 3.Comorbid psychiatric illness

37. Prevalence is 30 % Anxiety disorders Most common is social phobia Mixed anxiety depression, Ictal and postictal anxiety states (MC) Panic disorder OCD Complex phobias

38. Seizure phobia’ -a patient’s fear of having a seizure is more disabling than the seizures themselves The clinical picture resembles agoraphobia patients engaging in a range of safety and avoidant behaviours that maintain their anxiety (post surgery for seizures- avoidant behaviour anticipating seizure were noticed) Further complicated by benzodiazepine dependence( misuse for presumed prodromal symptoms, self medicatio for anxiety) Respond well to CBT

39. Mood disorders Depressive disorders (MC) 7.5-34% Dysthymia-most common  Inter ictal 80% report depressive symptoms not meeting criteria  intermittency  Dysthymia like disorder of epilepsy ( Kanner 2003) Depression  ictal, peri-ictal, Post-ictal. usually atypical – with / without psychotic symptoms Hypomania- more common  Ictal and peri-ictal Mania/mixed episodes - rare

40. 35 studies Point prevalence of MDD – 21.9 % 41

41. 3 times more frequent in epilepsy than in general population ( Verratti et al 2008 ) Attempted suicide more common Completed suicide are 4-5 times common Risk factors- TLE MDD temporal lobectomy BPD Psychosis command hallucination psychosocial stress agitation Suicide

42. Sexual disorders Prevalence – 50 % Women – Dysfunctions in the domains of desire Men – Erectile dysfunction and premature ejaculation Oxcarbazepine , Lamoreigine and Levetiracetam – Caused minimal dysfunction Other comorbid conditions and medications contribute to sexual dysfunction

43. Involuntary psychogenically induced spells that mimic epileptic behaviour Also known as Non epileptic behavioural disorder The term Pseudo seizures is discouraged Functional neurological symptom disorder – DSM 5 No EEG changes with bizarre movements It can be independent ,but may coexist with epilepsy . 30 – 40 % of persons with epilepsy have this Psychogenic non epileptic Seizure

44. Found in Females aged 26 – 32 Wiith psychological stressors ( Sexual / physical abuse ) and poor coping skils In children no specific gender prevalence Gold standard – video EEG monitoring Higher rate of Psychiatric comorbidities Depression and anxiety disorders Psychosic is uncommon PNES

45. Baribiturate – Depression Suicidal ideation Sedation Psychomotorslowing / Paradoxical hyper activity Leviteracetam – Irritability and aggression Gabapentin – Aggressive behaviour / Hypomania Phenytoin – Encephalopathy , Depression , Impaired attention Carbamezipine – Irritabiltiy , impaired attention Lamotrigine – Insomnia , agitation Antiepileptic drug induced behavioural Problems

46. Infective /Auto immune Infective cause – HSV can cause behavioural symptoms Head injury – Post traumatic seizures can cause various behavioural issues Auto immune disorders - Anti NMDAR encephalitis , VKGC encephalitis , Limbic encephalitis They can cause psychotic symptoms 4.Secondary epilepsy

47. Psychosis Personality disorder Type of seizure and psychopathology Focal dyscognitive seizure Major depressive episode Dissociative symptoms Obsessions Compulsions Temporal lobe epilepsy

48. Good history taking – Document classical episode , number of episodes , lase episode Semiology – Prodrome , Aura , Ictal , Post ictal , Inter ictal Check for psychiatric comorbidity Check for organicity and substance use Management of Neuropsychiatric issues

49. EEG LFT/ RFT / Electrolytes MRI Hormonal assay CSF study - Immunology – Study of serum and CSF CASPR2 NMDA antibodies , GAD 65 Video EEG Investigations

50. The aim of treatment is to achieve seizure control with a minimum of adverse effects Individualised treatment Seizure type Epilepsu syndrome Co medication Comorbidity Life style Risk assessment Involve family members in decision making for treatment Diagnosis should be critically evaluated if events continue despite an optimal dose of first line medication Management

51. Outcome is variable Pure motor weakness – Recover in weeks to months Predominant somatic symptoms – May persist through out More than half of the patients do not achieve remission Psychological comorbidities should be treated Long term psychological intervention + SSRI Treatment of PNES

52. Ictal psychotic symptoms Seizure control will be the focus of treatment neuroleptics have no role Postictal psychosis Admission and sedation with BZD neuroleptics usually will not be needed Interictal psychosis  seizure prevention Management- pharmacological and nonpharmacological Avoid Psychotropics that can lower seizure threshold

53. Majority ( 85 % ) of Inter ictal psychosis require antipsychotics No distinct difference between the efficacy of FGA and SGA So the consideration is Seizure threshold lowering property Low risk –Haloperidol, risperidone and trifluoperazine Higher risk - Amisulpiride , olanzapine and quetiapine Avoid depot preparations Clozapine- only in hospital settings Role of Antipsychotics

54. Antipsychotics  FGAs   Haloperidol2-20   Trifluoperazine10-30   Chlorpromazine200-1000  SGAs   Olanzapine5-20   Risperidone2-16   Quetiapine150-800    Amisulpride300-1200   Aripiprazole10-30   Antipsychotics High risk: Clozapine , chlorpromazine, loxapine , zotepine   Moderate risk: Olanzapine   Low risk: Aripiprazole , risperidone , amisulpride , ziprasidone , haloperidol, trifluoperazine , flupenthixol , fluphenazine

55. Antidepressants Alleviate anxiety and mood symptoms Overall efficacious of antidepressants in treating depressive symptoms are samae Most concerned issue for antidepressants in epilepsy is the seizure threshold lowering property SSRI is preferred TCA usually require higher dose for achieving antidepressants Benzodiazapine Rapid relief of symptoms Psychotherapy Long term Cognitive Behaviour therapy Depression and anxiety

56. Antidepressants  TCAs    Amitriptyline100-200   Nortriptyline50-200  SSRIs     Escitalopram5-30   Fluoxetine10-80   Sertraline25-200   Paroxetine10-60    SNRIs   Venlafaxine75-375   NDRIs Bupropion150-450   Psychotropics associated with reduction in seizure threshold Antidepressants  High risk: TCAs (high doses>200 mg), bupropion (>450 mg), maprotiline   Moderate risk: Trazodone , vilazodone , venlafaxine   Low risk: SSRIs, mirtazapine

57. Treatment considerations 1. Use of psychoactive convulsants whenever possible 2.Awareness of the potential reduction of seizure when psychotropic meds are used 3. Adjustment of meds considering drug interactions 4.Replacement of meds when suspected to cause psychopathology Review atleast once a year

58. Purple day MARCH 26 All over the world , purple day is celebrated once a year to spread awareness about epilepsy ”

59. ” References Comprehensive textbook of psychiatry Epilepsy and behaviour Journal Indian J Psychiatry.  2022 Mar; 64(Suppl 2): S319–S329.

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