Neuropsychiatric aspects of epilepsy

Neuropsychiatric aspects of Epilepsy

1. Neuropsychiatric aspects of Epilepsy Presenter: Kaushik Nandi Chairperson: Prof. Th. B ihari Singh

2. OVERVIEW: History Definitions Classification Of Epilepsy Epidemiology Psychiatric Disorders In Epilepsy localisation - related epilepsy Suicide In Epilepsy Personality Changes In Epilepsy Functional Non-epileptic Attacks Aggression In Epilepsy Epilepsy And Sexual Dysfunction Cognitive Function In Epilepsy Treatment Of Epilepsy

3. HISTORY: The oldest detailed account of epilepsy is on a Babylonian tablet  dating as far back as at least 2000 BC. It emphasizes the supernatural nature of epilepsy, with each seizure type associated with the name of a spirit or god - usually evil . Greek concept (5th century BC) describes it as "The Sacred Disease"  

4. HISTORY: The word "epilepsy" is derived from the Greek " epilepsia " which means "to take hold of" or "to seize .” Hippocrates viewed epilepsy as a brain disorder, but his view did not begin to take root until the 18th and 19th centuries.

5. HISTORY : P eople with epilepsy were viewed with fear, suspicion and misunderstanding, and were subjected to enormous social stigma. They were treated as outcasts and punished. However , some of them succeeded and, in fact, became famous the world over. Among them were Julius Caesar, Czar Peter the Great of Russia, Pope Pius IX, the poet Lord Byron and others.

6. HISTORY: The foundation of our modern understanding was laid in the 19th century with the proposal by Hughlings Jackson (1873), a London neurologist, that seizures were the result of sudden brief electro-chemical discharges of energy in the brain - the character of the seizures depending on the location and function of the seat of the discharges . In  1920s, Hans Berger , a psychiatrist, developed the human electroencephalograph (EEG  )

7. HISTORY: Emil Kraepelin emphasized that epileptic patients possessed personality changes & a predisposition to psychosis Psychiatric disorders were thought to result from psychosocial difficulties in epilepsy Defining temporal lobe epilepsy opened up research into disturbances in limbic or emotional brain

8. DEFINITIONS: Seizure is "a transient occurrence of signs and/or symptoms due to an abnormal, excessive or synchronous neuronal activity in the brain" However, a (single) seizure can occur in an otherwise healthy individual. S uch individuals are generally not considered to have epilepsy . Epilepsy is a neurological condition characterised by a tendency to unprovoked and recurrent seizures

9. DEFINITIONS: Epileptogenesis : Epileptogenesis is the process by which the previously normal brain is functionally altered and biased towards the generation of the abnormal electrical activity that subserves chronic seizures. The concept of a ‘mechanism of epilepsy’ refers to any biological feature of the brain that drives or supports recurrent, unprovoked seizures .

10. Examples of these biological features include molecular, anatomical or circuit level alterations, such as cell death or dysregulation of an ion channel or neurotransmitter receptor.

11. DEFINITIONS: Aura : Simple partial seizures, which may or may not progress into another seizure type. They are often mistakenly considered as a prodrome for a seizure . Fit : The physical manifestation of a seizure.

12. DEFINITIONS: Prodrome : A pre- ictal phenomenon characterised by subjective or objective awareness of a clinical change that heralds the onset of a seizure, but that does not form part of it.

13. CLASSIFICATION OF EPILEPSY Generalised seizures (bilaterally symmetrical and without local onset ) Tonic, clonic or tonic– clonic ( grand mal ) Absence ( petit mal ): with loss of consciousness only complex – with brief tonic, clonic or automatic movements

14. CLASSIFICATION OF EPILEPSY Generalised seizures contd … Lennox– Gastaut syndrome Juvenile myoclonic epilepsy Infantile spasms (West syndrome ) Atonic (astatic, akinetic ) seizures (sometimes with myoclonic jerks)

15. CLASSIFICATION OF EPILEPSY Partial or focal seizures (seizures that begin locally) Simple (without loss of consciousness or alteration in psychic function): motor somatosensory autonomic pure psychic Complex (with impaired consciousness)

16. CLASSIFICATION OF EPILEPSY Special epileptic syndromes Myoclonus and myoclonic seizures Reflex epilepsy Acquired aphasia with convulsive disorder (Landau Kleffner Syndrome) Febrile and other seizures of infancy and childhood Functional non-epileptic attacks

17. CLASSIFICATION OF SEIZURES The International League Against Epilepsy (ILAE ) 2017 describes seizures according to these criteria where seizures begin awareness in focal seizures motor and other symptoms in focal seizures

18. Classification of seizures FOCAL ONSET UNKNOWN ONSET GENERALISED ONSET Aware / Impaired awareness Motor Non-motor onset Focal to B/L tonic- clonic Motor onset Non-motor onset (absence) Motor onset Non-motor onset Unclassified

19. EPIDEMIOLOGY: 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.

20. EPIDEMIOLOGY: 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.

21. EPIDEMIOLOGY: It is estimated that there are more than 10 million persons with epilepsy in India. Its prevalence is about 1% in our population. The prevalence is higher in the rural (1.9%) compared to urban population (0.6 %) NMHS (2015-2016): Prevalence of epilepsy (GTCS only) is 0.3%

22. EPIDEMIOLOGY: Psychiatric comorbidity occurs in 20-40% of people with epilepsy. More psychopathology in people with epilepsy than in other chronic neurological conditions.

23. Psychopathology in epilepsy Epilepsy patients are prone to psychosis, depression, personality disorders, hypo-sexuality, & other behavioural disorders Psychiatric disturbances are common in patients with complex partial seizures than GTCS

24. Risk factors for psychopathology in epilepsy CLINICAL FACTORS Age at onset Duration Type & frequency of seizure Site of brain affected Inter-ictal & ictal EEG abnormalities PSYCHOSOCIAL FACTORS Chronicity Low socioeconomic status Low education Stigma Legal limitations Learned helplessness Overprotection by family BIOLOGICAL FACTORS Damage to brain areas of psychic functioning Kindling effect Secondary epileptogenesis Altered receptor sensitivity Antiepileptic drug side effects

25. Psychiatric disorders in Epilepsy Disorders clearly attributable to brain disorder causing epilepsy Learning disability Specific epileptic syndromes West syndrome Lennox - Gastaut syndrome Progressive myoclonic epilepsies Epilepsy with continuous spike-and-wave during slow-wave sleep Cognitive & behavioural manifestations of other acquired causes of epilepsy

26. Disorders strictly related in time to seizure occurrence PRE - ICTAL ICTAL POST-ICTAL INTER-ICTAL Prodrome Aura Automatisms Non-convulsive status epilepticus Delirium Psychosis Affective disorder Schizophrenia-like psychosis Personality disorder Dementia Dissociative seizures

27. PRE-ICTAL DISORDERS PRODROME Subjective symptoms occurring in the hours or even days leading up to a seizure seen in 7-20% patients Gradual onset; prolonged duration; affective symptoms Ill-defined, non-specific feelings – malaise, headache, tiredness, irritability, dysphoria

28. ICTAL DISORDERS EPILEPTIC AURA In simple partial seizure, ictal psychiatric phenomena may be the only manifestation of seizure In complex partial seizures aura precedes clouding of consciousness & loss of awareness

29. Ictal aura is brief, paroxysmal & highly stereotyped Hallucinations, forced thinking or crowding of thoughts can mimic psychosis Ictal anxiety can mimic panic disorder Clouding of consciousness with amnesia for the episode can be present

30. EPILEPTIC AUTOMATISMS More or less coordinated, repetitive motor activity usually occurring when cognition is impaired & for which subject is usually amnesic afterwards Automatic fumbling behaviour, such as lip-smacking, hand-rubbing, picking at objects, walking in circles, repeating meaningless phrases, or undressing may be seen

31. Terms describing automatisms 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

32. Terms describing automatisms Gestural (often unilateral ): Fumbling or exploratory movements with the hand, directed toward self or environment. Hyperkinetic : Involves predominantly proximal limb and axial muscles. 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

33. Terms describing automatisms Dysphasic: Impairment of language without dysfunction of relevant primary motor or sensory pathways, manifested as impaired comprehension, anomia, paraphasic errors or a combination of these. Gelastic : Bursts of laughter or giggling, usually without an appropriate affective tone Dyscrastic : Bursts of crying

34. Terms describing automatisms Vocal: Single or repetitive utterances consisting of sounds such as grunts or shrieks Verbal: Single or repetitive utterances consisting of words, phrases or brief sentences Spontaneous: Stereotyped, involve only self, virtually independent of environmental influences Interactive: Not stereotyped, involve more than self, environmentally influenced

35. NON-CONVULSIVE STATUS EPILEPTICUS Prolonged electrographic seizure activity results in non-convulsive seizure symptoms Most common forms are complex partial status & absence status Mental state abnormalities & behavioural disturbance that results may be mistaken as psychiatric disorder

36. Partial non-convulsive status epilepticus Complex partial status is the most common form of non-convulsive status Classical picture is one of fluctuating delirium with motor automatisms Psychomotor agitation or retardation, affective disturbances, hallucinations, paranoid ideation, or catatonic picture may be seen

37. Simple partial status commonly involves focal motor seizures Subjective experiential phenomena in absence of impaired consciousness ( aura continua ) are the most likely to be confused with psychiatric disorder Absence status : prolonged state of impaired consciousness associated with continuous 3-Hz spike-wave EEG abnormality

38. POST – ICTAL DISORDERS DELIRIUM Epileptic seizures begin abruptly but recovery occurs gradually Typically, patients are alert and responsive within 15 minutes On occasions, full recovery of consciousness may take much longer, especially in the elderly or in patients with learning difficulties

39. POST-ICTAL PSYCHOSIS Brief self-limiting episodes of psychosis that are of abrupt onset and follow seizures Accounts for about 25% of epileptic psychoses Prevalence is around 6% Epilepsy has usually been present for over 10 years before the first episode

40. Risk factors for development of post-ictal psychosis include: bilateral seizure foci processes associated with bilateral limbic lesions (e.g. encephalitis, head injury) relative increase in seizure frequency preceding the psychotic symptoms

41. Precipitating event can be an exacerbation of seizures followed by a lucid interval lasting 2 - 72 hrs ( mean-1 day ) where patient appears normal Onset of psychotic symptoms is sudden & dramatic accompanied by marked agitation & behavioural disturbance Affective symptoms with grandiose & religious delusions & simple auditory hallucinations are common

42. Duration of postictal psychosis is generally short (Mean – 3.5 days ) with a range from 16 hours to 18 days EEG may show diffuse background slowing or an increase in inter-ictal epileptiform abnormalities Episodes are self-limiting hence treatment with antipsychotics is usually not indicated

43. Severe agitation warrants hospitalisation and treatment with benzodiazepines or low dose antipsychotics 14 - 20% of patients with recurrent postictal psychosis will develop chronic inter-ictal psychoses after several years There is no prophylactic role for antipsychotics to prevent chronic psychosis

44. Psychotic symptoms often worsen with increasing seizure activity Rarely, psychotic symptoms alternate with seizures & when patients are seizure free they manifest mainly paranoid psychotic symptoms EEG normalizes during a psychotic episode is called forced or paradoxical normalization Alternating psychosis or forced normalization

45. INTER – ICTAL DISORDERS DEPRESSION Depression and anxiety are the most frequently encountered inter-ictal psychiatric disorders in epilepsy Estimated prevalence is 20-70%

46. The clinical picture is one of chronic dysthymia which is interrupted at frequent intervals by brief periods of normal mood Other symptoms include atypical pain, phases of euphoric/dysphoric affect, anxiety and phobic symptoms Antiepileptic drugs can lower serum folate levels and manifest with depressive symptoms

47. Escitalopram & Sertraline are preferred first-line medications MAO inhibitors have lower effect on seizure threshold and TCA have higher effect Antidepressant dose should be increased slowly in small increments

48. ANXIETY The most frequent diagnoses are agoraphobia, generalised anxiety disorder & social phobia Fears (phobic anxiety), often relate to the perceived risk of personal injury & brain damage, & having seizures in unfamiliar situations

49. INTER-ICTAL PSYCHOSIS Prevalence is between 3 & 7% Psychotic symptoms not temporally related to seizure activity & mental state characterised by delusions & hallucinations in clear consciousness Bizarre or disorganised behaviour, thought disorder, personality change, negative symptoms of schizophrenia or affective changes are not commonly seen

50. Mean age of onset is 30; after a mean duration of epilepsy of 10-15 years Risk factors include: early age of onset of seizures poorly controlled partial complex seizures (usually with secondary generalization) Temporal lobe or left sided lesions

51. TEMPORAL LOBE EPILEPSY Temporal lobe epilepsy (TLE) is the most common of the anatomically defined syndromes, accounting for around 60% of all patients with localisation -related epilepsy. Temporal lobe seizures produce the most varied and complex auras of all . The most frequent cause of TLE is hippocampal sclerosis , also known as mesial temporal sclerosis

52. Other causes of TLE include dysembryoplastic neuroepithelial tumours , cavernous angiomas , gliomas , cortical dysplasia and gliosis secondary to encephalitis or meningitis . Temporal lobe seizures may take the form of simple and complex partial seizures, with both occurring in some 70% of patients. A variety of autonomic features and visceral sensations figure prominently in temporal lobe auras .

53. The epigastric aura is the most common, being reported by up to 50% of patients. Other autonomic effects include changes in skin colour , blood pressure , heart rate, perspiration, salivation and piloerection . Subjective dizziness is common . Affective experiences are a feature of approximately 25% of temporal lobe auras. The most common is anxiety, which is often intense ( ictal fear)

54. Vocalisation is seen in approximately 50 % of temporal lobe seizures. The essential quality of recognition may change, with strong feelings of familiarity or unfamiliarity leading to déjà vu and jamais vu . Altered perceptual experiences include both distortions of real perceptions (illusions) and spontaneous hallucinations.

55. Hallucinations of taste (gustatory) and smell ( olfactory) derive from medial temporal lobe structures, particularly the amygdala, and are of considerable significance for the diagnosis of TLE. The most frequent automatisms are oro -alimentary ( lip smacking, chewing , swallowing) and gestural ( fumbling, picking , rubbing movements)

56. FRONTAL LOBE EPILEPSY 20–30% of localization-related epilepsy Post-traumatic aetiology is common, although tumours and cortical dysplasia are also frequent. Frontal lobe seizures tend to begin and end abruptly, are brief (usually less than 1 minute), often frequent, and show a tendency to occur at night and in clusters.

57. Motor phenomena, which may include complex posturing and behavioural automatisms, are usually present. Focal motor seizures may occur as a special form of status epilepticus ( Epilepsia partialis continua) Speech arrest is a feature of dominant hemisphere frontal seizures but speech automatisms accompanying hypermotor seizures arising from the non-dominant hemisphere may also be dramatic, with screaming and swearing.

58. PARIETAL LOBE EPILEPSY R are , less than 5% of localisation -related epilepsy Tumors are the most common aetiology . Somatosensory auras are reported by some 80% of patients, with elementary paraesthesia by far the most common feature like tingling, numbness , prickling, crawling or electrical sensations

59. OCCIPITAL LOBE EPILEPSY 5–7% of localisation - related epilepsy but is probably under- recognised . Childhood syndrome are frequently misdiagnosed as migraine and in adults occipital lobe seizures notoriously mimic other partial seizures because of rapid propagation to temporal and frontal lobes . Elementary visual hallucinations are the hallmark of occipital seizures but are not seen in all cases

60. The hallucinations consist mainly of bright, coloured spots , circles, balls or blobs. They typically appear in the contralateral hemifield and move, flash or twinkle . Negative phenomena , such as scotoma , ‘black or white outs’, and ictal amaurosis are less common. Complex visual illusions and hallucinations are associated with temporal lobe seizures but may be seen with occipito -temporal foci . Common causes of occipital lobe epilepsy include tumours , trauma and developmental malformations.

61. EPILEPSY AND SUICIDE Risk of suicide is 2.4 times higher in patients with epilepsy 11–12 times higher in those with epilepsy and anxiety or psychosis 32 times higher in those with epilepsy and depression

62. Death by suicide occurs in 3 to 7 percent of epilepsy patients Higher risk of suicide is associated with early age at onset of epilepsy, particularly during adolescence Contributors to successful suicides include paranoid hallucinations, agitated guilt to kill themselves, & occasional ictal command hallucinations to commit suicide

63. Personality changes associated with epilepsy Extent of personality disorders in association with epilepsy is 0.7–2.0% (most commonly borderline) In partial epilepsy (particularly TLE), rates of personality disorder range from 13 to 35% Treatment-refractory epilepsy commonly associated with dependent & avoidant personality disorders

64. Organic personality disorder : some people with epilepsy (complex partial seizures; particularly TLE) develop behavioural changes like: Viscosity – a tendency for prolonged interpersonal contact, with pedantry & lack of socially appropriate ending of conversations Hyposexuality – decreased libido & impotence

65. Religiosity – very strong preoccupation with religion and philosophy Hypergraphia – compulsive writing Aggression – increased incidence of inter-ictal violence & hostility Combination of these traits is sometimes referred to as Gastaut – Geschwind syndrome

66. FUNCTIONAL NON-EPILEPTIC ATTACKS These are a diverse group of disorders in which paroxysmal events may be mistaken for epilepsy, but are not caused by epilepsy Origin: physiological (10–20%) psychogenic (80–90%)

67. 5–20% of patients in epilepsy clinics have only non-epileptic fits About 80% of patients with psychogenic non-epileptic seizures are women & are aged between 15 - 35 years Non-epileptic seizures may occur in people with epilepsy (about 33%)

68. Common clinical presentation of non-epileptic fits: Panic attack – may resemble an epileptic seizure and loss of consciousness may occur Avoidance attack – typically this occurs when the individual is unable to cope with a stressful situation; the person may fall to the floor and remain inert, with reduced muscle tone

69. Abreactive attack – occurs as a delayed response to highly stressful experiences, and often happens towards the end of the day; hyperventilation may precede increased body tone and thrashing of the limbs Simulated attack – conscious or unconscious simulation of an epileptic seizure, usually involving some kind of gain

70. CAUSES OF FUNCTIONAL NON-EPILEPTIC ATTACKS Psychogenic causes Physiological causes Depersonalisation disorder Hypochondriasis Somatisation disorder Dissociative disorders Conversion disorders Panic disorders Factitious disorders Syncope Transient ischaemic attacks Paroxysmal movement disorders Narcolepsy Non-epileptic myoclonus

71. Comparative semiology of dissociative and epileptic seizures DISSOCIATIVE SEIZURES EPILEPTIC SEIZURES Duration > 2 min Common Rare Motor features Gradual onset Common Rare Fluctuating course Common Very rare Eyes closed Common Rare Thrashing, violent movements Common Rare Side-to-side head movements Common Rare Asynchronous clonic movements Common Very rare Pelvic thrusting Occasional Rare Opisthotonous Occasional Very rare Automatisms Rare Common

72. Comparative semiology of dissociative and epileptic seizures DISSOCIATIVE SEIZURES EPILEPTIC SEIZURES Weeping Occasional Very rare Recall for period of unresponsiveness Common Very rare

73. Observational features suggestive of non-epileptic fits: Undulating motor activity Convulsion lasting >2 minutes Resisted lid opening Rapid postictal re-orientation Asynchronous limb movements Lack of cyanosis Retained awareness of surroundings in apparent generalised fits

74. Common investigations in functional non-epileptic attacks: EEG: single inter-ictal EEG may not be helpful in diagnosis Provocation procedures: commonly used are hyperventilation, photic stimulation or sleep deprivation Serum prolactin: may not be very helpful due to low sensitivity & specificity Home videos can be a very helpful Gold standard is video-EEG telemetry

75. Paroxysmal neurological disorders that may be mistaken for Epilepsy: Transient ischaemic attacks Migraine Vertigo Hyperekplexia Paroxysmal movement disorders Sleep disorders Narcolepsy Non-REM disorders REM sleep behaviour disorder

76. AGGRESSION IN EPILEPSY Most aggression among epilepsy patients is not related to epileptiform activity It is usually associated with psychosis or with intermittent explosive disorder & correlates with subnormal intelligence, lower socioeconomic status, childhood behaviour problems, prior head injuries, & possible orbital frontal damage

77. Simple violent automatisms, such as spitting or flailing the arms, can occur at the onset of complex partial seizures Non-directed violent movements, aimless destructive behaviour, or angry verbal outbursts occur during postictal delirium

78. EPILEPSY AND SEXUAL DYSFUNCTION Men with epilepsy report less sexual interest. A history of erectile dysfunction is found in up to 57% In women, hyposexuality is common with abnormalities of arousal and orgasmic dysfunction Can be explained by biological factors (low testosterone), medication related, or psychosocial factors

79. COGNITIVE FUNCTION IN EPILEPSY Cognitive deficits are present at the time epilepsy is first diagnosed & may even precede the onset of seizures 10–20% children with epilepsy have impaired intellectual development manifest as persistent or progressive cognitive deficit Progressive decline of memory seen in 50 % patients with uncontrolled TLE

80. Antiepileptic drugs are an important cause of cognitive problems & is likely in patients taking two or more antiepileptic drugs Cognitive deficits are possible cumulative effects of neuronal damage incurred through repeated seizures, brain injury secondary to trauma or status epilepticus & psychosocial impact of disorder

81. TREATMENT OF EPILEPSY Anti-epileptic medications Epilepsy surgery Vagal nerve stimulation

82. Effectiveness of antiepileptic drugs against different seizure types. Partial-onset seizures Generalised onset: tonic– clonic seizures Generalised onset: absence seizures First line Carbamazepine Lamotrigine Valproate Ethosuxamide Alternatives First generation Valproate Phenobarbital Phenytoin Benzodiazepines Carbamazepine Phenobarbital Phenytoin Benzodiazepines Valproate Second generation Gabapentin Levetiracetam Oxcarbazepine Tiagabine Topiramate Zonisamide Pregabalin Lamotrigine Topiramate Levetiracetam Lamotrigine

83. Neuropsychiatric aspects of epilepsy surgery Patients with epilepsy who have not responded to two or more anti-epileptic drugs could be considered for epilepsy surgery Surgery involves removal of epileptogenic focus Most common surgery done is anterior temporal lobectomy. Others are hippocampectomy , lesionectomy & multiple subpial transection

84. Seizure-free or near seizure-free rates as high as 80–90% have been achieved using surgery About a third of patients can present with anxiety & depression 6–12 weeks after the surgery irrespective of surgery outcome De novo psychosis is rarely seen post-epilepsy surgery (0.5–1%)

85. Vagal nerve stimulation The procedure involves intermittent electrical stimulation of the vagus nerve via a stimulator inserted surgically over the anterior chest wall. The mechanism of action is unknown . VNS is usually considered for patients who prove unsuitable for epilepsy surgery.

86. Overall, a 50% reduction in seizure frequency is seen in approximately 30% of patients . VNS is generally well tolerated: the main side effects are intermittent hoarseness of the voice and throat discomfort during stimulation but patients usually habituate to this.

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