1 / 29

PSYCHIATRIC ASPECTS OF EPILEPSY

PSYCHIATRIC ASPECTS OF EPILEPSY. Dr John Mellers Department of Neuropsychiatry Maudsley Hospital. PSYCHIATRIC DISORDER IN EPILEPSY. Background Prevalence, aetiology Psychiatric presentations in epilepsy :- Related to underlying cause of the epilepsy Related to seizures Pre-ictal

terra
Télécharger la présentation

PSYCHIATRIC ASPECTS OF EPILEPSY

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PSYCHIATRIC ASPECTS OF EPILEPSY Dr John Mellers Department of Neuropsychiatry Maudsley Hospital

  2. PSYCHIATRIC DISORDER IN EPILEPSY Background • Prevalence, aetiology Psychiatric presentations in epilepsy :- • Related to underlying cause of the epilepsy • Related to seizures • Pre-ictal • Ictal • Post-ictal • Inter–ictal disorders Non-epileptic (dissociative) seizures Management

  3. Epilepsy and Psychiatric Disorder: overall perspective • Most patients with epilepsy do not suffer from psychiatric problems • Patients with severe epilepsy are at increased risk of psychiatric problems Relevance ? • Epilepsy and comorbid psychiatric disorder • Differential diagnosis: epilepsy or psychiatric disorder ? • Research: understanding psychiatric disorder

  4. Overall Prevalence of Psychiatric Morbidity • Population survey • Children : > 3-fold increased psychiatric morbidity in epilepsy (Graham&Rutter, 1968) • GP- surveys:- • 30 - 50% significant psychiatric morbidity • Lower prevalence in seizure-free patients (Jacoby, 1996; O’Donoghue, 1999) • Prevalence in specialist settings:- • 30% current, plus 30% past, DSM diagnoses in Lobectomy series (Manchanda, 1996) • Compared to other patient groups:- • Disability Claimants:- 35% epilepsy / 30% non-neurological disability (Steffansson, 1998) • Asthma:- no difference with epilepsy, both patient groups > controls (Ettinger, 2004)

  5. Overall risk factors for psychiatric disorder in epilepsy • Intractable epilepsy • associated brain damage • temporal lobe epilepsy • early onset epilepsy • perceived seizure severity • social handicap • adverse family background

  6. Models of Aetiology 1. Same underlying pathology responsible for epilepsy and psychiatric disorder. 2. Seizures produce pathogenic electrical / biochemical changes. 3. Effects of treatment. 4. Psychosocial correlates of epilepsy (disability/ stigma / family background).

  7. Classification of Psychiatric Disorders Associated with Epilepsy 1. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic epileptic syndromes (eg: Wests, Landau-Kleffner ) • Chronic organic brain syndromes • Focal brain disease 2. Disorders strictly related in time to seizure occurrence • Preictal - prodrome • Ictal - psychiatric manifestations of seizure activity (aura, automatisms, nc status, FLE) • Postictal - psychiatric abnormalities occurring in the immediate postictal period 3. Interictal psychiatric disorders • Childhood disorders • Neuroses • Psychoses • Personality disorder • Dementia

  8. Classification of Psychiatric Disorders Associated with Epilepsy 1. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic epileptic syndromes (eg: Wests, Landau-Kleffner ) • Chronic organic brain syndromes • Focal brain disease 2. Disorders strictly related in time to seizure occurrence • Preictal prodromata • Ictal - psychiatric manifestations of seizure activity (aura, automatisms, nc status) • Postictal - psychiatric abnormalities occurring in the immediate postictal period 3. Interictal psychiatric disorders • Childhood disorders • Neuroses • Psychoses • Personality disorder • Dementia

  9. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic epileptic syndromes • West’s syndrome • Lennox –Gastaut • Acquired Epileptic Aphasia (Landau-Kleffner) • Progressive Myoclonic Epilepsies • Chronic organic brain syndromes (eg: dementia) • Focal brain disease (eg: sol causing epilepsy)

  10. Classification of Psychiatric Disorders Associated with Epilepsy 1. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic epileptic syndromes (eg: Wests, Landau-Kleffner ) • Chronic organic brain syndromes • Focal brain disease 2. Disorders strictly related in time to seizure occurrence • Preictal prodromata • Ictal - psychiatric manifestations of seizure activity (aura, automatisms, nc status, FLE) • Postictal - psychiatric abnormalities occurring in the immediate postictal period 3. Interictal psychiatric disorders • Neuroses • Psychoses • Personality disorder • Dementia

  11. Disorders related in time to seizure occurrenceA. Pre-ictal “Prodrome” • Non-specific, unwell, dysphoria • Hours - days • 30% • Focal > Generalised epilepsy • Unknown pathophysiology

  12. Classification of Psychiatric Disorders Associated with Epilepsy 1. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic (generalised ) epileptic syndromes (eg: Wests, Landau-Kleffner ) • Chronic organic brain syndromes • Focal brain disease 2. Disorders strictly related in time to seizure occurrence • Preictalprodromata • Ictal - psychiatric manifestations of seizure activity (aura, automatisms, nc status, FLE) • Postictal - psychiatric abnormalities occurring in the immediate postictal period 3. Interictal psychiatric disorders • Childhood disorders • Personality disorder / behaviour disorder • Neuroses • Psychoses • Dementia

  13. Features that distinguish epileptic seizures from symptoms in functional psychiatric disorder “Psychic” / experiential symptoms in epilepsy are usually:- • Highly stereotyped • Brief in duration • Accompanied by other epileptic semiology • Impaired consciousness • Motor automatisms

  14. Disorders related in time to seizure occurrenceB. Ictal • Experiential aura • Affect (eg: ictal fear) • Dymnesic (eg: deja vu, jamais vu, panoramic memory) • Perceptual (illusions / hallucinations / elementary & complex) • Aberrations of subjective thinking (eg: forced thinking) • Frontal seizures • Bizarre: posturing, “hypermotor” seizures • Automatisms • Semi-purposeful activity with impaired consciousness • May be prolonged (20 minutes) in TLE • Non-convulsive status • Absence status: eyelid myoclonus in 50%, 3Hz EEG • Complex Partial status: fluctuations, motor features • Simple Partial Status: “Aura continua” rare

  15. Features that distinguish epileptic seizures from symptoms in functional psychiatric disorder “Psychic” / experiential symptoms in epilepsy are usually:- • Highly stereotyped • Brief in duration • Accompanied by other epileptic semiology • Impaired consciousness • Motor automatisms

  16. Classification of Psychiatric Disorders Associated with Epilepsy 1. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic (generalised ) epileptic syndromes (eg: Wests, Landau-Kleffner ) • Chronic organic brain syndromes • Focal brain disease 2. Disorders strictly related in time to seizure occurrence • Preictalprodromata • Ictal - psychiatric manifestations of seizure activity (aura, automatisms, nc status, FLE) • Postictal - psychiatric abnormalities occurring in the immediate postictal period 3. Interictal psychiatric disorders • Childhood disorders • Personality disorder / behaviour disorder • Neuroses • Psychoses • Dementia

  17. Disorders related in time to seizure occurrenceC. Post - ictal • Post-ictal delirium • May be prolonged (elderly, underlying brain disease) • Post-ictal Psychosis • Psychiatric features • Brief, dramatic, self-limiting psychosis (< 1 day – 18 days) • Follows seizure exacerbation • “lucid interval” (mean 1 day) • pleomorphic phenomenology • Marked Agitation • Rapidly changing affect / psychotic symptoms • May have degree of intermittent delirium • Prevalence / neurological features • 6-7% telemetry series • Focal epilepsy > Generalised epilepsy • Associated with bilateral pathology • Up to 20% develop inter-ictal psychosis

  18. Classification of Psychiatric Disorders Associated with Epilepsy 1. Disorders clearly attributable to the brain disorder causing the epilepsy • Learning disability • Symptomatic (generalised ) epileptic syndromes (eg: Wests, Landau-Kleffner ) • Chronic organic brain syndromes • Focal brain disease 2. Disorders strictly related in time to seizure occurrence • Preictal prodromata • Ictal - psychiatric manifestations of seizure activity (aura, automatisms, nc status, FLE) • Postictal - psychiatric abnormalities occurring in the immediate postictal period 3. Interictal psychiatric disorders • Neuroses • Psychoses • Personality disorder • Dementia

  19. Interictal psychiatric disorders Depression • Common • Up to 50% “atypical” (Mendez, 1986) • Interictal Dysphoric Disorder(Blumer, 1995; Kanner, 2002) • Up to 70% of depressed patients with epilepsy • Chronic, recurrent episodes of:- • Irritability, dysphoria, anxiety, brief episodes normality and hypomania • Somatic symptoms: anergia, atypical pain, insomnia. • Risk Factors • Severity of epilepsy (seizure frequency) (Jacoby, 1996) • Family history of affective disorder • Controversial relationship to laterality and type of epilepsy • Low folate • AEDs: eg: levetiracetam, tiagabine, topiramate • 3 - 5 x suicide rate • Major risk factor is psychiatric history. • also early onset (<18), and infrequent neurology follow-up) (Nilsson, 2002)

  20. Interictal psychiatric disorders Anxiety disorder • Similar prevalence to depression • Similar risk factors • “seizure Phobia” • fear of having attack in public • Agoraphobic avoidance • May be more disabling than seizures

  21. Interictal psychiatric disorders Non-Affective Psychosis • 2-3-fold increased risk • characteristics of the psychosis:- • onset 10 - 15 years after onset of epilepsy • PSE profiles very similar to that found in schizophrenia • -ve family history of schizophrenia • lack of premorbid personality disturbance • ?possible excess of women and left handedness • characteristics of the epilepsy:- • Severe epilepsy • Bilateral cerebral pathology • ?TLE / ?? left sided focus • gangliogliomas (of development origin) more common • variable relationship between seizures and psychosis • AEDs: eg. ethosuxamide, vigabatrin, levetiracetam

  22. Interictal psychiatric disorders Personality in Epilepsy • controversial / discredited temporal lobe “Geschwind syndrome”:- • hyposexuality • hypergraphia • Religiosity • Bear & Fedio (1977) • hyperemotionality (R) • Ruminative, humourless, philosophically inclined, (L) • Non-specific marker of psychiatric morbidity • Some support for hypergraphia in TLE (Sachdev, ‘81; Hermann, ‘83) • ? Overlap with autistic spectrum disorder • Intractable TLE: 18-22% DSM Personality Disorder (dependent / avoidant) • Juvenile Myoclonic Epilepsy: association with Emotional instability traits ?

  23. Interictal psychiatric disorders Epilepsy and Cognitive impairment • Most people with epilepsy have IQ in normal range • TLE: memory impairments • Dominant hemisphere: verbal memory • Non-dominant: non-verbal memory • small number of patients have slowly progressive dementia • status epilepticus • repeated head injury • cumulative effect of seizures • underlying degenerative brain disorder • Anti-epileptic medication

  24. Epilepsy and Violence • Prevalence of epilepsy in prisons is 4 times that in the general population • but, crimes committed by epileptics are not more violent • social factors may predispose towards epilepsy and crime • brain disorder causing epilepsy may predispose to criminality • psychosocial impact of epilepsy may predispose towards criminality • criminal lifestyle may predispose towards epilepsy • Ictal aggression is very rare • Usually “resistive” - provoked by attempts to contain patient during automatism

  25. DISSOCIATIVE SEIZURES OTHER TERMS • (Psychogenic) non-epileptic seizures, pseudoseizures, NEAD, hysterical seizures, functional seizures PREVALENCE • 20% of patients with medically intractable seizures • ~ 15 % also have epilepsy DEMOGRAPHIC CHARACTERISTICS • 75 % female • age onset • mean: early 20’s ; range : 4 - 71 (one third between 10 and 20) • duration at diagnosis • mean : 3 years ; range : 1 - 20 years

  26. MOST HELPFUL atypical sequence long duration (50 % > 2 mins) Specific Features:- Conscious but unresponsive... Eyes closed Violent movements Prolonged, motionless unresponsive NB: confusing features(~ 10%) injuries & incontinence pseudostatus arise in “sleep” past / family neurological Hx ON EXAMINATION out-of-phase clonic movement eyes closed avoidance / resistance “Henry & Woodruff” sign “Prof Binnie mirror sign” DISTINGUISHING CLINICAL FEATURES

  27. DIAGNOSIS - EXCLUDING EPILEPSY 1. Clinical suspicion 2. Inter-ictal EEG 3. Telemetry 4. Serum prolactin

  28. Principles of psychiatric management • Consider neurological, psychological and social factors • Optimise epilepsy treatment • Antidepressants and neuroleptics may worsen seizures • Usually NOT clinically relevant apart from clozapine… • Drugs of choice in epilepsy are said to be:- • neuroleptics: risperidone, sulpiride, olanzapine … • antidepressants: SSRIs, Venlafaxine, MAOI’s … • Look up interactions before prescribing …

  29. PSYCHIATRIC DISORDER IN EPILEPSY Background • Prevalence, aetiology Psychiatric presentations in epilepsy :- • Related to underlying cause of the epilepsy • Related to seizures • Pre-ictal • Ictal • Post-ictal • Inter–ictal disorders Non-epileptic (dissociative) seizures Management

More Related